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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 U n i v e r s i t y o f 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  ( E d u c a t i o n a l Psychology Department, S c h o o l Psychology Programme)  We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d  THE  UNIVERSITY OF BRITISH COLUMBIA November 1981  (c^ J e a n i n e Marie Harper, 1981  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the  requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t t h e L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by t h e head o f my department o r by h i s o r her r e p r e s e n t a t i v e s .  It i s  understood t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l n o t be allowed without my  permission.  Educational Psychology  Department o f  The U n i v e r s i t y o f B r i t i s h 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 „  Date  October 30,  '  1981  Columbia  written  - ii -  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 H o s p i t a l , a community general h o s p i t a l i n Surrey, B . C . The children were admitted for e l e c t i v e surgery which required an overnight stay.  The children and their parents participated i n the programmes three  days to two weeks p r i o r to the c h i l d ' s scheduled surgery.  Half of the  children and t h e i r 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 H o s p i t a l , which depicted the h o s p i t a l i z a t i o n 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 d i f f e r on sex, ations,  types of s u r g i c a l procedure, length of stay,  previous h o s p i t a l i z length of  anaesthesia,  or prehospital personality as measured by a modification of the Posth o s p i t a l 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 s i g n i f i c a n t differences were found between the two groups on the s e l f - r e p o r t , behavioural, or p h y s i o l o g i c a l outcome measures, except for incidence of postoperative vomiting.  The video group vomited less than  the tour group. Questions concerning the v a l i d i t y of the Hospital Fears Rating Scale and the modified Posthospital Behavior Questionnaire for this age group are raised i n the discussion.  Complicating factors, such as small sample  - iii -  s i z e , lack of a control group, and lack of control over physiological data c o l l e c t i o n are addressed i n this chapter.  Confounding factors, such as  a preoperative teaching class and the discussion groups, are also addressed. F i n a l l y , the impact of Preadmission Programmes and p r a c t i c a 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  vi  Acknowledgements  '  v i i  Chapter I  Introduction  1  Chapter I I  Review o f the L i t e r a t u r e  5  The Adverse E f f e c t s o f H o s p i t a l i z a t i o n Determinants o f A n x i e t y i n H o s p i t a l i z e d C h i l d r e n Methods o f A l l e v i a t i n g A n x i e t y i n H o s p i t a l i z e d C h i l d r e n Problem Statement and Research Hypotheses Chapter I I I  Methodology  Subjects V a r i a b l e s and I n s t r u m e n t a t i o n Procedures Data A n a l y s i s Chapter IV  Results  D e s c r i p t i o n o f the Sample Hypotheses Summary o f R e s u l t s Chapter V  Discussion  R e s u l t s o f the Study D i f f i c u l t i e s Encountered i n Attempting t o Conduct Research i n a General H o s p i t a l Confounding F a c t o r s Instrumentation P r a c t i c a l Considerations The Impact o f the Programmes Summary Recommendations f o r F u r t h e r Research Bibliography  5 7 11 18 20 20 22 25 29 30 30 33 39 42 42 43 45 46 49 50 51 >52 53  Appendices A - Items from the 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 Behavior Questionnaire B - Parent Consent Form  61 >65  - v L i s t of Tables  Table I  Title  Page  Means and standard deviations of treatment groups for age  30  II  Analysis of variance for age  III  Chi square analysis of the treatment groups for age, sex, and previous h o s p i t a l i z a t i o n Means and standard deviations of treatment groups for length of anaesthesia  IV  31  32 32  V  Analysis of variance of length for  VI  Chi square analysis of treatment groups for s u r g i c a l procedure, length of stay, and complications  33  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  34  Analysis of covariance with repeated measures for .Hospital Fears Rating Scale  35  VIII  anaesthesia  31  IX  Means, standard deviations and r e l i a b i l i t i e s for the Posthospital Behavior Questionnaire  X  Analysis of covariance with repeated measures for the Posthospital Behavior Questionnaire  37  Numbers of missing cases, means, and standard deviations for the p h y s i o l o g i c a l measures  38  Analysis of variance - of treatment groups for physiological measures  41  Chi square analysis of incidents of postoperative vomiting for treatment groups  4-1  Frequency of anticipate/-missing data and the frequency of missing data for the blood pressure variable  44  XI  XII XIII  XIV  36  - vi -  LIST OF FIGURES  Figure I  II  Title Exclusions study  Page  of s u b j e c t s from the  Changes i n H o s p i t a l Fears s c o r e s at t h r e e a d m i n i s t r a t i o n s  21  35  - vii -  ACKNOWLEDGEMENTS  I would l i k e t o express my a p p r e c i a t i o n t o Dr. O.A. ( B u f f ) O l d r i d g e , Dr. J u l i a n n e Conry, and Dr. G e o f f r e y Robinson,  whose  t h o u g h t f u l and c r i t i c a l s u g g e s t i o n s and e n d l e s s encouragement were of  i n v a l u a b l e a s s i s t a n c e to me i n c o n d u c t i n g t h i s r e s e a r c h . I would l i k e t o thank Dr. Robert  the s t a t i s t i c a l a n a l y s i s o f t h i s  Conry f o r h i s a s s i s t a n c e w i t h  study.  I would l i k e t o thank Mrs. Margaret  Woodward and the s t a f f o f  the Surrey Memorial H o s p i t a l f o r t h e i r a s s i s t a n c e and c o - o p e r a t i o n d u r i n g t h e study. I would l i k e t o thank Mrs. Maureen Wood, who h e l p e d to develop the study and r a n t h e p r e a d m i s s i o n  programmes.  I would l i k e to thank Ms. P a t r i c e Palmerino  f o r h e r time, p a t i e n c e ,  and e x p e r t i s e i n c r e a t i n g the v i d e o - t a p e programme. I would l i k e t o thank A l l y c e , B r a d l e y , and t h e i r f a m i l i e s , who appeared  i n the v i d e o - t a p e .  F i n a l l y , I would l i k e t o thank my f a m i l y and f r i e n d s f o r t h e i r p a t i e n c e , encouragement,• and senses o f 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 d i s t u r b i n g e x p e r i e n c e f o r young c h i l d r e n f o r a number o f reasons. encountered  by c h i l d r e n i n t h e i r d a i l y l i v e s ,  environment. any age  S t r e s s p r o d u c i n g s i t u a t i o n s , o f t e n not p r e v i o u s l y  S e p a r a t i o n from p a r e n t s and f r i e n d s may  ( L o c k h a r t , 1980).  i n t e n s i f i e d and d i f f i c u l t  forming concepts  i n the h o s p i t a l provoke a n x i e t y a t  Fears o f the unknown and u n f a m i l i a r may  be e x a c e r b a t e d by i l l n e s s or i n j u r y  Loss o f c o n t r o l over body f u n c t i o n s may  concern f o r body m u t i l a t i o n  (Belmont,  1970;  Ritchie,  are j u s t b e g i n n i n g to f e e l mastery  over t h e i r b o d i e s  The  i n t e r a c t i o n of f a n t a s y w i t h l i t t l e  or m i s i n f o r m a t i o n may  1952).  ment (Nagera,  and i n a p p r o p r i a t e f e a r s  C h i l d r e n may  1978).  r a t h e r than as i t may  interpret  They respond  1979).  be most d i s t r e s s i n g t o c h i l d r e n  who  Waldfogel,  every-  C h i l d r e n between the ages of 3 and 6 are  of s e l f and body p a r t s , and  development of unnecessary  become  t o cope w i t h i n the h o s p i t a l where almost  t h i n g i s u n f a m i l i a r or unknown.  may  are met  (Freud, 1952). l e a d t o the  ( J e s s n e r , Blom & .  i l l n e s s or s u r g e r y as a p u n i s h -  to the s i t u a t i o n as they p e r c e i v e i t ,  be.  The responses of a c h i l d to h i s i l l n e s s are u s u a l l y not determined by i t s a c t u a l s e v e r i t y . More s i g n i f i c a n t are h i s own f a n t a s i e s and i n t e r p r e t a t i o n s o f his illness. (Belmont, 19 70, p.477) For these reasons, i t i s p o s s i b l e t h a t c h i l d r e n undergoing s u r g i c a l procedures may  experience p s y c h o l o g i c a l d i s t r e s s .  even minor Estimates of  the numbers of c h i l d r e n n e g a t i v e l y a f f e c t e d by the e x p e r i e n c e of h o s p i t a l i z a t i o n v a r y from 10% t o 92%  (Melamed r &  P s y c h o l o g i c a l d i s t r e s s as a r e s u l t i n a v a r i e t y of ways.  Siegel,  1975).  of h o s p i t a l i z a t i o n may  be m a n i f e s t  B e h a v i o u r a l d i s t u r b a n c e s , such as p r o l o n g e d  crying,  - 2 -  apathy, and withdrawal have been observed i n hospitalized children ( G e l l e r t , 1958).  Regressive behaviour, such as enuresis,  thumb sucking, sleep d i s -  turbances, and rapid changes i n mood are often observed by parents  after  the c h i l d has returned home and may continue to be observed for up to s i x months (McKee, 1963; Nagera, 1978). repeated hospitalizations  Admissions longer than seven days and  of children under five years of age have been  associated with poor reading and behavioural disturbances l a s t i n g into adolescence (Douglas,  1975).  It has been suggested that preoperative anxiety i s a s i g n i f i c a n t factor i n impeding recovery from surgery (Dumas, 1963; G i l l e r , Andrew  1963).  (1970) found that recovery was speeded by preparatory i n s t r u c t i o n .  Therefore, for both medical and psychological reasons,  the effect of prep-  aratory i n s t r u c t i o n on children entering h o s p i t a l needs investigation. Vernon and Foley (1965) i d e n t i f i e d the three main objectives aratory programmes: emotional expression, the h o s p i t a l s t a f f .  of prep-  (1) to give factual information, (2) to encourage and (3) to establish a trusting relationship with Preparatory programmes for children take many forms.  Some are designed for potential health care recipients and may take place i n kindergartens and schools (Abbott, 1970; West, 1976) (Pomarico, Marsh, & Doubrava, 1979).  or i n the hospitals  Other programmes are designed for  children scheduled for e l e c t i v e surgery and occur a few days or weeks before the children are admitted to the h o s p i t a l (Anthony, 1977; Davis, Smith, 1971).  1977;  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 c h i l d ' s h o s p i t a l stay (Azarnoff, 1974; Schrader, 1979).  In a l l cases,  - 3 -  the  purpose  is  s i m i l a r ; to reduce the stress of h o s p i t a l i z a t i o n by  acquainting the c h i l d with the h o s p i t a l environment and routine, by providing accurate information, and by encouraging the c h i l d to express his thoughts and feelings freely i n the hope of releasing anxiety and c o r r e c t ing misinformation. Hospital preadmission programmes for scheduled e l e c t i v e surgery patients have become more common i n recent years. American paediatric hospitals, patients, patients),  In a recent survey of  42% of those responding prepared a l l  32% prepared only s p e c i f i c types of admissions  (eg.  surgical  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 i n 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  v a r i e s , but always contains the opportunity for both parents and children to ask questions and for the children to manipulate some h o s p i t a l equipment 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 f a m i l i a r i z i n g the c h i l d with the h o s p i t a l and i t s routines at these preadmission programmes are a tour of some of the areas of the h o s p i t a l and/or a film depicting a c h i l d ' s h o s p i t a l i z a t i o n . The tour-based programme i s widely used and i s advocated by the Canadian 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 i n some tours, but because of technical reasons and high usage rate are not always considered suitable. i s essential to obtain.  In a l l cases, the co-operation of the h o s p i t a l staff  (ACCH, B . C . A f f i l i a t e , 1980) but may not always be possible Staff working i n busy areas of the h o s p i t a l may find tour  groups to be a disruption and inconvenience. Film, s l i d e - t a p e ,  or video-tape based programmes may be used on their  own or i n conjunction with an abbreviated tour of the h o s p i t a l •1977; Smith, 1971; Stainton, 1974).-  (Davis,  Films depicting a peer-model  experiencing admission and h o s p i t a l procedures have been found effective i n decreasing children's anxiety, and indirect measures Melamed & Siegel,  as measured by behavioural, p h y s i o l o g i c a l ,  (Ferguson, 1979; Melamed, Myer, Gee, & Soul,  1975,  1976;  1980).  