RAJIVGANDHI UNIVERSITY OF THE HEALTH SCIENCES, KARNATAKA, BANGALORE ANNEXURE-II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
01 NAME OF THE CANDIDATE AND MS. VIJAYALAKSHMI.J ADDRESS Ist YEAR M.Sc NURSING RAJEEV COLLEGE OF NURSING, HASSAN.
02 NAME OF THE INSTITUTION RAJEEV COLLEGE OF NURSING, KR PURAM, HASSAN
03 COURSE OF THE STUDY AND M.Sc NURSING Ist YEAR SUBJECT CHILD HEALTH NURSING
04 DATE OF ADMISSION TO COURSE MAY 15TH 2007
EFFECTIVENESS OF PLAY THERAPY 05 TITLE OF THE STUDY IN REDUCING POST OPERATIVE PAIN OF TODDLERS ADMITTED IN POST OPERATIVE WARDS IN SELECTED HOSPITALS AT HASSAN.
5.1 STATEMENT OF THE PROBLEM A STUDY TO ASSESS THE EFFECTIVENESS OF PLAY THERAPY IN REDUCING POST OPERATIVE PAIN OF TODDLERS ADMITTED IN POST OPERATIVE WARDS IN SELECTED HOSPITALS AT HASSAN.
6. BRIEF RESUME OF INTENDED WORK
6.1. INDRODUCTION
“Play is a child's work and this is not a trivial pursuit" - Alfred Adler.
The way a child most naturally express himself / herself is through their play. Often we find that the child who is confronted with a major life adjustment. Play Therapy is designed to help children grow up as happy and well adjusted as possible 1.
Play is the language of children. Its their most natural activity. Through play children express themselves, explore their world & learn. Play can also be an important therapeutic intervention for children experiencing adjustment problems. Play therapy offers children a safe, natural and non-intrusive method of recovering from distressing life events. It can be useful intervention for children exhibiting a range of problematic behaviour such as regression, anxiety, extreme anger, aggression & fears 2.
Play Therapy is a specific counseling approach in which games, toys and mediums such as clay, drawings and painting are used to help a child to express their emotions, thoughts, wishes and needs. It helps them to understand muddled feelings and upsetting events that they have not had the chance or the skills to sort out properly. Rather than having to explain what is troubling them, as adult therapy usually expects, children use play to communicate at their own level and at their own pace, without feeling interrogated or threatened 3. .
In 1873, Spencer declared that play activity, driven by surplus energy is directed towards activities which have a prominent role in the animal's/person's life. He emphasized a close relationship between art and play saying that "..Art is but one kind of play."
Around the same time, however, Schiller (1875) believed that play had no real purpose other than to use up excess energy. He said ". Play is the aimless expenditure of exuberant energy.... children and young animals, not concerned with self preservation, have surplus energy which they expended through play."
Since then, people have recognized the importance of play. Freud, Piaget and Vygotsky developed theories that relate play to the world of children and many others have restated the significance of play within a child's life.
Virginia Axline (1947/69) has been instrumental in the development of this approach. She believed that the child has within them the ability to solve their own problems. She emphasized the use of play therapy to allow a child to reach for independence.
Bruner (1972); Nature and Uses of Immaturity; identifies play of having various different functions, such as minimizing the consequences of action, therefore learning in a less risky situation, and the opportunity to try combinations of behaviour that would not otherwise be tried. Others have since taken on board the therapeutic nature and the ability of play to help identify problems. Freud identified his theories of play as a repetition of symbolic games being the ego's attempt to repeat actively a traumatic event, previously experienced passively, thus allowing the child to gain mastery over the event. From this, a psychoanalytic approach to child analysis developed which used play to interpret the child's unconscious motivation.
Anna Freud looked for the unconscious motivation behind imaginative play, drawings and paintings, dreams and daydreams. She emphasized the importance of the relationship between the therapist and the child, in particular, the initial stages, She pointed out that this relationship was problematic because the parents (the original love object) are still very much active in the child's life, thus leading to strong positive transference, but difficult negative transference and a transference neurosis does not develop.
Non-directive play therapy looks at play as a healing process. It gives the child the opportunity to 'play out' feelings and problems and learns about themselves in relation to the therapist. It allows for the acceptance of the child without judgment or pressure to change. Play is the child's natural medium for expression and in play therapy; the child can play out feelings of tension, frustration, insecurity, aggression, fear, bewilderment and confusion 4.
