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I
Abstract of thesis entitled
“An Evidence-based Guideline of Using Video Viewing in
Reducing Preoperative Anxiety for Paediatric Patients”
Submitted by
Lam Po Chu
For the degree of Master of Nursing
at the University of Hong Kong
in July, 2014
Preoperative anxiety is common in paediatric patients because most of them do not
have previous surgical experience (Talbot, 2010), so they have less sense of
control over the upcoming stressful event (LeVieux-Anglin & Sawyer, 1993). If
children’s preoperative anxiety cannot be managed well, it may result in various
post operative negative consequences which may affect their development
(Lumley, Melamed & Abeles, 1993).
Video viewing is shown to be one of the most effective non-pharmachological
treatment for paediatric patients in reducing preoperative anxiety (Mifflin,
Hackmann & Chorney, 2012), and the benefits of this innovation are highlighted in
various studies, both physically and psychologically, but it is not a common
practice in Hong Kong.
This papers aims at developing an evidence-based guideline on the use of video
for preoperative anxiety reduction in children. A thoughtful implementation and
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evaluation plan will be discussed in this paper in the hope that nurses can make
use of this newly developed evidence-based guideline into their clinical practice
for preoperative anxiety management.
III
An Evidence-based Guideline of Using Video Viewing in
Reducing Preoperative Anxiety for Paediatric Children
by
Lam Po Chu
Master of Nursing, H.K.U.
A thesis submitted in partial fulfillment of the requirements for the degree of
Master of Nursing at the University of Hong Kong.
July, 2014
IV
Declaration
I declare that this dissertation represents my own work, except where due
acknowledgment is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a
degree, diploma or other qualifications.
Signed……………………………………………………………………..
Lam Po Chu
V
Acknowledgements
I would like to express my special thanks to my supervisors, Dr. William Li and
Ms. Joyce Chung for their guidance, supervision, and advice for my dissertation.
They have given full support and inspiration to me throughout these two years.
Without their encouragement, I can’t believe I can finish this dissertation with
great success. Also, I would like to say thank you to my fellow classmates as well,
we overcame all the difficulties and shared happiness with each other in this
period.
VI
Contents
Abstracts…………………………..………………………….………………….. I-III
Declaration…………………………..………………………….………………. IV
Acknowledgements…………………………..………………………….……… V
Table of contents……………………..………………………..….…………….. VI-VIII
Chapter 1 Introduction
1.1 Background………………………..………………….….……………. 1-3
1.2 Significance………………………..………………….….……………. 3-4
1.3 Affirming needs………………………..……………………………….. 4-8
1.4 Evidence-based question…………………………..……………...……. 8
1.5 Objectives………………………..……………………….…………… 8-9
Chapter 2 Critical Appraisal
2.1 Search and appraisal strategies…………………..….……………… 10-12
2.2 Data extraction………………………..……………………………….. 12
2.3 Quality assessment of the studies………………………..……………. 12-13
2.4 Results…………………………..……………………………………... 13-21
2.5 Summary and Synthesis……………………………………………….. 21-26
2.6 Recommendations……………………………………………………... 27-30
VII
Chapter 3 Assessing implementation potential
3.1 Transferability of the findings………………………………….……… 31-35
3.2 Feasibility of the findings………………………………………….…... 35-37
3.3 Cost-benefit ratio of the innovation…………………………………… 37-40
Chapter 4 Developing evidence-based practice protocol
4.1 Recommendations for developing an evidence-based guideline……… 41-46
4.2 Evidence-based guideline……………………………………………… 46-47
Chapter 5 Implementation plan
5.1 Communication plan…………………………………………………... 48-55
5.2 Pilot Testing…………………………………………………………… 56-58
Chapter 6 Evaluation plan
6.1 Identification of outcomes……………………………...……………… 59
6.2 Nature of clients to be involved………………………..……………… 60-61
6.3 Data analysis……………………………………………...…………… 62
6.4 Evaluate the effectiveness of the innovation………….……………….. 62-63
Chapter 7 Conclusion
Conclusion……………………………….………………………………… 64 -65
VIII
Appendices
Appendix I……………………………….………………………………… 66
Appendix II……………………………...………………………………… 67-74
Appendix III……………………………..………………………………… 75-90
Appendix IV…………………………..…………………………………… 91-92
Appendix V…………………………...…………………………………… 93
Appendix VI………………………..……………………………………… 94-95
References
References………………...……………………………………………… 96-104
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Chapter 1 Introduction
There is an increasing trend of the number and complexity of paediatric day surgery
in Hong Kong because of the economic benefit (Bittmann & Ulus, 2004). Surgery
statistics reveal the number of inpatient elective pediatric surgery has been decreased
by more than 50% in past 10 years while the number of outpatient or day surgery has
been increased by more than 200% in the United States (Rogers & Seward, 1997),
most of the paediatric patients are discharged on the same day of surgery, so they are
not well-prepared for the surgery which draws health care professionals’ attention to
develop an evidence-based video intervention to prepare children for operation or
invasive procedures in a feasible and economical way.
1.1 Background
Anxiety is characterized by generally unpleasant sensations including feelings of
tension, apprehension, nervousness and high autonomic nervous system activity
(Chorney & Kain, 2009).
Children are more susceptible to the stress of surgery which accounts for about
50-70% of paediatric patients planning for operation (Kain, Wang, Mayes, Krivutza
& Teague, 2001) because they have less self of control, limited experience of
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hospitalization and limited cognitive level (LeVieux-Anglin & Sawyer, 1993) that
may increase their feelings of fear, fright and helplessness (Brennan, 1994).
Induction of anesthesia has been identified as the most stressful experience to
children throughout the peri-operative period (Li & Lam, 2003), especially during
introduction of the anesthesia mask, and nearly 50% of children display high level of
stress and anxiety at this point. Vetter (1993) stated that children presenting extreme
agitation and noncompliance in the operating theatre may even need physical
restraint.
Adverse consequences of preoperative anxiety
Lumley, Melamed and Abeles (1993) showed that paediatric high anxiety level
during induction of anesthesia is associated with a number of postoperative problems,
including food rejection, poor sleep quality and even becoming pessimistic
afterwards. In addition, preoperative anxiety in children is associated with adverse
postoperative outcomes, for example, increasing frequency of emergence delirium,
increasing pain level during recovery (Wallance, 1986), lengthening hospital stays
and increasing the incidence of maladaptive postoperative behaviors (Kain, 2000).
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Kain, Wang, Mayes, Caramico and Hofstadter (1999) showed that about 70 % of
children presented new negative behaviors on post-operation day one, about 45% of
children reacted adversely on post-operation day two and 55% of children manifested
significant behavioral changes two weeks after outpatient operation. Unexpectedly,
20% of children have sustained behavior problems for six months after the operation
and even one year for about 10% of paediatric patients (Kain et al., 1996).
1.2 Significance
An appropriate psychological intervention which is given at the critical moment, not
only beneficial to children to prevent them from having an unforgettable stressful
experience, but also it is beneficial to nurses and institutions.
From patients’ perspective
Preparing pediatric patients adequately for surgery may increase their sense of
control when facing uncertainty or anxiety; prevent behavioral and physiological
manifestations of anxiety. Also, reduction in children’s anxiety will make the
hospital experience more pleasant and improve recovery status for both children and
their parents.
4
From nurses’ perspective
An effective filmed modeling may improve the quality of care because nurses care
patient’s psychological needs rather than physiological needs alone. Video-viewing
can help to reduce the demand of nursing care and the video can be directly
implemented by nurses without doctors’ prescription and it takes a minimum of staff
time to administer.
From institution’s perspective
Implementation of pre-operation video viewing is inexpensive. It can save health
care costs, so that the valuable medical resources can be allocated to other areas in
needed. Shortened hospitalization length can be result from better postoperative
outcomes psychologically or physiologically and less negative behaviors.
1.3 Affirming needs
In Hong Kong, the majority of preoperative preparation programs in children are not
well organized and supported by reliable and valid evidence. Children are often
given the information about the surgery when they are in doubt; there is also little
emphasis on anaesthesia induction and even underestimate their psychological needs.
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The degree of severity
Preoperative anxiety was a significant problem that affects the majority of paediatric
patients. In the United States, more than 5 million children have surgery every year;
about 50% to 75% of these children experience significant preoperative anxiety
(Talbot, 2010).
A study shows that a child who displays high anxiety level before operation is 4
times more likely to develop negative behavior problems postoperatively when
compares with a child who displays less preoperative anxiety level (Kain et al., 1999).
Thus, child preparation for surgery is vital to minimize negative emotions associated
with operation or analgesia.
In my clinical setting, there is no standardize protocol for nurses to provide
evidence-based preoperative preparation regarding satisfying the psychological needs
of paediatric surgical patients. Therefore, it is noteworthy to translate the update and
valid evidences into a clinical guideline to children aged above 6 years old, aiming at
decreasing their preoperative anxiety, increasing their satisfaction level by enhancing
their coping strategies.
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Current pharmacological and non-pharmacological interventions
Currently, pharmacological approach has been used. Midazolam has shown to be
effective in decreasing preoperative anxiety, however, there are also disadvantages,
such as, amnesia, delaying recovery time; increasing incidence of abnormal
behavioral changes postoperatively (Watson & Visram, 2003). Thus,
non-pharmacological methods are preferable.
However, non-pharmacological methods, including parental presence solely and
music are beneficial prior to surgery but they may not reliably reduce a child’s
anxiety during anaesthetic induction (Kain, 2000). The elevation of parental anxiety
may increase nurses’ workload in caring for them as well as their children (Doctor,
1994), and it may increase child behavioral problems while a study shows that music
therapy is not so effective in preoperative anxiety reduction (Kain et al., 2004). Thus,
these interventions may not be feasible, economical and effective in current clinical
situation.
In fact, the effectiveness of non-pharmacological methods in reducing preoperative
anxiety is highlighted in various studies, for example, providing children information
by computer package (Campbell, Hosey & McHugh, 2005), playing video games
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before the induction of anesthesia (Patel et al., 2006) and meeting clown doctors
(Vagnoli, Caprilli, Robiglio & Messeri, 2005), but little is known for the
effectiveness of video in reducing preoperative anxiety.
Film modeling is effective in reducing preoperative anxiety
Actually, simply providing paediatric patients with an easy-to-use distraction is a
time-efficient and cost-effective pediatric stress management method. With current
fiscal constraints and shortage of manpower in health care system, group program is
proved to be an effective method that not only benefits children, but also, their
parents and the institution. An effective preparation should include modeling, as well
as teaching stress coping skills, child-life preparation and involvement of parents
(Melamed & Siegel, 1975).
