Lampiran 1 CRITICAL APPRAISAL JURNAL 1 Effects of ...

Lampiran 1

CRITICAL APPRAISAL JURNAL 1

Effects of Auditory and Audiovisual Presentations on Anxiety and Behavioral

Changes in Children Undergoing Elective Surgery

Pertanyaan Fokus Yes No Unknown

Bagian A : Apakah hasilnya valid?

A. Apakah studi tersebut menjelaskan masalahnya secara fokus

(studi populasi, intervensi, kelompok kontrol/intervensi, hasil)

√

B. Apakah pembagian pasien kedalam kelompok intervensi dan

kontrol dilakukan secara acak (bagaimana dilakukan, apakah

alokasi pasien dilakukan secara tersembunyi dari penelitian

dan penelitian)

√

C. Apakah semua pasien yang terlibat dalam penelitian dicatat

dengan benar di kesimpulan (apakah dihentikan lebih awal,

apakah pasien dianalisis dalam kelompok untuk yang mereka

acak)

√

D. Apakah pasien, petugas kesehatan, dan responden pada

penelitian ini “blind” terhadap intervensi yang dilaksanakan

√

E. Apakah waktu pelaksanaan untuk setiap grup sama? √

F. Selain intervensi yang dilaksanakan, apakah setiap grup

diperlakukan sama/adil?

√

Bagian B : Apa hasilnya?

A. Seberapa besar efek dari intervensi tersebut (outcome,

hasilnya dijelaskan spesifik, hasil yang ditemukan, hasil

dari setiap outcome yang diatur)

√

B. Seberapa tepat dan akurat efek intervensi? √

Bagian C : Apakah hasil membantu secara lokal?

A. Bisakah hasilnya diterapkan pada populasi lokal, atau

konteks saat ini di lingkungan sekarang (apakah

karakteristik pasien sama dengan tempat bekerja/populasi

anda, jika berbeda apakah perbedaannya)

√

B. Apakah hasil penelitian ini penting secara klinis untuk

dipertimbangkan (apakah informasi yang anda inginkan

sudah terdapat dalam penelitian, jika tidak apakah akan

berpengaruh terhadap pengambilan keputusan)

√

C. Apakah manfaatnya sepadan dengan bahaya dan biaya

yang dibutuhkan (meskipun tidak tercantum dalam

penelitian, bagaimana menurut anda?)

√


Pengaruh Audiovisual Menonton Film Kartun terhadap Tingkat Kecemasan Saat

Prosedur Injeksi pada Anak Prasekolah





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dan penelitian)

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acak)

√



√




√





√







√





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Psychological Preparation Reduces Preoperative Anxiety in Children.

Randomized and Double-Blind Trial





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dan penelitian)

√




acak)

√



√




√





√







√





√




√


Video Distraction and Parental Presence for the Management of Preoperative Anxiety

and Postoperative Behavioral Disturbance in Children: A Randomized Controlled Trial





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dan penelitian)

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acak)

√



√




√





√







√





√




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Video Kartun dan Video Animasi dapat Menurunkan Tingkat Kecemasan Pre

Operasi pada Anak Usia Pra Sekolah





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dan penelitian)

√




acak)

√



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√





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√

Lampiran 2

INSTRUMEN PENERAPAN EVIDENCE BASED PRACTICE (EBP)

MODIFIED YALE PREOPERATIVE ANXIETY SCALE (M‑YPAS)

I. Kuesioner Data Demografi

Petunjuk pengisian : Isilah data di bawah ini dengan lengkap dan berilah

tanda (√) pada tempat pilihan yang tersedia.

1. Nomor Responden :

2. Nama Responden :

3. Jenis Kelamin : ( ) Laki-Laki ( ) Perempuan

4. Umur : Tahun

5. Tanggal Pemeriksaan :

6. Pukul Pretest : Post test :

7. Diagnosa Penyakit :

II. Lembar Observasi Tingkat Kecemasan

Petunjuk : Lingkari satu kategori pada masing-masing domain yang paling

menggambarkan kondisi dan situasi anak.

A. Kegiatan

1. Memperhatikan sekeliling, ingin tahu, bermain, membaca (atau

kebiasaan lainnya).

2. Tidak mau melakukan kegiatan, menunduk, gelisah dengan

memainkan tangan, duduk dekat dengan orang tua.

3. Bergerak tanpa aktivitas yang jelas, menggeliat, memegang orang

tuanya.

4. Menghindari tenaga kesehatan, menolak perlakuan dengan kaki dan

tangan atau dengan seluruh tubuh, tidak mau bermain dan tidak mau

terpisah dari orang tua.

B. Pernyataan

1. Membaca (tanpa suara), bertanya, berkomentar, menjawab

pertanyaan, terlalu asyik bermain untuk merespon.

2. Menanggapi orang yang lebih dewasa dengan berbisik, hanya

menganggukkan kepala

3. Diam, tidak ada respon terhadap orang lebih dewasa

4. Merengek, mengerang, merintih

5. Menangis atau bahkan berteriak “tidak mau di operasi”

6. Menangis, berteriak keras terus menerus.

C. Luapan Emosi

1. Terlihat senang, tersenyum, atau asyik dengan kegiatannya

2. Netral, tidak terlihat emosi yang berarti pada wajah

3. Sedih, wajah ketakutam, terlihat tegang

4. Menangis, menjadi sangat marah

D. Keadaan Ingin Tahu

1. Berjaga-jaga, melihat sekeliling, melihat apa yang dilakukan tenaga

kesehatan

2. Anak berdiam diri dengan duduk tenang dan diam, menatap orang

yang lebih dewasa

3. Waspada melihat sekitarnya, terkejut akan suara-suara tertentu, mata

waspada, bahkan menegang

4. Panik dan merengek, menangis, mendorong orang di sekitarnya.

E. Peranan Orang Tua

1. Sibuk bermain atau sibuk dengan kebiasaannya, duduk tenang, tidak

membutuhkan orang tua, mau berinteraksi dengan oang tua apabila

orang tuanya yang memulai

2. Menggapai orang tua, mencari perlindungan dan kenyamanan,

bersandar pada orang tua.

3. Menatap orang tua, tidak ingin berhubungan dengan orang lain,

melakukan apa yang disuruh bila orang tua berada di dekatnya.

Rentang skor kecemasan

1. Cemas ringan = 30- 53

2. Cemas sedang = 54- 77

3. Cemas berat = 78-100

4. Tidak bisa jauh dari orang tua dan akan marah/menangis apabila

berpisah dengan orang tuanya, memegang erat orang tua dan tidak

melepaskannya, atau mendorong menjauhi orang tuanya.

SKOR TOTAL : (A/4 +B/6+C/4+D/4+E/4) x 100/5

Lampiran 3

STANDAR OPERASIONAL PROSEDUR (SOP)

DISTRAKSI MENONTON VIDEO KARTUN DAN ANIMASI

Pengertian Salah satu distraksi audiovisual yang merupakan jenis distraksi

gabungan dari distraksi audio dan distraksi visual menggunakan

media kartun dan animasi

Tujuan a. Mengurangi cemas (ansietas), setres hospitalisasi dan nyeri akut

skala ringan hingga sedang

b. Pengalihan perhatian klien terhadap sesuatu yang sedang

dihadapi

c. Rasa lebih nyaman, santai, dan merasa berada pada situasi yang

lebih menyenangkan

Indikasi Klien dengan kecemasan, setres hospitalisasi, nyeri akut ringan

hingga berat dan kondisi ketegangan yang membutuhkan distraksi

Kontraindikasi Klien anak yang memiliki kelainan congenital dan penyakit lainnya

seperti down sindrom, tuna netra, tuna rungu serta kondisi anak

sangat lemah sehingga tidak memungkinkan untuk menonton video

Persiapan

Klien

a. Membaca status kesehatan klien

b. Kontrak waktu, tempat, topik, dan kesediaan klien

c. Jelaskan tentang prosedur yang akan dilakukan

d. Atur posisi klien sesuai situasi, kondisi, dan kebutuhan

e. Menjaga privasi klien

Persiapan Alat a. Menyiapkan peralatan (media untuk menonton video kartun dan

animasi)

