Lampiran P1337420919047

Lampiran 1
CRITICAL APPRAISAL JURNAL 1

Effects of Auditory and Audiovisual Presentations on Anxiety and Behavioral
Changes in Children Undergoing Elective Surgery
Pertanyaan Fokus
Yes No Unknown
Bagian A : Apakah hasilnya valid?
A. Apakah studi tersebut menjelaskan masalahnya secara fokus √
(studi populasi, intervensi, kelompok kontrol/intervensi, hasil)
B. Apakah pembagian pasien kedalam kelompok intervensi dan √
kontrol dilakukan secara acak (bagaimana dilakukan, apakah
alokasi pasien dilakukan secara tersembunyi dari penelitian
dan penelitian)
C. Apakah semua pasien yang terlibat dalam penelitian dicatat √
dengan benar di kesimpulan (apakah dihentikan lebih awal,
apakah pasien dianalisis dalam kelompok untuk yang mereka
acak)
D. Apakah pasien, petugas kesehatan, dan responden pada √
penelitian ini “blind” terhadap intervensi yang dilaksanakan
E. Apakah waktu pelaksanaan untuk setiap grup sama? √
F. Selain intervensi yang dilaksanakan, apakah setiap grup √
diperlakukan sama/adil?
Bagian B : Apa hasilnya?
A. Seberapa besar efek dari intervensi tersebut (outcome, √
hasilnya dijelaskan spesifik, hasil yang ditemukan, hasil
dari setiap outcome yang diatur)
B. Seberapa tepat dan akurat efek intervensi? √
Bagian C : Apakah hasil membantu secara lokal?
A. Bisakah hasilnya diterapkan pada populasi lokal, atau √
konteks saat ini di lingkungan sekarang (apakah
karakteristik pasien sama dengan tempat bekerja/populasi
anda, jika berbeda apakah perbedaannya)
B. Apakah hasil penelitian ini penting secara klinis untuk √
dipertimbangkan (apakah informasi yang anda inginkan
sudah terdapat dalam penelitian, jika tidak apakah akan
berpengaruh terhadap pengambilan keputusan)
C. Apakah manfaatnya sepadan dengan bahaya dan biaya √
yang dibutuhkan (meskipun tidak tercantum dalam
penelitian, bagaimana menurut anda?)
Pengaruh Audiovisual Menonton Film Kartun terhadap Tingkat Kecemasan Saat
Prosedur Injeksi pada Anak Prasekolah
Pertanyaan Fokus
Yes No Unknown
dan penelitian)
acak)
Psychological Preparation Reduces Preoperative Anxiety in Children.
Randomized and Double-Blind Trial
Pertanyaan Fokus
Yes No Unknown
dan penelitian)
acak)
Video Distraction and Parental Presence for the Management of Preoperative Anxiety
and Postoperative Behavioral Disturbance in Children: A Randomized Controlled Trial
Pertanyaan Fokus
Yes No Unknown
dan penelitian)
acak)
Video Kartun dan Video Animasi dapat Menurunkan Tingkat Kecemasan Pre
Operasi pada Anak Usia Pra Sekolah
Pertanyaan Fokus
Yes No Unknown
dan penelitian)
acak)
Lampiran 2
INSTRUMEN PENERAPAN EVIDENCE BASED PRACTICE (EBP)

MODIFIED YALE PREOPERATIVE ANXIETY SCALE (M-YPAS)
I. Kuesioner Data Demografi
Petunjuk pengisian : Isilah data di bawah ini dengan lengkap dan berilah
tanda (√) pada tempat pilihan yang tersedia.
1. Nomor Responden :
2. Nama Responden :
3. Jenis Kelamin : ( ) Laki-Laki ( ) Perempuan
4. Umur : Tahun
5. Tanggal Pemeriksaan :
6. Pukul Pretest : Post test :
7. Diagnosa Penyakit :
II. Lembar Observasi Tingkat Kecemasan
Petunjuk : Lingkari satu kategori pada masing-masing domain yang paling
menggambarkan kondisi dan situasi anak.
A. Kegiatan
1. Memperhatikan sekeliling, ingin tahu, bermain, membaca (atau
kebiasaan lainnya).
2. Tidak mau melakukan kegiatan, menunduk, gelisah dengan
memainkan tangan, duduk dekat dengan orang tua.
3. Bergerak tanpa aktivitas yang jelas, menggeliat, memegang orang
tuanya.
4. Menghindari tenaga kesehatan, menolak perlakuan dengan kaki dan
tangan atau dengan seluruh tubuh, tidak mau bermain dan tidak mau
terpisah dari orang tua.
B. Pernyataan
1. Membaca (tanpa suara), bertanya, berkomentar, menjawab
pertanyaan, terlalu asyik bermain untuk merespon.
2. Menanggapi orang yang lebih dewasa dengan berbisik, hanya
menganggukkan kepala
3. Diam, tidak ada respon terhadap orang lebih dewasa
4. Merengek, mengerang, merintih
5. Menangis atau bahkan berteriak “tidak mau di operasi”
6. Menangis, berteriak keras terus menerus.

C. Luapan Emosi
1. Terlihat senang, tersenyum, atau asyik dengan kegiatannya
2. Netral, tidak terlihat emosi yang berarti pada wajah
3. Sedih, wajah ketakutam, terlihat tegang
4. Menangis, menjadi sangat marah
D. Keadaan Ingin Tahu
1. Berjaga-jaga, melihat sekeliling, melihat apa yang dilakukan tenaga
kesehatan
2. Anak berdiam diri dengan duduk tenang dan diam, menatap orang
yang lebih dewasa
3. Waspada melihat sekitarnya, terkejut akan suara-suara tertentu, mata
waspada, bahkan menegang
4. Panik dan merengek, menangis, mendorong orang di sekitarnya.
E. Peranan Orang Tua
1. Sibuk bermain atau sibuk dengan kebiasaannya, duduk tenang, tidak
membutuhkan orang tua, mau berinteraksi dengan oang tua apabila
orang tuanya yang memulai
2. Menggapai orang tua, mencari perlindungan dan kenyamanan,
bersandar pada orang tua.
3. Menatap orang tua, tidak ingin berhubungan dengan orang lain,
melakukan apa yang disuruh bila orang tua berada di dekatnya.

4. Tidak bisa jauh dari orang tua dan akan marah/menangis apabila
berpisah dengan orang tuanya, memegang erat orang tua dan tidak
melepaskannya, atau mendorong menjauhi orang tuanya.
SKOR TOTAL : (A/4 +B/6+C/4+D/4+E/4) x 100/5
Rentang skor kecemasan
1. Cemas ringan = 30- 53

2. Cemas sedang = 54- 77
3. Cemas berat = 78-100
Lampiran 3
STANDAR OPERASIONAL PROSEDUR (SOP)

DISTRAKSI MENONTON VIDEO KARTUN DAN ANIMASI
Pengertian Salah satu distraksi audiovisual yang merupakan jenis distraksi

gabungan dari distraksi audio dan distraksi visual menggunakan
media kartun dan animasi
Tujuan a. Mengurangi cemas (ansietas), setres hospitalisasi dan nyeri akut
skala ringan hingga sedang
b. Pengalihan perhatian klien terhadap sesuatu yang sedang
dihadapi
c. Rasa lebih nyaman, santai, dan merasa berada pada situasi yang
lebih menyenangkan
Indikasi Klien dengan kecemasan, setres hospitalisasi, nyeri akut ringan
hingga berat dan kondisi ketegangan yang membutuhkan distraksi
Kontraindikasi Klien anak yang memiliki kelainan congenital dan penyakit lainnya
seperti down sindrom, tuna netra, tuna rungu serta kondisi anak
sangat lemah sehingga tidak memungkinkan untuk menonton video
Persiapan a. Membaca status kesehatan klien
Klien b. Kontrak waktu, tempat, topik, dan kesediaan klien
c. Jelaskan tentang prosedur yang akan dilakukan
d. Atur posisi klien sesuai situasi, kondisi, dan kebutuhan
e. Menjaga privasi klien
Persiapan Alat a. Menyiapkan peralatan (media untuk menonton video kartun dan
animasi)
b. Modifikasi lingkungan senyaman mungkin termasuk suasana
dan kondisi ruangan agar tetap tenang dan jauh dari kebisingan
serta faktor pengganggu saat klien menonton video kartun dan
animasi
Fase Orientasi a. Salam Terapeutik
b. Perkenalan diri pada klien dan keluarga
c. Lakukan evaluasi/ validasi
d. Jelaskan tujuan dan menfaat distraksi video kartun dan animasi
e. Kontrak waktu, tempat, topik, dan prosedur tindakan
f. Minta izin dan kesediaan keluarga untuk mempraktikkan
Evidence Based Nursing Praktice berupa menonton video kartun
dan animasi dalam menurunkan tingkat kecemasan pre operasi
pada anak usia pra sekolah
g. Persilahkan klien jika ingin izin ke toilet atau menyiapkan
makanan dan minuman sebelum menonton video kartun dan
animasi dimulai
Fase Kerja 1. Cuci tangan menggunakan 6 langkah cuci tangan dengan sabun
antiseptik di bawah air mengalir atau menggunakan antiseptik
gel dan keringkan
2. Ciptakan suasana perasaan menenangkan
3. Mengatur posisi klien agar rileks
4. Memberikan salah satu teknik distraksi yaitu menonton video
kartun dan animasi. Anak diberikan kesampatan memilih salah
satu kartun (Upin Ipin, Doraemon, Bobo Boy dan Masha and the
Bear) kemudian dilakukan pemutaran video kartun selama 15
menit dan video animasi 15 menit
5. Menganjurkan keluarga klien untuk melakukan teknik distraksi
menonton video kartun dan animasi jika klien merasakan
ketidaknyamanan
6. Berikan reinforcement positif pada klien dan setelah
mempraktikkan Evidence Based Nursing Praktice berupa
menonton video kartun dan animasi
7. Cuci tangan menggunakan 6 langkah cuci tangan dengan sabun
antiseptik di bawah air mengalir atau menggunakan antiseptik
gel dan keringkan
Terminasi a. Melakukan evaluasi respon dengan menanyakan perasaan klien
setelah menonton video kartun dan animasi
b. Jelaskan rencana tindak lanjut
c. Kontrak waktu, tempat, dan topik untuk pertemuan berikutnya
d. Salam terapeutik
Dokumentasi a. Catat waktu pelaksanaan tindakan
b. Catat respon klien terhadap teknik distraksi dalam menurunkan
tingkat kecemasan pre operasi pada anak usia pra sekolah
Hal yang perlu Melakukan komunikasi terapeutik selama tindakan, menjaga
diperhatikan ketenangan, tidak ragu dan tidak tergesa-gesa selama tindakan,
memastikan keamanan dan kenyamanan klien dan peneliti selama
tindakan, serta memperhatikan respon klien.
Lampiran 4
CUPLIKAN TAMPILAN VIDEO KARTUN DAN ANIMASI
a. Cuplikan Tampilan Video Kartun

Video 1 : Upin Ipin – Kawan - Kawan Hilang?
Sumber : https://www.youtube.com/watch?v=51SCDlUDfx4
Video 2 : Doraemon - Pesawat UFO Alien & Beso Anjing Pengganti Manusia
Sumber : https://www.youtube.com/watch?v=nKEp-7xXK44
Video 3 : BoBoiBoy – Season 1 Episode 2 Part 1
Sumber : https://www.youtube.com/watch?v=t_H8fQZQUDM&t=18s
Video 4 : Masha and the Bear - Monkey Business

Sumber :
b. Cuplikan Tampilan Video Animasi

Video 1 : Menjelaskan Anestesi pada Anak
Sumber : https://www.youtube.com/watch?v=FblP0vn3qxI
Lampiran 5
LEMBAR BIMBINGAN
PENYUSUNAN KARYA ILMIAH PROGRAM STUDI PROFESI NERS
JURUSAN KEPERAWATAN – POLTEKKES KEMENKES
SEMARANG
Nama Mahasiswa : Nurus Suroya

NIM : P1337420919047
Program Studi : Profesi Ners
Pembimbing Utama : Ns. Anwar Adi P, S.Kep
Pembimbing Pendamping : Suharto, S.Pd., MN
Judul : Video Kartun dan Animasi dalam Menurunkan Tingkat
Kecemasan Pre Operasi pada Anak Usia Pra Sekolah di
Ruang Prabu Kresna RSUD K.R.M.T Wongsonegoro
Kota Semarang
TTD
No Hari/Tanggal Materi Bimbingan Saran Bimbingan
Pembimbing
4. Selasa, 18 Perbaikan (revisi) Durasi pelaksanaan penerapan
Februari pasca Proposal EBP menonton video kartun
2020 KIN dan animasi lebih diperjelas
5. Rabu, 29 Bab 3 dan 4 Perbaiki kesalah ejaan sesuai

April 2020 kaidah penulisan KBBI
6. Selasa, 05 Kelengkapan KIN ACC dan lanjutkan ujian hasil

Mei 2020 KIN
7. Kamis, 2 Juli Perbaikan (revisi) ACC dan lanjutkan publikasi

2020 pasca ujian hasil hasil Karya Ilmiah
KIN dan naskah
publikasi
Lampiran 5
LEMBAR BIMBINGAN
PENYUSUNAN KARYA ILMIAH PROGRAM STUDI PROFESI NERS
JURUSAN KEPERAWATAN – POLTEKKES KEMENKES
SEMARANG
Nama Mahasiswa : Nurus Suroya

NIM : P1337420919047
Program Studi : Profesi Ners
Pembimbing Utama : Ns. Anwar Adi P, S.Kep
Pembimbing Pendamping : Suharto, S.Pd., MN
Judul : Video Kartun dan Animasi dalam Menurunkan Tingkat
Kecemasan Pre Operasi pada Anak Usia Pra Sekolah di
Ruang Prabu Kresna RSUD K.R.M.T Wongsonegoro
Kota Semarang
TTD
No Hari/Tanggal Materi Bimbingan Saran Bimbingan
Pembimbing
4. Selasa, 18 Perbaikan (revisi) Laporan KIN tidak dilakukan
Februari pasca Proposal implementasi karena adanya
2020 KIN pandemic Covid 19
5. Kamis, 26 Bab 3 dan 4 Bab hasil dan pembahan sesuai

Maret dengan tujuan
6. Sabtu, 16 Kelengkapan KIN ACC, persiapkan power point

Mei 2020 dan lanjutkan ujian hasil KIN
7. Rabu, 01 Juli Perbaikan (revisi) ACC dan lanjutkan publikasi

2020 pasca ujian hasil hasil Karya Ilmiah
KIN dan naskah
publikasi
Lampiran 6
LEMBAR PERBAIKAN (REVISI)

UJIAN KARYA ILMIAH NERS
NAMA MAHASISWA : NURUS SUROYA

NIM : P1337420919047
JUDUL KIN : VIDEO KARTUN DAN ANIMASI DALAM
MENURUNKAN TINGKAT KECEMASAN PRE OPERASI PADA ANAK
USIA PRA SEKOLAH DI RUANG PRABU KRESNA RSUD K.R.M.T
WONGSONEGORO KOTA SEMARANG
TELAH DIREVISI DAN DISETUJUI DENGAN PERBAIKAN SEBAGAI

BERIKUT :
NO. PERBAIKAN/ POIN REVISI TANDA TANGAN

1. 1. Perbaiki karya ilmiah sesuai masukan dari
PENGUJI I
pembimbing II
2. Klarifikasi mengenai risiko hambatan dalam
penerapan intervensi menonton video kartun
Ns. Anwar Adi P, S.Kep
dan animasi di ruang Prabu Kresna
NIP. 198005032005011007
K.R.M.T Wongsonegoro Kota Semarang
2. 1. Tambahkan studi pendahuluan pada latar
belakang PENGUJI II
2. Bab 3 pada sub bab hasil dan pembahan

dipisah dan disesuaikan dengan tujuan
khusus dan sesuai conclution abstrak Suharto, S.Pd., MN
3. Simpulan mengacu pada hasil dan saran NIP. 196605101986031001
mengikuti simpulan
LEMBAR PERSETUJUAN PERBAIKAN (REVISI)
UJIAN KARYA ILMIAH NERS
NAMA : NURUS SUROYA

NIM : P1337420919047
TANGGAL UJIAN : KAMIS, 21 MEI 2020
PROGRAM STUDI : PROFESI NERS
JUDUL KIN : VIDEO KARTUN DAN ANIMASI DALAM
MENURUNKAN TINGKAT KECEMASAN PRE OPERASI PADA ANAK
USIA PRA SEKOLAH DI RUANG PRABU KRESNA RSUD K.R.M.T
WONGSONEGORO KOTA SEMARANG
TELAH DIREVISI DAN DISETUJUI OLEH TIM PENGUJI/ TIM

PEMBIMBING
NO. NAMA PENGUJI TANDA TANGAN

1. PENGUJI I
Ns. Anwar Adi P, S.Kep
NIP. 198005032005011007
2. PENGUJI II
Suharto, S.Pd., MN
NIP. 196605101986031001
[Downloaded free from http://www.njcponline.com on Sunday, January 26, 2020, IP: 118.96.98.61]
Original Article
Effects of Auditory and Audiovisual Presentations on Anxiety and

Behavioral Changes in Children Undergoing Elective Surgery
Z Hatipoglu, E Gulec, D Lafli, D Ozcengiz
Department of
Anesthesiology and Background: Preoperative anxiety is a critical issue in children, and
ABSTRA
Reanimation, Faculty associated with postoperative behavioral changes. Aims: The purpose of the
of Medicine, Cukurova current study is to evaluate how audiovisual and auditory presentations about the
University, Adana, Turkey perioperative period impact preoperative anxiety and postoperative behavioral
disturbances of children undergoing elective ambulatory surgery. Materials and
Methods: A total of 99 patients between the ages of 5–12, scheduled to undergo
outpatient surgery, participated in this study. Participants were randomly assigned
to one of three groups; audiovisual group (Group V, n = 33), auditory group
(Group A, n = 33), and control group (Group C, n = 33). During the evaluation,
the Modified Yale Preoperative Anxiety Scale (M-YPAS) and the
posthospitalization behavioral questionnaire (PHBQ) were used. Results: There
were no significant differences in demographic characteristics between the
groups. M-YPAS scores were significantly lower in Group V than in Groups C
and A (P < 0.001 and P < 0.001, respectively). PHBQ scores in Group C were
statistically higher than in Groups A and V, but, no statistical difference was
found between Groups A and V. Conclusion: Compared to auditory
presentations, audiovisual presentations, in terms of being memorable and
interesting, may be more effective in reducing children’s anxiety. In addition, we
can suggest that both methods can be equally effective for postoperative
Date of Acceptance: behavioral changes.
22-Nov-2017
INTRODUCTION systems, preoperative information programs, hypnosis,

ospitalization and surgery are a serious and music, and acupuncture.[2]
H memorable event for children and their parents.