In summary, because of the growing concern over the possible negative effects of h o s p i t a l i z a t i o n on c h i l d r e n , more and more hospitals are establ i s h i n g preparation programmes.  Two- of the more common approaches to pre-  admission programmes are the hospital tour and the f i l m or video-tape of a c h i l d experiencing h o s p i t a l i z a t i o n .  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 h o s p i t a l i z a t i o n can have an adverse  effect  on children, what this effect might be, and how this effect might be a l l e v i a t e d are addressed singly and i n consort i n the l i t e r a t u r e on hospitalized  children.  The Adverse Effects of H o s p i t a l i z a t i o n The adverse effects of h o s p i t a l i z a t i o n have been described in various ways:  (1) the anxiety or stress experienced by the c h i l d during h o s p i t a l -  i z a t i o n , and (2) the negative changes i n behaviour noted after h o s p i t a l i z ation. The concept of anxiety or stress during h o s p i t a l i z a t i o n was f i r s t examined by Bowlby i n the 1940's.  He described (1958) the three phases  -through which a c h i l d may pass during h o s p i t a l i z a t i o n : test,  (1) a phase of pro-  (2) a phase of despair, and (3) a phase of detachment.  these phases i n both psychoanalytic and behavioural terms.  He described A variety of  behaviours and responses have been attributed to the anxiety or stress of  the h o s p i t a l i z a t i o n , including a low l e v e l of manageability  1968), and of co-operation (Wolfer & Vi-sintainer, 1975,  1979).  (Sauer, Elevations  in physiological responses, such as pulse and blood pressure, have also been attributed to the stress of h o s p i t a l i z a t i o n (Skipper & Leonard, 1968). Changes i n behaviour following h o s p i t a l i z a t i o n were f i r s t in studies by Prugh, et a l . behaviour included: crying, enuresis,  (1953) and Jessner, et a l . (1952).  observed Changes i n  sleep disturbances, regressive behaviours, c l i n g i n g ,  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 l e a r n i n g problems were c o r r e l a t e d w i t h earlier hospitalizations  (Douglas,  1975;  Quinton  & R u t t e r , 19 76).  Not a l l r e s e a r c h has supported the h y p o t h e s i s t h a t 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 . t u r e to 1964  Vernon and F o l e y (1965) reviewed  on h o s p i t a l i z e d c h i l d r e n .  concluded t h a t h o s p i t a l i z a t i o n was one  litera-  They noted f o u r s t u d i e s which  an u p s e t t i n g e x p e r i e n c e f o r c h i l d r e n , i . e , ,  t h a t r e s u l t e d i n a n e g a t i v e change i n b e h a v i o u r a f t e r the  r e t u r n e d home.  the  children  They a l s o noted one study w i t h mixed f i n d i n g s  which d i d not f i n d evidence t o support the h y p o t h e s i s t h a t  and  another  hospitaliza-  t i o n r e s u l t e d i n n e g a t i v e b e h a v i o u r a l changes. Davenport and Werry (1970) found no evidence t o support the  hypothe-  s i s t h a t h o s p i t a l i z a t i o n r e s u l t e d i n n e g a t i v e b e h a v i o u r a l changes.  In  t h e i r study, h o s p i t a l i z e d s u b j e c t s ' b e h a v i o u r , as measured by the P o s t h o s p i t a l i z a t i o n Behavior Q u e s t i o n n a i r e (Vernon,  Schulman & F o l e y , 1966) ,  changed no more than the n o n - h o s p i t a l i z e d c o n t r o l c h i l d r e n ' s N i n e t y - f i v e of the 145  behaviour.  c o n t r o l s u b j e c t s were the s i b l i n g s of the h o s p i t a l -  i z e d c h i l d r e n , but the q u e s t i o n o f 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  a d v e r s e l y a f f e c t a c o n t r o l c h i l d was  range  not addressed.  The wide  age  (1 t o 15 y e a r s ) 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 e x p e r i e n c e  care s u r g e r y and i n - p a t i e n t s u r g e r y ) 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  E s t i m a t e s of the numbers of c h i l d r e n a f f e c t e d a d v e r s e l y by a t i o n vary widely assessment. and F o l e y  depending  In one  study.  hospitaliz-  on the date of the study and the method of  of the b e s t of the e a r l y s t u d i e s reviewed by  (1965), Prugh, e t a l . (1953) found t h a t 92  hospitalized  (day-  out of t h e i r  Vernon 100  c o n t r o l s u b j e c t s showed some b e h a v i o u r a l d i s t u r b a n c e two weeks  a f t e r discharge.  Three months l a t e r , 66%  of the c o n t r o l group and 44%  of  -  7 -  the experimental group showed disturbances of behaviour.  The control group  saw t h e i r parents once a week and were confined to t h e i r beds for much of the time.  The experimental group had d a i l y parental v i s i t s ,  gramme, and preparation for each procedure.  a play pro-  Few children now experience  hos-  p i t a l i z a t i o n i n the same way as the children i n the control group of this study. The children i n Douglas' more recently published longitudinal study (1975) experienced h o s p i t a l i z a t i o n i n the 1950's and 10% were allowed no v i s i t o r s at a l l .  Douglas found that the behaviour of 22% of the pre-  schoolers i n his study deteriorated after h o s p i t a l i z a t i o n .  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 l a s t i n g longer than one week were related to l a t e r behavioural disturbance.  The l a t t e r study contained more  recently hospitalized children. The experience of h o s p i t a l i z a t i o n has changed i n the past twenty years. Attempts have been made to decrease the negative impact of h o s p i t a l i z a t i o n through changes i n v i s i t i n g regulations and other p o l i c i e s . also vary from h o s p i t a l to h o s p i t a l today (Post, 1979).  Conditions  It i s ,  therefore,  inappropriate to assume that children i n each h o s p i t a l are l i k e l y to be affected by the experience in the same way. Determinants of Anxiety in Hospitalized Children Why does the h o s p i t a l experience result i n anxious children who l a t e r demonstrate negative behaviour?  Few modern studies have attempted to  answer that question i n a systematic way.  Vernon and Foley (1965) i d e n t i -  fied four p r i n c i p a l determinants of anxiety with "limited support" i n the l i t e r a t u r e up to that time.  These are:  - 8 -  1.  unfamiliarity with the h o s p i t a l  setting,  2.  separation from parents, s i b l i n g s , and friends,  3.  age of the c h i l d , and  4.  prehospital personality of the c h i l d .  Other determinants have also been found to affect to h o s p i t a l i z a t i o n .  reactions  These are:  5.  parental attitudes  6.  loss of c o n t r o l .  1. Unfamiliarity  children's  and personality, and  Brown and Semple (1970) found that i n an experimental  s i t u a t i o n , subjects showed less mature motor and language behaviour i n an unfamiliar setting than i n a f a m i l i a r one and continued to show differences i n behaviour uhree days l a t e r .  Another study, involving h o s p i t a l i z e d  children, has shown that a preadmission tour programme, which f a m i l i a r i z e s the children with the h o s p i t a l environment, p o s i t i v e l y affects the c h i l d ren's behaviour while i n h o s p i t a l the hypothesis  (Sauer, 1968).  This lends support to  that unfamiliarity i s indeed a factor contributing to  behavioural disturbance in h o s p i t a l i z e d and posthospitalized c h i l d r e n . 2.  Separation  Vernon and Foley (1965) concluded that the second f a c t o r ,  separation from parents and family, was not as important as might seem because i t was generally compounded by other factors, such as u n f a m i l i a r i t y , r e s t r i c t e d a c t i v i t y , and others.  However, Jessner et a l .  (1952), i n a  study of 143 h o s p i t a l i z e d c h i l d r e n , 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 stressf u l time for both parents and c h i l d r e n .  In a comparison of children who  experienced no separation from t h e i r mothers (i.e.., the mothers roomed-in)  - 9 -  with those who experienced a routine h o s p i t a l i z a t i o n , Lehman (19 75) found the children whose parents roomed-in to be more aggressive to both t h e i r mothers and nurses but to also have fewer postoperative 3. Age  complications.  The relationship between the age of the h o s p i t a l i z e d c h i l d and  behavioural disturbance appears to be c u r v i l i n e a r (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 v u l n e r a b i l i t y , and then decreases i n f r e quency with older children (Prugh, et a l . , 1953).  Sides (1977) found age  to be the most s i g n i f i c a n t predictor of posthospitalization behavioural disturbance i n an inverse relationship i n 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 h o s p i t a l i z a t i o n (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 h o s p i t a l i z e d tended to be more anxious than t h e i r naive counterparts. Siegel (1975)  Melamed and  noted that state and t r a 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 measures and behavioural upset during h o s p i t a l i z a t i o n .  different  Recent  studies,  such as Melamed and Siegel's (1975), have not attempted to control for prehospital personality as they have for age and previous h o s p i t a l ization. 5; Parental Attitude  A further factor, which may be considered to have  some influence, i s parental attitude and anxiety.  Sides  (1977) concluded  -  10 -  that maternal anxiety was the second best predictor of posthospital behavi o u r a l upset after age. Vernon, Foley and Schulman (1967) found that as the c h i l d ' s perception of .threat i s increased, so i s the p o s i t i v e effect of the mother's presence on the child.  However, parents who f e e l f e a r f u l themselves are less l i k e l y to  v i s i t as long, l i v e i n , prepare the c h i l d , or become informed themselves 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 l e v e l increased, her distress decreased and her adaptation increased.  This has led other researchers (Mahaffy, 1965; Skipper &  Leonard, 1968)  to provide a more p o s i t i v e h o s p i t a l experience for children  by attempting to reduce the anxiety of the mothers through giving information and support.  Coleman (1976) found no s i g n i f i c a n t difference between  children receiving an orientation and play programme only and those whose parents also received an educationall.programme.  His measurement i n s t r u -  ment, however, was the Children's Manifest Anxiety Scale (Castaneda, McCandess,  & Palermo, 1956), which Melamed and Siegel (1975) found  insensitive  to changes other instruments  6. Loss of Control  detected.  Another determinant of anxiety i n h o s p i t a l i z e d  children i s based on psychoanalytic theory.  Anna Freud (1952) f e l t  that  for c h i l d r e n , the experience of being nursed and the loss of control over such a c t i v i t i e s  as eating, bladder evacuation, dressing, etc.  "means an  equal loss i n ego c o n t r o l , a p u l l back toward the e a r l i e r and more passive levels of i n f a n t i l e development."  (p.71-72)  This concurs with the opinions  of G e l l e r t (1958) and Lockhart (1980) and coincides with the d e f i n i t i o n 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 part i c u l a r l y over the amount of anxiety that overwhelms i t , as well as the situation that i s provoking i t . " (p.9). This theory that h o s p i t a l i z a t i o n i s a traumatic s i t u a t i o n because of the loss of ego control i s supported by the observations behaviour of children after h o s p i t a l i z a t i o n (McKee, 1963;  of  regressive  Sipowicz &  Vernon, 1965). Methods of A l l e v i a t i n g Anxiety i n Hospitalized Children The Role of Knowledge i n Reducing Pain and Anxiety  Fantasies and  misconceptions about h o s p i t a l i z a t i o n are considered to be dangerous by Becker (1972), Fassler (1979), and Steward (1980), especially i n children i n the 5 to 6 year age range.  Belmont (1970), C o p p o l i l l o (1980), and  Ritchie (1979) view pre-schoolers as being very concerned with t h e i r concepts of s e l f and body.  Children at this age view their bodies as  their concept of s e l f "and may . be mutilation.  For this reason,  greatly  concerned" about body:-,  fantasies and misconceptions  of  the reasons for h o s p i t a l i z a t i o n , surgery, and medical procedures are considered most dangerous for children at this age by p s y c h i a t r i s t s (Belmont, 1970; Steward, 1980).  