b. Modifikasi lingkungan senyaman mungkin termasuk suasana

dan kondisi ruangan agar tetap tenang dan jauh dari kebisingan

serta faktor pengganggu saat klien menonton video kartun dan

animasi

Fase Orientasi a. Salam Terapeutik

b. Perkenalan diri pada klien dan keluarga

c. Lakukan evaluasi/ validasi

d. Jelaskan tujuan dan menfaat distraksi video kartun dan animasi

e. Kontrak waktu, tempat, topik, dan prosedur tindakan

f. Minta izin dan kesediaan keluarga untuk mempraktikkan

Evidence Based Nursing Praktice berupa menonton video kartun

dan animasi dalam menurunkan tingkat kecemasan pre operasi

pada anak usia pra sekolah

g. Persilahkan klien jika ingin izin ke toilet atau menyiapkan

makanan dan minuman sebelum menonton video kartun dan

animasi dimulai

Fase Kerja 1. Cuci tangan menggunakan 6 langkah cuci tangan dengan sabun

antiseptik di bawah air mengalir atau menggunakan antiseptik

gel dan keringkan

2. Ciptakan suasana perasaan menenangkan

3. Mengatur posisi klien agar rileks

4. Memberikan salah satu teknik distraksi yaitu menonton video

kartun dan animasi. Anak diberikan kesampatan memilih salah

satu kartun (Upin Ipin, Doraemon, Bobo Boy dan Masha and the

Bear) kemudian dilakukan pemutaran video kartun selama 15

menit dan video animasi 15 menit

5. Menganjurkan keluarga klien untuk melakukan teknik distraksi

menonton video kartun dan animasi jika klien merasakan

ketidaknyamanan

6. Berikan reinforcement positif pada klien dan setelah

mempraktikkan Evidence Based Nursing Praktice berupa

menonton video kartun dan animasi

7. Cuci tangan menggunakan 6 langkah cuci tangan dengan sabun

antiseptik di bawah air mengalir atau menggunakan antiseptik

gel dan keringkan

Terminasi a. Melakukan evaluasi respon dengan menanyakan perasaan klien

setelah menonton video kartun dan animasi

b. Jelaskan rencana tindak lanjut

c. Kontrak waktu, tempat, dan topik untuk pertemuan berikutnya

d. Salam terapeutik

Dokumentasi a. Catat waktu pelaksanaan tindakan

b. Catat respon klien terhadap teknik distraksi dalam menurunkan

tingkat kecemasan pre operasi pada anak usia pra sekolah

Hal yang perlu

diperhatikan

Melakukan komunikasi terapeutik selama tindakan, menjaga

ketenangan, tidak ragu dan tidak tergesa-gesa selama tindakan,

memastikan keamanan dan kenyamanan klien dan peneliti selama

tindakan, serta memperhatikan respon klien.

Lampiran 4

CUPLIKAN TAMPILAN VIDEO KARTUN DAN ANIMASI

a. Cuplikan Tampilan Video Kartun

Video 1 : Upin Ipin – Kawan - Kawan Hilang?

Sumber : https://www.youtube.com/watch?v=51SCDlUDfx4

Video 2 : Doraemon - Pesawat UFO Alien & Beso Anjing Pengganti Manusia

Sumber : https://www.youtube.com/watch?v=nKEp-7xXK44

https://www.youtube.com/watch?v=51SCDlUDfx4

https://www.youtube.com/watch?v=nKEp-7xXK44

Video 3 : BoBoiBoy – Season 1 Episode 2 Part 1

Sumber : https://www.youtube.com/watch?v=t_H8fQZQUDM&t=18s

Video 4 : Masha and the Bear - Monkey Business

Sumber : https://www.youtube.com/watch?v=AxGlvetWIqc

b. Cuplikan Tampilan Video Animasi

Video 1 : Menjelaskan Anestesi pada Anak

Sumber : https://www.youtube.com/watch?v=FblP0vn3qxI

https://www.youtube.com/watch?v=t_H8fQZQUDM&t=18s

https://www.youtube.com/watch?v=AxGlvetWIqc

https://www.youtube.com/watch?v=FblP0vn3qxI

Lampiran 5

LEMBAR BIMBINGAN

PENYUSUNAN KARYA ILMIAH PROGRAM STUDI PROFESI NERS

JURUSAN KEPERAWATAN – POLTEKKES KEMENKES SEMARANG

Nama Mahasiswa : Nurus Suroya

NIM : P1337420919047

Program Studi : Profesi Ners

Pembimbing Utama : Ns. Anwar Adi P, S.Kep

Pembimbing Pendamping : Suharto, S.Pd., MN

Judul

: Video Kartun dan Animasi dalam Menurunkan Tingkat

Kecemasan Pre Operasi pada Anak Usia Pra Sekolah di

Ruang Prabu Kresna RSUD K.R.M.T Wongsonegoro

Kota Semarang

No Hari/Tanggal Materi Bimbingan Saran Bimbingan TTD

Pembimbing

4.

5.

6.

7.

Selasa, 18

Februari

2020

Rabu, 29

April 2020

Selasa, 05

Mei 2020

Kamis, 2 Juli

2020

Perbaikan (revisi)

pasca Proposal

KIN

Bab 3 dan 4

Kelengkapan KIN

Perbaikan (revisi)

pasca ujian hasil

KIN dan naskah

publikasi

Durasi pelaksanaan penerapan

EBP menonton video kartun

dan animasi lebih diperjelas

Perbaiki kesalah ejaan sesuai

kaidah penulisan KBBI

ACC dan lanjutkan ujian hasil

KIN

ACC dan lanjutkan publikasi

hasil Karya Ilmiah

Lampiran 5

LEMBAR BIMBINGAN

PENYUSUNAN KARYA ILMIAH PROGRAM STUDI PROFESI NERS

JURUSAN KEPERAWATAN – POLTEKKES KEMENKES SEMARANG

Nama Mahasiswa : Nurus Suroya

NIM : P1337420919047

Program Studi : Profesi Ners

Pembimbing Utama : Ns. Anwar Adi P, S.Kep

Pembimbing Pendamping : Suharto, S.Pd., MN

Judul

: Video Kartun dan Animasi dalam Menurunkan Tingkat

Kecemasan Pre Operasi pada Anak Usia Pra Sekolah di

Ruang Prabu Kresna RSUD K.R.M.T Wongsonegoro

Kota Semarang

No Hari/Tanggal Materi Bimbingan Saran Bimbingan TTD

Pembimbing

4.

5.

6.

7.

Selasa, 18

Februari

2020

Kamis, 26

Maret

Sabtu, 16

Mei 2020

Rabu, 01 Juli

2020

Perbaikan (revisi)

pasca Proposal

KIN

Bab 3 dan 4

Kelengkapan KIN

Perbaikan (revisi)

pasca ujian hasil

KIN dan naskah

publikasi

Laporan KIN tidak dilakukan

implementasi karena adanya

pandemic Covid 19

Bab hasil dan pembahan sesuai

dengan tujuan

ACC, persiapkan power point

dan lanjutkan ujian hasil KIN

ACC dan lanjutkan publikasi

hasil Karya Ilmiah

Lampiran 6

LEMBAR PERBAIKAN (REVISI)

UJIAN KARYA ILMIAH NERS

NAMA MAHASISWA : NURUS SUROYA

NIM : P1337420919047

JUDUL KIN : VIDEO KARTUN DAN ANIMASI DALAM

MENURUNKAN TINGKAT KECEMASAN PRE OPERASI PADA ANAK

USIA PRA SEKOLAH DI RUANG PRABU KRESNA RSUD K.R.M.T

WONGSONEGORO KOTA SEMARANG

TELAH DIREVISI DAN DISETUJUI DENGAN PERBAIKAN SEBAGAI

BERIKUT :

NO. PERBAIKAN/ POIN REVISI TANDA TANGAN

1. 1. Perbaiki karya ilmiah sesuai masukan dari

pembimbing II

2. Klarifikasi mengenai risiko hambatan dalam

penerapan intervensi menonton video kartun

dan animasi di ruang Prabu Kresna

K.R.M.T Wongsonegoro Kota Semarang

PENGUJI I

Ns. Anwar Adi P, S.Kep

NIP. 198005032005011007

2. 1. Tambahkan studi pendahuluan pada latar

belakang

2. Bab 3 pada sub bab hasil dan pembahan

dipisah dan disesuaikan dengan tujuan

khusus dan sesuai conclution abstrak

3. Simpulan mengacu pada hasil dan saran

mengikuti simpulan

PENGUJI II

Suharto, S.Pd., MN

NIP. 196605101986031001

LEMBAR PERSETUJUAN PERBAIKAN (REVISI)

