Effectiveness of Video Assisted pre-Operative preparation Programme on Anxiety of The mothers of Children Undergoing Surgery -Randomized Control Trial

Ms. Ria L¹, Mrs.Sumitra LA²

¹Lecturer, K.L.E. University’s Institute of Nursing Sciences, Belagavi, Karnataka.

²Professor. K.L.E. University’s Institute of Nursing Sciences, Belagavi, Karnataka.

Corresponding Author’s Email: ria190144@gmail.com

ABSTRACT:

Surgery either planned or unplanned is a potentially stressful experience for children. They may fail to understand the reason for surgical intervention and consider it an unjustifiable attack on their bodies. Children need their parents when they are facing the unknown. They need their parents’ strength to help them cope up with potentially threatening situations.Fear and anxiety in a child undergoing surgery are correlated positively with parent’s level of anxiety. Psychological problems can continue into the postoperative period with increased anxiety, disturbances in eating and sleeping, as well as increased pain and analgesic use. The parent’s anxiety is then critical to the anxiety the child experiences when entering the operating room. So, interventions to decrease the parent’s anxiety are appropriate.

A randomized control trial study was conducted in Dr. Prabhakar Kore Hospital and MRC, Belagavi among 30 mothers of children undergoing surgery to evaluate the effectiveness of video assisted pre-operative preparation programme on anxiety of mothers in experimental group as compared to control group and to find out the association between pre interventional anxiety scores with selected demographic variables.

The subjects were assigned to experimental and control groups by using random sampling with an evaluative approach. In experimental group, video assisted pre-operative preparation programme was administered for 20 mins while the control group was subjected to routine hospital care. Using Zung’s anxiety scale, the anxiety level of the mothers were measured before and next day of intervention prior to surgery.Data obtained were tabulated and analyzed in terms of objectives of the study using descriptive and inferential statistics. Mean anxiety level in the experimental group after video assisted pre-operative preparation programme was 42.5 while the correspondent in the control group was 58.6. An independent sample t-test showed significantly lower anxiety scores in the experimental group after video assisted pre-operative preparation programme as compared with the control group (t= 6.4, p<0.00001) but there was no association found between the pre interventional anxiety scores with selected demographic variables.

Key words: Video assisted pre-operative preparation programme, Anxiety, Mothers, Zung’s anxiety scale.

INTRODUCTION:

“Stress is inner biofeedback, signaling you that frequencies are fighting within your system. The purpose of stress isn't to hurt you, but to let you know it's time to go back to the heart and start loving”.

– Sara Paddison

Pre operational anxiety is defined as an unpleasant state of tension or uneasiness that results from a patient's doubts or fears (from a vast array) before an operation. The research carried out by several individuals concluded that there are many different fears that can cause preoperational anxiety. These fears include---fear for unknown; surgical failure;anesthesia;loss of personal identity; recuperation around strangers; pain; loss of control; death; unsuccessful recovery ;strange environment.² There are many different factors that play into the level of anxiety a patient might experience like previous hospital experiences ; age; marital status and education; ^.psychological characteristics such as coping strategies and perceived social support;gender i.e. females tend to have higher levels of preoperational anxiety than males.³

Each year, more than 2 million children undergo surgical procedures. The surgical procedures can be stressful for children, their parents. Parents may also experience anxiety and concern about the competency of staff, possible complications, and how to support their child. Unfamiliarity of surroundings and role expectations add to parental stress, and this anxiety can transmit to their children. Parental anxiety during a child’s illness not only interferes with the parent’s ability to provide support but may also be transmitted like an infection to the child. Majority of the parents want the understanding and sympathetic support.⁴

Pre-operative preparation encompasses cognitive, psychological, and physical preparation of the child for surgery. Preparation for the child and the family must focus on their unique needs and must include a holistic approach to the physical and psychological preparation of the child. Parental presence facilitates a more positive coping response from the child, and parents must be included in the child’s surgical experience.⁵

NEED FOR THE STUDY:

“It makes no sense to worry about things you have no control over because there's nothing you can do about them, and why worry about things you do control? The activity of worrying keeps you immobilized”.

