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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 205-216

Effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries


1 Clinical instructor, Faculty of Nursing, Modern University for Technology and Information, Cairo, Egypt
2 Professor of pediatric nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
3 Lecturer of pediatric nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Date of Submission03-Jan-2018
Date of Acceptance31-May-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Asmaa Abd El-Maksoud El-Moazen
Clinical instructor, Faculty of Nursing, Modern University for Technology and Information
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_2_18

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  Abstract 


Backgroun Hospitalization and surgery are stressful events children face especially during the early years. Through play activities, children can reduce the level of preoperative anxiety and fear.
Aim The aim of the current study was to evaluate the effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries.
Sample A convenient sample of 50 school-age children undergoing abdominal surgeries participated in the current study.
Design One-group pre–post-test time series quasi-experimental research design was used to achieve the aim of the current study.
Setting The current study was conducted at the General Pediatric Surgical unit at Cairo University Specialized Pediatric Hospital.
Tools Data were collected through the following tools: structured interview questionnaire, State-Trait Anxiety Inventory for Children (STAIC), and the Glasses Fear Scale (GFS).
Results The results revealed that preoperative anxiety scores on STAIC and preoperative fear scores on GFS were lower among the studied children after using the selected play activities than before. A highly statistically significant difference was detected between total mean score of STAIC and GFS in the pretest and after the first, second, and third play sessions and at 30 min before surgery.
Conclusion The current study concluded that the selected play activities were effective in reducing the level of anxiety and fear among children undergoing abdominal surgeries.
Recommendations It was recommended that establishing preoperative play activities for children undergoing abdominal surgeries is essential for preparation of the child for surgery.

Keywords: abdominal surgeries, children, fear, play activities, preoperative anxiety


How to cite this article:
El-Moazen AE, Mohamed SA, Kereem MA. Effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries. Egypt Nurs J 2018;15:205-16

How to cite this URL:
El-Moazen AE, Mohamed SA, Kereem MA. Effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries. Egypt Nurs J [serial online] 2018 [cited 2019 Aug 19];15:205-16. Available from: http://www.enj.eg.net/text.asp?2018/15/3/205/248962




  Introduction Top


Illness and hospitalization are the first crises children face especially during the early years. Children are particularly vulnerable to these stressors because stress represents a change from the usual state of health and environmental routine, and children have a limited number of coping mechanisms to resolve stressors. Major stressors of hospitalization include separation, loss of control, bodily injury, and pain. Children’s reactions to these stressors are influenced by their developmental age; their previous experience with illness, separation, or hospitalization; their innate and acquired coping skills; the seriousness of the diagnosis; and the support system available (Hockenberry and Wilson, 2015).

Surgical operations are situations performed for multiple reasons, causing stress for both children and their families. This stress is generally reflected as anxiety, fear, or anger. Parental separation, pain, loss of control, a strange environment, and unknown environmental conditions are among the important causes for anxiety in children during the preoperative period (Aytekin et al., 2016).

Perry et al. (2012) reported that more than five million children in the USA undergo surgery annually; of those five million children, 50–75% experience considerable fear and anxiety preoperatively. Preoperative anxiety in children is associated with a number of adverse postoperative outcomes, such as increased distress in the recovery phase, and postoperative regressive behavioral disturbances, such as nightmares, separation anxiety, eating disorders, and bedwetting.

Recently, Aytekin et al. (2016) had documented that it is difficult to predict the preoperative anxiety because of measurement methods; however, anxiety arising from both psychological and physiological findings was reported in 40–60% of children. The identification and treatment of these clinical phenomena are very important in terms of preventing both psychological and physiological adverse effects. Preoperative anxiety may obstruct anesthesia induction, extend its duration, and significantly affect early postoperative recovery.

Kar et al. (2015) documented that several behavioral interventions have been used successfully to reduce preoperative anxiety and fear, among which development of coping skill was found to be most effective. Other modes include modeling, play, operating room tour, printed materials, and music therapy. Coping therapy may include deep breathing, counting, watching a video, or handheld game.

