Effectiveness of Multimodal Preoperative Preparation Program on Children Undergoing Surgery

 

Priya Reshma Aranha¹*, Dr. Larissa Martha Sams², Dr. Prakash Saldanha³

¹Department of Child Health Nursing, Yenepoya Nursing College, Yenepoya University

²Department of Medical Surgical Nursing, Laxmi Memorial College of Nursing

³Department of Paediatrics, Yenepoya Medical College Hospital

 

ABSTRACT:

Background:

The advanced era of technological development in child healthcare has resulted in more paediatric procedures being performed in various settings. Millions of children undergo surgery every year which is a stressful event. Many non pharmacological strategies are being used to manage the preoperative fear and anxiety in children. The current study aims to assess the effectiveness of multimodal preoperative preparation program (MPPP) on children undergoing surgery in terms of its effect on the psycho physiological parameters. Methods: A quasi experimental study was conducted in a selected multi speciality hospital. Using the purposive sampling technique, a total of 110 children aged 8-12 years were assigned to non intervention (n = 55) and intervention (n = 55) groups respectively. The MPPP was administered to intervention group. The children in the non intervention group received the routine preoperative care. Child’s fear and anxiety was assessed on admission, prior to shifting the child to OT, 24 hours and 48 hours after surgery where as child’s pulse, respiration, blood pressure, oxygen saturation was assessed on admission, prior to shifting the child to OT, 6 hours, 12 hours, 24 hours and 48 hours after surgery and pain was assessed at 24 and 48 hours after surgery. Significant Findings of the Study: Mean fear and anxiety scores of children were significantly lower in intervention group than that of non intervention group (p<0.05). Among the physiological parameters, only pulse, respiration and blood pressure showed significant difference (p<0.05) between the groups, whereas oxygen saturation and pain scores did not differ significantly (p>0.05). The study also found that there is a significant association between the psycho physiological parameters of children with the selected demographic variables (p<0.05). A positive correlation was found between the psychological and physiological parameters of children undergoing surgery.  Conclusion: The MPPP is effective on psycho physiological parameters of children undergoing surgery in terms of decreasing the fear and anxiety, stabilizing the physiological parameters of children and can be used in preparing school aged children for surgery and can be practised in the clinical setup.

 

 

 

INTRODUCTION:

Technological advancement and changes in healthcare in the modern era have increased the number of pediatric procedures being performed in variety of settings¹. One of these procedures is surgery, which becomes a stressful event in the life of a child. When a child undergoes a surgery, it often becomes a very significant and memorable event in the life of the entire family. Unlike other significant events in the child’s life, it has an element of threat and fear of the unknown can be overwhelming².

 

The child may experience tension, apprehension, nervousness, and worry towards the upcoming surgery along with fear of separation from parents and home environment, loss of control, unfamiliar routines, surgical instruments, and hospital procedures³. Preoperative anxiety is a distressing feeling that results in adverse physiological and psychological reaction in children. With high level of anxiety, they may exhibit signs of delirium and post-procedure maladaptive behavior. They may have more post procedural pain and require additional pain control medications⁴.

 

It has been seen that 75% of children undergoing surgery experience anxiety⁵. Physiological changes like elevated pulse rate and blood pressure are also anticipated when there is high level of preoperative anxiety^6,7.

 

Many strategies have been tried to help children cope with the upcoming surgery and despite of these strategies, some children still become distressed during the procedure. Hence it is important to identify factors that may influence children’s responses to painful medical procedures⁸. Preparing children for surgery should be based on their age and developmental status. Therefore, it is essential to plan an individualized preoperative preparation program for children.

 

It is estimated that approximately 50 – 70% of children undergoing surgery experience severe anxiety and distress prior to surgery⁹. A study identified five dimensions of the surgical experience that can evoke anxiety in children - physical harm or bodily injury in the form of pain, mutilation or even death, separation from parents and absence of trusted adults, fear of the unknown and unfamiliar, uncertainty about "acceptable" and normative behavior in a hospital setting and loss of control, autonomy, and competence¹⁰.

 

According to different research studies, severe preoperative fear affects 40-60% of young children¹¹. Around 40 - 60% of pediatric patients experience preoperative anxiety which is associated with maladaptive behavior lasting for many weeks after surgery¹².

