Origami and Manifested Behaviour in Hospitalized Children

Ms. Jisha Susan Varghese¹, Dr. Ravichandran², Dr. Rebecca Samson³, ^*Mrs. Sujatha. S⁴

¹Lecturer/ Ward Incharge, College of Nursing, Pondicherry Institute of Medical Sciences (PIMS), Puducherry, India

²Asst. Professor, Dept. of Biostatistics, Pondicherry Institute of Medical Sciences (PIMS), Puducherry, India

³Dean, College of Nursing, Pondicherry Institute of Medical Sciences (PIMS), Puducherry, India

⁴Professor/HOD-Dept. of Child Health Nursing, Addl.Vice Dean, College of Nursing, PIMS, Puducherry, India

*Corresponding Author E-mail: sujatha.sugumar@gmail.com, jishasusanv@gmail.com

ABSTRACT:

Statement of the study:- A Study to Assess the Effectiveness of Origami on Selected Manifested Behaviour among Hospitalized Children in Paediatric Wards of PIMS, Puducherry

Introduction: - Play is vital for a child’s sensory, motor and cognitive development. Play is a diversional activity which reduces stress in children. Hospitalized children will regress with the skills that they had previously mastered. This concept helps to minimize the emotional trauma to the children and their parents for better adjustment during hospital stay. For carrying out these diversional measures the child doesn’t need any sophisticated toys, instead can do with waste papers or colour papers, which is very cheap and easily available. Making handicraft/ origami toys do not require a separate play room or special playing toys. It can be carried out in the bedside itself. Moreover, the investigators own creative thoughts of making origami/ handicraft toys during childhood also motivated and created interest in the investigator to carry out this study. Materials and Methods: -The study was quasi-experimental study with an evaluative approach. The study was conducted in Paediatric wards of P.I.M.S. Data collection period was one month. Population was hospitalized children. Samples were, children admitted in Paediatric ward, aged between 6-10 years. Randomized sampling technique was used to allocate children into experimental and control group. Sample size was 66(33 children in each experimental and control group). The tools used for data collection were demographic variables and behaviour observational checklist. Three point scale to assess the behaviour of the children. Results: -The findings shows that, 23(69.7%) children in the experimental group and 2(6.1%) children in the control group have never exhibited the manifested behaviour during post-test as when compared with the pre-test. There is statistically significant difference between the pre-test and post-test level of manifested behaviour among experimental group and control group (p<0.001 level).There is no statistically significant association between pre-test level of manifested behaviour with the selected demographic variables of experimental and control group. Conclusion:-The study findings reveal that origami helps children to adapt better to unpleasant situations, especially during hospitalization. This healthy adaptation promotes quick recovery from their illness.

KEYWORDS: Handicrafts/Origami, Manifested behaviour, Hospitalized children.

INTRODUCTION:

“The playing adult steps sideward into another reality; The playing child advances forward to new stages of mastery.” Erik. H. Erikson.

Children of school-age will have a developmental task of industry versus inferiority. In this, the child shows their industrial behaviour by playing and involving in competitive activities. So any event which is obstructing the child from getting involved in the tasks may hinder the child’s developmental prognosis.

Children play wherever they are. A child’s integral task is to play. Play promotes healing and helps the child to cope with stressful situations. Play is not a purposeless activity which serves only to pass the childhood hours, but is a vital factor in shaping intellectual, social and emotional development of a child (Ryan. S, 2000).

Child’s concept of hospitalization is viewed as a consequence of wrong doing. Hospitalization can produce major stressors for children that may limit their opportunities for play. Additionally hospitalization may thwart the opportunity to play. A study result reveals that, the children who were hospitalized have been found to display delayed play skills compared to typically developing children (Ryan. S, 2000).

Admission to the hospital can be a positive psychologic experience for children, if prepared properly. It helps to develop confidence in dealing with stressful situation in future. Consistent support to the children and their parents can help in bringing positive outcome. In addition, the hospitalized children are more likely to have a chronic or terminal disease or to have special needs that require specialized care. Hospitalization can be overwhelming for a child, and are stressful for both parents and children. Hospitalization of children upsets the family and puts the children in an unfamiliar place with strange people and may involve uncomfortable procedures. Hospitalized children will regress with the skills that they had previously mastered. Within a safe environment, the sick child needs expert physical care, emotional support, expression of feelings (through play) and continuation of schooleducation, to promote continued growth, both in acute and chronic illness. Thisconcept helps to minimize the emotional trauma to the children and their parents forbetter adjustment during hospital stay (James S. R., 2007).

