Open Journal of Nursing
Vol.4 No.7(2014), Article ID:47064,12 pages DOI:10.4236/ojn.2014.47059

Psychological Preparation of Children for Surgery: Awareness Survey Targeting Medical Professionals

Naomi Matsumori

Department of Nursing, Faculty of Health and Welfare, Prefectural University of Hiroshima, Hiroshima, Japan

Email: matumori@pu-hiroshima.ac.jp

Copyright © 2014 by author and Scientific Research Publishing Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

Received 17 April 2014; revised 26 May 2014; accepted 16 June 2014

ABSTRACT

The objective of this study was to conduct a nation-wide survey to investigate the state of: 1) the prevalence of psychological preparation of children undergoing surgery; and 2) the awareness of psychological preparation of children by medical professionals (physicians and nurses). We also aimed to identify the issues that need to be addressed next. A total of 178 physicians and 291 nurses working in hospitals where children undergo surgeries participated in this study. Anonymous self-administered questionnaire survey. Physicians and nurses in Japan are aware of the need to provide age-appropriate psychological preparation for children undergoing medical procedures. In current practice, however, our study revealed that surgical orientations are given solely to parents in the absence of the child in approximately 30% of cases. While approximately 60% of respondents felt that the use of “children’s picture books and booklets” are good methods for delivering explanations to children, only about 20% of respondents were implementing psychological preparation specific to each age group, and half of the respondents were providing verbal explanations alone. Meanwhile, 77% responded that it is “time-consuming” and 48% said, “on the contrary, it may heighten their anxiety”. Also 34.3% said that they “do not know how to explain to a child” and 54.8% of these medical professionals worked in mixed wards. We observed a gap between ideal requirements and current practices. We found that it is essential to: 1) organize training sessions for knowledge acquisition; 2) consciously strive to be informed of the actual post-surgery conditions and outcomes of the children; and 3) acquire physical and financial support.

Keywords:The Awareness, Psychological Preparation, Children Undergoing Surgery, Physicians and Nurses in Japan

1. Introduction

The need for psychological preparation to minimize the emotional stress of children undergoing medical procedures has been advocated in the West since the 1930s [1] . In the 1940s and 50s, along with allowing parents unlimited visitation, pediatric nursing practice began to consider the emotional impact of an illness and hospital stay on a child. Psychological preparation programs that incorporated pre-admission hospital tours, booklets and children’s picture books, puppets and drawing therapy were developed [2] . Around the 1970s, this concept was adopted in the field of nursing in Western countries. In 1994, triggered by the ratification of the Convention of the Rights of the Child in Japan, books and journals introduced psychological preparation as one of the ways to protect the rights of a child in the medical setting. In 1998, Kiuchi et al. introduced “preparation” as a word that points to a child’s informed consent, which had been used in Sweden as part of play therapy. In 1999, the Japanese Nursing Association included in its Standards of Practice for Pediatric Nursing the need to: 1) timely explain testing, treatment, medical condition and procedures to the child and the child’s guardians, and 2) strive to obtain consent, approval and understanding from them. The Japanese Nursing Association proposed the importance of using simple, developmentally appropriate language and pictures [3] . Since then, psychological preparation has gradually been introduced into practice in hospital wards and in research. There were 334 literature citations in the Japan Medical Abstracts Society website in the 10 years between 1999 and 2009. A rapid increase was observed after 2002, when 255 citations were found.

Since 2002, we have been investigating the status of the practice of psychological preparation and prevalence in the field [4] . In the present study, we added new items to our previous survey questions and conducted a nation-wide survey to investigate the current status and bring to light the relevant issues. This study will report the findings of an awareness survey of medical professionals working at hospitals where they are involved with children’s surgeries.

1.1. Definition of Terminology

In this study, “psychological preparation” refers to the mental and emotional preparedness of a child undergoing a medical procedure. This study focused on respecting the “right of a child to know”; therefore, psychological preparation was investigated from the perspective of “providing an explanation to the child”.

