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

II

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

1

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

2

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).

3

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.

5

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.

6

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

7

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.

8

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

9

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.

10

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

11

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

12

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

13

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

14

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.

20

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.

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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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