RESEARCH DETAIL

TITLE : Effectiveness and Appropriateness of Therapeutic Play Intervention in

Preparing Children for Surgery: A Randomized Controlled Trial Study.

RESEARCHER:

1. Cheung Li, PhD, is an Assistant Professor, Department of Nursing Studies, University of Hong Kong, Pokfulam, Hong Kong.

2. Violeta Lopez, PhD, is a Professor and Head of School, School of Nursing (NSW and ACT), Australian Catholic University, North Sydney, NSW, Australia.

SUBMITTED DATE : January 25, 2007

ACCEPTED DATE FOR PUBLICATION : July 21, 2007

PUBLISHED DATE : April, 2008

JOURNAL : Journal for Specialists in Pediatric Nursing

INTRODUCTION

It can be observed today that nursing is a dynamic profession,both internally and externally due to constant change occurring in the profession. As a dynamic profession, nursing is responsive and is adapting to meets the needs of patients and the public.Nursing is a practice discipline, which is dependant upon a high level of professionalism,ethics and human values that demand for intellect, skills and a high sense of social responsibility.The knowledge and essential skill that increased dramatically make nurses leading and developing new services in health care delivery. Nurses roles and resposibilities will continue to change in line with the health reforms that are improving care for patients.Therefore, nurses need to be encouraged to integrate the best available evidence with clinical judgment and the current climate in health care requires nuses to be able to apply the best evidence, usually through using research in order to provide the most effective health care.

EVIDENCE BASED PRACTICE

Evidence- based practice(EBP) is currently seen as being central to the delivery of quality healthcare. EBP has been defined as an approach to problem solving in clinical practice which involves asking questions and searching literature in order to adopt an evidence-based intervention for a problem (Rosenberg & Donald,1995 ) .
Nurses are also expected to contribute to the development of EBP. The changes in the health service make this a time of opportunity for the nursing profession.

The starting point for any strategy to promote EBP in nursing is to articulate the ways in which nurses engage in research at different points in their carrier .If nurses can actively engage with EBP, they can make a major contribution towards improving patient outcomes and thus meet the clinical effectiveness.EBP is essential if nurses are to improve patient outcomes. Sackett et al.(1997)stated that the development of EBP is essential because the constantly expanding nature of knowledge in health care has implications for the ways in which professionals treat and care for patients.

EBP makes healthcare professionals confident that their interventions (clinical, educational and managerial) are informed by a current and appropriate knowledge base(McSherry & Haddock 1999). According to McSherry & Haddock (1999) again, in order to facilitate and support health care professionals in having the necessary knowledge and skills to deliver evidence based practice, it is essential that their employing organization encourages this approach. Nurses should adopt evidence-based care as in order to ensure nurses have the knowledge and skills to critically appraise research evidence in promoting quality standards of care. Rising patient expectations and access to quality information means that as professionals nurses should as much as possible attempt not to do anything unless you have the proof it works (Kenworthy, 1996).

Tod et al.(2004)stated, EBP allows nurses to justify their practice and should be apriority for all nurses.The increasing opportunities for nurses working in new roles and reshaping professional boundaries creates new opportunities to support EBP.In the context of this scheme, the vision incorporated the view that EBP was a concern

for all nurses. However, it was also recognized that the achievement of this vision depended at least to some extent on staff who were interested in innovation and committed to bringing about change.

For nurses to be equal partners in clinical and healthcare decision-making, it is essential that they are conversant and competent in accessing and applying evidence in their work. The call for nursing to become an evidence-based profession is not new(Tod et al. 2004). According to Niessen et al.( 2000) priority placed on EBP in current health policy as a means of delivering effective and efficient health care and Palfreyman et al (2003) stated that some evidence shows that other clinical and managerial health professions are becoming more accomplished at using evidence in their decision-making than nurses.

