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A comparison of two hospital preadmission preparation programmes for young children Harper, Jeanine Marie 1981

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A COMPARISON OF TWO HOSPITAL PREADMISSION PREPARATION PROGRAMMES FOR YOUNG CHILDREN by JEANINE MARIE HARPER B.F.A., The University of V i c t o r i a , 1974 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Educational Psychology Department, School Psychology Programme) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA November 1981 (c^ Jeanine Marie Harper, 1981 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It i s understood that copying or pu b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of Educational Psychology The University of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 „ October 30, 1981 Date ' - i i - ABSTRACT The purpose of this study was to compare a tour-based preadmission preparation programme for young children to a video-tape-based programme.' Subjects were 30 English speaking children who were admitted to Surrey Memorial Hospital , a community general hospital in Surrey, B.C. The children were admitted for elective surgery which required an overnight stay. The children and their parents participated in the programmes three days to two weeks prior to the chi ld's scheduled surgery. Half of the children and their parents were taken on a tour of the paediatric ward and laboratory. The other group was shown a video-tape made at the Surrey Memorial Hospital, which depicted the hospitalization of a boy and g i r l for tonsillectomy and adenoidectomy. Both treatments were f o l - lowed by a discussion and play period. The two groups were not found to differ on sex, previous hospi ta l iz - ations, types of surgical procedure, length of stay, length of anaesthesia, or prehospital personality as measured by a modification of the Post- hospital Behavior Questionnaire (Vernon, Schulman, & Foley, 1966). How- ever, the tour group was found to contain more younger children (under 6 years of age) than the video group. No significant differences were found between the two groups on the self-report, behavioural, or physiological outcome measures, except for incidence of postoperative vomiting. The video group vomited less than the tour group. Questions concerning the va l id i ty of the Hospital Fears Rating Scale and the modified Posthospital Behavior Questionnaire for this age group are raised in the discussion. Complicating factors, such as small sample - i i i - s ize, lack of a control group, and lack of control over physiological data col lect ion are addressed in this chapter. Confounding factors, such as a preoperative teaching class and the discussion groups, are also addressed. F ina l ly , the impact of Preadmission Programmes and pract ica l considerations in choosing a programme are discussed. Thesis Supervisor: Dr. O.A. Oldridge TABLE OF CONTENTS Abstract i i L i s t of Tables y L i s t of Figures v i Acknowledgements ' v i i Chapter I Introduction 1 Chapter II Review of the L i t e r a t u r e 5 The Adverse E f f e c t s of H o s p i t a l i z a t i o n 5 Determinants of Anxiety i n Hospi t a l i z e d Children 7 Methods of A l l e v i a t i n g Anxiety i n Hospitalized Children 11 Problem Statement and Research Hypotheses 18 Chapter I II Methodology 20 Subjects - 20 Variables and Instrumentation 22 Procedures 25 Data Analysis 29 Chapter IV Results 30 Description of the Sample 30 Hypotheses 33 Summary of Results 39 Chapter V Discussion 42 Results of the Study 42 D i f f i c u l t i e s Encountered i n Attempting to Conduct Research i n a General Hospital 43 Confounding Factors 45 Instrumentation 46 P r a c t i c a l Considerations 49 The Impact of the Programmes 50 Summary 51 Recommendations f or Further Research >52 Bibliography 53 Appendices A - Items from the Hospital Fears Rating Scale and Posthospital Behavior Questionnaire 61 B - Parent Consent Form >65 - v - L i s t of Tables Table T i t l e Page I Means and standard deviations of treatment groups for age 30 II Analysis of variance for age 31 III Chi square analysis of the treatment groups for age, sex, and previous hospitalization 31 IV Means and standard deviations of treatment groups for length of anaesthesia 32 V Analysis of variance of length for anaesthesia VI Chi square analysis of treatment groups for surgical procedure, length of stay, and complications VII Means, standard deviations, and r e l i a b i l i t y coefficients for three administrations of the Hospital Fears Rating Scale 32 33 34 VIII Analysis of covariance with repeated measures for .- Hospital Fears Rating Scale 35 IX Means, standard deviations and r e l i a b i l i t i e s for the Posthospital Behavior Questionnaire 36 X Analysis of covariance with repeated measures for the Posthospital Behavior Questionnaire 37 XI Numbers of missing cases, means, and standard deviations for the physiological measures 38 XII Analysis of variance - of treatment groups for physiological measures 41 XIII Chi square analysis of incidents of postoperative vomiting for treatment groups 4-1 XIV Frequency of anticipate/-missing data and the frequency of missing data for the blood pressure variable 44 - v i - LIST OF FIGURES Figure T i t l e Page I Exclusions of subjects from the study 21 II Changes i n Ho s p i t a l Fears scores at three administrations 35 - v i i - ACKNOWLEDGEMENTS I would l i k e to express my appreciation to Dr. O.A. (Buff) Oldridge, Dr. Julianne Conry, and Dr. Geoffrey Robinson, whose thoughtful and c r i t i c a l suggestions and endless encouragement were of invaluable assistance to me i n conducting t h i s research. I would l i k e to thank Dr. Robert Conry for h i s assistance with the s t a t i s t i c a l analysis of t h i s study. I would l i k e to thank Mrs. Margaret Woodward and the s t a f f of the Surrey Memorial Hospital f or t h e i r assistance and co-operation during the study. I would l i k e to thank Mrs. Maureen Wood, who helped to develop the study and ran the preadmission programmes. I would l i k e to thank Ms. Pat r i c e Palmerino for her time, patience, and expertise i n creating the video-tape programme. I would l i k e to thank A l l y c e , Bradley, and t h e i r f a m i l i e s , who appeared i n the video-tape. F i n a l l y , I would l i k e to thank my family and friends f or t h e i r patience, encouragement,• and senses of humour throughout t h i s endeavor. CHAPTER I INTRODUCTION H o s p i t a l i z a t i o n can be a disturbing experience for young chi l d r e n for a number of reasons. Stress producing s i t u a t i o n s , often not previously encountered by ch i l d r e n i n t h e i r d a i l y l i v e s , are met i n the h o s p i t a l environment. Separation from parents and friends may provoke anxiety at any age (Lockhart, 1980). Fears of the unknown and unfamiliar may become i n t e n s i f i e d and d i f f i c u l t to cope with i n the h o s p i t a l where almost every- thing i s unfamiliar or unknown. Children between the ages of 3 and 6 are forming concepts of s e l f and body parts, and concern for body mu t i l a t i o n may be exacerbated by i l l n e s s or injury (Belmont, 1970; R i t c h i e , 1979). Loss of c o n t r o l over body functions may be most d i s t r e s s i n g to c h i l d r e n who are j u s t beginning to f e e l mastery over t h e i r bodies (Freud, 1952). The i n t e r a c t i o n of fantasy with l i t t l e or misinformation may lead to the development of unnecessary and inappropriate fears (Jessner, Blom & . Waldfogel, 1952). Children may i n t e r p r e t i l l n e s s or surgery as a punish- ment (Nagera, 1978). They respond to the s i t u a t i o n as they perceive i t , rather than as i t may be. The responses of a c h i l d to h i s i l l n e s s are usually not determined by i t s actual sev e r i t y . More s i g n i - f i c a n t are h i s own fantasies and i n t e r p r e t a t i o n s of h i s i l l n e s s . (Belmont, 19 70, p.477) For these reasons, i t i s possible that c h i l d r e n undergoing even minor s u r g i c a l procedures may experience psychological d i s t r e s s . Estimates of the numbers of ch i l d r e n negatively affected by the experience of h o s p i t a l - i z a t i o n vary from 10% to 92% (Melamed r & Siegel, 1975). Psychological d i s t r e s s as a r e s u l t of h o s p i t a l i z a t i o n may be manifest i n a v a r i e t y of ways. Behavioural disturbances, such as prolonged crying, - 2 - apathy, and withdrawal have been observed in hospitalized children (Gellert, 1958). Regressive behaviour, such as enuresis, thumb sucking, sleep dis- turbances, and rapid changes in mood are often observed by parents after the chi ld has returned home and may continue to be observed for up to six months (McKee, 1963; Nagera, 1978). Admissions longer than seven days and repeated hospitalizations of children under five years of age have been associated with poor reading and behavioural disturbances lasting into adolescence (Douglas, 1975). It has been suggested that preoperative anxiety is a significant factor in impeding recovery from surgery (Dumas, 1963; G i l l e r , 1963). Andrew (1970) found that recovery was speeded by preparatory instruction. Therefore, for both medical and psychological reasons, the effect of prep- aratory instruction on children entering hospital needs investigation. Vernon and Foley (1965) identif ied the three main objectives of prep- aratory programmes: (1) to give factual information, (2) to encourage emotional expression, and (3) to establish a trusting relationship with the hospital staff. Preparatory programmes for children take many forms. Some are designed for potential health care recipients and may take place in kindergartens and schools (Abbott, 1970; West, 1976) or in the hospitals (Pomarico, Marsh, & Doubrava, 1979). Other programmes are designed for children scheduled for elective surgery and occur a few days or weeks before the children are admitted to the hospital (Anthony, 1977; Davis, 1977; Smith, 1971). There are also preoperative programmes scheduled for the afternoon before surgery (Crocker, 1980; Thomson, 1972). Other programmes emphasize the need for continuing play therapy opportunities throughout the child's hospital stay (Azarnoff, 1974; Schrader, 1979). In a l l cases, - 3 - the purpose is similar; to reduce the stress of hospital ization by acquainting the chi ld with the hospital environment and routine, by provid- ing accurate information, and by encouraging the chi ld to express his thoughts and feelings freely in the hope of releasing anxiety and correct- ing misinformation. Hospital preadmission programmes for scheduled elective surgery patients have become more common in recent years. In a recent survey of American paediatric hospitals, 42% of those responding prepared a l l patients, 32% prepared only specific types of admissions (eg. surgical patients), while 26% provided no formal preparation programme at a l l . (Peterson & Ridley, 1980). In a Canadian survey of paediatric hospitals and general hospitals with over twenty paediatric beds, the provision of preparation programmes ranged from 82% (Alberta) to 13% (Saskatchewan) of the responding hospitals in each province (Post, 1979). These programmes are usually offered on a weekly or semi-monthly basis and are conducted by a paediatric nurse or volunteer. The composition of these programmes varies, but always contains the opportunity for both parents and children to ask questions and for the children to manipulate some hospital equip- ment such as stethescopes, tongue depressors, masks, etc. Many organizers advocate a "party atmosphere" (Anthony, 1977; Brown, 1971; J o l l y , 1977). Two of the more commonly used approaches for disseminating information and for famil iarizing the chi ld with the hospital and i t s routines at these preadmission programmes are a tour of some of the areas of the hospital and/or a fi lm depicting a child's hospital ization. The tour-based programme is widely used and is advocated by the Cana- dian Institute of Child Health (1979) and by the B.C. A f f i l i a t e of the - 4 - Association for the Care of Children's Health (1980). These tours generally include the Admission area, the Laboratory, the Paediatric Ward. Other areas, such as the X-ray, Emergency, and Operating Rooms, are included in some tours, but because of technical reasons and high usage rate are not always considered suitable. In a l l cases, the co-operation of the hospital staff is essential (ACCH, B.C. A f f i l i a t e , 1980) but may not always be possible to obtain. Staff working in busy areas of the hospital may find tour groups to be a disruption and inconvenience. Film, slide-tape, or video-tape based programmes may be used on their own or in conjunction with an abbreviated tour of the hospital (Davis, •1977; Smith, 1971; Stainton, 1974).