Besides the physiological effects of the health problem, the impact of illness and hospitalization on a child increases anxiety and fear. Sickness causes pain, restrain of movement, long sleepless periods, restriction of feeds, related to the overall process and the potential for bodily injury and pain. In addition, children are separated from their homes, families, friends, and what is familiar to them, which may result in separation anxiety. There is general loss of control over their lives and sometimes their emotions and behaviours. The result may be anger, guilt, regression, acting out, and other types of defense mechanisms to cope with this effect, which is exhibited as “manifested behaviour” (James S. R., 2007).

Some of the great thinkers like Aristotle and Plato, have reflected about the fundamental needs of play in a child’s life. There are several benefits that have been explained by several theorist, which have been described below.

Play is a joyful, fun and enjoyable activity that helps in elevating the innerspirits and brightens the outlook on life. It also helps in expanding the self-expression, self-knowledge, self-actualization and self-efficacy (North Carolina Association for play therapy). Play helps in relieving the feelings of stress, boredom, connects us to be with people in a positive way, stimulates creative thinking, exploration, regulates our emotions, and boosts our ego. In addition, play also allows us to practice skills and roles needed for survival. Fostering of learning and development are best achieved through play.

Children are free from anxiety and other hospital related stress and also they learn colours, numbers, sizes and shapes through play (ie) by making handicrafts/origami like paper boat, airplanes, fortune-teller etc, and the child enhance their creative skills and get diverted from their illness and parental separation. Diversional activity of making paper toys/ origami is a range of voluntary and motivated activities which creates pleasure and enjoyments in children. Diversional activity is always associated with child’s level of activity and also influences the children’s higher functioning. This is also associated with cognitive development and socialization and always promotes learning and also incorporates several behavioural changes in children. Modern findings in neuroscience suggest that play promotes flexibility of mind, which includes adaptive practices such as creating multiple ways to achieve a desired result, creative ways to improve or recognize a given situation. (Hockenberry M., 2008).

As nurses, when we create a stimulating environment, the children automatically move on to a higher level of functioning and thinking which improve their intellectual skill. Making handicrafts/ origami provides the child an opportunity for creative expression, diversion, and effective coping. In a hospital environment, a supervised and guided diversional program provides warmth, friendly and pleasant atmosphere which will help the child continue to grow and develop. In most of the super-speciality and multi-speciality hospitals, there is a specialist who coordinates the play as well as the diversional programmes.

OBJECTIVES:

1. To identify the pre and post-test level of selected manifested behaviour among hospitalized children in experimental group and control group.

2. To compare the pre and post-test level of selected manifested behaviour among experimental group and control group.

3. To compare the effectiveness of handicrafts (origami) among hospitalized children of experimental group with the hospital routine for control group.

4. To associate the pre-test level of selected manifested behaviour with the selected demographic variables of experimental group and control group.

MATERIALS AND METHODS:

Research approach: Evaluative approach

Research design: Quasi-experimental design

Setting of the study: Paediatric ward of PIMS

Population: Hospitalized children

Sample: Children admittedin Paediatric ward, aged between 6-10years

Sample size: 66 hospitalized children

Sampling technique: Randomized sampling technique

Criteria for sample selection:

Inclusion criteria:

Children who are,

· admitted in Paediatric ward during data collection.

· with any kind of illness.

· conscious.

· ambulated after surgery.

Exclusion criteria:

Children who are,

· treated as out-patients.

· critically ill, acutely ill and immediate post-operative children, admitted in special care area (PICU).

· from orphanages, homes etc.

· with special needs.

DEVELOPMENT AND DESCRIPTION OF THE TOOL:

Data collection tools are the procedures or instruments used by the researcher to observe or measure the key variables in the research problem (Burns. N, Grove. K, 2002).

After wide reading, the researcher developed the tool as per the following:

Section A:

The demographic variable included are age, sex, birth orders, place, type of family, income, religion, previous exposure to the hospital, number of hospitalization within last one year, reason for previous hospitalization.

Section B:

A behaviour observational checklist to assess the hospital acquired behaviour in children. It was prepared by the researcher, consisting of 20 behavioural response on different aspects. The behaviours were given score of three if it is absent, score of two if it is present at times and if it is present a score of one is given.

It has got three aspects namely, gaze behaviour, vocalization and co-operation.

The above three aspects had specific items under each heading such as,

· Gaze behaviour- 3 items

· Vocalization-7 items

· Co-operation- 10 items

Marks allotted for each item:

· Always → 1

· Sometimes → 2

· Never → 3

The score indicates:

· Always → <40%

· Sometimes → 40-50%

· Never → >50%

DESCRIPTION OF THE INTERVENTION USED:

Handicrafts or origami are the toys made of paper. They are constructed in several ways, by folding, or by cutting, decorating or assembling pieces of paper with glue or tape to create a paper doll or paper model.