A study was done by use of puppet shows, as therapeutic play, to decrease anxiety in hospitalized preschoolers (1998) in USA The results of this study support our group's research utilization project to educate nurses on the effects of therapeutic play on anxiety levels in hospitalized children. Nurses could use this information to implement therapeutic play in hospitals throughout the world. Feasibility issues would include the cost of materials needed and the time involved to educate nurses. More research should be done on therapeutic play as a method to decrease anxiety in children. Future research could be conducted using other cultures or age groups 5
6.2. NEED FOR THE STUDY
“Play is an occupation that enhances our quality of life. Play and an attitude of playfulness can make everyone’s life more interesting and enjoyable”.
— Vanessa Ong
Play provides children the opportunities to be free, creative and expressive. Play is synonymous with being a child and it is the universal language of children. Play allows children to learn social behaviour, develop cognitive abilities as well as gross and fine motor skills, and work through emotional conflicts. Hospitalization to any child is a very unpleasant and traumatic experience. The child undergoes a break from his normal routine, feels separated, encounters strangers and is subjected to a lot of interventions which are directed to the promotion of his health, but aggravate his pain and suffering.
The hospital is also an unfamiliar environment and hospitalization is a frightening experience to the child. The investigator from her observation feels that a child most often looks dull, anxious or afraid in the hospital. Many parents also verbalize that their children who are generally sociable and outgoing become very passive after their admission to the hospital 6. Hospitalized children require more than recreational play because illness and hospitalization constitute crisis in a child's life and since these situations are fraught with overwhelming stresses, children need to play out their fears and anxieties as a means of coping with these stresses. Play also helps temporarily to divert their mind from pain and loneliness.
The Investigator came across with the hospitalized children; they experienced more pain after the surgery. The investigator feels that the play therapy will help to express their emotions & to reduce the pain by diverting the mind. Painful procedures such as surgery.
6.3. STATEMENT OF THE PROBLEM:
“A STUDY TO ASSESS THE EFFECTIVENESS OF PLAY THERAPHY IN REDUCING POST OPERATIVE PAIN OF TODDLERS ADMITTED IN POST OPERATIVE WARDS IN SELECTED HOSPITALS AT HASSAN ”.
6.4. OBJECTIVES OF THE STUDY:
* Assess the post operative pain level of toddlers.
* Administer Play therapy among toddlers admitted in Postoperative ward.
* Asses the effectiveness of Play therapy in reducing post operative pain of toddlers.
* Compare the Pretest pain level & Posttest pain level of toddlers.
* Associate the posttest pain level of toddlers of experimental group with selected demographic variable.
6.5 HYPOTHESIS:
H1 : There will be a significant difference between the pretest and posttest pain level among toddlers during their post operative period.
H2 :There will be association of the posttest pain level of toddlers of experimental group with selected demographic variable.
6.6 OPERATIONAL DEFINITION:
1. Assess:
It is the statistical measurement pain level observed by Wong-Baker Faces Pain Rating Scale 2. Effectiveness:
The changes in the pain level after giving the play therapy among toddlers being measured through the structured tool.
3. Play therapy:
It is a specific counseling approach in which games, toys and mediums such as clay, drawings and paint are used to help a child to express their emotions, thoughts, wishes and needs
4. Postoperative pain:
It is the pain experienced by the toddlers after surgery
5. Toddlers:
The children who are between 1-3 yrs of age group
6. Postoperative ward:
It is the ward where the children are admitted after the surgery.
6.7: Inclusion & exclusion criteria :
I. Inclusion criteria:
1. The children who are in toddler age group [ 1-3 yrs]. 2. The children who are admitted in first day of after surgery in postoperative ward in selected hospital at Hassan
II . Exclusion criteria:
1. The children who are not in toddler age group [1-3 yrs] 2. The children who are not admitted in postoperative ward in selected hospital at Hassan 3. The children who are not available during collection of data. 4. The Children undergone major surgeries.
