effectiveness of play therapy among children after...

EFFECTIVENESS OF PLAY THERAPY AMONG CHILDREN AFTER OPEN HEART

SURGERY

PROJECT REPORT

Submitted in partial fulfillment of the requirements for the Diploma in Cardiac Nursing

Submitted by

Mariamma Philip

Roll No- 5776

SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND TECHNOLOGY

TRIVANDRUM

MAY2009

CERTIFICATE FROM THE SUPERVISORY GUIDE

This is to certify that Mrs.Mariamma Philip has completed the project

work on "Effectiveness of play therapy among children after open-heart

surgery" under my direct supervision for the partial fulfillment for the

Diploma in Cardiovascular and Thoracic nursing in the University of Sree

Chitra Tirunal Institute for Medical Sciences and Technology. It is also

certified that no part of this report has been included in any other thesis for

processing any other degree by the candidate.

Trivandrum May2009

Dr .P .P .Saramma Senior Lecturer in Nursing SCTIMST Trivandrum

CERTIFICATE FROM THE CANDIDATE

This is to certify that the project on "Effectiveness of play therapy

among children after open-heart surgery" is a genuine work done by me at

the Sree Chitra Tirunal Institute for Medical Sciences and Technology,

Trivandrum under the guidance of Dr.P.P.Saramma, Senior Lecturer in

Nursing, SCTIMST, Trivandrum. It is also certified that this work has not been

presented previously to any University for award of degree, diploma or other

recognition

Trivandrum

May2009

Mariamma Philip

Roll No.5776

I

APPROVAL SHEET

This is to certify that Mrs.Mariamma Philip bearing Roll No-

5776 has been admitted to Diploma In Cardiac Nursing in January in 2008

and she undertaken the project entitled "Effectiveness of play therapy

among children after open heart surgery" which is approved for the

Diploma in Cardiac Nursing awarded by the Sree Chitra Tirunal Institute for

Medical Sciences and Technology, Trivandrum as it is found satisfactory

Date:

Examiners

1)------------------------

2)------------------------

Guide(s)

1)----------------------

2)----------------------

ACKNOWLEDGEMENT

First of all let me thank God almighty for the unending love, care and

blessing during the tenure of this study.

I take this opportunity to express my sincere thanks to Dr.P.P.Saramma,

Senior Lecturer in Nursing, SCTIMST, Trivandrum for the Guidance, she

provided for this study. Her advices regarding the concept, basic guidelines

and analysis of data were very much encouraging. Her contributions and

suggestions have been of great help for which I am extremely grateful. With

profound sentiments and gratitude the investigator acknowledge the

encouragement and help received from the following persons for the

completion of this study

I am thankful. to Dr.Shyam Krishnan, HOD, Pediatric Cardiac Surgery

for this constant support and encouragement

All the staff and department of head of Paediatric cardiac surgery ward

were helped for the completion of this study at same time I am indebted to

them.

MARIAMMA PHILIP

ABSTRACT

EFFECTIVENESS OF PLAYTHERAPYAMONG CHILDREN AFTER OPEN HEART SURGERY

Congenital hemi defect is not a disease, a defect present at birth. CHD is

one of the most common inborn defects. 95% of these are corrected by surgery.

Hospitalized children require more than recreational play because illness and

hospitalization constitute crisis in a child's life and since these situations are

fraught with over-whelming stresses, children need to play out their fears and

anxieties as a means of coping with these stesses.

Objective of the study was to assess the effectiveness of pl~y in the post

operative recovery and cooperation in the preoperative and late postoperative

period. Pilot study was conducted in the month of November 2008 among 3

experimental and 3control samples Final study was conducted in the month

November 2008- January 2009 among 12 experimental and 12 control samples

by consecutive sampling technique from pediatric surgery ward in

SCTIMST.Play therapy was given in the day previous to the day of surgery.

Data analyzed by descriptive statistics, pie diagram and bar diagram. Major

finding of the study was play therapy was effective in children to a certain

extent to produce a better postoperative recovery as a non pharmacological

method.

CONTENTS

S.NO CHAPTER TITLE PAGE NO.

1. I Introduction 1-12

2. II Review of Literature 13-22

3. III Methodology 23-26

4. IV Analysis & Interpretation of Data 27-46

5. v Summary, Conclusion, Limitation 47-50 & Recommendation

6. References 51-53

7. Appendix 54-58

I LIST OF TABLES

S.NO Title Page No.

4.1 Distribution of samples according to sex 28

4.2 Comparison of samples according to age 30

4.3 Distribution of samples according to the surgery 31

Distribution of samples according to the 4.4 32

postoperative respiratory status


postoperative bowel and bladder status


postoperative oral intake status


postoperative ambulation status


postoperative hospital stay

4.9 Comparison of samples according to the total 41

postoperative recovery

4.10 Comparison of samples according to the 43 cooperative score of children in the preoperative

period

4.11 Comparison of samples according to the 45 cooperative score of children in the postoperative

period

I LIST OF FIGURES

S.NO Title Page No.

1 Distribution of samples according to sex 28

2 Distribution of samples according to the surgery 30

. Distribution of samples according to the 33 3

postoperative respiratory status

Distribution of samples according to the 35 4

postoperative bowel and bladder status

5 Distribution of samples according to the

36 postoperative oral intake status


38 postoperative ambulation status


40 postoperative hospital stay

8 Comparison of samples according to the total 42 •

postoperative recovery

Comparison of samples according to the

9 cooperative score of children in the

preoperative period 44

10 Comparison of samples according to the 46

cooperative score of children in the

postoperative period

LIST OF ABBREVATIONS

1. ASD = Atrial Septal Defect

2. AHA = American Heart Association

3. APT = Association Play Therapy

4. BGD = Bi-Directional Glenn Shunt

5. CHD = Congenital Heart Disease

6. Co A = Coactation of Aorta

7. PSWRD. Pediatric surgery Ward

8. TGA Transposition of Great Arteries

9. ICR = Intra Cardiac Repair

lO.VSD = Ventricular Septal Defect

CHAPTER I

INTRODUCTION

1.1 INTRODUCTION

The Hospital experience can be stressful for young children as they

move from familiar surroundings of their homes into an environment that is

unfamiliar. For some children this experience could have effects such as

withdrawal, depression, aggression, regression and phobias.