The investigator had gained skill in making the handicrafts (origami), mainly boat, tree, christmas tree, airplanes, hat, crown, snapper, fortune teller, jumping frog, butterfly, and hanging snowflakes, for the children between 6-10 years of age. The child was given an option to make the origami based on his/ her preference among the toys mentioned. The origami was made out of colour paper/ newspaper/ plain paper, which was provided by the investigator. The choice of the paper was also based on the child’s preference. The first step in making the toy was initiated by the investigator and was asked to repeat by the child, as it was explained to the child. The child was appreciated on completion of the toy. If the child is not able to complete the toy, the child will be helped by the investigator to re-do the origami.

Scoring key:

The score indicates,

· 1 mark - Always exhibits the manifested behaviour

· 2 mark-Sometimes exhibits the manifested behaviour

· 3 mark - Never exhibits the manifested behaviour

Grading of the scores:

The grading of the scores indicates,

· 41.0- 60.0%. Always exhibits the manifested behaviour

· 60.1-80.0%. Sometimes exhibits the manifested behaviour

· 80.1- 100%. Never exhibits the manifested behaviour

VALIDITY OF THE TOOL:

The content validity was sought from seven experts in the department of Paediatric Nursing.The experts were requested to give the opinions and suggestion regarding the relevancy, adequacy and appropriateness of the tool for further modification. The validation was based on the criteria checklist. All the items on the tool were rated to be relevant. The suggestions of the experts were included in the tool.

ETHICAL CONSIDERATION:

Written permission was obtained from the hospital authorities to conduct the study in PIMS. Written permission was obtained from the HOD of Department of Paediatrics, to conduct the study in the Paediatric wards. Participant information sheet were given to all the care givers of the participants and individual written consent obtained from primary care givers of the selected children. Children had their own voluntariness to participate or to withdraw from the study.

PILOT STUDY:

The pilot study was conducted in the month of September for 2 weeks from 16.09.2013. The total sample size for the pilot study was 8. The study was conducted after obtaining permission from the concerned authority and also got permission from the primary care giver of the children who took part in the study. It was conducted in a similar way as the final data collection. There were no modifications made in the tool after the pilot study. The tool was found to be reliable.

RELIABILITY OF THE TOOL:

The tool after validation was subjected to test for its reliability. The reliability was established using Cronbach’s Alpha method and it was found to be r= 0.85, which indicate that the tool is reliable.

DATA COLLECTION PROCESS:

The data collection was done from 07.10.2013 to 02.11.2013.The investigator self-introduced to the child and the family, and also explained the purpose of conducting the study. A good rapport was created with the child and the family, and then got their consent.

The demographic variables were collected with the help of interview questionnaire and the responses were documented. After that, the investigator has done the pre-test assessment of manifested behaviour using the behaviour observational checklist for both the experimental group and the control group.

Before introducing origami, the investigator had explained about origami to the children of the experimental group (33). Then the investigator made the child to sit comfortably on the bed and ensured that the child is free from pain, hunger and sleep. The child was encouraged to make toys of his/her preference for the next three consecutive days, as per the child’s interest. On the first, second and third day post test was conducted at the end of the day using the behaviour observational check list to identify the change inbehaviour.

For the control group children (33), the post test was conducted on the first, second and third day, after the routine play in the ward like watching television, children playing with their own toys. Using the same checklist the behaviour changes were identified during the post- test. All the post-test observations were made at the end of the day and the investigator see that the child is free from pain, hunger and sleep during the time of observation. After completing everything, the investigator extended her thanks towards the participants and the care-giver for their full cooperation. For each child it takes about 15-30 minutes for making a toy. There were no drop-outs of children from the pre-test group during the post-test.

PLAN FOR DATA ANALYSIS:

The data obtained were entered in MS-excel 2007 and analysed by statistical software SPSS 16.0 version. On the first day of assessment, the pre-test was conducted and after introducing origami to the experimental group and routine play activities for the control group, post- test was conducted on the three consecutive days and an average of these three post-test assessments were taken for analysis. The score obtained by the children are classified into three categories, which are explained in development and description of the tool. The data obtained are analysed in terms of objectives of the study using descriptive (mean and standard deviation) and inferential statistics (Paired ‘t’ test, Repeated measure analysis of variance (ANOVA) test, Chi-square test and Fisher’s Exact test). The significant difference between the levels of pre-test and post-test both in experimental group and the control group was determined by using paired “t” test. The significant difference between the experimental group and the control group was determined by repeated measure ANOVA test. The association between the pre-test levels of manifested behaviour with selected demographic variables was determined using Chi-square testor Fisher’s Exact test separately for experimental group and control group appropriately ‘p’ value less than 0.05 was considered as statistically significant.