Patients expects to receive clinically effective care, which makes it all the more important to educate nurses in delivering EBP. Evidence-based practice will only become a reality once nurses have equipped themselves with the knowledge and skills to critically appraise and evaluate the true benefits of their actions in light of patient outcomes.Therefore, a professional priority for nurses to engage with EBP. If they do not, EBP will fail to reflect the clinical concerns of nurses and nurses will become increasingly disenfranchised when trying to participate in the clinical decision making of the multidisciplinary team and will find themselves increasingly isolated and powerless if they fail to integrate evidence-based skills into their practice.

The main aim of EBP is to obtain the best outcomes for patients by selecting interventions that have the greatest chance of success (Craig & Smyth, 2007). An evidence-based approach does provide a systematic and structured way to access evidence and tackle uncertainty related to clinical decision-making. It is this contribution that has made EBP the subject of so much debate within the nursing profession (Thompson et al., 2002). According to Sackett et al (1996) evidence-based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

The development of evidence-based practice is essential because the constantly expanding nature of knowledge in health care has implications for the ways in which professionals treat and care for patients (Sackett et al, 1997).The amount of evidence available to the practitioner is central to the development of EBP.Without the support of current and valid evidence clinical expertise deteriorates and practice becomes outdated (Sackett et al, 1997. Lack of information practitioners are required to develop particular skills to critically appraise this information and make informed decisions about its applicability to a specific area of practice. In enthusiasm to shift towards EBP, the healthcare practitioners should know there is a variety forms of evidence such as clinical experience, books, video show, and narrative from the patients, clients, cares and research paper such as systematic review. Research with different design is considered to providing different form of evidence therfore the variety sources of evidence also indicate the different level of evidence.

I am a senior staff nurse that been involved in nursing profession for about 12 years. Specialist in general pediatric and has attended Post Basic Course in Pediatric for 6 months in year 2002. Until now I am working in a busy pediatric ward in Hospital S.
My clinical area is a multidisciplinary and one of the busiest ward in my hospital. It has 28 beds for general cases.

The aimed of this study was to test the effectiveness and appropriateness of therapeutic play in preparing children and their parents for elective surgery. The reason i choose this topic is because it is related and applicable to my workplace and in my daily nursing practice as my ward is general paediatric that multidisciplinary and receiving medical, orthopaedic and surgical cases. Most of children that admitted in my ward for elective or emergency surgery feeling anxious and frigthening once been hospitalized.

By choosing this piece of research as it’s supports the view that many psychological interventions can be of some benefit. A number of research studies have focused on psychological preparations methods that can mitigate the stress of hospitalization
( Zahr, 1998). Play is very important for children in hospital. It is been used for therapeutic purposes as part of the childs care plan and as a way of helping the child to adjust and gain control over a potentially frightening environment. Carroll (2000) defined therapeutic play as an intervention which utilizes play as the primary means of communication or healing . Play may helps the child to understand what is happening and the child will be able cope better with hospitalisation and specifically to the upcoming procedures or interventions.

At the end of this paper i will be able to articulate the meaning of evidence based practice and analyse differing forms of evidence. I will critically discuss different forms of knowledge used as evidence and identify how differing philosophical standpoints might affect the methods used to obtain and use evidence. I also will be able to critically discuss the strengths and weaknesses of different research methodologies, utilise a questioning approach to examine practice, evaluate strategies for developing evidence based inter-professional practice in the workplace and lastly i will be able to review frameworks for implementing evidence based practice.

THE RESEARH

PHENOMENON OF INTEREST

It has been well documented that surgery can be emotionally devasting for children and it can have profound effect on both children and their parents. Excessive anxiety and stress can affect children’s physical and psychological health, hinder their ability to cope with surgery (Li et al., 2007).

In this paper the reseracher identify the provision of preoperative information on pre and postopertive care is the common method of preparing children for surgery in
Hong Kong. However,this approach is mostly focused on providing procedural information but the psychological needs of children and their parents have seldom been taken into consideration.Li & Lam(2003) revealed that a relatively high

preoperative anxiety level of children and parents was reported despite their receiving information on pre-and postoperative care. These findings reveal that there is room for improvement in such preparation.