6.8. DELIMITATION:
1. The sample size is limited to 50 toddlers. 2. Prescribed data collection is only 4-6 weeks. 3. Study design is limited to Quasi experimental design 6.9 SIGNIFICANCE OF THE STUDY:
The study signifies the effectiveness of play therapy in reducing postoperative pain among toddlers.
6.10. CONCEPTUAL FRAMEWORK:
It is based on Johnson Behavioral Theory.
6.11: REVIEW OF LITERATURE:
Literature review is a standard requisition of scientific research. It means reading and writing the pertinent information of the attempt in research topic to understand better about the proposed topic. It also supports and explains why the proposed topics taken for research and avoid unnecessary duplication, explore the feasibility and illuminate way to new research 7.
A Questionnaire was given to assess the knowledge, attitude and practice of the parents and nursing personnel regarding the importance of play needs in hospitalized children between the age group of one month to twelve years. The assessment of the knowledge of parents reveals that 99.07% had adequate knowledge and 0.93% had a moderately adequate knowledge regarding the importance of play needs in children. The assessment of the knowledge of nursing personnel reveals that 86.11% of them had adequate knowledge and 13.89% had a moderately adequate knowledge regarding the importance of play in hospitalized children. This study recommends that the children can also be taken to the playroom where play can be organized because a playroom without toys or children will not serve the purpose of its existence in the ward 6.
The University of Hong Kong, conducted this study was to examine the effects of therapeutic play on outcomes of children undergoing day surgery [2007]. Two hundred and three children admitted for day surgery were invited to participate in a randomized controlled trial. The experimental group received therapeutic play; the control group received routine information preparation. Children in the experimental group reported significantly lower state anxiety scores in pre- and postoperative periods and exhibited fewer negative emotions at induction of anesthesia than children in the control group. No significant differences were found between the two groups in postoperative pain. The study provides some evidence that therapeutic play is effective in pre- as opposed to post surgical management of children 8 .
A study on Pretend play in medical settings indicates that pretend play interventions are effective in inpatient and outpatient settings for preventing and reducing anxiety and distress[2006] in USA. Pretend play also has effects on pain, externalizing behavior, and adaptation to chronic illness. Such effects have been demonstrated in the short term; however they have not been shown to be stable in the long term, indicating that intermittent refresher sessions may be necessary. This study concluded that play is a helpful intervention and that future research that addresses these limitations is warranted 9.
Therapeutic play has been demonstrated as an effective nursing intervention in Chang Jung Christian University, Taiwan [2006]. Through therapeutic play, children can acquire opportunities to express themselves and deal with stress related to health experiences. Also, nurses can gain insights into children's cognition, perception, and needs. This paper introduces concepts of therapeutic play. We hope that nurses will be able to incorporate it into pediatric nursing practice and provide care as a traumatically as possible10.
A study was design on Pretend play an application of an intervention program in autism [2006] Spain. The efficiency and effectiveness of the program is reflected in the results that indicated the subject's competence to generate and comprehend the pretense as well as to generalize the acquired knowledge into other areas of mentalistic functioning. This study discuss the possibility to develop a metarrepresentational knowledge based on the internalizing of the strategies of conceptual support 11.
A study on Music Play therapy the parent-child Psychotherapy for children 0-4 yrs was carried out in Berlin [2005]. It is the basis for the child's development of the ability to relate to others and his or her further emotional, social and cognitive development. In this important early phase various risk factors may alienate parents from their intuitive parental competence towards their children. Such interaction problems indicate an intervention in the form of parent-children psychotherapy. The early relationship is characterized mainly by complex communication sequences that address the senses at all levels. Therefore, the MPT concept integrates music as medium to communicate and opens up a playing space for play that allows emotions and experiences to be expressed. The components of music such as rhythm, sound, and melody stimulate babies and toddlers to express, play, and communicate preverbally.. Parents learn again to play and thereby learn to reach their children emotionally and to communicate with them 12.