MAJOR FINDINGS OF THE STUDY AND DISCUSSION:

The data are organized and presented in the following five sections

SECTION-1:

Distribution of demographic variables of the child by experimental group and control group.

SECTION-2:

Distribution of pre-test and post-test level of manifested behaviour among experimental group and control group.

SECTION-3:

Comparison of pre-test and post-test level of manifested behaviour among experimental group and control group.

SECTION-4:

Comparison of post-test manifested behaviour between experimental group and control group.

SECTION-5:

Association of pre-test manifested behaviour with selected demographic variables among experimental group and control group.

SECTION 1:

DISTRIBUTION OF DEMOGRAPHIC VARIABLES IN EXPERIMENTAL AND CONTROL GROUP.

Maximum number of children are 6yr old, in the experimental group, 9(27.3%), and in control group, 8(24.2%). Majority of children were boys, 17(51.5%) in experimental group and 20(60.6%) in the control group. Considering the birth order of the child, maximum number of children in the experimental and the control group is the second child, 17(51.5%) and 14(42.4%), respectively. Most of the children, both in experimental and control group lives in rural area, 18(54.5%) and 17(51.5). The maximum number of children belong to the nuclear family, 23(69.7%) in the experimental group and 25(75.8%) in the control group. With regard to the income of the family, children in both experimental 9(27.3%) and control 14(42.4%) group had a monthly income of Rs. 6001-10000 respectively. The highest number of childrenwere Hindus, 26(78.8%) in experimental group and 24(72.7%) in control group. In the experimental group, 21(63.6%) children and in the control group18(54.5%) children had previous history of hospitalization. Among children having history of hospitalization within last one year, 6(35.3%) children in the experimental group and 10(62.5%) children in the control group had two times of hospitalization. 18(85.7%) and 16(88.9%) children in the experimental and control group were admitted because of medical illness, whereas, 3(14.3%) of experimental group and 2(11.1%) children of control group were admitted for surgical reasons.

SECTION 2:

DISTRIBUTION OF pre-test and post-test LEVEL of manifested behaviour among experimental and control group.

Figure-1: Pre-test level of manifested behaviour among experimental and control group

The figure-1 reveals that, during pre-test there was 22(66.7%) children in experimental group and 30(90.9%) children in control group who always exhibited the manifested behaviour and 11(33.3%) children in the experimental group and 3(9.1%) children in the control group who had sometimes exhibited the manifested behaviour and there was none of the children who have never exhibited the manifested behaviour.

Figure-2: Post-test level of manifested behaviour among experimental and control group.

The figure-2 reveals that, during post-test there was no children in experimental group and 7(21.2%) children in control group who always exhibited the manifested behaviour and 10(30.3%) children in the experimental group and 24(72.7%) children in the control group who had sometimes exhibited the manifested behaviour and 23(69.7%) children in the experimental group and 2(6.1%) children in the control group have never exhibited the manifested behaviour.

SECTION 3:

COMPARISON OF PRE-TEST AND POST TEST LEVEL OF MANIFESTED BEHAVIOUR AMONG EXPERIMENTAL AND CONTROL GROUP.

Table-1:Comparison of pre-test and post-test level of manifested behaviour among experimental group. n=33

TEST STATUS

MEAN

t value

p value

PRE-TEST

34.4

4.9

-17.3

<0.001

POST-TEST

49.5

3.3

Paired t-test was done to compare the mean score of pre-test and post-test level of manifested behaviour among experimental group.

Table-1 reveals that, there is statistically significant difference between the pre-test and post-test level of manifested behaviour among experimental group at p<0.001.

Table -2: Comparison of pre-test and post-test level of manifested behaviour among control group. n=33

TEST STATUS

MEAN

t value

p value

PRE-TEST

30.6

3.7

-22.0

<0.001

POST-TEST

40.2

4.2

Paired t-test was done to compare the mean score of pre-test and post-test level of manifested behaviour among experimental group.

Table-2 depicts that, there is statistically significant difference between the pre-test and post-test level of manifested behaviour among control group at p<0.001.

SECTION 4:

COMPARISON OF POST TEST LEVELOF MANIFESTED BEHAVIOUR AMONG EXPERIMENTAL AND CONTROL GROUP.