Children undergoing surgery and their parents can be
Behavioral interventions that are used as preoperative
preparation programs are applied through coping skills,
anxious in the preoperative period, and it occurs up to
modeling, and play therapy.[2] The aim of behavioral
65% of children.[1] Preoperative anxiety is associated
programs is to teach coping skills through modeling
with postoperative pain, emergence delirium, and
for anxiety to children and also to provide information
postoperative behavioral changes (e.g., general anxiety,
about the perioperative process. These interventions
appetite changes, sleep disturbances, enuresis, and
should be prepared taking into consideration a child’s
temper tantrums).[2-4]
age, developmental stage, and previous experience.[2,6]
Pharmacological and nonpharmacological methods are
utilized to treat preoperative anxiety in children. In the Address for correspondence: Dr. Z Hatipoglu,
recent years, nonpharmacological methods are preferred Department of Anesthesiology and Reanimation, Faculty
of Medicine, Cukurova University, Adana 01260, Turkey.
due to possible adverse effects (e.g., excessive sedation E-mail: hatipogluzehra@gmail.com
and delayed discharge) of pharmacological methods.[5]
Nonpharmacological methods are as follows: the This is an open access journal, and articles are distributed under the terms of the
presence of parents, distraction techniques, fun Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as
transportation appropriate credit is given and the new creations are licensed under the identical
Access this article online terms.
Quick Response Code:
Website: www.njcponline.com For reprints contact: reprints@medknow.com
DOI: 10.4103/njcp.njcp_227_17 How to cite this article: Hatipoglu Z, Gulec E, Lafli D, Ozcengiz D.
Effects of auditory and audiovisual presentations on anxiety and
behavioral changes in children undergoing elective surgery. Niger
PMID: *******
J Clin Pract 2017;XX:XX-XX.
788© 2018 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow
Hatipoglu, et al.: Preoperative anxiety in
There are three methods which are known to be analgesia management, preoperative fasting, and regular
effective in learning; i.e., visual (pictures, images, use of the drug to be administered after surgery). Parents
demonstrations), auditory (reading, words, listening), and accompanied their children during this time. Patient’s
kinesthetic (touch, taste). Visual images are important
age, gender, history of previous surgery, type of surgery,
to visual learning, in which body language is also
and parent’s age, gender, and educational level were
used. It is also important to be informed by listening
recorded.
to auditory learning.[7] Most people learn best using
a combination of both, although visual learning is Measurements
usually the prominent component.[8] To the best of our The children in all groups were admitted with one
knowledge, an auditory-related (listening) study outside of the parents into the preoperative holding room.
of music therapy is not available for preoperative anxiety The preoperative anxiety levels of children were
management while there are limited audiovisual studies measured with the Modified Yale Preoperative Anxiety
involving children in the literature.[9-11] Scale (M-YPAS) at induction of anesthesia after being
The current study was designed to compare the effects taken into the operating room. This assessment was made
of audiovisual and auditory presentations on preoperative by an anesthesiologist who was blinded to the groups.
anxiety and postoperative behavioral disturbances of In brief, the M-YPAS is used to measure children’s
children undergoing elective ambulatory surgery. The anxiety in the preoperative holding area and during
primary end point was the preoperative anxiety levels induction of anesthesia. The M-YPAS contains 22 items
of patients. The secondary end point was the behavioral in five categories (activity, emotional expressivity,
changes of children in the postoperative period. state of arousal, vocalization, and use of parents). The
scoring in each category is done with a different number
MATERIALS AND METHODS of items (either four or six). A total adjusted score
Patients is calculated with a formula after evaluating partial
weight ([activity/4+ emotional expressivity/4+ state of
The study protocol was approved by the Institutional
arousal/4+ use of parents/4+ vocalization/6] ×100/5). The
Ethics Committee of the Cukurova University, Faculty
cutoff point of 30 on the M-YPAS leads to balance in
of Medicine (no: 45/2015). We enrolled patients between
March 2015 and February 2016. Written informed which the sensitivity and specificity are high, and the
consent was obtained from all the parents. Ninety-nine predictive value is 79%.[12]
patients with the American Society of Anesthesiologists Postoperative maladaptive behaviors of children were
physical Status I-II, aged 5–12 years old and scheduled assessed using the posthospitalization behavioral
for outpatient surgery (e.g., orchiopexy, hypospadias questionnaire (PHBQ). Parents were contacted by
surgery, inguinal hernia, tonsillectomy, adenoidectomy, telephone 7 days after hospital discharge, and this
and strabismus surgery) were accepted in the present assessment was performed by the same anesthesiologist.
study. Children with chronic illness, undergoing In brief, the PHBQ contains a total of 27 items in the
emergency surgery, cognitive disorders, and parents who following six subscales: general anxiety and regression,
refuse to participate were excluded from this study. separation anxiety, eating disturbance, aggression toward
Study design authority, apathy/withdrawal, and anxiety about sleep.
The study participants were allocated to the groups using The PHBQ is scored by parents using five response
a computer-generated randomization list at preoperative options: much less than before (1), less than before (2),
visit: audiovisual group (Group V, n = 33), auditory same as before (3), more than before (4), and much more
group (Group A, n = 33), and the standard of care than before.[13] Psychometric properties of the PHBQ
group (Group C, n = 33). have been shown in a study of Vernon et al.[14] We
considered the negative behavioral change as a response
After all patients were examined by an anesthesiologist of 4 or 5 for an item of the PHBQ.[15]
at hospital admission 1 week before surgery, the
following applications were presented: the patients in Anesthesia management
Group V were shown an audiovisual presentation to After 6 h of fasting, the children were taken into a
inform about preoperative preparation and postoperative preoperative holding area and none of the children
period [Appendix 1]. The sound recording of this video used any premedication. The children were taken
was listened to by the patients in Group A without the accompanied by their parents into the operating room
visual element of the audiovisual presentation. The from the preoperative holding area. Standard monitoring
patients in Group C were verbally informed on usual the was applied to patients (electrocardiogram, pulse
anesthesia practice of our hospital (e.g., anesthesia and oximeter, and noninvasive blood pressure). Anesthesia
induction was provided with 6%–8% sevoflurane and
Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 6 ¦ June 2018789
a gas mixture of (40%–60%) oxygen/nitrous oxide. the statistical hypotheses were fulfilled or not. For
After placing intravenous (IV) cannula on the hand, normally distributed data, regarding the homogeneity of
rocuronium 0.6 mg/kg was administered and all patients variances, Bonferroni, Scheffe, Tamhane tests were used
were intubated. Fluid resuscitation was accomplished for multiple comparisons of groups. For abnormally
with Ringer’s lactate solution (3–5 ml/kg/h). After distributed data, a Bonferroni adjusted Mann–Whitney
anesthesia induction, the parents were taken out of U-test was used for multiple comparisons of groups.
the operating room with a nurse. Maintenance of To evaluate the correlations between measurements, the
anesthesia was provided with 1%–2% sevoflurane and Pearson correlation coefficient was used. Multivariate
a gas mixture of (40%–60%) oxygen/nitrous oxide. logistic regression analysis was used to determine the
For intraoperative analgesia, fentanyl 1 g/kg was predictors of postoperative maladaptive behaviors.
given. Tramadol (2 mg/kg, IV) was administered for According to the “cutoff points,” patients were divided
postoperative analgesia in all patients. After the end into two subgroups; a calm group that included
of the surgery, anesthesia was terminated, and the patients who scored <30th percentile of the M-YPAS
neuromuscular blockade was antagonized with atropine and an anxious group that included patients who
(0.015 mg/kg, IV) and neostigmine (0.05 mg/kg, IV). scored >30th percentile of the M-YPAS.[12] The statistical
The awakened patients were transferred to the recovery level of significance for all tests was considered to be
room accompanied by their parents. After recovery, the 0.05.
children were transported to their clinical wards.
Statistical analysis RESULTS
Sample size analysis was performed using G*Power Flow diagram for the study is shown in Figure 1. The
version 3.1.9.2 (G*Power Software, Kiel, Germany). demographic characteristics of patients and parents were
We calculated the sample size with a power of 0.80 and similar between the three groups [Table 1]. No
an  of 0.05 as 24 patients for each group to detect 10 significant differences were found in terms of surgical
points difference in M-YPAS scores between the groups. data between the three groups [Table 2].
A control mean M-YPAS score of 50 with an SD of 12
was reported in a previous study.[16] All analyses were Table 2: Surgical data
performed using IBM SPSS Statistics software package Group V Group A Group C P
(IBM SPSS Statistics for Windows, Version 20.0; IBM Surgery
Corp., Armonk, New York, USA). Categorical variables ENT (other) 19 15 7 0.55
were expressed as numbers and percentages, whereas Ear tube insertion 3 5 2
continuous variables were summarized as a mean and Strabismus 4 6 11
standard deviation and as median and range where Dental surgery 2 2 3
appropriate. The normality of distribution for continuous Circumcision 2 3 1
variables was confirmed with the Kolmogorov–Smirnov Other 3 2 9
test. For comparison of continuous variables between Time of surgery (min)a 50.0±14.3 46.1±14.2 51.9±21.8 0.38
a
One-way ANOVA test was used. Values are presented as number
two groups, the Student’s t-test was used. For or mean±SD. ENT=Ear-nose-throat; ENT
comparison of three groups, the One-way ANOVA or (other)=Adenoidectomy, tonsillectomy, adenoidectomy and
Kruskal–Wallis test was used depending on whether tonsillectomy; SD=Standard deviation
Table 1: Patients and parents’ demographic data

Group V Group A Group C P
Patients
Age (years)a 7.6±2.0 7.4±1.9 7.6±2.3 0.93
Gender (female/male) 16/17 17/16 15/18 0.88
Birth order (first born/middle/later) 16/10/7 23/4/6 15/13/5 0.37
Previous surgery (yes/no) 10/23 10/23 17/16 0.12
Time of previous
surgery Last 1 year 6 4 6 0.21
Last 1 years ago 4 6 11
Parents
Age (years)a 36.9±5.4 34.6±5.1 36.7±5.3 0.13
Gender (female/male) 19/14 21/12 20/13 0.88
Education (literate/primary school/higher/university) 1/10/22 0/11/22 0/17/16 0.28
a
One-way ANOVA test was used. Values are presented as number or mean±SD. SD=Standard deviation
790Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 6 ¦ June 2018

Figure 1: Flow diagram of the study
Table 3: The means of the Modified Yale Table 4: Predictors for postoperative
Preoperative Anxiety Scale and Posthospitalization maladaptive behavioral changes
Behavioral Questionnaire Predictors OR 95% CI P
Group V Group A Group C P M-YPASa 1.03 1.01-1.06 0.002
M-YPAS 27.4±7.1 39.3±19.2 73.1±18.0 <0.001a,b,c Parent gender (female/male)b 4.05 1.39-1.06 0.01
PHBQ 81.4±2.6 82.1±1.8 87.6±3.4 <0.001a,b Agec 0.40 0.13-1.16 0.09
a
P<0.001 for Group C versus Group V; bP<0.001 for a
Anxious children (>30%) compared to less anxious (<30%); bMale
Group C versus Group A; cP<0.001 for Group A versus Group compared to female; c<7 years of age compared to >7 years of age.
V. PHBQ=Posthospitalization Behavioral Questionnaire; OR=Odds ratio; CI=Confidence interval; M-YPAS=Modified Yale
M-YPAS=Modified Yale Preoperative Anxiety Scale Preoperative Anxiety Scale
The M-YPAS scores were significantly lower in Group V of all patients, preschool children (<7 years old) had
than Groups C and A (P < 0.001) [Table 3]. When more anxiety (43.0 ± 23.3 vs. 52.3 ± 26.6, P = 0.071).
comparing the three groups, there were no statistically Similarly, the M-YPAS scores of 37 children who
relationships among age, previous surgery, type of underwent a previous surgery were compared with 62
surgery, the education level, and gender of parents on the nonoperated children, nonoperated children had lower
M-YPAS scores. However, on the basis of the evaluation M-YPAS scores (42.2 ± 23.9 vs. 54.0 ± 25.1, P = 0.022).

Table 5: New postoperative maladaptive behavioral Intervention for Preparation of Parents and Children
changes for Outpatient Surgery (WebTIPS) is a web-based
Behavioral changes Calm Anxious preoperative preparation program with features, including
group group information provision, modeling, and coping skills. The
(n=44) (n=55) study showed that WebTIPS reduces the anxiety of
Difficulty about going to bed at night 3 20* children in the preoperative settings.[21] Although both
When left alone for a few minutes, upset 1 11* studies are comprehensive programs and effective on
Need help to do things 1 8*
preoperative anxiety, the cost of these programs is quite
Avoid or afraid of new things 0 6*
expensive. In another study, Batuman et al. concluded
Temper tantrums 2 13*
Negative reaction to doctors or hospitals 2 28*
that informational videos about preoperative preparation
Follow you everywhere around the house 1 8* help to decrease children’s preoperative anxiety.[22]
Sleeping problems 0 19* Unlike our study, they evaluated the effects on the
*P<0.05 between the groups. Anxious children (M-YPAS >30%) preoperative anxiety of only audiovisual presentation.
compared to calm children (M-YPAS <30%). n=Number of The result of these studies shows that an audiovisual
patients; M-YPAS=Modified Yale Preoperative Anxiety Scale presentation about preoperative information produces
improved outcomes on children’s anxiety, and it is
The patients in Group C had statistically higher PHBQ considered a low-cost method.
scores than those in Groups A and V (P < 0.001) [Table
3]. For all patients, no correlation was found between A systematic review reported that music therapy might
PHBQ and children’s age, whereas there was a be an ineffective method for coping with anxiety,
correlation between PHBQ and parent gender (P = 0.01). and an audiovisual presentation is more effective
In addition, anxious child (<30th percentile) had 1.03 than music therapy in reducing preoperative anxiety
times greater risk of adopting negative behaviors than a in children.[9] Similar to the findings in our study,
calm child (>30th percentile) [Table 4]. Especially, in preoperative information video has a stronger impact
anxious children, there was a significant correlation on children’s anxiety than an auditory presentation.
between M-YPAS and general anxiety, separation Although both methods include the same information,
anxiety, apathy, and sleep disturbances (P < 0.05), and an audiovisual presentation may be more memorable
the number of new postoperative maladaptive and interesting to children. Since children have broad
behavioral changes is summarized Table 5. imaginations, the mental visualization in an auditory
presentation will be unique for each child. This may
DISCUSSION cause them to misperceive the given information from
The results of the present study showed that audiovisual auditory methods in unfavorable ways and become
presentation related to preanesthetic information in afraid of the upcoming surgery.
children is an effective approach in reducing preoperative In this study, there is no relationship between the
anxiety. Furthermore, children who were informed with children’s age and M-YPAS. This is consistent with
audiovisual and audio presentation had less behavioral the study by Vagnoli et al.[23] Although there was no
changes 1 week after discharge. statistical difference, children under the age of 7 years
In the literature, there are some trials that used were more anxious. Surgery creates a greater emotional
audiovisual presentations for providing information stress in younger children due to poorer comprehension
to patients.[17-19] Gaskey showed that the addition of increased dependency on the mother, less communication
audiovisual presentation to the routine preoperative with the social environment, and decreased the ability to
anesthesia visit did not produce a significant reduction manage anxiety.[24] The study also shows that children
in preoperative anxiety levels in adult patients. without any previous operations had less anxiety. This
However, patients were less nervous and had higher should be noted as preoperative information programs
levels of knowledge about anesthesia procedures. [18] In may adversely affect the emotional status in previously
contrast, the study findings demonstrated exposure to an hospitalized children.[6]
audiovisual presentation significantly reduced anxiety at Risk factors for negative postoperative behavior changes
anesthesia induction. In this regard, Kain et al. stated
have been reported to include the following; preoperative
that behavioral preparation program (ADVANCE:
anxiety, younger age, previous anesthesia experiences,
Anxiety-reduction, Distraction, Video modeling,
premedication, and increased parental anxiety. [1,4] In this
Adding parents, No excessive reassurance, coaching,
study, the children who received a standard information
and exposure/shaping) is efficient in the reduction of
had more PHBQ scores. Similarly, Hilly et al. indicated
children’s anxiety.[20] Similarly, Web-Based Tailored
that workshops for preoperative preparation decrease

both preoperative anxiety levels and postoperative

behavioral changes in children.[3] Regardless of the
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10. Bradt J, Dileo C, Shim M. Music interventions for preoperative
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APPENDICES
Appendix 1: The content of the audiovisual presentation
The total duration of the video recording was 344 s and it consisted of two sections: Part 1 and 2. Doctors, nurses,
an 11-year-old female, and her mother took part in the video and special permission was received from them to be
recorded. The audiovisual presentation was recorded in the anesthesia clinic and operating room of our hospital.
Part 1: This section is 300 s long and includes the verbal explanation by the anesthesiologist of preoperative
information, anesthesia management, and the postoperative period. Three people were involved in this section: the
anesthesiologist, the child, and her mother. The teddy bear was used as model. The child and her mother visit the
anesthesiologist for preoperative information in the anesthesia clinic. The anesthesiologist meets with them and then
informs them about the surgery and the anesthesia methods. First, the child asks “What is surgery?” and then she
mentions “I am afraid of the pain.” The doctor explains that “You will not be in any pain” and continues by saying,
“The duties of the anesthesiologist are to apply anesthesia to patients, to reduce their pain and ensure their well -being
during operation.” After the child relaxes, the anesthesiologist describes how anesthesia is administered by two
methods. The first method is to insert a small plastic tube into a vessel on the hand and some anesthetic drugs are
administered via the small tube. The anesthesiologist uses a teddy bear for the second method. The doctor explains
“This is a face mask and it smells nice.” She puts a small face mask on the face of the teddy bear and says, “It is
connected to the anesthesia machine by a plastic tube. Anesthetic gases are given through the plastic tube.” The
doctor pretends to tell the teddy bear to take deep breaths and says, “This will help you fall asleep quickly and after
that the surgery will be performed. At the end of surgery, you will be awakened by the administering of some drugs.
Furthermore, I will administer drugs for pain relief.” After explaining anesthesia, the doctor says to the child’s mother
“Your child will be safe and you should not feel restlessness related to the surgery or anesthesia.” The anesthesiologist
explains that preoperative fasting is six hours and postoperative drugs are given regularly. They leave and plan to meet
again the next day for the operation.
Part 2: This section is 44 s long and contains preoperative preparation, anesthesia induction, and a recovery period. The
child and mother come into the operating room with the personnel. The nurse meets them in the preoperative holding
area. The anesthesiologist comes into the preoperative holding area and takes the child and mother into the operating
room. The doctor inserts a device in the child’s finger and explains that “The device measures the amount of oxygen in
the blood.” The doctor performs anesthesia with the face mask and says, “Take deep breaths and have a good sleep.”
After completing the operation, the doctor wakes the child and takes her into the recovery room. The anesthesiologist
talks with the child and mother and leaves from the recovery room.