– Wayne Dye

Fear and anxiety in a child undergoing surgery are correlated positively with parent’s level of anxiety. Psychological problems can continue into the postoperative period with increased anxiety, disturbances in eating and sleeping, as well as increased pain and analgesic use. The parent’s anxiety is then critical to the anxiety the child experiences when entering the operating room. So, interventions to decrease the parent’s anxiety are appropriate.⁶

Research has shown that children whose parents are of less anxious have lower cortisol levels during surgeries than those children whose parents are more anxious in general.⁷

Anxiety can result in physiological responses such as tachycardia, hypertension, elevated temperature, sweating, nausea and a heightened sense of touch, smell or hearing, peripheral vasoconstriction; behavioral and cognitive changes which can result in increased tension, apprehension, nervousness and aggression, nervous and apprehensive that they cannot understand or follow simple instructions.⁸

Pre-operative preparation processes have been affected by changes in healthcare delivery systems and economic constraints. Preoperative hospital visits are now often replaced with information shared via telephone or Web sites. Parents are becoming increasingly responsible for preparing their child for surgery. Therefore, parents should be partners in the preparation process, receiving not only information about the procedure and sequence of events, but also the guidance and tools to provide support and prepare the child for the experience⁹.

Many hospitals are implementing programme that include parental presence during the induction and recovery phases of their children’s surgery. A parent’s presence during the induction of anesthesia results in significant decrease in the upset or agitation of the children.¹⁰

When the nurse has assessed the level of knowledge and anxiety of the child and parents and their coping resources, pre-operative teaching can be tailored to their general and specific needs. Teaching then becomes more meaningful and the results more productive. Successful preoperative teaching generally reduces anxiety, resulting in a decrease in the need for pain medication, the occurrence of vomiting, the number of psychological problems and complications, and the length of hospital stay.¹

The investigator in her clinical setting found that most of the parents especially the mothers were anxious and nervous when they heard the news about their children’s operations and they were inadequately prepared for the operation which in turns increased the anxiousness of the older children who can understand the parent’s reaction.So,the investigator feels that the anxiety of the mothers can be minimized if they are adequately prepared for it and that video assisted pre-operative preparation programme is the best way for preparing the mothers for operation of their children thereby reducing their anxiety.

STATEMENT OF THE PROBLEM:

“A study to evaluate the effectiveness of video assisted pre-operative preparationprogramme on anxiety of the mothers of children undergoing surgery in selected hospital,Belagavi-A Randomized Control Trial..”

OBJECTIVES OF THE STUDY:

1. To evaluate the effectiveness of video assisted pre-operative preparation programme on anxiety of mothers in experimental group as compared to control group.

2. To find out the association between pre interventional anxiety scores with selected demographic variables.

OPERATIONAL DEFINITIONS:

1. Evaluate: It refers to the statistical analysis of anxiety level perceived by mothers of children undergoing surgery.

2. Effectiveness: It refers to the extent or level of anxiety perceived by mothers of children undergoing surgery, as evidenced by difference in pre test and post test scores on Zung’s anxiety scale.

3. Video assisted pre-operative preparation Programme: It refers to the use of video on pre-operation preparation to induce a desired change in the anxiety level of the mothers of children undergoing operation.

4. Anxiety: It refers to the unpleasant state of tension or uneasiness feeling of the mothers of children undergoing surgeries that result from doubts or fears (from a vast array) before an operation.

5. Mother: It refers to the woman between the age grouped of 20-50 years whose children were planned for surgeries.

6. Children: Children between 1 month to 18 years who are planned for surgeries (abdominal, cardio thoracic and gastrointestinal surgeries)

7. Surgery: It refers to any of the surgeries like abdominal, cardio-thoracic and gastrointestinal surgeries.

HYPOTHESES:

H₁.The mean post-interventional anxiety scores will be lesser than the mean pre-interventional anxiety scores in experimental group as compared to the control group at 0.05 level of significance.

H₂.There will be statistically significant association between pre interventional anxiety scores with selected socio demographic variables.

