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Keywords:

  • anxiety;
  • children;
  • orientation tour;
  • surgery

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

Aim:  The purpose of this study was to investigate the effectiveness of an orientated tour in reduction of children's anxiety before elective surgeries. Anxiety is a common emotional reaction following surgical experience among children that can result in increasing postoperative pain, increasing analgesic use.

Methods:  The study was a blinded clinical trial; 70 children were randomized into two groups (intervention and control). All children received standard preoperative care, while those in the intervention group also received an orientated tour with their mother of the operation room the night before the surgery was carried out. The children's anxiety was assessed by the “Child Drawing: Hospital” instrument and vital signs measured before and after intervention in both groups. Data were analyzed with SPSS ver. 11.5 software.

Results:  Anxiety decreased in the intervention group following implementation of the orientated tour (P = 0.024). Following the orientated tour in the intervention group, respiration rate (P < 0.000) and blood pressure (P < 0.001 systolic and diastolic) were significantly reduced, while heart rate and body temperature were not significantly different to pre-intervention. Comparison changes of vital signs following the orientated tour between the two groups was not significant.

Conclusion:  Implementation of an orientated tour of the preoperative room can decrease anxiety levels in children before elective surgeries, but it has no clinical effect on vital signs.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

Anxiety is the most common psychological reactions during stress and is a common phenomenon that all humans experience (Black, Hawks, & Kneene, 2005; White, 2005). Important changes of life may cause anxiety. One of these effective changes is child hospital admission (Data, 2007). Illness and hospitalization often are the first crisis of children in early life (Hockenberry, Wilson, & Winkelstein, 2005). Surgery can be a devastating and threatening event for children and causes anxiety. Anxiety and fear could be worsened by the child's low ability to analyze the situation and understand the medical procedures (Brennan, 1994; Hockenberry & Wilson, 2007; William, Lopez, & Lee, 2007). The estimated prevalence of preoperative anxiety in children is approximately 60% (Justus et al., 2006). Studies have shown considerable anxiety in children even for minimal surgical procedures. In recent decades, researchers have paid more attention to the psychological preparation of children for surgical procedures. Sedation of children requiring medical or diagnostic interventions is common before surgical procedures, but often has unwanted side-effects including drowsiness and respiratory system suppression. These side-effects could become minimized using non-medical methods (Agarwal et al., 2005; William, 2006). Performing surgical procedures in children requires physical and mental preparation. These preparations are similar to those used for hospitalization of children including the use of videos, training manuals, brochures, tours, and playing (Hockenberry & Wilson, 2007). One of the most effective methods is an orientation tour. Orientation is defined in the pediatric hospitals as designing and planning recognition programs of the environment, staff, medical procedures, and hospital equipment, in consideration of the children's and their parents' psychological aspect (Zand shahri, Alhani, & Ahmadi, 2005).

Researchers have done numerous investigations to determine the effect of these programs on children's anxiety levels. Anxiety has been evaluated in most studies by observation of child behavior or parental reports but few studies have evaluated the anxiety in children through direct perception by themselves (Brewer, Gleditsh, Syblik, Tietiens, & Vacik, 2006; William et al., 2007). Verbal interviewing (e.g. Spillburger anxiety questionnaire) and behavior observation sometimes could not clearly demonstrate the mental condition of children (Brewer et al., 2006). Children often have less ability to express feelings and fears in the hospital and when questioned how they are they will say that they are “good”. Using drawing tools for measuring anxiety has been proven and children can better express their feelings in paints and using colors (Clatworthy, Simon, Tiedeman, 1999a,b).

Anxiety is a common sensation during surgeries in children and drug control of anxiety is the most common treatment. Considering the adverse effects of drugs which have made it non-preferable in many situations and nurses' tendency not to lower preoperative anxiety routinely, this study was designed to investigate the effect of orientation tours of the operating room environment on child anxiety before surgery.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

This was a single-blind clinical trial to determine the effect of an orientation tour on the child anxiety before surgery. The study population included all children aged 5–11 years who underwent surgery between July 2009 and January 2010 in Razi Hospital in Marand city, Iran. Inclusion criteria were: having no mental retardation and physical disability; painting ability (they should be able to paint a picture of a man); being alert; no need for extensive or emergency surgery; no history of hospitalization or surgery within 18 months; and no need for hospital admission of more than 1 night before surgery. Change in physical and mental conditions of children, the use of anti-anxiety drugs before surgery, requirement of emergency surgery or unwillingness to continue participating in the study were exclusion criteria. After a pre-study on 30 patients with the same characteristics of the main study, based on the results and with a confidence level of 95%, a sample size of 70 children was recruited. Patients were recruited consecutively.

