EFFECTIVENESS OF PLAY THERAPY AMONG CHILDREN AFTER...
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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
Distribution of samples according to the 4.5 34
postoperative bowel and bladder status
Distribution of samples according to the 4.6 36
postoperative oral intake status
Distribution of samples according to the 4.7 37
postoperative ambulation status
Distribution of samples according to the 4.8 39
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
6 Distribution of samples according to the
38 postoperative ambulation status
7 Distribution of samples according to the
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.
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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.
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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.
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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.
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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
Experimental Control
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
Experimental Control
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.
Experimental Control
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
Experimental Control
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
Experimental Control
Outcome score n(%) n(%)
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
Experimental Control
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
Experimental Control
Outcome score n(%) n(%)
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
4.3) Distribution of samples according to the post operative hospital stay
Table 4.8
Experimental Control
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
experimental control
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
Experimental Control
Outcome score n(0/o) n(0/o)
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
Experimental Control
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
Experimental Control
Outcome score n(0/o) n(0/o)
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