In t h e i r review of the l i t e r a t u r e , Vernon  and Foley (1965) noted that children may view h o s p i t a l i z a t i o n as a punishment and decried the lack of studies investigating the relationship between concepts of h o s p i t a l i z a t i o n and behavioural upset. that no preparation and "unhealthy attitudes  Weinick (1958) found  towards h o s p i t a l i z a t i o n " ,  measured by projective tests, resulted i n i n t e n s i f i c a t i o n of distress hospitalization.  as after  No preparation and "healthy attitudes" resulted i n a  s i g n i f i c a n t negative change i n attitude and anxiety l e v e l , while preparat i o n and "unhealthy attitudes" resulted i n a positive change.  No  -  12 -  d e f i n i t i o n of "healthy" and "unhealthy attitudes" was given.  Lende (1971)  compared unprepared and prepared children's behavioural responses to hospitalization.  She found a s i g n i f i c a n t negative c o r r e l a t i o n between  behavioural upset and knowledge about the h o s p i t a l i z a t i o n .  It appears,  then, that having p r i o r knowledge of the procedures which occur during a h o s p i t a l i z a t i o n reduces misconceptions and results i n increased adjustment to the h o s p i t a l i z a t i o n . Research studies looking at methods used to mitigate the negative effects of h o s p i t a l i z a t i o n 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" i s the descriptive t i t l e  given  by Wolfer and V i s i n t a i n e r (1975) to the care given by a single nurse at specified s t r e s s f u l points throughout the c h i l d ' s h o s p i t a l i z a t i o n .  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  c h i l d by this style of nursing with mixed r e s u l t s .  The children appeared  to react p o s i t i v e l y , but the parents did not report any p o s i t i v e  changes.  Mahaffy (1965), Skipper and Leonard (1968), and Wolfer and V i s i n t a i n e r (1975) hypothesized that with the attention of one nurse at  stressful  times, stress would be reduced i n the parents and reflected i n a lower anxiety l e v e l i n the c h i l d r e n .  The emphasis i n this nursing s t y l e i s on  the concerns of the mother as w e l l as those of the c h i l d . Preparation Programmes  Preparation programmes for s u r g i c a l patients  can be separated into two types, those which occur several days before the  c h i l d ' s admission and those which occur upon the c h i l d ' s a r r i v a l or after admission.  Because of the d i f f i c u l t y i n obtaining random subjects for this  research, the l a t t e r time of presentation has received greater research attention.  The question of the best time for preparation was asked by  Vernon and Foley i n 1965 and was s t i l l not answered eleven years l a t e r when Siegel (1976) reviewed the more recent l i t e r a t u r e . Freud (1952) f e 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 i n t e r n a l i z a t i o n 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 p r i o r to admission.  Older  children prepared in advance also demonstrated fewer behaviour problems after discharge.  Ferguson (1979) found s l i g h t l y different r e s u l t s .  A  v i s i t to the home of the c h i l d one week i n advance was more e f f e c t i v e i n reducing the anxiety i n children aged 3 and 4 than i n older c h i l d r e n .  ,. ' . C  Children aged 6 and 7 benefitted more by the preparation immediately p r i o r 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 h o s p i t a l i z a t i o n of two children. children (aged 4 to 7) did not benefit  Crocker (1980) found that younger  as much from preparation following  admission as did older children (7 to 10).  On the whole, preparation i n  advance appears to be more effective than preparation on the day of admission for younger children. As well as when to prepare, researchers have asked who should prepare the c h i l d .  Vernon and Foley, i n t h e i r review of the l i t e r a t u r e (1967, note  -  "...that findings was the logical  14 -  the only study which did not provide some positive with respect to preparation (Jessner, et a l . , 1952) only study which r e l i e d on parents to provide psychopreparation." (p.23)  Parents may have t h e i r own misconceptions  and fears with which to deal,  and i f anxious, may not prepare t h e i r c h i l d (Robinson, 1968).  Wolfer and  V i s i n t a i n e r (1979) sent home a h o s p i t a l k i t and booklet so that parents might prepare the subjects for h o s p i t a l i z a t i o n . aration was b e n e f i c i a l to a l l who used i t .  They note that home prep-  It appears, then, that parents  may have some d i f f i c u l t y i n preparing t h e i r c h i l d , but can do so effect i v e l y with assistance from the h o s p i t a l . a) Modelling Programmes  Modelling has proved to be a successful  tech-  nique i n demonstrating appropriate methods of behaviour and thereby reducing the avoidance or negative behaviour of the subject toward such varied stimu 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 i v e models were more effective than filmed models i n extinguishing avoidance behaviour, filmed modelling continues to be a popular approach to reducing medical and dental s t r e s s , especially (Siegel,  as i t i s assessed by physiological measures  1976; Thelen, Fry, Fehranbach, & Frautschi, 1979).  The more s i m i l a r the model i s to the subject, of treatment appears to be.  the greater the effect  Kazdin (1974), working with adults, and Kornhaber  and Schroeder (1975), working with children, both found that models s i m i l a r i n age and sex to the subject had the greater effect i n the cases of both coping and mastery models.  Miechenbaum (1971) found coping models to have  a s i g n i f i c a n t l y greater effect i n reducing avoidance behaviour i n adults than mastery models.  Thelen et al.,(1979) concluded, i n t h e i r review of the  l i t e r a t u r e on therapeutic video-tape  and f i l m 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 e f f e c t i v e element i n film and video modelling, especially i f the narration expresses the model's s e l f - v e r b a l i z a t i o n s  of thoughts,  feelings,  and coping techniques  during treatment. Multiple models have been shown to be more effective than one i n reducing avoidance behaviour (Bandura & Menlove, 1968). this variable to Thelen et a l . ' s  One might add  list.  Film modelling has been used successfully young children during dental treatment.  to change the behaviour of  White, et a l . (1975) found watching a  model receive treatment to be more e f f e c t i v e than having the children simply watch the dentist manipulate the equipment.  Melamed, Weinstein, Hawes,  and Katin-Borland (1975) found a s i g n i f i c a n t difference i n 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, fears,  and even parental and d e n t i s t ' s anxiety l e v e l s .  race, i n i t i a l  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, H i l p e r t , Michael, LaGama, and Sveun (1980), who compared groups viewing a filmed mastery model, a filmed coping model, and a control f i l m .  Although the group viewing the coping model obtained  lower scores on a Behavior P r o f i l e Rating, there was no s i g n i f i c a n t  differ-  ance found between the three groups. The sample was larger in this study than i n the two previously mentioned (n=60).  Measurement i n this study  consisted of behavioural observations only and did not include any physiol o g i c a l response measures.  This may have affected  the results of the study.  Vernon (1973) and Vernon and Bailey (1974) have used filmed modelling  -  16 -  in preparing children f o r anaesthesia induction. l i m i t e d f o r two p o s s i b l e reasons. up,  The  first  T h e i r success has been  i s t h a t the f i l m was  of a mock-  r a t h e r than a r e a l i n d u c t i o n , and the c h i l d r e n a c t i n g as models d i d not  react naturally.  The  o t h e r weakness may  be the measurement i n s t r u m e n t , a  seven p o i n t s c a l e on which the c h i l d r e n were r a t e d by the a n a e s t h e t i s t s . M u l t i p l e measures may  have been more s u c c e s s f u l i n d e t e c t i n g  S t u d i e s which compared two  differences.  treatment methods, r a t h e r than  comparing  m o d e l l i n g to a c o n t r o l , have found m o d e l l i n g t o be more e f f e c t i v e i n changing b e h a v i o u r of c h i l d r e n d u r i n g d e n t a l treatment than a d e s e n s i t i z a t i o n treatment. tist 1973;  D e s e n s i t i z a t i o n i n v o l v e d the c h i l d r e n watching  handle the instruments and d i s c u s s i n g what they say White, Akers, Green, It  & Yates,  1974;  Yercheshen,  the den-  (Johnson  & Machen,  1977).  i s from the success of f i l m e d m o d e l l i n g t h a t the i n t e r e s t i n the  f i l m and v i d e o - t a p e p r e a d m i s s i o n programme a r i s e s . Melamed and S i e g e l  (1975) found t h a t a f i l m d e p i c t i n g a peer c o p i n g  model shown immediately p r i o r to admission was in  s i g n i f i c a n t l y more e f f e c t i v e  r e d u c i n g a n x i e t y i n the c h i l d r e n than a c o n t r o l f i l m .  Gee,  Melamed, Myer,  and S o u l (1976) c o n s i d e r e d the time of v i e w i n g the f i l m as w e l l as  the added e f f e c t o f p r e o p e r a t i v e t e a c h i n g . ; Ferguson  (1979) c r e a t e d a v i d e o - t a p e u s i n g both  peer-aged models.  male and  female  The e x p e r i m e n t a l v i d e o - t a p e had a s i g n i f i c a n t e f f e c t  on  the c h i l d r e n ' s b e h a v i o u r a f t e r d i s c h a r g e , as w e l l as on t h e p h y s i o l o g i c a l measures of a n x i e t y throughout  the h o s p i t a l i z a t i o n .  A visit  from a nurse  one week i n advance of the admission had a g r e a t e r p o s i t i v e e f f e c t younger c h i l d r e n  (3 t o 4) than i t d i d on o l d e r c h i l d r e n  b) Tour Programmes  on  (aged 6 t o 7).  The t o u r - b a s e d programme has r e c e i v e d l i t t l e r e s e a r c h  -  attention.  17 -  Sauer (1968) compared 50 children who participated i n a weekly  tour programme, to 50 children who did not. the control and experimental groups. or d i f f i c u l t to manage.  No attempt was made to match  Nurses rated the children as easy  The results were that 14% of the experimental  group and 53% of the control group were considered d i f f i c u l t to manage. A l l children were i n v i t e d to attend the programme.  Reasons why the con-  t r o l children did not attend were not discussed and fundamental between the groups may have existed.  This study has many l i m i t a t i o n s ,  including the lack of data comparing the groups and the measuring instrument (nurses'  differences  unsophisticated  rating).  Azarnoff, Bourque, Green and Rakow (1975), i n a well controlled study, compared a tour programme to a booklet preparation and a control (no preparation) .  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 D i f f e r e n t i a l .  The interpretation  of the data i s not c l e a r , but they conclude that "tours are more e f f e c t i v e than booklets for certain children and parents, and i t i s usually better than no intervention." (p.57). Summary Children may be adversely affected by h o s p i t a l i z a t i o n .  The anxiety  and stress experienced during the h o s p i t a l stay may be observed i n t h e i r responses to the h o s p i t a l i z a t i o n and i n behavioural changes following discharge.  Hospitals have attempted to reduce the sequelae of h o s p i t a l i z -  ation by changing regulations and routines and implementing new programmes.  -  18 -  One o f these programmes i s t h e p r e a d m i s s i o n p r e p a r a t i o n programme. The purposes  o f t h i s programme a r e t o p r o v i d e a c c u r a t e i n f o r m a t i o n about  the f o r t h c o m i n g 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 age  the c h i l d  to express h i s concerns  and to encour-  so t h a t they may be a l l e v i a t e d .  There a r e many types of p r e p a r a t i o n programmes.  Two of the most com-  mon types are t h e v i d e o - t a p e programme and the h o s p i t a l t o u r . tape programme i s based  The v i d e o -  on symbolic m o d e l l i n g t h e o r y and has been shown  to be e f f e c t i v e i n r e d u c i n g the a n x i e t y of h o s p i t a l i z e d c h i l d r e n .  The  h o s p i t a l t o u r i s a p o p u l a r type o f programme w i t h l i m i t e d r e s e a r c h t o support i t s e f f e c t i v e n e s s . Problem Statement and Research T h i s study attempted Is  Hypotheses  t o answer the f o l l o w i n g q u e s t i o n :  a tour-based p r e a d m i s s i o n programme f o r c h i l d r e n s c h e d u l e d t o undergo  s u r g e r y e q u a l l y e f f e c t i v e i n r e d u c i n g the a n x i e t y and p s y c h o l o g i c a l d i s t r e s s i n c h i l d r e n as a v i d e o - t a p e - b a s e d  programme d e p i c t i n g 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 t h e  H o s p i t a l Fears R a t i n g S c a l e a d m i n i s t e r e d p r i o r t o admission, i n the evening f o l l o w i n g admission, and two weeks f o l l o w i n g d i s c h a r g e . 