Play provides a reassuring element of normality m a strange

environment. During play, the child can express feelings, thoughts, experiences

and behaviors. The playroom provides opportunities for children to have a

positive experience by having a fun time

Play is a familiar part of a child's day. It can help relieve tension for

both the parents and child, and can also provide distraction that helps the child

feel better. If the child is able to be up out of bed, ask about the playroom in

the hospital that he/she can go to. Also, bring storybooks, coloring books,

puzzles, board games, and other toys that can be used in bed. (Carmichael

2006)

Association of play therapy (APT) defines play therapy as "the

systematic use of a theoretical model to establish an interpersonal process

1

wherein trained play therapists use the therapeutic powers of play to help

clients prevent or resolve psychosocial difficulties and achieve optimal growth

and development."

Play therapy is used to help meet the emotional needs of children who

have an illness or surgery that requires hospitalization. Being in the hospital is

stressful for children and their families. Sometimes, children feel scared '

confused, and out of control. Play therapy is used to help children understand

and cope with illness, surgery, hospitalization, treatments, and procedures.

2

1.2 BACKGROUND OF THE STUDY

The application of play therapy principles and procedures can be found

in hospitals internationally. In the United States child life programmes have

been instrumental in incorporating playrooms and play therapy into what

would otherwise be a sterile environement. Using hospital equipment like

syringes, stethoscopes, masks etc. in combination with dolls or puppets

therapist can acquaint children with medical procedures through directed and

· there by significantly reduce children's hospital related anxiety. Positive results

also have been achieved by allowing children to choose materials and direct

their own play. Children often will act out their play procedures what they have

just experienced. This would be viewed as child's way of trying to under stand

what has been experienced or as the child's way of developing control

Golden (1983) believed that the play therapist's toys are every bit as

important as surgeon's knife in assisting children to leave the hospital healthier

than when they arrived. If children do not have an opportunity to appropriately

express and deal with fears and apprehensions, emotional problems may

emerge and healthy adjustment will be altered.

Riddle (1990) states that, another population who uses forms of play

therapy is hospitals. Children who are sick and hospitalized have disruptions in

their play patterns and may be feeling anxiety, fear, and concerns about their

situation. Nurse specialists are experienced in dealing with sick children and

3

the issues that the children are confronting. These nurses can provide

therapeutic play activities that will help the child master their experiences.

With the help of nurses, hospitalized children can regain a sense of control

through the use of unstructured play.

Congenital heart defects means the heart does not develop normally

before birth .According to American Heart Association (AHA) 1 percentage of

every newborn child suffer from CHD, and increasing number of children are

undergoing cariac surgery .About 13 percentage of patients who have one

CHD will have an additional cardiac defect .Between 1 0-15 percentage of

patients with cardiac defect will have one non cardiac defonnity (Campell

1965).There are two types of congenital heart defects.

iii. CONGENITAL HEART DISEASE

Congenital heart defects are problems with the hearts structure that are

present at birth. These defects can involve the interior wall of the heart, valves

inside the heart, or the arteries and veins that carry blood to the heart or out to

the body. Congenital heart defects change the normal floOw of blood through

the heart.

There are many different types of congenital heart defects. They range

from simple defects with no symptoms to complex defects with severe, life

threatening symptoms.

4

Congenital heart defects are the most common type of birth defect,

affecting 8 of every 1000 newborn. Each year more than 35000 babies in the

United States are born with congenital heart defects. Most of these defects are

simple conditions that are easily fixed or need no treatment.

A small number of babies are born with complex congenital heart

defects that need special medical attention soon after the birth. Over the past

few decades, the diagnosis and treatment of these complex defects has greatly

improved.

As a result almost all children with complex heart defects grow to adult

hood and live active, productive lives because their heart defects can be

effectively treated.

Most of the people with complex heart defects continue to need special

heart care through out their lives. They may need to pay special attention to

certain issues that their condition could affect such as health insurance,

employment, pregnancy and contraception and preventing infection during

routine health procedures.

Today in United States, about 1 million adults are living with congenital

heart defects.

5

1. A cyanotic Heart Defects

A.Atrial Septal Defects

The septum is a wall that separates the heart's right and left sides. Septal

defects are sometimes called a hole in the heart. A defect between the hearts

two upper chambers (the atria) is called an atrial septal defect (ASD)

B.Ventricular Septal Defect

Ventricular septal defect is a defect in the ventricular septem the wall

dividing the left and right ventricles of the heart.

C.Coactation of Aorta (CoA)

Co A is the localized narrowing of the aorta. It is most commonly occurs

just distal to the subclavian artery near the site of ductus arteriosus.

2. Cyanotic Heart Defects

A. Tetro logy of Fallot

Tetralogy of fallot is a congenital heart defect. Congenital heart defects

change the normal flow of blood through the heart. This rare and complex

heart defects occurs in about five out of every 10000 babies. It affects boys and

girls equally.

6

Tetro logy of fallot involve four defects.

• A large ventricular septal defect

• Pulmonary stenosis

• Right ventricular hypertrophy

• An over riding aorta

B. Total Anomalous Pulmonary Venous Connection

In T APVC pulmonary vems drain by abnormal routes directly or

indirectly in to the right atrium.

C. Pulmonary Atresia

In pulmonary atresia, no pulmonary valve exists consequently blood

cannot flow from the right ventricle in to the pulmonary artery &on the lungs

. The right ventricular function as blind pouch that may stay small not well

developed. The tricuspid valve often poorly developed.