Pengaruh Audiovisual Menonton Film Kartun Terhadap Tingkat Kecemasan
Saat Prosedur Injeksi Pada Anak Prasekolah
Lilis Fatmawati, Yuanita Syaiful, Diyah Ratnawati

Universitas Gresik, lilisfatmawati13@gmail.com
Abstrak
Anak usia prasekolah menganggap sakit adalah sesuatu hal yang menakutkan. Anak
mempunyai keterbatasan dalam mekanisme koping mengatasi krisis tersebut. Intervensi
audiovisual menonton film kartun merupakan teknik distraksi untuk menurunkan
kecemasan pada anak. Tujuan penelitian untuk menganalisis pengaruh audiovisual
menonton film kartun terhadap tingkat kecemasan saat prosedur injeksi pada anak
prasekolah. Penelitian ini Pre-experimental dengan jenis pretest and posttest one group
design. Pengambilan data dengan mengunakan teknik purposive sampling pada 28
responden. Variabel independen audiovisual menonton film kartun, sedangkan variabel
dependen tingkat kecemasan. Instrumen yang digunakan SOP dan skala kecemasan HAR-
S. Uji statistik menggunakan uji Paired Sample T-Test, dengan signifikasi p< 0,05. Hasil
analisis statistik didapatkan nilai sig (p = 0.001, t = 11,71) yang berarti ada pengaruh
audiovisual menonton film kartun terhadap tingkat kecemasan saat prosedur injeksi pada
anak prasekolah. Diharapkan intervensi audiovisual menonton film kartun dapat
diterapkan sebagai salah satu intervensi keperawatan untuk menurunkan kecemasan saat
prosedur injeksi pada anak prasekolah.
Kata kunci : Anak Prasekolah, Audiovisual, Kecemasan, Prosedur Injeksi
Abstract
Among preschoolers, illness is a scary thing. Children have limitations in coping
mechanisms to overcome the crisis. Audiovisual intervention in watching cartoons is a
distraction technique to reduce anxiety in children. The purpose of the study was to
analyze the effect of audiovisual cartoon movie on anxiety levels during injection
procedures in preschool children. The design of this study was using Pre-experimental
pretest and posttest one group design. The research collecting the data using purposive
sampling technique on 28 respondents. Independent variable audiovisual watching
cartoons, while dependent variable is anxiety level. The instrument used is SOP and
HAR-S anxiety scale. Statistical tests using the Paired Sample T-Test, with significance p
<0.05. From the results of the statistical analysis, the sig value was obtained (p = 0.001,
t=11.71) which means an audiovisual intervention by on watching cartoons movie was
effective to reduce anxiety levels during the injection procedure in preschool children.
We suggest that audiovisual intervention by watching cartoons movie can be applied as
one of the nursing interventions to reduce anxiety during injection procedures in
preschool children.
Keywords: Anxiety, Audiovisual, Injection Procedure, Preschool Children
PENDAHULUAN dipengaruhi dengan segala macam hal

Anak-anak adalah suatu awal kehidupan yang baru. Anak prasekolah memiliki
untuk masa-masa berikutnya (Nursalam, ketrampilan verbal dan perkembangan
2013). Anak prasekolah (3-6 tahun) menjadi lebih baik untuk beradaptasi di
merupakan masa yang menyenangkan, berbagai situasi, tetapi penyakit dan
15
16 Jurnal Ilmiah Kesehatan (Journal of Health Sciences), Vol. 12, No. 2, Agustus 2019, Hal. 15-29
hospitalisasi bisa menyebabkan stress. (James, 2010 dalam Saputro H dan Intan
Tetapi kenyataaannya tidak semua anak Fazrin, 2017). Di Indonesia sendiri jumlah
mengalami masa-masa menyenangkan, anak yang dirawat pada tahun 2014
anak juga mengalami sakit yang sebanyak 15,26% (Susenas, 2014). Anak
mengharuskan mereka dirawat di rumah usia prasekolah, anak usia sekolah
sakit (Utami, 2014). Sakit dan merupakan usia rentan terhadap penyakit,
hospitalisasi terjadi pada anak bisa sehingga banyak anak usia tersebut harus
mengakibatkan stress dan kecemasan dirawat di rumah sakit, serta menyebabkan
disemua tingkat usia. Penyebab kecemasan populasi anak yang dirawat di rumah sakit
dipengaruhi oleh banyak faktor, dari mengalami peningkatan sangat dramatis
petugas rumah sakit (dokter, perawat, serta (Wong, 2009).
tenaga kesehatan lainnya), lingkungan Miller (2002) kecemasan anak saat
baru, reaksi keluarga yang mendampingi menjalani hospitalisasi berkisar 10%
anak selama perawatan (Nursalam, dkk, mengalami kecemasan ringan, itu
2013). Seringkali mereka harus menjalani berlanjut, sekitar 2% mengalami kece-
intervensi medis atau tindakan invasive masan berat. Penelitian dilakukan untuk
yang dapat menimbulkan ketakutan pada melihat respon hospitalisasi terjadi anak
anak seperti prosedur injeksi, pengambilan usia 3-12 tahun didapatkan bahwa 77%
atau tes sampel darah, operasi, medikasi anak mengatakan nyeri serta takut saat
dan intervensi keperawatan lainnya. dilakukan pengambilan darah, 63% anak
WHO (2012) bahwa 3-10 % anak mengalami kekakuan otot, 63% anak
dirawat di Amerika Serikat baik anak usia menangis sampai berteriak (Burnsnader,
toddler, prasekolah ataupun anak usia 2014 dalam Carla, 2017). Diperkirakan 35
sekolah, di Jerman sekitar 3 - 7% anak per 100 anak menjalani hospitalisasi 45%
toddler dan 5 - 10% anak prasekolah yang diantaranya mengalami kecemasan saat
menjalani hospitalisasi (Purwandari, 2013 menjalani perawatan di Rumah Sakit
dalam Carla, 2017). UNICEF jumlah anak (Depkes, 2010 dalam Widiatmoko, 2018).
usia prasekolah di 3 negara terbesar dunia Berdasarkan data dari Badan Pusat
mencapai 148 juta, 958 anak dengan Statistik (BPS) Jawa Timur dapat
insiden anak yang dirawat di rumah sakit dijelaskan bahwa anak usia prasekolah dari
57 juta anak setiap tahunnya dimana 75% tahun ke tahun semakin meningkat, data
mengalami trauma berupa ketakutan dan tahun 2013 menunjukkan jumlah anak usia
kecemasan saat menjalani perawatan prasekolah yang ada di Jawa Timur
Lilis Fatmawati, Yuanita Syaiful, Diyah Ratnawati 17
Pengaruh Audiovisual Menonton Film Kartun Terhadap Tingkat Kecemasan Saat Prosedur Injeksi Pada Anak
Prasekolah
2.485.218 dengan angka kesakitan Anak usia prasekolah menganggap sakit

1.475.197, mengalami kecemasan saat adalah sesuatu hal yang menakutkan,
menjalani perawatan akibat sakitnya kehilangan lingkungan yang aman dan
sebanyak 85% (Dinkes Propinsi Jawa penuh kasih sayang, serta tidak
Timur, 2014 dalam Saputro H dan Intan menyenangkan (Supartini, 2014). Asuhan
Fazrin, 2017). Data yang di Rumah Sakit keperawatan pada anak biasanya
Semen Gresik tahun 2017 terdapat 3043 memerlukan tindakan invasif seperti
anak yang dirawat, diantaranya 758 anak injeksi atau pemasangan infus, hal ini
usia prasekolah. Pada bulan Januari - April merupakan stresor kuat yang dapat
2018 terdapat 1173 anak yang dirawat, membuat anak mengalami kecemasan.
terdapat 262 anak usia prasekolah. Perawat biasanya akan menjelaskan
Data tingkat kecemasan anak yang prosedur ini kepada orangtua dan
diukur dengan menggunakan kuisioner melakukan komunikasi terapeutik kepada
Hamilton Rating Scala for Anxiety (HRS- anak sebelum melakukan prosedur
A) yang dilakukan pada tanggal 21 - 27 tersebut, kondisi ini juga membuat anak
Mei 2018 di Rumah Sakit Semen Gresik menjadi panik dan biasanya melakukan
terdapat 10 anak usia prasekolah (3-5 th) perlawanan atau menolak untuk dilakukan
yang dirawat dan dilakukan tindakan posedur pemasangan infus atau injeksi
pemberian injeksi, terdapat 3 (30%) anak obat, yang biasanya akan memaksa petugas
mengalami kecemasan sedang, 5 (50%) kesehatan untuk sedikit melakukan
mengalami kecemasan berat, sedangkan 2 paksaan kepada anak yang mengakibatkan
(20%) anak mengalami kecemasan ringan, timbulnya trauma pada anak. Reaksi anak
dari data tersebut menunjukkan anak yang terhadap tindakan invasive ini ditunjukkan
mengalami kecemasan berat di ruang anak dengan agresi fisik dan verbal
rawat inap Rumah Sakit Semen Gresik (Hockenberry, Wilson & Winkelstein,
masih cukup banyak. Selama ini perawat 2008).
maupun tenaga kesehatan lainnya hanya Oleh karena itu anak seringkali
menggunakan teknik komunikasi langsung menunjukkan perilaku tidak kooperatif
(direct) berupa instruksi sederhana maupun seperti sering menangis, marah-marah,
modeling. Namun pemberian audiovisual tidak mau makan, rewel, susah tidur,
terhadap tingkat kecemasan saat dilakukan mudah tersinggung, meminta pulang dan
prosedur pemberian injeksi pada anak tidak mau berinteraksi dengan perawat dan
prasekolah belum bisa dijelaskan. seringkali menolak jika akan diberikan
pengobatan. Kondisi cemas yang terjadi Audiovisual yang digemari oleh anak-
pada anak akan menghambat dan anak usia prasekolah adalah kartun atau
menyulitkan proses pengobatan yang gambar bergerak, merupakan media yang
berdampak terhadap penyembuhan pada sangat menarik bagi anak-anak terutama
anak sehingga memperpanjang masa rawat anak usia prasekolah yang memiliki daya
dan dapat beresiko terkena komplikasi dari imajinasi tinggi. Anak juga dapat
infeksi nosokomial serta menimbulkan mengeksplorasi perasaan, emosi, dan daya
trauma pada anak. Untuk mengatasi ingat melalui audio visual, audio visual
memburuknya tingkat kecemasan pada juga dapat membantu perawat dalam
anak, seorang perawat dalam memberikan melaksanakan prosedur infus dan injeksi,
intervensi kepada anak harus memudahkan perawat dalam mendistraksi
memperhatikan kebutuhan anak sesuai agar anak kooperatif dalam pelaksanaan
dengan pertumbuhan anaknya. prosedur terapi (Tamsuri, 2007). Cara yang
Beberapa tindakan yang pernah dilakukan yaitu dengan memfokuskan
dilakukan untuk menurunkan tingkat perhatian pada suatu hal yang disukai oleh
kecemasan pada anak antara lain: bermain anak, misalnya menonton film kartun
boneka, bermain clay, bermain puzzle, (Maharezi, 2014 dalam Hapsari 2016).
aktivitas mewarnai, terapi musik, juga Berdasarkan latar belakang di atas, maka
tehnik komunikasi terapeutik, serta tehnik peneliti tertarik melakukan penelitian
pengalihan perhatian (distraksi). tentang pengaruh audiovisual menonton
Kombinasi antara distraksi pendengaran film kartun terhadap tingkat kecemasan
(audio) dan distraksi penglihatan (visual) saat prosedur injeksi pada anak prasekolah.
disebut distraksi audiovisual, yang
digunakan untuk mengalihkan perhatian METODE
pasien terhadap sesuatu yang membuatnya Penelitian ini menggunakan desain pra-
tidak nyaman, cemas atau takut dengan experimental dengan rancang bangun one-
cara menampilkan tayangan favorit berupa grup pra-post test design. Penelitian
gambar-gambar bergerak dan bersuara dilaksanakan pada 5-28 Januari 2019.
ataupun animasi dengan harapan pasien Populasinya adalah seluruh anak usia
asik terhadap tontonannya sehingga prasekolah yang masuk di Ruang Anak
mengabaikan rasa tidak nyaman dan Rumah Sakit Semen Gresik. Pengambilan
menunjukkan respon penerimaan yang sampel menggunakan teknik purposive
baik. sampling, sebanyak 28 responden.
Prasekolah
Variabel independen (audiovisual menonton film kartun, berupa salah satu

menonton film kartun), Upin Ipin, film kartun anak Upin Ipin, Frozen the
Doraemon dan Frozen The Snow yang snow, Doraemon, sesuai kesediaan pasien.
diputar dengan menggunakan tablet phone. Pemberian intervensi film kartun tersebut
Variabel dependen (tingkat kecemasan). diberikan minimal 10 menit. Sedangkan
Intervensi menonton film kartun diberikan prosedur injeksi diberikan durante
selama minimal 10 menit, sedangkan menonton film kartun. Dalam memberikan
prosedur injeksi durante menonton film intervensi audiovisual film kartun perawat
kartun. Alat ukur yang digunakan pada juga melibatkan keluarga dan teman
penelitian ini adalah kuesioner HAR-S perawat dalam satu ruang rawat inap
yang merupakan pengukuran kecemasan tersebut, demikian juga dalam proses
didasarkan pada munculnya simptom pada dokumentasi. Peneliti melakukan post test
individu yang mengalami kecemasan. untuk pengambilan data tingkat kecemasan
Prosedur penelitiannya yaitu peneliti akan responden menggunakan ceklis kuesioner
melakukan pre test kepada responden pada kecemasan skala HAR-S yang diisikan oleh
hari kedua rawat inap saat diberikan keluarga/orangtua responden.
prosedur injeksi. Kemudian kuesioner Dalam penelitian ini menggunakan analisa
(tingkat kecemasan HAR-S) diisi oleh univariat dan bivariat menggunakan uji
keluarga berdasarkan hasil observasi saat Paired T-test untuk mengamati ada
itu, pada hari yang sama saat jadwal tidaknya perbedaan dari dua data yang
pemberian injeksi selanjutya, peneliti akan merupakan sebuah sampel tetapi
memberikan intervensi audiovisual mengalami perlakuan yang berbeda.
Tabel 1. Tingkat Kecemasan Sebelum dan Sesudah Intervensi Audiovisual Menonton Film
Kartun Saat Prosedur Injeksi Pada Anak Prasekolah di Ruang Anak Rumah Sakit
Semen Gresik pada tanggal 5-28 Januari 2019
Tingkat Sebelum Interensi Sesudah Intervensi

Kecemasan Frekuensi Persentase (%) Frekuensi Persentase (%)
Tidak cemas 2 7.1 23 82.1
Ringan 6 21.4 3 10.7
Sedang 2 7.1 1 3.6
Berat 17 60.7 1 3.6
Panik 1 3.6 0 0
Total 28 100.0 28 100.0
Sumber: Data Primer 2019
64 Jurnal Ilmiah Kesehatan (Journal of Health Sciences), Vol. 12, No. 2, Agustus 2019, Hal. 15-
Tabel 2. Pengaruh Audiovisual Terhadap Tingkat Kecemasan Saat Prosedur Injeksi Pada
Anak Prasekolah di Ruang Anak Rumah Sakit Semen Gresik pada tanggal 5-28
Januari 2019
Intervensi Audiovisual Menonton Film Kartun

Tingkat Kecemasan Sebelum intervensi Sesudah intervensi
F % F %
Tidak cemas 2 7.1 23 82.1
Ringan 6 21.4 3 10.7
Sedang 2 7.1 1 3.6
Berat 17 60.7 1 3.6
Panik 1 3.6 0 0.0
Total 28 100.0 28 100.0
Mean 28.67 11.75
Std.Deviation 9.03 5.00
Paired Sample T-Test nilai sig (2-tailed) p = 0.000 t = 11.61
Sumber: Data Primer 2019
PEMBAHASAN diatasi. Bagi anak usia prasekolah (3-6

1. Tingkat Kecemasan Sebelum Inter- tahun) menjalani hospitalisasi dan
vensi Audiovisual Menonton Film mengalami tindakan invasif merupakan
Kartun Saat Prosedur Injeksi Pada suatu keadaan krisis disebabkan karena
Anak Prasekolah adanya perubahan status kesehatan,
Berdasarkan tabel 1 menunjukkan bahwa lingkungan, faktor keluarga, kebiasaan
hasil penelitian sebelum intervensi atau prosedur yang dapat menimbulkan
audiovisual menonton film kartun saat nyeri dan kehilangan kemandirian pada
prosedur injeksi pada anak prasekolah anak (Wong, 2009). Lingkungan rumah
sebagian besar mengalami kecemasan sakit, petugas kesehatan dan alat-alat yang
berat sebanyak 17 (60.7%). Sama dengan berada di rumah sakit yang baru dilihat
penelitian sebelumnya mengenai pengaruh oleh anak menyebabkan anak menjadi
terapi audiovisual terhadap tingkat takut dan cemas. Penyebab stress dan
kecemasan anak usia prasekolah yang kecemasan pada anak dipengaruhi oleh
dilakukan pemasangan infus sebagian banyak faktor, diantaranya perilaku yang
besar mengalami kecemasan berat 55.6% ditunjukkan petugas kesehatan (dokter,
(Ganda, 2017). perawat dan tenaga kesehatan lainnya),
Kondisi cemas yang terjadi pada anak pengalaman hospitalisasi anak, support
yang menjalani hospitalisasi dan system atau dukungan keluarga yang
mendapatkan tindakan invasif harus mendampingi selama perawatan. Faktor-
mendapat perhatian khusus dan segera faktor tersebut dapat menyebabkan anak
64 Jurnal Ilmiah Kesehatan (Journal of Health Sciences), Vol. 12, No. 2, Agustus 2019, Hal. 15-
menjadi semakin stress dan hal ini menggigit, menendang-nendang bahkan

berpengaruh terhadap proses penyembuhan berlari ke luar ruangan.
(Nursalam dkk., 2013). Selain umur, jenis kelamin juga dapat
Peneliti mengambil sampel usia 3-6 mempengaruhi kecemasan dan stress pada
tahun atau rentang perkembangan anak anak, dimana anak perempuan prasekolah
usia prasekolah. Berdasarkan karakteristik yang menjalani hospitalisasi memiliki
responden didapatkan umur responden tingkat kecemasan yang lebih tinggi
adalah anak usia 3-4 tahun sebanyak 46%, dibandingkan laki-laki. Distribusi dalam
usia 4,1-5 tahun 25%, usia 5,1-6 tahun penelitian ini didapatkan 57% responden
29%, dan usia 6 tahun 23%. Pengumpulan adalah perempuan. Demikian juga dalam
data penelitian yang dilakukan anak yang penelitian (Stubbe, 2008 dalam
berada pada usia 3 tahun memiliki tingkat Apriliawati, 2011) menyebutkan bahwa
kecemasan yang tinggi. Menurut Lau anak perempuan yang menjalani
(2002) dalam Apriliawati (2011) anak usia hospitalisasi memiliki kecemasan yang
infant, toodler, preschool lebih me- lebih tinggi dibandingkan dengan anak
mungkinkan mengalami stress akibat laki-laki.
perpisahan karena kemampuan kognitif Pengalaman hopitalisasi pada anak akan
anak yang masih terbatas untuk memahami mempengaruhi kecemasan yang dialami
hospitalisasi. oleh anak. Sebagaimana yang dijelaskan
Beberapa penelitian menyatakan bahwa oleh Tsai (2007) dalam Apriliawati (2011)
semakin muda usia anak, kecemasan anak yang memiliki pengalaman menjalani
hospitalisasi akan semakin tinggi (Mahat hospitalisasi memiliki kecemasan lebih
& Scoloveno, 2003). Menurut Utami rendah dibanding anak yang belum
(2014), anak merupakan populasi yang memiliki pengalaman hospitalisasi. Namun
sangat rentan terutama saat menghadapi dalam penelitian ini didominasi oleh anak
situasi yang membuat stress. Hal ini yang sebelumnya pernah dirawat di rumah
dikarenakan kondisi koping yang sakit sebanyak 18 anak (64%). Hal ini
digunakan oleh orang dewasa belum dimungkinkan terkait dengan tindakan atau
berkembang sempurna pada anak-anak. prosedur medis yang pernah didapat
Anak usia prasekolah menerima keadaaan sebelumnya mungkin menyebabkan
masuk rumah sakit dengan rasa ketakutan. trauma walaupun anak pernah dirawat
Jika anak sangat ketakutan dapat tetapi memiliki pengalaman tidak
menampilkan perilaku agresif, dari menyenangkan sehingga anak tetap
Prasekolah
mengalami kecemasan. Hal ini sesuai dengan marah, dan berontak. Demikian
dengan penelitian yang menyatakan bahwa pula disebutkan oleh Stuart (2009) anak
pengalaman hospitalisasi tidak yang dirawat di rumah sakit dengan
berpengaruh terhadap tingkat kecemasan kecemasan yang tinggi memiliki
anak (Stubbe, 2008 dalam Apriliawati, kecenderungan menjadi hiperaktif dan
2011). tidak kooperatif terhadap petugas
Berdasarkan teori dan hasil penelitian kesehatan serta menimbulkan gangguan
yang didapat, terdapat keselarasan dimana psikologik berupa perubahan perilaku
terdapat beberapa faktor yang dapat seperti gelisah, menangis, dan
mempengaruhi tingkat kecemasan pada memberontak.
anak. Pada anak usia prasekolah penyebab 2. Tingkat Kecemasan Sesudah Intervensi
kecemasan berkaitan dengan umur, Audiovisual Menonton Film Kartun
pengalaman dirawat sebelumnya, yang Saat Prosedur Injeksi Pada Anak
dapat menuyebabkan tinggi atau rendahnya Prasekolah
tingkat kecemasannya. Tingkat kecemasan Berdasarkan tabel 1 menunjukkan bahwa
saat prosedur injeksi sebelum intervensi hasil penelitian sesudah dilakukan
audovisual sebagian besar mengalami audiovisual menonton film kartun saat
kecemasan berat 17 responden (60.7%), prosedur injeksi pada anak prasekolah,
dan didapatkan rata-rata skor tertinggi hampir seluruhnya tidak mengalami
pada gejala menangis, merengek, berteriak kecemasan yaitu sebanyak 23 (82.1%).
dan memberontak. Hal ini selaras dengan Penelitian ini sesuai dengan
teori Supartini (2014) dimana anak usia Wahyuningrum (2015) dalam pengaruh
prasekolah menganggap sakit adalah cerita melalui audiovisual terhadap tingkat
sesuatu hal yang menakutkan, kehilangan kecemasan anak usia prasekolah yang
lingkungan yang aman dan penuh kasih mengalami hospitalisasi setelah dilakukan
sayang, serta tidak menyenangkan. Anak intervensi sebagian besar mengalami
menganggap tindakan dan prosedur rumah kecemasan dengan kategori ringan
sakit menyebabkan rasa sakit dan luka di (59.1%). Penelitian Patma (2017) dalam
tubuhnya. penelitiannya tingkat kecemasan setelah
Ketakutan anak muncul karena anak diberikan terapi audiovisual pada pasien
menganggap tindakan dan prosedurnya yang dilakukan pemasangan infus,
mengancam intregitas tubuhnya. Oleh sebagian besar mengalami kecemasan
karena itu, menimbulkan reaksi agresif ringan yaitu 6 responden (66.7%).
Demikian pula dalam penelitian ini serta dapat mengekspresikan perasaannya