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 H o s p i t a l Fears R a t i n g S c a l e . 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  P o s t h o s p i t a l Behaviour Q u e s t i o n n a i r e . 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 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 .  -  5.  19 -  There w i l l be no s i g n i f i c a n t differences i n temperature between  treatment groups on admission. 6.  There w i l l be no s i g n i f i c a n t differences i n pulse rate between  treatment groups on admission. 7.  There w i l l be no s i g n i f i c a n t differences i n s y s t o l i c blood pres-  sure between treatment groups on admission. 8.  There w i l l be no s i g n i f i c a n t differences i n s y s t o l i c blood pres-  sure between treatment groups after surgery. 9.  There w i l l be no s i g n i f i c a n t differences i n r e s p i r a t i o n rate  between treatment groups after surgery. 10.  There w i l l be no s i g n i f i c a n t differences i n pulse rate between  treatment groups after surgery. 11.  There w i l l be no s i g n i f i c a n t differences i n the incidence of  vomitting between treatment groups after surgery. 12.  There w i l l be no s i g n i f i c a n t differences i n the time after surgery  u n t i l f i r s t voiding between treatment groups.  - 20 -  CHAPTER I I I METHODOLOGY  In t h i s chapter t h e s u b j e c t s , i n s t r u m e n t a t i o n , p r o c e d u r e s , and d a t a analysis are described. Subjects The  (see F i g u r e I) s u b j e c t s of t h e study were 30 E n g l i s h s p e a k i n g c h i l d r e n between  the ages of 4 y e a r s , 0 months and 9 y e a r s , 11 months who were admitted f o r e l e c t i v e s u r g e r y t o Surrey Memorial H o s p i t a l , S u r r e y , B.C.  They were  expected t o be h o s p i t a l i z e d f o r 3 days, i n c l u d i n g the days of admission and d i s c h a r g e .  They were c o n s i d e r e d by t h e a d m i t t i n g p h y s i c i a n t o be  i n good mental and p h y s i c a l h e a l t h a t the time o f t h e i r  admission.  Surrey Memorial H o s p i t a l i s a community g e n e r a l h o s p i t a l w i t h a 35 bed p a e d i a t r i c ward.  D u r i n g t h e sampling p e r i o d o f March 15, 1981, t o  September 16, 1981, 125 p a r e n t s were i n v i t e d t o b r i n g t h e i r c h i l d r e n t o the p r e a d m i s s i o n p r e p a r a t i o n programme.  Of those i n v i t e d , 56, o r 45%  brought t h e i r c h i l d t o one of t h e two treatment Based on t h e c r i t e r i a l i s t e d  programmes.  above, 52 p a r e n t s were asked  t o par-  t i c i p a t e i n t h e study; 42 o f these, or 81% of the p a r e n t s agreed.  Twelve  s u b j e c t s were l o s t t o t h e study a f t e r p e r m i s s i o n was given, f o r t h e f o l l o w ing  reasons: 2 - s u r g e r y c a n c e l l e d due t o c h i l d ' s 3 - s u r g e r y c a n c e l l e d due t o Doctor's  illness cancellation  3 - s u b j e c t admitted w i t h o u t n o t i c e t o r e s e a r c h e r 1 - s u r g e r y c a n c e l l e d due t o c h i l d e a t i n g o r d r i n k i n g a f t e r ;on t h e day p r e c e e d i n g s u r g e r y 3 - p a r e n t s withdrew p e r m i s s i o n p r i o r t o data  collection.  midnight  - 21 -  FIGURE I Sample Selection Flow Chart  125 sent information booklets on programme  1st Exclusion  69  56  did not come to programme  came to programme  26  30  had Hospital Tour  saw Video Tape  2nd Exclusion - By Sample C r i t e r i o n  23  29  asked to p a r t i c i p a t e  asked to p a r t i c i p a t e  3rd Exclusion - Voluntary Exclusion  20  22 asked to p a r t i c i p a t e  agreed to p a r t i c i p a t e  .  Attrition -  15 Video Sample  _  (see page 20)  - - j  I  15 Tour Sample  - 22 -  Variables and Instrumentation Control Measures  Many factors have been considered to  children's reactions to h o s p i t a l i z a t i o n .  affect  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 c h i l d : 1.  age i n months,  2.  age group (children 60 months and younger were c l a s s i f i e d  as  young, children over 60 months were c l a s s i f i e d as o l d e r ) , 3.  sex,  4.  previous h o s p i t a l i z a t i o n ,  5.  prehospitalization personality (as measured by the Posthospital  Behavior Questionnaire, Form A ) , 6.  s u r g i c a l procedures, ~  7.  length of  8.  length of stay i n h o s p i t a l , and  9.  complications during surgery.  anaesthesia,  Prehospital personality was assessed using a modification of the Posthospital Behavior Questionnaire. d e t a i l below.  This scale i s described i n greater  A l l other data was obtained from the subjects'  medical  charts. Outcome Measures  In order to measure the effects of the  a multidimensional approach was used.  treatments,  The children's responses to the  h o s p i t a l i z a t i o n were indicated through s e l f - r e p o r t , behavioural, and physiol o g i c a l measures. a) Self-report Measure to be a s e l f  The Hospital Fears Rating Scale i s  report measure of s i t u a t i o n a l anxiety.  considered  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 v a l i d i t y for assessing hospital and nine non-related f i l l e r items (see Appendix A ) .  fears  Each c h i l d rated  his degree of fear for each item on a fear thermometer that ranged from one (not a f r a i d at a l l ) to five (very a f r a i d ) .  The sum of the ratings on  the sixteen medical fear items became the c h i l d ' s score for this measure. No r e l i a b i l i t y studies have been published on this measure. i t has been used i n previous studies by Melamed and Siegel et a l . (1976), and Penticuff  (1976).  However,  (1975), Melamed  Ferguson (1979) found a positive  c o r r e l a t i o n between scores on t h i s scale and on physiological measures. b) Behavioural Measure  The Posthospital Behavior Questionnaire was  developed from s i x studies by Vernon, Schulman and Foley (1966) to measure changes i n children's behaviour after h o s p i t a l i z a t i o n .  The questionnaire  consists of 27 behavioural items found i n two of more of these e a r l i e r studies to occur i n children following h o s p i t a l i z a t i o n (See Appendix A). Examples of items are: 1. 15.  Does your c h i l d make a fuss about going to bed at night? Is i t d i f f i c u l t to get your c h i l d to talk to you?  The questionnaire was modified by the investigator so that two forms existed.  Form A asked the mother to rate her c h i l d ' s behaviour for each  item for the s i x months preceeding h o s p i t a l i z a t i o n , and Form B asked the mother to rate her c h i l d ' s behaviour during the two weeks following hospitalization.  The questionnaire was further modified by the  tor so that the response alternatives were more s p e c i f i c ; (1) much less than before, (4) more than before,  (2) less than before,  i.e.,  investigainstead of  (3) same as before,  and (5) much more than before,  the alternatives now  - 24 -  read:  (1) not at a l l ,  (2) once i n two weeks, (3) once a week, (4) two or  three times a week, and (5) every day. b i l i t y of the instrument.  This should have increased the r e l i a -  It served as a measure with which to compare the pre-  h o s p i t a l 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 C a s s e l l (1965) i s cited by Vernon, Schulman, and Foley (1966) regarding the r e l i a b i l i t y of the questionnaire.  The c o r r e l a t i o n between  t o t a l scores 3 and 30 days after discharge i n 37 children undergoing cardiac catheterization was _r = .65.  Support for the v a l i d i t y of the instrument  comes from a study by Vernon, Schulman, and Foley (1966) i n which the scores on the questionnaire were compared to those from a p s y c h i a t r i c interview with the mothers of 20 children who had been hospitalized for tonsillectomies  (_r = .47).  Further support of the construct v a l i d i t y of  the questionnaire i s evidenced i n studies which indicate i t s a b i l i t y to predict changes (Ferguson, 1979; Sides, Visintainer,  1975,  Vernon et a l .  1979). (1966) factor analyzed the questionnaire and discovered  six orthogonal factors: anxiety,  (III)  1977; Vernon, 1973; Wolfer &  (I) general anxiety and regression,  anxiety about sleep,  (II)  separation  (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 i n temperature, s y s t o l i c blood pressure and pulse rate are considered by several researchers to be v a l i d indicators of stress and anxiety i n 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 i n these measures may be interpreted as indications of apprehension, 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 c o r r e l a t i o n between preoperative preparation and postoperative vomiting,  but Skipper and Leonard (1966), Mahaffy (1965), and Wolfer and  V i s i n t a i n e r (1975) have a l l found s i g n i f i c a n t decreases i n postoperative vomiting  to be associated with preparation for h o s p i t a l i z a t i o n .  (1978) considered differences The patient's  Taylor  i n this variable to be due to age.  a b 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 i n many studies of children's reactions to h o s p i t a l i z a t i o n  (Mahaffy, 1956; Skipper &  Leonard, 1968; Wolfer & V i s i n t a i n e r , 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 h o s p i t a l s t a f f .  The physiological  measures taken in this study did not increase the stress f e l t by the subjects  more than is experienced i n routine h o s p i t a l i z a t i o n .  Procedures When a c h i l d was booked for e l e c t i v e surgery at Surrey Memorial H o s p i t a l , his parents were sent preadmission forms and a booklet describing the preadmission preparation programme.  Approximately two weeks before  the c h i l d ' s scheduled surgery, and i f the parents had not already made an appointment for a programme, parents were telephoned and i n v i t e d to bring their children by the Paediatric Nurse C l i n i c i a n who operated the programme.  - 26 -  a) Treatments  Two treatment programmes were used i n t h i s study; a t o u r  which had been i n o p e r a t i o n a t S u r r e y Memorial H o s p i t a l f o r two y e a r s , and a v i d e o - t a p e which was produced In  t h e t o u r treatment,  at Surrey Memorial H o s p i t a l .  the c h i l d r e n and t h e i r p a r e n t s were met by t h e  P a e d i a t r i c Nurse C l i n i c i a n and a V o l u n t e e r in.;the Admission Lobby.  area of the  The c h i l d r e n were each g i v e n a w r i s t b a n d , s i m i l a r t o t h a t worn by  patients.  Then they were taken t o t h e Lab where they had a chance t o f e e l  the t o u r n i q u e t s and a l c o h o l and each c h i l d was g i v e n a "happy f a c e " bandaid.  Next, t h e c h i l d r e n and t h e i r p a r e n t s t o u r e d t h e P a e d i a t r i c Ward,  visiting Nurses' rails,  t h e Playroom, Lounge, Craftroom,  Snack K i t c h e n , Bathroom, and  S t a t i o n , as w e l l as a room where they were shown how a bed, and c a l l l i g h t  operated.  side  From t h e r e , t h e c h i l d r e n were taken t o  the OR T r a n s f e r Room where they saw t h e s t r e t c h e r s used f o r t a k i n g them to  t h e OR, t h e OR beds, and sometimes a nurse i n OR c l o t h e s and mask.  Then t h e c h i l d r e n saw t h e K i t c h e n b e f o r e going t o a Meeting had  Room where they  a chance t o d i s c u s s what they saw and p l a y w i t h some o f t h e common  h o s p i t a l equipment, such as s t e t h e s c o p e s , b l o o d p r e s s u r e c u f f s , and s y r i n g e s . Throughout the t o u r , i n f o r m a t i o n on t h e H o s p i t a l was g i v e n t o t h e parents.  While  t h e c h i l d r e n p l a y e d and had a snack,  t h e Head Nurse  from  P a e d i a t r i c s o r t h e P a e d i a t r i c Nurse C l i n i c i a n met w i t h t h e p a r e n t s t o g i v e out b r o c h u r e s , d i s c u s s h o s p i t a l i z a t i o n and p r e p a r a t i o n of c h i l d r e n , and answer any q u e s t i o n s . In in  t h e v i d e o - t a p e treatment,  t h e lobby and taken d i r e c t l y  Nurse C l i n i c i a n . old  t h e c h i l d r e n and t h e i r p a r e n t s were met  t o the Meeting  Room by the P a e d i a t r i c  There, they saw a v i d e o tape which f o l l o w e d a s i x - y e a r -  g i r l and a f i v e - y e a r - o l d boy throughout  their hospitalization for  - 27 -  tonsillectomy  and adenoidectomy.  