UJIAN KARYA ILMIAH NERS

NAMA : NURUS SUROYA

NIM : P1337420919047

TANGGAL UJIAN : KAMIS, 21 MEI 2020

PROGRAM STUDI : PROFESI NERS

JUDUL KIN : VIDEO KARTUN DAN ANIMASI DALAM

MENURUNKAN TINGKAT KECEMASAN PRE OPERASI PADA ANAK

USIA PRA SEKOLAH DI RUANG PRABU KRESNA RSUD K.R.M.T

WONGSONEGORO KOTA SEMARANG

TELAH DIREVISI DAN DISETUJUI OLEH TIM PENGUJI/ TIM

PEMBIMBING

NO. NAMA PENGUJI TANDA TANGAN

1. PENGUJI I

Ns. Anwar Adi P, S.Kep

NIP. 198005032005011007

2. PENGUJI II

Suharto, S.Pd., MN

NIP. 196605101986031001

788 © 2018 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow

Background: Preoperative anxiety is a critical issue in children, and associated with postoperative behavioral changes. Aims: The purpose of the current study is to evaluate how audiovisual and auditory presentations about the perioperative period impact preoperative anxiety and postoperative behavioral disturbances of children undergoing elective ambulatory surgery. Materials and Methods: A total of 99 patients between the ages of 5–12, scheduled to undergo outpatient surgery, participated in this study. Participants were randomly assigned to one of three groups; audiovisual group (Group V, n = 33), auditory group (Group A, n = 33), and control group (Group C, n = 33). During the evaluation, the Modified Yale Preoperative Anxiety Scale (M‑YPAS) and the posthospitalization behavioral questionnaire (PHBQ) were used. Results: There were no significant differences in demographic characteristics between the groups. M‑YPAS scores were significantly lower in Group V than in Groups C and A (P < 0.001 and P < 0.001, respectively). PHBQ scores in Group C were statistically higher than in Groups A and V, but, no statistical difference was found between Groups A and V. Conclusion: Compared to auditory presentations, audiovisual presentations, in terms of being memorable and interesting, may be more effective in reducing children’s anxiety. In addition, we can suggest that both methods can be equally effective for postoperative behavioral changes.

Keywords: Anxiety, audiovisual aids, behavioral rating scale, child behavior

Effects of Auditory and Audiovisual Presentations on Anxiety and Behavioral Changes in Children Undergoing Elective SurgeryZ Hatipoglu, E Gulec, D Lafli, D Ozcengiz

Address for correspondence: Dr. Z Hatipoglu, Department of Anesthesiology and Reanimation, Faculty of Medicine, Cukurova University, Adana 01260, Turkey.

E‑mail: [email protected]

systems, preoperative information programs, hypnosis, music, and acupuncture.[2]

Behavioral interventions that are used as preoperative preparation programs are applied through coping skills, modeling, and play therapy.[2] The aim of behavioral programs is to teach coping skills through modeling for anxiety to children and also to provide information about the perioperative process. These interventions should be prepared taking into consideration a child’s age, developmental stage, and previous experience.[2,6]

Original Article

Introduction

Hospitalization and surgery are a serious and memorable event for children and their parents.

Children undergoing surgery and their parents can be anxious in the preoperative period, and it occurs up to 65% of children.[1] Preoperative anxiety is associated with postoperative pain, emergence delirium, and postoperative behavioral changes (e.g., general anxiety, appetite changes, sleep disturbances, enuresis, and temper tantrums).[2‑4]

Pharmacological and nonpharmacological methods are utilized to treat preoperative anxiety in children. In the recent years, nonpharmacological methods are preferred due to possible adverse effects (e.g., excessive sedation and delayed discharge) of pharmacological methods.[5] Nonpharmacological methods are as follows: the presence of parents, distraction techniques, fun transportation

Department of Anesthesiology and Reanimation, Faculty of Medicine, Cukurova University, Adana, Turkey A

bstr

act

Access this article onlineQuick Response Code:

Website: www.njcponline.com

DOI: 10.4103/njcp.njcp_227_17

PMID: *******

Date of Acceptance: 22-Nov-2017

How to cite this article: Hatipoglu Z, Gulec E, Lafli D, Ozcengiz D. Effects of auditory and audiovisual presentations on anxiety and behavioral changes in children undergoing elective surgery. Niger J Clin Pract 2017;XX:XX-XX.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

[Downloaded free from http://www.njcponline.com on Sunday, January 26, 2020, IP: 118.96.98.61]

Hatipoglu, et al.: Preoperative anxiety in children

789Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 6 ¦ June 2018

There are three methods which are known to be effective in learning; i.e., visual (pictures, images, demonstrations), auditory (reading, words, listening), and kinesthetic (touch, taste). Visual images are important to visual learning, in which body language is also used. It is also important to be informed by listening to auditory learning.[7] Most people learn best using a combination of both, although visual learning is usually the prominent component.[8] To the best of our knowledge, an auditory‑related (listening) study outside of music therapy is not available for preoperative anxiety management while there are limited audiovisual studies involving children in the literature.[9‑11]

The current study was designed to compare the effects of audiovisual and auditory presentations on preoperative anxiety and postoperative behavioral disturbances of children undergoing elective ambulatory surgery. The primary end point was the preoperative anxiety levels of patients. The secondary end point was the behavioral changes of children in the postoperative period.

Materials and MethodsPatientsThe study protocol was approved by the Institutional Ethics Committee of the Cukurova University, Faculty of Medicine (no: 45/2015). We enrolled patients between March 2015 and February 2016. Written informed consent was obtained from all the parents. Ninety‑nine patients with the American Society of Anesthesiologists physical Status I‑II, aged 5–12 years old and scheduled for outpatient surgery (e.g., orchiopexy, hypospadias surgery, inguinal hernia, tonsillectomy, adenoidectomy, and strabismus surgery) were accepted in the present study. Children with chronic illness, undergoing emergency surgery, cognitive disorders, and parents who refuse to participate were excluded from this study.

Study designThe study participants were allocated to the groups using a computer‑generated randomization list at preoperative visit: audiovisual group (Group V, n = 33), auditory group (Group A, n = 33), and the standard of care group (Group C, n = 33).

After all patients were examined by an anesthesiologist at hospital admission 1 week before surgery, the following applications were presented: the patients in Group V were shown an audiovisual presentation to inform about preoperative preparation and postoperative period [Appendix 1]. The sound recording of this video was listened to by the patients in Group A without the visual element of the audiovisual presentation. The patients in Group C were verbally informed on usual the anesthesia practice of our hospital (e.g., anesthesia and

analgesia management, preoperative fasting, and regular use of the drug to be administered after surgery). Parents accompanied their children during this time. Patient’s age, gender, history of previous surgery, type of surgery, and parent’s age, gender, and educational level were recorded.

MeasurementsThe children in all groups were admitted with one of the parents into the preoperative holding room. The preoperative anxiety levels of children were measured with the Modified Yale Preoperative Anxiety Scale (M‑YPAS) at induction of anesthesia after being taken into the operating room. This assessment was made by an anesthesiologist who was blinded to the groups. In brief, the M‑YPAS is used to measure children’s anxiety in the preoperative holding area and during induction of anesthesia. The M‑YPAS contains 22 items in five categories (activity, emotional expressivity, state of arousal, vocalization, and use of parents). The scoring in each category is done with a different number of items (either four or six). A total adjusted score is calculated with a formula after evaluating partial weight ([activity/4+ emotional expressivity/4+ state of arousal/4+ use of parents/4+ vocalization/6] ×100/5). The cutoff point of 30 on the M‑YPAS leads to balance in which the sensitivity and specificity are high, and the predictive value is 79%.[12]

Postoperative maladaptive behaviors of children were assessed using the posthospitalization behavioral questionnaire (PHBQ). Parents were contacted by telephone 7 days after hospital discharge, and this assessment was performed by the same anesthesiologist. In brief, the PHBQ contains a total of 27 items in the following six subscales: general anxiety and regression, separation anxiety, eating disturbance, aggression toward authority, apathy/withdrawal, and anxiety about sleep. The PHBQ is scored by parents using five response options: much less than before (1), less than before (2), same as before (3), more than before (4), and much more than before.[13] Psychometric properties of the PHBQ have been shown in a study of Vernon et al.[14] We considered the negative behavioral change as a response of 4 or 5 for an item of the PHBQ.[15]

Anesthesia managementAfter 6 h of fasting, the children were taken into a preoperative holding area and none of the children used any premedication. The children were taken accompanied by their parents into the operating room from the preoperative holding area. Standard monitoring was applied to patients (electrocardiogram, pulse oximeter, and noninvasive blood pressure). Anesthesia induction was provided with 6%–8% sevoflurane and



790 Nigerian Journal of Clinical Practice ¦ Volume 21 ¦ Issue 6 ¦ June 2018

the statistical hypotheses were fulfilled or not. For normally distributed data, regarding the homogeneity of variances, Bonferroni, Scheffe, Tamhane tests were used for multiple comparisons of groups. For abnormally distributed data, a Bonferroni adjusted Mann–Whitney U‑test was used for multiple comparisons of groups. To evaluate the correlations between measurements, the Pearson correlation coefficient was used. Multivariate logistic regression analysis was used to determine the predictors of postoperative maladaptive behaviors. According to the “cutoff points,” patients were divided into two subgroups; a calm group that included patients who scored <30th percentile of the M‑YPAS and an anxious group that included patients who scored >30th percentile of the M‑YPAS.[12] The statistical level of significance for all tests was considered to be 0.05.