setelah intervensi audiovisual menonton (Koller dan Goldman, 2012, dalam Patma,
film kartun saat prosedur injeksi pada anak 2017).
prasekolah, masih didapatkan nilai rata- Anak-anak menyukai unsur-unsur
rata ketakutan pada skor tertinggi yaitu, seperti gambar, warna, cerita pada film
takut diinjeksi dan takut pada orang kartun animasi. Unsur-unsur seperti
asing/perawat. Hal ini selaras dengan teori gambar, warna dan cerita dan emosi
yang dikemukakan Kozlowski dkk., (senang, sedih, seru, bersemangat) yang
(2013), salah satu kecemasan yang terdapat pada film kartun merupakan unsur
dirasakan oleh pasien anak ketika harus otak kanan dan suara yang timbul dari film
mendapatkan perawatan di rumah sakit tersebut merupakan unsur otak kiri. Unsur
adalah tindakan invasif, seperti pemberian grafis pada sajian anak prasekolah adalah
obat injeksi yang dilakukan oleh tim unsur yang paling penting karena pada
kesehatan. Tindakan invasif pemberian anak prasekolah unsur lisan dan audio
obat injeksi, baik menyakitkan atau tidak hanya mendapatkan perhatian sebesar 2%
merupakan suatu ancaman bagi anak usia dan 98% sisanya diporsikan pada unsur
prasekolah karena mereka menganggap visual statis (Evans dkk., 2008 dalam
tindakan invasif merupakan sumber Wahyuningrum, 2015). Sehingga dengan
kerusakan terhadap integritas tubuhnya. menonton film kartun animasi seperti Upin
Mott (2005) lingkungan rumah sakit yang Ipin, Doraemon ataupun Frozen the Snow,
dianggap asing oleh anak akan otak kanan dan otak kiri anak pada saat
meningkatkan kecemasan anak pada saat bersamaan digunakan dua-duanya secara
dirawat di rumah sakit (Apriliawati, 2011). seimbang dan anak fokus pada film kartun
Kondisi cemas yang terjadi pada anak (Wahyuningrum, 2015).
yang menjalani hospitalisasi dan Dengan memberikan sajian interaktif
mendapatkan tindakan invasif harus visual (gambar statis) dan video (gambar
mendapat perhatian khusus dan segera dinamis) maka konsentrasi anak terhadap
diatasi (Wong, 2009). Intervensi audiovisual yang dilihat akan meningkat.
audiovisual menonton film kartun adalah Sehingga audiovisual menonton film
sebuah proses yang akan membentuk kartun dapat memudahkan anak untuk
imajinasi pada anak, memberikan mendapatkan pembelajaran dengan basis
kesempatan pada anak untuk lebih yang menyenangkan. Sehingga peman-
menangkap informasi, edukasi dan hiburan faatan audiovisual dapat membantu dan
Prasekolah
memudahkan perawat dalam mendistraksi kognitif kecemasan yang menyebutkan

agar anak kooperatif dalam pelaksanaan bahwa respon yang berbeda pada tiap
prosedur injeksi (Taufik, 2007). individu antara lain dipengaruhi oleh
3. Pengaruh Audiovisual Terhadap adanya kelemahan dalam berbagai proses
Tingkat Kecemasan Saat Prosedur informasi (Blackburn, 1990, dalam Juanita,
Injeksi Pada Anak Prasekolah 2017. Namun masih didapatkan 1 respon-
Hasil uji analisa Paired T Tes untuk den mengalami kecemasan berat sesudah
mengetahui Pengaruh Audiovisual intervensi audiovisual menonton film
Menonton Film KartunTerhadap Tingkat kartun, meskipun responden kooperatif
Kecemasan Saat Prosedur Injeksi Pada saat diberikan intervensi audiovisual
Anak Prasekolah, pada penelitian ini menonton film kartun, dan masih
didapatkan hasil sig (2-tailed) p = 0.000, menunjukkan rasa takut saat akan
p< 0.05 maka H0 ditolak dan H1 diterima diinjeksi, takut pada perawat, gelisah,
yang berarti ada pengaruh audiovisual tegang, menangis, berteriak dan
menonton film kartun terhadap tingkat memberontak hingga menunjukkan muka
kecemasan saat prosedur injeksi pada anak merah dan penurunan nafsu makan. Hal ini
prasekolah di Ruang Anak Rumah Sakit dimungkinkan karena pasien mempunyai
Semen Gresik. Hasil penelitian ini sejalan riwayat sudah pernah dirawat dua kali
pada penelitian Wahyuningrum (2015), sebelumnya, sehingga pernah mempunyai
bahwa pemberian cerita melalui pengalaman yang masih menjadi sumber
audiovisual efektif dalam menurunkan kecemasan baginya, diantaranya penga-
tingkat kecemasan pada anak usia laman mendapatkan prosedur injeksi serta
prasekolah yang mengalami hospitalisasi. pemasangan infus.
Berdasarkan tabel 3 tingkat kecemasan Apabila anak mengalami kecemasan
anak sesudah diberikan audiovisual tinggi saat dilakukan tindakan invasif,
menonton film kartun saat prosedur injeksi kemungkinan besar tindakan yang
pada anak prasekolah hampir seluruhnya dilakukan menjadi tidak maksimal dan
tidak mengalami kecemasan, yaitu tidak jarang harus mengulangi beberapa
sebanyak 23 responden (82,1%). Tingkat kali sehingga akan menghambat proses
kecemasan yang berbeda pada tiap anak penyembuhan anak. Kondisi ini memper-
disebabkan pula karena respon setiap sulit perawat dalam melakukan tindakan
manusia terhadap stressor memang keperawatan (Supartini, 2014). Perlu
berbeda. Hal ini sesuai dengan model adanya upaya dalam menurunkan tingkat
kecemasan terutama saat prosedur injeksi, walaupun anak masih tetap harus di
diantaranya dengan distraksi audiovisual dampingi dan tetap dekat dengan
(Tamsuri, 2007). orangtuanya. Hasil uji analisis statistik
Koller dan Goldman (2012) dalam didapatkan adanya perbedaan tingkat
studinya menyatakan bahwa pemberian kecemasan pada pre test dan post test pada
cerita melalui audiovisual guna menurun- anak yang diberikan audiovisual menonton
kan kecemasan termasuk teknik distraksi film kartun saat prosedur injeksi. Ini
kecemasan dengan teknik audiovisual. berarti bahwa ada pengaruh audiovisual
Perhatian anak yang terfokus kepada cerita menonton film kartun dalam menurunkan
audiovisual yang disimaknya mendis- tingkat kecemasan saat prosedur injeksi
traksikan atau mengalihkan persepsi pada anak prasekolah, baik secara
kecemasan anak dalam korteks serebral. subyekstif maupun obyektif. Hal tersebut
Dengan intervensi audiovisual menonton sesuai dengan teori bahwa salah satu cara
film kartun akan memberikan rangsangan yang dapat dilakukan untuk pengendalian
distraksi berupa visual, auditory dan kecemasan adalah tehnik distraksi
tactile. Perasaan aman dan nyaman yang audiovisual untuk mengalihkan perhatian
dirasakan anak akan merangsang tubuh anak (Tamsuri, 2007, dalam Agustina
untuk mengeluarkan hormon endorphine. 2015). Perhatian anak menjadi teralihkan
Melalui pemberian audiosivisual pada film kartun yang disukai anak, yang
menonton film kartun yang diberikan oleh menyebabkan anak tidak lagi memikirkan
perawat diharapkan dapat membantu anak prosedur injeksi, anak menjadi rileks dan
dalam mengatasi permasalahan dengan nyaman sehingga menurun kecemasannya.
meminta mereka ikut terlibat tentang
kegiatan atau tindakan injeksi yang KESIMPULAN
diberikan oleh petugas sehingga dapat Sebelum diberi intervensi sebagian
membantu membangun pikiran dan responden memiliki kecemasan berat,
kemungkinan dapat menyelesaikan sedangkan sesudah diberi intervensi
masalah yang berhubungan dengan hampir seluruh responden tidak mengalami
penyakit, perpisahan selama dirawat, kecemasan. Sehingga Ada pengaruh
kecacatan dan keterasingan. Hal ini terlihat pemberian audiovisual menonton film
pada saat penelitian anak menjadi fokus kartun terhadap penurunan tingkat
dengan tayangan audiovisual menonton kecemasan saat prosedur injeksi pada anak
film kartun dibandingkan prosedur injeksi, prasekolah.
Prasekolah
DAFTAR PUSTAKA Fakultas Keperawatan Universitas

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J Pediatr (Rio J). 2018;xxx(xx):xxx---xxx
ORIGINAL ARTICLE
Psychological preparation reduces preoperative

anxiety in children. Randomized and double-blind
trial6,66
∗
Dânia P. Melettia, , José Fernando A. Melettib, Rodrigo P.S. Camargoc,
Leopoldo M. Silvad, Norma S.P. Módoloe
a
Faculdade de Medicina de Jundiaí, Ciências da Saúde, São Paulo, SP, Brazil
b
Faculdade de Medicina de Jundiaí, Departamento de Anestesiologia, São Paulo, SP, Brazil
c
Faculdade de Medicina de Jundiaí, Departamento de Ginecologia e Obstetrícia, São Paulo, SP, Brazil
d
Universidade Estadual Paulista ‘‘Júlio de Mesquita Filho’’ (UNESP), Departamento de Anestesiologia, São Paulo, SP, Brazil
e
Universidade Estadual Paulista ‘‘Júlio de Mesquita Filho’’ (UNESP), Faculdade de Medicina de Botucatu, Departamento
de Anestesiologia, Botucatu, SP, Brazil
Received 26 September 2017; accepted 26 April 2018
Abstract
KEYWORDS
Objective: To verify the effect of psychological preparation on the relief of preoperative anxiety
Child;
in children and to correlate parents’ and children’s levels of anxiety.
Anxiety;
Method: After the approval of the institutional Research Ethics Committee and written consent
Psychologic
of the children’s parents or guardians, 118 children of both genders were prospectively selected,
al
aged between 2 and 8 years, physical condition classification ASA I, who were treated in the
preparation pre-anesthetic evaluation ambulatory of the University Hospital and who underwent ambula-
; tory surgeries at the same hospital. Two controlled groups of 59 children were randomized:
Anesthesia; control group basic preparation and psychological preparation group. On the day of surgery,
Surgery all selected children were evaluated regarding their level of anxiety using the modified Yale
Preoperative Anxiety Scale and their parents were evaluated regarding their level of anxiety
through the Visual Analog Scale. The evaluator was blinded to which study group the child
and family member belonged to.
Results: Nine children and their family members were excluded per group when the results
were analyzed. Children from the prepared group showed significant reductions in their level
of anxiety in relation to the control group (p = 0.04). There was no correlation between the
level of anxiety of children and their parents’ levels (p = 0.78).
6
Please cite this article as: Meletti DP, Meletti JF, Camargo RP, Silva LM, Módolo NS. Psychological preparation reduces preoperative
anxiety in children. Randomized and double-blind trial. J Pediatr (Rio J). 2018. https://doi.org/10.1016/j.jped.2018.05.009
66
Study conducted at the Master’s Degree Program of Faculdade de Medicina de Jundiaí, São Paulo, SP, Brazil
∗
Corresponding author.
E-mail: dpmeletti@gmail.com (D.P. Meletti).
https://doi.org/10.1016/j.jped.2018.05.009
0021-7557/© 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
JPED-686; No. of Pages 7

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2 Meletti DP et al.
Conclusion: The psychological preparation was effective in reducing the level of anxiety of
children. However, there was no relation between the level of anxiety of children and their
parents’ level.
© 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Prepara¸cão psicológica reduz ansiedade pré-operatória de crian¸cas.

PALAVRAS-CHAVE
Ensaio randomizado e duplamente encoberto
Crian¸ca;
Ansiedade; Resumo
Prepara¸cã Objetivos: Verificar o efeito da prepara¸cão psicológica no alívio da ansiedade pré-
o operatória de crian¸cas e avaliar se há correla¸cão com a ansiedade dos pais.
psicológica; Método: Após a aprova¸cão do Comitê de Ética e Pesquisa da Faculdade de Medicina e
Anestesia; obten¸cão do consentimento pelos responsáveis dos pacientes, foram selecionadas
Cirurgia prospectivamente 118 crian¸cas, de ambos os sexos, com idade entre dois e oito anos,
classifica¸cão de estado físico ASA I, atendidas no ambulatório de avalia¸cão pré-anestésica
do Hospital Universitário e submetidas a cirurgias ambulatoriais. Foram randomizados dois
grupos controlados de 59 crian¸cas: grupo de prepara¸cão básica e grupo prepara¸cão
psicológica. No dia da cirurgia, todas as crian¸cas foram avaliadas em rela¸cão ao seu grau de
ansiedade através da Escala de Ansiedade Pré-operatória de Yale Modificada e seus pais,
avaliados quanto ao seu nível de ansiedade pela Escala Visual Analógica. O avaliador era cego
sobre qual grupo do estudo a crian¸ca e seu familiar pertenciam. Resultados: Na análise dos
resultados, foram excluídas 9 crian¸cas e familiares de cada grupo. As crian¸cas do grupo
preparado tiveram redu¸cões significativas no grau de ansiedade em rela¸cão ao grupo
controle, (p = 0,04). Não houve correla¸cão entre os graus de ansiedade das crian¸cas e seus
pais (p = 0.78).
Conclusão: A prepara¸cão psicológica foi eficaz na redu¸cão do grau de ansiedade das
crian¸cas no momento da cirurgia. Não houve, entretanto, rela¸cão entre os graus de
ansiedade dos pais e seus filhos.
© 2018 Sociedade Brasileira de Pediatria. Publicado por Elsevier Editora Ltda. Este é
um artigo Open Access sob a licença de CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction they do not have adverse events; however, further studies

are required to demonstrate the efficacy of distraction tech-
Anxiety is present in approximately 50% of patients who niques such as the use of medical clowns, videogames, and
undergo an anesthetic-surgical procedure.1 The prospect cartoons, among others.7,8 Psychological preparation is seen
of postoperative pain, separation from family members, as expensive due to the need for several sessions;9
exposure to strangers, fear of the surgery and anesthesia, however, it has good results in reducing preoperative
and the possibility of becoming incapacitated are factors anxiety, as well as in the psychological recovery of the
that may increase the degree of anxiety in pediatric children and their family members after the surgery.10,11
patients.2 In the preoperative period, anxiety tends to Thus, the authors propose a single-session model of
manifest as feelings of tension, nervousness, worry, psychological preparation for parents and children, with
apprehensiveness, or psychological stress.3 Some children the main objective of verifying the effect of anxiety
verbalize their dreads, while others demonstrate anxiety reduction in children at the time of the surgery. Moreover,
through behavioral changes, such as becoming restless, the authors proposed to investigate whether there would
trembling, breathing deeply, ceasing to speak, crying, or be a correlation between parents’ and children’s
becoming, in some cases, dif- ficult to control.4 In anxiety.
relation to anesthesia, high levels of anxiety can have
negative effects, such as difficulty in achieving
anesthetic induction, reduction in defenses against Methods
infections, and increase in intraoperative anesthetic
consumption and postoperative analgesics.5
Clinical study description and participants
Diverse ways to alleviate preoperative anxiety have been
widely studied, such as preanesthetic medications, dis-
After approval by the Research Ethics Committee of Facul-
traction techniques, presence of parents during anesthesia
dade de Medicina de Jundiaí (CAEE:
induction, and preoperative psychological and educational
16288513.2.0000.5412) and after the informed consent
interventions.6 The non-pharmacological management of
form was signed by the patients’ parents or guardians, 118
anxiety has advantages when compared to anxiolytics, as
children of both genders, aged between 2 and 8 years,
with physical status
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Preparation reduces preoperative anxiety in children 3
classification according to the American Association of