D. Transposition of Great Arteries

In TGA aorta & pulmonary artery have changed places. Balloon at6rial

septostomy is advised to improve the mixing of blood between the two

circulations.

7

E. Tricuspid Atresia

In this condition, there's no tricuspid valve so no blood can flow from

the right atrium to the right ventricle. As a result, the right ventricle is small

and not fully developed. The child's survival depends on there being an

opening in the wall between the atria (atrial septal defect) and usually an

opening in the wall between two ventricles (ventricular septal defect). As a

result, the venous (bluish) blood that returns to the right atrium flows through

the ASD and into the left atrium. There it mixes with the oxygen -rich (red)

blood from the lungs. Most of this poorly oxygenated mixture goes from the

left ventricle into the aorta and on to the body.

8

1.3 NEED AND SIGNIFICANCE OF THE STUDY

"Play is a child's work and this is not a trivial pursuit," says Alfred

Adler. Play provides the children the opportunities to be free, creative and

expressive. Play is synonymous with being a child and it is the universal

language of children. Play allows children to learn social behaviour, develop

cognitive abilities as well as gross and fine motor skills, and word through

emotional conflicts. Hospitalization to any child is a very unpleasant and

traumatic experience. The child under goes a break from his normal routines,

feels separated, encounters strangers and is subjected to a lot of interventions

which are directed to the promotion of his health, but aggravate his pain and

suffering.

The hospital is also an unfamiliar environment and hospitalization is a

frightening experience to the child. The investigator from her observation feels

that a child most often looks dull, anxious or afraid in the hospital. Many

parents also verbalize that their children who are generally sociable and

outgoing become very passive after their admission to the hospital.

Hospitalized children reqmre more than recreational play because

illness and hospitalization constitute crisis in a child's life and since these

situations are fight with over whelming stresses, children need to play out their

fears and anxieties as a means of coping with these stresses. Play also helps

temporarily to divert their mind from pain and loneliness. (Sam BJ 2007)

9

1.4 Statement of the Problem

Study to asses the effectiveness of play therapy among children after

cardiac surgery.

1.5 Objectives

1. Assess the effectiveness of play among children in adjusting with the

pre operative and late postoperative period.

2. Assess the effectiveness of play in postoperative recovery of children

after cardiac surgery

1.6 Operational Definitions

i. Assessment

The assessment process consists of collection and analysis of data to

determine whether play is having any effects in children after open-heart

surgery

ii. Play therapy

The systematic use of a theoretical model to establish an interpersonal

process wherein trained play therapists use the therapeutic powers of play to

help clients prevent or resolve psychosocial difficulties and achieve optimal

growth and development.

10

r iii. Open heart surgery

The congenital heart surgery done with the assistance of

cardiopulmonary bypass.

1. 7 Methodology

Settings Pediatric Surgery Ward

Sample children between the age group of 4-1 Oyrs

Sample size 12 experimental, 12 control

Sampling technique consecutive sampling

1.8 Tool Preparation

Tool is used to assess the effectiveness of play therapy among children

after cardiac surgery in adjusting with the pre operative and late post operative

period and in post operative recovery. The physiological parameters included

were respiratory status,oral intake status,bowel and bladder status,ambulation

status,postoperative hospital stay status and cooperation of the child in the pre

and postoperative and late postoperative period.

1.9 Delimitations

The study is conducted only in pediatric cardiac surgery ward of SCTIMST.

The sample size is only 24.

11

1.10 Organization of the Report

This chapter deals with introduction, need and significance of the study,

statement of the problem objective, operational definitions, methodology, and

delimitations. Chapter II deals with review of literature. Chapter III deals with

the methodology &chapter 5 include su111111ary discussion conclusion

implication reco111111endation. Reference and appendices are given towards the

end.

12

CHAPTER II

REVIEW OF LITERATURE

Review of literature is an important aspect of the project. It helps to

understand more about the topic and for developing tool and analyzing data.

An intensive review of literature has been done

The revtew of literature relevant to this study 1s presented m the

following sections

2.1 Effectiveness of play therapy among children m adjusting with

preoperative and late postoperative period

2.2 Effectiveness of play in post operative recovery of children

2.1. Effectiveness of play therapy among children in adjusting with

preoperative and late postoperative period

The Hospital experience can be stressful for young children as they

move from familiar surroundings of their homes into an environment that is

unfamiliar. For some children this experience could have effects such as

withdrawal, depression, aggression, regression and phobias.

Play provides a reassuring element of normality in a strange

environment. During play, the child can express feelings, thoughts, experiences

13

and behaviors. The playroom provides opportunities for children to have a

positive experience by having a fun time

Li He (2007) conducted a study on evaluating the effectiveness of

preoperative\ interventions among school children who had undergone general

surgery. In this study he concluded that children receiving preoperative

preparation using therapeutic play reported statistically significant lower

anxiety levels fewer negative emotions and lower heart rates and mean arterial

pressure than children receiving information preparation. Children with high

preoperative anxiety levels manifested more negative emotional behavior

during anesthesia induction and were associated with faster heart rates and

higher mean blood pressure.

Zahr ( 1998) conducted a study on therapeutic play for hospitalized pre

schoolers. In his study the researchers found out that the children who received

therapeutic play interventions manifested markedly less anxiety and more

cooperation and had significantly lower pulse rate and lower mean ABP during

injection than control group.

Lee (2007) conducted a study on effects of therapeutic play on outcome

of children undergoing day surgery. 203 children admitted for day surgery

were invited to participated in a randomized controlled trial and the researcher

concluded that children in the experimental group reported significantly lower

state anxiety scores in pre and postoperative period.

14

! I Lopez (2007) conducted a study on effects of preoperative therapeutic

play on outcomes of school age children undergoing day surgery and he

concluded that therapeutic play is effective in pre and opposed to post surgical

management of children.

Ribeiro ( 1991) conducted a study and he concluded that therapeutic play

helped the children behave more according to what is expected of this 3-5 age

'~ group as well as show signs that they had adapted or presented ego strength.