ResultsFlow diagram for the study is shown in Figure 1. The demographic characteristics of patients and parents were similar between the three groups [Table 1]. No significant differences were found in terms of surgical data between the three groups [Table 2].

a gas mixture of (40%–60%) oxygen/nitrous oxide. After placing intravenous (IV) cannula on the hand, rocuronium 0.6 mg/kg was administered and all patients were intubated. Fluid resuscitation was accomplished with Ringer’s lactate solution (3–5 ml/kg/h). After anesthesia induction, the parents were taken out of the operating room with a nurse. Maintenance of anesthesia was provided with 1%–2% sevoflurane and a gas mixture of (40%–60%) oxygen/nitrous oxide. For intraoperative analgesia, fentanyl 1 µg/kg was given. Tramadol (2 mg/kg, IV) was administered for postoperative analgesia in all patients. After the end of the surgery, anesthesia was terminated, and the neuromuscular blockade was antagonized with atropine (0.015 mg/kg, IV) and neostigmine (0.05 mg/kg, IV). The awakened patients were transferred to the recovery room accompanied by their parents. After recovery, the children were transported to their clinical wards.

Statistical analysisSample size analysis was performed using G*Power version 3.1.9.2 (G*Power Software, Kiel, Germany). We calculated the sample size with a power of 0.80 and an α of 0.05 as 24 patients for each group to detect 10 points difference in M‑YPAS scores between the groups. A control mean M‑YPAS score of 50 with an SD of 12 was reported in a previous study.[16] All analyses were performed using IBM SPSS Statistics software package (IBM SPSS Statistics for Windows, Version 20.0; IBM Corp., Armonk, New York, USA). Categorical variables were expressed as numbers and percentages, whereas continuous variables were summarized as a mean and standard deviation and as median and range where appropriate. The normality of distribution for continuous variables was confirmed with the Kolmogorov–Smirnov test. For comparison of continuous variables between two groups, the Student’s t‑test was used. For comparison of three groups, the One‑way ANOVA or Kruskal–Wallis test was used depending on whether

Table 1: Patients and parents’ demographic dataGroup V Group A Group C P

PatientsAge (years)a 7.6±2.0 7.4±1.9 7.6±2.3 0.93Gender (female/male) 16/17 17/16 15/18 0.88Birth order (first born/middle/later) 16/10/7 23/4/6 15/13/5 0.37Previous surgery (yes/no) 10/23 10/23 17/16 0.12

Time of previous surgeryLast 1 year 6 4 6 0.21Last 1 years ago 4 6 11

ParentsAge (years)a 36.9±5.4 34.6±5.1 36.7±5.3 0.13Gender (female/male) 19/14 21/12 20/13 0.88Education (literate/primary school/higher/university) 1/10/22 0/11/22 0/17/16 0.28

aOne‑way ANOVA test was used. Values are presented as number or mean±SD. SD=Standard deviation

Table 2: Surgical dataGroup V Group A Group C P

SurgeryENT (other) 19 15 7 0.55Ear tube insertion 3 5 2Strabismus 4 6 11Dental surgery 2 2 3Circumcision 2 3 1Other 3 2 9

Time of surgery (min)a 50.0±14.3 46.1±14.2 51.9±21.8 0.38aOne‑way ANOVA test was used. Values are presented as number or mean±SD. ENT=Ear‑nose‑throat; ENT (other)=Adenoidectomy, tonsillectomy, adenoidectomy and tonsillectomy; SD=Standard deviation




Table 4: Predictors for postoperative maladaptive behavioral changes

Predictors OR 95% CI PM‑YPASa 1.03 1.01‑1.06 0.002Parent gender (female/male)b 4.05 1.39‑1.06 0.01Agec 0.40 0.13‑1.16 0.09aAnxious children (>30%) compared to less anxious (<30%); bMale compared to female; c<7 years of age compared to >7 years of age. OR=Odds ratio; CI=Confidence interval; M‑YPAS=Modified Yale Preoperative Anxiety Scale

Table 3: The means of the Modified Yale Preoperative Anxiety Scale and Posthospitalization Behavioral

QuestionnaireGroup V Group A Group C P

M‑YPAS 27.4±7.1 39.3±19.2 73.1±18.0 <0.001a,b,c

PHBQ 81.4±2.6 82.1±1.8 87.6±3.4 <0.001a,b

aP<0.001 for Group C versus Group V; bP<0.001 for Group C versus Group A; cP<0.001 for Group A versus Group V. PHBQ=Posthospitalization Behavioral Questionnaire; M‑YPAS=Modified Yale Preoperative Anxiety Scale

The M‑YPAS scores were significantly lower in Group V than Groups C and A (P < 0.001) [Table 3]. When comparing the three groups, there were no statistically relationships among age, previous surgery, type of surgery, the education level, and gender of parents on the M‑YPAS scores. However, on the basis of the evaluation

of all patients, preschool children (<7 years old) had more anxiety (43.0 ± 23.3 vs. 52.3 ± 26.6, P = 0.071). Similarly, the M‑YPAS scores of 37 children who underwent a previous surgery were compared with 62 nonoperated children, nonoperated children had lower M‑YPAS scores (42.2 ± 23.9 vs. 54.0 ± 25.1, P = 0.022).

Figure 1: Flow diagram of the study




The patients in Group C had statistically higher PHBQ scores than those in Groups A and V (P < 0.001) [Table 3]. For all patients, no correlation was found between PHBQ and children’s age, whereas there was a correlation between PHBQ and parent gender (P = 0.01). In addition, anxious child (<30th percentile) had 1.03 times greater risk of adopting negative behaviors than a calm child (>30th percentile) [Table 4]. Especially, in anxious children, there was a significant correlation between M‑YPAS and general anxiety, separation anxiety, apathy, and sleep disturbances (P < 0.05), and the number of new postoperative maladaptive behavioral changes is summarized Table 5.

DiscussionThe results of the present study showed that audiovisual presentation related to preanesthetic information in children is an effective approach in reducing preoperative anxiety. Furthermore, children who were informed with audiovisual and audio presentation had less behavioral changes 1 week after discharge.

In the literature, there are some trials that used audiovisual presentations for providing information to patients.[17‑19] Gaskey showed that the addition of audiovisual presentation to the routine preoperative anesthesia visit did not produce a significant reduction in preoperative anxiety levels in adult patients. However, patients were less nervous and had higher levels of knowledge about anesthesia procedures.[18] In contrast, the study findings demonstrated exposure to an audiovisual presentation significantly reduced anxiety at anesthesia induction. In this regard, Kain et al. stated that behavioral preparation program (ADVANCE: Anxiety‑reduction, Distraction, Video modeling, Adding parents, No excessive reassurance, coaching, and exposure/shaping) is efficient in the reduction of children’s anxiety.[20] Similarly, Web‑Based Tailored

Intervention for Preparation of Parents and Children for Outpatient Surgery (WebTIPS) is a web‑based preoperative preparation program with features, including information provision, modeling, and coping skills. The study showed that WebTIPS reduces the anxiety of children in the preoperative settings.[21] Although both studies are comprehensive programs and effective on preoperative anxiety, the cost of these programs is quite expensive. In another study, Batuman et al. concluded that informational videos about preoperative preparation help to decrease children’s preoperative anxiety.[22] Unlike our study, they evaluated the effects on the preoperative anxiety of only audiovisual presentation. The result of these studies shows that an audiovisual presentation about preoperative information produces improved outcomes on children’s anxiety, and it is considered a low‑cost method.

A systematic review reported that music therapy might be an ineffective method for coping with anxiety, and an audiovisual presentation is more effective than music therapy in reducing preoperative anxiety in children.[9] Similar to the findings in our study, preoperative information video has a stronger impact on children’s anxiety than an auditory presentation. Although both methods include the same information, an audiovisual presentation may be more memorable and interesting to children. Since children have broad imaginations, the mental visualization in an auditory presentation will be unique for each child. This may cause them to misperceive the given information from auditory methods in unfavorable ways and become afraid of the upcoming surgery.