- Films depicting a peer-model experiencing admission and hospital procedures have been found effective in decreasing children's anxiety, as measured by behavioural, physiological, and indirect measures (Ferguson, 1979; Melamed, Myer, Gee, & Soul, 1976; Melamed & Siegel, 1975, 1980). In summary, because of the growing concern over the possible negative effects of hospitalization on children, more and more hospitals are estab- l ishing preparation programmes. Two- of the more common approaches to pre- admission programmes are the hospital tour and the fi lm or video-tape of a child experiencing hospital ization. The purpose of this study was to compare the effectiveness of these two approaches to preparation programmes. - 5 - CHAPTER II REVIEW OF THE LITERATURE The questions of whether hospitalization can have an adverse effect on children, what this effect might be, and how this effect might be alleviated are addressed singly and in consort in the l i terature on hos- pi ta l ized children. The Adverse Effects of Hospitalization The adverse effects of hospitalization have been described in various ways: (1) the anxiety or stress experienced by the chi ld during hospital- izat ion, and (2) the negative changes in behaviour noted after hospital iz- ation. The concept of anxiety or stress during hospitalization was f i r s t examined by Bowlby in the 1940's. He described (1958) the three phases -through which a chi ld may pass during hospital ization: (1) a phase of pro- test, (2) a phase of despair, and (3) a phase of detachment. He described these phases in both psychoanalytic and behavioural terms. A variety of behaviours and responses have been attributed to the anxiety or stress of the hospital ization, including a low level of manageability (Sauer, 1968), and of co-operation (Wolfer & Vi-sintainer, 1975, 1979). Elevations in physiological responses, such as pulse and blood pressure, have also been attributed to the stress of hospitalization (Skipper & Leonard, 1968). Changes in behaviour following hospitalization were f i r s t observed in studies by Prugh, et a l . (1953) and Jessner, et a l . (1952). Changes in behaviour included: sleep disturbances, regressive behaviours, cl inging, crying, enuresis, and others. In longitudinal studies, conduct disorders, - 6 - such as l y i n g and s t e a l i n g , and learning problems were correlated with e a r l i e r h o s p i t a l i z a t i o n s (Douglas, 1975; Quinton & Rutter, 19 76). Not a l l research has supported the hypothesis that h o s p i t a l i z a t i o n adversely a f f e c t s c h i l d r e n . Vernon and Foley (1965) reviewed the l i t e r a - ture to 1964 on h o s p i t a l i z e d c h i l d r e n . They noted four studies which concluded that h o s p i t a l i z a t i o n was an upsetting experience for c h i l d r e n , i . e , , one that resulted i n a negative change i n behaviour a f t e r the children returned home. They also noted one study with mixed findings and another which did not f i n d evidence to support the hypothesis that h o s p i t a l i z a - t i o n resulted i n negative behavioural changes. Davenport and Werry (1970) found no evidence to support the hypothe- s i s that h o s p i t a l i z a t i o n resulted i n negative behavioural changes. In t h e i r study, h o s p i t a l i z e d subjects' behaviour, as measured by the Post- h o s p i t a l i z a t i o n Behavior Questionnaire (Vernon, Schulman & Foley, 1966) , changed no more than the non-hospitalized control children's behaviour. Ninety-five of the 145 control subjects were the s i b l i n g s of the h o s p i t a l - ized c h i l d r e n , but the question of whether the h o s p i t a l i z a t i o n of a s i b l i n g may adversely a f f e c t a control c h i l d was not addressed. The wide age range (1 to 15 years) and the v a r i a t i o n i n the h o s p i t a l i z a t i o n experience (day- care surgery and in-patient surgery) l i m i t the i n t e r p r e t a t i o n of t h i s study. Estimates of the numbers of c h i l d r e n a f f e c t e d adversely by h o s p i t a l i z - ation vary widely depending on the date of the study and the method of assessment. In one of the best of the early studies reviewed by Vernon and Foley (1965), Prugh, et a l . (1953) found that 92 out of t h e i r 100 h o s p i t a l i z e d control subjects showed some behavioural disturbance two weeks a f t e r discharge. Three months l a t e r , 66% of the control group and 44% of - 7 - the experimental group showed disturbances of behaviour. The control group saw their parents once a week and were confined to their beds for much of the time. The experimental group had daily parental v i s i t s , a play pro- gramme, and preparation for each procedure. Few children now experience hos- pi ta l izat ion in the same way as the children in the control group of this study. The children in Douglas' more recently published longitudinal study (1975) experienced hospitalization in the 1950's and 10% were allowed no v is i tors at a l l . Douglas found that the behaviour of 22% of the pre- schoolers in his study deteriorated after hospital ization. Of those admitted more than once, 38% were found to show behavioural disturbance. These findings were confirmed by Quinton and Rutter (1976), who concluded that multiple admissions and admissions lasting longer than one week were related to later behavioural disturbance. The latter study contained more recently hospitalized children. The experience of hospitalization has changed in the past twenty years. Attempts have been made to decrease the negative impact of hospitalization through changes in v i s i t i n g regulations and other pol ic ies . Conditions also vary from hospital to hospital today (Post, 1979). It i s , therefore, inappropriate to assume that children in each hospital are l ike ly to be affected by the experience in the same way. Determinants of Anxiety in Hospitalized Children Why does the hospital experience result in anxious children who later demonstrate negative behaviour? Few modern studies have attempted to answer that question in a systematic way. Vernon and Foley (1965) ident i - fied four pr inc ipal determinants of anxiety with "limited support" in the l i terature up to that time. These are: - 8 - 1. unfamiliarity with the hospital setting, 2. separation from parents, s ibl ings , and friends, 3. age of the chi ld , and 4. prehospital personality of the chi ld . Other determinants have also been found to affect children's reactions to hospital ization. These are: 5. parental attitudes and personality, and 6. loss of control. 1. Unfamiliarity Brown and Semple (1970) found that in an experimental s ituation, subjects showed less mature motor and language behaviour in an unfamiliar setting than in a familiar one and continued to show differences in behaviour uhree days later. Another study, involving hospitalized children, has shown that a preadmission tour programme, which familiarizes the children with the hospital environment, positively affects the ch i ld - ren's behaviour while in hospital (Sauer, 1968). This lends support to the hypothesis that unfamiliarity i s indeed a factor contributing to behavioural disturbance in hospitalized and posthospitalized children. 2. Separation Vernon and Foley (1965) concluded that the second factor, separation from parents and family, was not as important as might seem because i t was generally compounded by other factors, such as unfamiliarity, restricted act iv i ty , and others. However, Jessner et a l . (1952), in a study of 143 hospitalized children, found fear of separation to be the focus of the children's anxiety. Godfrey (1955) found that the time when parents and children separated after v i s i t i n g hours to be the most stress- fu l time for both parents and children. In a comparison of children who experienced no separation from their mothers (i.e.., the mothers roomed-in) - 9 - with those who experienced a routine hospital ization, Lehman (19 75) found the children whose parents roomed-in to be more aggressive to both their mothers and nurses but to also have fewer postoperative complications. 3. Age The relationship between the age of the hospitalized chi ld and behavioural disturbance appears to be curvil inear (Vernon & Foley, 1965). Children up to 7 months old show l i t t l e behavioural disturbance when hospitalized. Upset becomes increasingly apparent after this age, with 3 and 4 year olds showing greatest vulnerabi l i ty , and then decreases in fre- quency with older children (Prugh, et a l . , 1953). Sides (1977) found age to be the most significant predictor of posthospitalization behavioural disturbance in an inverse relationship in a sample of children 5 weeks to 15 years of age. 4. Prehospital personality and experiences are considered to be a fourth factor determining children's reactions to hospitalization (Vernon & Foley, 1965), but l i t t l e work has been done to investigate this factor. Crocker (1980) confirmed that children who had been previously hospitalized tended to be more anxious than their naive counterparts. Melamed and Siegel (1975) noted that state and t ra i t anxiety instruments did not appear to measure the same personality variable but did not investigate whether there was any relationship between the scores on the different measures and behavioural upset during hospital ization. Recent studies, such as Melamed and Siegel's (1975), have not attempted to control for prehospital personality as they have for age and previous hospital- ization. 5; Parental Attitude A further factor, which may be considered to have some influence, is parental attitude and anxiety. Sides (1977) concluded - 10 - that maternal anxiety was the second best predictor of posthospital behav- ioural upset after age. Vernon, Foley and Schulman (1967) found that as the child's perception of .threat is increased, so is the positive effect of the mother's presence on the ch i ld . However, parents who feel fearful themselves are less l ike ly to v i s i t as long, l ive i n , prepare the ch i ld , or become informed them- selves than parents who are less anxious (Robinson, 1968) and may not be there when they are most needed. Skipper (1966) found that as a mother's information level increased, her distress decreased and her adaptation increased. This has led other researchers (Mahaffy, 1965; Skipper & Leonard, 1968) to provide a more positive hospital experience for children by attempting to reduce the anxiety of the mothers through giving informa- tion and support. Coleman (1976) found no significant difference between children receiving an orientation and play programme only and those whose parents also received an educationall.programme. His measurement instru- ment, however, was the Children's Manifest Anxiety Scale (Castaneda, McCandess, & Palermo, 1956), which Melamed and Siegel (1975) found insensitive to changes other instruments detected. 