Anesthesiologists (ASA) I, treated at the pre-anesthetic Psychological preparation
outpatient clinic of the University Hospital of Faculdade
de Medicina de Jundiaí, and who underwent outpatient Four main questions were addressed with the parents or
surgeries at that hospital were selected. A randomized, family members present in the psychological session using
parallel-controlled, prospective, and double-blinded trial a semi-open interview model, i.e., the questions were
was carried out to evaluate the effect of psychological nec- essarily the same, but the interview varied according
preparation on the preoperative anxiety levels of children to the family responses and demands. The first question
and their parents. The methodology was not changed after addressed the feelings about the surgery by the parent
the study was started. and the child; specifically asking for the verbalization of
feelings such as fear, anxiety, concern and others as an
initial approach. In the second question, adult aspects
Allocation were questioned regarding the mother-child, or father-child
separation, from simple separations such as leaving the
Participants were randomly allocated using the List random- child with a relative for a few hours, adaptation to school,
izer program (Randomness and Integrity Services Ltd, School and other separation experiences. The third question
of Computer Science and Statistics at Trinity College, Dublin, addressed how the mother or father perceived and dealt
Ireland). This allocation was implemented by two anesthe- with the child’s health and illness situations, and the last
siologists responsible for the pre-anesthetic consultation: question addressed the child’s attachment to objects. This
they enrolled the participants, applied the exclusion cri- session with the parents was used to guide and to calm
teria and directed the participants to intervention when them down regarding the anesthesia and surgery aspects,
necessary. The exclusion criteria were children with as well as to support the children’s separation from their
proven behavioral and cognitive alterations; history of parents, so they would feel confident going into the
previous surgeries and general anesthesia; users of operating room.
psychoactive medications; and history of seizures, mental
illness, or chronic pain. Five children were excluded for
these reasons and three patients were excluded because
their parents did not agree to their participation in the Measures
study (Fig. 1).
At the pre-anesthetic evaluation outpatient clinic, on the
day of the consultation, the following tools were applied
Interventions to the parents: a questionnaire to assess the
sociodemographic profile, a questionnaire about the role of
From November 6, 2014 to October 5, 2015, two groups the anesthesiologist, the parents’ apprehensions and
of children and their parents or guardians were randomly fears related to anesthesia and assessment of their
assigned, as described below: degree of anxiety through the visual analogue scale (VAS).
Basic preparation group (BPG): a group that received Such scale, used as a secondary outcome measure, was
the standard preparation at the pre-anesthetic consulta- also applied to parents or guardians at the time of the
tion, where parents could have their questions answered and surgery. The scale measured 100 mm, where 0 (zero)
receive explanations from the anesthesiologist; as for the was equivalent to ‘‘calm’’ and 100 mm meant ‘‘very
children, on the day of surgery, they waited for the anxious.’’13 Mild anxiety was expressed by the scores 0, 1,
moment of surgery in the toy library, a place with toys and 2; moderate anxiety, 3,
and books reserved for them and their family members. 4, 5, 6, and 7; and intense anxiety, 8, 9, and 10.
Psychological preparation group (PPG): a group that, in On the day of the surgery, all children selected from both
addition to the basic preparation, underwent a psycholog- groups were referred to the toy library attached to the surgi-
ical interview always performed by the same psychologist, cal center, where their anxiety levels were assessed through
after the pre-anesthetic consultation, with the presence the modified Yale Preoperative Anxiety Scale (m-YPAS).
of the family member and the child. Parents were briefed This observational scale consists of 27 items divided into
on the aspects of the surgery and the separation that five categories: activity, vocalization, emotional expression,
would occur when the child entered the operating room, apparent awakening state, and family interaction. The score
aiming to help them cope with these situations. A story was ranges from 23.5 to 100; when above 30, the higher the
told to the child, with the support of a children’s book score, the greater the anxiety.14 The m-YPAS Scale was
entitled ‘‘Gaspar in the hospital’’ by Anne Gutman and applied continuously, from the pre-anesthetic preparation
Georg Hallensleben, published by Cosacnaif. Gaspar is a room at the time of the child’s separation from the
child character who suffers an accident and needs to parents to the moment of anesthetic induction, and was
undergo an emergency surgery.12 He was at school and is performed by a single and the same resident physician in
taken to the hospital by ambulance alone. He needs to be anesthesiology, under the supervision of the
operated on and during anesthesia he sleeps and has a anesthesiologist in charge for the division, after previous
good dream. The book high- lights Gaspar’s courage and training. The evaluator was blinded to the child’s group.
independence, how happy he is with his dream and when The basic protocol of anesthetic induction was performed
he wakes up, how happy he is to see his mother. The in a closed-loop anesthesia delivery system with 33% O2
approach used with the child is that of coping with a new and 66% N2O, with a total flow of 5 L.min-1 for one minute,
situation without the presence of the parents. followed by administration of sevoflurane at 8%. After the
child
lost consciousness, the gas flow was reduced to 2 L min −1 and
the anesthetic concentration, to 2---3%.
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4 Meletti DP et al.
Eligible patients: 118

Excluded: 8
Did not meet the inclusion criteria: 5
Refused to participate: 3
Randomized: 110
Allocated to the Basic Preparation Group (BPG): 55 Allocated to the psychological preparation group (PPG): 55
Excluded after allocation: Excluded after allocation:

Yale scale was not applied: 4 Surgery was cancelled: 1 Yale scale was not applied: 3 Surgery was cancelled: 2
50 children were analyzed for the basic preparation group 50 children were analyzed for the psychological preparation group
Figure 1 Flowchart according to the CONSORT randomization guidelines and participants’ study.
Sample size determination and statistical analysis

Results
After the 110 children were allocated in both groups, five
children from each group were lost to follow-up due to The groups were homogeneous regarding gender, age,
surgery cancellation or non-application of the anxiety level of schooling, and type of surgery. In both groups, a
scale on the day of the surgery. The final analysis was prevalence of boys for both groups and children
restricted to 50 children from each studied group. attending preschool was observed (Table 1).
Considering that the prevalence of anxiety in the oper- No significant differences were found regarding the
ating room in children is 50%1 and that the proposed parents’ characteristics (chi-squared test) when the two
intervention was able to reduce children’s anxiety by 20% groups were compared regarding gender (p = 0.76),
after a pilot study with 20 children, and using an α-error schooling (p = 0.39), income (p = 0.32), occupation (p =
0.20), and marital status (p = 0.36). Most interviewees were
of 5%, β-error of 20%, and 95% confidence interval (95%
CI), the number of patients was determined at 42 in each women (87%), who were generally the mothers, had
group, totaling a number of 84 participants in the finished high school (39%), belonged to the middle class
proposed study. (57%), and were employed (58%) and married (77%).
The statistical analysis was performed using the soft- When comparing the groups, both parents and children
ware Stata/SE version 9.0 for Windows (Stata Corporation from the PPG group had significantly lower anxiety levels
--- College Station, Texas, USA). In the analysis of groups, at the time of surgery when compared with parents and
medians and the 25---75% percentiles were used as a children from the BPG. There was no difference between
measure of central tendency and variability due to the parents’ level of anxiety assessed by the VAS at the
the non-normal distribution trend of the sample sep- time of the preanesthetic consultation (Table 2).
arated in groups. Categorical variables were shown as There was no correlation between parental anxiety at the
absolute values and percentages. Histograms and the time of surgery and the children’s anxiety the two studied
Shapiro-- Wilk test were used to verify the symmetry of data groups (r = 0.0276, p = 0.78; Fig. 2).
distribution. None of the children’s demographic data, such as
The chi-squared test and Fisher’s exact test were used gender (p = 0.20), age (p = 0.88), and level of schooling
for categorical variables, and the chi-squared partition (p = 0.52; chi-squared test) presented a significant
was performed if p-value was less than 0.05 (significance association with anxiety.
level used). The comparisons between two groups for
continuous or ordinal variables were performed using the
Mann-Whitney test.
Discussion
Spearman’s correlation was used to evaluate the
association intensity of ordinal variables in the same This clinical trial demonstrated that the children and their
individual. parents who received psychological preparation care in a
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Table 1 Characteristics of the study children: comparison by group.
Variables Basic Preparation Psychological Preparation p-value

Group BPG Group
Frequency and percentage PPG
Frequency and percentage
Gender 0.76a
Male 44(88) 43(86)
Female 6 (12) 7 (14)
Child’s age 0.19a
≥2 and ≤4 27 (54) 18 (36)
>4 and ≤6 1 5(30) 21 (42)
>6 and ≤8 8 (16) 11 (22)
Child’s level of schooling 0.59a
No schooling 5 (10) 5 (10)
Daycare 10 (20) 5 (10)
Pre-school 21 (42) 20 (40)
First grade 8 (16) 12 (24)
Second grade 6 (12) 8 (16)
Type of surgery performed
Postectomy 19 (38) 22 (44) 0.684a
Thyroglossal cyst correction 0 3 (6) 0.242b
Inguinal herniorrhaphy 4 (8) 7 (14) 0.523a
Umbilical herniorrhaphy 7 (14) 5 (10) 0.758a
Nevus excision 3 (6) 1 (2) 0.617b
Adenoamigdalectomy 17 (34) 12 (24) 0.378a
a
Yates’ chi-squared test.
b
Fisher’s exact test.
Values expressed as frequency and percentage (%); p < 0.05.
Table 2 Parents’ and children’s anxiety: comparison by

120
group.
Modified Yale Preoperative Anxiety Scale
Scales BPG PPG p-value

100
Median and Median and
percentiles percentiles
VAS (consulta- 8 (6.75---10) 7 (5---10) 0.12 80
tion)
VAS (surgery) 9 (7---10) 7 (5---10) 0.01
m-YPAS 33.4 26.6 0.04 60
(23.4---45.85) (23.4---33.4)
Mann---Whitney test.
40
Values expressed as medians and percentiles (25---75%).
20
1 3 5
7 9 11
single session had their preoperative degree of anxiety sig- Visual Analogue Scale – Anxiety before the surgery
nificantly reduced when compared with the group that did
not receive this care (p = 0.04 for the children and = 0.01 for Figure 2 Correlation between the parents’ anxiety (VAS)
parents at the time of surgery). scale at the time of surgery and the modified Yale Preoper-
The preparation was focused on alleviating separation ative Anxiety Scale (m-YPAS) applied in children. Spearman’s
anxiety in young children. According to the care protocol correlation: p = 0.78.
used at the University Hospital where this study was per-
formed, the parents did not accompany their children during seizures and the fear of separation from parents still
anesthetic induction, and the separation took place at the remain in some children between the ages of 4---8 years.15
toy library attached to the surgical ward. The authors con- In his review article, Moro16 discusses the question of
sider the age limit of 8 years as a predisposing factor to age related to preoperative anxiety and concludes that
this anxiety,15 due to the peculiar fact that children there is still no consensus on the subject. The literature
between 6 months and 4 years of age manifest a greater contains some assertions that younger children, up to 6
intensity of years of age,
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6 Meletti DP et al.
are more likely to suffer from preoperative anxiety

related to separation. Older children, however, would be possible to verify the extent of the benefits in this psycho-
more con- cerned with the surgery itself. Some studies logical preparation model. It was also not possible to
have reported that older children are more anxious, and match the genders in the studied groups, which
other authors did not find any evidence related to age.16 In predominantly consisted of boys, due to the high
the present study, no differences regarding an age-related frequency of postectomies in the service. The psychological
degree of anxiety were observed; younger children preparation for preanesthetic medication use was not
between 2 and 4 years, or those aged 5 and 6 years, were compared, and ethical reasons prevented the creation of a
no more anxious than those aged 7 and 8 years (p = 0.08). control group without any pre- anesthetic preparation.
Similarly to the present results, Wollin et al.17 found no Children who received psychological preparation were
significance in the association between anxiety and the compared with children awaiting surgery in a toy library,
children’s age between 5 and 12 years --- they divided the since it has already been shown that toys help reduce
children into age groups: 5---6 years, 7---10 years, and 11--- anxiety.3,23,24
12 years. The present authors therefore believe that Finally, the study could have selected parents and chil-
maintaining the focus on the separation anxiety approach dren with a high risk of anxiety based on the information
for the age group of 2---8 years reduced the number of collected during the psychological consultation and compare
consultations to a single session. them to the anxiety assessed by VAS and YALE scale at the
Kain et al. performed a family-centered preparation.9 time of surgery. This prognosis would have been useful in
In this intervention, parents received counseling through estimating which parents and children would need a more
videos, booklets, or by telephone, and the children received comprehensive approach with more than one session. The
a surprise box at the time of anesthetic induction; their authors suggest this approach for future studies.
parents were monitored by a researcher who asked them Children in the PPG and their parents benefited from
to use planned distraction strategies for children, if the anxiety reduction when compared to the group that
necessary. This advanced preparation group presented did not receive this preparation. Therefore, the authors
superior results in reducing the children’s anxiety in conclude that a single psychological session was effective in
comparison with the other study groups that were not preparing parents and children for separation anxiety and
submitted to this preparation. coping with the surgical procedure in most cases. This
Although the trial concluded that the psychological result has prac- tical and clinical importance and thus, this
preparation significantly contributed to the reduction of approach was shown to be as effective as programs that
preoperative anxiety in children, the program was expensive rely on multiple sessions.
and feasible only in large hospitals. Moreover, because of
the complexity involved, it was not clear which
component would be essential in this preparation. Funding
Another study, comparing children who underwent a pre-
operative psychological preparation to a group of children The study was registered in the Registro de Ensaios
who did not receive this type of care showed that the Clínicos Brasileiros. Primary Identifier: RBR-5jh9sf.
group of children trained by the psychologist had lower
anxiety levels than those who underwent only distraction
techniques.18 Another trial19 evaluated the psychologist’s Conflicts of interest
presence at the time of anesthetic induction and
concluded this method was more effective in reducing The authors declare no conflicts of interest.
anxiety in children when compared with distraction
techniques. In that study, it was necessary to have the
presence of a professional psychologist, who is part of References
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Society for Pediatric Anesthesia
Section Editor: James DiNardo
Video Distraction and Parental Presence for

the Management of Preoperative Anxiety and
Postoperative Behavioral Disturbance in
Children: A Randomized Controlled Trial
Hyuckgoo Kim, MD, Sung Mee Jung, MD, Hwarim Yu, MD, and Sang-Jin Park, MD, PhD
BACKGROUND: The anxiolytic efficacy of video watching, in the absence of parents, during the mask induction of anest
METHODS: In this prospective trial, 117 children aged 2 to 7 years scheduled for elective minor surgery were randomly a
RESULTS: The mYPAS scores were comparable (P = 0.558), and the number of children exhibiting baseline anxiety (an
CONCLUSIONS: Video distraction, parental presence, or their combination showed similar effects on preoperative anxie
P
reschool children undergoing surgery are
room (OR) and the smooth induction of anesthesia without
particularly vulnerable to separation anxiety before
heightened anxiety may be of paramount importance in
anesthesia because they are dependent on their
terms of minimizing perioperative distress and improving
parents and are
behavioral outcome.
old enough to recognize parental absence. 1–3 Furthermore,
Portable multimedia devices, such as smart phones,
the placement of a mask on the face and the inhalation of
tablet computers, and handheld DVD players, are readily
volatile anesthetics in the absence of parents further dis-
available at low cost. Age-appropriate video clips and
tresses young children, sometimes to the extent of refusal
video games are commonly used as effective distraction
of mask induction.1,2,4,5 A more anxious state preoperatively
tools for medical and surgical procedures in children.8,9 In
results in poor cooperation at anesthetic induction and
anesthetic practice, active distraction by a handheld video
may be associated with emergence delirium and negative
game with parental presence was found to be more
behavioral change after surgery.6,7 Therefore, the transfer of effective than premedication or parental presence only
children from a preoperative holding area to the operating for reducing anxiety
and improving cooperation during mask induction in chil-
From the Department of Anesthesiology and Pain Medicine, Yeungnam dren aged 4 to 12 years.10 In younger children, whose cog-
University School of Medicine, Daegu, Republic of Korea.
nitive and motor development were not advanced enough
Accepted for publication April 15, 2015.
to play interactive video games, passive viewing of an
Funding: This work was funded by Yeungnam University Grant-in-Aid of
2012. animated cartoon also proved a more effective distraction
The authors declare no conflicts of interest. than traditional storytelling, game-playing, nonprocedural
Reprints will not be available from the talking, or humor during mask induction.11 However, pre-
authors. vious studies did not completely control for parental pres-
Address correspondence to Sung Mee Jung, MD, Department of Anesthe- ence or used parents to keep children relaxed during video
siology and Pain Medicine, Yeungnam University School of Medicine, 170, distraction.9–11
Hyeonchung-ro, Nam-gu, Daegu 705-703, Republic of Korea. Address e-
mail to applejsm@gmail.com. Thus, we performed this study to determine whether
Copyright © 2015 International Anesthesia Research Society video distraction per se is capable of alleviating
DOI: 10.1213/ANE.0000000000000839 preoperative
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
778 www.anesthesia-analgesia.org September 2015 • Volume 121 • Number 3
anxiety and improving cooperation independent of paren- to 3.0% in 50% oxygen and by IV remifentanil infusion at
tal presence and whether a combination of video distrac- a rate of 0.05 to 0.1 μg/kg/min during surgery. At the end
tion and parental presence is more effective than either of surgery, sevoflurane administration was discontinued,
intervention in preschool children during mask induction and after awakening with adequate spontaneous ventila-
of anesthesia. The primary end point of this study was a tion, children were tracheally extubated and transferred to
change in anxiety level from baseline to induction. In addi- the postanesthesia care unit (PACU). Heart rate, Spo2, and
tion, we investigated the effect of each proactive interven- respiratory rate were monitored in the PACU. Parents
tion on postoperative behavioral outcomes, that is, on the were allowed to rejoin their children in the PACU. If a
incidences of emergence delirium and new-onset maladap- child com- plained of pain or exhibited signs or symptoms
tive behavioral changes. of pain, IV fentanyl 1 μg/kg was administered in the
PACU. All clinical management decisions were made by
METHODS the anesthesiologist responsible for the care of the patients.
This prospective, randomized study was approved by the Children’s anxiety levels throughout anesthesia induc-
IRB of Yeungnam University Hospital in South Korea and tion were assessed using the modified Yale Preoperative
was registered with ClinicalTrials.gov on the December 30, Anxiety Scale (mYPAS) at 3 time points, that is, while wait-
2013 (NCT02027844). One hundred seventeen children ing in the preoperative holding area (T0; baseline), on
aged between 2 and 7 years, ASA physical status I or II enter- ing the OR (T1), and during mask induction (T2).
scheduled for elective minor surgery under general mYPAS scores are obtained by summing the scores of 22
anesthesia were enrolled. Children with a chronic illness, items in 5 behavioral categories: activity, state of apparent
developmental delay, a neuropsychiatric disease, cancer, arousal, vocalization, emotional expression, and the use of
experience of a recent stressful life event, previous parents.12 In group V, the interaction with the parent was
anesthetic experience, sedative medication, or emergency assessed by slightly modifying the original components of
surgery were excluded. Written informed consent was the “use of parents” because of parental absence.
obtained from parents, and verbal assent was obtained An mYPAS score of >30 indicates the presence of signifi-
from children older than 6 years before the day of surgery. cant anxiety.12 The induction compliance checklist (ICC)
No participant received sedative premedication before was used to assess cooperation during induction.13 Both
anesthesia. After arriving in the preoperative holding area, mYPAS and ICC scores were assessed by a trained
participants were allocated to 1 of the 3 study groups: observer in real time during the perioperative period.
group V (distraction by watching an animated cartoon Before patients were enrolled in this study, the observer
video), group P (parental presence), or group VP (video was trained in how to perform mYPAS and ICC scoring by
distraction plus parental presence), throughout induction reviewing videotapes of children at induction of anesthesia
of anesthesia, using a computer-generated random until 80% agreement with the scores allocated by a
assignment scheme. In group V, children were allowed to psychologist was achieved consistently, as suggested by
select 1 animated cartoon video in a smartphone offered by Sadhasivam et al.14
the researcher or parents and started to watch it with or Parental anxiety was assessed using the Korean version
without parents while waiting in the preoperative of Spielberger’s State-Trait Anxiety Inventory (STAI),
holding area. Children in group V were separated from which evaluates trait (baseline) and state (situational)
their parents in the preoperative holding area and anxiety.15 In the preoperative holding area, both trait and
transported to the OR. Anesthesia was induced while state anxiety scores were measured to investigate the effect
children continued to view the chosen video. In group P, 1 of parental anxiety on child anxiety. State anxiety scores
parent accompanied the child to the OR and stayed dur- after induction were obtained to assess the effect of the 3
ing the induction of anesthesia, and in group VP, children interventions on situational anxiety changes in parents.
watched a cartoon video with their parents throughout the After surgery, postoperative pain was assessed using
whole anesthesia induction process. the Children’s Hospital of Eastern Ontario Pain (CHEOP)
After arrival in the OR, children were given the choice scale.16 Emergence delirium was evaluated using the
to sit up or lie down on the operating table. All Pediatric Anesthesia Emergence Delirium (PAED) scale
participants were introduced to the facemask, which was at 10-minute intervals for 30 minutes after arrival in the
detached from the anesthetic circuit, before induction. The PACU.17 When the highest PAED score recorded at any
anesthesiologist explained the anesthesia induction time exceeded 10, emergence delirium was deemed to be
process to children and gently asked them to breathe present. An investigator, unaware of group assignments,
deeply. A pulse oximeter and electrocardiogram were used contacted parents and requested that they complete the
for continuous monitoring during induction. Anesthesia Post- Hospitalization Behavior Questionnaire (PHBQ) at 1
was induced by mask inhalation with incrementing and 14 days postoperatively by phone. The PHBQ contains
sevoflurane up to 8% with N2O (4 L/min) and oxygen (2 27 items in 6 categories: general anxiety, separation
L/min). The anesthesiologist carefully positioned the anxiety, anxiety about sleep, eating disturbance,
facemask/anesthesia circuit so as not to interfere with
aggression toward authority, and apathy/withdrawal.18
video watching or the parent. When a participant closed
Negative behavioral change development after anesthesia
his/her eyes and failed to respond to his/her name, the
and surgery was recorded. Both CHEOP and PAED
video was discontinued and the parent was escorted out of
scores and PHBQ interviews were performed by an
the OR by a nurse. Noninvasive arte- rial blood pressure
independent observer unaware of group
was measured as soon as possible. After endotracheal assignments.
intubation, anesthesia was maintained by sevoflurane Power analysis was conducted using G*Power ver.
inhalation at an end-tidal concentration of 1.5% 3.1.5. An effect size of 0.31 was estimated from the
variance of
September 2015 • Volume 121 • Number 3 www.anesthesia-analgesia.org 779
Video Distraction and Parental Presence in Children
mean mYPAS differences between the baseline and the