Play is the main job of children; through it, they express emotions and release unacceptable impulses in a socially acceptable way. Play is essential for children’s mental, emotional, and social well-being, and children need to act out their fears and anxieties as a means of coping with the stress of illness and hospitalization. Children are able to experiment and test fearful situations and can assume and vicariously master the roles and positions that they are unable to perform in the world of reality. Throughout their play activities, children need the acceptance of adults and their presence to help them control aggression and to channel their destructive tendencies (Hockenberry and Wilson, 2015).

In a study conducted by Nisha and Umarani (2013) to determine the effectiveness of play interventions on 60 preoperative school-age children in the age of 6–12 years, the finding of the study showed that play intervention was effective in reducing anxiety among preoperative children. In the same context, the study findings concluded that participating in playrooms and using play activities may reduce the trend of increment in the anxiety level induced by surgical procedures. Similarly, Gao et al. (2014) reported that engagement in an interesting game can reduce children’s preoperative anxiety and fear and improve their compliance with anesthesia induction.

A randomized controlled trial by He et al. (2015) was done on 95 children to examine play interventions on reducing perioperative anxiety, negative emotional manifestation, and postoperative pain in children undergoing inpatient elective surgery. They concluded that play intervention is effective in reducing negative emotional manifestations in children undergoing inpatient elective surgeries. These results suggest that it is useful to give children therapeutic play intervention before surgery.

An Egyptian study by Sabaq and El-Awady (2012) evaluated the effect of preoperative preparation program and mothers presence during induction on anxiety level and behavior change in 120 young children undergoing elective surgery (appendectomy and herniorrhaphy) and their mothers. It concluded that the nursing personnel should take the preoperative therapeutic play intervention as a duty and regard it as a role in doing the nursing practices to give the children the psychological care beside the routine physical care. Moreover, they should enhance the development of their communication skills and coping abilities of children that help in reducing their anxiety.

Significance of the study

Children experience significant anxiety and fear before surgeries, and literature from around the world indicates that preoperative anxiety is a global concern for healthcare providers. Control of preoperative anxiety and fear in children is an important challenge in pediatric nursing practice. The challenge that nurses face is to better manage children’s anxiety. Play is not always given a high priority in the hospitalized child’s total care, with the result that insufficient time is allocated to its provision in the nursing care plan. The effects of such incomplete patient care are far reaching for children in hospital, especially those undergoing surgeries.

According to the Statistics Department at Cairo University Specialized Pediatric Hospital (CUSPH) (2015), the total annual admission to the general pediatric surgical unit is ∼1600 children. The number of children who underwent abdominal surgeries was 200, and 85 of them were of school age (43%). Through empirical observations, literature review, and clinical experience in the pediatric surgical units for many years, it is noticed that many of the children who are scheduled for abdominal surgeries are exposed to varying level of anxiety and fear immediately before surgery. Scarce research studies were conducted nationally on the effect of selected play activities on preoperative anxiety and fear among children undergoing abdominal surgeries.

Therefore, the aim of the current study is to evaluate the effectiveness of selected play activities on preoperative anxiety level and fear among school age children undergoing abdominal surgeries, which may improve the preoperative anxiety level and fear of those children, and this in turn would decrease the cost of care. Moreover, the application of those play activities by the nurses would improve their performance and enhance their systematic approach of thinking while dealing with the children undergoing surgeries. Eventually, the results of the current study might generate attention and motivation for further research studies in the field of pediatric surgery nursing.

Operational definition

Play activities

For the current study, the selected play activities are a group of activities chosen based on recommendations found in the literature, age-appropriate characteristics, and health condition of the child. The six play activities are colored cards, puzzles, dolls, art and craft materials, short Arabic stories and music tables. Children were asked to choose one from the six play activities. Children would choose the playing activities based on personal preferences, individual characteristics, and level of attraction for a particular item.

Aim

The aim of the current study was to evaluate the effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries.

Research hypotheses

The current study results tested the following research hypotheses:
  1. Children who use the selected play activities will have lower preoperative scores on State-Trait Anxiety Inventory for Children (STAIC) than before.
  2. Children who use the selected play activities will have lower preoperative fear scores on Glasses Fear Scale (GFS) than before.



