Pre Operative Anxiety of Children undergoing Elective Abdominal Surgery

 

Sumathi P. V¹., Dr. Sreedevi T. R².

¹Assistant Professor, Lisie College of Nursing, Lisie Hospital, Ernakulum- 682018, Kerala, India

²Associate Professor, Govt. College of Nursing, Gandhinagar P.O, Kottayam 686008, Kerala, India

 

ABSTRACT:

Pre-operative anxiety is an important concern in children as it negatively affects the post operative recovery. The present study aimed to assess the preoperative anxiety of children undergoing elective abdominal surgery, its correlation with mother’s anxiety and association with selected variables. After getting ethical clearance from the Institutional ethical committee, written consent was obtained from the mothers of eligible children waiting for elective abdominal surgeries. Data was collected after the admission of the child to the ward which is the day before surgery. Measurement of anxiety was done by administering the anxiety rating scale to the child which was prepared by the investigator. Mother’s anxiety was measured by administering the State-Trait Anxiety Inventory STAI form Y1. A total of eighty eligible children with their respective mothers were enrolled in the study. Among the children 47.5 % had mild anxiety, 41.25% had moderate anxiety and 11.25% had severe anxiety. Among the mothers 18.75 % had mild anxiety, 31.25% had moderate anxiety and 50% had severe anxiety. There was a statistically significant correlation between child’s anxiety and mother’s anxiety (r = 0.348, p<.01). Association between patient factors and child’s anxiety revealed that there was a significant association between type of surgery and child’s anxiety (χ² = 4.334, p<.05), where as age, gender, previous history of hospitalisation and previous history of surgery did not have a significant association with child’s anxiety. Among the maternal factors education, previous experience of mother in child’s hospitalisation and previous experience of mother in child’s surgery did not show a statistically significant association.

 

 

 

INTRODUCTION:

Surgical procedures are a major cause of anxiety defined as feelings of worry, discomfort and fear in response to a perceived or real threat in children and their parents¹. In the preoperative period, parents may experience increased anxiety relating to the efficacy of surgery, risk of complications, lack of knowledge and social and economic concerns²: they also may have feelings of helplessness and guilt.

 

In contrast, children predominantly experience fear, anger and guilt in the preoperative period³. Anxiety in, paediatric patients may result in negative postoperative behaviours such as nightmares, separation anxiety, eating disorders and enuresis⁴. Concepts relating to, preoperative anxiety, postoperative behaviours and parental anxiety are becoming increasingly important⁵. The main targets in improving these interrelated factors should be to maintain the parent–child relationship, to alleviate fear resulting from lack of knowledge and to provide psychological support for the parents.

 

Parental anxiety may be associated with various factors. A study identified specific factors such as age of the child, previous surgery, if other children in the family had surgery, gender of the parent, educational level of the parents, and whether or not parents had received preoperative information from an anaesthesiologist prior to surgery that produced preoperative anxiety in the parents⁶. Children are influenced by parental advice and guidance in coping with new or stressful situations. Parents play a critical role in preparing and helping the children to cope with their surgery⁷.

 

High parental preoperative anxiety is associated with high peri operative anxiety in children undergoing surgery⁸. Mothers were identified as being more pathologically anxious than fathers. The ‘anxious’ parents were specifically more anxious about the surgery, anaesthesia, postoperative pain and treatment, and hospitalization in general⁹.

 

A study revealed that poorly educated parents had significantly higher state anxiety scores. Significant relationship did not exist between parental and patient factors and state anxiety scores of either the children or the parents¹⁰. Maternal education level and socioeconomic status had no effect on anxiety scores¹¹. Ambulatory procedures, previous surgical experience and visit to pre-anaesthesia clinic had no influence on the anxiety expressed by children. Child anxiety is significantly correlated with anxiety at parental separation¹².

 

Children were significantly more anxious on entering theatre, and on induction of anaesthesia, than in the waiting area. Older children experienced less anxiety, which was statistically significant. Demographic and socio-economic factors (sex of the child, race, language, nationality, parent’s education, parent’s employment, parent’s income, and single parenthood) were not shown to have a significant association with an increase in anxiety in the child at induction of anaesthesia¹³. Factors related to anxiety in children undergoing elective abdominal surgery need to be explored in order to plan appropriate interventions to manage preoperative anxiety.

 

Statement of the problem:

A study to determine the pre operative anxiety of children undergoing elective abdominal surgery in a selected tertiary care hospital in Ernakulum, Kerala.

 

OBJECTIVES:

1    Assess the level of anxiety among children undergoing elective abdominal surgery.

2    Assess the level of anxiety among mothers of children undergoing elective abdominal surgery.

3    Find out the correlation between anxiety scores of children undergoing elective abdominal surgery and their mothers anxiety scores.

3    Determine the association of anxiety of children undergoing elective abdominal surgery with selected variables.

 

Hypothesis:

H₁  There is a significant correlation between the anxiety scores of children posted for elective abdominal surgery and their mother’s anxiety.