ASSUMPTIONS

1. Mothers of the children undergoing surgery may have anxiety.

2. Video assisted pre-operative preparation programme will have effect on anxiety of the mothers.

DELIMITATION

This study was delimited to the mothers of the children undergoing surgery and admitted in the Pediatric surgical ward of KLE’s Dr. Prabhakar Kore Hospital and MRC, Belagavi, Karnataka.

CONCEPTUAL FRAMEWORK

Imogene M. King’s theory of Goal Attainment is used as a conceptual framework for this study, identifies factors of perception, judgment, action, reaction, interaction and transaction between the research investigator and the mothers of children undergoing surgeries regarding the effectiveness of video assisted pre-operative preparation programmed in reducing their anxiety.

RESEARCH METHODOLOGY:

Research Approach: An evaluative research approach was adopted in this study.

RESEARCH METHODOLOGY

Research approach:An evaluative research approach was adopted in this study.

Research Design: The research design adopted in this study was randomized control trial.

Research Setting: Pediatric surgical ward of KLE Dr. Prabhakar Kore Hospital and MRC, Belagavi, Karnataka.

Variables under study:The independent variable in the present study was video assisted pre-operative preparation programme.

The dependent variable in the present study was anxiety of mothers.

The extraneous variables in the present study were support from family members, previous experience of surgeries.

Population: In the present study, the population comprised of the mothers of children undergoing operation in KLE Dr. Prabhakar Kore Hospital and MRC, Belagavi, Karnataka.

Sample and Sample Size: The sample for the present study consisted of 30 mothers of children undergoing operation in the pediatric surgical ward of KLE Dr. Prabhakar Kore hospital andMRC, Belagavi.

Sampling Technique: The sampling technique used for the study was random samplingtechnique.

Description of Tool:

The instruments used for collecting data in the present study were:

a. 8questions seeking socio -demographic Proforma.

b. Zung’s anxiety scale

Standardized Zung’s self-rating anxiety scale is used to assess the anxiety level. Maximum anxiety index score was ‘100’. A score of ‘1’ was given to little or none of the time answer, score ‘2’ was given to some of the time answer, score ‘3’ was given to a large part of the time and score ‘4’ was given to the most or all of the time. There are 20 anxiety questions in the Zung’s self-rating standardized scale.

Some questions asks the information positively and others negatively. But in all cases the symptoms severity is scored from 1 to 4.

Total number of positive statements = 15

Total number of negative statements= 5

The total raw score is usually converted to a 100 point scale (anxiety index) that is

Anxiety Index = (score/80 total points) X 100 OR

Anxiety index raw = raw score X 1.25

Anxiety index:

< 45: Normal

45-59: Minimal to moderate

60-74: Marked to severe anxiety

>74: Extreme anxiety

{Note: reverse scoring will be done for negative statement}

The final tool consists of 3 sections:

RESULTS:

The data obtained was analyzed in terms of the objectives of the study using descriptive and inferential statistics. Experts in the field of nursing and statistics directed the development of data analysis plan which was as follows:

1. Organizing data on a master sheet.

2. Tabulation of the data in terms of frequencies, percentage to describe the data.

3. Inferential statistics used were paired t- test, unpaired t - test andchi square.

MAJOR FINDINGS OF THE STUDY WERE:

1. Findings related to socio-demographic variables of subjects in experimental and control group.

In the experimental group, majority of the mothers,7(46.7%) belonged to the age group 20-30years;5(33.3%)belonged to 41-50 years;3(20%) belonged to 31-40 years while in the control group, majority of the mothers 8(53.3%) belonged to 20-30 years;5(33.3%) in the age group of 31-40 years and 2 (13.3%) belonged to 41-50 years.

In relation to the educational status,8(55.3%) of mothers had secondary education;3(20%) had primary education and 2(13.3%) had graduate and non-formal education while in the control group, majority of mothers,5(33.3%) had primary education;4(26.7%) had secondary and graduate education;2(13.3%) had post graduate education.