Modeling film is a mean of preparation program that helps to deliver both sensory
and procedural information to children, for example, the admission procedure, the
environment of operation theatre, instruction of coping skills and so on. Thus,
children can get familiar with the environment, know what he does afterwards,
experience anesthesia and surgery, and especially learn how to cope with stress.
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Mifflin, Hackmann and Chorney (2012) showed that streaming video clips are
effective method to distract children who need induction of anesthesia than the usual
methods of nonprocedural talk, humor, or game playing. Therefore, video viewing
about the anaesthetic procedure for lower children anxiety level is an inexpensive
option.
Film modeling is cost beneficial. Pinto and Hollandsworth (1989) showed that video
preparation could save about $183 for every patient, or a total of about $7,330. It is
believed that if more children use the video preparation, more money can be saved.
1.4 Evidence-based practice question
My translational nursing research question in PICO format is: ‘What is the
effectiveness of video-viewing in reducing preoperative anxiety for paediatric
patients in Hong Kong?’
1.5 Objectives
1. To perform a literature review on the effectiveness of video viewing in reducing
preoperative anxiety for paediatric patients.
2. To obtain evidence from the chosen articles by forming tables of evidence to
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develop an evidence-based guidelines on anxiety reduction for paediatric
patients regarding the use of video.
3. To perform a critical appraisal for the chosen articles.
4. To discuss the implementation and evaluation plan for the video viewing in
clinical setting after synthesis all findings from the articles.
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Chapter 2 Critical Appraisal
In this chapter, the process of gathering significant evidence is presented in details.
Relevant and potential studies are selected by keyword search, inclusion and
exclusion criteria. Then the evidence is gathered after quality appraisal and synthesis
of various studies.
2.1 Search and appraisal strategies
Identification of studies
The literatures searching using the electronic databases were performed on 12th
of
August in 2013. The used electronic databases were 1) Pubmed, 2) ProQuest (Health
and Medicine databases) which included British Nursing Index (1994-current),
ComDisDome (2000-current), ebrary® e-books, GenderWatch, Health &
SafetyScience Abstracts (2000-current), MEDLINE® (2000-current), PILOTS:
Published International Literature On Traumatic Stress (2000-current), ProQuest
Medical Library, ProQuest Research Library: Health & Medicine, PsycARTICLES
(2000-current), PsycBooks (2000-current), PsycINFO (2000-current) and TOXLINE
(2000-current), and 3) Google Scholar to find articles using the video intervention
published between 1975-2012. Over 250 articles were identified in this period using
keywords including ‘preoperative’, ‘anxiety’, ‘video*’, ‘film’, ‘modeling’ while
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MeSH term ‘anxiety’ was used in the electronic database of Pubmed. The search
history is shown in Appendix I.
Then, review of the abstracts of these articles produced 25 articles in which video
intervention was actually researched, 2 of them which were not published in English
were excluded after failure in obtaining English version by all means. The whole
content of remaining 23 articles would then be reviewed in order to sort out potential
articles. Only those studies evaluate the effectiveness of the video or the preparation
program containing the component of video to reduce children’s preoperative anxiety
were included in the final review. Finally, the syntheses of the findings were based on
8 studies that met the inclusion criteria.
The inclusion criteria were:
1. Paediatric patients aged between 2- 18 years old
2. Performing elective surgery under general anaesthesia
3. Receiving video intervention or joining preparation program including video
4. Randomized controlled studies
5. Quasi-experimental studies
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The exclusion criteria were:
1. Patients have mental problems and physical problems
2. Patients have already taken anti-anxiety medication
3. Patients have history of hospitalization or surgical experience
2.2 Data extraction
The studies reviewed were published between 1975 -2012, there were total 8 articles
after elimination of duplicated articles, and these articles were then reviewed in
details. 7 out of 8 studies which were published between 1975- 2009 from Pubmed,
ProQuest (Health and Medicine databases) and Google Scholar, except Mifflin
(2012), examined the role of video modeling in reducing stress and anxiety. A table
of evidence was formed for data summary which are shown in Appendix II.
2.3 Quality assessment of the studies
Scottish Intercollegiate Guidelines Network (SIGN) checklists were used in order to
perform quality assessment of the articles by assessing their internal validity and
overall assessment (SIGN, 2008). Finally, the level of evidence and grade of
recommendation were determined according to the studies’ quality. The details of
SIGN checklists are shown in Appendix III for assessing the level of evidence of
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selected studies while the summary of all SIGN checklists is shown in Appendix IV.
2.4 Results
Summarize study characteristics
Type of study
The articles were published between 1975 and 2012. Four of them were randomized
controlled trials (Kain et al., 1998; Mifflin et al., 2012; Pinto & Hollandsworth, 1989;
Wakimizu, Kamagata, Kuwabara & Kamibeppu, 2009) while the remaining four
articles were quasi-experimental studies (Faust, Olson & Rodriquez, 1991; Karabulut
& Arikan, 2009; Lynch, 1994; Melamed & Siegel, 1975).
Sample size
The sample size of four randomized controlled trials were varied from 60-158 (Kain
et al., 1998; Mifflin et al., 2012; Pinto & Hollandsworth, 1989; Wakimizu et al, 2009)
while that of four quasi-experimental studies were varied from 26- 90 (Faust et al.,
1991; Karabulut & Arikan, 2009; Lynch, 1994; Melamed & Siegel, 1975).
Patient characteristics
Patients in all studies were paediatric patients, including both female and male
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participants, aged between 2 to 12 years old who were physically and mentally
healthy. Patients in three randomized controlled trials (Mifflin et al, 2012; Kain, et al.,
1998; Pinto & Hollandsworth, 1989) and two quasi-experimental studies (Lynch,
1994; Melamed & Siegel, 1975) had no previous experience of surgery or
hospitalization while patients in a quasi-experimental study had previous surgery
experience (Faust et al., 1991) and one quasi-experimental study did not mention the
previous surgery experience (Karabulut & Arikan, 2009). The video instruction was
used for patients having elective surgery, for example, herniorrhaphy, hernia,
tonsillectomies, ear tube surgery and urinary-genital tract surgery.
Video intervention characteristics
Three randomized controlled trials and two quasi-experimental studies investigated
the effect of video viewing to preoperative anxiety in the form of modeling or
delivering sensory and procedural information. Mifflin et al. (2012) showed the
effect of video distraction in reducing anxiety at anaesthesia induction. Faust et al.
(1991), Lynch (1994) and Wakimizu et al. (2009) examined the effect of film
modeling delivering sensory and procedural information on the amount of
information the children were given and their anxiety level. Pinto and Hollandsworth
(1989) compared the effect of adult-narrated and peer-narrated videotape delivering
15
operation information on preoperative anxiety while Melamed and Siegel (1975)
compared the result of modeling film showing operation information with the control
film. On the other hand, Kain et al. (1998) determined the effect of three types of
preoperative preparation program including information, modeling and coping-based
and Karabulut & Arikan (2009) determined the effect of different training programs
including video, booklet and control.
Videotape production was discussed in five studies in details. Articles that did not
specifically mention modeling or demonstration techniques were excluded from the
review. The length of videotape was described in six studies and ranged from 9 to 22
minutes or 12 to 15 scenes.
Time of data collection
Patients in five studies were followed up and data collected on a daily basis (Faust et
al., 1991; Karabulut & Arikan, 2009; Lynch, 1994; Mifflin et al., 2012; Pinto &
Hollandsworth, 1989) while data in remaining three studies were gathered on a
weekly basis (Kain et al., 1998; Melamed & Siegel, 1975; Wakimizu et al., 2009).
Outcome measures for anxiety
16
The tools used for measuring children’s anxiety level were in three aspects, including
self-reported, observational and physiological. Some studies used more than one tool
for anxiety measurement.
For self- reported measure, there were Hospital Fears Rating Scale (Melamed &
Siegel, 1975; Pinto & Hollandsworth, 1989), Visual Analog Anxiety Scale (Kain et
al., 1998), State-Trait anxiety inventory for children (Karabulut & Arikan, 2009) and
Self-Assessment Faces Scale (Lynch, 1994).
For observational measure, the tools included Yale Preoperative Anxiety Score
(mYPAS) (Kain et al., 1998; Mifflin et al., 2012), Manifest Upset Scale (Lynch,
1994), Wong-Baker FACES Rating Scale (Wakimizu et al., 2009), Observer Rating
Scale of Anxiety (Melamed & Siegel, 1975; Pinto & Hollandsworth, 1989) and
Personality Inventory for Children (Melamed & Siegel, 1975).
Last but not least, Faust et al. (1991) used physiological measurement by measuring
heart rate and sweat level while Kain et al. (1998) used cortisol level to measure
children’s anxiety.
17
Summarize methodological characteristics
All studies had asked a clear and appropriate question in PICO format on the
effectiveness of video viewing in reducing preoperative anxiety in paediatric
patients.
Among four randomized controlled studies, two of them were in high quality and so
were ranked as ‘1++’ which were the highest level of evidence (Kain et al., 1998;
Wakimizu et al, 2009) and remaining two were ranked as ‘1+’ (Mifflin et al., 2012;
Pinto & Hollandsworth, 1989) which was well-conducted randomized controlled
studies.
High quality and well-conducted randomized controlled studies
Treatment decision
Participants in four studies were randomly assigned to experimental group and
control group, the randomization methods included a random number generator
(Mifflin et al., 2012), drawing lots even it was a poor randomization method
(Wakimizu et al., 2009) and a random number table (Kain et al., 1998; Pinto &
Hollandsworth, 1989). An appropriate randomization method is essential to minimize
the selection bias.
18
Blinding method
All these studies used blinding method including single, double and triple (Mifflin et
al., 2012; Kain et al., 1998; Pinto & Hollandsworth, 1989; Wakimizu et al., 2009), so
as to minimize the Hawthorne effect. Although there was the chance of observer bias
because the observer was not blinded at the induction phrase in the study of Mifflin
et al. (2012), double-coded 20% of findings was used to ensure inter-rater reliability
while the study of Pinto and Hollandsworth (1989), two blinded raters were
responsible for about 30% of the data from random sample by applying absolute
agreement. These methods can ensure the data reliability.
Statistical analysis, validity and reliability of measurement tools
Power calculation was used in two studies whilst Pinto and Hollandsworth (1989)
and Wakimizu et al. (2009) did not mention the power analysis. In a study by Mifflin
et al. (2012), the effect size of 0.61 was used for data analysis and 80% power with a
set α of 0.05 was used while in a study by Kain et al. (1998), the effect size was 40%,
α of 0.05(two-tail) and power of 80%, so the studies were more precise to make a
decision. However, the sample size in the study by Pinto and Hollandsworth (1989)
was too small to generalize its findings, so it was ranked as ‘1+’. The reliability and
19
validity of the measurements had been confirmed.
