Nisha K.

et al

EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF

ANXIETY AMONG PREOPERATIVE CHILDREN
IJCRR
Vol 05 issue 11
Section: Healthcare
Category: Research
Received on: 05/05/13
Revised on: 23/05/13
Accepted on: 09/06/13

Nisha K., Umarani J.

Department of Pediatric Nursing, Yenepoya Nursing College, Yenepoya University,
Deralakatte, Mangalore, Karnataka, India
E-mail of Corresponding Author: nishakch@gmail.com

ABSTRACT
An important index used to estimate the Nations health is the health status of children in the country.
Children are more vulnerable due to their lack of knowledge of procedures, a lack of control, a lack of
explanation in child-appropriate terms, and a lack of pain management. Hospitalized children may
experience high level of anxiety due to many different factors both physical and psychological factors.
The present study aimed to determine the effectiveness of play intervention on anxiety among children
admitted in preoperative wards of selected hospitals at Mangalore. The objectives of the study were to
determine the effectiveness of play intervention among experimental group. The study design was two
group pre-test post- test design. The sample comprised of 60 preoperative school age children in the
age of 6-12 years who were selected by Purposive sampling technique and divided into experimental
and control group. Pretest anxiety was assessed and play intervention (video game) was given to the
experimental group along with the routine care and only routine care to the control group. The data was
collected by using demographic proforma and numerical state anxiety scale. The study result showed
that the calculatedt value (t= 4.225) was greater than the table value (t58 = 1.671) at 0.05 level of
significance. The pre-test anxiety score was independent of all the demographic variables such as age,
gender, religion, type of family, residence, care giver present during hospital stay, past child reactions
to any procedures. The finding of the study shows that the play intervention was effective in reducing
the anxiety among preoperative children.
Keywords: Effectiveness, school age children, anxiety, play intervention.
INTRODUCTION
An important index used to estimate the Nations
health is the health status of children in the
country1. Unfortunately, even the healthiest baby
can get sick2. Surgery can be a threatening
experience for everyone, especially for children.
Hospitalized children may experience high level
of anxiety due to many different factors both
physical and psychological factors1. It is not
surprising therefore that up to 65% of children
experience significant anxiety associated with
the preoperative period2. A childs surgery is
often a very significant and memorable event in
the life of the entire family and especially the
childs personal history3. Preoperative anxiety is

an extremely unpleasant sensation for children4.

Preoperative anxiety refers to anxiety regarding
the events that take place prior to surgery5.
In India approximately 3 million of children
undergo surgery, among them boys are more
than girls and the ratio is 7:4 6. Up to 25% of
children have been noted to require physical
restraint7. Loss of freedom can produce stress
and anxiety in children8. Play therapy in a
hospitalized setting is innovative and concisely
accomplishes the task of supporting children
emotionally in their time of chaos, fear, and
pain9. The nurses play an important role in
helping the parent and child cope with their
anxiety and stress7.

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EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

The anxiety caused by the hospital environment

and surgical procedure may be harmful during
the preoperative period because it might affect
cognitive, social, and affective development, in
addition to increasing negative behaviours
during the childs postoperative period10. The
pharmacological and non pharmacological
therapy is used to reduce the anxiety of the
child11. Play is an important part of child life and
it is an important aspect to foster the growth and
development of a child12. Play comes naturally to
children and is often their favourite activity.
Providing an environment conducive to play
activities like giving a toys or using of handheld
game technology to make the environment less
threatening, has been shown to reduce anxiety
and this also help in getting child cooperation
with medical procedures and anaesthesia
induction13.
A study was conducted to identify the effect of
play on pre-operational anxiety among children.
There was a significant reduction in the trend of
anxiety increment after surgery in the
intervention group in comparison to the control
group. Attending in playrooms and using play
activities might have reduced the trend of
increment in the anxiety level induced by
surgical procedures 6. The influence of play
activity among children between 5 and 12 years
of age undergoing medical procedures at the
outpatient surgical centre revealed that during
the preoperative period, children who
participated in playful activities in the recreation
room had their anxiety reduced in comparison
with those that only stayed in the preoperative
holding area14.
The child copes up with the anxiety in different
ways. So the investigator felt the need of using a
distracter as diversion therapy. A conceptual
framework is an interrelated concepts or
abstractions assembled together in a rational
scheme by virtue of their relevance to a common
theme. The conceptual framework used in the
present study was adapted from the General