In this study, there is no relationship between the children’s age and M‑YPAS. This is consistent with the study by Vagnoli et al.[23] Although there was no statistical difference, children under the age of 7 years were more anxious. Surgery creates a greater emotional stress in younger children due to poorer comprehension increased dependency on the mother, less communication with the social environment, and decreased the ability to manage anxiety.[24] The study also shows that children without any previous operations had less anxiety. This should be noted as preoperative information programs may adversely affect the emotional status in previously hospitalized children.[6]

Risk factors for negative postoperative behavior changes have been reported to include the following; preoperative anxiety, younger age, previous anesthesia experiences, premedication, and increased parental anxiety.[1,4] In this study, the children who received a standard information had more PHBQ scores. Similarly, Hilly et al. indicated that workshops for preoperative preparation decrease

Table 5: New postoperative maladaptive behavioral changes

Behavioral changes Calm group (n=44)

Anxious group (n=55)

Difficulty about going to bed at night 3 20*When left alone for a few minutes, upset 1 11*Need help to do things 1 8*Avoid or afraid of new things 0 6*Temper tantrums 2 13*Negative reaction to doctors or hospitals 2 28*Follow you everywhere around the house 1 8*Sleeping problems 0 19**P<0.05 between the groups. Anxious children (M‑YPAS >30%) compared to calm children (M‑YPAS <30%). n=Number of patients; M‑YPAS=Modified Yale Preoperative Anxiety Scale




both preoperative anxiety levels and postoperative behavioral changes in children.[3] Regardless of the format of presentation, we demonstrated a positive effect on behavioral changes in children in the postoperative period. In addition, we found that there is an association between preoperative anxiety and postoperative maladaptive behaviors such as separation anxiety, general anxiety, apathy, and sleep disturbances, which is consistent with the results of previous studies.[1] This study also shows that maternal presence may prevent the development of postoperative negative behavioral changes, regardless of other personal information of the parents. This situation can be explained by the emotional bond between mother and child.[25,26]

The present study has a number of limitations. First, the anxiety levels of parents were not evaluated. Parental anxiety has an effect on the child in the preoperative period.[2] McEwen et al. have reported that preoperative information videos can lessen the anxiety of parents.[27] Cassady et al. also agree with this study, but Chundamala et al. presented a different viewpoint that parental presence does not reduce the parents’ or the children’s anxiety.[28,29] Considering these results, we cannot eliminate the effect of parental anxiety on children. Second, the relationship between pain and behavioral changes is a controversial issue.[4,30] Pain may have a negative effect on a child’s behavior; however, we did not evaluate the children’s pain scores as an indicator of postoperative behavioral changes. Thus, we recommend the evaluation of pain in future studies. Third, M‑YPAS was measured only at the point of anesthesia induction. We do not know anxiety levels of the children in the preoperative waiting room or at hospital admission. Finally, there was no validity and reliability of the Turkish version of the M‑YPAS and PHBQ.

ConclusionAudiovisual presentation is an effective and inexpensive method to preoperative anxiety reduction in children. It is a more memorable and interesting approach compared to auditory presentations for children. Both audiovisual and auditory presentations have equal effects on postoperative behavioral changes.

AcknowledgmentsThe authors would like to thank Ilker UNAL (PhD, from Cukurova University, Faculty of Medicine, Department of Biostatistics) for the statistical analysis of this study.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

References1. Kain ZN, Caldwell‑Andrews AA, Maranets I, McClain B,

Gaal D, Mayes LC, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg 2004;99:1648‑54.

2. Ahmed MI, Farrell MA, Parrish K, Karla A. Preoperative anxiety in children risk factors and non‑pharmacological management. Middle East J Anaesthesiol 2011;21:153‑64.

3. Hilly J, Hörlin AL, Kinderf J, Ghez C, Menrath S, Delivet H, et al. Preoperative preparation workshop reduces postoperative maladaptive behavior in children. Paediatr Anaesth 2015;25:990‑8.

4. Stargatt R, Davidson AJ, Huang GH, Czarnecki C, Gibson MA, Stewart SA, et al. A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia. Paediatr Anaesth 2006;16:846‑59.

5. Manyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non‑pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev 2015;14:CD006447.

6. Kain ZN, Mayes LC, Caramico LA. Preoperative preparation in children: A cross‑sectional study. J Clin Anesth 1996;8:508‑14.

7. Gilakjani AP. Visual, auditory, kinesthetic learning styles and their impacts on English language teaching. J Stud Educ 2011;2:104‑13.

8. Felder RM, Soloman BA. Learning Styles and Strategies. Available from: http://www4.ncsu.edu/unity/lockers/users/f/felder/public/ILSdir/styles.htm

9. Chow CH, Van Lieshout RJ, Schmidt LA, Dobson KG, Buckley N. Systematic review: Audiovisual interventions for reducing preoperative anxiety in children undergoing elective surgery. J Pediatr Psychol 2016;41:182‑203.

10. Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Database Syst Rev 2013;6:CD006908.

11. Millett CR. The Effect of Music Therapy Interaction on Child and Parental Preoperative Anxiety in Parents of Children Undergoing Day. Theses and Dissertations‑Music. Student, University of Kentucky, Lexington, Kentucky, USA; 2015. p. 42.

12. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB, et al. The Yale preoperative anxiety scale: How does it compare with a “gold standard”? Anesth Analg 1997;85:783‑8.

13. Jenkins BN, Kain ZN, Kaplan SH, Stevenson RS, Mayes LC, Guadarrama J, et al. Revisiting a measure of child postoperative recovery: Development of the post hospitalization behavior questionnaire for ambulatory surgery. Paediatr Anaesth 2015;25:738‑45.

14. Vernon DT, Schulman JL, Foley JM. Changes in children's behavior after hospitalization. Some dimensions of response and their correlates. Am J Dis Child 1966;111:581‑93.

15. Faulk DJ, Twite MD, Zuk J, Pan Z, Wallen B, Friesen R. Hypnotic depth and the incidence of emergence agitation and negative postoperative behavioral changes. Paediatr Anaesth 2010;20:72‑81.

16. Kain ZN, Caldwell‑Andrews AA, Krivutza DM, Weinberg ME, Gaal D, Wang SM, et al. Interactive music therapy as a treatment for preoperative anxiety in children: A randomized controlled trial. Anesth Analg 2004;98:1260‑6.

17. Rice M, Glasper A, Keeton D, Spargo P. The effect of a preoperative education programme on perioperative anxiety in children: an observational study. Paediatr Anaesth 2008;18:426‑30.

18. Gaskey NJ. Evaluation of the effect of a preoperative anesthesia




videotape. AANAJ 1987;55:341‑5.19. Cumino DO, Vieira JE, Lima LC, Stievano LP, Silva RA,

Mathias LA. Smartphone‑based behavioural intervention alleviates children's anxiety during anaesthesia induction: A randomised controlled trial. Eur J Anaesthesiol 2017;34:169‑75.

20. Kain ZN, Caldwell‑Andrews AA, Mayes LC, Weinberg ME, Wang SM, MacLaren JE, et al. Family‑centered preparation for surgery improves perioperative outcomes in children a randomized controlled trial. Anesthesiology 2007;106:65‑74.

21. Fortier MA, Bunzli E, Walthall J, Olshansky E, Saadat H, Santistevan R, et al. Web‑based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): Formative evaluation and randomized controlled trial. Anesth Analg 2015;120:915.

22. Batuman A, Gulec E, Turktan M, Gunes Y, Ozcengiz D. Preoperative informational video based on model making reduces preoperative anxiety and postoperative negative behavioral changes in children. Minerva Anestesiol 2016;82:534‑42.

23. Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics 2005;116:563‑7.

24. McGraw T. Preparing children for the operating room:

Psychological issues. Can J Anaesth 1994;41:1094‑03.25. Messeri A, Caprilli S, Busoni P. Anaesthesia induction in

children: a psychological evaluation of the efficiency of parents’ presence. Paediatr Anaesth 2004;14:551‑6.

26. Rancourt KM, Chorney JM, Kain Z. Children’s immediate postoperative distress and mothers’ and fathers’ touch behaviors. J Pediatr Psychol 2015;40:1115‑23.

27. Mc Ewen A, Moorthy C, Quantock C, Rose H, Kavanagh R. The effect of videotaped preoperative information on parental anxiety during anesthesia induction for elective pediatric procedures. Paediatr Anaesth 2007;17:534‑9.

28. Cassady JF, Wysocki TT, Miller KM, Cancel DD, Izenberg N. Use of a preanesthetic video for facilitation of parental education and anxiolysis is before pediatric ambulatory surgery. Anesth Analg 1999;88:246‑50.

29. Chundamala J, Wright JG, Kemp SM. An evidence‑based review of parental presence during anesthesia induction and parent/child anxiety. Can J Anaesth 2009;56:57‑70.

30. Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioral changes in children following day‑case surgery: A 4‑week follow‑up of 551 children. Anaesthesia 1997;52:970‑6.

AppendicesAppendix 1: The content of the audiovisual presentationThe total duration of the video recording was 344 s and it consisted of two sections: Part 1 and 2. Doctors, nurses, an 11‑year‑old female, and her mother took part in the video and special permission was received from them to be recorded. The audiovisual presentation was recorded in the anesthesia clinic and operating room of our hospital.