  Participants and methods Top


Research design

One-group time-series quasi-experimental research design was utilized in the present study. The group was treated as the study group and its own control group at the same time. A quasi-experimental design is an experimental design that is very similar to the true experimental design. Time series studies are often conducted for the purpose of determining the intervention or treatment effect. Multiple observations are obtained before and after the intervention (Burns and Grove, 2012).

Setting

The study was conducted at the General Pediatric Surgical Unit in CUSPH. It receives children from all over Egypt. The General Pediatric Surgical Unit includes general pediatric surgeries such as abdominal, plastic, and renal surgeries. The unit involves four rooms, and each room is occupied by three patient beds, and one large room contains 14 beds. The unit also involves an intermediate surgical care unit composed of nine beds.

Participants

A convenient sample of 50 school-age children undergoing abdominal surgeries participated in the current study.

Inclusion criteria

The following were the inclusion criteria:
  1. School-age children 6–12 years.
  2. Children undergoing abdominal surgery for the first time.
  3. Children in the preoperative period (the day before surgery).
  4. Need to stay in the hospital for more than 24 h.


Exclusion criteria

The following were the exclusion criteria:
  1. Children with neurological health problems such as epilepsy.
  2. Children with mental problems such as mental retardation.
  3. Children who use any anxiolytic drugs at preoperative period.


Data collection tools

The required data were collected through the following tools.

Tool 1: Structured interview questionnaire

It was developed by the research investigator after extensive review of related literature. It contains 12 items and involves two parts:
  • Part I contains five items about personal data about the child’s age, sex, rank within the family, level of education, and place of residence.
  • Part II encompasses seven elements covering disease history of children, for example, diagnosis, date of admission, previous hospitalization, times of previous hospitalization, and play activity chosen by the child and performed at preoperative period.


Tool 2: State-Trait Anxiety Inventory for Children

This was developed by Spielberger (1970) to measure transitory anxiety state. The STAIC measures anxiety in children between the ages of 6 and 14 years. The scale examines the shorter-term state anxiety that is commonly specific to situations. The scale consists of 20 statements that ask children how they feel at a particular time. Scale statements are categorized under five subscales (sadness, worry, fear, uncertainty, and anxious). Children were instructed to respond according to how they felt about their surgeries. Children respond to the STAIC by selecting one of the three alternatives (rarely, sometimes, and often). Response categories were assigned values of one, two, and three.

Scoring system: The total scores are a summation of the item scores; the total scores were 60. For statistical purposes, scores ranged from 20 to 30 were considered low anxiety, 30–40, indicating average; 40–50, indicating above average; and 50–60 suggesting very high level of stress. The scale was translated into Arabic, and then back translated into English by El-Samman et al. (2009). Translation was judged and tested for its content validity by nine experts in pediatric nursing and psychiatric nursing fields.

Tool 3: The glasses fear scale

It is a variation of the visual analog scale, which was adopted from Aiken (1959) and modified by Gift (1989). This scale is used to measure self-reported fear among children. The child’s version consists of six cylinders or glasses. The first cylinder, which is empty, represents ‘no fear or not scared at all,’ whereas the next five cylinders are filled with incremental amounts of ‘fear’, ranging from ‘low fear to very fearful’, and the last cylinder is completely filled representing the ‘extreme fear and most scared’. For statistical purposes, each glass is assigned a numerical value from 0 to 5. Cavender et al. (2004) found support for the construct validity of the scale in a distraction study of children 4–11 years old who were undergoing surgeries. Wong and Baker (1988) reported an acceptable level of test–retest reliability, supporting the concurrent validity of the Glasses Scale in 3–18-year olds.

Validity and reliability

Data collection tools of the study were given to a group of five experts in the field of pediatric surgery, pediatric surgery nursing, and psychiatric nursing to test the content validity. Reliability was performed to confirm consistency of the tool. The reliability coefficients’ α between items of STAIC was 0.86.