Intention to treat analysis
The drop out rate was ranged from the lowest: 0 % (Kain et al., 1998) to the highest
8.9% (Wakimizu et al., 2009). Intention to treat was applied in two studies (Kain et al.
1998; Wakimizu et al., 2009).
High quality and well-conducted quasi-experimental studies
Among four quasi-experimental studies, one of them was in high quality and so were
ranked as ‘2++’ (Melamed & Siegel, 1975) and remaining three were ranked as ‘2+’
(Faust et al., 1991; Lynch, 1994; Karabulut & Arikan, 2009) which were well-
conducted.
Treatment decision
The remaining four articles were quasi-experimental studies, so that randomization
method was not applied in the group assignment. In the study by Lynch (1994),
participants chose their preferred group while in the study by Faust et al. (1991) and
Melamed and Siegel (1975), participants were grouped according to their
demographic characteristics, while in a study by Karabulut & Arikan (2009), data
was collected until getting enough sample size.
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Blinding method
Although participants in these studies did not blind, the assessors or observers were
blinded, so blinding method was still used (Faust et al., 1991; Lynch, 1994; Melamed
& Siegel, 1975), except in a study by Karabulut & Arikan, (2009), the blinding
method was not mentioned.
Statistical analysis, validity and reliability of measurement tools
All studies did not mention the statistical significance; it might because most of them
were published in the old days. However, these studies showed significant result of
video viewing in reducing children’s preoperative anxiety level with p-value less
than 0.05 although confidence interval was not clearly stated. On the other hand, the
validity and reliability of all measurement tools used in these four articles were tested
and proved.
Intention to treat analysis
There was no one drop out in these four quasi-experimental studies, so it can’t be
concluded that intention to treat was applied.
21
Therefore, all studies provide sufficient evidences to my proposed intervention which
would benefit children undergoing surgery and make a change for the insufficient
current practice.
2.5 Summary and Synthesis
Effect of video viewing in reducing preoperative anxiety
Two randomized controlled trials and three quasi-experimental studies revealed
significant findings in the use of videotape intervention to reduce children’s
preoperative anxiety level (Lynch, 1994; Karabulut & Arikan, 2009; Melamed &
Siegel, 1975; Pinto & Hollandsworth, 1989; Wakimizu et al., 2009).
Although there was a significant result in reducing children’s emotional distress level
(p<0.0001), anxiety level (p<0.0001) and increasing cooperation level (p<0.05) in
the study by Lynch (1994), the small sample size was only thirty, the self- selected
groups and children had previous emergency room experience which might increase
their preoperative anxiety, last but not least, this study did not mention the method of
power calculation. All these circumstances might limit the ability of generalizability.
In the study by Mifflin et al. (2012), there was only significant result at anesthesia
22
induction and smaller increase in anxiety from holding to induction (p<0.001). There
was a possibility that the behavior of anesthesiologists in the control group were not
recorded as part of the study, result in a relatively large difference between two
groups. However, considering anesthesiologists were well-trained and they were
observed that they interacted with participants skillfully, so the possibility of bias
was reduced.
Kain et al. (1998) showed that there was only significant result in the holding area on
the operation day. In this study, it showed quite large range of observed anxiety,
although the possibility of type II error had been accounted when comparing the
groups after intervention and on separation to the operation theatre, it could not
explain the result during the induction of anesthesia, ICU and two weeks after
surgery, so the significant result was obtained only in the holding area.
Faust et al.(1991) showed that only those children viewing the modeling slide-tape
alone had significant result in both heart rate reduction (p<0.01) and sweating
responses (p<0.01) post-intervention. Though children viewing the tape with their
caregivers also showed a heart rate reduction, the result was insignificant (p>0.15). It
might because the parental presence hindered children from benefit most from the
23
videotape, children might rely heavily on their mothers, rather than engaging in skill
reproduction that they learnt from the video.
In addition, parental presence during the intervention may create a possibility that
mothers show high anxiety level during the intervention affect children’s
preoperative anxiety level since there is strong correlation between childrens’ and
mothers’ anxiety levels during medical treatments (Bush. Melamed, Sheras &
Greenbaum, 1986), so they influence each other positively.
Effect of video viewing in reducing behavioral distress or increasing
cooperation level
A study by Pinto and Hollandsworth (1989), patients viewed the peer-narrated tape
with parents and patients viewed the adult-narrated tape either with or without
parents also showed significant result in reducing behavioral distress (p<0.0001). It
proved that parental presence during the intervention calmed down their children and
gave them appropriate explanation, so they can learn more from the video. The result
was consistent with that of Kain et al. (1998), children reported that their anxiety
level was significantly reduced by talking to their mothers (p=0.04) and parents gave
spiritual support to their children (Wakimizu et al., 2009).
24
Therefore, the importance of parental presence is highlighted, but parents must be
aware that they should not give negative comment about the video because it may
increase the preoperative anxiety unexpectedly rather than helping them to alleviate
the preoperative anxiety.
On the other hand, the video should be adult-narrated because children may think
that information given by adults is more superior and accurate, so they are more
likely to follow what adults tell them.
For the study of Lynch (1994), it showed significant result in both decreasing
behavioral distress and increasing cooperation level (p<0.0001). It indicated that
children attending the preadmission program for receiving sensory and procedural
information can help them to alleviate preoperative anxiety than children in the
control group. Although there was no randomization used and small sample size in
this study which might limit the generalizability, we can still use the result.
For the study of Faust et al. (1991), children watched the modeling slide tape with
both procedural and sensory information alone had significant fewer distress
25
behaviors (p<0.01) than those viewed the tape with mothers (p<0.02), but the result
might be due to the small sample size and the data of behavior distress was collected
in the recovery room. Since children in all groups are accompanied by mothers in
recovery room, it might not affect the evaluation of the child viewing the video either
with or without mother, so it is still possible that the parental presence has a
clinically important notion on decreasing children’s distress levels.
For the study of Melamed and Siegel (1975), children in the control group who
viewed a film unrelated to hospitalization had a higher fear level (p<0.01) and more
anxiety-related behaviors in preoperative and postoperative period (p<0.05) than
those in the experimental group who viewed a film presenting hospital routine. There
was no significant effect of age or sex on this dependent measure.
It provided an insight that no matter how old the children are, children will be benefit
from the intervention which anticipates them the stressful event, but we still need to
take children’s cognitive level into account, in order to provide age-appropriate
information.
Effect of video viewing in improving recovery status
26
There is only one study which was published by Pinto and Hollandsworth (1989)
showed a significant result in better recovery status in experimental group that
children viewed video with parent (p<0.001). It might because children’s anxiety
level was reduced because of gaining more sense of control, so there were less
postoperative negative outcomes, so improving recovery status in turn.
However, postoperative content should not be included in the video because they
were considered to cause adverse effects on some children, but it can be included in a
pamphlet for parents as preparation resource and so to provide explanation to their
children (Wakimizu et al., 2009).
Limitation of the studies
Although all studies show the significant result in the effectiveness of using video in
reducing preoperative anxiety level, their primary outcomes mainly focus on
children’s anxiety levels, rather than measuring children’s sense of control and their
knowledge level. Since the age groups of participants in these studies are below 12
years old, it might quite difficult to measure their knowledge gain and self efficacy
level, but we can still conclude that the reduction in preoperative anxiety level and
decrease in arousal reflect they acquire sufficient knowledge in coping the stressful
event and increase the sense of control.
27
2.6 Recommendations
All studies support that videotape intervention was effective in reducing preoperative
anxiety experienced by paediatric patients, thus, the use of video should be highly
recommended among paediatric patients and applied in my clinical setting (Faust et
al., 1991; Mifflin et al., 2012; Kain et al., 1998; Lynch, 1994; Pinto & Hollandsworth,
1989; Melamed & Siegel, 1975; Wakimizu et al., 2009). There are several
recommendations based on the findings of the studies.
The target group: children aged 6 to 12 years old without
hospitalization experience
The intervention should be given to children aged above 6 years old (Faust et al.,
1991; Lynch, 1994). Reissland (1983) stated that children under six years old have
insufficient coping abilities. These children’s sense of control will be raised if they
are taught coping skills. The intervention should be made according to children’s
developmental characteristics to help them understand and match with their
experiences related to surgery (Mifflin et al., 2012, Robinson & Kobayashi, 1991;
Wakimizu et al., 2009).
28
Performing preoperative assessment
Nurses need to assess patient’s age, cognitive level and developmental ability, prior
experience of medical procedure or surgery and preoperative anxiety level before
giving the intervention. If patients have previous hospitalization experience, it may
affect their emotion in the current hospitalization, predisposing them to more
polarizing emotional responses resulting from more sensitization to the surrounding
environment (Kain et al., 1998; Melamed & Siegel, 1975; Whaley & Wong, 1991),
so that the video should not be played to children with previous hospitalization
experience. Moreover, information provision through video viewing should be
tailored to the children’s characteristics; children with high preoperative anxiety level
may make them unable to practice their learnt technique (Mifflin, et al., 2012; Kain,
et al., 1998; Wakimizu et al., 2009).
The timing of the intervention
The video should be given to children on the same day of surgery regarding the
feasibility because children always admit to my clinical setting on the day of
operation, so there is insufficient time for nurses to meet children before the surgery.
The content of the intervention
29
The duration of the intervention should be 14 minutes on average or 12 to 15 scenes
(Faust et al., 1991; Karabulut & Arikan, 2009; Melamed & Siegel, 1975; Pinto &
Hollandsworth, 1989; Wakimizu et al., 2009).
Older children are able to recognize what will be expected and use the coping skills
during stressful condition. Also, patients should be provided relevant information
about the surgery, in contrast, less new information should be provided just before
and during the procedure (Kain et al., 1998; Wakimizu et al., 2009). Kain et al. (1998)
stated that video given to children at the most stressful period may prevent children
from thinking carefully and using the skills what they have learnt.
The video adopts a modeling approach; the contents of the video include sensory and
procedural information which meet children’s cognitive level. Procedural
information includes the ward orientation, admission procedure, and medical staff
including the surgeon and anesthesiologist, the explanation of the hospital and
surgical routines provided by the medical staff, having a laboratory test and exposure
to medical equipments, separation from the mother, and scenes in the operation
threatre, recovery rooms and discharge process (Faust et al., 1991; Lynch, 1994;
Karabulut & Arikan, 2009; Melamed & Siegel, 1975; Pinto & Holandsworth, 1989;
30
Wakimiu et al., 2009). Sensory information includes what the child will experience
in operating and recovery rooms, various scenes are narrated by the child who
describes his feelings and worries. Also, relevant coping skills like breathing deeply
will be presented (Faust et al., 1991) and children are encouraged to practice these
skills during the presentation.