6. Loss of Control Another determinant of anxiety in hospitalized children is based on psychoanalytic theory. Anna Freud (1952) fe l t that for children, the experience of being nursed and the loss of control over such act iv i t ies as eating, bladder evacuation, dressing, etc. "means an equal loss in ego control, a pu l l back toward the earl ier and more passive levels of infanti le development." (p.71-72) This concurs with the opinions of Gellert (1958) and Lockhart (1980) and coincides with the definit ion of a "traumatic situation" given by Nagera (1978): - 11 - " . . . a psychological state during which time the ego loses the capacity to keep control over i t s function, and par- t i cu lar ly over the amount of anxiety that overwhelms i t , as well as the situation that is provoking i t . " (p.9). This theory that hospitalization is a traumatic situation because of the loss of ego control is supported by the observations of regressive behaviour of children after hospitalization (McKee, 1963; Sipowicz & Vernon, 1965). Methods of Al leviat ing Anxiety in Hospitalized Children The Role of Knowledge in Reducing Pain and Anxiety Fantasies and misconceptions about hospitalization are considered to be dangerous by Becker (1972), Fassler (1979), and Steward (1980), especially in children in the 5 to 6 year age range. Belmont (1970), Coppolil lo (1980), and Ritchie (1979) view pre-schoolers as being very concerned with their concepts of self and body. Children at this age view their bodies as their concept of se l f "and may . be greatly concerned" about body:-, mutilation. For this reason, fantasies and misconceptions of the reasons for hospital ization, surgery, and medical procedures are considered most dangerous for children at this age by psychiatrists (Belmont, 1970; Steward, 1980). In their review of the l i terature , Vernon and Foley (1965) noted that children may view hospitalization as a punish- ment and decried the lack of studies investigating the relationship between concepts of hospitalization and behavioural upset. Weinick (1958) found that no preparation and "unhealthy attitudes towards hospitalization", as measured by projective tests, resulted in intensif ication of distress after hospital ization. No preparation and "healthy attitudes" resulted in a significant negative change in attitude and anxiety leve l , while prepara- tion and "unhealthy attitudes" resulted in a positive change. No - 12 - definit ion of "healthy" and "unhealthy attitudes" was given. Lende (1971) compared unprepared and prepared children's behavioural responses to hospital ization. She found a significant negative correlation between behavioural upset and knowledge about the hospital ization. It appears, then, that having prior knowledge of the procedures which occur during a hospitalization reduces misconceptions and results in increased adjust- ment to the hospital ization. Research studies looking at methods used to mitigate the negative effects of hospitalization on children by providing information may be divided into two areas: (1) varying the actual nursing care, and (2) using preparation programmes. Nursing Care "Stress point nursing" is the descriptive t i t l e given by Wolfer and Visintainer (1975) to the care given by a single nurse at specified stressful points throughout the child's hospital ization. The times specified as "stressful" vary from study to study but often include admission, preoperative medication administration and postoperative recovery. Godfrey (1955) attempted to ease the separation of parent and chi ld by this style of nursing with mixed results. The children appeared to react posit ively, but the parents did not report any positive changes. Mahaffy (1965), Skipper and Leonard (1968), and Wolfer and Visintainer (1975) hypothesized that with the attention of one nurse at stressful times, stress would be reduced in the parents and reflected in a lower anxiety level in the children. The emphasis in this nursing style is on the concerns of the mother as well as those of the chi ld . Preparation Programmes Preparation programmes for surgical patients can be separated into two types, those which occur several days before the child's admission and those which occur upon the child's arr iva l or after admission. Because of the d i f f i cu l ty in obtaining random subjects for this research, the latter time of presentation has received greater research attention. The question of the best time for preparation was asked by Vernon and Foley in 1965 and was s t i l l not answered eleven years later when Siegel (1976) reviewed the more recent l i terature . Freud (1952) fe l t that too lengthy a time period between preparation and surgery might create dangerous fantasies, but that too short a time would not allow for the internalization of the material and the preparation of defenses. Melamed, et a l . , (1976) addressed the question and found that children prepared one week in advance were less anxious at the time of admission than those prepared immediately prior to admission. Older children prepared in advance also demonstrated fewer behaviour problems after discharge. Ferguson (1979) found s l ight ly different results. A v i s i t to the home of the child one week in advance was more effective in reducing the anxiety in children aged 3 and 4 than in older children. ,. ' . C Children aged 6 and 7 benefitted more by the preparation immediately prior to admission. This may have been due to the types of preparation rather than the times of preparation, since the advance preparation was a v i s i t by a nurse and the immediate preparation was a video-tape whose subject was the hospitalization of two children. Crocker (1980) found that younger children (aged 4 to 7) did not benefit as much from preparation following admission as did older children (7 to 10). On the whole, preparation in advance appears to be more effective than preparation on the day of admis- sion for younger children. As well as when to prepare, researchers have asked who should prepare the chi ld . Vernon and Foley, in their review of the l i terature (1967, note - 14 - " . . . that the only study which did not provide some positive findings with respect to preparation (Jessner, et a l . , 1952) was the only study which rel ied on parents to provide psycho- logical preparation." (p.23) Parents may have their own misconceptions and fears with which to deal, and i f anxious, may not prepare their chi ld (Robinson, 1968). Wolfer and Visintainer (1979) sent home a hospital k i t and booklet so that parents might prepare the subjects for hospital ization. They note that home prep- aration was beneficial to a l l who used i t . It appears, then, that parents may have some d i f f i cu l ty in preparing their ch i ld , but can do so effec- tively with assistance from the hospital . a) Modelling Programmes Modelling has proved to be a successful tech- nique in demonstrating appropriate methods of behaviour and thereby reducing the avoidance or negative behaviour of the subject toward such varied stim- u l i as dogs (Bandura, et a l . , 1967), snakes (Kazdin, 1974), and dental treat- ments (White, et a l . , 1974). Although Bandura and Menlove (1968) found that l ive models were more effective than filmed models in extinguishing avoidance behaviour, filmed modelling continues to be a popular approach to reducing medical and dental stress, especially as i t i s assessed by physiological measures (Siegel, 1976; Thelen, Fry, Fehranbach, & Frautschi, 1979). The more similar the model is to the subject, the greater the effect of treatment appears to be. Kazdin (1974), working with adults, and Kornhaber and Schroeder (1975), working with children, both found that models similar in age and sex to the subject had the greater effect in the cases of both coping and mastery models. Miechenbaum (1971) found coping models to have a s ignif icantly greater effect in reducing avoidance behaviour in adults than mastery models. Thelen et al.,(1979) concluded, in their review of the l i terature on therapeutic video-tape and film modelling, that to be of greatest - 15 - effect the model should be of peer age or younger and provide a coping, rather than a mastery model. They also described narration as an effective element in film and video modelling, especially i f the narration expresses the model's self-verbalizations of thoughts, feelings, and coping techniques during treatment. Multiple models have been shown to be more effective than one in reducing avoidance behaviour (Bandura & Menlove, 1968). One might add this variable to Thelen et a l . ' s l i s t . Film modelling has been used successfully to change the behaviour of young children during dental treatment. White, et a l . (1975) found watching a model receive treatment to be more effective than having the children simply watch the dentist manipulate the equipment. Melamed, Weinstein, Hawes, and Katin-Borland (1975) found a significant difference in the behaviour of 5 to 9 year olds after viewing a filmed model. Although the sample was very small (n=15), the groups were matched for age, sex, race, i n i t i a l fears, and even parental and dentist's anxiety levels. Similar results were obtained by Melamed, Hawes, Heiby, and Glick (1975), again with a small sample (n=16) and a large age spread (5 to 11 years). These results were not confirmed by Klorman, Hi lpert , Michael, LaGama, and Sveun (1980), who compared groups viewing a filmed mastery model, a filmed coping model, and a control f i lm. Although the group viewing the coping model obtained lower scores on a Behavior Profi le Rating, there was no significant d i f fer- ance found between the three groups. The sample was larger in this study than in the two previously mentioned (n=60). Measurement in this study consisted of behavioural observations only and did not include any physio- logica l response measures. This may have affected the results of the study. Vernon (1973) and Vernon and Bailey (1974) have used filmed modelling - 16 - i n preparing ch i l d r e n f or anaesthesia induction. Their success has been l i m i t e d f o r two possible reasons. The f i r s t i s that the f i l m was of a mock- up, rather than a r e a l induction, and the c h i l d r e n acting as models did not react n a t u r a l l y . The other weakness may be the measurement instrument, a seven point scale on which the c h i l d r e n were rated by the anaesthetists. M u l t i p l e measures may have been more successful i n detecting differences. Studies which compared two treatment methods, rather than comparing modelling to a c o n t r o l , have found modelling to be more e f f e c t i v e i n changing behaviour of ch i l d r e n during dental treatment than a d e s e n s i t i z - ation treatment. Desensitization involved the c h i l d r e n watching the den- t i s t handle the instruments and discussing what they say (Johnson & Machen, 1973; White, Akers, Green, & Yates, 1974; Yercheshen, 1977). It i s from the success of filmed modelling that the i n t e r e s t i n the f i l m and video-tape preadmission programme ar i s e s . Melamed and Siegel (1975) found that a f i l m depicting a peer coping model shown immediately p r i o r to admission was s i g n i f i c a n t l y more e f f e c t i v e i n reducing anxiety i n the ch i l d r e n than a control f i l m . Melamed, Myer, Gee, and Soul (1976) considered the time of viewing the f i l m as w e l l as the added e f f e c t of preoperative teaching.; Ferguson (1979) created a video-tape using both male and female peer-aged models. The experimental video-tape had a s i g n i f i c a n t e f f e c t on the children's behaviour a f t e r discharge, as w e l l as on the p h y s i o l o g i c a l measures of anxiety throughout the h o s p i t a l i z a t i o n . A v i s i t from a nurse one week i n advance of the admission had a greater p o s i t i v e e f f e c t on younger c h i l d r e n (3 to 4) than i t did on older c h i l d r e n (aged 6 to 7). b) Tour Programmes The tour-based programme has received l i t t l e research - 17 - attention. Sauer (1968) compared 50 children who participated in a weekly tour programme, to 50 children who did not. No attempt was made to match the control