Bery1(2006) conducted study in pediatric wards of CMC V ellore

Chennai to asses the knowledge, attitude and practice of the parents and

nursing personnel regarding the importance of play needs in hospitalized

children. In her study she found on that some of the parents felt that allowing a

sick hospitalized child to play with medical equipment like stethoscope,

Spatula, syringes etc would help in alleviating child fear.

Currey NE (1988) states that dramatic play is seldom seen in

hospitalized children. It is hypothesized that children recapitulate the

separation-individuation process during hospitalization and, thus, are not

capable of dramatic play until the process of self-development is restored. This

article discusses the functions of play with hospitalized children and focuses

on: (a) the relevance of play to the child's sense of self; (b) the impact of illness

and hospitalization on the child, with emphasis on regression to earlier stages

of self-development and on the developing capacity for symbolic play; and (c)

15

the remedial activities to move children forward developmentally so that they

can use play's potential for therapeutic benefit.

Ray et al (2001) conducted a meta analysis of 94 research studies

focusing on the efficacy of play therapy as a viable psychotherapy intervention

and found a large positive effect of play therapy on treatment outcome with

children. They reported play therapy was effective across modality, age,

' gender, clinical and non-clinical populations, settings, and theoretical schools

of thought .Play therapy has been demonstrated as an effective therapeutic

approach for reduction of stress and anxiety in hospitalized children.

Ziegler D B,Prior MM(1994) states that physical and psychosocial

stress of hospitalization may be influenced by the child's developmental level,

causing behavioral changes, somatic complaints, and a prolonged hospital stay.

Through the use of careful development assessments, preoperative tours, and

therapeutic play techniques fears can be allayed, misconceptions corrected,

emotionally charged issues addressed, and a positive self-image created.

Dreger VA ,Tremback TF (1994) states that although anesthesia during

surgery prevents children from recalling actual surgical events, they are

subjected to stressful events while preparing for surgery. One estimate suggests

that 60% of children experience significant anxiety before anesthesia induction

and surgery, and literature from around the world indicates that preoperative

16

anxiety is a global concern for health care providers. The challenge that nurses

face is to better manage children's anxiety in today's fast paced ORs.]

Jessee PO (1992) states that child's play is recognized as a useful tool

for nurses in the diagnostic process of making judgments about a hospitalized

child's compliance with medical procedures, adjustment to the hospital

environment, degree of pain, and level of psychosocial functioning. However,

the knowledge base that is required to effectively help a pediatric patient

"play" in a therapeutic mode appears to be extremely limited for most nurses

and is rarely addressed in a substantive manner in nursing education.

Educational programs must be willing to incorporate a "developmentally

appropriate, culturally sensitive, and family-centered approach" using clinical

experiences and professional role models in their nursing curricula. The end

product should be nurses who are competent in a much wider range of medical

technological and psychosocial issues than has been necessary in the past. In

short, nurses must learn to play.

17

r 2.2. Effectiveness of play in postoperative recovery of children

LiHc et al (2007) conducted a study on psycho educational preparation

of children for surgery; the importance of parental involvement. In their study

investigator observed that both children and parents in experimental group

reported lower state anxiety score pre and postoperative period. Children in the

experimental group exhibited fewer instance of negative emotional behavior

and parents in experimental group reported greater satisfaction.

Bowmer (2002) conducted a study by educating nurses on the effects of

therapeutic play on anxiety levels in hospitalized children. In his study he

suggested that nurses could use this information to implement therapeutic play

in hospital through out the world.

Riddle (1990) states that, another population who uses forms of play

therapy is hospitals. Children who are sick and hospitalized have disruptions in

their play patterns and may be feeling anxiety, fear, and concerns about their

situation. Nurse specialists are experienced in dealing with sick children and

the issues that the children are confronting. These nurses can provide

therapeutic play activities that will help the child master their experiences.

With the help of nurses, hospitalized children can regain a sense of control

through the use of unstructured play

Zahr ( 1998) conducted a study on therapeutic play for hospitalized pre

schoolers. In his study he found out that the children who received therapeutic

18

I I

I

t l

r' . '

play interventions manifested markedly less anxiety and more cooperation and

I' I

I! i!

had significantly lower pulse rate and lower mean ABP during injection than

control group. Following surgery the experimental group took less time to void

their bladder

William (2007) conducted a study on effects of preoperative

therapeutic play on outcomes of school age children undergoing surgery and

they concluded that children in the experimental group exhibited fewer

negative emotions at induction of anesthesia than children in control group. No

significant differences were found between the two groups in postoperative

period.

Golden (1983) believed that the play therapist's toys are every bit as

important as surgeon's knife in assisting children to leave the hospital healthier

than when they arrived. If children do not have an opportunity to appropriately

express and deal with fears and apprehensions, emotional problems may

emerge and healthy adjustment will be altered.

Catworthy et al (1981) states that using hospital equipment, syringes,

stethoscopes, masks etc in combination with dolls or puppets the therapist can

acquaint children with medical procedures through directed and thereby

significantly reduce children's hospital related anxiety.

19

D'Antonio I J (1984) done a study on effect of therapeutic play in

hospitals The researcher states that Play can be a tool to understand and

intervene with pediatric patients. Collaboration with nurses who are clinical

specialists, early childhood educators, and others who have expert knowledge

of children and play equipment is useful to plan purposeful play programs ot

play sessions for the special needs of hospitalized children. For some children,

hospitalization is a challenging experience that promotes a sense of

competence. For other children, hospitalization is an experience that results in

a negative outcome. Nurses can use play to provide pediatric patients with

emotional and cognitive growth-promoting activities which facilitate a more

positive hospital experience and long-term outcome.