Pilot study

The pilot study was carried out on 10% of the total sample (five) of children having preoperative anxiety and fear undergoing abdominal surgeries to test study tools in terms of its clarity, applicability, and time required to fulfill it. The needed modifications were done, and then the final format was developed.

Procedure

Before conducting the study, an official permission was obtained from the directors of CUSPH and from the head of general pediatric surgery unit. The research investigator introduced self to the child and the mother fulfilling study criteria and explained the aim of the study. In the preoperative days, a written informed consent was obtained from each child’s mother who fit the inclusion criteria after complete description of the purpose and nature of the study, and then the research investigator collected personal data of the child using the structured interview sheet (tool 1 part I) from all children on an individual basis at their bedside area. Children disease history was obtained by the research investigator using tool 1 part II. It also includes items related to previous hospitalization, its times, and causes.

Then all children were exposed to the pretest sheet (tool 2 and tool 3). Assessment of children level of anxiety and fear was assessed before surgery within the preoperative days as scheduled by the pediatric surgeon (pretest). The preoperative level of anxiety was assessed using STAIC (tool 2) on an individual basis, and the preoperative fear was assessed using The GFS (tool 3) on an individual basis.

All children who participated in the current study were exposed to the intervention, which consisted of three planned assisted play sessions in presence of the research investigator and mothers to assist and interact with them. The research investigator used six age-appropriate play materials (toys) believing that if children had a choice, it might foster a sense of mastery and control over the situation and empower their coping ability. Children were asked to choose one from six toys. The six play activities were colored cards, puzzles, dolls, art and craft materials, short Arabic stories, and music tables.

The selected play activities consisted of three play sessions for 1 h per day for 3 consecutive days before surgery. Each play session tool ∼45–60 min on an individual basis or sometimes as a group of children of 2–4 as preferred by the children (cooperative play). The play sessions were implemented in the child’s inpatient room (bedside area), and sometimes with group play, as it was implemented in the playroom of the pediatric surgical ward after coordination with the assigned nurses. For evaluation, the preoperative level of anxiety and fear was assessed on an individual basis immediately after each play session and 30 min before surgery (post-test). Data collection was conducted over a 4-month period extending from January 2017 till April 2017.

Ethical considerations

Primary approval was obtained from the Research Ethical Committee in the Faculty of Nursing, Cairo University, to conduct the study. A written informed consent was obtained from the mothers of children after a complete description of the purpose and nature of the study. Children and their mothers were informed that participation in the study was voluntary; the research investigator also informed the mothers about their rights to withdraw from the study at any time without giving any reason and without any effect on the care of their children. Confidentiality was assured to each child and their mothers. After completion of data collection, the final approval was obtained from the Research Ethical Committee in the Faculty of Nursing, Cairo University.


  Results Top


Regarding children personal characteristics ([Table 1]), half (50%) of the children’s age ranged from 10 to 12 years, and their mean age was 9.2±2.3 years. It is evident from the same table that the highest percentage of children (28%) was in the sixth grade primary education, followed by 24% first-grade primary education, whereas a minority (2%) dropped out from school. [Figure 1] reveals that more than half of the children were male, whereas 44% of them were female. [Figure 2] demonstrates that the highest percentage (60%) of children came from urban areas and 40% of them were from rural areas.
Table 1 Percentage distribution of personal data of school-age children (n=50)

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Figure 1 Percentage distribution of school-age children regarding sex (n=50).

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Figure 2 Percentage distribution of school-age children regarding place of residence (n=50).

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[Figure 3] illustrates that the highest percentage of school-age children (80%) had no history of previous hospitalization. [Figure 4] clarifies that the highest percentage of the studied child (44%) were undergoing appendectomy, followed by those undergoing splenectomy, cholecystectomy, and renal stone removal (18, 14, and 10%, respectively). On the contrary, a minority (6%) of the children were undergoing abdominal exploration.
Figure 3 Percentage distribution of school-age children in relation to their history of previous hospitalization (n=50).

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Figure 4 Percentage distribution of school-age children in relation to their diagnosis (n=50).