H₂  There is a significant association with the anxiety levels of children posted for elective abdominal surgery and selected patient variables.

H₃  There is a significant association with the anxiety levels of children posted for elective abdominal surgery and selected mothers’ variables.

 

MATERIALS AND METHODS:

A quantitative non experimental research approach with a descriptive design was used to conduct the study. The study was conducted in the paediatric wards of a tertiary care Hospital, Ernakulum, Kerala. Purposive sampling technique was adopted to select the subjects. Sample size was 80. Children admitted for elective abdominal surgeries with their respective mothers were included. Children between the ages of 7 and 15 and who were able to read the local language (Malayalam) were selected. Children who did not give consent, critically ill and mentally unfit were excluded. Mothers who are willing to participate and who were able to read Malayalam were selected.

 

After getting ethical clearance certificate from the Institutional ethical committee, a formal written permission to conduct the research study was obtained from the Director of the concerned Hospital, Ernakulam. Data collection was done over a period of eight months. Data was collected after the admission of the child to the ward which is the day before surgery. Informed consent from the parents and verbal consent from the children was taken. Prior to the data collection, the investigator familiarised herself with the subjects and explained to them the purpose of the study. The investigator obtained full co-operation from the participants and assured their confidentiality.

 

Measurement of child anxiety was done by administering the anxiety rating scale. This instrument was developed by the investigator. This tool consists of 36 items under five headings. The five headings are general anxiety (5 items), physical signs and symptoms (6 items), Separation anxiety(5 items), hospital related anxiety (8 items) and surgery related anxiety (12 items). All items are marked on a 4 point scale (eg; from “not at all” to “very much”). Higher scores indicate greater anxiety. Total Score is - 144. Scores between 38 to 72 indicates mild anxiety. Scores between 73 to 108 indicates moderate anxiety and 109 to 144 indicate severe anxiety. The tool was translated to Malayalam and back translation was done until a 90% consensus was obtained. Test-retest reliability was computed using Karl Pearsons correlation co efficient and was found to be 0.98. Pre testing was done to determine clarity, feasibility and time taken to complete it. Time taken to complete it ranged from 10 to 20 minutes.

 

Mother’s anxiety was measured by administering the State-Trait Anxiety Inventory (STAI). The State-Trait Anxiety Inventory (STAI) is a widely used measure of trait and state anxiety (Spielberger, Gorsuch, Lushene, Vagg, and Jacobs, 1983) Form Y1, its most popular version, has 20 items for state anxiety. State anxiety items include: “I am tense; I am worried” and “I feel calm; I feel secure.” All items are rated on a 4-point scale. Higher scores indicate greater anxiety. The tool was translated to Malayalam and back translation was done until a 90% consensus was obtained. Test retest reliability was computed using Karl Pearsons correlation co efficient and was found to be 0.89.Pre testing was done to determine clarity, feasibility and time taken to complete it. Time taken to complete it ranged from 10-12 minutes.

 

Mothers were instructed to indicate “what they have been feeling when they learned their children being operated” by rating their level of anxiety on a 4 point scale (1=not at all, 2=somewhat, 3=moderately so, 4=very much). Possible scores range from a minimum of 20 to a maximum score of 80. Scores 20-37 indicates mild anxiety, 38-44 indicates moderate anxiety and 45-80 indicates high anxiety. (Ruffingo et al 2009)

 

RESULTS:

Section 1; Sample characteristics:

Results showed that among the children 31.25% belonged to 7 to 9 years,38.75% were in the age group 10 to 12 years and 30 % of them between11-15 years. Of the subjects 50% were males and 50% were females. Among the subjects 37.5% were studying in classes between 1st to 5^th standard, 35% in classes between 6^th to 8^th standard and 27.5% in classes of 9^th standard and above. Majority (73.75%) had previous history of hospitalisation and 22.5% of children had undergone previous surgery. Among the mothers 42.5% had high school education and 45% had collegiate education. Majority (77.5%) had previous experience in child’s hospitalisation and 20% of mothers had previous experience in child’s surgery.

 

Section 1a: Clinical data of children:

Clinical data on children based on the type of surgery is presented in the bar diagram

 

Figure 1: Percentage of children based on the type of surgery.

 

Section 2: Level of anxiety

Table 1; Frequency distribution and percentage of children undergoing elective abdominal surgery based on level of anxiety N=80

Level of anxiety of children	f	%
Mild (38-72)	38	47.5
Moderate (73-108)	33	41.25
Severe(109-144)	9	11.25

 

Table 2; Frequency distribution and percentage of mothers of children undergoing elective abdominal surgery based on level of anxiety N=80

Level of anxiety of mothers	f	%
Mild (20-37)	15	18.75
Moderate (38-44)	25	31.25
Severe (45-80)	40	50

 

Section 3; Correlation between anxiety of children and mothers

Correlation between child’s anxiety and mother’s anxiety was computed by Karl pearson’s correlation coefficient and presented in table 3.