The children were seen coming into the  h o s p i t a l , being admitted and given a wristband, having their blood t e s t s , 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  t h e i r suppers and t o l d where the suppers came from. t i o n , being moved on the OR stretchers, also b r i e f l y shown, as well as waking room and on the ward and going home.  Preoperation medica-  and anaesthesia induction were from anaesthesia i n the recovery  Throughout the video-tape,  the  children narrated the events and discussed their reactions to h o s p i t a l 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 take a tour group.  to  The tape showed actual procedures, not mock-ups.  This twenty-five minute video-tape was shown to the chidren and t h e i r parents i n the meeting room.  After viewing the tape, the children  had an opportunity to discuss the tape and play with the h o s p i t a l equipment, while the parents met with the Head Nurse or Paediatric Nurse Clinician. In each treatment programme, equal opportunities for discussion and play were provided. the video-tape  The difference  i n the programmes was i n substituting  for the tour.  b) Treatment Selection nated every two weeks.  (see Figure 1)  The tour and video programmes a l t e r -  Thus a c h i l d ' s p a r t i c i p a t i o n i n a p a r t i c u l a r programme  - 28 was determined s o l e l y by his date of admission.  At the conclusion of the  preadmission programme, the Paediatric Nurse C l i n i c i a n 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 p a r t i c i p a t i n g i n the  study were met by the investigator at the time of the c h i l d ' 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 the Hospital Fears Rating Scale to the c h i l d .  administered  The children were than  admitted to the Hospital i n 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 c h i l d ' s discharge from the H o s p i t a l , the investigator v i s i t e d the parents and children i n t h e i r homes.  The  parents completed the Posthospital Behavior Questionnaire, Form B, while the investigator again administered the Hospital Fears Rating Scale  to  the c h i l d . The following data were obtained from the subjects' h o s p i t a l charts: 1.  date of b i r t h ,  2.  previous h o s p i t a l i z a t i o n ,  3.  s u r g i c a l procedure,  4.  length of stay,  5.  length of anaesthesia,  6.  complications,  7.  temperature, pulse, and s y s t o l i c blood pressure years of age and older) on admission,  (in children 6  - 29 -  8.  pulse, r e s p i r a t i o n , and s y s t o l i c blood pressure (in children 6 years of age and older) one hour after surgery,  9. 10.  time after surgery u n t i l f i r s t voiding, and incidence o f postoperative vomiting.  Data Analysis Descriptive s t a t i s t i c s for the t o t a l sample and the two treatment groups on a l l variables were generated using the S t a t i s t i c a 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 v a r i a b l e s .  A corrected chi square was  used to determine significance on the dichotomous v a r i a b l e s . 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 c o - e f f i c i e n t 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. the scores on these scales.  Age was used as a covariate to further examine The Biomedical Computer Programmes, P Series,  1977 (BMDP-77) (Dixon & Brown, 19 77) was used for this purpose. The confidence l e v e l was established at p = .05.  - 30 -  CHAPTER IV RESULTS  The sample i s 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 i n d i v i d u a l difference variables: 1.  age in months,  2.  age group (children 60 months and younger were c l a s s i f i e d  as  young, children over 60 months were c l a s s i f i e d as o l d e r ) , 3.  sex,  4.  previous h o s p i t a l i z a t i o n , and  5.  scores on the Posthospital Behavior Questionnaire, Form A (modi-  fied to describe behaviour p r i o r to h o s p i t a l i z a t i o n ) . Table I shows the means and standard deviations of each treatment group for age i n months. Table II shows the results of the analysis of variance of this v a r i a b l e . age (_F(1,28)  =  The groups were not found to d i f f e r s i g n i f i c a n t l y i n  .23, j> = .63)  (_F(1,28) = 1.01, _p_ = .32).  or i n behaviour p r i o r to h o s p i t a l i z a t i o n See Hypothesis 4 for description of  of the Posthospital Behavior Questionnaire, Form A. TABLE I Means and Standard Deviations of Treatment Groups for Age.  Video Tour  Mean  S.D.  71.67 69.00  11.89 17.84  analysis  - 31 -  TABLE II Analysis of variance for age. Source of Variance  Sum of Squares 53.33  1  53.33  .6433.33  28  229.76  Between groups Within groups  Mean Square  df  F  Sig.  .23  .63  The groups were compared on age grouping as well as age i n months because during the administration of the Hospital Fears Rating Scale,  it  was observed that younger children responded i n a different way to the task than older children (see Chapter V) and because i t was observed that there was a discrepancy i n the variance of the ages between the two groups. Table III shows the results of the chi square analysis made on the i n d i v i d u a l difference variables.  No difference was found between the  2 treatment groups on sex (x (1) = .57, _p_ = .45) 2 (X (1) = .0, _p_ = 1.00).  or previous h o s p i t a l i z a t i o n  There was found, however, to be more children 5 2  years of age and younger i n Treatment 2 than i n Treatment 1 (x (1) =3.75, p = .05). TABLE III Chi square analyses of the treatment groups for age, sex, hospitalization Variable  and previous 2  Video (n=15)  Tour (n=15)  X  2 13  8 7  3.,75  .05  11 4  8 7  .57  .45  6 9  5 10  .0  Age < 60 months > 60 months Sex Male Female Previous H o s p i t a l i z a t i o n Yes No NOTE.  The reported  x  i  s  corrected with  df = 1 .  Sig.  1.00  -  32 -  Other v a r i a b l e s , considered to affect children's reactions to h o s p i t a l i z a t i o n , were also described and differences between the two groups were tested for significance.  These variables were:  1.  the s u r g i c a l procedure undergone,  2.  length of anaesthesia,  3.  length of stay i n h o s p i t a l , and  4.  frequency of complications following surgery.  Table IV shows the means and standard deviations for the length of anaesthesia.  Table V shows the results of the analysis of variance of this  variable. anaesthesia  The groups were not found to d i f f e r s i g n i f i c a n t l y on length of (F(l,28) = .28, £ =  .60).  TABLE IV Means and standard deviations of treatment groups for length of Group  Mean  SD  Video (n=15)  46.13  15.40  Tour (n=15)  43.67  9.44  anaesthesia  TABLE V Analysis of variance for length of Source of Variance Between groups Within groups  anaesthesia  Sum of Squares  df  Mean Square  F .28  45 .63  1  45.63  4569 .07  28  163.18  The other variables were analysed using the c h i square.  Sig. .60  No s i g n i f i -  cant differences were found between the two groups on type', of s u r g i c a l  -33-  procedure  ( x ( l ) = -29, p_ = .59), l e n g t h of s t a y i n h o s p i t a l Z  (x^(l) ='1.48,  2 £ = .22), or frequency  of c o m p l i c a t i o n s (x (1) = .0, _p_ = 1.0) (see Table V I ) .  S u r g i c a l procedures were grouped i n t o two c a t e g o r i e s a c c o r d i n g t o the s i m i l a r i t i e s i n degree of p h y s i c a l trauma a s s o c i a t e d w i t h the procedure.  TABLE VI Chi square a n a l y s i s of treatment s t a y , and c o m p l i c a t i o n s  groups f o r s u r g i c a l procedure,  Video  Variable S u r g i c a l Procedure T o n s i l l e c t o m y and/or Adenoidectomy and Myringotomy and Tubes  (n=15)  Tour (n=15)  12 3  1.48  .22  1 14  .0  iJ.  3  Length of Stay 3 days 4 days  15 0  Complications Yes No  1 14  The r e p o r t e d  x  i s corrected with  Sig.  .59  12  NOTE.  2  .29  14  H e r n i a and h y d r o c e l e , o r Orchidopexy  X  l e n g t h of  1.00  df = 1 .  Hypotheses The H o s p i t a l Fears R a t i n g S c a l e was used as the outcome measure of the c h i l d r e n ' s r e p o r t of t h e i r a n x i e t y l e v e l a t t h r e e d i f f e r e n t An i n t e r n a l c o n s i s t e n c y c o e f f i c i e n t was c a l c u l a t e d f o r each t r a t i o n o f t h i s measure. admission  The Hoyt e s t i m a t e of r e l i a b i l i t y  a d m i n i s t r a t i o n was .16',  adminis-  f o r the pre-  f o r the p o s t a d m i s s i o n a d m i n i s t r a t i o n  was .84, and f o r the p o s t d i s c h a r g e a d m i n i s t r a t i o n was .82. of  times.  The r e s u l t s  t h i s a n a l y s i s and t h e means and s t a n d a r d d e v i a t i o n s a r e r e p o r t e d i n  Table VII.  TABLE VII Means, s t a n d a r d d e v i a t i o n s and r e l i a b i l i t y c o e f f i c i e n t s f o r t h r e e t r a t i o n s of the H o s p i t a l Fears R a t i n g S c a l e .  On  SD  Mean  Administration Admission Video Tour  R  adminis-  SEM  a  37.37 34.47 40.27  10.95 12.77 8.19  .76  5.07  Evening a f t e r Video Tour  Admission  33.53 30.87 36.20  12.41 11.90 12.73  .84  4.77  2 weeks a f t e r Video Tour  Discharge  37. 10 34.20 40.00  12.54 15.31 8.56  .82  5.21  3  Hoyt E s t i m a t e of  Reliability  Because the treatment  groups were found t o be d i f f e r e n t  i n the  age  grouping of the c h i l d r e n , an a n a l y s i s of c o v a r i a n c e w i t h r e p e a t e d measures was  performed  to c o n t r o l the p o s s i b l e e f f e c t s of age  H o s p i t a l Fears R a t i n g S c a l e . on t h i s measure (F_ = 7.41, f o r treatment was  Age was  j> = .01).  found between the two  found  on the s c o r e s of the  t o have a s i g n i f i c a n t  effect  However, no s i g n i f i c a n t main e f f e c t groups.  (F = 1.93,  £ = .18),  and  the d i f f e r e n c e s between the groups on t h i s measure remained c o n s t a n t throughout  the a d m i n i s t r a t i o n s (F = 0.01,  p_ = .99).  The  between the a d m i n i s t r a t i o n s f o r both groups combined was (See T a b l e  V I I I and F i g u r e II.)  difference F_ = 2.92,  Because these a n a l y s e s showed no  cant d i f f e r e n c e s , no f u r t h e r a n a l y s i s was  conducted.  (p_ = .06) signifi-  - 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 i n Hospital Fears scores at three administrations  Preadmission  Hypothesis 1 stated:  Postadmission  Postdischarge  There w i l l be no s i g n i f i c a n t main effect for  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. Because no s i g n i f i c a n t 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  ween the treatment and r a t i n g time  be no s i g n i f i c a n t i n t e r a c t i o n b e t -  on the H o s p i t a l Fears R a t i n g  Scale.  Because t h e d i f f e r e n c e s between treatment groups on the H o s p i t a l Rating  Scale  Fears  remained c o n s t a n t over time (F = 0.01, p_ = .9 9 ) , H y p o t h e s i s  2 was not r e j e c t e d . The  P o s t h o s p i t a l Behavior Questionnaire,  Forms A and B,  was used t o  measure change i n the c h i l d r e n ' s b e h a v i o u r a f t e r h o s p i t a l i z a t i o n . i n t e r n a l consistency of t h i s scale. for  The Hoyt e s t i m a t e o f r e l i a b i l i t y  form B was .79.  reliabilities  c o e f f i c i e n t was c a l c u l a t e d f o r each  An  administration  f o r form A was  .68, and  T a b l e IX shows the means, s t a n d a r d d e v i a t i o n s and  f o r the two forms.  TABLE IX Means, s t a n d a r d d e v i a t i o n s , Questionnaire  and r e l i a b i l i t i e s  Form  Mean  f o r the P o s t h o s p i t a l  SEM  SD  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  Behavior  R = Hoyt E s t i m a t e of R e l i a b i l i t y  An a n a l y s i s of c o v a r i a n c e w i t h repeated measures r e v e a l e d  no  signifi-  cant d i f f e r e n c e s between e i t h e r group on t h e i r p r e h o s p i t a l and p o s t h o s p i t a l behaviour  ( F ( l , 1, 27) = 1.74, p_ = .20), although age d i d 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 summarized i n Table X.  is  Because no s i g n i f i c a n t differences were found  between groups, no further analysis was done.  TABLE X Analysis of Covariance with repeated measures for the Posthospital Behaviour Questionnaire adjusted for age. Source of Variance  Sum of Squares  df  Mean Square  Between Persons Treatment Individual (within treatment)  191.67  1  191.67  2981.40  27  110.42  Within Persons Pre/Post Treatment x Time Time x Individual  6.67 21.60 1034.73  1 1 28  6.67 21.60  . 18 .58  Covariate  1188.80  1  1188.80  10.77  Hypothesis 3 stated :  Sig.  „ I 1.74  0.20  .67 .45 0.003  There w i l l be no s i g n i f i c a n t 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 s i g n i f i c a n t  interaction  between the treatment groups and.time on the Posthospital Behavior Questionnaire.  