Hall D , Cleary J ( 1988) states that lay in hospitals has developed

alongside of changes toward a more family-centered model of care. The

recreational and educational role of play has been significantly extended

toward a therapeutic purpose. This article considers the relationships between

play workers and teachers, nurses and parents, and presents some European

examples of the use of play in hospitals. Finally, problems encountered in the

operation of play programs are discussed in the context of ensuring the

viability of play in the hospital.

Play therapy has been demonstrated as an effective therapeutic approach

for reduction of stress and anxiety in hospitalized Children. The goal of play

therapy is to provide a family-centered approach to help your child adjust to

20

hospital care. A child life specialist can help meet the emotional needs of

children in the hospital by getting to know your child, giving him/her a chance

to express themselves, and allowing him/her to adjust to being in the hospital

through play therapy. Parents of infants are offered a chance to learn new skills

to comfort their baby and ways they can encourage their baby's continued

development while their baby is recovering in the hospital.

Play therapy is implemented as a treatment of choice in mental health,

school, agency, developmental, hospital, residential, and recreational settings,

with clients of all ages (Carmichael, 2006; Reddy, Files-Hall & Schaefer,

2005).

Play therapy treatment plans have been utilized as the pnmary

intervention or as an adjunctive therapy for multiple mental health conditions

and concerns (Gil & Drewes, 2004; Landreth, Sweeney, Ray, Homeyer &

Glover, 2005), e.g. anger management, grief and loss, divorce and family

dissolution, and crisis and trauma, and for modification of behavioral disorders

(Landreth, 2002), e.g. anxiety, depression, attention deficit hyperactivity

(ADHD), autism or pervasive developmental, academic and social

developmental, physical and learning disabilities, and conduct disorders

(Bratton, Ray & Rhine, 2005).

Play therapy is used to help meet the emotional needs of children who

have an illness or surgery that requires hospitalization. Being in the hospital is

21

stressful for children and their families. Sometimes, children feel scared,

confused, and out of control. Play therapy is used to help children understand

and cope with illness, surgery, hospitalization, treatments, and procedures

22

CHAPTER III

METHODOLGY

This chapter deals with the research approach, study design the sample

and sampling techniques, development and description of the tool, pilot study

data collection procedures and plan of analysis.

3.1 Research approach

Used survey method for method for this study

3.2 Objectives

1. Assess the effectiveness of play among children in adjusting with the pre

operative and late postoperative period.

2. Assess the effectiveness of play in postoperative recovery of children after

cardiac surgery

3.3 Settings

The study was conducted in the pediatric surgery ward of Sree Chitta

Tirunal Institute for Science and Technology, Thiruvanandapuram

23

3.4 Population

The population of the study was those who aged between 4-10 yrs and

undergone open-heartsurgery for congenital heart disease

3.5 Sample and sampling technique

A consecutive sampling technique was used to select 12 experimental

and 12 control group patients who had undergone open heartsurgery (4-10) for

congenital heart defects. Assessment of the patient has been done in 2 aspects.

Child's cooperation assessed through out the hospital stay (both preoperative

and postoperative). Therapeutic play preperations given on the day second

previous to the day of surgery for one hour with medical equipments like

stethoscope, syringes scissors ·and doll. The postoperative recovery was

assessed through out the postoperative stay. The total duration of the study was

from November 2008 to February 2009.

3.6 Exclusion criteria

Children who are below 4yrs and above lOyrs.Surgeries other than

ASD, VSD, and ICR are excluded from the study

3.7 Inclusion criteria

Children (4-10) who undergone open-heart surgeries like ASD, VSD,

ICR are included in the study

24

3.8 Development of tool

An extensive study and review of literature helped in the preparation of

the tool. A questionnaire containing 10 questions about the postoperative

recovery and 7 questions about the assessment of cooperation in pre and

postoperative period of children who are undergoing open heart surgery ( 4-

1 Oyrs) for congenital heart defects was used to assess the effectiveness of play

therapy in children after open heart surgery and tool was scrutinized and

approved by experts in SCTIMST

3.9 Description of the tool

Questionnaire 1

Part-1 This part contains items such as patients name, age, sex, date of

surgery and name of surgery

Part-II This part containing questions about the assessment of cooperation of

the child in the pre and postoperative period

Questionnaire 2

Part I This part contains items such as name, age, sex, date of surgery and

name of surgery

Part II This part containing questions about the respiratory status, bowel and

bladder status, oral intake status, ambulation status and number of total post

operative hospital stay.

25

3.10 Pilot study

This study was conducted in the month of November 2008 after

obtaining necessary permission from the authorities. The purpose of the study

was to assess the effectiveness of play therapy in children after open-heart

surgery

Six patients (3 experimental and 3 control) were taken for pilot study;

selected group included both male and female ( 4-1 Oyrs ). The duration of study

was from November 2008 to February 2009.

3.11 Data collection

The data was collected from pediatric surgery ward of Sree Chitra

Tirunal Institute for Medical Science and Technology, with the help of the

questionnaire. The period of data collection was from November 2008 to

January 2009.

3.12 Plan of Analysis

The investigator developed the plan of data analysis after the study. The

data obtained from the samples were analyzed using descriptive statistics.

3.13 Summary

This chapter deals with methodology samples and sampling techniques,

data collection and plan of analysis.

26

CHAPTER IV

ANALYSIS AND INTERPRETATION OF DATA

Analysis is a process of organizing and synthesizing of data such a way

that project question can be answered. The overall analysis is to organize

structure and to elucidate meaning from collected data (Polit & Beck 2006)

Interpretation is the process of making sense of the result, and

examining of the implication of finding of the study.

Objectives

1. Assess the effectiveness of play among children in adjusting with the pre

operative and late postoperative period.