 

It has been seen that developmentally appropriate pre surgical educational programs, preoperative visits¹³, humour and distraction¹⁴ are effective in relieving preoperative anxiety in children and their parents. Studies have also shown that adequate parental preparation alone may minimize the anxiety in children¹⁵

Preoperative preparation of children should be based on their age and developmental stages¹⁶ and performing surgical procedures in children requires both physical and mental preparation which should include the use of videos, training manuals, brochures, tours, and playing¹⁷.

 

Studies have also showed that providing children with information about the hospital stay by using films¹⁸, computer presentations and animations¹⁹, role-playing with the clown physician³ and special books²⁰ telling stories or reading books by nurses²¹ may help children in dealing with anxiety. Literature reveals various preoperative preparations for children, which includes role rehearsals with dolls^22,23,24,25, puppet shows^26,27, the teaching of coping and relaxation skills²⁸, orientation tours of the operating room^23,24, as well as educational videos²⁹ and books^30,31 are effective in preparing children for surgery.

 

The researcher in her day-to-day practice has seen that despite routine preoperative preparation, nothing much is done to alleviate children’s fears and anxiety. The routine preoperative preparation of children includes only verbal instructions given by doctors and nurses. There is a need for developing a preoperative preparation program customized to the needs of children Therefore, to prepare the school age children for surgery, the researcher has developed a multimodal preoperative preparation programme (MPPP) based on the needs of school age children. It is an individualized preoperative preparation program for a child undergoing surgery and the accompanying parent. It includes a combination of audio-visual aids and real life experience. It was prepared based on the needs and developmental concerns. The program is both for the child and parent and it aims to increase their confidence and bonding.

 

The study aims to assess the effectiveness of multimodal preoperative preparation program on children undergoing surgery, in terms of its effect on the psycho physiological parameters, i.e., to reduce the fear and anxiety, stabilize physiological parameters, decrease post operative pain.

 

MATERIALS AND METHODS:

A quasi experimental study with non equivalent control group design was conducted in a selected multi speciality hospital with an exclusive paediatric surgical unit at Mangaluru, India. Ethical approval was obtained from the institutional ethics committee. The study population comprised children aged 8 to 12 years undergoing elective surgery. Following the informed consent process, purposive sampling technique was used to select 110 children and were assigned to non intervention (n=55) and intervention (n=55) groups respectively.

The intervention in the study was the MPPP, was administered by the researcher to the children in the intervention group. It included audio-visual instructions along with the real life situations provided to the child and parent, i.e., an information video, pamphlet and interactive sessions for children and their parents, medical play and theatre tour for children. It includes audiovisual material that may help the child and parent get information they needed in a more realistic manner. Along with the audio-visual material, the interactive sessions will be more useful as the parent and the child can interact with the researcher and clear their doubts. Children were oriented to the theatre and provided with medical play which is a real life experience for them and will be helpful to reduce the preoperative fear and anxiety. The children in the non intervention group received the routine preoperative preparation provided by the hospital staff after admission to the hospital.

 

Researcher collected data using the reliable tools. The demographic proforma was used to collect the socio demographic data of children. Child’s fear (measured using children's fear scale) and anxiety (measured using Numerical 0-10 state anxiety scale) were assessed on admission, prior to shifting the child to OT, 24 hours and 48 hours after surgery where as child’s pulse and blood pressure (measured using Omaron digital blood pressure monitor), respiration and oxygen saturation (measured using Nidex fingertip pulse oxymeter) were assessed on admission, prior to shifting the child to OT, 6 hours, 12 hours, 24 hours and 48 hours after surgery and pain (measured using Faces Pain Scale –Revised (FPS-R)) was assessed at 24 and 48 hours after surgery.

 

FINDINGS OF THE STUDY:

The majority (67.3%) of children in the intervention group were in the age group 10-12 years and majority (63.6%) in the non-intervention group were in the age group of 8-10 years. Majority (59%) of the study sample were males. Majority (65.5% in non intervention and 76.4% of intervention group) of children underwent general surgery. Majority (52.7% in non intervention group and 69.1% in intervention group) of children were admitted only one day prior to surgery and majority (87.3%) had not been hospitalized earlier.