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 s i g n i f i c a n t  i n temperature between treatment-groups on admission.  differences No s i g n i f i c a n t  difference was found between the groups i n temperature at admission,  - 38 -  F_(l, 28) = .15, £ = .70 (see Tables XI and X I I ) . Hypothesis 5 was not rejected. Hypothesis 6 stated:  There w i l l be no s i g n i f i c a n t differences  pulse rate between treatment groups  on admission.  in  No s i g n i f i c a n t  dif-  ference was found between the groups on pulse rate at admission, F(l,  26) = .002, p_ = .97 (see Tables XI and X I I ) .  Hypothesis 6 was not  rejected. Hypothesis 7 stated:  There w i l l be no s i g n i f i c a n t  differences  i n s y s t o l i c blood pressure between treatment groups on admission.  No  s i g n i f i c a n t 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 s i g n i f i c a n t  differences  i n s y s t o l i c blood pressure between treatment groups after surgery.  No  s i g n i f i c a n t 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 s i g n i f i c a n t differences i n  r e s p i r a t i o n rate between treatment groups after surgery.. No s i g n i f i c a n t difference was found between the groups on r e s p i r a t i o n 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 s i g n i f i c a n t  i n pulse rate between treatment groups after surgery.  differences  No s i g n i f i c a n t  difference was found between the groups on pulse rate one hour after surgery, F ( l , 28) = .45, p_ = .41 (see Tables XI and X I I ) .  Hypothesis 10  - 39 -  was not r e j e c t e d . Hypothesis  11 s t a t e d :  There w i l l be no s i g n i f i c a n t  d i f f e r e n c e s i n -the  i n c i d e n c e of p o s t o p e r a t i v e v o m i t i n g between treatment groups  a f t e r surgery.  C h i l d r e n i n Treatment .1 d i d 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 t h e i n c i d e n c e of v o m i t i n g between the'two groups, _p_ = .05 (see T a b l e X I I I ) . Hypothesis  Hypothesis  12 s t a t e d :  significant  Hypothesis  differences i n  v o i d i n g between treatment groups.  d i f f e r e n c e was found between groups  thesia u n t i l f i r s t XII).  11 was r e j e c t e d .  There w i l l be no s i g n i f i c a n t  the time a f t e r s u r g e r y u n t i l f i r s t  (i.) =3.84,  on minutes  after  No  anaes-  v o i d i n g , F ( l , 27) = 1.32, p_ = .26 (see T a b l e s XI and 12 was not r e j e c t e d .  Summary o f R e s u l t s The treatment groups were not found t o d i f f e r on any o f t h e c o n t r o l v a r i a b l e s except age group.  Although age was found t o have a s i g n i f i c a n t  e f f e c t on the P o s t h o s p i t a l Behavior Q u e s t i o n n a i r e and H o s p i t a l Fears R a t i n g S c a l e , when age was c o n t r o l l e d f o r no s i g n i f i c a n t found between the two treatment groups  on these v a r i a b l e s .  l o g i c a l v a r i a b l e s , only incidence of vomiting c a n t l y between t h e treatment  groups.  d i f f e r e n c e s were Of t h e p h y s i o -  was found t o d i f f e r  signifi-  -  40 -  TABLE XI Numbers o f m i s s i n g cases, means, and s t a n d a r d d e v i a t i o n s f o r t h e p h y s i o l o g i c a l measures  Variable  Number of Missing Cases  Meaii  SD  Pulse at Admission Video (n=15) Tour (n=15)  1 1  95.86 96.00  11.11 6.23  Temperature at Admission Video (n=15) Tour (n=15)  0 0  36.85 36.79  .50 .32  S y s t o l i c Blood Pressure at Admission Video "(n=15) Tour (n=15)  10 9  100.00 99.33  11.75 11.08  Systolic Blood Pressure after Surgery Video (n=15) Tour (n=15)  8 10  111.43 117.60  11.82 13.45  Respiration Rate after Surgery Video (n=15) Tour (n=15)  0 0  19.33 20.13  1.95 2.45  Pulse After Surgery Video (n=15) Tour (n=15)  0 0  106.00 109.53  13.33 15.46  Time to F i r s t Voiding i n Minutes Video (n=15) Tour (n=15)  1 0  572.00 475.13  284.00 155.32  - 41 -  TABLE X I I A n a l y s i s o f v a r i a n c e f o r treatment groups on p h y s i o l o g i c a l measures Source  Sum o f Squares  df  Mean Square  J_  Sig.  Pulse at admission Between groups W i t h i n groups  .14 2107.71  1 26  .002  .97  .03 4.94  1 28  .15  .70  S y s t o l i c Blood P r e s s u r e at admission Between groups W i t h i n groups  1.21 1165.33.  1 9  1.21 129.48  .009  .93  S y s t o l i c Blood P r e s s u r e a f t e r surgery Between groups W i t h i n groups  111.09 1560.9 1  1 10  111.09.;' 156.09  .71  .42.  4.80 137.07  1 28  4.80 4.90  ,98  33  93.63 5338.73  1 28  93.63 208.35  .45  .41  67946.96 1386261.73  1 27  67946.96 51343.03  1.32  ,26  Temperature a t a d m i s s i o n Between groups W i t h i n groups  R e s p i r a t i o n Rate a f t e r Surgery Between groups W i t h i n groups P u l s e a f t e r Surgery Between groups W i t h i n groups Minutes a f t e r s u r g e r y to f i r s t v o i d i n g Between groups W i t h i n groups  • .14 81.07  .03 . 18~ L  TABLE X I I I Chi  square a n a l y s i s o f i n c i d e n c e f o r p o s t o p e r a t i v e v o m i t i n g Category Yes No NOTE.  Video 0 15  (n=15)  Tour 5 10  (n=15)  X  2  Sig.  3.84  Reported c h i square i s c o r r e c t e d w i t h df = 1.  .05  - 42 -  CHAPTER V DISCUSSION  In t h i s chapter, the results of the study are discussed.  Difficulties  encountered i n conducting a research project i n a community general h o s p i t a l are enumerated. are discussed,  Factors which may have confounded the results of the study as are the concerns which arose during the data c o l l e c t i o n  period i n regard to the instrumentation.  In conclusion, the findings i n  the study are re-evaluated and recommendations for further research are made. Results of the Study The two treatment groups did not d i f f e r s i g n i f i c a n t l y on the i n d i v i d u a l c h a r a c t e r i s t i c variables age, sex, previous h o s p i t a l i z a t i o n , or prehospital behaviour but were found to d i f f e r on age group, with more younger c h i l d ren i n the Tour treatment.  The treatment groups were not found to d i f f e r  on the h o s p i t a l experience variables; s u r g i c a l procedure, length of anaesthesia,  length of stay, and complications.  No s i g n i f i c a n t differences were found on any outcome measures except for incidence of vomiting. group subjects.  Tour group subjects vomited  more than video  This variable was not analysed by type of surgery, although  the video group contained 2 more subjects who had tonsillectomies, cedure more l i k e l y to be associated with vomiting  a pro-  than hernia r e p a i r s .  When age was controlled as a covariate, no s i g n i f i c a n t  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 s i g n i f i c a n t difference between the video-tape and h o s p i t a l  - 43 -  tour treatment programmes. No differences were found between the ratings of behaviour p r i o r to h o s p i t a l i z a t i o n and two weeks after discharge.  The conclusion that both  treatments were equally effective i n eliminating posthospital behaviour sequelae i s discussed under Instrumentation. D i f f i c u l t i e s Encountered i n Attempting to Conduct Research i n a General Hospital 1.  Data c o l l e c t i o n took twice as long as was o r i g i n a l l y anticipated.  By looking at the numbers of children attending the programme i n the previous years, the data c o l l e c t i o n period was estimated at three months. It was also anticipated that a more r e s t r i c t e d age range (4-7 only two surgical procedures  (tonsillectomy  years) and  and adenoidectomy)  could be  selected, thereby c o n t r o l l i n g for age and s u r g i c a l procedure factors. However, i t soon became apparent that to l i m i t the sample i n these ways would result i n a data c o l l e c t i o n period too long to be p r a c t i c a l l y possible.  Therefore, older children and other s u r g i c a l procedures were  allowed i n the sample.  This meant that more control measures had to be  incorporated into the study, to consider the c h a r a c t e r i s t i c s of the groups on  these variables.  Although projections can be made from previous  years, trends i n 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 v a l i d indicators  - 44 "  t o the h o s p i t a l s t a f f but a r e not u s e f u l t o a r e s e a r c h e r .  I t was  antici-  pated t h a t b l o o d p r e s s u r e would not be taken on s u b j e c t s under 6 y e a r s of age.  T a b l e XIV l i s t s  the numbers of s u b j e c t s under 6 and the numbers of  m i s s i n g d a t a f o r the b l o o d p r e s s u r e v a r i a b l e s .  I t can be seen t h a t a t  l e a s t one c h i l d under 6 had h i s b l o o d p r e s s u r e taken, but o t h e r s u b j e c t s 6 y e a r s and over were missed.  The amount of m i s s i n g d a t a and the d i f f e r -  ences between the two groups on age make t h i s d a t a u n i n t e r p r e t a b l e .  TABLE XIV Frequency of a n t i c i p a t e d m i s s i n g d a t a and•the frequency d a t a f o r the Blood P r e s s u r e (BP) V a r i a b l e s Video A n t i c i p a t e d M i s s i n g Data No. of s u b j e c t s < 6 y e a r s A c t u a l M i s s i n g Data f o r BP a t Admission f o r BP a f t e r Surgery  3.  I t s h o u l d be noted  of m i s s i n g  (n=15)  Tour  -  (n=15)  7  10  10 8  9 10  t h a t one of t h e o b j e c t i v e s f o r t h i s r e s e a r c h  p r o j e c t was t o be as u n o b t r u s i v e as p o s s i b l e .  I t was c o n s i d e r e d impor-  t a n t not t o make what might be c o n s i d e r e d s t r e s s f u l demands on the s u b j e c t s , such as c o l l e c t i n g d a t a on p h y s i o l o g i c a l responses by r o u t i n e h o s p i t a l p r o c e d u r e s . experience  not n o r m a l l y  recorded  T h i s o b j e c t i v e was a c h i e v e d , and t h e  of the s u b j e c t s i n t h i s h o s p i t a l i z a t i o n may be c o n s i d e r e d  s i m i l a r t o t h a t of o t h e r 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 o b j e c t i v e must be weighed a g a i n s t t h e c o m p l i c a t i o n s r e s u l t i n g from m i s s i n g data. 4.  No c l a s s i c a l c o n t r o l group was used  i n t h i s study.  I t has been  -  45  -  shown that parental attitude to h o s p i t a l i z a t i o n and anxiety l e v e l may affect a c h i l d ' s response to h o s p i t a l i z a t i o n (Azarnoff, et a l . , Sides,  1977).  It was, therefore,  1975;  concluded that parents and children who  did not choose to attend a preadmission programme might d i f f e r from those who did choose to p a r t i c i p a t e 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 , placebo attention group was created.  and therefore no  It i s unfortunate that a control  group was no possible, because i t cannot be ascertained whether either programme is effective,-  only that they. do not d i f f e r s i g n i f i c a n t l y from  each other i n t h e i r effectiveness. As reported i n Chapter I I , negative effects of h o s p i t a l i z a t i o n and the effects of preparation programmes have differed through time and place. Hospitals, t h e i r r u l e s , and routines have changed dramatically in the past twenty years.  It has been noted that hospitals s t i l l d i f f e r markedly,  one from another (Post, 1979).  For these reasons, a control group to  demonstrate the need for and l e v e l of effectiveness of preparation programmes within a given h o s p i t a l 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 i n Chapter I I I , children  were encouraged to play with hospital equipment, such as syringes, blood pressure cuffs,  tongue depressors, masks, etc.  Parents were i n v i t e d to  discuss t h e i r concerns with the Head Nurse or Paediatric Nurse C l i n i c i a n  -  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 i n the study also participated i n a Preoperative Teaching programme. The l a t t e r programme was scheduled for 4:30 p.m. on the day of the c h i l d ' s admission and consisted of s l i d e s and a discussion to prepare the c h i l d for h i s / h e r s u r g i c a l procedure the following day.  The preoperative teaching programme  focussed on the preoperative medication, the preparation for surgery, anaesthetic,  and recovery room procedures.  was covered i n the video-tape,  Although some of this material  i t was not discussed i n the same d e t a 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  of this study were confounded by the subjects'  results  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 i m i t i n g factor of the study was the small sample s i z e . Because of the small numbers of children entering the h o s p i t a l for elective s u r g i c a l procedures requiring an overnight stay, to obtain a sample of 30 c h i l d r e n . larger differences  i t took over six months  The small sample size infers  that  are necessary to show a s i g n i f i c a n t difference between  groups than i f a larger sample size was used. Instrumentation The Posthospital Behavior Questionnaire was modified i n two ways. F i r s t , the response categories were changed from subjective categories to s p e c i f i c frequencies.  