A pamphlet will be provided to caregivers accompanying the child for the
intervention to provide them some common answers to anticipated questions from
children (Lynch, 1994; Wakimizu et al., 2009), also they are welcomed to approach
nurses for any enquiry.
Conclusion
There were a total of eight studies including four randomized controlled trials and
four quasi-experimental studies which were reviewed in this paper.
The quality of the sampled studies was assessed. Synthesized data will be useful to
develop the clinical guideline on the use of video for anxiety reduction on paediatric
patients in the later chapter.
31
Chapter 3 Assessing implementation potential
This chapter concentrates on the assessment of the implementation potential of the
innovation. There will be a detailed discussion on transferability and feasibility of
the findings to the target setting and evaluation on the cost-benefit ratio of the
innovation, so as to develop an evidence-based practice guideline.
Target audience of the innovation
Children aged between six and twelve years old are admitted for elective surgery
under general anaesthesia, including circumcision, herniotomy, eye surgery,
incision and drainage of abscess, tonsillectomy, adenoidectomy and orthopedic
surgery. This age group occupies the largest proportion of paediatric surgical cases
of the target hospital. According to the Piaget’s (1963) theory, this group of
patients belongs to the concrete operational stage; they are able to solve problems
logically, so they can benefit most from the innovation.
Children should be coached by their parents during peri-operative period.
Children are physically and mentally healthy who have normal cognitive
development, so they are able to perceive the information given from the
innovation.
32
Target setting of the innovation
The innovation will be carried out in a paediatric surgical ward of a private
hospital in Hong Kong. There are 40 beds in the ward with high turnover rate,
especially during weekends and long holidays. Generally, it is estimated that about
1100 paediatric surgical cases every year.
3.1 Transferability of the findings
The essence of the translational nursing research is to determine whether the
findings from the selected studies can be fitted to my clinical environment in
terms of the similarity of the findings from studies to my clinical area, philosophy
of care of the innovation fit the target setting, the number of paediatric patients
benefit from the innovation and the length of time for implementation and
evaluation.
Similarities between the research findings and the target setting
Among eight studies, patients aged ranged from two to twelve years old were
admitted for elective surgery without previous hospitalization and previous
surgical experience. They were physically and mentally healthy, so they were
similar to the target audience of my clinical setting. On the other hand, the settings
33
of the reviewed studies were paediatric ward and the waiting room of the
operation theatre which were also similar to my target setting for innovation
implementation.
Although all studies were conducted in foreign countries, people with different
cultural backgrounds flocked together in Hong Kong who had been influenced by
western culture for long (Li & Lopez, 2008), and also the local hospital setting is
similar with that in foreign countries. In order to enhance children’s perception
about the operation procedure, the language used in the video is Cantonese, so as
to make the video more cultural specific.
Philosophy of care
The first mission of the target hospital is to provide a love and dedicated service to
the sick with kindness and compassion. As a nurse, we show empathy to our
patients that we understand our patients’ needs. Video viewing not only enhances
children’s sense of control, but also alleviates their worries about the upcoming
stressful event (Mifflin, Hackmann & Chorney, 2012). By giving them sufficient
support, they can have higher ability to cope with unexpected hospitalization
experience (Board, 2005; Brewer, Gleditsch, Syblik, Tietjens & Vacik, 2006) and
34
adjust their emotions positively.
The second mission of the target hospital is to treat patients equally regardless of
their race and color. The hospital tries to maintain a high standard of service in the
aspects of disease prevention, health promotion and restoration of health.
Although our target population is children, we still cannot look upon their needs.
We should provide quality service to people with different race or cultural
background, not to say elderly or even children. Furthermore, underestimating
children’s preoperative anxiety is harmful in their development (Lumley,
Melamed & Abeles, 1993). Thus, the new intervention can meet the mission of
the target hospital.
Number of patients benefit from the intervention
In fact, nearly 60% of children display high level of anxiety during peri-operative
period (KARIMI, FADAIY, NIKBAKHT NASRABADI, GODARZI &
MEHRAN, 2012). There are about 1100 paediatric surgical cases admitted to the
target setting every year and it is estimated that there will be more paediatric
surgical cases in the near future because of the opening of the new paediatric ward.
Therefore, it is noteworthy to implement the innovation.
35
Time for implementation and evaluation
Generally, the video will be played to children on the same day of surgery and it
does not take much time to implement and evaluate the outcomes. Children view
the video which is 14 minutes on average with their parents (Faust et al., 1991;
Karabulut & Arikan, 2009; Melamed & Siegel, 1975; Pinto & Hollandsworth,
1989; Wakimizu et al., 2009). Nurses respond to any inquiry when parents
encounter. The pre-intervention assessment and evaluation takes only less than ten
minutes by completing a questionnaire. Besides, the overall evaluation will be
performed in a year to analyze whether the objectives of the intervention are met.
3.2 Feasibility of the findings
When implementing a new intervention, we need to consider its feasibility
regarding the administrative support, disruption to staff functions, availability of
equipment and skills and evaluation tools.
Administrative support
Since the organizational structure of the target hospital is hierarchy in nature and
mangers are quite conservative, so they may not want to try something new. In
addition, the target hospital is a private hospital, so the mangers may focus on cost
36
saving. It can be predicted that if I propose a new intervention, I may encounter
difficulties. Thus I may need to persuade them hardly by stating more pros of my
intervention, especially the low cost to benefit ratio.
Disruption to current staff functions
On the other hand, staffs of the target setting are in open-minded who are willing
to change and implement evidence-based practice since they are enthusiastic
about providing high quality of nursing care to children. In addition, the video
intervention will not take much time for implementation; nurses only perform
pre-assessment and answer patient’s inquiries when necessary, so it will not
increase their workload and disrupt ward routine.
Availability of equipments and skills
The equipments needed for the intervention include the physical equipments for
playing the video, like the TV panel and the materials used for producing the
video. There is an existing TV panel on each bed side; a soft copy of the video
will be installed to the database of the TV panel system, so patients can access to
it before surgery. On the other hand, equipments used for demonstrating medical
procedures like blood pressure machines, pulse oximeters, cardiac monitors,
37
anesthesia masks, stethoscopes and intravenous catheters are already available in
the target setting.
Staff training is important for running the video intervention efficiently. Two
training sessions will be provided to staffs which take about half hour per session.
Staffs are taught how to perform preoperative assessment, implement the
intervention and evaluation.
An organizing committee is formed in advance for communication, planning,
implementation and evaluation of the innovation. Nurses can approach organizing
committee for technical support.
Availability of measuring tools
An evaluation tool ‘The Chinese version of the State Anxiety Scale for Children
(CSAS-C)’ will be used for evaluation of the innovation (Li & Lopez, 2004).
3.3 Cost-benefit ratio of the innovation
It is essential to analyze the cost-benefit ratio when implementing an innovation to
obtain the greatest benefits for patients, nurses and the organization.
38
Benefits and risks of implementing the innovation
After reviewing the eight studies, there is no potential risk; instead, the innovation
brings certain benefits. To be start with, the quality of nursing care to children will
be improved because we are not only care patients’ physical needs, but rather, we
help them to gain sense of control by providing sufficient information about the
surgery, so that their preoperative anxiety will be significantly reduced (Brewer,
Gleditsch, Syblik, Tietjens & Vacik, 2006). With the lower preoperative anxiety,
there will be less postoperative adverse outcomes and high recovery rate (Mifflin
et al., 2012), so the medical cost will be reduced in turn. Also, the satisfactory
level of the patients and their parents will be increased as they may feel nurses are
care for them both physically and psychologically. Besides, nurses’ autonomy will
be increased since they implement the innovation by themselves and it is
anticipated that lower turnover rate (Baernholdt & Mark, 2009). Further, it
enhances nurses’ job satisfactory level. As a result, the high quality of service also
increases the reputation of the hospital and it can be benefit from the reduced
individual and overall medical costs (Wakimizu, 2009).
Cost of implementing the innovation
There are material costs for implementing the innovation, including the printing
39
cost of the teaching notes for the training charges $1 per nurse while that of each
set of assessment and evaluation forms charges $3 and printing of hardcopies of
the protocol charges $1.5. As stationery, the TV panel and earphone sets are
already available in the hospital, so no extra cost will be spent on this aspect. Thus,
the potential printing cost is estimated to be $3,330.
There are also nonmaterial costs including manpower and venue. According to the
pay scale of the registered nurse, the monthly salary of a nurse working in a
general ward is $35,000 and they work 44 hours a week. An hourly salary is about
$198.9. Two nurses will be actresses in the video which is estimated to use five
hours to finish. The cost will be $1989; on the other hand, a nurse’s child is
invited to be a model in the video, so no cost is charged. Also, every nurse needs
to attend a half hour training session which costs $99.5 per nurse. There will be a
total of 25 nurses attending the training sessions which costs $2487.5. In addition,
an IT technician uses about three hours to set up a database whose hourly pay is
$100, so the cost will be $300. No extra cost will be charged on venue as the
training will be held in the nurse station of the ward. Thus, the total cost for
implementing the innovation in one year will be $8106.5. Details are shown in the
Appendix V.
40
Generally, patients’ length of hospitalization will be shortened if their
preoperative anxiety level is reduced. The cost staying one more day in a general
ward is about $ 3000 including room charges, doctor’s bill and miscellaneous
items. Regarding the easy administration, low production cost, the benefit far
outweighs the cost of implementing the innovation, so it is worthwhile to
implement it.
41
Chapter 4 Developing EBP guideline/protocol
Based on the finding of the eight selected studies, there are several recommendations
regarding the use of video on reducing preoperative anxiety of pediatric patients.
4.1 Recommendations for developing and evidence based
guideline
Assessment
1. Assessing patient’s age, cognitive level and developmental ability, prior experience
of surgery and preoperative anxiety level before implementing intervention.
(Grade of recommendation: B)
Evidence:
Assessment before carrying out the intervention is important to maximize the effect of
the intervention. Since older children have advanced cognitive development, so they
are more active in seeking and using information for managing stressful event.
(LaMontagne, Hepworth, Cohen & Salisbury, 2003) (1+)
If patients have previous hospitalization experience, it may affect their emotion in the
current admission. Moreover, information provision through video viewing should be
42
tailored to the children’s characteristics; children with high preoperative anxiety level
may make them unable to practice their learnt technique (Kain et al., 1998; Lynch,
1994; Melamed & Siegel, 1975; Mifflin et al., 2012) (1++; 2+; 2++; 1+).