2. Assess the effectiveness of play in postoperative recovery of children

after cardiac surgery

This chapter represents the analysis and interpretation of data collected

from sample ( 4-1 Oyrs) who have undergone open heart surgery for congenital

heart defects at Sree Chitra Tirunal Institute for Medical Science and

Technology, Thiruvanandapuram

27

Analyses of data are divided in 3 sections. It contains

4.1- Demographic and clinical characteristics of the sample

4.2 Distribution of samples according to the postoperative recovery score

4.3- Effect of play therapy among children after selected open-heart surgery

in the postoperative recovery and cooperation of children during

hospitalization

4.1 Demographic and clinical characteristics of the sample

The total number of 24 samples selected from the children ( 4-1 Oyrs)

who had undergone open-heart surgery for congenital heart defects. The

demographic data included were age and sex.

28

Table 4.1

Distribution of samples according to sex

Experimental Control

SEX n(%) n(%) MALE 7 (58.3) 5 (41.7)

FEMALE 5 (41.7) 7 (58.3) TOTAL 12 (100) 12(100)

This data above in the table and below in the bar diagram shows that in

experimental group 58.3% were males and 41.7% were females whereas in

control group 41.7% were males and 58.3% were females

Figure 1

100 90 80

1

70 601 50 40 30 20 10 + 0

fl

J3: experimental % control control %

• male • female • total

29

Table 4.2

Comparison of sample according to the age


Age(yrs) Median Mean S.D Mean S.D P value

4-10 5 5.43 1.6 5.64 1.79 0.76

The age of the experimental group ranged from 4-1 Oyrs with a median

of 5 and a mean of 5.43 (1.6).The age of the control group ranged from 3.9-

lOyrs with a median of 5 and a mean of 5.64(1.79).An unpaired t'test showed

that there is no significant difference between the mean postoperative score of

experimental and control group.

30

Table 4.3

Distribution of samples according to the surgery


Surgery n(%) n(%)

ASD 5(41.7) 7(58.3)

VSD 4(33.3) 2(16.7)

ICR 3(25.0) 3(25.0)

TOTAL 12(100) 12(100)

Figure 2

1

1 1 , ,1*41 •• 1 "

• ASD • VSD • ICR • TOTAL

experimental control %

This data above in the table and bar diagram shows that in experimental group

41.7% were ASD,33.3% were VSD and 25% were ICR where as in control

group 58.3% were ASD 16.7% were VSD and 25% were ICR

31

4.2 Distribution of sample according to the post operative recovery

This contains the distribution of samples according to the 5 parameters

,that are respiratory status, postoperative bowel and bladder status, ambulatory

status, oral intake status and hospital stay.

Table 4.4

Distribution of samples according to the postoperative respiratory status.


Outcome score n(%) n(%)

Fair <3 1(8.3) 4(33.3)

Good (4-6) 6(50.0) 6(50.0)

Very Good(7-9) 5(41.7) 2(16.7)

Total 12(100) 12(100)

32

Figure 3

100i 90-'

experimental Control

• Fair<3 • Good(4-6)

• Very Good(7-9) • Total

The data in the table and bar diagram shows that in experimental group

41.7% of the sample shows very good outcome and in control group only 16.7

% sample is having very good outcome. It is calculated from 3 respiratory

parameters (duration in hours for waking up after surgery, extubation and for

stopping oxygen supply). Each parameter is carrying a score of 1-3 and the

total score ranged from 3-9. Higher score indicates better outcome.

33

Table 4.5

Distribution of samples according to the postoperative bowel and

bladder status


Outcome score n(01o) n(o/o)

Fair<2 0 3(25.0)

Good (3-4) 6 (50.0) 8 (66.7)

Very Good (5-6) 6(50.0) 1(8.3)

Total 12(100) 12(100)

34

Figure 4

100

90

80

70

60

50

40

30

20

10

1

I..

El 3-D Column 1 • Fair<2 • Good3-4 • Very Good 5-6 • Total

experimental Control

The data above in the table and bar diagram shows 50%sample in the

experimental group having very good outcome and in control group only 8.3%

is having better out come. It is calculated from 2 parameters (duration in hours

for voiding after catheter removal and bowel opening after surgery). Each

question is carrying a score of 1-3 and the total score ranges from 3-6. Higher

score indicates better outcome

35

Table 4.6

Distribution of samples according to the post operative oral intake status



Fair (1) 2(16.7) 7(58.3)

Good (2) 5(41.7) 4(33.3)

Very Good (3) 5(41.7) 1(8.3)

Total 12(100) 12(100)

It is calculated from the parameter duration in hours for starting oral

intake after surgery. The question is carrying a score of 1-3 .Higher score

indicates better outcome.

Figure 5

1 -

1

I.

I- — — — — — —

H •

I- — — — — —

I ) n , .rff I, II . a I

• fair

I Good

•Very Good

•total

experimental control

36

Table 4.7

Distribution of samples according to the post operative ambulation status


Outcome score n(0/o) n(0/o)

Fair <2 0 1(8.3)

Good (3-4) 8 (66.7) 9(75.0)

Very good (5-6) 4(33.3) 2(16.7)

Total 12(100) 12(100)

It is calculated from the 2 ambulation parameters (duration in hours for

moving out of bed and starting walking after surgery ).Each question is

carrying a score of 1-3 and the total score ranges from 3-6

37

Figure 6

100 90 80 70 60 50 40 + 30 -20 10

0 experimental

i i

control

@fair<2 • good3-4

• very good5-6

• total

The data above in the bar diagram and table in the previous page shows

that there is not much difference between the control and experimental group

in the postoperative ambulation status.

38

Table 4.6

Distribution of samples according to the post operative oral intake status



Fair (1) 2(16.7) 7(58.3)

Good (2) 5(41.7) 4(33.3)

Very Good (3) 5(41.7) 1(8.3)

Total 12(100) 12(100)

It is calculated from the parameter duration in hours for starting oral

intake after surgery. The question is carrying a score of 1-3 .Higher score

indicates better outcome.

Figure 5

1 -

1

I.