The researcher mention about an increase in the use of therapeutic play to help children cope with the stress of hospitalization in many western country. Numerous case studies have described and suggest benefits of therapeutic play in hospitalized children but regretfully most of these suggestions based on theories and clinical observations only. Although these theory-based recommendations seem practical and reasonable, the effectiveness of therapeutic play has seldom been tested. Regardeless of different cultural background or settings, play is a very important part of children’s lives and they need play even when they are ill. Therefore researcher believe that the findings of their research paper can also be applicable to children in different cultural settings.

PURPOSE

As been mention earlier, the purpose of this study was to test the effectiveness and appropriateness of therapeutic play in preparing children and their parents for elective surgery . The result of this research paper promote awareness in nurses and parents that play is a very important part of children’s lives, and heighten the importance of integrating therapeutic play as an essential component of holistic and nursing care to prepare children for surgery to diminish their anxiety. The researcher

also mention this information is applicable to nursing practice regardless of different cultural background.

METHODOLOGICAL APPROACH

The methodological approach chosen in this study is a qualitative research and was conducted as Randomized Controlled Trials (RCTs). The application of RCTs in this study was seen as apporopriate method in determining the effectiveness of the interventions. RCTs are considered as the most reliable form of scientific evidence and it involve the random allocation of different interventions to subject (Lachin et. al, 1988). This research is also conducted to promote understanding of human experiences and situations. It also concerned with the opinions, experiences and feelings of individuals that producing subjective data. Because human emotions are difficult to quantify, qualitative research seems to be a more effective method of investigating emotional responses than quantative research(Burns & Grove, 2007).

The qualitative approach is appopriate as it congruent with the aim of the study especially in measuring people’s feelings and experience. If application of quantitative used in this study it will focus on numbers and is more likely to report on variety. Quantitative research may look at very specific variables and one part of an experience. According to Burns & Grove ( 2007) qualitative research focuses on understanding the whole which is cosistent with the holistic philosophy of nursing and in qualitative data analysis occurs concurrently with data collection, rather than sequentially as in quantitative research.

METHOD

Design

The study was carried out in a well-established day surgery unit. To examine the effectiveness of therapeutic play in preparing children and their parents for pediatric surgery, a randomized controlled trial, two group between-subjects design was employed. The researcher using a single complete randomization methods where participants were randomly assigned to experimental group who receiving therapeutic play intervention and the control group that receiving routine information preparation.

In the control group, children and their parents received routine information intervention in a group of five children and parents, in one room on the preoperative assessment day. The information intervention comprised of a briefing session focused on procedural information in pre- and postoperative care, a video about a scenario that demonstrated how a parent and her child had gone through all of the preoperative procedures until to discharge home.

In the experimental group, children that consists five children and their parents were invited to receive therapeutic play intervention 1 week before each child’s operation.
The therapeutic play intervention used in this study included a set of structured activities that designed to prepared children psychologically for surgery according to their psychosocial and cognitive development, corresponding to their age of 7-12 years. The content of therapeutic play included a preoperative tour visit to the operation room, a doll demonstration by the researcher and a return demonstration

by the children on preoperative procedure and the procedure for anesthesia induction. The whole therapeutic play intervention was standardized and lasted for 1 hour.

Sampling

The selection of sampling were children whom admitted for elective day surgery and their parents were invited to participate in this study. The inclusion criteria were children should be between 7-12 years old and able to speak cantonese and read chinese, and accompanied by their parents (either mother or father) on the preoperative assessment day and in the day of surgery.

The exclusion criteria in this study were children with previous surgical experience and those with cognitive or learning problems identified during health assessment by nurses and doctors on admission.

Measures

In this study researcher used The Chinese version of the State Anxiety Scale for Children (CSAS-C) to measured state anxiety level of the children. The CSAS-C asks children to indicate degree they are experinecing that current moment by placing an “X” from three possible responses. The scale consists of 20 items and each is scored from 1-3. The total possible scores range from 20-60 with higher score indicating higher anxiety.

The reseracher also use The Chinese version of the State Anxiety Scale for Adults(CSAS-A) to measured state anxiety level of the parents. The scale also consists of 20 items and each is scored from 1-4. The total possible scores range from 20-80 with higher score indicating higher anxiety.