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In relation to the type of play activities chosen by the children during play sessions, [Table 2] shows that 50% of children chose colored cards as a preferred toy during the first play session, whereas music tables were not chosen by children. At the second play session, 36% of the children preferred to play by art and craft materials and the minority (2%) of them chose colored cards. During the third play session; music tables were chosen by 38% of children to play with it. Mental paly was the most preferred type of play as chosen by the vast majority of children (94%) during the first play session. Similarly, 66% chose play activities representing mental play during the second play session. Moreover, 58% of the children preferred mental play and 42% chose physical play during the third play session.
Table 2 Percentage distribution of play activity and preferred type of play as chosen by school-age children during play sessions (n=50)

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Concerning the STAIC among school-age children undergoing abdominal surgery, [Table 3] shows that the total mean score of STAIC among children before implementation of play activities was 45.3±5.2 and decreased to 23.6±2.3 after implementation of the first play session. A highly statistically significant difference was detected between total mean score of STAIC in the pretest and after the first play session (t=23.978, P=0.0001). [Table 4] highlighted that the total mean score of STAIC among children declined to 24.4±2.1 after implementation of the second play session. There was a highly statistically significant difference between the total mean score of STAIC in the pretest and after the second play session (t=28.4, P=0.0001).
Table 3 Comparison between total mean score of State-Trait Anxiety Inventory for Children among children before and after implementation of the first play session (n=50)

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Table 4 Comparison between total mean score of State-Trait Anxiety Inventory for Children among children before and after implementation of the second play session (n=50).

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[Table 5] shows that the total mean score of STAIC among children was reduced to 21.2±1.9 after implementation of the third play session. There was a highly statistically significant difference between the total mean score of STAIC in the pretest and after the third play session (t=34.03, P=0.0001). [Table 6] highlighted that the total mean score of STAIC among children was decreased to 23.3±4.5 at 30 min before the surgical operation. There was a highly statistically significant difference between total mean score of STAIC in the pretest and 30 min before the surgical operation (t=36.7, P=0.0001).
Table 5 Comparison between total mean score of State-Trait Anxiety Inventory for Children among children before and after implementation of the third play session (n=50)

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Table 6 Comparison between total mean score of State-Trait Anxiety Inventory for Children among children before play sessions and at 30 min before surgery (n=50)

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Regarding the level of anxiety among children, [Table 7] demonstrates that 68% had above average anxiety on STAIC in the pretest, whereas this level changed to low anxiety among 82% of them after the first paly session. Most children (88 and 82%, respectively) had low level of anxiety after the second and the third play sessions. More than three-quarters (78%) of children had low level of anxiety 30 min before surgery.
Table 7 Percentage distribution of level of anxiety among children undergoing abdominal surgeries (n=50)

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Regarding the measurement of GFS for school-age children undergoing abdominal surgeries, the results of the current study revealed that more than two-thirds (68%) of children experienced severe fear in the preoperative period before implementation of the play sessions. After the first play session, it was found that 82% of children had their fear diminished to moderate level. Furthermore, most children (88%) had their fear reduced to low level after the second play session. Similarly, 80% of them had low level of fear after the third play session. Consequently, the majority (84%) of children still had low level of fear in the immediate preoperative period ([Table 8]).
Table 8 Percentage distribution of Glasses Fear Scale for school-age children undergoing abdominal surgeries (n=50)

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[Table 9] revealed that there were statistically positive significant correlations between children’ preoperative level of fear and their diagnosis and place of residence. On the contrary, there were no statistically significant correlations between children’ preoperative level of fear and their age, sex, and previous hospitalization.
Table 9 Correlation between level of preoperative fear based on Glasses Fear Scale and selected personal data of children (n=50)

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  Discussion Top


The results of the current study indicated that more than half of the school-age children who participated in the study were males, and the mean of age was 9.2±2.3 years. These results were consistent with Noronha and Shanthi (2015) who evaluate the effect of performing preoperative preparation program on 122 school-age children’s anxiety. It was found that the highest percentage of children in the control group (53.33%) was in the age group of 8–10 years, whereas in the experimental group, 60% were in the age group of 6–8 years. The highest percentage of the participants in the experimental group and control group (66.66%) was males and the least percentage (33.33%) was females.