The patients were randomly assigned into two groups: 35 in the intervention group and 35 in the control group. After detailed explanation, parents gave informed consent and children gave verbal consent. Random assignment was achieved by offering each child a basket of two balls, with inclusion in the experiment or control group based on their choice. After admission, usual and standard care, and preoperative, intraoperative, and postoperative preparation, a basic orientation tour of the department and nurses was performed for all subjects.

The recorded baseline characteristics included identifying data, parents' educational level and employment, income level and surgical history, and the usefulness of the orientation tour from the point of view of the parents.

Instrument

Children's anxiety was evaluated by the “Child Drawing: Hospital” (CD: H) instrument (Clatworthy et al., 1999a,b). The CD: H was specifically developed as a means of measuring the emotional status of hospitalized school-aged children (5–11 years; Clatworthy et al., 1999b). This instrument was designed to assess children's anxiety in hospital from the child's point of view. Children are asked to draw a picture of a person upon admission and postoperatively in the hospital. The instrument consists of a box with eight crayons (yellow, orange, red, blue, green, purple, black, and brown) and a white, blank, 8.5 × 11 inch sheet of paper. The CD: H Manual and Scoring Guide was used to score each drawing to determine anxiety levels pre- and post-surgery. The drawings were scored based on three sections of the manual. The first section, part A, which consists of 14 items, assesses general anxiety by the number of colors used, length of person, position of person, and facial expression. Each item was given a numerical value ranging 1–10. The second section, part B, measured higher levels of anxiety evident in the drawings and included eight items. Presence of each item in part B was considered pathological and scored 5 or 10. For example, distortion of bodily figures received 10 points and omission of a body part would receive an additional 5 points. The last section, part C, was an overall rating of the picture. The lowest score would indicate lowest anxiety whereas a score such as 9 and 10 indicated the highest levels of anxiety (the manual was rated 1–10). All three sections were summed for the overall anxiety score for the picture and the lowest and highest scores were 15 and 200, respectively. Clatworthy et al. (1999b) determined the reliability and validity of the CD: H instrument. Internal consistency was determined by a coefficient 0.67–0.75. Interrater reliability was demonstrated previously by Pearson's r correlation coefficients ranging from 0.68–0.84 (Clatworthy et al., 1999b). Consistency among the raters was analyzed in a pilot study with a Cronbach's alpha of 0.74. For this sample, no formal psychometrics were calculated on the basis of strength of the analysis was reported by Clatworthy et al. (1999a).

Procedure

Children and parents were taken to a room and each child was given the CD: H instrument. Each subject was asked to draw a picture of a person. Parents were not allowed to comment or help the child. After the drawing was complete, subjects in the control group received routine information preparation (usual care). In the control group, children were not made familiar with the operation room. Both children and family of the intervention group received an additional 20 min orientation tour of the operation room and all the relevant areas of day surgery, as well as the children receiving an appropriate explanation of the surgery process. The nurse explained the purpose of the waiting area and the surgery room. A room equipped with actual medical equipment was then used to prepare each child and his or her family for the surgery process. Children were asked to explore and touch the relevant equipment and supplies such as the anesthesia mask, pulse oximeter, electrocardiogram leads, and i.v. catheter. Questions were answered and misconceptions were alleviated during the intervention. Data on participants from both the first and second protocols were collected and analyzed. The second drawing was completed at the first postoperative day. A psychologist, blind to each participant's intervention status, evaluated the drawings. All procedures were in accordance with the ethical standards for research with human subjects.

The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences (no. 1362/130/D/90).

Statistical analyses

The Statistical Package for Social Sciences ver. 11.5 for Windows (SPSS, Chicago, IL, USA) was used for data analysis. For comparison between control and intervention groups in demographic profile and some preoperative variables, the χ2-test, Fisher's exact test and Mann–Whitney U-test were used. The Wilcoxon rank sum test was performed for comparing mean anxiety before and after intervention in each group. Finally, the Mann–Whitney U-test was performed for comparing mean anxiety between the two groups before and after intervention and also to compare painting scores of parts A, B, and C between control and intervention groups. Significance level was set at P ≤ 0.05. All analyses were performed using SPSS ver. 11.5.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

From the 70 enrolled patients, 35 were assigned to the intervention group and 35 to the control group. All patients received the assigned intervention (Fig. 1). All participants were aged 5–11 years with a mean age 7.23 ± 1.61 years in the intervention and 7.54 ± 2.06 years in the control group (P = 0.756). The subjects were 62.9% male in the intervention group and 65.7% male in the control group (P > 0.05). The baseline characteristics can be seen in Table 1. No significant difference was seen between the baseline characteristics of both groups.