1.2. Study Objective

The objective of this study was to conduct a nation-wide survey to investigate the state of: 1) the prevalence of psychological preparation of children undergoing surgery; and 2) the awareness of psychological preparation of children by medical professionals (physicians and nurses). We also aimed to identify the issues that need to be addressed next.

2. Methods

2.1. Participants

A total of 178 physicians and 291 nurses working in hospitals where children undergo surgeries participated in this study.

2.2. Survey Method

Anonymous self-administered questionnaire survey Prior to conducting the survey, requests were sent out to 2400 hospitals with pediatric practices. Questionnaires were delivered to those hospitals that indicated their willingness to cooperate. Completed forms were collected through either the placement method or by return mail.

2.3. Scope of the Survey

Medical professionals (physicians and nurses) participated by providing their opinions about the “psychological preparation of children undergoing surgery”. The main questions on the survey sought to investigate: 1) the need to provide explanations to children about their surgeries and current practices; 2) actual details of explanations that are currently given and suggestions on areas where briefing and support is further needed; 3) actual methods of presenting the information and opinions on successful delivery methods; and 4) opinions and personal experiences on briefing children undergoing surgery and how to assist with their psychological preparation.

2.4. Method of Analysis

Numerical data was tabulated using Microsoft Excel. Statistical analysis was conducted using the x2 test in SPSS software version 19 (IBM, Chicago, IL). Data were rounded to two decimal points.

2.5. Ethical Considerations

A request to the participants was attached to the questionnaire in the form of a letter from the Hospital Director. Participation in the study was on a voluntary basis. Consent was assumed upon return of the completed questionnaire. To ensure anonymity, there was no place to write facility or personal names on the questionnaire. To prevent data leakage, data were stored on a computer secured by a password and were only used for purposes of this study.

3. Results

3.1. Basic Attributes of Participants (

Table 1)

A total of 236 medical professionals (50.7% response rate) working at hospitals where surgeries on children are

Table 1. Background of participants.

performed responded to the questionnaire. The breakdown was as follows: 51 physicians (28.7% response rate) and 185 nurses (63.6% response rate). The number of beds in the hospitals where the participants worked was as follows: <300 bed hospital (25.6%), between 300 and 500 bed hospital (34.0%), and ≥500 bed hospital (38.2%). As for their affiliation, 55.1% of the respondents worked in hospital wards exclusively for children and 42.4% worked in mixed wards alongside adult patients. Hospital stay required for postoperative recovery, from the most common type of surgery to the least common, was “between 4 to 7 days” (51.3%), “8 to 14 days” (20.6%) and “1 to 3 days” (18.5%).

3.2. The Need to Explain Surgical Procedures to Children and Current Practices

With regard to explaining surgical procedures to children, 85.3% of participants “strongly agree” that “depending on the child’s age, explanation of surgical procedures to the child is necessary”. Combined with the 8.4% of participants who said, “slightly agree”, more than 90% of participants expressed the need. In current practice, 49.6% replied that they “often” provide “explanations depending on the child’s age”. Similarly, 26.1% said that explanations are provided “most of the time”. Out of the36 participants (15.1%) who responded “sometimes” and “none at all” to the question whether in current practice “explanations are provided depending on the child’s age”, all participants said that they either “strongly agree” or “slightly agree” to the question “depending on the child’s age, explanation of surgical procedures to the child is necessary” (Figure 1).

A total of 14.2% responded that they “strongly agree” and “slightly agree” that it is “sufficient to brief the parents during surgical orientation and children do not have to be present”. Combined with those who responded, “slightly disagree” and “strongly disagree” the total was 77.7% (Figure 2). Out of these respondents, 23 participants (53.5%) said that they are currently “conducting surgical orientation for parents with children”. As for those who are currently “conducting surgical orientation for parents without children”, 13.0% responded “often” and 16.4% said “most of the time”, which indicated that approximately 30% are engaged in this practice. In this 30% of respondents, 66.7% replied that they “slightly disagree” and “strongly disagree” that it is “sufficient to brief parents during surgical orientation and children do not have to be present” (p < 0.01) and they all responded that “depending on the child’s age, explanation of surgical procedure to the child is necessary” (Figure 3).