Categorical variables were analyzed using the χ2 test or
induction of anesthesia among the 3 groups and the square
the Fisher exact test. Wilson score interval without
of the common SD within each group based on the results
continu- ity correction19 was used to compare Bonferroni-
of a pilot study conducted on 27 children. The data of the
adjusted 95% confidence interval for differences in
pilot study were not included in data analysis in the current
proportion of participants with increased anxiety from
study. A sample size of 35 participants per group was
baseline to OR entry and induction of anesthesia among
calculated by 1-way analysis of variance (ANOVA) to yield
interventions. Statistical significance was considered for P
an 80% power to detect this effect size at a set α value of
< 0.017 after Bonferroni adjustment for 3 comparisons
0.05 among the 3 groups. Thirty-nine participants per
(0.05/3). The McNemar test was used to compare the
group were recruited to account for a 10% dropout rate
incidence of newly developed maladaptive behavior 1 day
due to withdrawal of consent, a change in
and 2 weeks after surgery. Correlations between mYPAS
anesthetic/surgical plan, or follow-up loss. Statistical
score during induction of anesthesia and PAED scores or
analysis was performed using SPSS version 19 (SPSS Inc.,
numbers of patients exhibiting a postoperative negative
Chicago, IL). The Kolmogorov-Smirnov Lilliefors
behavioral change were assessed using the Pearson
goodness-of-fit test was used to verify normalities of the
correlation or the Spearman rank correlation coefficients,
residuals of all continuous variables. When P values of the
respectively. Statistical significance was accepted for P
data were >0.05, they were considered normally distrib-
values <0.05.
uted. The normally distributed continuous variables, such
as age, weight, and duration of anesthesia, were presented
as the means ± SDs and were compared using the 1-way RESULTS
One hundred seventeen children were initially enrolled.
ANOVA. Statistical significance was accepted for P values
Eleven children were excluded because of withdrawal of
<0.05. Nonnormally distributed continuous variables, such
consent, incomplete data, or loss to follow-up (Fig. 1). Two
as mYPAS scores at each time point and ICC, were
children in group P were excluded because they viewed
presented as medians and ranges and compared using the
an animated cartoon with their parents while waiting in
nonpara- metric Kruskal-Wallis test. The test was followed
the preoperative holding area after random allocation.
the Mann- Whitney U test with Bonferroni adjustment for
Thus, 104 participants completed the study, and they were
multiple pairwise comparisons (3 comparisons) if a
included in the data analysis. No significant intergroup
significant intergroup difference was found. A
differences in demographic or surgical characteristics
Bonferroni-adjusted P value
were observed (Table 1). Mothers predominantly
<0.017 (0.05/3) was considered statistically significant. The
accompanied children to the OR and stayed during
change in mYPAS scores over time among the 3 groups
anesthesia induction in groups P (n = 27, 81.8%) and VP (n
was compared using the repeated measures ANOVA.
= 26, 70.3%).
Eligibilit
y (n =
125)
Not meeting inclusion criteria (n = 6)

Decline to participate (n = 2)
Randomization (n = 117)
Group V Group P
(n = 39) (n = 39)
Figure 1. Flow diagram of participants.
Group VP Group V = video distraction; group
Withdrawal of consent (n = 3) Withdrawal of consent (n = 2) (n = 39) P = parental presence; group VP = com-
bination of video distraction and parental
Incomplete data (n = 2) Noncompliance to protocol
presence.
(n = 2)
Withdrawal of consent (n = 1)
Loss of follow-up (n = 2)
Loss of follow-up (n = 1)
Completion of the study (n = 34) Completion of the study (n = 33) Completion of the study (n = 37)
Data analysis
(n = 104)
780 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Anesthesiologist physical status.
The median mYPAS scores were comparably lower

than 30 at T0 (P = 0.558), and the number of children
exhibiting baseline anxiety (an mYPAS score > 30) was not
different among groups (Table 2, P = 0.824) before
intervention. After intervention, mYPAS scores were
different among the 3 groups at T1 (P = 0.002) and T2 (P =
0.012). Specifically, children in group V exhibited lower
mYPAS scores compared with the other 2 groups at both
T1 (P < 0.001 versus group P and P = 0.015 versus group
VP) and T2 (P = 0.012 versus group P and P = 0.008
versus group VP). However, the overall changes in
mYPAS scores from baseline to induction of anesthesia
were not different among the 3 groups (P = 0.049). The
proportion of children who increased their mYPAS scores
was higher in group P compared with group V from T0 to
T1 (Bonferroni-adjusted 95% confidence interval for
difference 2 to 49) but was similar in all groups from T0 to
T2 (Fig. 2, Table 3).
The compliance of children at mask induction was
signif-
icantly different among groups (P = 0.001; Table 2).
Children in group V were more cooperative during mask
induction than children in the other 2 groups (P = 0.0005
versus group P and 0.001 versus group VP). ICC scores
were found to be significantly correlated with mYPAS
scores at each time point (P < 0.001, r = 0.338, 0.531, and
0.869 at T0, T1, and T2,
respectively) and with the amount of mYPAS score change
(P = 0.042, r = 0.199 from T0 to T1; P < 0.001, r = 0.702 from
T0 to T2).
Parent anxiety was assessed using STAI before
intervention and after completing anesthesia induction in
all groups. Both trait and state anxiety scores in the
preoperative holding area and changes in state and
anxiety scores over the peri-induction period were not
different in the 3 groups (Table 2). Parent state anxiety
score changes were found to be weakly correlated with
the mYPAS score changes from T0 to T2 (P = 0.025, r = 0.221)
and with ICC scores at mask induction (P = 0.035, r =
0.207). However, parent trait anxiety scores were not
found to affect children’s anxiety
Table 1. Demographic and Surgical Characteristics

of Patients
Group V Group P Group VP P
(n = 34) (n = 33) (n = 37)
Age (y) 5.5 ± 1.0 5.3 ± 1.4 5.0 ± 1.3 0.097
Sex (M/F) 15/19 12/21 18/19 0.581
Weight (kg) 20.7 ± 4.1 22.4 ± 6.5 20.6 ± 6.0 0.372
Height (cm) 114.9 ± 10.6 114.0 ± 111.7 ± 9.3 0.494
10.1
ASA PS (I/II) 34/0 32/1 37/0 0.317
Type of surgery, 0.250
n (%)
Eye surgery 17 (50.0) 21 (63.6) 23 (62.2)
Tonsillectomy 9 (26.5) 8 (24.2) 10 (27.0)
Herniorrhaphy 5 (14.7) 0 3 (8.1)
Excision of 3 (8.8) 4 (12.1) 1 (2.7)
neck mass
Duration of 37.0 ± 16.5 40.9 ± 10.1 39.1 ± 10.6 0.449
surgery (min)
Duration of 60.0 ± 19.3 62.9 ± 14.5 61.7 ± 11.5 0.748
anesthesia
(min)
Values are mean ± SD and number of patients (%).
V = video distraction; P = parental presence; VP = combination of
video distraction and parental presence; ASA PS = American Society of
In the present study, video distraction, parental presence,
scores during the perioperative period. The majority of parents or a combination of both had a similar effect on
(75%) stated that they would prefer to be present during preoperative anxiety during inhaled induction of
anesthesia induction in the future if their child had to undergo anesthesia in preschool children undergoing surgery. We
surgery. However, a significant intergroup difference was found that the overall changes in anxiety levels from
found in this respect (P < 0.001), and fewer parents of group V preoperative holding area to induction of anesthesia were
children (39.1%) favored parental presence at the induction of not different among the 3 groups although children with
anesthesia for any future surgery than parents of group P (95.8%, video distraction had lower anxiety levels compared with
P < 0.001) or group VP (86.2%, P < 0.001) those with parental presence only or their combination at
children. entry to the OR and during induction of anesthesia.
Emergence statuses were comparable except for pain scores Our results suggest that video distraction and paren-
among groups (P = 0.041). Postoperative pain scores were weakly tal presence appeared to have different anxiolytic mecha-
correlated with changes in anxiety scores among children nisms in the perioperative setting. Video distraction makes
between T0 and T2 (P = 0.041, r = 0.200). Median PAED scores and children oblivious to the unfamiliar OR environment and
incidences of significant emergence delirium were comparable absorbs them in a familiar imaginary world, whereas
in the 3 groups and were not linked to the anxiety levels of parental presence simply relieves the distress associated
children or parents at any of the 3 time points (Table 4). with separation from parents. Previous studies demon-
Number of children who developed new-onset negative strated that the addition of viewing age-appropriate video
behavior over the 2 weeks after surgery were comparable in all provided greater reduction of anxiety than control or con-
groups. Eating disturbance (31.7%), separation anxiety (14.9%), ventional distraction techniques in children accompanied
and aggression toward authority (13.9%) were common on the by their parents during induction of general anesthesia. 11,20
first postoperative day but decreased significantly with time However, the changes in anxiety levels from holding area
over the next 2 weeks (7.0%, P < 0.001, 7.0%, P = 0.02 and 8.0%, to anesthetic induction were similar not only between
P = 0.07, respectively). The incidence of newly developed parental presence and video distraction, but also between
negative behavior was not found to be related to the anxiety each single intervention and combination of both interven-
levels of children or parents, postoperative pain scores, or the tions in the present study. This inconsistency in the results
number of children who experienced emergence delirium in the may be explained by different study designs. Allowing
PACU. that parental presence and type of anesthetic induction
were different. Mifflin et al.11 demonstrated that video
DISCUSSION distraction more effectively reduced preoperative anxi-
ety compared with control during inhaled induction of
Table 2. Anxiety Levels in Children and Parents in the Perioperative Period

Group V Group P Group VP P
(n = 34) (n = 33) (n = 37)
Children’s anxiety
mYPAS 0.049a
T0 28.4 (23.4 to 36.6) 28.4 (23.4 to 46.6) 23.4 (23.4 to 65.3) 0.558b
T1 23.4 (23.4 to 31.6) 33.4 (23.4 to 50.0)† 28.4 (23.4 to 46.6)* 0.002b
T2 28.4 (23.4 to 46.6) 43.4 (23.4 to 65.0)*‡ 43.4 (23.4 to 70.0)*‡§ 0.012b
Baseline anxiety, n (%) 14 (41.2) 15 (45.5) 14 (37.8) 0.824c
ICC 0.0 (0.0 to 0.0) 1.0 (0.0 to 3.0)† 1.0 (0.0 to 5.0)† 0.001b
Parental anxiety
STAI, trait 41.8 ± 4.5 41.0 ± 6.8 38.4 ± 7.8 0.465d
STAI, state 0.911a
Before intervention 44.0 ± 9.4 44.2 ± 9.0 42.8 ± 8.2 0.446d
After intervention 43.1 ± 8.0 44.0 ± 9.6 43.6 ± 8.9 0.465d
Change of score 0.0 (−6.0 to 3.0) 0.0 (−3.0 to 3.0) 0.0 (0.0 to 3.0) 0.543b
Values are median (interquartile ranges) or mean ± SD for continuous variables and number of patients (%) for categorical variables.
V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; mYPAS = modified Yale preoperative anxiety scale;
T0 = preoperative holding area; T 1 = entry to the operating room; T 2 = induction of anesthesia; ICC = induction compliance checklist; STAI = state and trait anxiety
inventory.
*Bonferroni-adjusted P < 0.017 versus group V after Mann-Whitney U test.
†Bonferroni-adjusted P < 0.003 versus group V after Mann-Whitney U test.
‡P < 0.05 versus T0 within group.
§P < 0.05 versus T1 within group.
a
Repeated measures analysis of variance (ANOVA).
b
Kruskal-Wallis test.
χ test.
c 2
d
One-way ANOVA.
Increase
No increase Table 3. Group Differences for Proportions with
50 Increased Anxiety from Baseline to Operating
Room Entry and Induction of Anesthesia
T0T1 T0T2
40 T0T1 T0T2
95% CI of 95% CI of
mYPAS proportion proportion
* change differences P differences P
30 Group P to 2 to 49 0.009* −9 to 44 0.112
group V
Number of
Group P to −19 to 32 0.542 −33 to 19 0.503

20 group VP
Group VP to −3 to 42 0.038 −1 to 50 0.022
group V
10
Data are Bonferroni-adjusted confidence interval for difference in
proportions (%) between groups.
V = video distraction; P = parental presence; VP = combination of video
0
distraction and parental presence; mYPAS = modified Yale preoperative
V P VP
V P VP anxiety scale; T0T1 = from preoperative holding area to the operating
room entry; T0T2 = from preoperative holding area to induction of
Group anesthesia; CI = confidence interval.
Figure 2. The proportions of children with changes in anxiety *Bonferroni-adjusted P < 0.017 between groups.
levels in the perioperative period. Anxiety level in children was
measured using modified Yale Preoperative Anxiety Scale
(mYPAS). this study, the anxiety levels were significantly different
*Bonferroni-adjusted P < 0.017 versus group V. V = video distrac- at each time point after intervention, but the changes in
tion; P = parental presence; VP = combination of video anxiety levels through 3 different time points (from hold-
distraction and parental presence; T0T1 = from preoperative
holding area to operating room entry; T0T2 = from preoperative ing area to induction) were not different among groups. In
holding area to induction of anesthesia. addition, the proportions of children who had increased
anxiety from baseline to induction of anesthesia were simi-
anesthesia in children who had parents absent. However, lar in all 3 groups although children had increased anxiety
Lee et al.20 demonstrated that animated cartoon distraction levels from baseline to transport in the video distraction
produced a greater reduction of anxiety compared with group compared with the parental presence only group.
control or toy distraction during IV induction of anesthesia Our findings indicate that by diverting a child’s attention,
in children who had parental presence and an IV cannula audiovisual distraction is more effective in alleviating anx-
in situ. In addition, both previous studies compared the iety from the stress of separation from parents, but not
change in anxiety levels from holding area to induction by during induction of anesthesia, than parental presence.
subtracting holding area mYPAS from induction mYPAS Also parental presence does not seem to augment the
to determine the anxiolytic effect of each intervention. In anxiolytic efficacy of video distraction in children during
transport
Table 4. Postoperative Emergence Delirium and Negative Behavioral Changes in Children
Group V Group P Group VP
(n = 34) (n = 33) (n = 37) P
Awakening time (min) 9.0 ± 3.9 12.2 ± 7.0 10.7 ± 5.0 0.056
CHEOP score 7.0 (6.0–8.3) 8.0 (6.5–9.5) 9.0 (7.0–10.0)* 0.041
Peak PAED score 7.9 ± 6.3 8.0 ± 5.5 9.3 ± 6.0 0.517
Emergence delirium, n (%) 13 (38.2) 13 (39.4) 20 (43.5) 0.324
Negative PHBC, n (%)
≥1
1d 17 (50.0) 19 (57.6) 15 (40.5) 0.354
2 wk 7 (21.2) 5 (15.2) 3 (5.2) 0.299
≥4
1d 1 (2.9) 1 (3.0) 4 (11.4) 0.224
2 wk 2 (6.1) 1 (3.0) 0 0.551
Values are median (interquartile ranges) or mean ± SD for continuous variables and number of patients (%) for categorical variables.
V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; CHEOP = Children’s Hospital of Eastern Ontario Pain
Scale; PAED = Pediatric Anesthesia Emergence Delirium scale; PHBC = post-hospital behavior change.
*Bonferroni-adjusted P < 0.017 versus group V.
and induction of anesthesia. Thus, each intervention or a