Part 1: This section is 300 s long and includes the verbal explanation by the anesthesiologist of preoperative information, anesthesia management, and the postoperative period. Three people were involved in this section: the anesthesiologist, the child, and her mother. The teddy bear was used as model. The child and her mother visit the anesthesiologist for preoperative information in the anesthesia clinic. The anesthesiologist meets with them and then informs them about the surgery and the anesthesia methods. First, the child asks “What is surgery?” and then she mentions “I am afraid of the pain.” The doctor explains that “You will not be in any pain” and continues by saying, “The duties of the anesthesiologist are to apply anesthesia to patients, to reduce their pain and ensure their well‑being during operation.” After the child relaxes, the anesthesiologist describes how anesthesia is administered by two methods. The first method is to insert a small plastic tube into a vessel on the hand and some anesthetic drugs are administered via the small tube. The anesthesiologist uses a teddy bear for the second method. The doctor explains “This is a face mask and it smells nice.” She puts a small face mask on the face of the teddy bear and says, “It is connected to the anesthesia machine by a plastic tube. Anesthetic gases are given through the plastic tube.” The doctor pretends to tell the teddy bear to take deep breaths and says, “This will help you fall asleep quickly and after that the surgery will be performed. At the end of surgery, you will be awakened by the administering of some drugs. Furthermore, I will administer drugs for pain relief.” After explaining anesthesia, the doctor says to the child’s mother “Your child will be safe and you should not feel restlessness related to the surgery or anesthesia.” The anesthesiologist explains that preoperative fasting is six hours and postoperative drugs are given regularly. They leave and plan to meet again the next day for the operation.

Part 2: This section is 44 s long and contains preoperative preparation, anesthesia induction, and a recovery period. The child and mother come into the operating room with the personnel. The nurse meets them in the preoperative holding area. The anesthesiologist comes into the preoperative holding area and takes the child and mother into the operating room. The doctor inserts a device in the child’s finger and explains that “The device measures the amount of oxygen in the blood.” The doctor performs anesthesia with the face mask and says, “Take deep breaths and have a good sleep.” After completing the operation, the doctor wakes the child and takes her into the recovery room. The anesthesiologist talks with the child and mother and leaves from the recovery room.


Pengaruh Audiovisual Menonton Film Kartun Terhadap Tingkat Kecemasan Saat

Prosedur Injeksi Pada Anak Prasekolah

Lilis Fatmawati, Yuanita Syaiful, Diyah Ratnawati

Universitas Gresik, [email protected]

Abstrak

Anak usia prasekolah menganggap sakit adalah sesuatu hal yang menakutkan. Anak

mempunyai keterbatasan dalam mekanisme koping mengatasi krisis tersebut. Intervensi

audiovisual menonton film kartun merupakan teknik distraksi untuk menurunkan

kecemasan pada anak. Tujuan penelitian untuk menganalisis pengaruh audiovisual

menonton film kartun terhadap tingkat kecemasan saat prosedur injeksi pada anak

prasekolah. Penelitian ini Pre-experimental dengan jenis pretest and posttest one group

design. Pengambilan data dengan mengunakan teknik purposive sampling pada 28

responden. Variabel independen audiovisual menonton film kartun, sedangkan variabel

dependen tingkat kecemasan. Instrumen yang digunakan SOP dan skala kecemasan

HAR-S. Uji statistik menggunakan uji Paired Sample T-Test, dengan signifikasi p< 0,05.

Hasil analisis statistik didapatkan nilai sig (p = 0.001, t = 11,71) yang berarti ada

pengaruh audiovisual menonton film kartun terhadap tingkat kecemasan saat prosedur

injeksi pada anak prasekolah. Diharapkan intervensi audiovisual menonton film kartun

dapat diterapkan sebagai salah satu intervensi keperawatan untuk menurunkan kecemasan

saat prosedur injeksi pada anak prasekolah.

Kata kunci : Anak Prasekolah, Audiovisual, Kecemasan, Prosedur Injeksi

Abstract

Among preschoolers, illness is a scary thing. Children have limitations in coping

mechanisms to overcome the crisis. Audiovisual intervention in watching cartoons is a

distraction technique to reduce anxiety in children. The purpose of the study was to

analyze the effect of audiovisual cartoon movie on anxiety levels during injection

procedures in preschool children. The design of this study was using Pre-experimental

pretest and posttest one group design. The research collecting the data using purposive

sampling technique on 28 respondents. Independent variable audiovisual watching

cartoons, while dependent variable is anxiety level. The instrument used is SOP and

HAR-S anxiety scale. Statistical tests using the Paired Sample T-Test, with significance p

<0.05. From the results of the statistical analysis, the sig value was obtained (p = 0.001,

t=11.71) which means an audiovisual intervention by on watching cartoons movie was

effective to reduce anxiety levels during the injection procedure in preschool children.

We suggest that audiovisual intervention by watching cartoons movie can be applied as

one of the nursing interventions to reduce anxiety during injection procedures in

preschool children.

Keywords: Anxiety, Audiovisual, Injection Procedure, Preschool Children

PENDAHULUAN

Anak-anak adalah suatu awal kehidupan

untuk masa-masa berikutnya (Nursalam,

2013). Anak prasekolah (3-6 tahun)

merupakan masa yang menyenangkan,

dipengaruhi dengan segala macam hal

yang baru. Anak prasekolah memiliki

ketrampilan verbal dan perkembangan

menjadi lebih baik untuk beradaptasi di

berbagai situasi, tetapi penyakit dan

15

mailto:[email protected]

16 Jurnal Ilmiah Kesehatan (Journal of Health Sciences), Vol. 12, No. 2, Agustus 2019, Hal. 15-29

hospitalisasi bisa menyebabkan stress.

Tetapi kenyataaannya tidak semua anak

mengalami masa-masa menyenangkan,

anak juga mengalami sakit yang

mengharuskan mereka dirawat di rumah

sakit (Utami, 2014). Sakit dan

hospitalisasi terjadi pada anak bisa

mengakibatkan stress dan kecemasan

disemua tingkat usia. Penyebab kecemasan

dipengaruhi oleh banyak faktor, dari

petugas rumah sakit (dokter, perawat, serta

tenaga kesehatan lainnya), lingkungan

baru, reaksi keluarga yang mendampingi

anak selama perawatan (Nursalam, dkk,

2013). Seringkali mereka harus menjalani

intervensi medis atau tindakan invasive

yang dapat menimbulkan ketakutan pada

anak seperti prosedur injeksi, pengambilan

atau tes sampel darah, operasi, medikasi

dan intervensi keperawatan lainnya.

WHO (2012) bahwa 3-10 % anak

dirawat di Amerika Serikat baik anak usia

toddler, prasekolah ataupun anak usia

sekolah, di Jerman sekitar 3 - 7% anak

toddler dan 5 - 10% anak prasekolah yang

menjalani hospitalisasi (Purwandari, 2013

dalam Carla, 2017). UNICEF jumlah anak

usia prasekolah di 3 negara terbesar dunia

mencapai 148 juta, 958 anak dengan

insiden anak yang dirawat di rumah sakit

57 juta anak setiap tahunnya dimana 75%

mengalami trauma berupa ketakutan dan

kecemasan saat menjalani perawatan

(James, 2010 dalam Saputro H dan Intan

Fazrin, 2017). Di Indonesia sendiri jumlah

anak yang dirawat pada tahun 2014

sebanyak 15,26% (Susenas, 2014). Anak

usia prasekolah, anak usia sekolah

merupakan usia rentan terhadap penyakit,

sehingga banyak anak usia tersebut harus

dirawat di rumah sakit, serta menyebabkan

populasi anak yang dirawat di rumah sakit

mengalami peningkatan sangat dramatis

(Wong, 2009).

Miller (2002) kecemasan anak saat

menjalani hospitalisasi berkisar 10%

mengalami kecemasan ringan, itu

berlanjut, sekitar 2% mengalami kece-

masan berat. Penelitian dilakukan untuk

melihat respon hospitalisasi terjadi anak

usia 3-12 tahun didapatkan bahwa 77%

anak mengatakan nyeri serta takut saat

dilakukan pengambilan darah, 63% anak

mengalami kekakuan otot, 63% anak

menangis sampai berteriak (Burnsnader,

2014 dalam Carla, 2017). Diperkirakan 35

per 100 anak menjalani hospitalisasi 45%

diantaranya mengalami kecemasan saat

menjalani perawatan di Rumah Sakit

(Depkes, 2010 dalam Widiatmoko, 2018).