With regard to religion, 9(60%) of mothers werehindu; 3(20%) were Christian and Muslims in the experimental group while in the control group, 10(66.75) of mothers were hindu; 3(20%) were Muslim and 2(13.3%) were Christian.

Majority of mothers, 14(93.3%) had no previous experience of hospitalization; 1(6.7%) had previous experience of hospitalization in the experimental group while in the control group, 8(53.3%) had no previous experience of hospitalization; 7(46.7%0 had previous experience of hospitalization.

Majority of mothers, 14(93.3%) had no previous experience of surgery; 1(6.7%) had previous experience of surgery in the experimental group while in the control group, 9(60%) had no previous experience of surgery;7(46.7%0 had previous experience of surgery.

In relation to the type of family, 12(80%) of mothers belonged to joint family; 3(20%) belonged to nuclear family in the experimental group while in the control group, 8(53.3%) of mothers belonged to joint family; 7(46.7%) belonged to nuclear family.

With regard to parity of mothers, 12(80%) of mothers were multipara; 3(20%) were primipara in the experimental group while 10(66.7%) were multipara and 5(33.3%) were primipara in the control group.

About 9 (60%) of mothers obtained the information regarding operation from health professional; 3(20%0 from family;2(13.3%) from mass media and 1(6.7%) from relatives in the control group while 12(80%0 obtained the information from health professional; 2(13.3%) from family and mass media and 1(6.7%) from relatives.

Graph 1.Cylindrical graph showing percentage distribution of age of mothers.

Graph 2.Conical graph showing percentage distribution of educational status of mothers.

Graph 3.Column graph showing percentage distribution of religion of mothers.

Graph 4.Cylindrical graph showing percentage distribution of previous history of hospitalization of mothers.

Graph 5.Cylindrical graph showing percentage distribution of previous history of surgery of mothers.

Graph 6.Column graph showing percentage distribution of type of family of mothers.

Graph 7.Conical graph showing percentage distribution of parity of mothers

Graph 8.Column graph showing percentage distribution of source of information of mothers.

II. Findings on distribution of anxiety scores based on Zung’s anxiety scale in experimental and control group.

Table 1: Mean pretreatment score, Mean post treatment score, Mean difference and standard deviation for the anxiety assessment of mothers in experimental group. n=15+15=30

Experimental Group Control Group

Mean anxiety scores SD Mean anxiety scores SD

Pretest 53.7 7.4 58.6 7.1

Post test 42.5 6.7 58.6 7

Difference 11.2 0.7 0 0.1

Table 1 revealed that the anxiety experienced by mothers in the experimental group before video assisted preoperative preparation programme was 53.7 and after video assisted preoperative preparation programme was 42.5.

While the anxiety experienced by mothers in the control group without video assisted preoperative preparation programme was 58.6

Section III: Findings related to comparison of anxiety scores based on observation within the groups.

Table 2 Mean difference, standard error and paired t-test values of anxiety scores of mothers in experimental group and control group. n=15 +15=30

Mean difference SD Paired t-test

Cal Tab

Experimental group 11.2 7.6 5.708* 2.145

Control Group 0 2.6 0 2.145

*P<0.05

Table -2 revealed that in the experimental group, the calculated ‘t’ value (t= 5.780) was greater than the tabulated ‘t’ value (t= 2.145).This revealed that video assisted pre-operative preparation programme was effective in reducing anxiety.

While in the control group, the calculated ‘t’ value (t= 0) was lesser than the tabulated ‘t’ value (t= 2.145).This revealed that there was no effect on the anxiety level.

Section IV. Findings on comparison of anxiety scores between both groups

Table 3: Mean difference of pre-test scores and post test scores, Standard error difference of experimental and control groups and testing of significance by using unpaired t-test. n =30

Mean difference SED Unpaired t-test P

Cal Tab Value

Pre test 4.9 2.3 1.8 2.145 0.076

Post test 16.1 2.5 6.4 2.145 <0.0001*

*p<0.05

Comparison of the mean pretest scores between the experimental and control groups by unpaired t test yielded p value>0.05 which suggested no significance difference. While the p value obtained by comparing the post test scores was p<0.05 which implied that there was a highly significant difference observed. Hence, H₁ can be accepted i.e. the mean post-interventional anxiety scores will be lesser than the mean pre-interventional anxiety scores in experimental group as compared to the control group at 0.05 level of significance.