I- — — — — — —

H •

I- — — — — —

I ) n , .rff I, II . a I

• fair

I Good

•Very Good

•total


36

4.3) Distribution of samples according to the post operative hospital stay

Table 4.8


Outcome score n(o/o) n(0/o)

Fair <2 0 2(16.7)

Good (3-4) 1(8.3) 1(8.3)

Very Good (5-6) 11(91.7) 9(75.0)

Total 12(100) 12(100) --

It is calculated from 2 parameters (duration of total d of ICU stay and

total postoperative hospital stay). Each question is carrying a score of 1-3 and

the total score ranges from 3-6.

39

Figure 7

. n

• fair<2

• good3-4

• very good5-6

• total


Hie data above in the bar diagram and table in the previous page shows

that in experimental group 91.7% sample having better outcome where as in

control group 75% is having better outcome

40

4.4 Effect of play therapy among children after open heart surgery in

postoperative recovery and cooperation during hospitalization

Table 4.9

Comparison of samples according to the total postoperative recovery score



Good (11-20) 2(16.7) 9(75)

Very Good (21-30) 10(83.3) 4(25)

Total 12(100) 12(100)

41

Figure 8

100 90 80

I

/mm

"' 1

1—,—.ITOJI

60 50 40 30 + 20

experimental

• good11-20 • very good 21-30 • total

control

It is calculated from the total postoperative parameters(respiratory

status, oral intake status ,bowel and bladder status ambulation status and

postoperative hospital stay). Each question is carrying a score of 1-3 and total

score ranges from 10-30.The assessment of effectiveness of play therapy in the

post operative recovery of children after open heart surgery reveals that 83.3 %

of children in the experimental group had a very good outcome score and

16.7% children had a good outcome score. Whereas in control group only 25%

of children had a very good outcome and 75% of children had a good outcome

42

Table 4.10

Comparison of samples according to the cooperation score of the children

in the preoperative period


Outcome score n(o/o) n(0/o)

Fair <7 1(8.3) 0

Good (8-14) 6(50.0) 7(58.3)

Very Good (15•20) 5(41.7) 5(41.7)

Total 12(100) 12(100)

43

Figure 9

100

90

80

70

60

50

40

30

20

10

0 experimental

n

n n 11 ._A- t i l

• fair<7

• good8-14

• verygood 15-20

• total

control

It is calculated from 7questions to assess the cooperation of the children

(how is the cooperation of child with nursing staff, procedures and other

children, how is the child's cooperation when he is taking medicines and food,

is the child active or playful). Each question is carrying a score of 1-3 and the

total score ranges from 1-20.

44

Figure 8

100 90 80

I

/mm

"' 1

1—,—.ITOJI

60 50 40 30 + 20

experimental

• good11-20 • very good 21-30 • total

control

It is calculated from the total postoperative parameters(respiratory

status, oral intake status ,bowel and bladder status ambulation status and

postoperative hospital stay). Each question is carrying a score of 1-3 and total

score ranges from 10-30.The assessment of effectiveness of play therapy in the

post operative recovery of children after open heart surgery reveals that 83.3 %

of children in the experimental group had a very good outcome score and

16.7% children had a good outcome score. Whereas in control group only 25%

of children had a very good outcome and 75% of children had a good outcome

42

Table 4.11

Comparison of samples according to the cooperation score of the children in the postoperative period



Fair <7 1(8.3) 2(16.7)

Good (8-14) 6(50.0) 8(66.6)

Very good (15-20) 5(41.7) 2(16.7)

Total 12(100) 12(100)

It is also calculated from 7 question to assess the cooperation of the

children in the postoperative period (how is the cooperation of child with

nursing staff, procedures and other children, how is the child's cooperation

when he is taking medicines and food, is the child active or playful). Each

question is carrying a score of 1-3 and the total score ranges from 1-20.

45

Figure 10

100

90

80

70

60

50

40

30

20

10

0

I I I JTlf

control

• fair<7

• good 8-15

• very good 15-20

• total

The assessment of cooperation of the children reveals that, experimental

group remains in the same score in both pre and postoperative period. Whereas

the control group's cooperation declined in the postoperative period than in the

preoperative period.

46

CHAPTERV

SUMMARY, CONCLUSION, LIMITATIONS, AND INTERPRETATIONS

This chapter g1ves a brief account of present study including

conclusions drawn from the findings and possible applications of the result,

recommendations for future research and suggestions for improving the present

study is also included.

5.1 SUMMARY

The study was undertaken to assess the effectiveness of play therapy in

children ( 4-1 Oyrs) after open-heart surgery at Sree Chitra Tirunal Institute of

Medical Science and Technology, Trivandrum

The specific Objectives of the Study were

- To assess the effectiveness of play therapy in the post operative recovery

- To assess the effectiveness of play therapy in adjusting with the preoperative

and late postoperative period

Need of this study was to assess the effectiveness of play therapy in children

(4-lOyrs) after open-heart surgery

The review of literature helped the investigator to gain knowledge about the

47

play therapy, types of play therapy, duration of the therapy and the

effectiveness in the children during the hospitalization

A questionnaire containing 10 questions was used to assess the

postoperative recover and 7 questions were used to assess cooperation of the

child. A pilot study was done prior to the main investigation. The study was

conducted in in Sree Chitra Tirunal Institute of Medical Science and

Technology, Trivandrum, Kerala during the period November 2008- January

2009. Te sample size of this study is 12 experimental and 12 control patients,

the data obtained were analyzed by busing descriptive statistics, both bar and

pie diagram were utilized to illustrate the findings of the study.

5.2) The major findings of the study

This study reveals that play therapy was effective in the experimental

group to a certain extent to produce a better postoperative outcome as a non

pharmacological method .In the assessment of cooperation of children in the

pre and postoperative period the experimental group remained in the same

level in both pre and postoperative period where as experimental group

declaimed from the preoperative level.

48

.

I J' l I . .

I

5.3) Limitations

1. Study was limited to the SCTIMST, Trivandrum

2. The study was conducted in only patients who undergone surgeries for

ASD, VSD and ICR

3. The study was limited to children between the ages of 4-1 Oyrs

5.4) Conclusions

Based on the findings of the study the following conclusions also drawn, with

this limited number of patients it is not possible to generalize findings.

