An Evidence-based Guideline of Using Video Viewing in. Reducing Preoperative Anxiety for Paediatric Patients. Lam Po Chu

Transcription

1 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

2 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.

3 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

4 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

5 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.

6 VI Contents Abstracts..... I-III Declaration.... IV Acknowledgements... V Table of contents VI-VIII Chapter 1 Introduction 1.1 Background Significance Affirming needs Evidence-based question Objectives Chapter 2 Critical Appraisal 2.1 Search and appraisal strategies Data extraction Quality assessment of the studies Results Summary and Synthesis Recommendations

7 VII Chapter 3 Assessing implementation potential 3.1 Transferability of the findings Feasibility of the findings Cost-benefit ratio of the innovation Chapter 4 Developing evidence-based practice protocol 4.1 Recommendations for developing an evidence-based guideline Evidence-based guideline Chapter 5 Implementation plan 5.1 Communication plan Pilot Testing Chapter 6 Evaluation plan 6.1 Identification of outcomes Nature of clients to be involved Data analysis Evaluate the effectiveness of the innovation Chapter 7 Conclusion Conclusion

8 VIII Appendices Appendix I. 66 Appendix II Appendix III Appendix IV Appendix V Appendix VI References References

9 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

10 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).

11 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.

12 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.

13 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.

14 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

15 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.

16 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

17 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.

18 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 12 th of August in 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 Over 250 articles were identified in this period using keywords including preoperative, anxiety, video*, film, modeling while

19 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

20 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 , 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 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

21 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 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 (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 (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

22 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

23 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

24 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.

25 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.

26 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

27 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.

28 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.

29 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

30 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

31 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).

32 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

33 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

34 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.

35 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).

36 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

37 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;

38 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.

39 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.

40 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

41 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

42 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.

43 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

44 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,

45 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.

46 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

47 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 $ 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 $ 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 $ Details are shown in the Appendix V.

48 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.

49 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

50 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)