Preparation
2. Obtained an informed consent before starting the video.
(Grade of recommendation: A)
Evidence:
Most of the studies state the need of an informed consent before initiation of video.
Thus, getting the consent from parents should be considered as a routine practice
before any video viewing sessions (Mifflin et al., 2012; Kain et al., 1998; Lynch, 1994;
Karabulut & Arikan, 2009; LaMontagne et al., 2003; Melamed & Siegel, 1975; Pinto
& Hollandsworth, 1989; Wakimizu et al., 2009) (1+; 1++; 2+;1+; 1+; 1+; 1++).
Video viewing intervention
3.1. The video intervention should be implemented at ward about one hour before the
surgery.
(Grade of recommendation: B)
43
Evidence:
The video should be played one hour before the surgery and prior laboratory
investigations to optimize the intervention effect because performing different
medical procedures or meeting various hospital staffs may increase patient’s fear level
(Melamed & Siegel, 1975; Pinto & Hollandsworth, 1989; Karabulut & Arikan, 2009)
(2++; 1+; 2+).
Also, the intervention is the most effective in low-stress period which is preoperative
holding or at ward instead of during the induction of anesthesia (Kain et al., 1998)
(1++).
3.2. The duration of the intervention should be 14 minutes on average or 12 to 15
scenes.
(Grade of recommendation: B)
Evidence:
The video lasts for 22 minutes and consists of roughly 13 scenes (Pinto &
Hollandsworth, 1989)(1+), the video lasts for 12 minutes (Karabulut & Arikan,
2009)(2+), the video lasts for 16 minutes in length and consists of 15 scenes
44
(Melamed & Siegel, 1975)(2++), so the video lasts for 14 minutes on average.
3.3. Parental presence is necessary during the video viewing session, but they should
not give negative comment about the video.
(Grade of recommendation: A)
Evidence:
Children rate parental support positively as a way of dealing with anxiety and they
show less preoperative anxiety when chatting with their mothers. (Faust et al., 1991;
Kain, et al., 1998; Lynch, 1994; Mifflin, 2012; Pinto & Hollandsworth, 1989) (2+;
1++; 2+; 1+; 1+).
However, parents must be aware that they should not give negative comment about
the video because it may increase the preoperative anxiety unexpectedly rather than
helping them to alleviate the preoperative anxiety (Wakimizu et al., 2009) (1++).
3.4. Providing clear information via the video, including procedural information and
sensory information together with coping strategies by peer-modeling all
peri-operative steps from admission to discharge, but should be less focus on
45
post-operative content.
(Grade of recommendation: A)
Evidence:
Older children are able to recognize what will experience and use the coping skills
during stressful condition. Also, patients should be provided relevant procedural and
sensory information about the surgery which describes the upcoming event and shows
what the child will experience (Faust et al., 1991; Kain et al., 1998; Lynch, 1994;
Melamed & Siegel, 1975; Wakimizu et al., 2009) (2+) (1++) (2+) (2++)(1++).
Peer-modeling is effective to reduce children’s anxiety which demonstrated children’s
significantly high preoperative anxiety diminished gradually when the modeling child
gained sense of control about the upcoming event(Melamed & Siegel, 1975; Pinto &
Hollandsworth)(2++) (1+).
3.5. A pamphlet will be given to the caregivers.
(Grade of recommendation: A)
Evidence:
46
An information pamphlet explaining the purpose of the intervention, some common
problems than children may encounter during the operation and postoperative content
will be provided to the caregivers (Lynch, 1994; Wakimizu et al., 2009) (2+) (1++).
Evaluation
4. The Chinese version of the State Anxiety Scale for Children (CSAS-C) is used to
evaluate children’s anxiety level.
(Grade of recommendation: A)
Evidence:
Regarding cultural differences, the Chinese version of the State Anxiety Scale for
Children (CSAS-C) is used to evaluate schoolchildren’s fear level which has high
internal reliability and validity. Thus, it is an objective measurement method to
evaluate children’s anxiety level (Li & Lopez, 2004) (1+).
4.2 Evidence-based guideline
There is an evidence- based guideline of video viewing by generating all the
recommendations above. The format of the guideline is as follows while the activity
plan is attached in Appendix VI.
47
Title:
‘An evidence based guideline for the video viewing in managing preoperative anxiety
level in paediatric patients.’
Aim:
The aim is to formulate clinical practice instructions to guide nurses on the use of
video viewing in reducing preoperative anxiety in paediatric patients.
Objectives:
The objectives of this evidence based guideline are:
1. To reduce preoperative anxiety of children
2. To encourage the use of video through this evidence based guideline
Target Population:
1. Paediatric patients aged between six and twelve years old
2. Experience preoperative anxiety
2. Normal physical and cognitive development
3. No previous experience of medical procedure or surgery
48
Chapter 5 Implementation Plan
When carrying out a new intervention, it is no doubt that various obstacles may arise,
therefore, it is vital to generate an implementation plan to provide solutions for all
foreseeable difficulties and obstacles. An implementation plan is a comprehensive and
organized plan which consists of a set of strategies and steps for implementing a new
intervention. Moreover, a communication plan with potential stakeholders and a pilot
testing are essential components of an implementation plan to ensure the innovation
can be carried out in a successful way.
5.1 Communication Plan
Communication with stakeholders is a significant component of an implementation
plan which provides a channel for potential users to voice out their concerns and
comments about the innovation, and thus corresponding solutions can be made.
Therefore, a communication plan is necessary to convince potential stakeholders so as
to get their full support for the new intervention.
Identification of potential stakeholders
49
Identifying potential stakeholders is important because they may be influenced by the
proposed innovation. The potential stakeholders for the video viewing for paediatric
patients in reducing their preoperative anxiety are Department Operation Manager,
Senior Nursing Officers, Nursing Officers, nurses, including registered nurses and
enrolled nurses, doctors, paediatric patients and their parents.
Role of Department Operation Manager
Department Operation Manager is the head of the department, so she is the key person
who has the superior power to decide or pass any new policy of her managed
department.
Role of Senior Nursing Officers and Nursing Officers
Senior Nursing Officers and Nursing Officers of the paediatric department of the
target hospital are those who are so experienced in the paediatric field. They have the
authority to make important decision in nursing aspect and they have the votes to
allocate resources for an innovation. In an environment of shrinking resources and
budgets, they may concern about the cost-effectiveness and feasibility of the
innovation. Thus, they are the important stakeholders to decide whether the
intervention can be implemented or not. Getting an endorsement from Senior Nursing
50
Officers is essential for implementing an innovation because it represents they agree
that the new intervention is worth supporting and implementing after their thoughtful
discussion and analysis, so that the innovation proposal can be sent further for final
approval.
Role of nurses
Nurses of the paediatric department of the target hospital are frontline staff to use the
proposed evidence-based practice guideline. Nurses are the one who implement the
video intervention for surgical children, they may have questions about the
effectiveness of the innovation, the interference of their workload and current routine,
the flow of the intervention implementation, so their attitudes and beliefs are the
important factors to determine whether the innovation is successful or not. Thus,
training sessions or discussion groups will be held for them to know more about the
new intervention.
Role of paediatric patients and their parents
Paediatric patients who are scheduled for surgery are the main receivers of the
proposed innovation, however, their parents may refuse them to view the video
because parents may think that their children have been so scared to be admitted to
51
the hospital, they afraid the video will increase their child’s anxiety level
unexpectedly, so it is essential to convince parents to ease their concern.
A comprehensive communication plan to gain support
Undoubtedly, different stakeholders may show various attitudes towards the proposed
change, so it is vital to communicate with them well in order to gain support from
them and get resources for the innovation.
Communication process
The proposer of the innovation first identifies a significant clinical problem in current
practice, followed by searching evidences by conducting literature review on video
intervention to show that there are significant evidences for a change of current
practice, so as to improve the quality of care.
Communication with Senior Nursing Officers
First of all, the proposed change will be presented to the senior nursing officers in a
departmental meeting. Thereby a 15-minute of presentation, including the
intervention guideline, implementation and evaluation plan and the cost-benefit ratio
will be presented to obtain their support. This step is important because it can act as a
52
preliminary screening of the innovation before approval by the Department Operation
Manager.
Communication with the Department Operation Manager
Once Senior Nursing Officers show acceptance about the innovation, the proposed
innovation will be sent to the Department Operation Manager for final approval and
thus allocate resources to the innovation.
Communication with doctors
Afterwards, doctors will be notified about the introduction of the innovation by
presenting the details about the innovation during the monthly clinical meeting.
Communication with frontline staff
Then, the proposer approaches frontline staff of the paediatric department, including
nurses and nursing officers, and discusses the new issue with them during the
handover time.
There is a 5-minute handover time for the ward In-Charge to announce important
issue about the ward every day. The proposer should make use of that golden period
53
to present her innovation precisely and clearly to deliver simple messages to nurses
and point out benefits of the innovation.
Afterwards, 2 sessions of 30-minute focus groups will be held. Nurses are free to raise
questions, comments and advices about the innovation while the proposer tries her
best to convince them by showing significant evidences for an urge to change, solve
their problems and act on their valuable comments towards the new guideline. On the
other hand, posters will be posted in the paediatric ward to deliver a message and to
raise the awareness of frontline staff about the significant impact of children’s
preoperative anxiety. It is noteworthy that if the frontline staff support the innovation,
the persuasion to the higher administration hierarchy will be much easier because they
may consider frontline staff’s comments towards the change.
Communication with patients and their parents
Last but not least, paediatric patients and their parents will be introduced about the
intervention via posters and leaflets. They are free to give comments about the
innovation.
Data collection during the communication period
54
After getting the endorsement from various stakeholders, there is a 3-week
communication period before the pilot test is held for different stakeholders to voice
out their opinions and thus appropriate amendment or modification can be made
regarding the innovation.
Facilitating the change via an organizing committee
In order to facilitate the change of the current practice, the organizing committee is set
up for clinical or technical support for the innovation. Group members include
nursing officers from paediatric ward and the operating theatre, and 6 nurses from the
paediatric department, one of them is the proposer, and a technician. If nurses have
questions about the implementation of the innovation or they need technical support,
they can approach the organizing committee. A user manual and a sample of
preoperative assessment will be given to the paediatric ward to guide the use of the
video intervention.