The article reports the results of a pilot study comparing traditional behavioural approaches and natural play interventions for young children with autism over a 10 week period in Singapore [2004]. Two matched groups of eight young children with autism participated. Using a crossover design, children in both groups showed positive gains in compliance, attending, play and communication with their therapists and parents. Improvements in attending and compliance were higher following the behavioural condition compared with the natural play condition. Seven participants had reduced autism scores after the intervention. The findings suggest that behavioural and play approaches affect behavior in different ways and that autistic symptomatology of young children may be amenable to treatment13. A qualitative study on Doing Play: competency, control & expression among 19 participants aged 8-13 were conducted in Canada [2003]. The three themes uncovered in the data include (a) doing play, (b) it's my way that matters, and (c) how I see me. The sub-theme safety also emerged. This study showed that children with physical disabilities are often limited in their play experience compared to their peers without physical disabilities. Children perceived engagement in a virtual reality play intervention program as an enjoyable experience, which increased their self-competence and self-efficacy. Participants experienced a sense of control and mastery over the virtual environment and were provided a safe way to explore and challenge their abilities. Participants perceived experiencing flow and reported perceived physical changes and increased social acceptance from both peers and family. These findings provide evidence that virtual reality continues to show promise as a pediatric rehabilitation play intervention tool 14.
A study was conducted on Therapeutic Play: developing humor in the nurse-patient relationship in New York acute care hospital [2003]. This study was identified as Therapeutic Play, in which humor involves caring for self or another. This study offers nurses and others involved in professional relationships an explanation of the development of humor as an alternative healing-caring strategy15.
A Study on Play therapies are psychotherapies with the medium of play primarily for children under 12 years of age [2003], Play therapies have gained importance and relevance in the 1990's, reflected in a wide range of publications. Different forms of play therapy, as well as behavioural and family therapy have been integrated16
A study on Playing in Hospital: addition to nursing care [1999]. Playing is one of the essential activities for the physical, emotional and social development to the child. The empiric data collection was realized through the participant observation of 11 children who were intern in a pediatric unit of a teaching hospital of State of Sao Paulo up country. This study concluded that the act to play has repercussions in the child, nurse and hospital. To the child it is not obstruct the development; help it in the understanding about what is occurring with itself and discharge fear, tension, anxiety and frustration; promote satisfaction, funny and spontaneity and allows it transforms experiences that should support inactive in active discharge. To the nurse it is a tool of intervention and a way of communication, that allows detect the uniqueness of each child. Related to the hospital, change the current view that is only a pain and suffering place17.
Therapeutic play in the form of an interactive puppet show was administered to 50 preschool children one day before surgery in a hospital in Lebanon [1998]. A control group of 50 preschool children received routine care. but no therapeutic play. Physiological and behavioral measures were assessed on admission, at the time of a stressful procedure (preoperative injection), after surgery, and after discharge. Although on admission there had been on significant differences between the means on physiological measures for the two groups, the children who received the therapeutic play intervention manifested markedly less anxiety and more cooperation and had significantly lower mean blood pressures and pulse rates during the injection than the control group. Following surgery, the experimental group took less time to void their bladders, another physiological indication of lower stress level. After hospital discharge, the children who had received therapeutic play had significantly lower scores on all six factors of the Post Hospital Behavior Questionnaire. This study demonstrates that therapeutic play is a valid means of reducing stressful responses to hospitalization and surgery among children in Lebanon18.
An article discusses the difference between play therapy with toys and play therapy with games from a psychodynamic point of view [1998] in Israel. Toys are regarded as offering the child an opportunity to develop a variety of transference reactions, while games, because of their inherent competitive characteristic, restrain the scope of possible transference reactions. The authors claim that therapists should consider these eventualities when choosing which games or toys are to be available in the therapy room. This choice might determine, in advance, the initial characteristics of the patient's transference19.
A study on Therapeutic Play in the care on hospitalized children: experience of an undergraduate student in Sao Paulo [1998]. This study describes a phenomenological analysis of an nursing under graduated students discourse, who used the therapeutic play for caring a hospitalized child. The goal of the study was to understand the meaning of the experience for this student 20.
Magnetic resonance (MR) imaging has become an important technique in the evaluation of a wide range of congenital and acquired conditions in children [1997] in UK. This study describe a technique involving play therapy which we have found useful in the preparation of young children for MR imaging and which has reduced the number of non- diagnostic scans and the need for sedation or anesthesia 21.
7. MATERIALS AND METHODS OF STUDY 7.1 SOURCE OF DATA:
The data will be collected from toddlers admitted in postoperative wards in Selected hospital at Hassan.
7.2 RESEARCH DESIGN: A Quasi-experimental research design with pretest and posttest which includes randomizations and no control group.