 

Table 1 :Comparison of fear scores of children within intervention and non intervention groups at different time intervals   n= 55+55

***Very highly significant (p<0.001), Study groups : I=Intervention ; NI=Non intervention

 

Table 2 : Comparison of anxiety scores of children within intervention and non intervention groups at different time intervals   n=55+55

*** Very highly significant p<0.001 , **Highly significant p<0.01 ; Study groups : I=Intervention ; NI=Non intervention

 

Table 3 : Pair wise comparison of pain scores at different time points within the groups                                           n=55+55

***Very highly significant p<0.001; Study groups : I=Intervention ; NI=Non intervention

 

 

Table 4: Comparison of pain scores of children at different time points between the groups                               n=55+55

Study groups : I=Intervention ; NI=Non intervention

 

 

Fig 1 : Comparison of pulse scores of children between the groups at different time points

 

Fig 2 : Comparison of respiration scores of children between the groups at different time points

 

 

Fig 3 : Comparison of systolic scores of children between the groups at different time points

 

Fig 4 : Comparison of diastolic scores of children between the groups at different time points

 

Fig 5 : Comparison of oxygen saturation scores of children between the groups at different time points

 

 

 

The comparison of fear (table 1) and anxiety (table 2) scores of children within the groups is done by Friedman test which showed the difference in the scores is statistically significant (p<0.001). Further pair wise comparison by Wilcoxon signed rank test showed that in both the groups, reduction of fear as well as anxiety scores were significant prior to shifting to OT and subsequently it showed the significant reduction at 24 hours after surgery and 48 hours after surgery (p<0.001). To find the difference in the fear and anxiety scores between the intervention and non intervention groups, MannWhitney’s test was computed. It showed that there is a significant difference in the mean scores of both fear and anxiety between intervention and non intervention groups at prior to shifting (p<0.001), at 24 hours after surgery (p<0.001) and also at 48 hours after surgery (p<0.001). The change was significantly higher in intervention group compared to non intervention groups at all the time points.

 

Fig 1-5 depict the comparison of physiological parameters of children between the groups. It was observed that, at every time point reduction in the mean pulse, respiration, blood pressure and oxygen saturation scores in both intervention and non intervention groups is minimal. But the computed ANOVA test showed that reduction was statistically significant within the intervention (Pulse : F_(5,270) =23.18, p<0.001; Respiration: F_(5,270) =11.44, p<0.001; Systolic BP: F_(5,270) =25.04, p<0.001; Diastolic BP: F_(5,270) =17.48, p<0.001; Oxygen saturation: F_(5,270) =17.60, p<0.001) and non intervention (Pulse : F_(5,270) =24.84, p<0.001; Respiration : F_(5,270) =28.93, p<0.001; Systolic BP: F_(5,270) =7.53, p<0.001; Diastolic BP: F_(5,270) =3.60, p<0.01; Oxygen saturation: F_(5,270) =10.92, p<0.01) groups. Further, post hoc analysis is done using Bonferroni test to compare the effect between different times of observation. The Bonferroni test showed significant changes (p<0.05) in mean difference over different time points in both the groups in most of the times for all the physiological parameters.

 

To find the difference in the scores of physiological parameters between the two groups, t test was computed. It was seen that there is a significant difference in the mean change pre and post tests scores of pulse, respiration and systolic as well as blood pressure of children between intervention and non intervention groups at different point of time. (p<0.05) but not in oxygen saturation scores.

 

The study also revealed that (table 3) the mean difference in pain scores of children between 24 and 48 hours of surgery is more in the intervention than that of non intervention group. But the Wilcoxon signed rank test Z value shows that in both the groups, the mean difference is statistically significant (p<0.001). When compared the scores between the groups (table 4), computed Mann Whitney's Z value was not statistically significant (Z=1.032, p>0.05).

 

The study findings also revealed that there is a significant association between the age and anxiety of children (c² = 9.73; p<0.05) , anxiety and type of surgery underwent (c² = 9.57; p<0.05), pulse and type of surgery (c² = 23.10; p<0.05), systolic blood pressure and duration of admission prior to surgery (c² = 29.57; p<0.05), diastolic blood pressure and type of surgery (c² = 83.33; p<0.001), diastolic blood pressure and duration of admission prior to surgery (c² = 35.25; p<0.05).

 

The study also found that there is a statistically significant positive correlation between the psychological and physiological parameters of children undergoing surgery (p<0.05).