Facilitating the change via training sessions to frontline nurses
There are two 2- hour training sessions will be given to nurses which aims at
equipping them with sufficient knowledge about the innovation. The training session
focuses on the introduction of the innovation, the presentation of the new guideline, as
55
well as teaching nurses how to perform the preoperative assessment to recruit
potential participants, followed by case scenarios demonstration in order to enhance
their confidence in implementing the intervention, then a question and answer session
will be provided for nurses to raise their concerns and problems encountered.
Facilitating the change via sharing session
Apart from training sessions provided to staff before the initiation of the innovation, a
5-minute sharing session which lasts for a week will be held during the handover time
for problem sharing and trouble shooting at the beginning of the innovation
implementation.
Sustaining the change
In order to sustain the change of the innovation, it is necessary to assess nurses’
compliance with the new guideline by comparing paediatric patients’ preoperative
anxiety level between the innovation given and the existing practice through charts
and regular audits. Nurses are also encouraged to share their successful stories with
their colleagues for positive reinforcement. In addition, revisions of the new guideline
will be made when necessary to ensure better patients’ outcomes.
56
5.2 Pilot Testing
A pilot testing is imperative that it does not only determine whether the innovation is
feasible to be carried out before the implementation in a clinical situation, but also it
helps to assess the appropriateness of the evaluation tools, the acceptability of the
innovation by patients and implementers. In the pilot testing, any unexpected
obstacles can be figured out and thus appropriate revisions about the innovation
guideline can be made.
The pilot testing will be done by the organizing committee and 20 nurses working in
the paediatric unit.
Setting
The pilot testing will be carried out in a 37-bed paediatric ward in the target hospital.
Target audience
Children aged between six and twelve years old are admitted for elective surgery
without previous experience of medical procedure or surgery will be recruited. They
must be physically and mentally healthy who have normal cognitive development, so
that they are able to understand the information given. They should be accompanied
57
by their parents or guardian during the intervention.
Sample size
30 patients are recruited for the pilot setting through convenience sampling. Assuming
5 patients are recruited every week, so total 6 weeks for recruiting enough patients.
Assess for feasibility- the availability of equipments
The main equipments for the proposed intervention are the TV panel and earphone
sets which are already available in the target hospital, but the main concern for nurses
may be the use of the newly set up database, nurses may not familiar with it.
Assess for feasibility- patient’s preoperative anxiety level and nurses
compliance to the guideline
Paediatric patients need to be assessed for their preoperative anxiety level by the
CEMS while nurses need to finish a 5-point graded survey for assessing their
compliance to the guideline, their acceptability and difficulties regarding the use of
the new intervention.
Revision of the guideline
58
Data collected through the pilot testing is useful for the new guideline revision to
achieve better patient’s outcome. The findings provide useful insight for the
feasibility, acceptability, either patients or nurses, regarding the new intervention and
the cost-effectiveness of the proposed change, so as to increase the chance of
successfulness of the new guideline.
59
Chapter 6 Evaluation Plan
An evaluation plan aims at evaluating the effectiveness of the innovation in the local
paediatric setting.
6.1 Identification of outcomes
The newly introduced video viewing intervention focuses on reducing paediatric
patients’ preoperative anxiety, so a significant decrease in the paediatric patients’
preoperative anxiety shows a success of the innovation.
Primary outcome: children preoperative anxiety level
The primary patient’s outcome is paediatric patients’ preoperative anxiety level. The
Chinese version of the State Anxiety Scale for Children (CSAS-C) will be used to
evaluate schoolchildren’s anxiety level (Li & Lopez, 2004). It is an objective
measurement method which has high internal reliability and validity. There are 20
items for assessing children anxiety level. The higher the children’s anxiety level, the
higher the scores obtained.
Secondary outcome: children behavioral manifestations
The secondary outcome is paediatric patients’ behavioral manifestations of anxiety
60
which is evaluated by Children’s Emotional Manifestation Scale (CEMS). The scale
is proved to be effective in evaluating the emotional and behavioral responses of
patients regarding the nursing intervention in the local setting (Li, 2007). There are
various categories which descript children’s behaviors. There are 5 scores for each
category, total score ranged from the lowest, 5 marks to the highest, 25 marks. The
higher the score obtained, the more the children present negative behaviors.
Secondary outcome: nurses’ knowledge and satisfaction in
implementing the intervention
Regarding nurses’ outcome, it is expected that nurses can gain more knowledge and
skills in providing the innovation to paediatric patients and they are satisfied with the
use of the new intervention. A multiple-choice questionnaire and a return
demonstration will be given to nurses for evaluating their knowledge in implementing
the intervention and a 5-point graded scale survey is used to evaluate nurses’
satisfaction of the new guideline, their confidence level, as well as their compliance to
the use of the new intervention, the survey will be ended up with open-ended
questions which allow nurses to give comment regarding the guideline.
6.2 Nature of clients to be involved
61
The inclusion criteria of the patients of the video intervention are children aged
between six and twelve years old who are admitted for elective surgery, for example,
herniorrhaphy, hernia, tonsillectomies, ear tube surgery and urinary-genital tract
surgery. They do not have previous experience of medical procedure or surgery. They
are physically and mentally healthy, so that they are able to apprehend the information
given to them. Last but not least, children should be accompanied with parents or
guardians on the day of surgery.
Sample Size
The sample size is calculated by using G-Power, 95% level of confidence and 80%
power are accepted, so 140 patients will be recruited as optimal sample size.
Assuming 5 potential participants can be recruited every week, it is estimated that
those 140 patients can be recruited within 28 weeks.
Method of analysis
The significance testing and a two-tailed t-test will be used to analyze the
effectiveness of the proposed innovation. A one group pre test and post test is used to
evaluate whether the paediatric patient’s anxiety level is changed due to the
implementation of the innovation.
62
6.3 Data analysis
Data collection
Patients will be recruited by convenience sampling. When children admit to the
hospital, the nurse will perform a preoperative assessment to recruit eligible sample
for the video intervention. The patient’s demographic data and the children’s
preoperative anxiety level will be collected at the same time. Then the nurse
implements the video intervention following the guideline. Children’s preoperative
anxiety level will be measured again before the operation and their emotional
behaviors will be observed just before going to the operation theatre by using the
CEMS.
Then, a 5-point graded survey will be distributed to the nurse for collecting data
regarding nurses’ knowledge, satisfaction level and compliance in implementing the
intervention. The survey and collected data will be sent to the support team for further
data analysis, so that appropriate amendment of the guideline can be made.
6.4 Evaluate the effectiveness of the innovation
The innovation is said to be effective if all outcomes are achieved in respective of
patients’, parents’ and nurses’ aspects.
63
To begin with, children’s preoperative anxiety level will be reduced after they have
received the video viewing intervention; also they manifest less negative behaviors
after the intervention and before going to the operation theatre. The innovation is
considered to be effective if the anxiety level is decreased by 2 of the total scores of
the Chinese version of the State Anxiety Scale for Children (CSAS-C) (Li & Lopez,
2004) and the total scores of negative behaviors is decreased by 3 scores of Children’s
Emotional Manifestation Scale (CEMS) (Li, 2007).
Regarding nurses’ outcome, nurses’ compliance rate is said to be satisfactory if the
compliance rate of the innovation is above 80% and they acquire sufficient knowledge,
so that they are so confidence enough to implement the proposed innovation.
The above evaluation methods and data can help to determine whether the innovation
is effective or not and to show the innovation is worth to be implemented.
64
Chapter 7 Conclusion
To conclude, the dissertation develops an evidence-based practice guideline on the
video viewing in reducing preoperative anxiety in paediatric children. A research
question in PICO format is formed based on the significant clinical problem. A
systematic literature review was done. A total of eight articles were identified based
on the inclusion and exclusion criteria, then an assessment of the quality of the
selected articles was performed and thus different levels of evidence of the selected
studies were determined. Afterwards, data were extracted from those studies after
synthesis.
In order to implement a new protocol, it is important to assess the implementation
potential of the proposed guideline, therefore, the transferability, feasibility of the
findings and the cost and benefit ratio should be outlined before the implementation
of the new guideline into the clinical environment. After the assessment, the
implementation potential of the innovation is high, so a further communication plan
with different stakeholders is essential for final approval of the implementation of the
innovation.
Afterwards, a pilot testing was done to assess the potential difficulties and challenges,
65
and thus various solutions could be made beforehand. Finally, an evaluation plan,
including the outcomes of the proposed innovation and evaluation of the outcomes
were established in the dissertation.
Preoperative anxiety is common in paediatric children (Kain, Wang, Mayes, Krivutza
& Teague, 2001). There is a trend for non-pharmachological methods to reduce
children’s preoperative anxiety, as well as video viewing which is shown that an
effective anxiety alleviate method (Melamed & Siegel, 1975). It is believed that the
innovation not only benefits paediatric patients, but also improves the quality of
nursing care, as well as promotes the autonomy of nurses, so as to earn the reputation
of the hospital.
66
Appendix I: Search history
Item Electronic Databases
Pubmed ProQuest (Health
and Medicine
databases)
Handpicks from
Google Scholar
Keyword
search
1. Preoperative
2. Anxiety
3. Video *
MeSH
1. Anxiety
1. Preoperative
2. Anxiety
3. Film
4. Modeling
MeSH
1. Anxiety
1. Preoperative
2. Anxiety
3. Video OR film modeling
No. of articles 48 26 105 100
Limits Child: birth-18 years
MeSH: infant, Child
N/A N/A
No. of articles 25 15
Review by
titles
18 22 9
Review by
abstracts
14 9 2
Review by full
papers and
reference lists
4 3 3
Total articles
after
elimination of
duplication
8
67
Appendix II Table of evidence
1.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Faust et al.,
1991
Quasi-
experi
mental
2+ Same-day surgery patients
with previous surgery
experience ranging in age
from 4 to 10 years,
scheduled to undergo
elective ear tube surgery
with general anesthesia
and no handicapped
Group 1:
Children watch the
participant
modeling slide-tape
presenting both
procedural and
sensory information
through model
alone
(n=9)
Group 2
Children view the
same slide-tape
with their mothers
present
Grop1(n=8)
Group 3
Standard
procedure
information is
given which is
routinely used at
the hospital,
including
surgical
information
(n=9)
One hour
before surgery
to
post-operation
one hour
1. Anxiety level
a.(Heart rate)
b.(Sweat level)
2. Behavioral
distress during
recovery
(Pediatric
Recovery Room
Rating Scale)
1a. Group 1: -19 (p < 0.01)
Group 2:-9.5 (p > 0.15)
1b. Group 1: -0.9 (p< 0.01)
Group 2: 0.3 (p>0.08)
2. Group 1: -3.79 (p <0.01)
Group 2: -3.12 (p <0.02)
68
2. Appendix II: Table of evidence
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Kain et al.,
1998
RCT 1++
Outpatients aged 2-12
years, ASA physical status
I or II, scheduled to
undergo general anesthesia
and elective outpatient
surgery without history of
previous surgery,
hospitalization,
prematurity, chronic illness
or developmental delay.