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Figure 1. Enrollment and outcomes.

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Table 1. Demographic, clinical, and baseline characteristics of intervention and control groups
Demographic characteristicsIntervention, N = 35 (%)Control, N = 35 (%) P-value
Sex   P = 0.803
 Female13 (37.1)12 (34.3)
 Male22 (62.9)23 (65.7)
Weight (kg)   P = 0.323
 <2011 (31.5)19 (54/3)
 20–3018 (51.4)9 (25.7)
 30–402 (5.7)6 (17.1)
 >404 (11.4)1 (2.9)
Educational grade   P = 0.186
 Preschool17 (48.6)14 (40)
 16 (17.1)5 (14.3)
 27 (20)4 (11.4)
 32 (5.7)3 (8.6)
 41 (2.9)3 (8.6)
 52 (5.7)6 (17.1)
History of surgery in parents   P = 0.584
 Yes8 (22.9)10 (28.6)
 No27 (77.1)25 (71.4)
History of surgery in siblings   P = 0.239
 Yes6 (17.1)3 (8.6)
 No29 (82.9)32 (91.4)
Type of surgery performed   P = 0.510
 Herniorrhaphy10 (28.6)10 (28.6)
 Eye operation2 (5.7)0 (0)
 Ear–nose–throat operation15 (42.9)19 (54.3)
 Urologhy operation8 (22.9)6 (17.1)
Class of birth   P = 0.889
 118 (51.4)20 (57.1)
 210 (28.6)9 (25.7)
 ≥37 (20)6 (17.1)

The mean anxiety score in children showed decrease in the intervention group after the longer tour from 71.03 ± 15.65 to 59.83 ± 18.22 (P < 0.001), but this score increased after the basic tour in the control group from 69.97 ± 20.72 to 78.14 ± 18.29 (P = 0.001) (Tables 2,3).

Table 2. Comparison of anxiety in children undergoing surgery before and after orientation by group
Level of anxiety (Child Drawing: Hospital score)Before intervention, N (%)After intervention, N (%)Result, Wilcoxon rank sum test
  1. SD, standard deviation.

Very little (<44)2 (5.7)5 (14.3) P < 0.0001
Little (44–83)25 (71.4)26 (74.3)
Moderate (84–129)8 (22.9)4 (11.4)
Mean of anxiety score (Mean ± SD)71.03 ± 15.6559.83 ± 18.22 P < 0.0001
Mean of anxiety score part A (mean ± SD)56.82 ± 12.9847.88 ± 14.88 P < 0.0001
Mean of anxiety score part B (mean ± SD)9.14 ± 6.807.10 ± 6.09 P < 0.05
Mean of anxiety score part C (mean ± SD)5.07 ± 1.514.80 ± 1.49 P < 0.3336
Table 3. Comparison of anxiety in children undergoing surgery before and after orientation in control group
Level of anxiety (Child Drawing: Hospital score)Before intervention N = 35 (n, %)After intervention N = 3 (n, %)Result (Wilcoxon rank sum test)
Very little (<44)2 (5.7)1 (2.9) P = 0.0001
Little (44–83)26 (74.3)24 (68.6)
Moderate 84–1296 (17.1)10 (28.5)
High (130–167)1 (2.9)0 (0)
Mean of anxiety score69.97 ± 20.7278.14 ± 18.29 P = 0.001
Mean of anxiety score part A54.11 ± 11.8060.82 ± 16.73 P = 0.007
Mean of anxiety score part B9.14 ± 7.6211.71 ± 7.27 P = 0.006
Mean of anxiety score part C4.91 ± 1.505.60 ± 1.41 P = 0.017

There was no significant difference in anxiety, and parts A, B, and C of the CD: H, of either group before the orientation tour, but the anxiety score of the intervention group was significantly lower than control group after their respective tours (59.83 ± 18.22 vs 78.14 ± 18.29, P < 0.001) (Table 4).