Systems Theory introduced by Ludwig Van

Bertalanffy (1968)15,16.
MATERIAL AND METHODS
The study design chosen was two group pre-test
post- test design. The population of the study
was school age children at selected private
hospitals at Mangalore. Permission from the
institution ethics committee was obtained prior
to the study. The parents of the children gave
written consent for the study. Purposive
sampling technique was used for selecting the
study subjects. The sample comprised of 60
school age children of 6-12 years who got
admitted in the preoperative ward subjected to
surgery within 24 hours and divided into 30 for
experimental and 30 for control group. The tool
used for the study was demographic proforma
and Numerical State Anxiety Scale. After a brief
self introduction, the investigator explained the
purpose of the study and obtained informed
consent from the parents. On the first day the
investigator observed the setting, structure, and
the appliances for use. The investigator obtained
consent from the parents to participate in the
study. The parents were interviewed on the basis
of baseline proforma. The investigator made the
children comfortable on the bed comfortably.
Pretest was assessed for both experimental and
control group using numerical state anxiety
scale. Then the experimental group children
were provided with standard care and play
intervention [video game] half an hour in the
morning and half an hour in the evening for one
day prior to surgery and the children in the
control group was given only standardized care.
Post test was assessed to both groups using
Numerical State Anxiety Scale. The data was
analyzed by descriptive and inferential statistics.

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EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

RESULT
In experimental group highest percentage
(43.3%) of children were in the age group 810yrs, where as in control group majority
(36.3%) of children were in the age group 1012yrs. Highest percentages of children were
females (53.3%) in the experimental group and
in the control group (50%). Majority of the
children were in joint family the experimental
group (50%) and the control group majority
(43.3%). Most of the children in experimental
group were from rural area (53.3%) and in the
control group children were (50%) from both
rural and urban area. Highest percentages of care
giver present in the experimental group were
(33.3%) both mothers and fathers whereas in
control groups (36.3%) were mothers. With
regard to past reaction to any other procedure is
minimal with the percentage of (56.3%) in the
experimental group and (50%) control group.
The experimental and control group (100%) has
not under gone any distraction technique during
hospital stay.
Figure.1. depicts that all the children in the
experimental group and control group were
having a lot anxious. In the post-test of
experimental group 80% of them had medium
anxious level and 20% were having little
anxious. In the post test score of control group
87% were having a lot anxious, 13% had
medium anxious and pre-test remained the same
even in the experimental group.
The post-test level of anxiety in the experimental
group was found to be lower than the control
group. Computed pairedt test showed the
effectiveness of play intervention in reducing the
anxiety in the experimental group. Table.1and 2
showed that the mean post-test anxiety score
(3.431) was lower than mean pre-test score
(6.4 0.5). The calculated t value ( t= 4.225)
was greater than the table value (t29 = 1.699) at
0.05 level of significance. To test the
effectiveness of play intervention, statistical
significance between the post- test anxiety scores

in the experimental and control group,

unpairedt test was computed. The mean score
of experimental group (3.431) was lower than
mean of control group (4.43 0.83). The
calculatedt value (t= 4.225) was greater than
the table value (t58 = 1.671) at 0.05 level of
significance. Hence the research hypothesis was
accepted. Hence there is a significant difference
in the anxiety score of children between
experimental and control group.
The associations of the pre-test anxiety score
with selected demographic variables were found
out by using Chi-square test. The data presented
in experimental group shows there was a no
significant association of the pre-test anxiety
score with selected demographic variable as the
calculated value is less than the table value at
0.05 level of significance, but for the gender,
table value is lower than the calculated value.
Hence the hypothesis was accepted as there was
a significant association between gender and
anxiety. The data presented in the control group
shows there was a no significant association of
the pre-test anxiety score as calculated value is
less than the table value at 0.05 level of
significance. Hence the hypothesis is rejected as;
there is no significant association between
anxiety level and selected demographic
variables.
DISCUSSION
The pre-test anxiety scores in both control and
experimental group showed that the entire
sample had alot anxious. But in the post-test,
anxiety level in the experimental group showed
that majority (80%) of the sample experienced
medium anxious and 20% little. In the control
group majority (90%) was found to have
medium anxious and 10% experienced alot
anxious. A study was done to evaluate the level
and prevalence of anxiety at the preoperative
period using the YPAS-m in preschool children.
The study result showed that their is significant