Group 1:
Information +
modeling-based
program ( operating
room tour +
videotape)
(n=25)
Group 2:
Information +
modeling+
coping-based
program (operating
room tour+
videotape +child
life)
(n=24)
Group 3:
Information
based program
(10-minute
operating room
tour)
(n=24)
Two to ten
days before
surgery to 14
days after the
surgery
1.Children’s
anxiety in the
preoperative
holding area
(VAS)
2. Children’s
anxiety behavior
during entry into
operating room
and induction of
anesthesia
mask( YPAS)
3. Children’s
anxiety
presented by
cortisol level
(ug/mL)
4. Parents’
anxiety (STAIS)
1. Group 1: 32(IQR: 8-50)
Group 2: 9 (IQR: 6-33)
Group 3: 44 (IQR: 10-72),
P = 0.02
2. Entry into operating room
Group 1: 36 (IQR: 23-100)
Group 2: 46 (IQR: 23-100)
Group 3: 46 (IQR: 23-88)
Induction of anesthesia mask
Group 1: 44 (IQR: 23-100)
Group 2: 52 (IQR: 23-100)
Group 3: 46 (23-83)
(P=0.8)
3. Group 1: 0 Vs Group 2: 1.
(P=0.8)
4. Group 1: -3
Group 2: -5 (P=0.047)
69
Appendix II: Table of evidence
3.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Karabulut et
al., 2009
Quasi-
experi
mental
2+ Children aged between
9-12 undergoing inguinal
hernia operation, normal
cognitive development that
the measuring scale can be
applied and they are able
to understand and perceive
Group 1
The VCD(video)
group
(n=30)
Group 2
The booklet group
(n=30)
Group 3
The control
group
(n=30)
2 days before
the operation
to 1 day after
the operation
1. Children’s
state anxiety
(State-Trait
anxiety
inventory for
children)
a. before 48
hours
b. before 24
hours.
1a. Group 1: 2.8 (p< 0.01)
Group 2: -3.43 (p> 0.05)
1b. Group 1: -16.44 (p< 0.01)
Group 2: -11.77 (p> 0.05)
70
Appendix II: Table of evidence
4.
Bibliographi
c
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Lynch et al.,
1994
Quasi-
experi
mental
2+ Children aged 2- 10 years
old who were scheduled
for elective surgery, had no
previous hospitalizations
and had no medical
condition that require
medical special medical
care
The preadmission
program contains a
video incorporates
both procedural and
sensory information
(n=15)
Children did not
participate in
the program
(n=15)
13 days before
surgery to the
day of surgery
1. Emotional
distress level
(Manifest Upset
Scale)
2. Cooperation
level
(Cooperation
Scale)
3. Anxiety level
(Self-
Assessment
Faces Scale)
1. -1.4 ( p< 0.0001)
2. -1.6 ( p< 0.0001)
3. -0.9 ( p< 0.05)
Remarks: The small sample size and the self-selected groups limit the ability to generalize the results.
Self Assessment Faces Scale was modified from Wong-Baker FACES Rating Scale
71
Appendix II: Table of evidence
5.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Melamed et
al., 1975
Quasi-
experi
mental
2++ 60 children between ages
of 4- 12 years old who
were admitted for elective
surgery, they had no prior
history of hospitalization
Children view the
experimental
modeling film and
receive preoperative
instruction
(n=30)
Children do not
view the
modeling film
and receive
preoperative
instruction
(n=30)
1 hour prior to
the scheduled
admission
time to
21-31days
after discharge
1. State Anxiety
a.(Hospital
Fears Rating
Scale)
b. (Observer
Rating Scale of
Anxiety)
2. Trait Anxiety
(Personality
Inventory for
Children)
3. Behavior
problem
(Behavior
problems
checklist)
1a. Control group has a higher
fear rating than the experimental
group at all assessment times,
i.e. at preoperative (p< 0.01)
1b. Experimental group exhibited
significantly fewer (p<0.05)
anxiety- related behaviors than
the control group at both the
preoperative and postoperative
2.-2.27 (p <0.02)
3.Younger females and older
males exhibited the most behavior
problems in the experimental
group Vs older females has the
highest number of behavior
problems in the control group
(p< 0.004)
Remarks: Only significant results are presented.
Because of the wide range of ages, the data were reanalyzed with sex and age.
72
Appendix II: Table of evidence
6.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Mifflin et al.,
2012
RCT 1+ Healthy children between
ages of 2 and 10 years
undergoing ambulatory
surgery, ASA physical
status I or II, who had no
previous exposure to
anesthesia or surgery
without language barriers,
developmental disabilities
and taking psychoactive
medications
A video clip of the
child’s preference
(n=42)
Traditional
distraction
methods
(imagery,
storytelling,
game-playing,
nonprocedural
talk, or humor)
(n=47)
On the day of
surgery before
the operation
and during the
induction of
anesthesia
1. Anxiety level
(Yale
Preoperative
Anxiety Score)
1.-31.2 scores ( 95% CI , 27.1 -
33.3, p < 0.001)
Remarks: 2 coders for 20% of the observational data gathering for possible observer bias, no significant difference between 2 mYPAS coded scores (r = 0.9).
The scores are the median of the differences between scores in intervention group and control group.
The scores are compared for each participant in the control group with each participant in the intervention group to describe the difference.
73
Appendix II: Table of evidence
7.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Pinto et al.,
1989
RCT 1+ Children aged 2 – 12 years
old undergoing first time
elective surgery
Group1
Adult-narrated
videotape
with parent
(n=10)
Group 2
Peer- narrated
videotape with
parent
(n=10)
Group 3
No video
control group
with parent
(n=10)
1 hour before
scheduled
admission
time to
post-operation
day 2
1. Preoperative
Fear
(Hospital Fears
Rating Scale)
2. Behavioral
manifestations
of anxiety
(Observer
Rating Scale of
Anxiety)
3.Recovery
level (Recovery
Index)
1. Group 1: -10.4
Group 2: -6.5
(p < 0.002)
2. Group 1: -0.7
Group 2: -1.3
(p < 0.0001)
3. Group 1: -3.4
Group 2: -4.7
(p < 0.001)
Group 1a
Adult-narrated
videotape
without parent
(n=10)
Group 2a
Peer- narrated
videotape without
parent
(n=10)
Group 3a
No video
control group
without parent
(n=10)
1: Group 1a: 0
Group 2a: -1.9
(p <0.002)
2. Group 1a: -0.6
Group 2a: 0.4
(p< 0.0001)
3. Group 1a: -3.4
Group 2a: -6.1
( p< 0.001)
74
Appendix II: Table of evidence
8.
Bibliographic
citation
Study
type
Level of
Evidence
Patient
characteristics
Intervention Comparison Length of
follow up
Outcome
measures
Effect size
Wakimizu et
al., 2009
RCT 1++ Children aged 3-6 who
were scheduled to undergo
elective herniorrhaphy, no
chronic pain or suffering,
problems with any of the
five senses( touch, taste,
hearing, eyesight and
smell), mental disorders or
other diseases that require
special treatments,
problems with
communication or
challenges of reading and
writing skills in Japanese
language
A patient-
educational video
and a booklet are
given to children
and they are used as
frequently as
possible
(n=77)
Children view
the same
patient-
educational
video once
without further
preparation
(n=81)
7 days before
surgery to 31
days after
surgery
Primary
Outcome
1. Children’s
anxiety
(Wong-Baker
FACES Rating
Scale)
2.Caregivers’
anxiety
(State-Trait
Anxiety
Inventory)
Secondary
Outcome
3.Information
that caregivers
give children
4. Satisfaction
(%)
1. -0.76 (P < 0.05)
2. -1.87 ( P = 0.017)
3. Pre-hospital information about
‘the reason for undergoing
surgery’ (Z= -2.84, P = 0.004) and
‘anesthesia induction’ ( Z= -2.19,
P = 0.029) given more in
experimental group than control
group
4. 91.7% caregivers in
experimental group expressed
satisfaction
75
Appendix III: SIGN evaluation
1. Faust, J., Olson, R., & Rodriguez, H. (1991). Same-day surgery preparation:
reduction of pediatric patient arousal and distress through participant modeling.
Journal of Consulting and Clinical Psychology, 59(3), 475-478.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
No
Subjects in each group were
matched for age, gender and
number of previous surgical
experiences.
1.3 An adequate concealment method is used. No
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
1.6 The only difference between groups is the
treatment under investigation.
Yes
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
Acceptable(+)
76
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes. The validity and
reliability of methods are
proved
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
Small sample size may limit the generalizability.
Children viewing the modeling slide- tape have less preoperative anxiety when
given relevant information before surgery. Mother participant coaching may reduce
children’s sense of self-efficacy. Information without coping skills in this study was
not beneficial in preparing children for day surgery.
77
Appendix III: SIGN evaluation
2. Kain, Z. N., Caramico, L. A., Mayes, L. C., Genevro, J. L., Bornstein, M.H. &
Hofstadter, M. B. (1998). Preoperative preparation programs in children: a
comparative examination. Anesthesia and Analgesia, 87, 1249-1255.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
Yes
Random number table is
used
1.3 An adequate concealment method is used. Yes
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
Two psychologists served as
assessors, the
anesthesiologist, research
nurses were blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
1.6 The only difference between groups is the
treatment under investigation.
Yes
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias? High quality (++)
78
Code as follows:
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
This study did not use no-intervention comparison group, but it is acceptable
because some type of preoperative preparation should be offered to children.
Venham Picture Test is not appropriate for children in the preoperative setting
because of lack of discriminative sensitivity.
Children in extensive behavioral intervention exhibited less anxiety immediately
after the intervention and on separation to operating room which did not reach
statistical significance. However, if assuming type II error occurred, the extensive
behavioral intervention is more effective only at the preoperative period and has no
effect on intraoperative and postoperative outcomes.
79
Appendix III: SIGN evaluation
3. Karabulut, N. & Arikan, D. (2009). The Effect of Different Training Programs
Applied Prior to Surgical Operation on Anxiety Levels. New/Yeni Symposium Journal,
47(2), 64-69.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
No
1.3 An adequate concealment method is used. No
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Can’t say
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
72.2% are boys, but gender
has no significant effect on
children’s anxiety
1.6 The only difference between groups is the
treatment under investigation.