Table 4. Comparison of anxiety in children undergoing surgery after orientation in intervention and control group
Level of anxiety (Child Drawing: Hospital score)Intervention N = 35 (n, %)Control N = 35 (n, %)Result (Wilcoxon rank sum test)
Very little (<44)5 (14.3)1 (2.9) P < 0.0001
Little (44–83)26 (74.3)24 (68.6)
Moderate (84–129)4 (11.4)10 (28.5)
Mean of anxiety score59.83 ± 18.2278.14 ± 18.29 P < 0.0001
Mean of anxiety score part A47.88 ± 14.8860.82 ± 16.73 P < 0.001
Mean of anxiety score part B7.10 ± 6.0911.71 ± 7.27 P < 0.006
Mean of anxiety score part C4.80 ± 1.495.60 ± 1.41 P = 0.038

DISCUSSION AND CONCLUSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

According to the study, the intervention group showed reduced anxiety after intervention. Brewer et al. (2006) reported that intervention at the day of surgery could significantly prevent anxiety. William et al. (2007) also showed no increase in anxiety after the play therapy during the pre-surgical day in children. Clatworthy et al. (1999a) found decreased anxiety measured by CD: H after play therapy . This reduction has been reported by other studies using different interventions including orientation tours, videos, books, and plays (Cook, Chaboyer, Schluter, & Hiratos, 2005; Puig et al., 2003). In contrast to our findings, anxiety was shown to be increased in children receiving intervention and decreased in their parents in another study by Ellerton and Merriam (1994) in which the patients were not brought into the operation room. Therefore, this unknown environment remained a source of increased anxiety. As shown in the results, the anxiety of the control group increased after surgery which was in line with findings of other studies. It could be due to lack of insight of these patients into the operation room and some unknown fear of the children (Brewer et al., 2006; William et al., 2007). The control group showed elevated anxiety after intervention by Ellerton and Merriam (1994) but this elevation was lower than intervention group . An increase was seen in the drawing anxiety after the intervention in controls, but not in the state anxiety (Mami yanloo, Alhani, & GHofrani, 2000). Increased anxiety before surgery in the control group in the present study could be related to the unfamiliar environment. This could be dealt with in the preoperative preparation (Taylor, Lillis, Lemon, & Lynn, 2008).

Based on the results of the present study, preoperative anxiety in child candidates for elective surgery was significantly lower in the intervention group than the control group after the intervention (additional orientation tour). This finding was in line with other investigations which reported lower anxiety after intervention and surgery in the intervention group (Brewer et al., 2006, p. 5) and in contrast to the findings of Ellerton and Merriam (1994). These differences could be caused by different intervention programs. Also, different family culture and clinical environment between countries should not be ignored. Culturally, orientation tours for surgical and medical procedures are not common in Iran. In some cases, parents and hospital staff often do not believe the child's expression of anxiety and hide the truth from them and the children are neglected. In addition, the child may be given wrong information and brought into the operation room unexpectedly and into an unfamiliar environment. This could lower the self-confidence of children and become the main source of their fear and anxiety. Therefore, an orientation tour, paying attention to the child, and believing in their expressions of anxiety could lead to reduction of their anxiety and elevated self-confidence. Making children familiar with the operating room environment could reduce preoperative anxiety in children and be useful in the modulation of anxiety in children or at least prevent anxiety elevation after surgery. Referring to these results, lack of familiarity with medical environments can be one of the main sources of stress and fear in children and therefore sufficient orientation could reduce anxiety and fear. The results showed the requirement of employing non-pharmacological interventions to reduce preoperative anxiety in children and preoperative preparation programs such as an orientation tour.

Preoperative anxiety reduction is an aspect of pre-surgical care. Regarding long-term contact with children, nurses have a prominent role in anxiety control. An orientation tour of the operating room environment for children and parents could be a simple and easy method for nurses to implement. Performing orientation tours could minimize drug consumption. Also, children will feel better because – in addition to anxiety reduction – they will have a mentally and physically comfortable experience, and relaxed and happy memories of their stay in hospital. The results of this investigation can provide principles of child nursery including care without causing damage and minimal pain and anxiety.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

This research was supported by a research grant from the Vice-Chancellor of Tehran University of Medical Sciences in 2009. We thank the staff nurses of the pediatric ward and operation room in Razi Hospital and the children's hospital who participated in our research. The authors also would like to thank Farzan Institute for Research and Technology for technical assistance.

CONFLICTS OF INTEREST

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES

No conflict of interest has been declared by the authors.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION AND CONCLUSION
  7. ACKNOWLEDGMENTS
  8. CONFLICTS OF INTEREST
  9. REFERENCES
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