Berdasarkan data dari Badan Pusat

Statistik (BPS) Jawa Timur dapat

dijelaskan bahwa anak usia prasekolah dari

tahun ke tahun semakin meningkat, data

tahun 2013 menunjukkan jumlah anak usia

prasekolah yang ada di Jawa Timur

http://journal2.unusa.ac.id/index.php/JHS


Pengaruh Audiovisual Menonton Film Kartun Terhadap Tingkat Kecemasan Saat Prosedur Injeksi Pada Anak

Prasekolah

17

2.485.218 dengan angka kesakitan

1.475.197, mengalami kecemasan saat

menjalani perawatan akibat sakitnya

sebanyak 85% (Dinkes Propinsi Jawa

Timur, 2014 dalam Saputro H dan Intan

Fazrin, 2017). Data yang di Rumah Sakit

Semen Gresik tahun 2017 terdapat 3043

anak yang dirawat, diantaranya 758 anak

usia prasekolah. Pada bulan Januari - April

2018 terdapat 1173 anak yang dirawat,

terdapat 262 anak usia prasekolah.

Data tingkat kecemasan anak yang

diukur dengan menggunakan kuisioner

Hamilton Rating Scala for Anxiety (HRS-

A) yang dilakukan pada tanggal 21 - 27

Mei 2018 di Rumah Sakit Semen Gresik

terdapat 10 anak usia prasekolah (3-5 th)

yang dirawat dan dilakukan tindakan

pemberian injeksi, terdapat 3 (30%) anak

mengalami kecemasan sedang, 5 (50%)

mengalami kecemasan berat, sedangkan 2

(20%) anak mengalami kecemasan ringan,

dari data tersebut menunjukkan anak yang

mengalami kecemasan berat di ruang anak

rawat inap Rumah Sakit Semen Gresik

masih cukup banyak. Selama ini perawat

maupun tenaga kesehatan lainnya hanya

menggunakan teknik komunikasi langsung

(direct) berupa instruksi sederhana maupun

modeling. Namun pemberian audiovisual

terhadap tingkat kecemasan saat dilakukan

prosedur pemberian injeksi pada anak

prasekolah belum bisa dijelaskan.

Anak usia prasekolah menganggap sakit

adalah sesuatu hal yang menakutkan,

kehilangan lingkungan yang aman dan

penuh kasih sayang, serta tidak

menyenangkan (Supartini, 2014). Asuhan

keperawatan pada anak biasanya

memerlukan tindakan invasif seperti

injeksi atau pemasangan infus, hal ini

merupakan stresor kuat yang dapat

membuat anak mengalami kecemasan.

Perawat biasanya akan menjelaskan

prosedur ini kepada orangtua dan

melakukan komunikasi terapeutik kepada

anak sebelum melakukan prosedur

tersebut, kondisi ini juga membuat anak

menjadi panik dan biasanya melakukan

perlawanan atau menolak untuk dilakukan

posedur pemasangan infus atau injeksi

obat, yang biasanya akan memaksa petugas

kesehatan untuk sedikit melakukan

paksaan kepada anak yang mengakibatkan

timbulnya trauma pada anak. Reaksi anak

terhadap tindakan invasive ini ditunjukkan

dengan agresi fisik dan verbal

(Hockenberry, Wilson & Winkelstein,

2008).

Oleh karena itu anak seringkali

menunjukkan perilaku tidak kooperatif

seperti sering menangis, marah-marah,

tidak mau makan, rewel, susah tidur,

mudah tersinggung, meminta pulang dan

tidak mau berinteraksi dengan perawat dan

seringkali menolak jika akan diberikan


pengobatan. Kondisi cemas yang terjadi

pada anak akan menghambat dan

menyulitkan proses pengobatan yang

berdampak terhadap penyembuhan pada

anak sehingga memperpanjang masa rawat

dan dapat beresiko terkena komplikasi dari

infeksi nosokomial serta menimbulkan

trauma pada anak. Untuk mengatasi

memburuknya tingkat kecemasan pada

anak, seorang perawat dalam memberikan

intervensi kepada anak harus

memperhatikan kebutuhan anak sesuai

dengan pertumbuhan anaknya.

Beberapa tindakan yang pernah

dilakukan untuk menurunkan tingkat

kecemasan pada anak antara lain: bermain

boneka, bermain clay, bermain puzzle,

aktivitas mewarnai, terapi musik, juga

tehnik komunikasi terapeutik, serta tehnik

pengalihan perhatian (distraksi).

Kombinasi antara distraksi pendengaran

(audio) dan distraksi penglihatan (visual)

disebut distraksi audiovisual, yang

digunakan untuk mengalihkan perhatian

pasien terhadap sesuatu yang membuatnya

tidak nyaman, cemas atau takut dengan

cara menampilkan tayangan favorit berupa

gambar-gambar bergerak dan bersuara

ataupun animasi dengan harapan pasien

asik terhadap tontonannya sehingga

mengabaikan rasa tidak nyaman dan

menunjukkan respon penerimaan yang

baik.

Audiovisual yang digemari oleh anak-

anak usia prasekolah adalah kartun atau

gambar bergerak, merupakan media yang

sangat menarik bagi anak-anak terutama

anak usia prasekolah yang memiliki daya

imajinasi tinggi. Anak juga dapat

mengeksplorasi perasaan, emosi, dan daya

ingat melalui audio visual, audio visual

juga dapat membantu perawat dalam

melaksanakan prosedur infus dan injeksi,

memudahkan perawat dalam mendistraksi

agar anak kooperatif dalam pelaksanaan

prosedur terapi (Tamsuri, 2007). Cara yang

dilakukan yaitu dengan memfokuskan

perhatian pada suatu hal yang disukai oleh

anak, misalnya menonton film kartun

(Maharezi, 2014 dalam Hapsari 2016).

Berdasarkan latar belakang di atas, maka

peneliti tertarik melakukan penelitian

tentang pengaruh audiovisual menonton

film kartun terhadap tingkat kecemasan

saat prosedur injeksi pada anak prasekolah.

METODE

Penelitian ini menggunakan desain pra-

experimental dengan rancang bangun one-

grup pra-post test design. Penelitian

dilaksanakan pada 5-28 Januari 2019.

Populasinya adalah seluruh anak usia

prasekolah yang masuk di Ruang Anak

Rumah Sakit Semen Gresik. Pengambilan

sampel menggunakan teknik purposive

sampling, sebanyak 28 responden.




Prasekolah

19

Variabel independen (audiovisual

menonton film kartun), Upin Ipin,

Doraemon dan Frozen The Snow yang

diputar dengan menggunakan tablet phone.

Variabel dependen (tingkat kecemasan).

Intervensi menonton film kartun diberikan

selama minimal 10 menit, sedangkan

prosedur injeksi durante menonton film

kartun. Alat ukur yang digunakan pada

penelitian ini adalah kuesioner HAR-S

yang merupakan pengukuran kecemasan

didasarkan pada munculnya simptom pada

individu yang mengalami kecemasan.

Prosedur penelitiannya yaitu peneliti akan

melakukan pre test kepada responden pada

hari kedua rawat inap saat diberikan

prosedur injeksi. Kemudian kuesioner

(tingkat kecemasan HAR-S) diisi oleh

keluarga berdasarkan hasil observasi saat

itu, pada hari yang sama saat jadwal

pemberian injeksi selanjutya, peneliti akan

memberikan intervensi audiovisual

menonton film kartun, berupa salah satu

film kartun anak Upin Ipin, Frozen the

snow, Doraemon, sesuai kesediaan pasien.

Pemberian intervensi film kartun tersebut

diberikan minimal 10 menit. Sedangkan

prosedur injeksi diberikan durante

menonton film kartun. Dalam memberikan

intervensi audiovisual film kartun perawat

juga melibatkan keluarga dan teman

perawat dalam satu ruang rawat inap

tersebut, demikian juga dalam proses

dokumentasi. Peneliti melakukan post test

untuk pengambilan data tingkat kecemasan

responden menggunakan ceklis kuesioner

kecemasan skala HAR-S yang diisikan oleh

keluarga/orangtua responden.

Dalam penelitian ini menggunakan analisa

univariat dan bivariat menggunakan uji

Paired T-test untuk mengamati ada

tidaknya perbedaan dari dua data yang

merupakan sebuah sampel tetapi

mengalami perlakuan yang berbeda.