Therefore, the studies using more number of patients may be useful to validate

the finding.

5.5 ) Recommendations

The following recmmnendations were made based on the present study.

Similar studies can be conducted in other health care institutions.

Constructive, therapeutic play is an essential part of the care of children

with long-term hospitalizations. The O'Connor theoretical framework supports

the importance of play in ensuring the emotional, developmental, and physical

health of children. The negative effects of long-term hospitalization are

particularly evident for children who have undergone open-heart surgery

(Kuntz etal 1988)

49

The assessment of effectiveness of play therapy in children ( 4-1 Oyrs)

after open-heart surgery will help to know how play therapy is helpful in the

postoperative recovery and adjusting with the preoperative and late post

operative period

50

1

REFERENCES

1. Li Hc,etal (2007),Psycho educational preparation of children for surgery; the

importance of parental involvement ,Patient education Council, 65(1 ),34-41.

Retrieved from Pub med Abstract Plus on 7.8.2008 therapy

2. Lopez V,etal (2008), Effectiveness and appropriateness of therapeutic play

intervention in preparing children for surgery; a randomized controlled trial

study. Spec Pediatric Nursing ;13(2) ,63-73.Retrieved from Pub med AbstraCt

Plus on 21.7.2008

3. Lee TL,etal (2007), Effects of preoperative therapeutic play on outcomes of

school age children undergoing day surgery. Res Nurs Health,30(3), 320-332.

Retrieved From Pub med Abstract Plus on 24.7.2008

4. Zahr LK (1998), Therapeutic play for hospitalized preschoolers in Lebanon.

Pediatric Nursing; 24(5), 449-454,Retrieved from Pub med Abstract Plus on

21.7.2008

5. Li He (2007), evaluating the effectiveness of preoperative interventions; the

appropriateness of using the children's Emotional Manifestation Scale. J Clin

Nurs; 16(10),919-926.Retrieved from Pub medon 21.7.2008

6. Bowmer n(2002) ,Therapeutic play and the impact on anxiety in .hospitalized

children . Ky Nurse;50(1) 15, Retrieved from Pub med Abstract Plus on

24.7.2008

51

7. Ribeiro CA(1991), The effect of the use of therapeutic play by the pediatric

Nurse on the behavior of recently hospitalized children, Rev Esc Enferm

USP;25(1),41-59.Reteieved from Pub medon 24.7.2008

8. Clatworthy S (1981), Therapeutic play ;Effect on hospitalized children, Child

Health Care;9(4),108-113 .Retrieved from Pub medon 24.7.2008

9. Sam BJ (2007),Importance of Play for Hospitalized children, Nursing Journal

of India ;18(10),224-226

lO.Gibbons and Boren (1985),Therapeutic Play with medical equipment, Abstract

from yahoo

11. Hall D (2000) ,Social and psychological care before and during

hospitalization,(25), 721-732,England Abstract from Pub med.

12.Roe WA,etal (1989), The psychological impact of play on hospitalized

children,l4(4),1617-27, Abstract from Pub med.

13. Singer J (2000), What is play therapy? ,Kid power, Abstract from Yahoo.

14. Suitable M,etal (1975), Child's play is therapy, Canadian Nursel7(12),35-37,

Abstract from pub med.

15. Thompson RH (1988),Approaches to studying play in health care settings ,

Child Health Care 16(3 ), 186-94,Abstract from pub med

\

52

-- ------------------------- ______ ...... _

16. Waechter (1985),Nursing Care of Children, J B Lippincott Co, Philadelphia

,Ed-1 0,87-87

17. Wong D,(1999),Whaley and Wongs Nursing Care of Infants and Children,_

CV, Mosby Co;St.Louis,Ed-6,1171

53

POST-OP RECOVERY ASSESSEMENT CHART

Name: Age: Sex:

D.O.A: D.O.S:

Surgery: D.O.D

1. The child is awake after surgery is

a. with in 1 hr

b. 2-4 hrs

c. after 4 hrs

2. The child is extubted from the ventilator

a. with in 8 hrs

b. 8-12 hrs

c. after 12 hrs

3.02 supply is put off

a. with in 12 hrs

b. 12-24 hrs

c. after 24 hrs

54

4.The patient passed urine after catheter removal

a. with in 4 hrs

b. 4-6 hrs

c. after 6hrs

5.The child started oral feeds after surgery

a. with in 12 hrs

b. 12-16 hrs

c. after 16 hrs

6.The child passed motion after surgery

a. with in 24 hrs

b.24-48 hrs

c.after 48 hrs

7. The patient is out of bed after surgery

a. with in 24 hrs

b. 24-48 hrs

c. after 48 hrs

55

8. The total period of ICU stay

a. <48 hrs

b. 48-72 hrs

c. after 72 hrs

9.The patient started walking after surgery

a. 24-48 hrs

b.48-72 hrs

c. after 72 hrs

10. The child is discharged on

a.4-6 pop days

b. 7-8 pop days

c. after 8 days

56

COOPERATION ASSASSEMENT CHART

1. How is the child's cooperation when taking medications?

Pre Post

a. Poor

b. Average

c. Above average

2. How is the child's cooperation when taking diet?

Pre Post

a. Poor

b. Average

c. Above average

3. How is the child's bowel atid bladder pattern during hospitalization?

Pre Post

a. Poor

b. Average

c. Above average

4.How is the child's cooperation with the nursing staff?

Pre Post

a. Poor

b. Average

c. Above average

57

5.How is the child's cooperation during nursing procedures?

Pre Post

a. Poor

b. Average

c. Above average

6. How is the child's cooperation with the other children?

Pre Post

a. Poor

b. Average

c. Above average

7. Is the child active, playful and live?

Pre Post

a. Yes

b.No

58

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