3.3. The Ideal Method for Explaining to Children and Current Practices

As for the ideal method for explaining to children, approximately 60% of the participants responded that for each age group, “dolls” and “children’s picture books and booklets” should be used, and 10% to 30% responded that “only verbally” was ideal. In current practice, approximately 40% of the participants explain “only verbally” and about 25% use “children’s picture books and booklets” (Figure 4).

3.4. Awareness of Psychological Preparation of Children

Over 90% of the participants “strongly agree” and “slightly agree” that psychological preparation both “nurtures a trusting relationship with the child” and “nurtures a trusting relationship with the family”. In addition, 80% of participants responded that it is “necessary for the future emotional development of the child” and that they “understand that this means ‘to explain to the child before hand’”. Meanwhile, 77% responded that it is “timeconsuming” and 48% said, “on the contrary, it may heighten their anxiety”. Also 34.3% said that they “do not know how to explain to a child” and 54.8% of these medical professionals worked in mixed wards.

3.5. Requirements for the Provision of Psychological Preparation of Children

When the participants were asked what was required for psychological preparation, over 90% responded that they “strongly agree” and “slightly agree” that the following is required: “information on the significance and effects of psychological preparation”; “training sessions on how to implement psychological preparation”; “collaborative relationships with other members involved in preparation process (i.e. doctors and nurses)”; “providing not only pre-surgery explanation, but also to be informed of the child’s actual post-surgery conditions and outcome”; “reorganizing workload to free up time”; “understanding and cooperation from superior doctors and nurses”; “one’s motivation and drive to implement psychological preparation”; and “funding to purchase materials for the explanation”.

Figure 1. Explanations are provided depending on the child’s age.

Figure 2. Sufficient to brief parents during surgical orientation and children do not have to present.

Figure 3. Conduct surgical orientation for parents without children.

Figure 4. Awareness and current practice in explanation process.

3.6. Open-Ended Responses (

Table 2)

The responses to the open-ended questions received from the doctors and nurses were divided into 10 categories depending on the content of their replies and presented within [brackets]. Within each category, some representative responses are quoted directly, using quotation marks.

In the [implementation by nurses] category, a participant responded that “surgical nurses are responsible for providing the explanation”. Participants noted that “dolls are used”, “a ward mascot was created” and “used praise” as [methods of explanation and preparation]. As for [considerations for implementing psychological preparation], they suggested that it is “important to have a good time with the child” and to “build a rapport with the nurse”. Whether [psychological preparation of the child is necessary], a participant said that it is “not limited to surgical procedures”. As for the [effectiveness of explaining to children], a respondent said that “awareness of the importance of child preparation is raised when psychological preparation is implemented”. As a [positive reaction of children and their families], a participant responded that he/she was “able to build a trusting relationship with the child’s family”. However, as a [difficulty in post-implementation evaluation] a participant raised the point of “evaluations being difficult as the surgery only required a short hospital stay”. Also, respondents listed “busy schedule”, “time-consuming”, and “short hospital stay” as reasons for [not practicing psychological preparation]. For those who [do not know], they responded that they “did not know how to proceed”. As for [requirements for dissemination of the practice], respondents expressed “interest in opportunities to learn” and “interest in finding out approaches of other hospitals”.

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4. Discussion

4.1. The Need to Explain Surgical Procedures to Children and Current Practices

Over 90% of participants responded either “strongly agree” or “slightly agree” that surgical explanation for children is needed “depending on the age of the child”. Ebina et al. (2004) found that 10% of physicians and 30% of nurses felt the need to explain surgical procedures to children between the ages of 3 and 5 [4] . Similarly, slightly less than 40% and 70% of physicians and nurses, respectively, felt that explanations were needed for children between the ages of 6 and 8. For children between the ages of 13 and 16, 70% of physicians and approximately 90% of nurses responded that explanations were needed. Since this study did not investigate the need of explanation by proportion for different age groups, their perception for each age group was not identified. However, their awareness has been raised. While approximately 30% of all the participants responded that

Table 2. Responses to the open-ended questions.