 

Table 3: Correlation between anxiety of children posted for elective abdominal surgery with mothers anxiety N=80

Correlation	r	Pvalue
Child anxiety and mother’s anxiety	0.3489**	0.0015

^**p<.01

 

It is evident from the above table that the calculated r value shows a positive correlation between child’s anxiety and mother’s anxiety which is statistically significant at p< .01.

 

Section 4: Association of child’s anxiety and selected variables

Association between anxiety of children posted for elective abdominal surgery with selected patient variables and selected variables of mother is computed using chi square test and presented in Table 4 and Table 5.

 

 

 

 

Table 4; Significance of association of anxiety of children undergoing elective abdominal surgery with selected patient variables

Variables		Levels of child anxiety			χ2 value
		Mild	Moderate	Severe
Age	7-10	15	16	5	0.8931NS
	11-15	23	19	2
Gender	Male	27	20	1	1.875NS
	Female	13	13	6
Class of study	1-5	17	15	5	0.4525NS
	6-10	23	18	2
Previous history of hospitali sation	Yes	33	22	4	3.1638NS
	No	7	11	3
Previous history of surgery	Yes	12	5	1	2.5806NS
	No	28	28	6
Type of surgery	Major	25	27	5	4.2334*
	Minor	16	5	2

^*significant at p< .05

 

Table 4 shows that the calculated chi square value for type of surgery and anxiety of children undergoing elective surgery is significant at p< .05 showing a association with the variable.

 

Table 5: Significance of association of anxiety of children undergoing elective abdominal surgery with selected mother’s variables

Variables	Levels of mothers anxiety				χ2 value
		Mild	Moderate	Severe
Education	High school	16	16	4	0.3686NS
	College	24	17	3
Previous experience in child’s hospitalisation	Yes	32	24	5	0.4305NS
	No	8	9	2
Previous experience in child’s surgery	Yes	11	4	1	2.8125NS
	No	29	29	6

 

Table 5 shows that all there is no association with anxiety of children undergoing elective abdominal surgery with the mother’s variables based on the chi-square values.

 

DISCUSSION:

In the present study, among the children 47.5 % had mild anxiety, 41.25% had moderate anxiety and 11.25% had severe anxiety. In a study done in 60 children between 7 to 12 years scheduled for elective surgery reports 48% of children had high baseline anxiety¹². In a cross sectional survey on 113 children, aged 2-12 years, undergoing minor elective surgery 30% were significantly anxious. These findings support the current study results¹³.

Among the mothers 18.75 % had mild anxiety, 31.25% had moderate anxiety and 50% had severe anxiety. This finding is almost similar to the findings in a study done to measure the anxiety levels in 100 parents of children scheduled for elective surgery at the Royal Aberdeen Children's Hospital which revealed that forty-two per cent of parents were significantly anxious⁹.

 

There was a statistically significant correlation between child’s anxiety and mother’s anxiety (r = 0.348, p<.01) in the present study. This finding is contradictory to the findings of earlier researcher¹⁰ who has conducted a study in 117 children during pre operative anaesthesia visit. Association between patient factors and child’s anxiety revealed that there was a significant association between type of surgery and child’s anxiety (χ² = 4.334, p<.05), which was contradictory to the findings of earlier researcher¹⁰. In the same study it did not find any association of child’s previous surgery and parental education with child anxiety. This finding is similar to the current study findings. In the present study it is also found that there is no association of age, gender, class of study and previous history of hospitalisation with child’s anxiety. Among the maternal factors education, previous experience of mother in child’s hospitalisation and previous experience of mother in child’s surgery did not show a statistically significant association. A study conducted by Torlutter, Michéle on 113 children undergoing minor elective surgery revealed that gender of the child and parent’s education were not associated with child anxiety¹³.

 

Anxiety states are not universal. Factors associated with anxiety of child and mother may differ in different cultures and countries. In the Indian context it is the mother ,who always care for the child in the hospital and home. It is important to explore the factors related to children and their mothers in the particular settings where specific preparation programmes for surgeries are planned.

 

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11.     Mathew P, Malik R, Yaddanappudi S, et al. PS-072 Assessment Of Factors Affecting Pre-operative Anxiety And Compliance To Anaesthesia Induction In School-going Children.Archives of Disease in Childhood 2014;99:A137-A138 http://dx.doi.org/10.1136/archdischild-2014-307384.368

12.     Torlutter, Michéle A Cross Sectional Survey investigating the prevalence of Preoperative anxiety In Children, and association with cultural and socio-economic background African journal Of Primary Health Care and Family Medicine, March 2012 ISSN: 2071-2928 (print) | ISSN: 2071-2936 (online)

 

 

 

Received on 14.06.2017       Modified on 28.08.2017

Accepted on 29.10.2017      ©A&V Publications All right reserved