and experimental groups. Nurses rated the children as easy or d i f f i c u l t to manage. The results were that 14% of the experimental group and 53% of the control group were considered d i f f i cu l t to manage. A l l children were invited to attend the programme. Reasons why the con- t r o l children did not attend were not discussed and fundamental differences between the groups may have existed. This study has many l imitations, including the lack of data comparing the groups and the unsophisticated measuring instrument (nurses' rating). Azarnoff, Bourque, Green and Rakow (1975), in a well controlled study, compared a tour programme to a booklet preparation and a control (no prep- aration) . These treatments occurred immediately preceeding the admission. One hundred and twenty eight children between the ages of 4 and 11 were assessed on three measures: Posthospital Behaviour Questionnaire, Human Figure Drawing, and a Non-verbal Semantic Dif ferent ia l . The interpretation of the data is not clear, but they conclude that "tours are more effective than booklets for certain children and parents, and i t is usually better than no intervention." (p.57). Summary Children may be adversely affected by hospital ization. The anxiety and stress experienced during the hospital stay may be observed in their responses to the hospitalization and in behavioural changes following discharge. Hospitals have attempted to reduce the sequelae of hospital iz- ation by changing regulations and routines and implementing new programmes. - 18 - One of these programmes i s the preadmission preparation programme. The purposes of t h i s programme are to provide accurate information about the forthcoming h o s p i t a l i z a t i o n and the h o s p i t a l environment and to encour- age the c h i l d to express h i s concerns so that they may be a l l e v i a t e d . There are many types of preparation programmes. Two of the most com- mon types are the video-tape programme and the h o s p i t a l tour. The video- tape programme i s based on symbolic modelling theory and has been shown to be e f f e c t i v e i n reducing the anxiety of h o s p i t a l i z e d children. The h o s p i t a l tour i s a popular type of programme with l i m i t e d research to support i t s effectiveness. Problem Statement and Research Hypotheses This study attempted to answer the following question: Is a tour-based preadmission programme for chi l d r e n scheduled to undergo surgery equally e f f e c t i v e i n reducing the anxiety and psychological d i s - tress i n chi l d r e n as a video-tape-based programme depicting a peer-model experiencing h o s p i t a l i z a t i o n ? Hypotheses: 1. There w i l l be no s i g n i f i c a n t main e f f e c t f o r treatment on the Hospital Fears Rating Scale administered p r i o r to admission, i n the evening following admission, and two weeks following discharge. 2. There w i l l be no s i g n i f i c a n t i n t e r a c t i o n between the treatment and r a t i n g time on the Hos p i t a l Fears Rating Scale. 3. There w i l l be no s i g n i f i c a n t main e f f e c t f o r treatment on the Posthospital Behaviour Questionnaire. 4. There w i l l be no s i g n i f i c a n t i n t e r a c t i o n between the treatment groups and time on the Posthospital Behavior Questionnaire. - 19 - 5. There w i l l be no significant differences in temperature between treatment groups on admission. 6. There w i l l be no significant differences in pulse rate between treatment groups on admission. 7. There w i l l be no significant differences in systolic blood pres- sure between treatment groups on admission. 8. There w i l l be no significant differences in systol ic blood pres- sure between treatment groups after surgery. 9. There w i l l be no significant differences in respiration rate between treatment groups after surgery. 10. There w i l l be no significant differences in pulse rate between treatment groups after surgery. 11. There w i l l be no significant differences in the incidence of vomitting between treatment groups after surgery. 12. There w i l l be no significant differences in the time after surgery unt i l f i r s t voiding between treatment groups. - 20 - CHAPTER I I I METHODOLOGY In t h i s chapter the subjects, instrumentation, procedures, and data analysis are described. Subjects (see Figure I) The subjects of the study were 30 English speaking ch i l d r e n between the ages of 4 years, 0 months and 9 years, 11 months who were admitted for e l e c t i v e surgery to Surrey Memorial Hospital, Surrey, B.C. They were expected to be h o s p i t a l i z e d f or 3 days, including the days of admission and discharge. They were considered by the admitting physician to be i n good mental and ph y s i c a l health at the time of t h e i r admission. Surrey Memorial Hospital i s a community general h o s p i t a l with a 35 bed p a e d i a t r i c ward. During the sampling period of March 15, 1981, to September 16, 1981, 125 parents were i n v i t e d to bring t h e i r c h i l d r e n to the preadmission preparation programme. Of those i n v i t e d , 56, or 45% brought t h e i r c h i l d to one of the two treatment programmes. Based on the c r i t e r i a l i s t e d above, 52 parents were asked to par- t i c i p a t e i n the study; 42 of these, or 81% of the parents agreed. Twelve subjects were l o s t to the study a f t e r permission was given, for the follow- ing reasons: 2 - surgery cancelled due to ch i l d ' s i l l n e s s 3 - surgery cancelled due to Doctor's c a n c e l l a t i o n 3 - subject admitted without notice to researcher 1 - surgery cancelled due to c h i l d eating or drinking a f t e r midnight ;on the day preceeding surgery 3 - parents withdrew permission p r i o r to data c o l l e c t i o n . - 21 - FIGURE I Sample Selection Flow Chart 125 sent information booklets on programme 1st Exclusion 69 did not come to programme 56 came to programme 30 saw Video Tape 26 had Hospital Tour 2nd Exclusion - By Sample Criterion 29 23 asked to participate asked to participate 3rd Exclusion - Voluntary Exclusion 22 asked to participate 20 agreed to participate . _ - - j A t t r i t i o n - (see page 20) I 15 15 Video Sample Tour Sample - 22 - Variables and Instrumentation Control Measures Many factors have been considered to affect children's reactions to hospital ization. In order to determine whether any of these factors may have influenced the scores on the outcome measures, the following variables were assessed for each chi ld: 1. age in months, 2. age group (children 60 months and younger were c lass i f ied as young, children over 60 months were c lass i f ied as older), 3. sex, 4. previous hospital ization, 5. prehospitalization personality (as measured by the Posthospital Behavior Questionnaire, Form A), 6. surgical procedures, ~ 7. length of anaesthesia, 8. length of stay in hospital , and 9. complications during surgery. Prehospital personality was assessed using a modification of the Posthospital Behavior Questionnaire. This scale is described in greater detai l below. A l l other data was obtained from the subjects' medical charts. Outcome Measures In order to measure the effects of the treatments, a multidimensional approach was used. The children's responses to the hospitalization were indicated through self-report, behavioural, and physio- logical measures. a) Self-report Measure The Hospital Fears Rating Scale is considered to be a self report measure of situational anxiety. It is comprised of - 23 - eight items from the Medical Fears subscale, factor analyzed from the Fear Survey for Children (Scherer and Nakamura, 1966). Added to these, are eight items considered to have face val id i ty for assessing hospital fears and nine non-related f i l l e r items (see Appendix A). Each chi ld rated his degree of fear for each item on a fear thermometer that ranged from one (not afraid at a l l ) to five (very afraid) . The sum of the ratings on the sixteen medical fear items became the child's score for this measure. No r e l i a b i l i t y studies have been published on this measure. However, i t has been used in previous studies by Melamed and Siegel (1975), Melamed et a l . (1976), and Penticuff (1976). Ferguson (1979) found a positive correlation between scores on this scale and on physiological measures. b) Behavioural Measure The Posthospital Behavior Questionnaire was developed from six studies by Vernon, Schulman and Foley (1966) to measure changes in children's behaviour after hospital ization. The questionnaire consists of 27 behavioural items found in two of more of these ear l ier studies to occur in children following hospitalization (See Appendix A). Examples of items are: 1. Does your child make a fuss about going to bed at night? 15. Is i t d i f f i c u l t to get your chi ld to talk to you? The questionnaire was modified by the investigator so that two forms existed. Form A asked the mother to rate her chi ld's behaviour for each item for the six months preceeding hospital ization, and Form B asked the mother to rate her chi ld's behaviour during the two weeks following hospital ization. The questionnaire was further modified by the investiga- tor so that the response alternatives were more specif ic; i . e . , instead of (1) much less than before, (2) less than before, (3) same as before, (4) more than before, and (5) much more than before, the alternatives now - 24 - read: (1) not at a l l , (2) once in two weeks, (3) once a week, (4) two or three times a week, and (5) every day. This should have increased the r e l i a - b i l i t y of the instrument. It served as a measure with which to compare the pre- hospital personality of each group. The score was the sum of the ratings associated with each alternative for a l l items on this questionnaire. A study by Cassell (1965) is cited by Vernon, Schulman, and Foley (1966) regarding the r e l i a b i l i t y of the questionnaire. The correlation between tota l scores 3 and 30 days after discharge in 37 children undergoing cardiac catheterization was _r = .65. Support for the va l id i ty of the instrument comes from a study by Vernon, Schulman, and Foley (1966) in which the scores on the questionnaire were compared to those from a psychiatric interview with the mothers of 20 children who had been hospitalized for tonsillectomies (_r = .47). Further support of the construct va l id i ty of the questionnaire is evidenced in studies which indicate i t s ab i l i ty to predict changes (Ferguson, 1979; Sides, 1977; Vernon, 1973; Wolfer & Visintainer, 1975, 1979). Vernon et a l . (1966) factor analyzed the questionnaire and discovered six orthogonal factors: (I) general anxiety and regression, (II) separation anxiety, (III) anxiety about sleep, (IV) eating disturbances, (V) aggression toward authority, and (VI) apathy, withdrawal. c) Physiological Measures Data on physiological indicators of anxiety were collected by routine measures from the subjects' medical charts. Fluctuations in temperature, systol ic blood pressure and pulse rate are considered by several researchers to be val id indicators of stress and anxiety in children (Silver et a l . , 1955; Stuart & Stevenson, 1954). Unlike adults, children's v i t a l signs do not show a normal v a r i a b i l i t y ; - 25 - and changes in these measures may be interpreted as indications of appre- hension, fear, or anxiety (Mahaffy, 1965). The incidence of vomiting postoperatively has been shown to be affected by nursing care (Dumas & Leonard, 1963). Crocker (1980) found a positive correlation between preoperative preparation and postoperative vomiting, but Skipper and Leonard (1966), Mahaffy (1965), and Wolfer and Visintainer (1975) have a l l found significant decreases in postoperative vomiting to be associated with preparation for hospital ization. Taylor (1978) considered differences in this variable to be due to age. The patient's ab i l i t y to void postoperatively has been shown to be related to emotions: (Hollander, 1958) and time