Second, i t was modified to measure behaviour p r i o r  -  47 -  to admission and after discharge, rather than asking for the parent's perception of change. It was found that the subject's behaviour did not change during the two weeks following surgery. 1.  that both treatment programmes are effective  h o s p i t a l behaviour sequelae, 2.  Two competing conclusions may be drawn: i n eliminating post-  or  that the instrument i s not sensitive enough to record changes i n -  behaviour. The i n t e r n a l 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 i g h t l y 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 o r i g i n a l questionnaire. The o r i g i n a l scale was designed to measure behaviour i n children 1 month to 16 years of age (Vernon, et a l . , 1966).  The age range i n this study was  much smaller, as i t was in most other recent studies Melamed and Siegel,  1980; Wolfer and V i s i n t a i n e r ,  (Ferguson, 1979;  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. 1.  Questions which arose during this study were:  Are the items s i g n i f i c a n t i n d i f f e r e n t i a t i n g among subjects who  are closer i n age then i n the o r i g i n a l 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 v a l i d i t y study of this scale i s necessary before any conclusions can be drawn regarding the results from this measure. a study is strongly recommended before the scale is used again.  Such  -  48 -  The Hospital Fears Rating Scale has been used i n three studies with samples ranging i n 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 i n this study that 5 of the subjects, aged between 48 and 61 months, responded to the scale i n sequence; e i t h e r : 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 d i f f e r i n t h e i r response  styles,  making t o t a l score comparisons across age groups inappropriate. Scherrer and Nakamura (1968) note: "Most studies show a general decline i n the number of fears i n normal children and a change i n the type of fears from immediate tangible fears to a n t i c i p a t o r y , 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 v a l i d i t y of this scale for use with children aged 3 through 8 i s  questionable. Internal consistency coefficients  for each administration of the  Hospital Fears Scale i n this study were .84,  .76, and .82.  Because of  the response patterns observed i n some of the subjects, however, further r e l i a b i l i t y and v a l i d i t y studies of this scale are recommended. * The; Fear Survey Schedule i s 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 s i g n i f i c a n t effect on this v a r i a b l e , differences between the groups were not  significant.  The analysis also revealed an i n s i g n i f i c a n t difference between the times of administration (p_ = .06)  (see Figure I I ) .  It appears that the  scores at the postadmission administration were lower than at the other two administrations.  There are two possible explanations for this  differ-  ence: 1.  that the c h i l d r e n , after r e a l i z i n g that t h e i r h o s p i t a l  experience  was proceeding exactly as they were t o l d i t would, were able to relax after t h e i r admission, or 2.  that the lower scores are an a r t i f a c t of the t e s t - r e t e s t s i t u a t i o n ,  i n that the time between f i r s t and second administrations was approximately 4 hours and between second and t h i r d administrations was approximately 2 weeks. Without t e s t - r e t e s t r e l i a b i l i t y data, i t is impossible to determine the reason for this fluctuation i n scores. P r a c t i c a l Considerations In choosing a method to prepare children for h o s p i t a l i z a t i o n and surgery, the f i r s t concern should be with .the effectiveness of the programme.  Other, more p r a c t i c a l , considerations must also be weighed.  The  following i s a comparison of the video and tour treatment programmes on these issues: Costs 1.  A video programme i s more expensive to produce i n i t i a l l y .  2.  Staff time i n operating both programmes i s equal.  - 50 -  Convenience 1.  Only one or two s t a f f members and one room are required for the  video programme. 2.  Children move through the h o s p i t a l on a tour and some areas must  be available and the staff  aware, i f not actively p a r t i c i p a t i n g , i n the  tour programme. Maintenance 1.  A consistent standard for the quality of the programme is guaran-  teen with the video programme. 2.  The q u a l i t y 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 i n other areas of the h o s p i t a l may become actively  involved if. they so choose. 2.  A s k i l l f u l tour leader is  critical.  A s k i l l f u l discussion leader i s necessary to transform the more  passive a c t i v i t y of watching the tape to a more active  play/discussion  involvement. These issues must be carefully examined by anyone i n i t i a t i n g a preparation programme.  No attempt was made i n this study to draw any conclu-  sions as to which programme i s more p r a c t i c a l .  This decision must be  made for each i n d i d i v u a l h o s p i t a l . The Impact of the Programmes Although no attempt was made i n this study to evaluate the need for and effectiveness of Preadmission Preparation Programmes i n the Surrey Memorial H o s p i t a l , a related issue should be discussed,  that i s :  the  - 51 -  inefficiency  of such programmes to serve their t o t a l audience.  It has  been observed that Preadmission Programmes are attended by less than half of t h e i r potential audience (Cox, 1976; Peterson & Ridley, 1980). This i s true of the Surrey Memorial Hospital where 125 children were sent brochures for the programme i n 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 to an i n a b i l i t y to attend at that p a r t i c u l a r time.  or concern  E f f o r t s should now be  turned toward programmes which can reach these children.  Possibilities  include school programmes, public education, and programmes immediately p r i o r to admission. areas.  The advantages of the video-programme may be i n these  Ferguson (1979) and Melamed and Siegel  (1975) found a video pro-  gramme administered immediately preceeding admission to be effective i n reducing anxiety i n children h o s p i t a l i z e d for surgery.  Further research  may explore the use of video i n 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  s i g n i f i c a n t differences were found between the two programmes on s e l f report, behavioural, or physiological measures except incidence of vomiting. The study was limited by several factors including small sample s i z e , lack of control group, and lack of control over c o l l e c t i o n of p h y s i o l o g i c a l data.  Concerns about the r e l i a b i l i t y and v a l i d i t y of the Hospital  Fears Rating Scale and the Posthospital Behaviour Questionnaire were raised. These features  created weaknesses i n 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. conclusions  No  can be drawn as to the strength of the effects because of the  lack of control group. Recommendations for Further Research 1.  R e l i a b i l i t y and v a l i d i t y 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. Dress rehearsal for the h o s p i t a l . American Journal of Nursing, 1970, 70 (11) 2360-2362. ANDREW, J . M . Recovery from surgery with and without preparatory i n s t r u c tion for three coping s t y l e s . Journal of Personality and S o c i a l Psychology, 1970, 15, 223-226. ANTHONY, S. Applying c h i l d education techniques i n the h o s p i t a l . Forum, 1977, 22 (7), 9-11. AUERBACH, S.M. T r a i t - s t a t e anxiety and adjustment to surgery, of Consulting and C l i n i c a l Psychology, 1973, 40, 264-271.  Hospital  Journal  AZARNOFF, P. Mediating the trauma of serious i l l n e s s and h o s p i t a l i z a t i o n in childhood. Children Today, 1974, 3. (4), 12-17. AZARNOFF, P . , Bourque, L . , Green, J . , & Rakow, S. Preparation of C h i l d ren for H o s p i t a l i z a t i o n : A F i n a l Report to NIMH. Los Angeles: U.C.L.A. Department of P a e d i a t r i c s , 1975. BANDURA, A . , Grusic, J . E . , & Menlove, F . L . Vicarious extinction of avoidance behaviour. Journal of Personality and S o c i a l Psychology, 1967, 5_, 16-23. BANDURA, A. & Menlove, F . L . Factors determining vicarious extinction of avoidance behaviour through symbolic modelling. Journal of Persona l i t y and Social Psychology, 1968, 8, 99-108. BECKER, R.D. Therapeutic approaches to psychopathological reactions to hospitalization. International Journal of Child Psychotherapy, 1972 (April) 1_ (2), 65-97. BELMONT, H.S. H o s p i t a l i z a t i o n and i t s effects upon the t o t a l C l i n i c a l P a e d i a t r i c s , (Phil) 1970,. 9. (8), 472-483. BOWLBY, J .  Separation of mother and c h i l d .  Lancet, 1958,  child.  480.  BROWN, M . J . Preadmission orientation for children and parents. Nurse, 1971, 67_ (2), 29-31.  Canadian  BROWN, R.D. & Semple, L . Effects of unfamiliarity on the overt v e r b a l i z ation and preconceptual motor behaviour of nursery school children. B r i t i s h Journal of Educational Psychology, 1970, 40, 291-198. CASSELL, S. Effect of b r i e f puppet therapy upon the emotional responses of children undergoing cardiac catheterization. Journal of Consulting Psychology, 1965, 29_, 1-8. CASTANEDA, A . , McCandess, B . R . , & Palermo, D.S. The children's form of the Manifest Anxiety Scale. Child Development, 1956, 21_, 317-326.  - 54 -  COLEMAN, K . P . Preventing and reducing anxiety i n paediatric s u r g i c a l patients: an educational and d i r e c t treatment approach. Dissertation Abstract, 1976, 36 (9-A), 5819. COPPOLILLO, H.P. The c h i l d i n the perioperative period. Emotional and Psychological Responses to Anesthesia and Surgery. E d . by Guerra, F . , and Aldrete, J . A . New York: Grune and Stratton, 1980, 145-153. COX, N.C.  Psychological effects of surgery on children.  1976, 24 (3), 425-432.  AORN Journal,  CROCKER, E . Preparation for e l e c t i v e surgery: does i t make a difference? Journal of the Association for the Care of Children's Health, 1980,  9_ (1), 3-11.  DAVENPORT, H . T . , Werry, J . S . The effect of general anaesthesia, surgery and h o s p i t a l i z a t i o n upon the behaviour of c h i l d r e n . American Journal of Orthopsychiatry, 1970, 40 (5), 806-824. DAVIS, J . L . Pre-operative program prepares children for surgery. Journal, 1977, 26 (2), 249-256. DIXON, W . J . , & Brown, M.B. Biomedical Computer Programmes P Series (BMDP-77). Berkley: University of C a l i f o r n i a Press, 1977.  AORN 1977  DOUGLAS, J.W.B. Early h o s p i t a l admissions and l a t e r disturbances of behaviour and learning. Developmental Medicine and Child Neurology,  1975, JL7, 456-480. DOWNING, M.E. Blood pressure of normal g i r l s from three to sixteen years of age. American Journal of Diseases of Children, 1947, 73_, 316. DUMAS, R.G. Psychological preparation for surgery.  Nursing,  American Journal of  1963, 63, 52-55.  DUMAS, R . G . , & Leonard, R.D. postoperative vomiting.  The effect of nursing on the incidence of Nursing Research, 1963, _12_, 12-15.  EPSTEIN, S . , & Rouperman, A. Heart rate and skin conductance during experimentally induced anxiety: The effect of uncertainty about receiving a noxious stimulus. Journal of Personality and Social  Psychology, 19 70, 16_, 20-28. FASSLER, D. Preparing the young c h i l d for h o s p i t a l i z a t i o n . Forum, 1979, 22 (7), 5-7.  Hospital  FERGUSON, B . F . Preparing young children for h o s p i t a l i z a t i o n : of two methods. P a e d i a t r i c s , 19 79, 64 (5), 656-664. FERGUSON, F . , et a l .  Learning about the. h o s p i t a l at home.  1979, 54_ (a), 44-48.  a comparison  Canadian Nurse,  - 55' -  FREUD, A. The role of bodily i l l n e s s i n the mental l i f e of c h i l d r e n . The Psychoanalytic Study of the C h i l d , 1952, V I I I , 69-81. GELLERT, E . Reducing the emotional stress of h o s p i t a l i z a t i o n for c h i l d ren. American Journal of Occupational Therapy, 1958, _12 (3), 125-129. GERSTEIN, D. A developmental study of the influence of the sex of a model upon the imitative behaviour of children. Dissertation Abstract, 1977, 38 (5-B) 24-27. GILLER, D.W. Some psychological factors i n recovery from surgery. p i t a l Topics, 1963, j U , 83-85.  Hos-  GODFREY, A . E . Study of nursing care designed to a s s i s t hospitalized children and t h e i r parents i n t h e i r separation. Nursing Research, 1955, 4_ (2), 52-70. HEALY, K.M. Does pre-operative i n s t r u c t i o n make a difference? Journal of Nursing, 1968, 68^, 62. HOLLENDER, M. The Psychology of Medical P r a c t i c e . Q.B. Saunders C o . , 1958.  