 

DISCUSSION:

The present study showed that MPPP is effective in reducing the preoperative fear and anxiety of children (p<0.05). This finding is consistent with previous research studies which proved that children prepared for surgery were less anxious³² and preoperative anxiety was less in children who were prepared psychologically³³. At the same time hospital tours, play therapy, information videos, surgical brochures³⁴, preoperative cognitive behavioral program³⁵, preoperative education programs³⁶ viewing animated cartoons and phone interviews³⁷, therapeutic play intervention³⁸ were also proved effective in reducing preoperative anxiety of children. Moreover even if it was not studied here, the reduction in anxiety has positive impact on postoperative recovery and it was seen that children who were prepared for surgery had a speedy recovery and fewer emotional problems than those who were not prepared³⁹.

 

The present study evaluated that MPPP of children is effective in stabilizing pulse, respiration and BP (p<0.05). It was studies earlier that children who had an influence of adult behaviour had significantly lower mean value for pulse rate and blood pressure during invasive procedure⁸. But with regard to mean pulse score, the current study findings contradict with a study³ where although the mean scores of physiological parameters in the experimental group were less than that of control group, the pulse score did not achieve the statistical significance but there was a significant difference found in the mean blood pressure scores between the experimental and control groups.

 

There was a significant association between the psycho physiological of children and selected demographic variables parameters (p<0.05). This finding is consistent with the studies which showed that child's anxiety was associated with age of the child⁴⁰, age and socioeconomic status influence the occurrence of preoperative anxiety⁴¹. The current study found that psychological and physiological parameters of children undergoing surgery were correlated. A previous study results also showed that the anxiety, fear, and pain had an effect on hemodynamic, ventilator, and cardiovascular parameters during the extraction procedure⁴². It was also seen that during all routine dental procedures, the pulse rate values increased intra operatively from the preoperative baseline values and then decreased in the postoperative phase. Hence it concluded that dental anxiety and fear may have an effect on the normal physiologic parameters during routine dental procedures⁴³.

 

IMPLICATIONS:

Several implications for nursing education, nursing practice, nursing administration, and nursing research can be stated based on the findings of the study. In the child health nursing curriculum, pre and post operative care of children is an important topic but the preoperative education programs used in preoperative preparation of children is given least importance. It is essential to help students to develop knowledge, skill and attitude towards these programs and the nursing faculty can be oriented regarding the same. Students should be taught to assess preoperative fear and anxiety of children and their parents and also should be encouraged to develop and use various preoperative education programs during their clinical postings. Nurses working in the pediatric surgery units need to develop the practice of routine assessment of preoperative fear and anxiety and use preoperative preparation programs in preparing children and their parents for surgery. Other than providing routine information regarding surgery, no other special programs for preoperative preparation of children as a routine are available in the hospitals in India. But in abroad, such facilities are available in many of the hospitals. Therefore nursing administrators in India should develop nursing practice standards, protocols, and manuals for assessment of preoperative fear and anxiety of children and parents and incorporate various preoperative preparation programs for children and parents. Nursing administrators should make a policy for using preoperative education programs routinely. Administrators should ensure the availability of a variety of age appropriate preoperative preparation programs for children and parents and provide training for nurses regarding this matter. Hospital authorities can also develop a customized preoperative preparation program exclusively for their hospital and involve the entire surgical team in the same. Preoperative anxiety is common among children undergoing surgery and their parents and various preoperative preparation programs have been developed and tested to see its effectiveness. Further research in this area will help nurses to find out other effective preoperative preparation programs to reduce the fear and anxiety of children and parents and also enhance parental satisfaction regarding preoperative preparation of children. Emphasis should be given to the utilization of research findings. Appropriate utilization of research helps nurses to make evidence-based decisions regarding care of the children. Nurses can develop customized preoperative preparation programs and test its effectiveness and use this evidence in providing nursing care to children and their parents.

 

RECOMMENDATIONS:

Based on the findings of the present study, the recommendations offered for the future research are:

1.      Similar study can be conducted on a large sample of school aged children.

2.      Similar study can be conducted on the other age groups with age appropriate preoperative preparation programs.

3.      Study can be conducted to compare the effectiveness of various preoperative education programs.

4.      Further research can be conducted by using other preoperative preparation programs like picture books, play therapy, games, information leaflets etc. for various age groups of children and their parents.

5.      A study can be conducted on the effectiveness of various preoperative preparation programs exclusively for parents.

6.      Home preparation programs using home visits, telephone, internet can be developed to prepare the children and parents for surgery and its effectiveness can be studied.

 

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Received on 04.09.2017          Modified on 10.10.2017

Accepted on 15.11.2017          © A&V Publications all right reserved