V. Association between the pre-interventional pain scores with selected socio-demographic variables

The chi square test result showed that there was no significant association between the pre interventional anxiety scores with selected socio- demographic variables of the study subjects.

CONCLUSION:

The result of the study showed that there was a statistically significant difference in the post interventional anxiety scores between experimental and control group at 0.05 level of significance. i.e. there was significant reduction in the anxiety of the mothers in the experimental group. So, video assisted preoperative preparation programme was proved to be effective in reducing anxiety..

NURSING IMPLICATIONS:

The findings of this study have implication for nursing services, nursing education, nursing administration and nursing research.

1. Nursing services:

This study highlights the nurses about the importance of the preoperative preparation of the mothers of children undergoing surgery. Based on the findings of the study results, videos on preoperative preparation can be used by the nurses to prepare the mothers which in turn lead to preparation of their children for surgery.

2. Nursing education:

Anxiety is a common phenomenon for the mothers whose children were planned for surgeries. The study findings will help the nurse educator to know about the anxiety of mothers of children undergoing surgeries and thus guide her in imparting knowledge regarding assessment as well as treatment of anxiety. This study will also help the nurse educator to motivate the student nurses to prepare the mothers for the surgeries of their children.

3. Nursing Administration:

The findings of the study can be utilized for the development of evidenced based protocols and policies regarding assessment of anxiety of mothers and its care. Also, the nurse administrator can encourage the utilization of the study findings in daily clinical nursing practices and plan for in –service and continuing education.

4. Nursing research:

The findings of the study contribute to the body of knowledge of nursing research. It provides guidelines for the researcher to carry out other similar studies in different settings and on a different population on a large scale for greater generalization of the results. The evidenced based nursing will gain higher scope in nursing setting.

LIMITATIONS:

1. The study was delimited to pediatric surgical ward of KLE Dr. Prabhakar Kore Hospital, Belagavi, Karnataka.

2. The study included only 30 mothers between 20-50 years.

RECOMMENDATIONS:

1. A similar study can be carried out on larger sample for a longer period of time for broader generalization of the result.

2. A similar study can be conducted in different setting.

3. A similar study can be done on children undergoing surgeries.

4. A study can be undertaken using other modalities like STP to evaluate the effect on knowledge regarding pre-operative preparation of parents or children.

REFERENCES:

1. Marlow DR, Redding BA. Textbook of Pediatric nursing.7th edt. Pennsylvania: Saunder publication.301-32.

2. Pre operational anxiety, Wikipedia.

3 Dirik, G., A.N. Karanci “Predictors of Pre- and Post-operational Anxiety in Emergency Surgery Patients” Journal of psychosomatic Research 55.4 (2003): 363-369. Science Direct. Web. 29 September 2009.

4 P. J. Shirley, N. Thompson, M. Kenward, G. Johnston. Parental anxiety before elective surgery in children A British perspective.

5 Hockenberry MJ. Wong’s Essentials of Pediatric Nursing.7th edt. Elsevier publication. New Delhi: 2005.712-17

6 Zuwala R, Barber KR. Reducing anxiety in parents before and during pediatric anesthesia induction. AANA J. 2001 Feb; 69(1):21-5.

7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/11759134)

8. Kain ZN, Mayes LC, Caramico LA, et al. Parental presence during induction of anaesthesia: a randomized control trial.Anaesthesiology.1996;8:1060-67

9. Pritchard, Michael John "Identifying and assessing anxiety in pre-operative patients." Nursing Standard 23.51 (2009): 35-40. Academic Search Premier. EBSCO. Web. 29 September 2009.

10. Bayne A, Kirkland P. Prepare children for surgery one stage at atime. OR Nurse 2014; 2(8).p36-9.

11. McGraw T. Preparing children for the operating room; psychological issue. Can J Anaesth.1994; 41:1094-1103