Figure-3: Comparison of post- test levels of manifested behaviour among experimental and control group.

Repeated measures ANOVA was done to compare the mean score between the post-test levels of manifested behaviour of experimental and control group.

The figure-3 depicts that, there is statistically significant difference between the experimental and the control group in the post-test levels of manifested behaviour and there is significant difference between each day in both experimental and control group.

SECTION 5:

ASSOCIATION OF PRE-TEST MANIFESTED BEHAVIOUR WITH SELECTED DEMOGRAPHIC VARIABLES AMONG EXPERIMENTALGROUP.

In experimental group, there is no statistically significant association between pre-test score and socio-demographic variables such as age, sex, birth order of the child, area of residence, type of family, income of the family, religion, previous exposure of hospitalization and number of hospitalization within last one year (p>0.05). The p value for the variables sex of the child and area of residence of the child were obtained by Chi-square test. For all the other variables p values were obtained by Fisher’s Exact test.

In control group, there is no statistically significant association between pre-test score and socio-demographic variables such as age, sex, birth order of the child, area of residence, type of family, income of the family, religion, previous exposure of hospitalization and number of hospitalization within last one year (p>0.05). All the p values were obtained by Fisher’s Exact test.

RECOMMENDATIONS:

1. A similar study can be replicated on larger sample to make generalizability.

2. A similar study can be done in a community set-up.

3. A similar study can be conducted in terminally ill children, in post-operative children, and in physically disabled children.

4. A comparative study can be conducted among rural children and urban children’s manifested behaviour.

5. A similar study can be conducted with different study design.

6. The similar study can be replicated to assess the cost effectiveness.

7. The study can be done in different age group of children.

IMPLICATIONS:

The findings of the study have implication in following areas of the nursing profession. It is explained in the following heading like nursing service, nursing education, nursing administration and nursing research.

Implications in nursing service:

1. The result of the study will help to enlighten the knowledge of nurses in making handicrafts and thus reducing the manifested behaviour in children when they are admitted in the hospital.

2. Children in the hospital need play provision because they have natural needs for play. Also play helps to prevent developmental regression, to reduce parental and child’s stress and anxiety. In relation with hospitalization, play helps to facilitate communication between staff and children, to encourage child’s cooperation in hospital procedure and moreover will help a child to get adapted to the hospital environment by reducing the exhibition of manifested behaviour in them.

3. Nurse should have adequate knowledge regarding different indoor play activity and its importance in hospitalized children and nurses should play a critical role in helping the child and the family to cope effectively with hospitalization through play activities like making handicrafts, puppet shows etc.

4. So this study would not only emphasize the need for play, but also implicates that nurses must motivate the involvement of children in enhancing play in children’s ward.

Implications in nursing education:

1. Curriculum of nursing should include the play activity training as one of the nursing care for hospitalized children.

2. Nurse’s education must motivate the students to include the play activity practices in nursing care of children in the wards.

3. Nursing curriculum should provide an opportunity to plan and conduct play activities in a variety of setting like family, community, industry, hospital, schools and other health care agencies.

4. Nurses with higher education must develop theories related to play needs.

Implications in nursing administration:

1. The nurse administrator should take active part in policy making related to health education on play activities.

2. The nurse administrators should provide a provision for nurses to devote time for giving play activities which helps in reducing the manifested behaviour in hospitalized children.

3. Necessary administration support should be provided to conduct play activities in any setting as required and cost-effective health education material should be encouraged.

4. A hospital policy should be adopted to provide play activities to all the children who are admitted and for those children who come to out-patient department.

Implications in nursing research

1. The study can be published in journals to disseminate knowledge regarding the effectiveness of handicrafts in reducing manifested behaviour in hospitalized children among the health professionals.

2. The findings of the study serve as a basis for the nursing professionals and the students to conduct further studies in different aspects of play activities in hospitalized children.

CONCLUSION:

The conclusion drawn from the findings of the study are During pre-test there was no child who falls under the category of never exhibiting the manifested behaviour and during post-test there were 23(69.7%) children in the experimental group and 2 (6%) children in the control group who have never exhibited the manifested behaviour during their hospitalization.

There was a significant difference between the pre and the post-test levels of manifested behaviour among experimental group. t-value being -17.29 at p<0.001 level.

There is significant difference between the pre and the post-test levels of manifested behaviour among control group. t-value being -22.01 at p<0.001 level.

The final results showed that both the groups had difference in exhibiting the manifested behaviour, however the experimental group children could adapt faster than the control group children. (mean difference of both the groups= 9.25).

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