after surgery u n t i l f i r s t voiding has been used as a dependent variable in many studies of children's reactions to hospitalization (Mahaffy, 1956; Skipper & Leonard, 1968; Wolfer & Visintainer, 1975, 1979). In this study, time to f i r s t voiding was measured from when the anaesthetic was stopped. Temperature, pulse, blood pressure, postoperative vomitting, and time to f i r s t voiding are routinely noted by hospital staff. The physiological measures taken in this study did not increase the stress fe l t by the sub- jects more than is experienced in routine hospital ization. Procedures When a child was booked for elective surgery at Surrey Memorial Hospital, his parents were sent preadmission forms and a booklet describing the preadmission preparation programme. Approximately two weeks before the child's scheduled surgery, and i f the parents had not already made an appointment for a programme, parents were telephoned and invited to bring their children by the Paediatric Nurse Cl in ic ian who operated the programme. - 26 - a) Treatments Two treatment programmes were used i n t h i s study; a tour which had been i n operation at Surrey Memorial Hospital f o r two years, and a video-tape which was produced at Surrey Memorial Hospital. In the tour treatment, the ch i l d r e n and t h e i r parents were met by the Pa e d i a t r i c Nurse C l i n i c i a n and a Volunteer in.;the Admission area of the Lobby. The c h i l d r e n were each given a wristband, s i m i l a r to that worn by patients. Then they were taken to the Lab where they had a chance to f e e l the tourniquets and alcohol and each c h i l d was given a "happy face" band- aid. Next, the c h i l d r e n and t h e i r parents toured the Pa e d i a t r i c Ward, v i s i t i n g the Playroom, Lounge, Craftroom, Snack Kitchen, Bathroom, and Nurses' Station, as we l l as a room where they were shown how a bed, side r a i l s , and c a l l l i g h t operated. From there, the chil d r e n were taken to the OR Transfer Room where they saw the stretchers used for taking them to the OR, the OR beds, and sometimes a nurse i n OR clothes and mask. Then the c h i l d r e n saw the Kitchen before going to a Meeting Room where they had a chance to discuss what they saw and play with some of the common h o s p i t a l equipment, such as stethescopes, blood pressure c u f f s , and syringes. Throughout the tour, information on the Hospital was given to the parents. While the ch i l d r e n played and had a snack, the Head Nurse from Pae d i a t r i c s or the Pa e d i a t r i c Nurse C l i n i c i a n met with the parents to give out brochures, discuss h o s p i t a l i z a t i o n and preparation of child r e n , and answer any questions. In the video-tape treatment, the ch i l d r e n and t h e i r parents were met i n the lobby and taken d i r e c t l y to the Meeting Room by the P a e d i a t r i c Nurse C l i n i c i a n . There, they saw a video tape which followed a six-year- old g i r l and a fi v e - y e a r - o l d boy throughout t h e i r h o s p i t a l i z a t i o n f or - 27 - tonsillectomy and adenoidectomy. The children were seen coming into the hospital , being admitted and given a wristband, having their blood tests, and being admitted to the ward. The l i t t l e g i r l was shown learning about her room and bed and being examined by the nurse. Different rooms on the paediatric ward were shown and the children narrated an explanation of each area, including the nurses' station. The children were shown eating their suppers and told where the suppers came from. Preoperation medica- t ion, being moved on the OR stretchers, and anaesthesia induction were also br ie f ly shown, as well as waking from anaesthesia in the recovery room and on the ward and going home. Throughout the video-tape, the children narrated the events and discussed their reactions to hospital procedures. They also gave advice on how to handle some of the more un- pleasant procedures, such as "needles". A l l areas seen by the children on the tour are also shown on the tape, but with the addition of areas such as the operating and recovery rooms where i t would be impossible to take a tour group. The tape showed actual procedures, not mock-ups. This twenty-five minute video-tape was shown to the chidren and their parents in the meeting room. After viewing the tape, the children had an opportunity to discuss the tape and play with the hospital equip- ment, while the parents met with the Head Nurse or Paediatric Nurse Cl in ic ian . In each treatment programme, equal opportunities for discussion and play were provided. The difference in the programmes was in substituting the video-tape for the tour. b) Treatment Selection (see Figure 1) The tour and video programmes al ter- nated every two weeks. Thus a child's participation in a particular programme - 28 - was determined solely by his date of admission. At the conclusion of the preadmission programme, the Paediatric Nurse Cl in ic ian invited the parents and their children between the ages of 4 and 9 to participate in the study. The reason for the study and the nature of the involvement was explained, and a signed consent form was obtained at that time (see Appendix B). c) Data Collection Those parents and children participating in the study were met by the investigator at the time of the chi ld's admission for surgery at the Admission Desk. The Posthospital Behavior Questionnaire, Form A was f i l l e d out by the parent while the investigator administered the Hospital Fears Rating Scale to the chi ld . The children were than admitted to the Hospital in the regular manner. In the evening of the f i r s t day of admission, the investigator re- administered the Hospital Fears Rating Scale. Approximately two weeks after the chi ld's discharge from the Hospital, the investigator v is i ted the parents and children in their homes. The parents completed the Posthospital Behavior Questionnaire, Form B, while the investigator again administered the Hospital Fears Rating Scale to the chi ld . The following data were obtained from the subjects' hospital charts: 1. date of b i r t h , 2. previous hospital ization, 3. surgical procedure, 4. length of stay, 5. length of anaesthesia, 6. complications, 7. temperature, pulse, and systol ic blood pressure (in children 6 years of age and older) on admission, - 29 - 8. pulse, respiration, and systolic blood pressure (in children 6 years of age and older) one hour after surgery, 9. time after surgery u n t i l f i r s t voiding, and 10. incidence of postoperative vomiting. Data Analysis Descriptive s tat i s t ics for the total sample and the two treatment groups on a l l variables were generated using the S ta t i s t i ca l Package for the Social Sciences, Version 8.00 (SPSS:8) (Kita, 1980). A one-way analysis of variance was used to determine whether the two groups differed s i g n i f i - cantly on any of the continuous variables. A corrected chi square was used to determine significance on the dichotomous variables. The two scales, The Hospital Fears Rating Scale and the Posthospital Behavior Questionnaire, were analysed to determine a r e l i a b i l i t y co-efficient for each administration. The Laboratory of Educational Research Test Analysis Package (LERTAP) (Nelson, 1974) was used for this purpose. An analysis of covariance with repeated measures was performed on the data from the two scales. Age was used as a covariate to further examine the scores on these scales. The Biomedical Computer Programmes, P Series, 1977 (BMDP-77) (Dixon & Brown, 19 77) was used for this purpose. The confidence level was established at p = .05. - 30 - CHAPTER IV RESULTS The sample is described on the control measures. The outcome measures were used to test the hypotheses. Description of the Sample The sample and the two treatment groups were described on the following individual difference variables: 1 . age in months, 2. age group (children 60 months and younger were class i f ied as young, children over 60 months were class i f ied as older), 3. sex, 4. previous hospital ization, and 5. scores on the Posthospital Behavior Questionnaire, Form A (modi- fied to describe behaviour prior to hospital ization). Table I shows the means and standard deviations of each treatment group for age in months. Table II shows the results of the analysis of variance of this variable. The groups were not found to differ s ignif icantly in age (_F(1,28) = .23, j> = .63) or in behaviour prior to hospital ization (_F(1,28) = 1.01, _p_ = .32). See Hypothesis 4 for description of analysis of the Posthospital Behavior Questionnaire, Form A. TABLE I Means and Standard Deviations of Treatment Groups for Age. Mean S.D. Video Tour 71.67 69.00 11.89 17.84 - 31 - TABLE II Analysis of variance for age. Source of Variance Sum of Squares df Mean Square F Sig. Between groups 53.33 1 53.33 .23 .63 Within groups .6433.33 28 229.76 The groups were compared on age grouping as well as age in months because during the administration of the Hospital Fears Rating Scale, i t was observed that younger children responded in a different way to the task than older children (see Chapter V) and because i t was observed that there was a discrepancy in the variance of the ages between the two groups. Table III shows the results of the chi square analysis made on the individual difference variables. No difference was found between the 2 treatment groups on sex (x (1) = .57, _p_ = .45) or previous hospitalization 2 (X (1) = .0, _p_ = 1.00). There was found, however, to be more children 5 2 years of age and younger in Treatment 2 than in Treatment 1 (x (1) =3.75, p = .05). TABLE III Chi square analyses of the treatment groups for age, sex, and previous hospitalization Variable Video (n=15) Tour (n=15) 2 X Sig. Age .05 < 60 months 2 8 3.,75 > 60 months 13 7 Sex Male 11 8 .57 .45 Female 4 7 Previous Hospitalization Yes 6 5 .0 1.00 No 9 10 NOTE. The reported x i s corrected with df = 1 . - 32 - Other variables, considered to affect children's reactions to hospital- izat ion, were also described and differences between the two groups were tested for significance. These variables were: 1. the surgical procedure undergone, 2. length of anaesthesia, 3. length of stay in hospital , and 4. frequency of complications following surgery. Table IV shows the means and standard deviations for the length of anaes- thesia. Table V shows the results of the analysis of variance of this variable. The groups were not found to di f fer s ignif icantly on length of anaesthesia (F(l,28) = .28, £ = .60). TABLE IV Means and standard deviations of treatment groups for length of anaesthesia Group Mean SD Video (n=15) 46.13 15.40 Tour (n=15) 43.67 9.44 TABLE V Analysis of variance for length of anaesthesia Source of Variance Sum of Squares df Mean Square F Sig. Between groups 45 .63 1 45.63 .28 .60 Within groups 4569 .07 28 163.18 The other variables were analysed using the ch i square. No s i g n i f i - cant differences were found between the two groups on type', of surgical - 3 3 - procedure ( x Z(l) = -29, p_ = .59), length of stay i n h o s p i t a l (x^(l) ='1.48, 2 £ = .22), or frequency of complications (x (1) = .0, _p_ = 1.0) (see Table VI). Sur g i c a l procedures were grouped into two categories according to the s i m i l a r i t i e s i n degree of ph y s i c a l trauma associated with the procedure. TABLE VI Chi square analysis of treatment groups for s u r g i c a l procedure, length of stay, and complications Variable Video (n=15) Tour (n=15) 2 X Sig. S u rgical Procedure Tonsillectomy and/or Adenoidectomy and 14 12 .29 .59 Myringotomy and Tubes Hernia and hydrocele,or i 3 Orchidopexy J. Length of Stay 3 days 15 12 1.48 .22 4 days 0 3 Complications Yes 1 1 .0 1.00 No 14 14 NOTE. The reported x i s corrected with df = 1 . Hypotheses The Hospital Fears Rating Scale was used as the outcome measure of the children's report of t h e i r anxiety l e v e l at three d i f f e r e n t times. An i n t e r n a l consistency c o e f f i c i e n t was calculated f o r each adminis- t r a t i o n of th i s measure. The Hoyt estimate of r e l i a b i l i t y f o r the pre- admission administration was .16', f o r the postadmission administration was .84, and for the postdischarge administration was .82. The r e s u l t s of t h i s analysis and the means and standard deviations are reported i n Table VII. TABLE VII Means, standard deviations and r e l i a b i l i t y c o e f f i c i e n t s for three adminis- t r a t i o n s of the Hospital Fears Rating Scale. Administration Mean SD R a SEM On Admission 37.37 10.95 .76 5.07 Video 34.47 12.77 Tour 40.27 8.19 Evening a f t e r Admission 33.53 12.41 .84 4.77 Video 30.87 11.90 Tour 36.20 12.73 2 weeks a f t e r Discharge 37. 