INTRODUCTION:

The presence of a child’s parents while the child is posted for surgery reduces patient’s anxiety and increase co operation. While the role of parental presence in alleviating a child’s anxiety has yet to be proven, the effect on parental anxiety has been investigated. Some studies have found that parental presence can result in disruptive behavior. Parent’s also report feeling upset to see their child in the surgical dress and at having to leave them¹.

Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive and behavioral components^. The meaning of the word anxiety is “to trouble” (Spielberger, 1966).

Psychologically, the term ‘anxiety’ refers to at least two related, but different, constructs. Very often, the word ‘anxiety’ is used to describe an unpleasant emotional state that relates to a stressful situation. Anxiety can also describe a personality trait².

The concepts of state and trait anxiety were first introduced by Cattell, 1996 and have been elaborated by Spielberger, 1979. Anxiety states are characterized by subjective feelings of tension, apprehension, nervousness, and by the arousal of the autonomic nervous system. Anxiety is often transitory and can recur when evoked by appropriate stimuli; however, anxiety may be prolonged if the evoking conditions persist. In contrast, a personality trait is a relatively enduring characteristic that relates to an individual’s perception of the world and disposition to react or behave in a certain manner with predictable regularity³. Thus, having an anxious personality trait can be considered a consistent feature of a person. Such a person is likely to become anxious easily and to experience an anxiety state when faced with ordinary difficulties.

An individual who is not usually anxious, however, may experience only transient episodes of anxiety whenever a stressful situation has to be faced. Hence, the level of anxiety one feels at a given moment (i.e. anxiety state) is determined both by an individual’s personality (anxiety trait) and by how stressful the situation is. In examining the particular effect of a specific situation on an individual’s anxiety state, it is important to take their personality trait into consideration ⁴. Anxieties are considered to be a normal reaction to a stressor. Anxiety is a generalized mood that can occur without an identifiable triggering stimulus .Fear is related to the specific behavior of escape and avoidance where as anxiety is related to situations perceived as uncontrolled or unavailable. Seems to be understood by everybody on the basis of personal experiences, however anxiety have many meanings (Spielberger,1979) and are reflected in many different definitions of scientific literature⁵.

The important role of anxiety in disrupting the wellbeing of an individual is demonstrated by its relationship with both physical and psychological health. The conventional view of the stress-illness relationship is that extensive bodily changes can result from stress generated emotions such as anxiety. In addition, immunological incompetence is considered to be linked to stress and illness.

Various anxiety disorders, which are classified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM IV), also outline the relationship between anxiety and mental health. Because of the way stress and anxiety affect the psychological well-being of people of different cultures; the impact of parental presence while the child is sent to operation theatre on parental wellbeing in Indian populations is a major concern. Most frequently the hospital admission of the children posted for elective surgery is done on the day of surgery and it is crucial in reducing preoperative parental anxiety ⁶.

Although numerous papers have been published on the topic of level of parental anxiety present during preoperatively i.e. just before the child is shifted to the Operation theatre, not many have studied the effect of being present on the parents’ psychological well-being. But there is a little information on the incidence and severity of pre operative anxiety in Indian parents whose children are scheduled for surgery. Very few studies are conducted to assess the anxiety in parents. Furthermore, there is currently no report on this subject in an Indian population. Anxiety reducing interventions can be applied to parents who have severe anxiety. It needs a proper assessment of anxiety experienced by the parents of children admitted for elective surgery.

The aims of this study were as follows: to explore the anxiety experienced by ethnic Indian parents presence while their child is sent to operation theatre for surgery and to compare the type of anxiety experienced by the parents whose child is posted for abdominal surgeries, herniotomy and other surgeries such as tonsillectomy, orthopedic operations, fistula correction in hypospadiasis and phimosis correction.

METHODS:

Design and setting

This was a descriptive non- experimental explorative research carried at a tertiary care centre, among parents whose children were scheduled for elective surgery from October 2012 to February 2013. Study participants were selected through a random sampling method of database of patients attending the pediatric surgery inpatient department. Those parents who met the inclusion criteria were the study participants. The study criteria were parents whose children were scheduled for elective surgery, who had children under 18 years old and who can understand or speak English or and regional language. The study sample comprised of 151 parents.

Measurement tools

The questionnaire used for the present study consisted of two parts. The first part collected personal information from the participants such as Gender of the parent, age, marital status, educational status, gender of the child posted for the surgery, type of surgery, number of previous surgery. The second part explored the parents’ level of anxiety by being present with their child preoperatively, with the help of State Trait Anxiety Inventory.