The Postoperative Parents’ Satisfaction Questionnaire(PPSQ) been used to measure parents perceptions and opinions of the interventions received preoperatively and also use of postoperative information and skills to help their children cope with the stress of surgery. The PPSQ consists of 8 items written in chinese which use a 4-point Likert-type rating scale to measure parents satsfaction from “strongly disagree” to “strongly agree”, scored 1-4 and possible scores range from 8-32 with higher scores indicating greater satisfaction.

DATA COLLECTION

Study approval was obtained from the Clinical Research Ethics Committee of the Chinese University of Hong Kong and from the study hospital’s ethics committees.
The units heads of the day surgery unit and the operating theatre were fully informed about the study’s purpose, design and duration. Written consent was obtained from the parents after they were told about the purpose of the study. Children were also invited to put their names on a special individual assent form.In this study both children and parents were told that they were under no obligation to participate and could withdraw from the study with impunity at any time and were assured of the confidentiality.

On the preoperative assessment day, children and their parents were invited to participate in the study. The demographic data and state anxiety scores of the children and their parents were collected. On the day of surgery, state anxiety scores of the children and their parents was again assessed preoperatively and 4 hours postoperatively. Upon discharge home, PPSQ distribute to parents.

The researcher also do a single-blind study to ensure the data collection was objective and impartial which research nurses responsible for data collection not aware of the treatment allocation of the study participants.

DATA ANALYSIS

The researcher able to explained the validity of the tools used in this study.
The psychometric properties of the CSAS-C have been tested (Li & Lopez, 2004).
The test-retested reliability coefficients for the CSAS-C were .79 and .78 for the age groups 7-8 and 9-12 respectively. The validity of the CSAS-C was supported by correlation of scale scores with children’s heart rate and mean arterial blood pressure at pre- and postoperative period. Results showed that there were positive correlations between the state anxiety and these psychological parameters. Confirmatory factor analysis further confirmned that construct validity of the CSAS-C, with a good fit between the factor structure if the scale and the observed data.

The researcher also mention about the psychometric properties of the CSAS-A and according to Shek(1993) this scale have been empirically tested. Internal consisitency was .90. The scale also significantly correlates with other measures of psychological well-being and thus has concurrent validity. In addition, the factorial structure of the scale was also confirmed by factor analyses.

Lastly,the PPSQ to measure parents perception and opinion shows that the evaluation of the psychometric properties of the PPSQ demonstrated good content validity and high internal consistency reliability.

FINDINGS

The results of inferential statistic showed that the experimental and control group were similar with respect to the age and gender of children, educational attainment of parents, type of surgery performed and baseline state anxiety scores for children and their parents, suggesting of variance between these two group.

The mean and standard deviation of result shows children in the experimental group reported lower state anxiety scores in the preoperative period, t(201)=3.6, p=.001 and in the postoperative period t(201)=3.2, p=.002 than the children in control group.
In addition, result showed that parents in the experimental group reported significantly lower state anxiety scores in the preoperative period, t(201)=3.11, p=.002 and in the postoperative period t(201)=2.02, p=.03 than parents in control group.

Researcher able to obtained data levels of parents satisfaction and results shows parents in experimental group reported higher of levels satisfaction with scores t(201)=4.40, p=.001 compared to parents in control group.

DISCUSSION

The purpose of this study was to test the effectiveness and appropriateness of therapeutic play in preparing children and their parents for elective surgery.
The overall results supports the view that psychological intervention can be some of benefit. It’s provide support for the effectiveness and appropriateness of using therapeutic play in preparing children and their parents for surgery.

There are some factors that shed light on these findings. First, lack of familiarity with the environment and lack of control over upcoming medical procedures contribute of stress for children. It was reasoned that if the children believe that they have adequate control over the unfamiliar environment and upcoming stressful procedures, their perception of threat would decrease. The major function of therapeutic play used in this study was to help children regain self-control. Therapeutic play not only give the child opportunity to practice the procedure and interact with environment in an active non-threatening way but would also allow the child to become desensitized to the potential stressful situation and be instilled with a sense of control over situation.