10 12.54 .82 5.21 Video 34.20 15.31 Tour 40.00 8.56 3 Hoyt Estimate of R e l i a b i l i t y Because the treatment groups were found to be d i f f e r e n t i n the age grouping of the chi l d r e n , an analysis of covariance with repeated measures was performed to c o n t r o l the possible e f f e c t s of age on the scores of the Hospital Fears Rating Scale. Age was found to have a s i g n i f i c a n t e f f e c t on t h i s measure (F_ = 7.41, j> = .01). However, no s i g n i f i c a n t main e f f e c t for treatment was found between the two groups. (F = 1.93, £ = .18), and the differences between the groups on t h i s measure remained constant throughout the administrations (F = 0.01, p_ = .99). The d i f f e r e n c e between the administrations for both groups combined was F_ = 2.92, (p_ = .06) (See Table VIII and Figure II.) Because these analyses showed no s i g n i f i - cant differences, no further analysis was conducted. - 35 - TABLE VIII Analysis of covariance with repeated measures for Hospital Fears Rating Scale Source of Variance Sum of Squares df Mean Square F_ Sig. Between Persons Treatment Individual .512.52 7179.68 1 27 512.52 265.91 1.93 . 18 Within Persons Between Administrations Treatment x Time Time x Within Treatment 274.87 1.09 2631.38 2 2 56 137.43 0.54 46.99 2.92 0.01 0.06 0.99 Covariate 1970.14 1 1970.14 7.41 0.01 Figure II Changes in Hospital Fears scores at three administrations Preadmission Postadmission Postdischarge Hypothesis 1 stated: There w i l l be no significant main effect for treatment on the Hospital Fears Rating Scale administered prior to admis- sion, in the evening following admission, and two weeks following discharge. Because no significant main effect was found on this variable when age was controlled for (F = 1.93, p_ = .18), Hypothesis 1 was not rejected. - 36 - Hypothesis 2 stated: There w i l l be no s i g n i f i c a n t i n t e r a c t i o n bet- ween the treatment and r a t i n g time on the Hospital Fears Rating Scale. Because the differences between treatment groups on the Hos p i t a l Fears Rating Scale remained constant over time (F = 0.01, p_ = .9 9), Hypothesis 2 was not rejected. The Posthospital Behavior Questionnaire, Forms A and B, was used to measure change i n the children's behaviour a f t e r h o s p i t a l i z a t i o n . An i n t e r n a l consistency c o e f f i c i e n t was calculated f o r each administration of t h i s scale. The Hoyt estimate of r e l i a b i l i t y f o r form A was .68, and for form B was .79. Table IX shows the means, standard deviations and r e l i a b i l i t i e s f o r the two forms. TABLE IX Means, standard deviations, and r e l i a b i l i t i e s f o r the Posthospital Behavior Questionnaire Form Mean SD SEM Form A Sample (n=30) Video (n=15) Tour (n=15) 43.47 41.87 45.07 8.70 7.57 9.71 .68 4.79 Form B Sample (n=30) Video (n=15) Tour. (n=15) 44.13 41.33 46.93 10.70 5.70 13.70 .79 4.84 a R = Hoyt Estimate of R e l i a b i l i t y An analysis of covariance with repeated measures revealed no s i g n i f i - cant differences between eit h e r group on t h e i r prehospital and posthospital behaviour ( F ( l , 1, 27) = 1.74, p_ = .20), although age did have a s i g n i f i c a n t - 37 - effect on this variable (F( l , 1, 27) = 10.77, p_ = .003). This analysis is summarized in Table X. Because no significant differences were found between groups, no further analysis was done. TABLE X Analysis of Covariance with repeated measures for the Posthospital Behav- iour Questionnaire adjusted for age. Source of Variance Sum of Squares df Mean Square „ I Sig. Between Persons Treatment 191.67 1 191.67 1.74 0.20 Individual (within treatment) 2981.40 27 110.42 Within Persons Pre/Post 6.67 1 6.67 . 18 .67 Treatment x Time 21.60 1 21.60 .58 .45 Time x Individual 1034.73 28 Covariate 1188.80 1 1188.80 10.77 0.003 Hypothesis 3 stated : There w i l l be no significant main effect for treatment on the Posthospital Behaviour Questionnaire. Because no s i g n i f i - cant main effect was found on this variable when age was controlled for (F (1, 1, 27) = 1. 74, p_= .20), Hypothesis 3 was not rejected. Hypothesis 4 stated: There w i l l be no significant interaction between the treatment groups and.time on the Posthospital Behavior Question- naire. Because the differences between treatment groups on this measure remained constant over time (F_(l, 1, 28) = .58, _p_ = .45), Hypothesis 4 was not rejected. Hypothesis 5 stated: There w i l l be no significant differences in temperature between treatment-groups on admission. No significant difference was found between the groups in temperature at admission, - 38 - F_(l, 28) = .15, £ = .70 (see Tables XI and XII). Hypothesis 5 was not rejected. Hypothesis 6 stated: There w i l l be no significant differences in pulse rate between treatment groups on admission. No significant d i f - ference was found between the groups on pulse rate at admission, F ( l , 26) = .002, p_ = .97 (see Tables XI and XII). Hypothesis 6 was not rejected. Hypothesis 7 stated: There w i l l be no significant differences in systolic blood pressure between treatment groups on admission. No significant difference was found between the groups on this measure, F ( l , 9) = .009, £ = .92 (see Tables XI and XII). Hypothesis 7 was not rejected. Hypothesis 8 stated: There w i l l be no significant differences in systol ic blood pressure between treatment groups after surgery. No significant difference was found on this measure after surgery, F ( l , 10) = .71, p_ = .42 (see Tables XI and XII). Hypothesis 8 was not rejected. Hypothesis 9 stated: There w i l l be no significant differences in respiration rate between treatment groups after surgery.. No significant difference was found between the groups on respiration rate one hour after surgery, F ( l , 28) = .98, £ = .33 (see Tables XI and XII). Hypothesis 9 was not rejected. Hypothesis 10 stated: There w i l l be no significant differences in pulse rate between treatment groups after surgery. No significant difference was found between the groups on pulse rate one hour after surgery, F ( l , 28) = .45, p_ = .41 (see Tables XI and XII). Hypothesis 10 - 39 - was not rejected. Hypothesis 11 stated: There w i l l be no s i g n i f i c a n t differences i n -the incidence of postoperative vomiting between treatment groups a f t e r surgery. Children i n Treatment .1 did not vomit at a l l . There was a s i g n i f i c a n t difference 2 found i n the incidence of vomiting between the'two groups, (i.) =3.84, _p_ = .05 (see Table XIII). Hypothesis 11 was rejected. Hypothesis 12 stated: There w i l l be no s i g n i f i c a n t differences i n the time a f t e r surgery u n t i l f i r s t voiding between treatment groups. No s i g n i f i c a n t difference was found between groups on minutes a f t e r anaes- thesia u n t i l f i r s t voiding, F ( l , 27) = 1.32, p_ = .26 (see Tables XI and XII). Hypothesis 12 was not rejected. Summary of Results The treatment groups were not found to d i f f e r on any of the co n t r o l variables except age group. Although age was found to have a s i g n i f i c a n t e f f e c t on the Posthospital Behavior Questionnaire and Hospital Fears Rating Scale, when age was co n t r o l l e d f or no s i g n i f i c a n t differences were found between the two treatment groups on these v a r i a b l e s . Of the physio- l o g i c a l v a r i a b l e s , only incidence of vomiting was found to d i f f e r s i g n i f i - cantly between the treatment groups. - 40 - TABLE XI Numbers of missing cases, means, and standard deviations f o r the physio- l o g i c a l measures Variable Number of Missing Cases Meaii SD Pulse at Admission Video (n=15) 1 95.86 11.11 Tour (n=15) 1 96.00 6.23 Temperature at Admission Video (n=15) 0 36.85 .50 Tour (n=15) 0 36.79 .32 Systolic Blood Pressure at Admission Video "(n=15) 10 100.00 11.75 Tour (n=15) 9 99.33 11.08 Systolic Blood Pressure after Surgery Video (n=15) 8 111.43 11.82 Tour (n=15) 10 117.60 13.45 Respiration Rate after Surgery Video (n=15) 0 19.33 1.95 Tour (n=15) 0 20.13 2.45 Pulse After Surgery Video (n=15) 0 106.00 13.33 Tour (n=15) 0 109.53 15.46 Time to F irs t Voiding in Minutes Video (n=15) 1 572.00 284.00 Tour (n=15) 0 475.13 155.32 - 41 - TABLE XII Analysis of variance f o r treatment groups on p h y s i o l o g i c a l measures Source Sum of Squares df Mean Square J_ Sig. Pulse at admission Between groups .14 1 • .14 .002 .97 Within groups 2107.71 26 81.07 Temperature at admission Between groups .03 1 .03 L .15 .70 Within groups 4.94 28 . 18~ S y s t o l i c Blood Pressure at admission Between groups 1.21 1 1.21 .009 .93 Within groups 1165.33. 9 129.48 S y s t o l i c Blood Pressure a f t e r surgery Between groups 111.09 1 111.09.;' .71 .42. Within groups 1560.9 1 10 156.09 Respiration Rate a f t e r Surgery Between groups Within groups 4.80 137.07 1 28 4.80 4.90 ,98 33 Pulse a f t e r Surgery Between groups Within groups 93.63 5338.73 1 28 93.63 208.35 .45 .41 Minutes a f t e r surgery to f i r s t voiding Between groups Within groups 67946.96 1 67946.96 1.32 1386261.73 27 51343.03 ,26 TABLE XIII Chi square analysis of incidence f o r postoperative vomiting Category Video (n=15) Tour (n=15) 2 X Sig. Yes 0 5 3.84 .05 No 15 10 NOTE. Reported c h i square i s corrected with df = 1. - 42 - CHAPTER V DISCUSSION In this chapter, the results of the study are discussed. Di f f icu l t ies encountered in conducting a research project in a community general hospital are enumerated. Factors which may have confounded the results of the study are discussed, as are the concerns which arose during the data collection period in regard to the instrumentation. In conclusion, the findings in the study are re-evaluated and recommendations for further research are made. Results of the Study The two treatment groups did not differ s ignif icantly on the individual characteristic variables age, sex, previous hospital ization, or prehospital behaviour but were found to differ on age group, with more younger ch i ld - ren in the Tour treatment. The treatment groups were not found to differ on the hospital experience variables; surgical procedure, length of anaes- thesia, length of stay, and complications. No significant differences were found on any outcome measures except for incidence of vomiting. Tour group subjects vomited more than video group subjects. This variable was not analysed by type of surgery, although the video group contained 2 more subjects who had tonsillectomies, a pro- cedure more l ike ly to be associated with vomiting than hernia repairs. When age was controlled as a covariate, no significant differences were found between the groups on the Posthospital Behavior Questionnaire or the Hospital Fears Rating Scale. Therefore, i t was concluded that there was no significant difference between the video-tape and hospital - 43 - tour treatment programmes. No differences were found between the ratings of behaviour prior to hospitalization and two weeks after discharge. The conclusion that both treatments were equally effective in eliminating posthospital behaviour sequelae is discussed under Instrumentation. Di f f icu l t ies Encountered in Attempting to Conduct Research in a General Hospital 1. Data col lection took twice as long as was original ly