State Trait Anxiety Inventory [STAI]

The original State-Trait Anxiety Inventory (STAI) [Form X] was developed by Spielberger in 1970; the present version of the STAI was revised in 1983.The STAI has two parts: the State Anxiety Inventory (SAI) and the Trait Anxiety Inventory (TAI) ⁷. The former part measures situational anxieties while the latter measures baseline anxiety; each part consists of 20 items. These items are rated on a 4-point scale, with a higher score equating to a greater anxiety level.

Validity and Reliability of the tools

According to studies by Spielberger et al in 1976, the test-retest correlation for the TAI is higher than that for the SAI. Despite the fluctuating test-retest correlations of the SAI, which reflect its validity in measuring state anxiety, the internal consistency of the SAI, as measured by the Cronbach’s alpha score has been found to be high with a the positive correlation scores of 0.73 and 0.85 ⁸.

Test-retest reliability of the STAI was evaluated using 29 male undergraduate students before and after a stressful social analogue situation (Rule & Traver, 1983). Correlations provided by Spielberger et al. in 1970 the state anxiety should have a 0.54 (state) and the 0.86 (trait) correlation. Rule’s and Tarver’s findings of 0.40 (state) and 0.86 (trait) were similar to the reliability coefficients reported by the test author. The similarities of the study and the author’s correlations emphasize the STAI’s reliability ⁹.

Data Collection

Self introduction and brief explanation of the study was done. The standardized tool was administered to the parents in the waiting area of the operation theatre (just before the child is shifted to operation theatre). Participants were asked to complete the Personal information questionnaire and STAI. Data were collected by the primary author through self report of the participants. It took approximately 10 to 20 minutes to complete the questionnaire. The first 50 participants filled in only the personal information questionnaire. The subsequent 101 parents completed both the questionnaire.

Statistical Analysis

On the basis of scoring instruction for STAI (Charles D Spielberg, 1970).The selected question which needed recoding, was recoded. The data was analyzed using inferential and descriptive statistics. For the STAI, statistical analysis was performed only for those who completed all items. The Pearson correlation coefficient (r) was calculated to explore the relationship of the SAI and TAI for participants. The variables explored in the questionnaire that related to the SAI were also analysed. Duncan’s multiple range tests was used to determine which group (type of surgery) comparisons resulted in a significant difference.

Ethical Consideration

The study protocol was reviewed and approved by the ethic committee of the concern hospital. Written consent was obtained from the participants and they were given freedom to quit the study. Participant’s confidentiality was respected and a code was used for the individual tool, so that participants could not be identified from their responses.

RESULTS:

Of the 151 participants, 119(78.8%) were mother of the child and 30 (19.9%) were the father of the child. The age of the participants ranged from 24 – 59 years (mean, 36years; standard deviation [SD], six years) and all of the participants were married. Fifty nine (39.1%) of the participants had been educated at the primary level or below, While the remainder had received secondary education. Of the pediatric patients who had a parent involved in the study, most (126; 83.4%) were boys and only 25 (16.6%) were girls. Their ages ranged from one year to 12 years (mean, five years; standard deviation [SD], three years).

There were two main types of surgeries: abdominal surgeries (82[54.35] patients) and herniotomy (23[15.2%] patients).the remaining 46(30.4%) patients had undergone various kinds of surgery – viz., tonsillectomy, orthopedic operations. For most of the patients 87%, this occasion was the first time posted for surgery; 11% patients had posted for a follow up surgeries such as colostomy closure, correction of hyospadiasis, phimosis and two participants did not respond to this question.

State trait anxiety inventory [STAI]

Of the 100 patients who answered all the items in the SAI (minimum score, 20; maximum score 80), scores ranged from the 20-65(mean, 34; SD, 9.3).Of the 99 subjects who answered all items in the TAI, the scores ranged from 20-68(mean, 39.3; SD, 8.3). The correlation between the SAI and TAI was found to be positive and significant(r = 0.31; P<0.05). As has been found in previous studies, the main effect of gender was found to be significant in the TAI (ratio of variances [F] = 5.76; P<0.05).The TAI score for the women ranged from 25 to 68(mean, 40.3; SD, 8.2) Whereas for the men, it ranged from 20 - 46 (mean, 34.8; SD, 7.9).However the main effect of gender on the SAI was not found to be statistically significant.