American  Philadelphia, P a . :  JESSNER, L . , Blom, G . E . , & Waldfogel, S. Emotional implications of tonsillectomy and adenoidectomy i n c h i l d r e n . E i s s l e n , R.S. (ed) The Psychoanalytic Study of the C h i l d , 1952, VII, 126-169. JOHNSON, B.H. Before h o s p i t a l i z a t i o n : Today, 1974, 3, (6), 18-21.  a preparation program.  Children  JOHNSON, J . E . Effects of structuring patient's expectations on t h e i r reactions to threatening events. Nursing Research, 1971, 21_ (6), 499-503. JOHNSON, R. , & Machen, J . B . Behaviour modification techniques and maternal anxiety. Journal of Dentistry for Children, 1973, 40, 272-276. JOLLY, J . D . How to be i n h o s p i t a l without being frightened. Times, 1977, 73 (48), 1887-1888.  Nursing  KAZDIN, A . E . Covert modeling model s i m i l a r i t y and reduction of avoidance behaviour. Behaviour Therapy, 1974, _5, 325-340 (a). KITA, S. U . B . C . S . P . S . S . : S t a t i s t i c a l Package for the S o c i a l Sciences Version 8.00 (Under MTS). Vancouver: Computing Centre, University of B r i t i s h Columbia, 1980. KLORMAN, R. , H i l p e r t , 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 i m i l a r i t y on extinction of avoidance behaviour i n 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 i n and anxiety on the behaviour of preschool children during h o s p i t a l i z a t i o n 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 C i n c i n a t i , 1971. LEVY, E . Children's behaviour under stress and i t s r e l a t i o n to training by parents to respond to stress functions. Child Development, 1959, 30, 307-324. LIPTON, S.D. On the psychology of childhood tonsillectomy. analytic Study of the C h i l d , 1962, XVII, 363-417.  The Psycho-  LOCKHART, D. P r a c t i c a l considerations i n the pre-operative psychological preparation of the p e d i a t r i c patient. Emotional and Psychological Responses to Anesthesia and Surgery, ed. by Guerra, F. and A l d r e t e , J . A . New York: Grune and Stratton, 1980, 123-131. MAHAFFY, P.R. Effects of h o s p i t a l i z a t i o n on children admitted for t o n s 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 . A controlled study of the effects of tonsillectomy and adenoidectomy i n children. B r i t i s h Journal of Preventative and Social Medicine, 1963, 17_ (2), 49-69. MELAMED, B . G . , Hawes, R . R . , Heiby, E . , & G l i c k , J . The use of filmed modelling to reduce uncooperative behaviour of children during dental treatment. Journal of Dental Research, 1975, _54_ (1), 797-801. MELAMED, B . , Myer, R., Gee, C . , & Soul, L . The influence of time and type of preparation on children's adjustment to h o s p i t a l i z a t i o n . Journal of P e d i a t r i c Psychology, 1976, 1_ (4), 31-37. MELAMED, B . C . & Siegel, L . J . Reduction of anxiety i n children facing h o s p i t a l i z a t i o n and surgery by use of filmed modelling. Journal of Consulting C l i n i c a l Psychology, 1975, 43, 511. MELAMED, B. & Siegel, L . Psychological preparation for h o s p i t a l i z a t i o n . Behavioral Medicine, New York: Springer Publishing C o . , 1980, 307-355. MELAMED, B . G . , Weinstein, D . , Hawes, R. & Katin-Borland, M. Reduction of fear-related dental management problems using filmed modeling. The American Dental Association Journal, 1975, 9_0_, 822-826.  - 57 MIECHENBAUM, D.H. Examination of model characteristics i n reducing avoidance behaviour. Journal of Personality and S o c i a l Psychology, 19 71, _17, 298-307. NAGERA, H. Children's reactions to h o s p i t a l i z a t i o n and i l l n e s s . Psychiatry and Human Development, 1978, 9_ (1), 3-19.  Child  NELSON, L . R . Guide to LERTAP Use and Interpretation. Dunedin, New Zealand: Department of Education, University of Otago, 1974. PENTICUFF, J . H . The effect of filmed peer modeling, cognitive appraisal, and autonomic r e a c t i v i t y i n changing children's attitudes about health care procedures and personnel. Dissertation Abstract, 1976, Dec. 37, (60B), 3089. PETERSON, L . & Ridley, J . F . P e d i a t r i c h o s p i t a l response to survey on prehospital preparation for children. Journal of Pediatric Psychology 1980, 5_ (1), 1-7. PETRILLO, M. Preventing h o s p i t a l trauma i n p e d i a t r i c patients. Journal of Nursing, 1968, 68 (7), 1469-1473.  American  POMARICO, C . , Marsh, K . , & Doubrava, P. Hospital orientation for c h i l d ren. AORN Journal, 1979, 29_ (5), 864-875. POST, S. Trends i n p e d i a t r i c hospitals, May, 1979, 51-53.  Dimensions i n Health Services,  Pre-Admission Hospital Orientation Programmes for Children. Vancouver Association for the Care of Children i n H o s p i t a l , B . C . A f f i l i a t e , 1980. Preparation for H o s p i t a l i z a t i o n : A Guide for Parents, Hospitals, and Teachers. Ottawa: Canadian Institute for Child Health, 1979. PRUGH, D . G . , Straub, E . , & Sands, H . H . , A study of the emotional reactions of children and families to h o s p i t a l i z a t i o n and i l l n e s s . American Journal of Orthopsychiatry, 1953, 23, 70-106. QUINTON, D. & Rutter, M. Early h o s p i t a l admissions and l a t e r disturbances of behaviour: An attempted r e p l i c a t i o n of Douglas' findings. Devel^ opmental Medicine and Child Neurology, 1976, 18, 447-459. RITCHIE, J . A . Preparation of toddlers and preschool children for h o s p i t a l procedures. Canadian Nurse, 1979, 75_ (11), 30-32. ROBINSON, D. Mothers' fear their children's well being i n h o s p i t a l , and the study of i l l n e s s behaviour. B r i t i s h Journal of Preventative and Social Medicine, 1968, T2_, 228-33. SAUER, J . E . Preadmission orientation effect on patient Hospital Topics, 1968, 46 (3), 79-83.  manageability.  SCAHILL, M. Preparing children for procedure and operations. Outlook, 1969, 1_7 (6), 36-38.  Nursing  SCHACHTER, S. & Singer, J . E . Cognitive, s o c i a l , and physiological determinents of emotional state. Psychological Review, 1962, 69, 379-399. SCHERER, M.W. & Nakamura, C.Y. A fear survey schedule for children (ESS-FC): A factor analytic comparison with manifest anxiety (CMAS). Behaviour Research Therapy, 1968, 6-7, 173-182. SCHRADER, E . S . Preparation play helps children i n hospitals. 1979, 30 (2), 336-341.  AORN Journal,  SIDES, J . P . Emotional responses of children to physical i l l n e s s and hospitalization. Dissertation, Auburn University, Alabama, 1977. SIEGEL, L . J . Preparation of children for h o s p i t a l i z a t i o n : A selected review of the research l i t e r a t u r e . Journal of Pediatric Psychology, 1976, 1 (4), 26-30. SILVER, H.K. and others. Handbook of P e d i a t r i c s . Lange Medical Publications, 1955.  Los A l t o s ,  California:  SIPOWICZ, R.R. & Vernon, D.T.A. Psychological responses of children to hospitalization. American Journal of Diseases of Children, 1965, 109, 228-31. SKIPPER, J . K . Mothers' distress over their children's h o s p i t a l i z a t i o n for tonsillectomy. Journal of Marriage and the Family, 1966, 28, 145. SKIPPER, J . K . & Leonard, R . C . Children, s t r e s s , and h o s p i t a l i z a t i o n : A f i e l d experiment. Journal of Health and Social Behaviour, 1968, j), 275-189. SMITH, L . G . Preparing a c h i l d for h o s p i t a l stay. 1971, 48 (2), 46-8.  Canadian H o s p i t a l ,  SPIELBERGER, C D . , Auerbach, S.M. , Wadsworth, A . 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 h o s p i t a l . (Sept.), 70 (9), 38-40.  Canadian Nurse,  1974,  STEWARD, D . J . Psychological considerations i n the p e d i a t r i c 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. Textbook of P e d i a t r i c s , 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 B u l l e t i n ,  1979, 86, 701-720.  THOMSON, E .  Preop v i s i t s - for the nurse - for the patient?  1972, 16_ (4), 75-81.  AORN Journal  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. & B a i l e y , W.C. The use of motion pictures i n the psychol o g i c a 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 p o t e n t i a l l y s t r e s s f u l situation on responses to stress impact. Journal of Personality 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 t e r a t u r e . Springfield, Illinois: Charles C. Thomas, P u b l . , 1965. VERNON, D . T . A . , Foley, J . M . , & Schulman, J . L . Effect of mother-child separation and b i r t h order on young children's responses to two potent i a l l y s t r e s s f u l experiences. Journal of Personality and Social Psychology, 1967, 5_, 162-174. VERNON, D . T . A . , Schulman, J . L . , & Foley, J . M . Changes i n children's behaviour after h o s p i t a l i z a t i o n . 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 h o s p i t a l to preschoolers.  Children Today,  1976,  5 (2), 16-19. WHITE, W., Akers, J . , Green, J . , & Yates, D. Use of imitation i n the treatment of dental phobia i n early childhood: A preliminary report. Journal of Dentistry for Children, 1974, J26, 106. WOLFER, J . A . & V i s i n t a i n e r , M.A. P e d i a t r i c s u r g i c a l patients' and parents' stress responses and adjustment as a function of psychological preparation and stress-point nursing. Nursing Research, 1975, 24_ (4),  244-254.  WOLFER, J . A . & V i s i n t a i n e r , M.A. Prehospital psychological preparation for tonsillectomy patients: Effects on children's and parents' adjustment. P e d i a t r i c s , 1979, 6k_ (5), 646-655.  - 60 -  YURGHESON, R..." The effects of peer modelling vs. f a m i l i a r i z a t i o n and the influence of s p e c i f i c information on fear behaviours..in children undergoing dental treatment. Dissertation Abstraction, 1977, _38 (2-B), 941.  - 61 -  APPENDIX A  Items from H o s p i t a l Fears  the  Rating  Scale  and Posthospital Behavior  Questionnaire  Scored Hospital  Items from  the Fear  Survey  Items from t h e Fears Rating Scale  f o r Children  1.  sharp  objects  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 shot from  4.  going to the d e n t i s t  the nurse  or doctor  5..::-going t o t h e d o c t o r 6.  getting a  7.  deep w a t e r  8.  haircut o r the ocean  si:getting c a r s i c k  Items w i t h f a c e  validity  1.  germs o r g e t t i n g v e r y  sick  2.  t h e s i g h t Of b l o o d  3.  being alone without your  4.  h a v i n g an o p e r a t i o n  5.  people wearing  6.  not being able to breath  7.  getting a cut or hurt  8.  going t o bed i n t h e dark  masks  parents  - 63  -  Items from the P o s t h o s p i t a l Behavior Questionnaire  1.  Does your c h i l d make a f u s s about going to bed a t n i g h t ?  2.  Does your c h i l d make a f u s s about  3.  Does your c h i l d  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  6.  I s your c h i l d u n i n t e r e s t e d i n what goes on around  7.  Does your c h i l d wet  8.  Does your c h i l d b i t e h i s / h e r  9.  Does your c h i l d  eating?  spend time j u s t s i t t i n g o r l y i n g  seem to be a f r a i d  about and doing n o t h i n g ?  o f l e a v i n g the house w i t h you? him/her?  the bed a t n i g h t ? fingernails?  get upset when you l e a v e him/her a l o n e f o r a few  minutes? 10. Does your c h i l d need a l o t of h e l p d o i n g t h i n g s ? 11. I s i t d i f f i c u l t  to get your c h i l d  p l a y i n g games, w i t h t o y s , 12. Does your c h i l d  i n t e r e s t e d i n doing things  (like  etc.)?  seem to a v o i d o r 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 h i s / h e r mind? 14. Does your c h i l d have temper 15. I s i t d i f f i c u l t 16.  Does your c h i l d  tantrums?  to get your c h i l d  to t a l k t o you?  seem to get upset when someone mentions d o c t o r s o r  hospitals? 17. Does your c h i l d  f o l l o w you everywhere around the house?  18. Does your c h i l d  spend time t r y i n g to get or h o l d your a t t e n t i o n ?  19. I s your c h i l d a f r a i d  o f the dark?  20. Does your c h i l d have bad dreams a t n i g h t or wake up and cry?  -64-  21.  I s your c h i l d i r r e g u l a r i n h i s / h e r bowel movements?  22.  Does your c h i l d have t r o u b l e g e t t i n g to s l e e p a t n i g h t ?  23.  Does your c h i l d  24.  Does your c h i l d have a poor a p p e t i t e ?  25.  Does your c h i l d tend to disobey you?  26.  Does your c h i l d break toys o r o t h e r  27.  Does your c h i l d  seem to be shy o r a f r a i d  around  objects?  suck h i s / h e r f i n g e r s o r thumbs?  strangers?  - .65 -  APPENDIX B  P a r e n t C o n s e n t Form  - -66.-  PARENT CONSENT FORM Dear Parent; We'are attempting to determine which of two preadmission orientation procedures is the most effective way to prepare children for their hospitalization experience. We would very much appreciate the participation 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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