anticipated. By looking at the numbers of children attending the programme in the previous years, the data collection period was estimated at three months. It was also anticipated that a more restricted age range (4-7 years) and only two surgical procedures (tonsillectomy and adenoidectomy) could be selected, thereby controlling for age and surgical procedure factors. However, i t soon became apparent that to l imit the sample in these ways would result in a data collection period too long to be pract ical ly pos- s ible . Therefore, older children and other surgical procedures were allowed in the sample. This meant that more control measures had to be incorporated into the study, to consider the characteristics of the groups on these variables. Although projections can be made from previous years, trends in admissions may change, and the projections may not be accurate for a short period of time. 2. Not a l l the physiological data that was needed could be obtained from the medical charts. It was anticipated that data would be collected for the evening following surgery and preceding discharge. However, i t was not possible to locate consistent data for each subject from the medical charts. Phrases such as "normal v i t a l signs" may be va l id indicators - 44 " to the h o s p i t a l s t a f f but are not useful to a researcher. I t was a n t i c i - pated that blood pressure would not be taken on subjects under 6 years of age. Table XIV l i s t s the numbers of subjects under 6 and the numbers of missing data f o r the blood pressure v a r i a b l e s . I t can be seen that at least one c h i l d under 6 had h i s blood pressure taken, but other subjects 6 years and over were missed. The amount of missing data and the d i f f e r - ences between the two groups on age make t h i s data uninterpretable. TABLE XIV Frequency of ant i c i p a t e d missing data and•the frequency of missing - data f o r the Blood Pressure (BP) Variables Video (n=15) Tour (n=15) Anticipated Missing Data No. of subjects < 6 years 7 10 Actual Missing Data for BP at Admission 10 9 for BP a f t e r Surgery 8 10 3. It should be noted that one of the objectives f o r t h i s research project was to be as unobtrusive as possible. It was considered impor- tant not to make what might be considered s t r e s s f u l demands on the subjects, such as c o l l e c t i n g data on p h y s i o l o g i c a l responses not normally recorded by routine h o s p i t a l procedures. This objective was achieved, and the experience of the subjects i n t h i s h o s p i t a l i z a t i o n may be considered s i m i l a r to that of other c h i l d r e n h o s p i t a l i z e d f o r the same reasons. This concern and objective must be weighed against the complications r e s u l t i n g from missing data. 4. No c l a s s i c a l control group was used i n t h i s study. I t has been - 4 5 - shown that parental attitude to hospitalization and anxiety level may affect a chi ld's response to hospitalization (Azarnoff, et a l . , 1975; Sides, 1977). It was, therefore, concluded that parents and children who did not choose to attend a preadmission programme might di f fer from those who did choose to participate and could not be considered as a control group. It was considered undesirable by the ;hhospital to withold a service (th preadmission programme) from, parents who wanted i t , and therefore no placebo attention group was created. It is unfortunate that a control group was no possible, because i t cannot be ascertained whether either programme is effective,- only that they. do not differ s ignif icantly from each other in their effectiveness. As reported in Chapter II, negative effects of hospitalization and the effects of preparation programmes have differed through time and place. Hospitals, their rules, and routines have changed dramatically in the past twenty years. It has been noted that hospitals s t i l l d i f fer markedly, one from another (Post, 1979). For these reasons, a control group to demonstrate the need for and level of effectiveness of preparation programmes within a given hospital should be considered essential to research of this type. Confounding Factors The Preadmission Preparation Programmes did not consist only of the tour or video-tape treatments. As was described in Chapter III , children were encouraged to play with hospital equipment, such as syringes, blood pressure cuffs, tongue depressors, masks, etc. Parents were invited to discuss their concerns with the Head Nurse or Paediatric Nurse Cl in ic ian - 46 - and received copies of the Paediatric Ward's information booklets. To what extent the common properties of each treatment programme confounded the effects of treatment could not be ascertained. As well as the Preadmission Preparation Programme, the subjects in the study also participated in a Preoperative Teaching programme. The latter programme was scheduled for 4:30 p.m. on the day of the child's admission and consisted of sl ides and a discussion to prepare the chi ld for his/her surgical procedure the following day. The preoperative teaching programme focussed on the preoperative medication, the preparation for surgery, anaesthetic, and recovery room procedures. Although some of this material was covered in the video-tape, i t was not discussed in the same deta i l . It could not be determined by this study what effect the preoperative programme may have had on the subjects and to what extent the results of this study were confounded by the subjects' exposure to this programme. Melamed, et a l . , (1976) found that their preadmission video presentation had an effect above the effect achieved by preoperative teaching, but this conclusion could not be drawn from this study. A further l imit ing factor of the study was the small sample size. Because of the small numbers of children entering the hospital for elective surgical procedures requiring an overnight stay, i t took over six months to obtain a sample of 30 children. The small sample size infers that larger differences are necessary to show a significant difference between groups than i f a larger sample size was used. Instrumentation The Posthospital Behavior Questionnaire was modified in two ways. F i r s t , the response categories were changed from subjective categories to specific frequencies. Second, i t was modified to measure behaviour prior - 47 - to admission and after discharge, rather than asking for the parent's per- ception of change. It was found that the subject's behaviour did not change during the two weeks following surgery. Two competing conclusions may be drawn: 1. that both treatment programmes are effective in eliminating post- hospital behaviour sequelae, or 2. that the instrument is not sensitive enough -to record changes in behaviour. The internal consistency coefficients calculated for this scale were .68 for Form A (measuring prehospitalization behaviour) and .79 for Form B (measuring posthospital behaviour). These are only s l ight ly higher than the r e l i a b i l i t y of .65 quoted by Vernon, et a l . , (1966) for the original questionnaire. The original scale was designed to measure behaviour in children 1 month to 16 years of age (Vernon, et a l . , 1966). The age range in this study was much smaller, as i t was in most other recent studies (Ferguson, 1979; Melamed and Siegel, 1980; Wolfer and Visintainer, 19 79). Item Analysis of the scale revealed two items which a l l parents answered as "not at a l l " and several more with very low or negative correlations with the scale (see Appendix B. Questions which arose during this study were: 1. Are the items significant in differentiating among subjects who are closer in age then in the original sample? and 2. Is the instrument as modified sensitive to change over a short period of time (2 weeks)? A r e l i a b i l i t y and va l id i ty study of this scale is necessary before any conclusions can be drawn regarding the results from this measure. Such a study is strongly recommended before the scale is used again. - 48 - The Hospital Fears Rating Scale has been used in three studies with samples ranging in age from 4 to 12 years (Melamed and Siegel, 1980) and in one study with an age range from 3 to 7 years (Ferguson, 1979). It was observed in this study that 5 of the subjects, aged between 48 and 61 months, responded to the scale in sequence; either: a) 1, 2, 3, 4, 5, 1, 2, 3, 4, . . . ; or b) 1, 2, 3, 4, 5, 4, 3, 2, 1, 1, . . . . It was also noted that another 4 subjects, aged between 64 and 85 months used only the 1 and 5 response categories. Because of these response patterns, two questions are raised: 1. whether the younger subjects understood the concept of the temper- ature analogy scale, and 2. whether different age groups differ in their response styles, making total score comparisons across age groups inappropriate. Scherrer and Nakamura (1968) note: "Most studies show a general decline in the number of fears in normal children and a change in the type of fears from immediate tangible fears to anticipatory, less tangible fears with increasing age." (p.173) femphasis, this author} The Fear Survey Schedule* was developed for use with children aged 9 through 12. The va l id i ty of this scale for use with children aged 3 through 8 is questionable. Internal consistency coefficients for each administration of the Hospital Fears Scale in this study were .84, .76, and .82. Because of the response patterns observed in some of the subjects, however, further r e l i a b i l i t y and va l id i ty studies of this scale are recommended. * The; Fear Survey Schedule is the scale from which the Hospital Fears Rating Scale is derived. - 49 - The analysis of covariance with repeated measures indicated that although age had a significant effect on this variable, differences between the groups were not s ignif icant. The analysis also revealed an insignificant difference between the times of administration (p_ = .06) (see Figure II) . It appears that the scores at the postadmission administration were lower than at the other two administrations. There are two possible explanations for this d i f fer- ence: 1. that the children, after real iz ing that their hospital experience was proceeding exactly as they were told i t would, were able to relax after their admission, or 2. that the lower scores are an art i fact of the test-retest situation, in that the time between f i r s t and second administrations was approximately 4 hours and between second and third administrations was approximately 2 weeks. Without test-retest r e l i a b i l i t y data, i t is impossible to determine the reason for this fluctuation in scores. Pract ica l Considerations In choosing a method to prepare children for hospitalization and surgery, the f i r s t concern should be with .the effectiveness of the pro- gramme. Other, more pract ica l , considerations must also be weighed. The following is a comparison of the video and tour treatment programmes on these issues: Costs 1. A video programme is more expensive to produce i n i t i a l l y . 2. Staff time in operating both programmes is equal. - 50 - Convenience 1. Only one or two staff members and one room are required for the video programme. 2. Children move through the hospital on a tour and some areas must be available and the staff aware, i f not actively part ic ipating, in the tour programme. Maintenance 1. A consistent standard for the quality of the programme is guaran- teen with the video programme. 2. The quality of the tour programme may change with each programme or with each tour leader. Important elements may be missed. Interaction 1. The tour demands greater interaction between the participants and the tour leader. Staff in other areas of the hospital may become actively involved if. they so choose. A s k i l l f u l tour leader is c r i t i c a l . 