Aranha et al. (2017) evaluate the effectiveness of multimodal preoperative preparation program on fear and anxiety of 12 children undergoing surgery. The study results indicated that 83.3% of children in the experimental group and 66.7% in the control group were in the age group of 10–12 years. Most (83.3%) were boys. On the contrary, these results are incongruent with Nisha and Umarani (2013) who studied the effect of play intervention in the reduction of anxiety among preoperative children and found that more than half of the children were females, and the highest percentage (43.3%) of children was in the age group 8–10 years.

In relation to child’s level of education, the current study indicated that the highest percentage of children was in the sixth grade primary education, whereas the minority of them dropped out from the school as the result of recurrent hospitalization for blood transfusion and follow-up, as those children complained of thalassemia with a complicated case with the final decision of splenectomy, and 8% of the children did not enroll in the school as a result of their illness and poverty. These results need deep insight from education authorities.

In Egypt, based on the United Nations Children’s Fund, UNICEF Egypt (2017), Ministry of Education, Statistical Yearbook 2014–2015, the net enrolment rate was 91% in primary education, and 84% in preparatory school. According to a study conducted by UNICEF (2015), 3% or 320 000 children at primary school age never enrolled or dropped out of school. Most of them are from poor families who live in remote rural communities.

Concerning diagnosis among the studied children, the current study clarified that the highest percentage of school-age children underwent appendectomy, followed by splenectomy, cholecystectomy, and renal stone removal. This result corresponded to an Egyptian study conducted by Sabaq and El-Awady (2012) to evaluate the effect of preoperative preparation program and mothers presence during induction on anxiety level and behavior change among 153 young children undergoing elective surgery in Zagazig University Hospital. The study results concluded that 80% of children had appendicitis in study group and 83.3% in the control group. Similarly, Hosseinpour and Ahmadi (2016) conducted a study about emergency abdominal surgery in infants and children in Iran, and the study results reported that the differential diagnosis of surgical acute abdomen from 6 to 11 years was appendicitis, cholecystitis, and pancreatitis.

Regarding the history of previous hospitalization for school age children, the current study indicated that most children had no history of previous hospitalization. A minority of the children were hospitalized several times before. Similarly, a randomized clinical trial conducted by Potasz et al. (2013) to explore the effect of play activities on stress in 53 hospitalized children in Brazil found that the highest percentage of children (64%) had no previous experience of hospitalization.

In relation to type of play and toy as chosen by school-age children during play sessions, the current study proved that half of the children chose colored cards as a preferred toy during the first play session, whereas music tables were not chosen by children. At the second play session, it was found that more than one-third of the children preferred to play by art and craft materials and the minority of them chose colored cards. Regarding the third play session, music tables were chosen by the highest percentage of children to play with it. The research investigator believed that children would choose the toys based on personal preferences, unique individualities, and level of attraction for a particular toy.

The results of the current study were in accordance to the empirical evidence by O’brien and Duren (2014) that documented a list of suitable toys and activities for various ages. According to school-age children, there are physical play activities such as dolls and musical toys and mental play activities such as arts and crafts, puzzles, and colored cards. The same explanation was mentioned by Joe et al. (2012) who outlined play materials that are appropriate for school-age children such as puzzles, dolls, art and craft materials, musical instruments, storybooks, and colored cards. Similarly, Kyle and Carman (2013) stated that school-age children also enjoy solitary activities including board, card, video and computer games, dollhouse, and other small-figure play.

Regarding the level of anxiety among school-age children undergoing abdominal surgeries, the current study results state that more than two-thirds of the children experienced above average anxiety on STAIC before implementation of play activities followed by about one-fifth of them experiencing high anxiety level. This could be interpreted as school-age children were not given any of the play activities for relieving preoperative anxiety and fear, and lack of child’s play before surgery may reveal unvoiced concerns about mutilation, body changes, and loss of self-control.