Different types of surgeries and State- trait anxiety inventory results

According to the ANOVA results presented in Table 1&2, a significant difference in the SAI was found between the different types of surgery (F = 3.67; P< 0.05) and whether the child had undergone previous surgery (F = 5.84; P< 0.05). Results of the Duncan’s multiple range test found that parents of a child undergoing for an abdominal surgery had a significantly higher level of state anxiety than those whose child was going for herniotomy (P< 0.05).

Table 1 State Anxiety Inventory Scores According to Type of Surgery

Types of Surgeries	N	Mean	SD
Abdominal surgery	15	39.3	10.9
Herniotomy	53	32.3	53
Other Surgeries	.32	32.3	53

Table 2 State Anxiety Inventory Scores According to Number of Previous Surgeries

No. of Previous Surgeries	N	Mean	SD
1^st surgery	87	33.0	8.5
Follow-up surgery	11	42	12.0

DISCUSSION:

To our knowledge, this was the first study from developing countries that explored the anxiety experienced by the parents of children admitted for elective surgeries. The STAI results obtained in this study show that the population questioned was a heterogeneous group of parents in terms of their state and trait anxiety. The results are similar to those found by other studies of STAI. The small positive relationship between TAI and SAI indicate the parents with a higher trait anxiety tend to have a higher state anxiety as well, but this relationship was not a strong one.

Consequently, while the personality trait of a parent in terms of trait anxiety contributes to their anxiety state to a certain extent, other variables should also be considered. Of the variables explored, the type of surgery and history of previous surgery were identified as having a significant effect on the level of a parent’s anxiety state. This result seems to be related to the perception of parents as to the nature of the surgery. Apparently, abdominal surgery is considered treatment for an illness and was more anxiety provoking than herniotomy. Similarly, the parental perception of child’s condition was an important factor that affected the level of anxiety. A higher level of state anxiety was seen in parents whose child had a previous experience of surgery. The present study findings coincides with the study conducted by Shirley et al (1998) saying worldwide, there is a tendency for increased pathological anxiety in mothers, parents of very young children and those admitted for repeat surgery ¹⁰. However, more work would need to be done to justify the targeting of information on these groups.

CONCLUSION:

There is a need for the preparation of parents so that they are in a position to contribute constructively for the preoperative preparation of the child. Indeed, in developing country like India, where often there is shortage in manpower, money and material, there will be always lacuna in providing comprehensive care to the parents because the available resources focus on the child’ treatment rather than the parent. The widely, differing medico-legal environments, healthcare systems and family dynamics in the India. Parents have also indicated their willingness and enthusiasm for increased information and practical involvement in their child's hospital treatment.

ACKNOWLEDGEMENTS:

The researchers would like to thank the participants for their valuable contributions. The authors also thank the blind reviewers for their constructive suggestions.

Conflict Of Interest: None

REFERENCES:

1. Abidin RR (1992) The determinants of parenting behavior. Journal of Clinical Child Psychology 21: 407-412.

2. Spielberger CD (1966) Anxiety and behavior. Academic Press, New York

3. Ader R (1981) Psycho-neuroimmunology. Academic Press, New York

4. Cattell RB (1996) Handbook of multivariate experimental psychology. Rand McNally & Co., Chicago (IL)

5. Spielberger CD (1979) Preliminary manual for the State-Trait Personality Inventory (STPI). Tampa (FL), University of South Florida

6. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders. 4th edn. American Psychiatric Association ,Washington (DC)

7. Spielberger CD, Gorsuch RL, Lushene RE (1970) Manual for the State-Trait Anxiety Inventory (Form X) (self-evaluation questionnaire). Consulting Psychologists Press, Inc Palo Alto (CA)

8. Spielberger CD (1976) The nature and measurement of anxiety. In: Spielberger CD, Diaz-Guerrero R editors. Cross-cultural anxiety. Hemisphere/Wiley, Washington (DC)

9. Rule WR & Traver MD (1983) Test –Retest Reliabilities of STAI in a Stressful Social Analogue Situation. Journal of Personality Assessment. 47(3):276-277

10. Shirley PJ, Thompson N, Kenward M, Johnston G (1998) Parental anxiety before elective surgery in children. A British perspective, British Journal of Nursing, Foresterhill, UK

Received on 05.09.2013 Modified on 10.11.2013

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 123-126