showed an emotional reaction at separation. In this study,
combination of both interventions may result in similar
the number of parents who reported their presence helped
effects on preoperative anxiety in children undergoing
their child during transport to the OR and induction of
inhaled induction of anesthesia.
anesthesia and would be present during the induction of
The similar changes in anxiety levels from baseline to anesthesia if required in the future was significantly higher
induction among the 3 interventions in the present study
in both parental presence groups than in the video
suggest 2 interesting possibilities. First, contrary to the
distraction group. These findings suggest that parental
general belief, separation from parents may not be the most
anxiety interacts with child anxiety during induction of
important cause of preoperative anxiety in preschool
anesthesia and that a more objective instrument may be
children. Although children accompanied by their parents
required to measure parental anxiety.
did not experience separation anxiety, their changes in
Although the pathogeneses of postoperative emergence
anxiety levels until induction of anesthesia were similar to
delirium and negative behavioral changes remained unde-
children with video distraction (parental absence) in this
fined, preschool children, sevoflurane anesthesia, and high
study. In fact, parental presence was shown to be briefly
anxiety levels in the preoperative holding area and at
effective in reducing a child’s anxiety only at separation
induction of anesthesia are considered potential risk
from parents but not at induction of anesthesia.21 Our data
factors.6,7,22 This means that postoperative emergence
are consistent with previous reports that placement of a
delirium and negative behavioral change might be reduced
mask for anesthetic induction caused the greatest distress to
by a preoperative intervention targeting anxiety
children undergoing surgery.5,6,22 Next, the anxiety levels at reduction. The addition of active distraction with a
the separation time point (transport to the OR) were lower handheld video game effectively reduced the change of
in children with video distraction than parental presence anxiety from holding area to mask induction of anesthesia
only or a combination of both despite similar changes in but did not improve postoperative behavioral change
anxiety levels over time. In addition, the proportion of
compared with children accompanied by their parents.10 In
children who had increased anxiety levels from baseline to
this study, emergence delirium occur- ring within the first
OR entry was higher in children with parental presence than
30 minutes after anesthesia occurred similarly among the 3
video distraction. Our data suggest that parental presence
groups and largely resolved in 10 to 20 minutes. New-
is unlikely to be a more effective intervention to reduce
onset negative behavior occurred in 49% of children on the
separation anxiety than video distraction even in preschool
first day after surgery and persisted for 2 weeks after
children at greatest risk of devel- oping a separation anxiety
surgery in 14%.
reaction.3 Lee et al.20 demonstrated that, in preschool
Several limitations related to this study should be dis-
children accompanied by their parents, the cartoon
cussed. First, parental anxiety was assessed using a self-
distraction group showed less change in anxiety levels at
report- ing rating scale. Although the state-trait anxiety
separation from parents compared with a control group. In
inventory is a validated anxiety assessment instrument for
contrast, the addition of video distraction did not provide
adults, we found some discrepancies between subjective
additional benefit in reducing separation anxiety in
reports and objective behaviors. Second, we did not
children with parental presence in this study.
measure the baseline temperament of children using a
Increased parental anxiety can increase child anxiety validated behavioral assessment tool, and baseline
and prolong anesthetic induction by generating temperament characteristics can affect the effectiveness of
interactions between children and parents.23,24 We found an anxiolytic intervention by influencing how a child will
that a change in parent situational anxiety was influenced respond emotionally in a stressful situation. Third,
by a change in child anxiety or compliance at anesthetic blinding was impossible in this study because video
induction and vice versa. Although no significant watching and parental presence were visible to
differences in parental anxiety change were found with investigators and participants, and thus, observer bias may
respect to intervention, a few parents in both groups that have influenced assessments of anxiety levels and
had a parent present (group P and VP) left the OR in tears. compliance at induction of anesthesia. Fourth, we were
However, no parent in the video distraction group unable to calculate the use of parents’ item of the mYPAS
accurately because parental presence
was lacking in group V. Although we matched children’s 4. Przybylo HJ, Tarbell SE, Stevenson GW. Mask fear in children
responses in group V with the components of the use of presenting for anesthesia: aversion, phobia, or both? Paediatr
parents, this may have affected the psychometric integrity Anaesth 2005;15:366–70
of the mYPAS. Finally, the inability to relate the anxiolytic 5. Fortier MA, Del Rosario AM, Martin SR, Kain ZN.
Perioperative anxiety in children. Paediatr Anaesth
effects of video distraction and parental presence on the 2010;20:318–22
short- and long-term postoperative behavioral outcomes in 6. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal
children may be related to sample size. We calculated D, Mayes LC, Feng R, Zhang H. Preoperative anxiety and
sample size based on a change in anxiety levels from emergence delirium and postoperative maladaptive behaviors.
Anesth Analg 2004;99:1648–54
baseline to induction of anesthesia, the primary end point
7. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE,
of this study, and thus, the number of children recruited McClain BC. Preoperative anxiety, postoperative pain, and
may have been insufficient to detect the effects of the 3 behavioral recovery in young children undergoing surgery.
different interventions on postoperative behavioral Pediatrics 2006;118:651–8
changes. 8. Low DK, Pittaway AP. The ‘iPhone’ induction—a novel use
for the Apple iPhone. Paediatr Anaesth 2008;18:573–4
In conclusion, we found that video distraction, parental 9. Burk CJ, Benjamin LT, Connelly EA. Distraction anesthe-
presence, or combination of both interventions had a simi- sia for pediatric dermatology procedures. Pediatr Dermatol
lar effect on preoperative anxiety during inhaled induction 2007;24:419–20
of anesthesia and postoperative behavioral outcomes such 10. Patel A, Schieble T, Davidson M, Tran MC, Schoenberg C,
Delphin E, Bennett H. Distraction with a hand-held video
as emergence delirium and new-onset negative behavioral game reduces pediatric preoperative anxiety. Paediatr
changes in preschool children. A further large-scale study Anaesth 2006;16:1019–27
is required to determine the ability of video distraction to 11. Mifflin KA, Hackmann T, Chorney JM. Streamed video clips
to reduce anxiety in children during inhaled induction of
improve postoperative behavioral outcomes. E anesthesia. Anesth Analg 2012;115:1162–7
12. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD,
DISCLOSURES Hofstadter MB. The Yale Preoperative Anxiety Scale: how
Name: Hyuckgoo Kim, MD. does it compare with a “gold standard”? Anesth Analg
Contribution: This author helped design and conduct the 1997;85:783–8
study, acquire the data, review and analyze the data, and draft 13. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter
MB. Parental presence during induction of anesthesia versus
and revise the manuscript. sedative premedication: which intervention is more effective?
Attestation: Hyuckgoo Kim has seen the original study data, Anesthesiology 1998;89:1147–56
reviewed the analysis of the data, and approved the final 14. Sadhasivam S, Cohen LL, Hosu L, Gorman KL, Wang Y,
manuscript. Nick TG, Jou JF, Samol N, Szabova A, Hagerman N, Hein
Name: Sung Mee Jung, MD. E, Boat A, Varughese A, Kurth CD, Willging JP, Gunter JB.
Contribution: This author helped design and conduct the Real-time assessment of perioperative behaviors in children
and parents: development and validation of the periopera-
study, acquire data, analyze and interpret the data, draft and
tive adult child behavioral interaction scale. Anesth Analg
revise the manuscript, and is the corresponding author. 2010;110:1109–15
Attestation: Sung Mee Jung has seen the original study data, 15. Spielberger CD, Gorsuch RL, Lushene PR, Vagg PR, Jacobs
reviewed the analysis of the data, approved the final manu- GA. Manual for the State-Trait Anxiety Inventory STAI (Form
script, and is the archival author. Y) (“Self-Evaluation Questionnaire”). Palo Alto, CA:
Name: Hwarim Yu, MD. Consulting Psychologists Press, Inc., 1983
16. McGrath PJ, Johnson G, Goodman JT, Schillinger J, Dunn
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Attestation: Hwarim Yu has seen the original study data and 1985
approved the final manuscript. 17. Sikich N, Lerman J. Development and psychometric evalu-
Name: Sang-Jin Park, MD, PhD. ation of the Pediatric Anesthesia Emergence Delirium scale.
Contribution: This author helped design the study, analyze Anesthesiology 2004;100:1138–45
and interpret the data, and revise the data. 18. Vernon DT, Schulman JL, Foley JM. Changes in children’s
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traction alleviates anxiety in children during induction of
ACKNOWLEDGMENTS anesthesia. Anesth Analg 2012;115:1168–73
The authors thank Ji Eun Jang, Department of Statistics, 21. Wright KD, Stewart SH, Finley GA. When are parents helpful?
Yeungnam University, for assistance with statistical analysis. A randomized clinical trial of the efficacy of parental presence
for pediatric anesthesia. Can J Anaesth 2010;57:751–8
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Jurnal Keperawatan Silampari
Volume 3, Nomor 1, Desember 2019
e-ISSN: 2581-1975
p-ISSN: 2597-7482
DOI: https://doi.org/10.31539/jks.v3i1.837
VIDEO KARTUN DAN VIDEO ANIMASI DAPAT MENURUNKAN TINGKAT

KECEMASAN PRE OPERASI PADA ANAK USIA PRA SEKOLAH
Ajeng Dwi Retnani1, Titin Sutini2, Suhendar Sulaeman3

Program Studi Magister Keperawatan, Universitas Muhammadiyah Jakarta1
Program Studi Keperawatan, Universitas Muhammadiyah Jakarta2
Program Studi Manajemen, Universitas Muhammadiyah Jakarta3
Ajeng.dwi17@yahoo.co.id1
ABSTRAK
Tujuan penelitian ini ialah menganalisis pengaruh video kartun dan video animasi
terhadap penurunan tingkat kecemasan pre operasi pada anak usia pra sekolah. Metode
penelitian ini menggunakan quasi eksperimental dengan pendekatan pre and post-
test without control. Hasil penelitian menunjukkan bahwa penurunan tingkat
kecemasan pre operasi pada anak usia pra sekolah setelah diberikan intervensi video
kartun sebesar 4,20, setelah diberikan intervensi video animasi sebesar 4,70 dan setelah
diberikan intervensi kombinasi antara video kartun+video animasi sebesar 7,20.
Berdasarkan hal tersebut, tingkat kecemasan pre operasi menggunakan intervensi
kombinasi video kartun+video animasi menunjukkan penurunan paling besar. Hasil
penelitian juga didapatkan p value > 0,000. Simpulan, adanya pengaruh video kartun
dan video animasi terhadap penurunan tingkat kecemasan pre operasi pada anak usia pra
sekolah.
Kata Kunci: Animasi, Kecemasan, Pre Operasi, Video Kartun
ABSTRACT
The purpose of this study was to analyze the effect of cartoon videos and animated
videos on reducing preoperative anxiety levels in pre-school age children. This
research method uses quasi-experimental with a pre and post-test approach with out
control. The results showed that the reduction in preoperative anxiety levels in pre-
school children after being given a cartoon video intervention by 4.20, after being given
an animated video intervention by 4.70 and after being given a combination
intervention between cartoon videos + animated videos by 7.20. Based on this, the level
of preoperative anxiety using a cartoon video + animated video combination
intervention showed the greatest decrease. The results of the study also obtained p
value> 0,000. Conclusions, the influence of cartoon videos and animated videos on the
reduction of preoperative anxiety levels in pre-school age children.
Keywords: Animation, Anxiety, Pre Operation, Cartoon Video
33
2019. Jurnal Keperawatan Silampari 3 (1) 332-
PENDAHULUAN
Anak usia pra sekolah merupakan anak yang berusia 3 sampai 5 tahun yang
memiliki kemampuan berinteraksi dengan sosial dan lingkungannya sebagai tahap
menuju perkembangan selanjutnya (Astarani, 2017). Anak usia pra sekolah memiliki
resiko besar untuk mengalami masalah kesehatan jika dikaitkan dengan respon imun
dan kekuatan pertahanan dirinya yang belum optimal (Papalia, et al, 2010). Alini (2017)
juga menyatakan bahwa pada masa usia pra sekolah aktifitas anak yang meningkat
menyebabkan anak kelelahan dan menjadikan anak rentan terhadap penyakit akibat
daya tahan tubuh yang lemah sehingga anak diharuskan menjalani hospitalisasi,
termasuk operasi.
Menurut Utami (2014) anak merupakan populasi yang sangat rentan terutama saat
menghadapi situasi yang membuat stress. Hal ini dikarenakan kondisi koping yang
digunakan oleh orang dewasa belum berkembang sempurna pada anak-anak. Anak usia
prasekolah menerima keadaaan masuk rumah sakit dengan rasa ketakutan. Jika anak
sangat ketakutan dapat menampilkan perilaku agresif, dari menggigit, menendang-
nendang bahkan berlari ke luar ruangan.
Tindakan operasi merupakan hal yang sangat beresiko. Lebih dari 230 juta operasi
mayor dilakukan setiap tahun di dunia yang menyebabkan keadaan pasien saat operasi
akan lemah, meningkatkan komplikasi setelah operasi dilakukan bahkan dapat
menyebabkan kematian (Priece, Moreno, 2012). Tindakan operasi memerlukan sebuah
tindakan keperawatan pre operasi yang merupakan tahapan awal dari keperawatan
operatif yang dimulai sejak pasien diterima masuk di ruang terima pasien dan berakhir
ketika pasien dipindahkan ke meja operasi untuk dilakukan tindakan pembedahan
(Wijayanti, 2011). Salah satu persiapan pre operasi ialah persiapan mental/psikis.
Persiapan mental merupakan hal yang tidak kalah pentingnya dalam proses
persiapan operasi karena mental pasien yang tidak siap atau labil dapat berpengaruh
terhadap kondisi fisiknya dan kelancaran proses operasi. Perawat perlu mengkaji
mekanisme koping pasien dalam menghadapi stres, dimana tindakan operasi merupakan
salah satu keadaan pemicu kecemasan dan stress pada pasien terutama pada pasien anak
(Sjamsuhidajat, De Jong, 2010). Terdapat sekitar 50%-70% dari anak-anak yang
menjalani operasi mengalami kecemasan dan kesusahan yang parah sebelum operasi
(Alini, 2017).
Kecemasan merupakan suatu kondisi yang tidak menyenangkan yang dapat
mempengaruhi perilaku pasien yang melakukan perawatan (Gracia, 2012). Kecemasan
dental pada pasien anak usia 6-8 tahun biasanya timbul karena belum adanya
pengalaman ke dokter gigi. Kecemasan dental pada anak tersebut menyebabkan anak
sering menunda bahkan menolak untuk dilakukan perawatan di dokter gigi yang juga
mengakibatkan betambah parahnya kondisi kesehatan gigi dan mulut pada anak
(Rehatta dkk, 2014). Kecemasan pada tindakan dental disebabkan oleh banyak hal, di
antaranya penggunaan alat dental yang dimasukan secara berurutan dan bergantian ke
mulut dan suara yang ditimbulkan dari alat-alat tersebut (Gracia, 2012). Setiap orang
menunjukkan tanda-tanda kecemasan berbeda-beda, di antaranya ditandai dengan
meningkatnya denyut nadi (Pontoh dkk, 2015). Penelitian yang dilakukan oleh Collip’s,
menyatakan bahwa terjadi peningkatan denyut nadi pada saat anak diberikan tindakan
medis (Stuart, Laira, 2005).
Kecemasan yang dialami anak usia pra sekolah jika tidak segera ditangani akan
mengakibatkan tubuh menghasilkan hormon yang menyebabkan kerusakan pada
seluruh tubuh termasuk menurunkan kemampuan sistem imun (Putra, 2011). Anak yang
33
mengalami cemas juga cenderung menolak perawatan dan pengobatan yang sedang
dijalani (tidak kooperatif). Anak yang tidak kooperatif akibat kecemasan akan
menyebabkan terjadinya delay terhadap tindakan operasi yang akan dilakukan.
Hasil studi pendahuluan di ruang rawat inap RS Islam A. Yani Surabaya melalui
wawancara dengan perawat ruang anak didapatkan data bahwa 4 dari 5 perawat ruangan
mengalami kesulitan dalam menghadapi pasien anak yang akan menjalani operasi. Anak
cenderung melakukan penolakan saat perawat akan mengukur tanda-tanda vital,
menginjeksi obat atau mengganti cairan infus. Hal lain juga dikemukakan oleh perawat
bedah RS Islam A. Yani Surabaya yaitu untuk melakukan tindakan operasi pada pasien
anak cenderung membutuhkan waktu yang sedikit lebih lama daripada pasien dewasa.
Mereka perlu menunggu hingga anak berhenti menangis dan mau untuk didekati
perawat. Kecemasan ini memberikan dampak negatif jangka panjang pada anak-anak
terhadap tindakan medis di kemudian hari. Kecemasan pre operasi pada anak usia pra
sekolah ini perlu diatasi dengan melakukan persiapan psikologis berbasis caring dan
diharapkan dapat menurunkan kecemasan pre operasi pada anak usia pra sekolah seperti
teori model keperawatan yang digambarkan oleh Kristen Swanson dalam teori caring.
Perawat memerlukan teknik komunikasi terapeutik yang efektif dalam setiap
tindakan yang akan diberikan kepada klien, selain itu diperlukan pula teknik non
farmakologis agar anak dapat bersikap kooperatif misalnya dengan teknik distraksi
(pengalihan) (Prasetyo, 2010). Salah satu teknik distraksi yang bisa dilakukan pada anak
adalah menonton kartun animasi (Wong, 2009). Ketika anak lebih fokus pada kegiatan
mononton film kartun, hal tersebut mengakibatkan impuls nyeri yang disebabkan
adanya cedera tidak mengalir melalui tulang belakang, pesan nyeri tidak tersampaikan
ke otak sehingga anak tidak merasakan nyeri (Brannon, 2013)
Terdapat beberapa macam persiapan psikologis guna mengurangi kecemasan pre
operasi pada anak pra sekolah, salah satunya ialah teknik non-farmakologi, seperti
kehadiran orang tua, musik, akupunktur, terapi bermain, bermain dengan mainan yang
sudah dikenal, dan menonton kartun (Potter, Perry, 2012). Amerika Academy of
Pediatrics merekomendasikan beberapa cara untuk mengurangi kecemasan dan
membantu anak-anak mengatasi stres rawat inap dan operasi, yaitu dengan pemberian
informasi, pendidikan kesehatan, dan membina hubungan saling percaya dengan anak-
anak dan orang tua mereka dengan menggunakan beberapa alat, seperti gambar,
diagram, boneka, orientasi tour area operasi atau ruang perawatan (Brown, 2012).
METODE PENELITIAN
Penelitian ini menggunakan desain quasi eksperimental dengan pendekatan pre
and post-test without control. Populasi yang digunakanadalam penelitian ini adalah
anak usia pra sekolah yang akan menjalani operasi di RS Islam A. Yani Surabaya.
Teknik pengambilan sampel menggunakan purposive sampling. Sampel dalam
penelitian ini ialah anak yang akan menjalani operasi di RS Islam A. Yani Surabaya
yakni sebanyak 30 anak yang dibagi menjadi 3 kelompok. Proses pengambilan data
dilakukan selama empat bulan. Instrumen yang digunakan ialah kuesioner HARS untuk
mengukur kecemasan anak usia pra sekolah.
Kriteria inklusi pada penelitian ini diantaranya anak usia 3-5 tahun, anak
menjalani rawat inap di rumah sakit minimal 1 hari sebelum jadwal operasi, anak yang
akan menjalani operasi sedang dan orang tua bersedia anak menjadi responden. Untuk
kriteria ekslusi pada penelitian ini adalah anak yang dilakukan operasi cito, anak yang
memiliki kelainan konginetal dan penyakit lainnya seperti sindrom down, tuna netra,
33
dan sebagainya, serta kondisi anak sangat lemah sehingga tidak memungkinkan untuk
menonton video.
Penentuan kelompok kartun, animasi dan video+animasi dilakukan dengan cara
acak. Anak dengan jadwal operasi awal akan masuk dalam kelompok video kartun, anak
kedua akan masuk dalam kelompok video animasi, anak ketiga akan masuk dalam
kelompok video kartun+animasi, dan anak keempat akan masuk ke dalam kelompok
video kartun, begitu seterusnya. Sebelum dilakukan proses pengambilan data, orang tua
calon responden diberikan informasi tentang penelitian yang akan dilakukan,
keuntungan dan dampak yang mungkin dapat ditimbulkan selama proses penelitian, bila
orang tua calon responden menyetujuinya maka dilanjutkan dengan pengisian lembar
persetujuan menjadi responden. Kemudian dilakukan pengukuran kecemasan anak
sebelum intervensi menggunakan skala HARS 40 menit sebelum anak dibawa ke ruang
operasi.
Pada kelompok video kartun, anak diberi kesempatan memilih salah satu kartun
(bobo boy, tayo the little bus dan marsha and the bear) kemudian dilakukan pemutaran
video kartun selama 15 menit. Pada kelompok video animasi, dilakukan pemutaran
video animasi selama 15 menit. Pada kelompok kombinasi video kartun+video animasi,
anak diberi kesempatan memilih salah satu kartun (bobo boy, tayo the little bus dan
marsha and the bear) kemudian dilakukan pemutaran video kartun 15 menit dan video
animasi 15 menit. Setelah pemutaran video dilakukan pengukuran kecemasan anak
setelah dilakukan intervensi menggunakan skala HARS 5 menit sebelum anak masuk ke
ruang operasi.
HASIL PENELITIAN
Tabel. 1
Distribusi Frekuensi Responden (n=30)
No. Variabel Frekuensi Persentase (%)