Yes
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
Acceptable (+)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
The inadequate concealment
may overestimate the effect
80
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
of the intervention
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
The study shows the importance of audio-visual tools for the pre-operation training
to be given to the children of the age group between 9- 12. It also proves that
mothers have to be included in all the care and training activities to be made for the
children.
81
Appendix III: SIGN evaluation
4. Lynch, M. (1994).Preparing Children for Day Surgery. Children’s Health Care,
23(2), 75-85.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
No
1.3 An adequate concealment method is used. No
Subjects select the group, so
they know which group they
are
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
Blinded observer rating were
made at designated times
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
Difference in gender and
prior emergency room visit
1.6 The only difference between groups is the
treatment under investigation.
Yes
Similar number of parents in
both groups discuss their
hospitalization with their
children and read story
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
82
2.1 How well was the study done to minimise
bias?
Code as follows:
Acceptable(+)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes, but bias may arise
because more children in
control group visited
emergency room before
predisposing them to more
hospital-related distress and
parents in both groups use
other preparation techniques
for their child which are
uncontrolled by investigator
may affect the result
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
Age-specific reactions to the preparation program cannot be carried out due to
limited sample size.
The results suggest that group preparation for children preparing surgery in a day
care setting is worth, but need to be cost-effective.
83
Appendix III: SIGN evaluation
5. Melamed, B. G. & Siegel, L. J. (1975). Reduction of anxiety in children facing
hospitalization and surgery by use of filmed modeling. Journal of Consulting and
Clinical Psychology, 43(4): 511-521.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
No
Group assignment base on
age, sex, race and the type of
operation.
1.3 An adequate concealment method is used. No
The experimenter who
recorded the behavioral
observations left the room
prior to start of the film to
maintain unaware of group
assignment
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
1.6 The only difference between groups is the
treatment under investigation.
Yes
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Does not apply
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
84
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
High quality (++)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes.
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
The 4-week post hospital examination supports the generalization of the film’s
effectiveness. The content of the film must be specific to procedure, for example,
hospital procedures to reduce children’s anxiety level. Children’s anxiety level is
affected by the previous hospital experiences.
85
Appendix III: SIGN evaluation
6. Mifflin, K. A., Hackmann, T. and Chorney, J. M. (2012). Streamed video clips to
reduce anxiety in children during inhaled induction of anesthesia. Anesthesia and
analgesia, 115(5): 1162-1167.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
Yes
Sealed envelopes whose
sequence determined by
random number generator.
1.3 An adequate concealment method is used. Yes
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
Parents were presence on
induction for only 5%, so they
are still homogeneous group
which didn’t change the effect
of the intervention.
1.6 The only difference between groups is the
treatment under investigation.
Yes
Video might be different
because video are chosen
according to subjects’
preference
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
An independent research
assistant double-coded 20% of
data to assess interrater
reliability
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
2.2%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No
1.10 Where the study is carried out at more than Does not apply
86
one site, results are comparable for all sites.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
Acceptable (+)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
Yes. Possibility of observer
bias, observer was blinded
before the randomization of
subjects, but they do not blind
during induction phrase, so 2
coders are used for 20% of the
observational data gathering,
and no significant difference
in the 2 mYPAS coded scores
(r=0.9), indicating high
interrater reliability
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
Children in the video distraction group displayed less anxiety at anesthesia induction
and having smaller increase in anxiety from holding to induction than did children in
the standard care group.
Children may not benefit from parental presence.
Video is an inexpensive distraction option.
The exclusion of children who were pre-medicated limits generalizability to certain
extents
87
Appendix III: SIGN evaluation
7. Pinto, R. P. & Hollandsworth, J. G. Jr. (1989). Using videotape modeling to prepare
children psychologically for surgery: influence of parents and cost versus benefits of
providing preparation services. Health Psychology, 8 (1), 79-85.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
Yes
Random number table is
used
1.3 An adequate concealment method is used. Yes
The rater left the room
before intervention started
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
1.6 The only difference between groups is the
treatment under investigation.
Yes
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
1.67%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
No
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
Acceptable (+)
2.2 Taking into account clinical considerations, Palmer Sweat Index may not
88
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
so updated, but the overall
effect is due to the study
intervention.
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
The sample size was too small to evaluate the interaction between age and the
treatment.
The psychological preparation is effective and cost-effective, but parental present
may not reduce children’s anxiety
89
Appendix III: SIGN evaluation
8. Wakimizu, R., Kamagata, S., Kuwabara, T., & Kamibeppu, K. (2009). A
randomized control trial of an at-home preparation programme for Japanese preschool
children: effects on children’s and caregivers’ anxiety associated with surgery, Journal
of Evaluation in Clinical Practice, 15: 393-401.
SECTION 1: INTERNAL VALIDITY
In a well conducted RCT study….. Did the study do this?
1.1 The study addresses an appropriate and
clearly focused question.
Yes
1.2 The assignment of subjects to treatment
groups is randomised.
Yes
1.3 An adequate concealment method is used. Yes
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
Yes
1.5 The treatment and control groups are similar
at the start of the trial.
Yes
1.6 The only difference between groups is the
treatment under investigation.
Yes
Caregivers in experimental
group explained more
actively to children
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes
1.8 What percentage of the individuals or clusters
recruited into each treatment arm of the study
dropped out before the study was completed?
8.9%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Does not apply
SECTION 1: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise
bias?
Code as follows:
High quality (++)
2.2 Taking into account clinical considerations, Yes
90
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
study intervention?
2.3 Are the results of this study directly
applicable to the patient group targeted by this
guideline?
Yes
2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question and
mention any areas of uncertainty raised above.
Video is an easy administer, cost-efficient programme. Children should be provided
with procedural ad sensory information without post-operative content.
91
Appendix IV: Quality assessment summary of the sampled studies
Quality Assessment of the Studies Faust et al.,
1994
Kain et al.,
1998
Karabulut et
al., 2009
Melamed
et al., 1975
Mifflin et
al., 2012
Lynch et
al., 1994
Pinto et
al., 1989
Wakimizu et
al., 2009
The study addresses an appropriate and clearly focused
question.
Yes Yes Yes Yes Yes Yes Yes Yes
The assignment of subjects to treatment groups is
randomised.
No
Yes
No No
Yes
No Yes
Yes
An adequate concealment method is used. No
Yes
No No
Yes No
Yes
Yes
Subjects and investigators are kept ‘blind’ about treatment
allocation.
Yes Yes
Can’t say Yes Yes Yes
Yes
Yes
The treatment and control groups are similar at the start of
the trial.
Yes
Yes Yes
Yes
Yes
.
Yes
Yes Yes
The only difference between groups is the treatment under
investigation.
Yes
Yes Yes
Yes
Yes
Yes
Yes Yes
All relevant outcomes are measured in a standard, valid and
reliable way.
Yes Yes Yes Yes Yes
Yes Yes Yes
What percentage of the individuals or clusters recruited into
each treatment arm of the study dropped out before the
study was completed?
0% 0% 0% 0% 2.2% 0% 1.67% 8.9%
All the subjects are analysed in the groups to which they Does not Yes Does not Does not No Does not No Yes
92
were randomly allocated (often referred to as intention to
treat analysis).
apply apply apply apply
Where the study is carried out at more than one site, results
are comparable for all sites.
Does not
apply
Does not
apply
Does not
apply
Does not
apply
Not
applicable
Does not
apply
Does not
apply
Does not
apply
How well was the study done to minimise bias?
Code as follows: Acceptable
(+)
High quality
(++)
Acceptable
(+) High
quality
(++)
Acceptable
(+)
Acceptable
(+)
Acceptable
(+)
High quality
(++)
Taking into account clinical considerations, your evaluation
of the methodology used, and the statistical power of the
study, are you certain that the overall effect is due to the
study intervention?
Yes Yes
Yes
Yes Yes Yes, but
there might
have bias
Yes Yes
Are the results of this study directly applicable to the patient
group targeted by this guideline?
Yes. Yes Yes Yes Yes Yes Yes Yes
Level of evidence 2+ 1++ 2+ 2++ 1+ 2+ 1+ 1++
93
Appendix V Cost of the innovation implementation
Type of cost Nature of the cost Sub-total Total
Material
Costs
1
.
Printing cost of the teaching notes
($1/teaching notes)
$5.5/Printing $5.5 x 605
=$3,330
2
.
Printing cost of Assessment and
Evaluation forms($3/form)
3
.
Print cost of protocol
($1.5/protocol)
Non-material
Costs
1
.
Manpower cost: the hourly salary of
the Registered Nurse
($198.9/ nurse)
$198.9 x 2 nurses
x5 hours
=$1,989
$4,776.5
2
.
Manpower cost: the salary of the
child actor ($0/ child)
$0
3
.
Manpower cost: nurses attend the
training cost ($99.5/ nurse)
$99.5 x 25 nurses
= $2487.5
4
.
Manpower cost: the salary of an IT
technician ($100/IT technician)
$100 x 1 technician
x 3 hour
=$300
5
.
Venue for training: $0
$0 $0
Total Cost $8106.5
94
Appendix VI: Activity plan for the innovation
Step Activities Content
1 Pre-intervention assessment Assessing patient’s age, cognitive level and
developmental ability, prior experience of
medical procedure or surgery and preoperative
anxiety level before the intervention.
2 Obtain a consent -Obtain consent from parents or guardians if
paediatric patients meet the inclusion criteria of
the intervention.
-A pamphlet will be given to parents.
3. -The video is played one
hour before the surgery and
prior initiation of different
laboratory investigations.
- Parents are allowed to
accompany the child during
the intervention.
-Children view the video via the bedside TV
panel and use the earphone sets provided in the
admission kit.
- The peer modeling video lasts for 14 minutes
providing procedural and sensory information,
including
1) packing things for the hospital stays;
2) getting ready for the surgery on the day of
surgery;
3) preparation for the surgery, e.g. continue
keep fast for the operation;
4) admission to the hospital and meeting the
doctor and anasethesiologist;
5) putting on the operation cloth in the surgical
ward;
6) doing the laboratory tests;
95
7) walking to the operation threatre
accompanied by a nurse;
8) having a simple conversation with the
operation theatre nurse, doctor and
anaesthesiologist;
9) being confirmed by the name tag;
10) wearing a surgical cap;
11) lying on the operating table;
12) having ECG leads putting on the chest,
putting blood pressure cuff applied on the arm,
having Sao2 monitoring;
13) breathing through an anesthestic mask.
The child narrates how he copes with the
stressful event throughout the peri-operative
process.
4. Q & A when necessary Parents can approach nurses if they have any
inquiry.
96
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