Secondly, the researcher discover that therapeutic play intervention used in this study included the preparation of procedures for anaesthesia induction, which was lacking in the existing clinical practice. The use of a doll to explain the procedure could help make complicated concepts more accessible and thus minimize the children’s anxiety but the content of therapeutic play intervention used in this study took Erickson’s psychosocial and Piaget’s cognitive development of children into consideration which is crucial for designing age-appropriate interventions for children to cope with surgery.

One inclusion criterion was the parents were able to accompany their child for the therapeutic play intervention in the experimental group. The involvement of parents might enhance their perceptions of professional competence and quality of care
( Squires, 1995) and that explains why parents in this group have lower state anxiety in pre- and postoperative period. The overall result provide evidence that therapeutic play intervention is effective in minimizing the pre- and postoperative anxiety levels of children and their parents.

Although the effectiveness of an intervention is important but it will meaningless if the intervention is not appropriate or acceptable to patients. In this study, parents satisfaction was measured postoperatively using PPSQ and result shows that parents receiving preoperative therapeutic play intervention have higher level of satisfaction. Although play has traditionally been view as less important for hospitalized children by Chinese parents but most parents in the experimental group commented that it was helpful to attend such intervention. All this results demonstrate

the appropriateness of using therapeutic play intervention in preparing children and their parents for surgery in Chinese culture.

This study was limited by not including a process component in measuring the effectiveness of the intervention even though it is important to identify the strengths and limitations from the participants perspectives. Therefore, a process evaluation such as conducting interviews with children and their parents on their perceptions of the process of therapeutic play intervention they received, should be incorporated in future studies.

IMPLICATIONS FOR FUTURE PRACTICE

Drawing conclusion from research findings is not the end of evidence-based nursing practice, it is crucial to ensure the research findings can put into clinical practice.It is expected that the therapeutic play interventions implemented in this study can be quickly learned by nurse and will take little effort if used regularly. This study demonstrated that it only took about one hour of a staff nurses time to provide a comprehensive preoperative psychoeducational care to a group of children and their parents. It would be feasible for healthcare system to consider utilize this therapy as a routine nursing preparation of children and their parents for surgery.

RECOMMENDATIONS

The barriers to the development of an evidence-based culture in nursing is well documented. In clinical practice, the barriers to EBP clearly identified as lack of time (Bertulis,2008) and workload pressure where competing priorities impede research and development.In order to facilitate and support healthcare professionals in having the necessary knowledge and skills to deliver evidence-based practice, it is essential that their employing organization encourages philosophies that are open to enquiry, change and development.

Nurses need encouragement and support in the development of such skills to critically appraise research . Encouragement and sustained support are an essential factor in enable nurses to gain confidence in developing and learning new skills and it should be fostered and enhanced from the earliest possible opportunity.

Tailoring specific teaching and learning strategies to embed a culture of EBP is essential if the philosophy of delivering clinically effective health care is to become reality. This has implications for the education and continuing professional development of nurses.

CONCLUSION

This is a time of opportunity which nursing needs to capitalize on in order to move forward and engage in EBP. Evidence-based practice is closely related to clinical effectiveness. Forms of evidence are policy directives,expert opinion and personal and professional experience.It is clearly stated that all practitioners must maintain and improve their professional knowledge and competence. Fostering the culture knowledge and capabilities to execute evidence-based practice will ensure the progression of nursing profession that will influence policy and practice for future generations.

The execution of evidence-based practice relies on a sound knowledge of what it is and the skills that are needed to apply it in practice.These skills are the cornerstones of EBP and if used effectively, will enhance patient care and outcomes. While acknowledging that implementing EBP is not without its difficulties, it is integral to the provision of good quality patient focused nursing practice. There are many potential barriers including lack of time, lack of access to the research findings, lack of skills in critiquing and appraising, and lack of support from organization due to the lack of value to the research findings.But if nurse able to overcome the barrier, as stated by Li & Lopez(2008) it will not only contribute in promoting nurses accountability and resposibility for patients care through EBP, but will also facilitate the development of more autonomy in the advancement of nursing practice.