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EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

difference in the level of anxiety in experimental

and control group17.
Effectiveness of play intervention is calculated
using unpaired t test. The mean score of
experimental group (3.431) was lower than
mean of control group (4.430.83). The
calculatedt value (t= 4.225) was greater than
the table value (t58 = 1.671) at 0.05 level of
significance. This study is supported by another
study done among children between ages of 36
yr who were randomized into two equal groups.
The anxiety of each child was assessed using the
Modified Yale Preoperative Anxiety Scale. The
experimental group was provided with a toy and
standard care and control group by only standard
care. The results showed significantly less
anxiety in children who received a toy than the
other group who did not 18.
A study was done with a total of 150 children
aged 2-16 yrs, the sample was divided into two
groups; experimental group were provided with
standard care and play room activity and control
group with standard care. The State-Trait
Anxiety Inventory was used to assess anxiety.
The analysis showed that 51.1% of children in
experimental group were having reduced
anxiety19.
For determine the association between level of
anxiety among children in preoperative wards
with selected demographic was done there were
no significant association between anxiety level
and selected demographic variables in control
groups. But in experimental group the gender of
children shows significant association. This
study was supported by a study in which the
children of age group 3-7 yrs showed a
significant association between anxiety level and
age and gender20.
The present study was confined to a specific
geographical area which obviously imposes
limits to any larger generalization. The study was
confined to a small number of subjects. However
it could be done on more samples for larger
generalization. Anxiety was assessed using only

Numerical State Anxiety Scale. Play intervention

was given just, a day prior to surgery.
CONCLUSION
The present study highlighted the effectiveness
of play intervention on anxiety as a nonpharmacological and cost effective intervention
for children. Anxiety is a situation where all
children will face in all age group. Diversion
therapy is chosen as the primary intervention for
decreasing the anxiety level of children in
preoperative ward because it provides a simple
approach in reducing anxiety. A better
understanding of health issues associated with
the anxiety among school children has
constituted a challenge for clinician and
researchers. So there is a great lot scope for
exploring this area. Research should be
conducted to identify the scope of play
intervention to alleviate anxiety among children
REFERENCES
1. Marlow DR, Redding BA. Text book of
Pediatric Nursing. 6th ed. Pennsylvania: WB
Saunders Publication; 2008.p. 386-8.
2. Wilson D &Hockenberry MJ. Nursing Care
of Infants and Children. 8th ed. New Delhi:
Elsevier Pvt Limited; 2007.p. 456-9.
3. Kain, Z. N., & Caldwell-Andrews, A.
(2005).
Preoperative
psychological
preparation of the child for surgery: An
update. Anesthesiology Clinics of North
America, 23, 597-614.
4. Cooke M, Chaboyer W, Hiratos M, Schluter
P. The effect of music on pre-operative
anxiety in day surgery. Journal of Advanced
Nursing. 2005;52(1):47-55.
5. Peter J. D, Franklyn P. and Etsuro K.
Smiths Anesthesia for Infants and
Children,
8th
ed.
Elsevier
Pvt
Limited;philadelfia;2007.457-8
6. Wright k.d , Sherry H. S, Allen F G etl.(
2007)
Prevention
and
Intervention
Strategies to Alleviate Preoperative Anxiety

Int J Cur Res Rev, June 2013/ Vol 05 (11)

Page 107

Nisha K. et al

7.

8.

9.

10.

11.

12.

13.

14.

EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

in Children. A critical review. Behavior

Modification; 2007, 31:52-79.
Lumley MA, Melamed BG, Abeles LA.
Predicting children's presurgical anxiety and
subsequent behavior changes.Source;jpj,
1993 Aug;18(4):481-97.
Julie L. Lerwick. The Impact of ChildCentered Play Therapy on Anxiety Levels
in Pre Neurosurgical Pediatric Patients;
Anesthesiology Clinics of North America,
23, 58-7.
Li, H. C., Lopez, V., & Lee, T. L. (2007).
Effects of preopertive therapeutic play on
outcomes of school-age children undergoing
day surgery. Research in Nursing and
Health, 30, 320-332.
Susan C. Reinhard. Barbara G. Nirvana
Huhtala P. Ann B. Supporting Family
Caregivers in Providing Care. Bookshelf
ID: NBK2665PMID: 21328765.
Browne NT, Flanigan LM, McComiskey
CA, Pieper P. Nursing Care of the Pediatric
Surgical Patient. Boston, Mass: Jones &
Bartlett Publishers; 2007:3-16.
Golden L, Pagala M, Sukhavasi S, Nagpal
D, Ahmad A, Mahanta. Giving toys to
children reduces their anxiety about
receiving premedication for surgery.
AnesthAnalg. 2006;102:1070-2.
Ammed M.J, Farrell M.A, Karala A etl,
preoperative anxiety in children risk factors
and nonpharmacolcogical management.
M.E.J. ANESTH .2011, 21 (2).
Weber Fernanda Seganfredo. The influence
of playful activities on children's anxiety
during the preoperative period at the
outpatient surgical center. J. Pediatr. (Rio
J.) [serial on the Internet]. 2010 June

15.

16.
17.

18.

19.

20.

[cited 2013 May 18] ; 86(3): 209-214.

Available
from:http://www.scielo.br/scielo.php?script
=sci_arttext&pid=S0021755720100003000
08&lng=en.
http://dx.doi. org/10.1590/
S0021-75572010000300008.
Polit DF, Hungler BP. Nursing research
principles and methods. 6th ed. Philadelphia:
Lippincott; 1999.
Talbot LA. Principles and practice of
nursing research. St. Louis: Mosby; 1995
Talbot LA. Principles and practice of
nursing research. St. Louis: Mosby; 1995
Kain ZN, Mayes LC, Cicchetti DV, Bagnall
AL, Finley JD, HofstadterMB. The Yale
Preoperative Anxiety Scale: how does it
comparewith
a
gold
standard?
AnesthAnalg. 1997;85:783-8.
Clatworthy, S. (1981). Therapeutic play:
Effects on hospitalized children. Journal of
the Association for the Care of Childrens
Health, 9(4), 108-114.
Caprilli, S., Anastasi, F., Grotto, R., Abeti,
M. S., &Messeri, A. (2007). Interactive
music as a treatment for anxiety and stress
in children during preoperative period: A
randomized prospective study. Journal of
Developmental and Behavioral Pediatrics,
28(5), 399-403
Li, H. C., & Lopez, V. (2008). Effectiveness
and appropriateness of therapeutic play
intervention in preparing children for
surgery: A randomized controlled trial
study. Journal forSpecialists in Pediatric
Nursing, 13(2), 63-73.

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EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

Table 1: Mean, median and standard deviation of pre-test and post-test anxiety scores in

experimental and control group

Group

Mean

Experimental group

Control group

N=60
Median

Standard

Mean

deviation

percentage

Pre-test

6.4

0.5

64

Post test

3.43

34

Pre-test

6.73

0.45

67

Post test

4.43

0.82

44

Data presented in table 1; shows that, in experimental group mean post-test anxiety score (3.431) was
lower than that of mean pre-test score (6.4 0.5), where as in control group , mean post-test anxiety
score (4.430.82) was almost similar to the mean pre-test score (6.73 0.45). It is also observed that
mean post-test scores of experimental group was lesser than mean post-test scores of control group.
Table 2 : Mean, standard deviation, mean difference and t value of post-test anxiety scores in the
experimental and control group. N=60
Group

Mean score

Standard

Mean

deviation

difference

Experiment group

3.43

Control group

4.43

0.82

t58 = 1.671, p < 0.05

t value

4.225*

*significant

Data in table 2 shows that, the mean anxiety score of experimental group (3.431) was lower than mean
of control group (4.430.83). The calculatedt value ( t= 4.225) was greater than the table value (t58 =
1.671) at 0.05 level of significance. Hence the hypothesis was accepted as there was a significant
difference in the anxiety score of children between experimental and control group

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EFFECT OF PLAY INTERVENTION IN THE REDUCTION OF ANXIETY AMONG PREOPERATIVE

CHILDREN

N=60

Fig.1 Bar diagram representing percentage distribution of samples according to level of anxiety in
experimental group and control group.
Figures 1 show that in experimental group and control group were having 100% of a lot anxious. The
post-test of experimental group were 80% of them had medium anxious level and 20% were has little
anxious. In post test score control group 87% of sample were a lot anxious, 13% had of sample had
medium anxious and pre-test remained same even in the experimental group.

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