1. Jenis Kelamin
- Video kartun
a. Laki-laki 6 60
b. Perempuan 4 40
- Video animasi
a. Laki-laki 5 50
b. Perempuan 5 50
- Video kartun+video animasi
a. Laki-laki 6 60
b. Perempuan 4 40
2. Riwayat operasi
- Video kartun
a. 0 10 100
b. 1 0 0
c. >1 0 0
- Video animasi
a. 0 10 100
b. 1 0 0
c. >1 0 0
- Video kartun+video animasi
a. 0 10 100
b. 1 0 0
c. >1 0 0
33
Tabel 1 menunjukkan bahwa sebagian besar anak berjenis kelamin laki-laki. Pada
data riwayat operasi, seluruh responden belum memiliki riwayat operasi sebelumnya
yang artinya semua responden baru pertama kali menjalani operasi.
Tabel. 2
Distribusi Frekuensi Tingkat Kecemasan Sebelum Intervensi
Berdasarkan Jenis Kelamin (n=30)
Jenis Kecemasan responden

kelamin Kecemasan sedang Kecemasan Berat Total
responden F % F % N %
Laki-laki 17 100 0 0 17 100
Perempuan 9 69,2 4 30,8 13 100
Total 26 86,7 4 13,3 30 100
Sumber : data primer, 2019
Tabel 2 menunjukkan terdapat 17 anak berjenis kelamin laki-laki termasuk dalam

kecemasan sedang. Pada anak yang berjenis kelamin perempuan, terdapat 9 anak
termasuk dalam kecemasan sedang dan 4 anak termasuk dalam kecemasan berat.
Tabel. 3
Perbedaan Rata-Rata Tingkat Kecemasan Pre Operasi pada Anak Usia Pra Sekolah
Sebelum dan Setelah Intervensi Menonton Video Kartun, Video Animasi,
Serta Kombinasi Video Kartun+Video Animasi (n=30)
Variabel Mean SD 95% CI p value n

a.Menonton video kartun
Tingkat kecemasan sebelum 24,70 2,111 3,258-5,142 0,000 10
Tingkat kecemasan setelah 20,50 2,506
Selisih -4,20
b. Menonton video animasi
Tingkat kecemasan setelah 19,70 2,058
Selisih -4,70
c. Menonton video kartun+video animasi
Tingkat kecemasan setelah 17.70 1,567
Selisih -7,20
Berdasarkan tabel 3 menunjukkan bahwa pada kelompok anak yang diberikan

intervensi menonton video kartun mengalami penurunan tingkat kecemasan pre operasi
sebesar 4,20. Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat
kepercayaan 95% (3,258-5,142), sehingga dapat disimpulkan bahwa ada perbedaan
antara tingkat kecemasan pre operasi pada anak sebelum dan setelah diberikan
intervensi menonton video kartun.
Tabel 3 juga menunjukkan bahwa pada kelompok yang diberikan intervensi
menonton video animasi terjadi penurunan tingkat kecemasan pre operasi sebesar 4,70.
Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat kepercayaan 95%
(3,529-5,871), sehingga dapat disimpulkan bahwa ada perbedaan antara tingkat
kecemasan pre operasi anak sebelum dan setelah diberikan intervensi menonton video
animasi.
33
Tabel di atas juga menunjukkan bahwa pada kelompok anak dengan intervensi
kombinasi video kartun+video animasi terjadi penurunan tingkat kecemasan pre operasi
sebesar 7,20. Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat
kepercayaan 95% (5,947-8,453), sehingga dapat disimpulkan bahwa ada perbedaan
antara tingkat kecemasan pre operasi anak sebelum dan setelah diberikan intervensi
kombinasi video kartun+video animasi.
Berdasarkan penjelasan di atas, dapat diketahui bahwa penurunan tingkat
kecemasan pre operasi anak setelah diberikan video kartun lebih kecil daripada
penurunan tingkat kecemasan pre operasi anak setelah diberikan video animasi. Maka,
pemberian video animasi lebih efektif daripada video kartun dalam menurunkan tingkat
kecemasan pre operasi pada anak usia pra sekolah.
Untuk penurunan tingkat kecemasan pre operasi anak setelah diberikan video
kartun juga lebih kecil daripada penurunan tingkat kecemasan pre operasi anak setelah
diberikan kombinasi video kartun+video animasi. Maka, kombinasi video kartun+video
animasi lebih efektif daripada video kartun dalam menurunkan tingkat kecemasan pre
operasi pada anak usia pra sekolah. Untuk penurunan tingkat kecemasan pre operasi
anak setelah diberikan video animasi lebih kecil daripada penurunan tingkat kecemasan
pre operasi anak setelah diberikan kombinasi video kartun+video animasi. Maka,
kombinasi video kartun+video animasi lebih efektif daripada video animasi dalam
menurunkan tingkat kecemasan pre operasi pada anak usia pra sekolah.
Berdasarkan, ketiga intervensi di atas dapat disimpulkan bahwa intervensi
kombinasi video kartun+video animasi memiliki penurunan yang paling besar daripada
dua intervensi yang lain, sehingga intervensi kombinasi video kartun+video animasi
lebih direkomendasikan untuk digunakan dalam menurunkan tingkat kecemasan pre
operasi anak usia pra sekolah.
PEMBAHASAN
Jenis Kelamin
Hasil analisis didapatkan bahwa anak laki-laki yang termasuk dalam kecemasan
sedang ialah sebanyak 17 anak dan tidak ada yang termasuk dalam kecemasan berat,
sedangkan pada anak perempuan yang termasuk dalam kecemasan sedang ialah
sebanyak 9 anak dan yang termasuk dalam kecemasan berat sebanyak 4 anak. Potter,
Perry (2012) menyebutkan bahwa salah satu faktor yang mempengaruhi kecemasan
ialah jenis kelamin. Kecemasan lebih sering terjadi pada anak perempuan dibandingkan
anak laki-laki.
Hal ini karena laki-laki lebih aktif dan eksploratif sedangkan perempuan lebih
sensitif dan banyak menggunakan perasaan. Pada perempuan juga lebih mudah
dipengaruhi oleh tekanan-tekanan lingkungan daripada laki-laki, kurang sabar dan
mudah menggunakan air mata. Mudatsir (2010) menyatakan bahwa anak harus
mendapatkan penanganan medis dan tindakan operasi di rumah sakit yang mampu
menimbulkan kecemasan akan suasana rumah sakit.
Riwayat Operasi
Hubungan riwayat operasi dengan tingkat kecemasan pre operasi anak usia pra
sekolah dalam penelitian ini tidak dapat dianalisis karena semua responden belum
pernah menjalani operasi sehingga kali ini merupakan pengalaman pertamanya. Maka,
perlu adanya penelitian yang menggunakan responden yang variatif. Menurut Supartini
(2013) anak yang baru mengalami perawatan di rumah sakit akan berisiko
menimbulkan
33
perasaan cemas yang ditimbulkan baik oleh anak maupun orang tua. Berbagai kejadian
dapat menimbulkan dampak atraumatik terutama pada anak yang baru pertama kali
mengalami perawatan di rumah sakit, salah satunya karena adanya pengalaman interaksi
yang tidak baik dengan petugas kesehatan.
Hockberry, Wilson (2010) juga menyebutkan bahwa anak yang mempunyai
pengalaman sebelumnya akan mulai membentuk respon koping dibandingkan dengan
anak yang belum mempunyai pengalaman. Hal ini disebabkan karena anak yang pernah
dirawat sebelumnya di rumah sakit yang sama akan merasa lebih terbiasa dibandingkan
dengan yang baru pertama kali dirawat serta anak akan merespon sakitnya dengan lebih
positif. Hal ini juga didukung oleh Pelander, Leino-Kilpi (2010) menyebutkan bahwa
semakin sering anak berhubungan dengan rumah sakit maka semakin kecil bentuk
kecemasan atau sebaliknya.
Pengaruh Video Kartun terhadap Penurunan Tingkat Kecemasan Pre Operasi

pada Anak Usia Pra Sekolah
Hasil penelitian menunjukkan bahwa ada perbedaan tingkat kecemasan anak
sebelum dan setelah diberikan intervensi video kartun (p value = 0,000) dengan
penurunan nilai rata-rata tingkat kecemasan pre operasi anak sebesar 4,20. Video kartun
cocok digunakan untuk mendistraksi/mengalihkan rasa cemas anak menjelang operasi
(Noorlaila, 2010). Teknik distraksi yang dapat dilakukan untuk mengatasi kecemasan
anak yaitu melibatkan anak dalam permainan, karena bermain merupakan salah satu alat
komunikasi yang natural bagi anak-anak (Suryanti et al, 2011). Penelitian oleh Lee
(2012) menyatakan bahwa menonton video kartun oleh pasien bedah anak adalah
metode yang sangat efektif untuk mengurangi kecemasan pra operasi. Intervensi ini
merupakan metode yang murah, mudah dikelola, dan komprehensif untuk mengurangi
kecemasan dalam populasi bedah pediatrik.
Pengaruh Video Animasi terhadap Penurunan Tingkat Kecemasan Pre Operasi

pada Anak Usia Pra Sekolah
sebelum dan setelah diberikan intervensi video animasi (p value = 0,000) dengan
penurunan tingkat kecemasan pre operasi anak sebesar 4,70. Penurunan tingkat
kecemasan pre operasi menggunakan video animasi ini lebih besar daripada pemberian
video kartun. Kecemasan pada anak timbul karena menghadapi sesuatu/lingkungan
yang baru dan belum pernah ditemui sebelumnya, serta ketidaknyamanan/ketakutan
terhadap sesuatu karena merasa bahaya dan menyakitkan (Townsend, 2009 dalam
Suprobo, 2017). Pada anak usia pra sekolah, ia akan beranggapan bahwa saat
dipindahkan ke ruang operasi hal tersebut merupakan sebuah hukuman baginya
sehingga timbul perasaan malu dan bersalah, merasa dipisahkan, merasa tidak aman dan
kemandiriannya terhambat (Hockenberry & Wilson, 2010).
Salah satu cara yang dapat digunakan perawat untuk mengurangi kecemasan pre
operasi anak ialah dengan pemberian informasi menggunakan beberapa alat, seperti
gambar, diagram, boneka, orientasi tour area operasi atau ruang perawatan (Brown,
2012). Tour area operasi yang dimodifikasi dengan menggunakan media video animasi
dapat memudahkan anak usia pra sekolah yang memiliki daya imajinasi tinggi untuk
mendapatkan informasi ringan berbasis menyenangkan, sekaligus menurunkan
kecemasan pre operasinya.
33
Pengaruh Kombinasi Video Kartun+Video Animasi terhadap Penurunan Tingkat

Kecemasan Pre Operasi pada Anak Usia Pra Sekolah
sebelum dan setelah diberikan intervensi video animasi (p value = 0,000) dengan
penurunan tingkat kecemasan pre operasi anak sebesar 7,20. Intervensi kombinasi video
kartun+video animasi ini memiliki penurunan tingkat kecemasan paling besar daripada
pemberian video kartun maupun video animasi.
Intervesi ini memiliki jenis video yang lebih bervariasi dan waktu penayangan
yang lebih lama, sehingga mampu lebih efektif dalam menurunkan tingkat kecemasan
pre operasi pada anak usia pra sekolah. Hal tersebut dikarenakan video kartun
menayangan tokoh kartun yang lucu dan disukai anak-anak sehingga membuat anak
merasa senang, terhibur dan melupakan rasa cemasnya menjelang operasi. Kemudian
penayangan video kedua yaitu video animasi tour area operasi dimana memudahkan
anak usia pra sekolah yang memiliki daya imajinasi tinggi untuk mendapatkan
informasi ringan mengenai situasi dan kondisi ruang operasi atau ruang perawatan
berbasis menyenangkan, sekaligus menurunkan kecemasan pre operasi anak dengan
mengatasi ketidaktahuan dan kewaspadaan anak terhadap ruang operasi/ruang
perawatan.
Sejalan dengan penelitian yang dilakukan oleh Fatmawati, Syaiful & Ratnawati
(2019) yang menyatakan bahwa ada pengaruh audiovisual menonton film kartun
terhadap tingkat kecemasan saat prosedur injeksi pada anak prasekolah. Hasil penelitian
ini juga sejalan dengan penelitian Wahyuningrum (2015) yang menyatakan bahwa
pemberian cerita melalui audiovisual efektif dalam menurunkan tingkat kecemasan pada
anak usia prasekolah yang mengalami hospitalisasi.
Apabila anak mengalami kecemasan tinggi saat dilakukan tindakan invasif,
kemungkinan besar tindakan yang dilakukan menjadi tidak maksimal dan tidak jarang
harus mengulangi beberapa kali sehingga akan menghambat proses penyembuhan anak.
Kondisi ini memper-sulit perawat dalam melakukan tindakan keperawatan (Supartini,
2014).
Koller, Goldman (2012) dalam studinya menyatakan bahwa pemberian cerita
melalui audiovisual guna menurun-kan kecemasan termasuk teknik distraksi kecemasan
dengan teknik audiovisual. Perhatian anak yang terfokus kepada cerita audiovisual yang
disimaknya mendis-traksikan atau mengalihkan persepsi kecemasan anak dalam korteks
serebral. Dengan intervensi audiovisual menonton film kartun akan memberikan
rangsangan distraksi berupa visual, auditory dan tactile. Perasaan aman dan nyaman
yang dirasakan anak akan merangsang tubuh untuk mengeluarkan hormon endorphine.
SIMPULAN
Berdasarkan hasil penelitian dapat disimpulkan bahwa terdapat perbedaan rata-
rata tingkat kecemasan pre operasi anak sebelum dan setelah diberikan video kartun (p
value = 0,000, selisih = 4,20), setelah diberikan video animasi (p value = 0,000, selisih
= 4,70), dan setelah diberikan kombinasi video kartun+video animasi (p value = 0,000,
selisih = 7,20).
33
SARAN
Perawat diharapkan dapat menerapkan pemberian kombinasi video kartun+video
animasi untuk anak usia pra sekolah yang akan menjalani operasi. Intervensi ini
merupakan salah satu tindakan atraumatic care berbasis caring. Bagi peneliti
selanjutnya diharapkan dapat mempertimbangkan jumlah sampel yang lebih besar,
karakteristik responden yang lebih variatif dari sisi pengalaman operasi sebelumnya,
jenis operasi yang sama dan penggunaan instrumen lain untuk mengukur tingkat
kecemasan pada anak.
DAFTAR PUSTAKA
Alini, A. (2017). Pengaruh Terapi Bermain Plastisin (Playdough) terhadap Kecemasan
Anak Usia Pra Sekolah (3-6 Tahun) yang Mengalami Hospitalisasi di Ruang
Perawatan Anak RSUD Bangkinang. Jurnal Ilmu Kedokteran, 1(2), 4-7
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in Children. Master’s thesis The University of Alabama
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Bolus. Skripsi. Stikes Insan Cendekia Medika Jombang
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Film Kartun terhadap Tingkat Kecemasan saat Prosedur Injeksi pada Anak
Prasekolah. Jurnal Ilmiah Kesehatan (Journal of Health Sciences), 12(2), 15-29
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Tuminting Manado, Jurnal e-GiGi, 3(1): 13-17
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CRITICAL APPRAISAL JURNAL 1

INSTRUMEN PENERAPAN EVIDENCE BASED PRACTICE (EBP)

I. Kuesioner Data Demografi

tanda (√) pada tempat pilihan yang tersedia.

3. Jenis Kelamin : ( ) Laki-Laki ( ) Perempuan

6. Pukul Pretest : Post test :

Petunjuk : Lingkari satu kategori pada masing-masing domain yang paling

menggambarkan kondisi dan situasi anak.

1. Memperhatikan sekeliling, ingin tahu, bermain, membaca (atau

2. Tidak mau melakukan kegiatan, menunduk, gelisah dengan

memainkan tangan, duduk dekat dengan orang tua.

3. Bergerak tanpa aktivitas yang jelas, menggeliat, memegang orang

4. Menghindari tenaga kesehatan, menolak perlakuan dengan kaki dan

terpisah dari orang tua.

1. Membaca (tanpa suara), bertanya, berkomentar, menjawab

pertanyaan, terlalu asyik bermain untuk merespon.

2. Menanggapi orang yang lebih dewasa dengan berbisik, hanya

3. Diam, tidak ada respon terhadap orang lebih dewasa

4. Merengek, mengerang, merintih

5. Menangis atau bahkan berteriak “tidak mau di operasi”

6. Menangis, berteriak keras terus menerus.

1. Terlihat senang, tersenyum, atau asyik dengan kegiatannya

2. Netral, tidak terlihat emosi yang berarti pada wajah

3. Sedih, wajah ketakutam, terlihat tegang

4. Menangis, menjadi sangat marah

D. Keadaan Ingin Tahu

1. Berjaga-jaga, melihat sekeliling, melihat apa yang dilakukan tenaga

yang lebih dewasa

3. Waspada melihat sekitarnya, terkejut akan suara-suara tertentu, mata

waspada, bahkan menegang

4. Panik dan merengek, menangis, mendorong orang di sekitarnya.

E. Peranan Orang Tua

1. Sibuk bermain atau sibuk dengan kebiasaannya, duduk tenang, tidak

membutuhkan orang tua, mau berinteraksi dengan oang tua apabila

orang tuanya yang memulai

2. Menggapai orang tua, mencari perlindungan dan kenyamanan,

bersandar pada orang tua.

3. Menatap orang tua, tidak ingin berhubungan dengan orang lain,

melakukan apa yang disuruh bila orang tua berada di dekatnya.

melepaskannya, atau mendorong menjauhi orang tuanya.

SKOR TOTAL : (A/4 +B/6+C/4+D/4+E/4) x 100/5

Rentang skor kecemasan

1. Cemas ringan = 30- 53

STANDAR OPERASIONAL PROSEDUR (SOP)

Pengertian Salah satu distraksi audiovisual yang merupakan jenis distraksi

CUPLIKAN TAMPILAN VIDEO KARTUN DAN ANIMASI

a. Cuplikan Tampilan Video Kartun

Video 4 : Masha and the Bear - Monkey Business

b. Cuplikan Tampilan Video Animasi

Nama Mahasiswa : Nurus Suroya

5. Rabu, 29 Bab 3 dan 4 Perbaiki kesalah ejaan sesuai

6. Selasa, 05 Kelengkapan KIN ACC dan lanjutkan ujian hasil

7. Kamis, 2 Juli Perbaikan (revisi) ACC dan lanjutkan publikasi

Nama Mahasiswa : Nurus Suroya

5. Kamis, 26 Bab 3 dan 4 Bab hasil dan pembahan sesuai

6. Sabtu, 16 Kelengkapan KIN ACC, persiapkan power point

7. Rabu, 01 Juli Perbaikan (revisi) ACC dan lanjutkan publikasi

LEMBAR PERBAIKAN (REVISI)

NAMA MAHASISWA : NURUS SUROYA

TELAH DIREVISI DAN DISETUJUI DENGAN PERBAIKAN SEBAGAI

NO. PERBAIKAN/ POIN REVISI TANDA TANGAN

2. Bab 3 pada sub bab hasil dan pembahan