2. A s k i l l f u l discussion leader is necessary to transform the more passive act ivi ty of watching the tape to a more active play/discussion involvement. These issues must be carefully examined by anyone in i t i a t ing a pre- paration programme. No attempt was made in this study to draw any conclu- sions as to which programme is more pract ica l . This decision must be made for each indidivual hospital . The Impact of the Programmes Although no attempt was made in this study to evaluate the need for and effectiveness of Preadmission Preparation Programmes in the Surrey Memorial Hospital, a related issue should be discussed, that i s : the - 51 - inefficiency of such programmes to serve their total audience. It has been observed that Preadmission Programmes are attended by less than half of their potential audience (Cox, 1976; Peterson & Ridley, 1980). This is true of the Surrey Memorial Hospital where 125 children were sent brochures for the programme in a 6 month period and 79 were contacted by phone, but only 56 attended a preadmission programme. Reasons why these children do not attend, vary from the parents lack of interest or concern to an inab i l i ty to attend at that particular time. Efforts should now be turned toward programmes which can reach these children. Poss ib i l i t i es include school programmes, public education, and programmes immediately prior to admission. The advantages of the video-programme may be in these areas. Ferguson (1979) and Melamed and Siegel (1975) found a video pro- gramme administered immediately preceeding admission to be effective in reducing anxiety in children hospitalized for surgery. Further research may explore the use of video in other methods of preparation. Summary This study was designed to compare the effectiveness of a tour-based preadmission preparation programme to a video-tape-based programme. No significant differences were found between the two programmes on sel f - report, behavioural, or physiological measures except incidence of vomiting. The study was limited by several factors including small sample size, lack of control group, and lack of control over col lection of physiologi- cal data. Concerns about the r e l i a b i l i t y and va l id i ty of the Hospital Fears Rating Scale and the Posthospital Behaviour Questionnaire were raised. These features created weaknesses in the study and the one tenable conclusion is that the Video-tape and Hospital Tour treatments appear to - 52 - have equal effects on children hospitalized for elective surgery. No conclusions can be drawn as to the strength of the effects because of the lack of control group. Recommendations for Further Research 1. Re l iab i l i ty and va l id i ty studies of the Hospital Fears Rating Scale and the Posthospital Behaviour Questionnaire for extended age ranges. 2. The development and evaluation of programmes which might reach more of the population of interest. - 53 - BIBLIOGRAPHY ABBOTT, N . C . , Hansen, P . , & Lewis, K. 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Nursing Times, 1977, 73 (48), 1887-1888. KAZDIN, A . E . Covert modeling model s imi lar i ty and reduction of avoidance behaviour. Behaviour Therapy, 1974, _5, 325-340 (a). KITA, S. U.B.C. S .P.S .S . : S ta t i s t i ca l Package for the Social Sciences Version 8.00 (Under MTS). Vancouver: Computing Centre, University of Br i t i sh Columbia, 1980. KLORMAN, R. , Hi lpert , P . , Michael, R. , LaGama, C . , & Sveun 0. Effects of coping and mastery modeling on experienced and inexperienced pedontic patients' disruptiveness. Behaviour Therapy, 1980, _11_ (2), 156-168. KORNHABER, R.C. & Schroeder, H.E. Importance of model s imi lar i ty on extinction of avoidance behaviour in children. Journal of Consulting and C l i n i c a l Psychology, 1975, 43_, 601-607. LEHMAN, E . J . The effects of rooming in and anxiety on the behaviour of preschool children during hospitalization and follow-up. Disseration Abstract, 1975, 36 (6-B), 3052. LENDE, E.W. The effect of preparation on children's response to t o n s i l l - ectomy and adenoidectomy surgery. Dissertation, University of Cin- c inat i , 1971. LEVY, E. Children's behaviour under stress and i t s relation to training by parents to respond to stress functions. Child Development, 1959, 30, 307-324. LIPTON, S.D. On the psychology of childhood tonsillectomy. The Psycho- analytic Study of the Child, 1962, XVII, 363-417. LOCKHART, D. Pract ical considerations in the pre-operative psychological preparation of the pediatric patient. Emotional and Psychological Responses to Anesthesia and Surgery, ed. by Guerra, F. and Aldrete, J . A . New York: Grune and Stratton, 1980, 123-131. MAHAFFY, P.R. Effects of hospitalization on children admitted for tons i l - lectomy and adenoidectomy. Nursing Research, 1965, 1_4, 12-19. MASON, Edward, A. Hospital and family cooperating to reduce psychological trauma. Community Mental Health Journal, 1978, _14 (2), 153-159. MCKEE, W.J .E. 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P . , Dunn, T.M. & Taulbee, E .S . Emotional reactions to surgery. Journal of Consulting and C l i n i c a l Psychology, 1973, 40, 33-38. STAINTON, C. Preschoolers' orientation to hospital . Canadian Nurse, 1974, (Sept.), 70 (9), 38-40. STEWARD, D.J . Psychological considerations in the pediatric patient. Emotional and Psychological Responses to Anesthesia and Surgery, ed. by Guerra, F. and Aldrete, J . A . , New York: Grune and Stratton, 1980, 133-143. STUART, H.C. & Stevenson, S.S. Physical growth and development. Text- book of Pediatrics, ed. by Waldo E. Nelson, Philadelphia, P a . : . W.B. Saunders Co. 1954, 141. - 59 " TAYLOR, F . L . Educational preparation for surgery: An examination of physical and behavioural parameters post-operatively, Dissertation Abstract, 1978, 38 (11-A), 6416. THELEN, M.H. , Fry, R .A . , Fehranbach, P.A. & Frautschi, N.M. Therapeutic videotape and film modeling: A review. Psychological Bul le t in , 1979, 86, 701-720. THOMSON, E. Preop v i s i t s - for the nurse - for the patient? AORN Journal 1972, 16_ (4), 75-81. VERNON, D.T.A. Use of modelling to modify children's responses to a natural potentially stressful situation. Journal of Applied Psychology, 1973, 58, 351. VERNON, D.T.A. & Bailey, W.C. The use of motion pictures in the psycho- log ica l preparation of children for induction of anesthesia, Anesthesiology, 1974, 40, 68-72. VERNON, D.T.A. & Bigelow, D.A. Effect of information about a potentially stressful situation on responses to stress impact. Journal of Per- sonality and Social Psychology, 1974, 29, 50-59. VERNON, D.T.A. & Foley, J .M. The Psychological Responses of Children to Hospitalization and Illness - a review of the l i terature . Spring- f i e l d , I l l i n o i s : Charles C. Thomas, Publ . , 1965. VERNON, D . T . A . , Foley, J . M . , & Schulman, J . L . Effect of mother-child separation and birth order on young children's responses to two poten- t i a l l y stressful experiences. Journal of Personality and Social Psychology, 1967, 5_, 162-174. VERNON, D . T . A . , Schulman, J . L . , & Foley, J .M. Changes in children's behaviour after hospital ization. Diseases of Children, 1966, 111, 581. WEINICK, H.M. Psychological study of emotional reaction of children to Tonsillectomies. Doctoral Dissertation, 1958. WEST, A.R. Bringing the hospital to preschoolers. Children Today, 1976, 5 (2), 16-19. WHITE, W., Akers, J . , Green, J . , & Yates, D. Use of imitation in the treatment of dental phobia in early childhood: A preliminary report. Journal of Dentistry for Children, 1974, J26, 106. WOLFER, J .A . & Visintainer, M.A. Pediatric surgical patients' and parents' stress responses and adjustment as a function of psychological prep- aration and stress-point nursing. Nursing Research, 1975, 24_ (4), 244-254. WOLFER, J . A . & Visintainer, M.A. Prehospital psychological preparation for tonsillectomy patients: Effects on children's and parents' adjustment. Pediatrics, 1979, 6k_ (5), 646-655. - 60 - YURGHESON, R..." The effects of peer modelling vs. famil iarization and the influence of specific information on fear behaviours..in children undergoing dental treatment. Dissertation Abstraction, 1977, _38 (2-B), 941. - 61 - APPENDIX A Items from t h e H o s p i t a l F e a r s R a t i n g S c a l e and P o s t h o s p i t a l B e h a v i o r Q u e s t i o n n a i r e S c o r e d Items f r o m t h e H o s p i t a l F e a r s R a t i n g S c a l e Items from t h e F e a r Survey f o r C h i l d r e n 1. s h a r p o b j e c t s 2 . h a v i n g t o go t o t h e h o s p i t a l 3. g e t t i n g a s h o t from t h e n u r s e o r d o c t o r 4. g o i n g t o t h e d e n t i s t 5..::-going t o t h e d o c t o r 6. g e t t i n g a h a i r c u t 7. deep w a t e r o r t h e ocean 8. s i :getting c a r s i c k Items w i t h f a c e v a l i d i t y 1. germs o r g e t t i n g v e r y s i c k 2 . the s i g h t Of b l o o d 3. b e i n g a l o n e w i t h o u t y o u r p a r e n t s 4. h a v i n g an o p e r a t i o n 5. p e o p l e w e a r i n g masks 6. n o t b e i n g a b l e t o b r e a t h 7. g e t t i n g a c u t o r h u r t 8. g o i n g t o bed i n t h e d a r k - 63 - Items from the Posthospital Behavior Questionnaire 1. Does your c h i l d make a fuss about going to bed at night? 2. Does your c h i l d make a fuss about eating? 3. Does your c h i l d spend time j u s t s i t t i n g or l y i n g about and doing nothing? 4. Does your c h i l d need a p a c i f i e r ? 5. Does your c h i l d seem to be a f r a i d of leaving the house with you? 6. Is your c h i l d uninterested i n what goes on around him/her? 7. Does your c h i l d wet the bed at night? 8. Does your c h i l d b i t e his/her f i n g e r n a i l s ? 9. Does your c h i l d get upset when you leave him/her alone f o r a few minutes? 10. Does your c h i l d need a l o t of help doing things? 11. Is i t d i f f i c u l t to get your c h i l d interested i n doing things ( l i k e playing games, with toys, etc.)? 12. Does your c h i l d seem to avoid or be a f r a i d of new things? 13. Does your c h i l d have d i f f i c u l t y making up his/her mind? 14. Does your c h i l d have temper tantrums? 15. Is i t d i f f i c u l t to get your c h i l d to t a l k to you? 16. Does your c h i l d seem to get upset when someone mentions doctors or hospitals? 17. Does your c h i l d follow you everywhere around the house? 18. Does your c h i l d spend time t r y i n g to get or hold your attention? 19. Is your c h i l d a f r a i d of the dark? 20. Does your c h i l d have bad dreams at night or wake up and cry? - 6 4 - 21. Is your c h i l d i r r e g u l a r i n his/her bowel movements? 22. Does your c h i l d have trouble getting to sleep at night? 23. Does your c h i l d seem to be shy or a f r a i d around strangers? 24. Does your c h i l d have a poor appetite? 25. Does your c h i l d tend to disobey you? 26. Does your c h i l d break toys or other objects? 27. Does your c h i l d suck his/her fingers or thumbs? - .65 - APPENDIX B P a r e n t Consent Form - -66.- PARENT CONSENT FORM Dear Parent; We'are attempting to determine which of two preadmission orienta- tion procedures is the most effective way to prepare children for their hospitalization experience. We would very much appreciate the partici- pation of you and your child in this study. This would entail you and your child responding to questionaires at the hospital prior to your child's admission and in your home two weeks after his/her discharge. Some data from your child's hospital chart will also be obtained. All information will be kept confidential. You will have the right to withdraw from this study at any time and withdrawal will not prejudice further medical care or treatment of your child. The hospital has approved this study and is interested in the findings. We would appreciate your consent for participation. Sincerely, Jeanine M. Harper, Graduate Student, U.B.C. O.A. Oldridge, D.Ed. Professor, Educational Psychology, U.B.C. I give my consent for myself and my child to participate in this study, of the Preadmission Orientation Programmes at Surrey Memorial Hospital. Name Date

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