Group Pretest Intervention Posttest
Toddlers Experimental admitted Group 01 02 in selected hospitals at Hassan Key:
01 – Pretest pain level - Intervention [Play therapy] 02 - Posttest pain level after giving play therapy.
7.3 METHOD OF DATA COLLECTION:
Data will be collected with Observational Schedule.
The Structured Interview Schedule consists of 2 parts.
Section A: Semi Structured Questionnaire seeks information about Demographic Data. Section B: Structured Questionnaire seeks information about Pain level
Sampling Procedure:
Population:
All toddlers in selected Hospitals at Hassan.
Sample:
Toddlers admitted in postoperative ward in selected hospitals at Hassan;
Sample size:
Sample comprises to 50 toddlers in experimental group.
Sample technique:
Probability method- randomoization method.
Setting:
The study will be conducted in Selected hospitals at Hassan.
Pilot study:
Pilot study is planned with the 10% of population
8 . VARIABLES:
8.1 Independent variable:
Play therapy
8.2 Dependent variable:
Postoperative pain of toddlers admitted in postoperative wards. 9. ETHICAL CONSIDERATION:
1. Does the study require any intervention to be conducted on toddlers? Yes
2. Has ethical clearance being obtained from your institution? Yes
3. Has consent taken from hospital authorities? Yes
10. LIST OF REFERENCES:
1. Willam.A. Rae etal. The Psychosocial Impact of Play in Hospatalised Children. 2002; Oct :2
2. Boland. Play Therapy. 2000; Feb: 23
3. Linda. Shekerdemian. The Importance of Play. 1998;Nov:10
4. Welesley. A Brief history of Play and Play Therapy Theories. 2007; Nov:8
5. Bowmer. N. therapeutic Play and the impact on Anxiety in hospitalized children.2002; Jan-mar:50[1]:15.
6. Beryl Juilet Sam. Importance of Play for Hospitalized Children. The Nursing Journal OF India.2007; Vol 98; Oct: 10
7. Denise.F.Pilot. Cherryl Tataro Beck. Nursing Research Principles & Methods. 200; 7 th edition : 88-91.
8. Willam. Etal. Effects of preoperative therapeutic play on outcomes of school age children undergoing day surgery. 2007; June: 30[3];320-32.
9. Moore.M,Russ SW. Pretend Play as resource for children:Implications for Pediatricians & health Professionals. 2006;June:27[3]:237-48
10. Wang YL,Lo LH. Therapeutic play. 2006;June53[3]: 79-83.
11. Paz Miguez MJ. Etal. Pretend Play:an application of an intervention program in autism. 2006; Feb:18[1]:9-17.
12. Stumptner.K. Etal. Music Play Therapy- A parent child Psychotherapy for children 0-4 yrs old.2005;Oct:54 [8]:684-99. 13. Bernard Opitz. Etal.Comparison of Behavioural & Natural Play Interventions for Young Children with autism.2004;Sep:8 [3]:319-33.
14. Miller.S. Reid D. doing Play: Competency, control & Expresion. 2003; Dec :6[6]:623-32. 15. Greenberg. M. Therapeutic Play: Developing Humor in the Nurse Patient Relationship. 2003; Spring Summer: 34[1]: 25-31.
16. Von Gontard. A. Etal. Play Therapy- Pschotherapy with Play as the medium. 2003; Feb:52[2]:88-97.
17. Furtado. MC.Etal. Playing in Hospital –addition to nursing care. 1999; Dec: 33[4] :364-369.
18. Zahr. LK. Therapeutic Play for hospitalized preschoolers in Lebanon. 1998; Sep-Oct; 24[5]:449-54.
19. Meschiany. A Etal. Toys & Games in Play Therapy. 1998; 35[1]:31-37.
20. Riberio CA. therapeutic Play in the care of Hospitalized children: experince of an undergraduate student.1998;April; 32[1]:73-79
21. Presdee.D. Etal. The use of play therapy in the preparation of children undergoing MR Imaging.1997; Dec;52[12]: 945-7.
12 Signature of the candidate
13 Remarks of the guide
14 Name and designation
14.1 Guide
14.2 Signature
14.3 Head of the Department
14.4 Signature
15 Remarks of the Principal
15.1 Signature