This result is consistent with Fincher et al. (2012) who reported that it is estimated that around 50–70% of hospitalized children experience severe anxiety and distress before surgery. Children who are highly anxious and distressed preoperatively are likely to be distressed on awakening and have negative postoperative behavior. The same explanation was mentioned by Nisha and Umarani (2013) who emphasized that children are more vulnerable to anxiety owing to their lack of knowledge of procedures, a lack of control, a lack of explanation in child-appropriate terms, and a lack of pain management. Hospitalized children may experience high level of anxiety owing to many different factors both physical and psychological factors.

After implementation of the play activities, it was evident that the total mean score of STAIC among school-age children who participated in the current study was decreased after implementation of the first, second, and third play sessions and at 30 min before surgery (23.6±2.3, 24.4±2.1, 21.2±1.9, and 23.3±4.5, respectively). A highly statistically significant difference between total mean score of STAIC in the pretest and after the first, the second, and the third play sessions, and at 30 min before surgery. These results support the first proposed hypothesis of the current study and indicate the effectiveness of play activities on reduction of preoperative level of anxiety.

In a similar study conducted by Ghabeli et al. (2014) to determine the effect of toys and visit on reducing children’s anxiety before the surgery and their mothers and satisfaction with the treatment process, it was found that the mean anxiety scores of the children and mothers in the experimental group were lower than the control group, and providing toys for children and informing the parents about medical information have a major effect in reducing children’s and other’s anxiety and increasing maternal satisfaction with the treatment process.

Noronha and Shanthi (2015) found that 80% of the children in the experimental group had severe anxiety and 60% of the control group had moderate to severe anxiety in pretest and during post-test. More than half (53.33%) of children in the experimental group had mild to moderate anxiety as compared with the control group. The mean post-test anxiety level (24.8±2.98) was lower than the pretest anxiety level (32.86±3.29). The mean post-test level of anxiety in experimental group (24.8±2.98) was significantly lower than the mean post-test anxiety level of the control group (30.07±2.96). Hence, it is revealed that picture book is found to be effective in reducing preoperative anxiety among children.

In a recent nonequivalent control group pretest–post-test study by Al‐Yateem and Rossiter (2017) in the United Arab Emirates to examine the effects of unstructured play activities on the anxiety levels of 81 hospitalized children, the study results summarized that anxiety scores in both groups were similar at baseline and decreased significantly over the 3 days. Compared with the control group, anxiety scores in the intervention group were significantly lower on day 2 and day 3. They also concluded that low-cost play intervention implemented by nurses resulted in statistically and clinically significant decreases in the anxiety levels of children.

In a previous study by Nisha and Umarani (2013) on 60 preoperative school-age children in the age of 6–12 years to determine the effectiveness of play intervention on reduction of anxiety among preoperative children, the study results concluded that the mean score of experimental group was lower than mean of control group. There is a significant difference in the anxiety score of children between experimental and control group.

Furthermore, in a recent empirical evidence by Saharan et al. (2017) who assessed and compared the level of anxiety before and after the administration of play interventions among hospitalized children in experimental and comparison group and determined the association of anxiety among hospitalized children with selected variables, the findings of this study revealed that in comparison of post-test mean score of anxiety in experimental and comparison group, the obtained t-value and P-value were 12.23 and 0.001, respectively, hence found to be significant level. It was concluded from the study that play interventions are effective in reducing anxiety among hospitalized children.

In an earlier Egyptian study by El-Samman et al. (2009) to examine the effect of play on reducing anxiety of 90 hospitalizations among school-age children from the medicine and surgery wards in CUSPH, the study results indicated that 52.8% of children gained 41–50 scores based on STAIC in the pretest, and the mean scores was 44.57±6.5, which also suggests high anxiety. After play interventions, 34.8% of children in surgery wards had low level of anxiety and the mean score was 36.02±8.86 on STAIC. Moreover, empirical evidence and previously cited research by Aranha et al. (2016) in their study found that the mean fear and anxiety score of school-age children undergoing surgery was less in the experimental group compared with the control group after the intervention. A significant change was observed in the experimental group for the mean fear score.

Concerning the level of fear among school-age children based on GFS, the current study revealed that more than two-thirds of them experienced severe fear in the preoperative period before implementation of play sessions. Fortunately, after the first play session, the highest percentage of children had their fear diminished to moderate level. Furthermore, the majority of children had their fear reduced to low level after the second play session. The majority of them had low level of fear after the third play session. Consequently, most children still had low level of fear in the immediate preoperative period. These results indicate that the play activities were significantly effective in reducing the level of fear among children who participated in the current study. These findings also support the proposed second hypothesis of the current study.

Regarding children’s fear, Förnäs et al. (2009) documented that fear in children is connected with their imagination; when they attain school age, children can think more concrete. Concrete thinking makes children more aware of realistic fears, such as physical danger and fear of pain. Moreover, most disturbing situations for children in surgical units are negative repercussion of surgery, problems or an unsuccessful operation, and pain.

Similarly, an earlier quasi-experimental study by Cavender et al. (2004) on 43 children, aged from 4 to 11 years, concluded that the experimental group showed significantly lower fear compared with the control group. An Egyptian study carried out by Mohamed (2011) to evaluate the effect of selected distractors (paly materials) on the intensity of pain and fear among 50 children undergoing painful procedures in the pediatric surgical ward concluded that 52% of children in the pediatric surgical ward experienced severe fear during painful procedure in the pretest, whereas 66% of them saw venipuncture as just fearful procedure in the post-test, which suggests reduced experienced fear level in the post-test.

The current study proved that no statistically significant correlation was detected between the total mean score of STAIC among children undergoing abdominal surgery and their age, sex, diagnosis, place of residence, and previous hospitalization. This result corresponds with Nisha and Umarani (2013) who found that there was no statistically significant correlation between anxiety level and age, sex, and place of residence in the control group. Nonetheless, in the experimental group, the results regarding the sex of the children contradicted with the current study, which shows significant association.

Besides, Noronha and Shanthi (2015) in their study found that there was no significant association between the post-test preoperative anxiety scores with demographic variables in the experimental group and control group. Recently, Nabavi et al. (2017) carried out a descriptive study to determine the relationship between anxiety in 81 school-age children before surgery and parental state-trait anxiety. It was found that no statistically significant relationship was observed between children’ anxiety and their age.

In relation to correlation between children’ preoperative level of fear and their diagnosis and place of residence, the study demonstrated that children diagnosis and place of residence had statistically positive significant correlations with children’s preoperative level of fear. On the contrary, the child’s preoperative fear level was independent of some personal characteristics of children such as age, sex, and previous hospitalization. These results are supported by Mohamed (2011) who found that there were statistically significant correlations between total score of GFS gained by children in the surgery ward and their age and diagnosis. However, there were no statistically significant correlations between total score gained by children regarding GFS and the other sociodemographic factors such as child’s rank and previous hospital admission.


  Conclusion Top


The results of the current study concluded that children who utilize the selected play activities had lower preoperative scores on STAIC than before and less preoperative fear scores on GFS than before. So, the selected play activities among school-age children undergoing abdominal surgeries are appropriate and effective methods for minimizing preoperative level anxiety and fear, and these results support the proposed current study hypotheses.

Recommendations

Based on the results of the current study, the following recommendations were suggested:
  1. Establishing preoperative play activities for children undergoing abdominal surgeries is essential for preparation of the child for surgery.
  2. Offering a well-designed play activity room in the hospitals for the children with different age groups to relieve their anxiety and fear.
  3. Establishing a comprehensive preoperative preparation program for children and their parents starting from admission, including play activities.
  4. Updating knowledge and practice of nurses through implementation of continuing educational programs about the importance of preoperative play activities.


Recommendations for further researches

  1. It is especially important to focus research studies on hospitalized children to study their coping strategies toward the surgical experience after play interventions.
  2. Replication of this study is warranted, and this would enhance opportunities to generalize the findings to other pediatric-age groups, and other surgical clinical settings.
  3. Studying the effect of play activities on a wide variety of surgical disorders preoperatively with longer duration of play session is mandatory.


Acknowledgements

The authors thank to all pediatric surgeons and nursing staff of the Pediatric Surgery Department in CUSPH who facilitated conduction of this study, and great thanks and gratitude to all children and their mothers who participated actively in this study.[32]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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