Tabel 1. Tingkat Kecemasan Sebelum dan Sesudah Intervensi Audiovisual Menonton Film

Kartun Saat Prosedur Injeksi Pada Anak Prasekolah di Ruang Anak Rumah Sakit

Semen Gresik pada tanggal 5-28 Januari 2019

Tingkat

Kecemasan

Sebelum Interensi Sesudah Intervensi

Frekuensi Persentase (%) Frekuensi Persentase (%)

Tidak cemas 2 7.1 23 82.1

Ringan 6 21.4 3 10.7

Sedang 2 7.1 1 3.6

Berat 17 60.7 1 3.6

Panik 1 3.6 0 0

Total 28 100.0 28 100.0

Sumber: Data Primer 2019


Tabel 2. Pengaruh Audiovisual Terhadap Tingkat Kecemasan Saat Prosedur Injeksi Pada

Anak Prasekolah di Ruang Anak Rumah Sakit Semen Gresik pada tanggal 5-28

Januari 2019

Tingkat Kecemasan

Intervensi Audiovisual Menonton Film Kartun

Sebelum intervensi Sesudah intervensi

F % F %

Tidak cemas 2 7.1 23 82.1

Ringan 6 21.4 3 10.7

Sedang 2 7.1 1 3.6

Berat 17 60.7 1 3.6

Panik 1 3.6 0 0.0

Total 28 100.0 28 100.0

Mean 28.67 11.75

Std.Deviation 9.03 5.00

Paired Sample T-Test nilai sig (2-tailed) p = 0.000 t = 11.61

Sumber: Data Primer 2019

PEMBAHASAN

1. Tingkat Kecemasan Sebelum Inter-

vensi Audiovisual Menonton Film

Kartun Saat Prosedur Injeksi Pada

Anak Prasekolah

Berdasarkan tabel 1 menunjukkan bahwa

hasil penelitian sebelum intervensi

audiovisual menonton film kartun saat

prosedur injeksi pada anak prasekolah

sebagian besar mengalami kecemasan

berat sebanyak 17 (60.7%). Sama dengan

penelitian sebelumnya mengenai pengaruh

terapi audiovisual terhadap tingkat

kecemasan anak usia prasekolah yang

dilakukan pemasangan infus sebagian

besar mengalami kecemasan berat 55.6%

(Ganda, 2017).

Kondisi cemas yang terjadi pada anak

yang menjalani hospitalisasi dan

mendapatkan tindakan invasif harus

mendapat perhatian khusus dan segera

diatasi. Bagi anak usia prasekolah (3-6

tahun) menjalani hospitalisasi dan

mengalami tindakan invasif merupakan

suatu keadaan krisis disebabkan karena

adanya perubahan status kesehatan,

lingkungan, faktor keluarga, kebiasaan

atau prosedur yang dapat menimbulkan

nyeri dan kehilangan kemandirian pada

anak (Wong, 2009). Lingkungan rumah

sakit, petugas kesehatan dan alat-alat yang

berada di rumah sakit yang baru dilihat

oleh anak menyebabkan anak menjadi

takut dan cemas. Penyebab stress dan

kecemasan pada anak dipengaruhi oleh

banyak faktor, diantaranya perilaku yang

ditunjukkan petugas kesehatan (dokter,

perawat dan tenaga kesehatan lainnya),

pengalaman hospitalisasi anak, support

system atau dukungan keluarga yang

mendampingi selama perawatan. Faktor-

faktor tersebut dapat menyebabkan anak



menjadi semakin stress dan hal ini

berpengaruh terhadap proses penyembuhan

(Nursalam dkk., 2013).

Peneliti mengambil sampel usia 3-6

tahun atau rentang perkembangan anak

usia prasekolah. Berdasarkan karakteristik

responden didapatkan umur responden

adalah anak usia 3-4 tahun sebanyak 46%,

usia 4,1-5 tahun 25%, usia 5,1-6 tahun

29%, dan usia 6 tahun 23%. Pengumpulan

data penelitian yang dilakukan anak yang

berada pada usia 3 tahun memiliki tingkat

kecemasan yang tinggi. Menurut Lau

(2002) dalam Apriliawati (2011) anak usia

infant, toodler, preschool lebih me-

mungkinkan mengalami stress akibat

perpisahan karena kemampuan kognitif

anak yang masih terbatas untuk memahami

hospitalisasi.

Beberapa penelitian menyatakan bahwa

semakin muda usia anak, kecemasan

hospitalisasi akan semakin tinggi (Mahat

& Scoloveno, 2003). Menurut Utami

(2014), anak merupakan populasi yang

sangat rentan terutama saat menghadapi

situasi yang membuat stress. Hal ini

dikarenakan kondisi koping yang

digunakan oleh orang dewasa belum

berkembang sempurna pada anak-anak.

Anak usia prasekolah menerima keadaaan

masuk rumah sakit dengan rasa ketakutan.

Jika anak sangat ketakutan dapat

menampilkan perilaku agresif, dari

menggigit, menendang-nendang bahkan

berlari ke luar ruangan.

Selain umur, jenis kelamin juga dapat

mempengaruhi kecemasan dan stress pada

anak, dimana anak perempuan prasekolah

yang menjalani hospitalisasi memiliki

tingkat kecemasan yang lebih tinggi

dibandingkan laki-laki. Distribusi dalam

penelitian ini didapatkan 57% responden

adalah perempuan. Demikian juga dalam

penelitian (Stubbe, 2008 dalam

Apriliawati, 2011) menyebutkan bahwa

anak perempuan yang menjalani

hospitalisasi memiliki kecemasan yang

lebih tinggi dibandingkan dengan anak

laki-laki.

Pengalaman hopitalisasi pada anak akan

mempengaruhi kecemasan yang dialami

oleh anak. Sebagaimana yang dijelaskan

oleh Tsai (2007) dalam Apriliawati (2011)

anak yang memiliki pengalaman menjalani

hospitalisasi memiliki kecemasan lebih

rendah dibanding anak yang belum

memiliki pengalaman hospitalisasi. Namun

dalam penelitian ini didominasi oleh anak

yang sebelumnya pernah dirawat di rumah

sakit sebanyak 18 anak (64%). Hal ini

dimungkinkan terkait dengan tindakan atau

prosedur medis yang pernah didapat

sebelumnya mungkin menyebabkan

trauma walaupun anak pernah dirawat

tetapi memiliki pengalaman tidak

menyenangkan sehingga anak tetap




Prasekolah

65

mengalami kecemasan. Hal ini sesuai

dengan penelitian yang menyatakan bahwa

pengalaman hospitalisasi tidak

berpengaruh terhadap tingkat kecemasan

anak (Stubbe, 2008 dalam Apriliawati,

2011).

Berdasarkan teori dan hasil penelitian

yang didapat, terdapat keselarasan dimana

terdapat beberapa faktor yang dapat

mempengaruhi tingkat kecemasan pada

anak. Pada anak usia prasekolah penyebab

kecemasan berkaitan dengan umur,

pengalaman dirawat sebelumnya, yang

dapat menuyebabkan tinggi atau rendahnya

tingkat kecemasannya. Tingkat kecemasan

saat prosedur injeksi sebelum intervensi

audovisual sebagian besar mengalami

kecemasan berat 17 responden (60.7%),

dan didapatkan rata-rata skor tertinggi

pada gejala menangis, merengek, berteriak

dan memberontak. Hal ini selaras dengan

teori Supartini (2014) dimana anak usia

prasekolah menganggap sakit adalah

sesuatu hal yang menakutkan, kehilangan

lingkungan yang aman dan penuh kasih

sayang, serta tidak menyenangkan. Anak

menganggap tindakan dan prosedur rumah

sakit menyebabkan rasa sakit dan luka di

tubuhnya.

Ketakutan anak muncul karena anak

menganggap tindakan dan prosedurnya

mengancam intregitas tubuhnya. Oleh

karena itu, menimbulkan reaksi agresif

dengan marah, dan berontak. Demikian

pula disebutkan oleh Stuart (2009) anak

yang dirawat di rumah sakit dengan

kecemasan yang tinggi memiliki

kecenderungan menjadi hiperaktif dan

tidak kooperatif terhadap petugas

kesehatan serta menimbulkan gangguan

psikologik berupa perubahan perilaku

seperti gelisah, menangis, dan

memberontak.

2. Tingkat Kecemasan Sesudah Intervensi

Audiovisual Menonton Film Kartun

Saat Prosedur Injeksi Pada Anak

Prasekolah

Berdasarkan tabel 1 menunjukkan bahwa

hasil penelitian sesudah dilakukan

audiovisual menonton film kartun saat

prosedur injeksi pada anak prasekolah,

hampir seluruhnya tidak mengalami

kecemasan yaitu sebanyak 23 (82.1%).

Penelitian ini sesuai dengan

Wahyuningrum (2015) dalam pengaruh

cerita melalui audiovisual terhadap tingkat

kecemasan anak usia prasekolah yang

mengalami hospitalisasi setelah dilakukan

intervensi sebagian besar mengalami

kecemasan dengan kategori ringan

(59.1%). Penelitian Patma (2017) dalam

penelitiannya tingkat kecemasan setelah

diberikan terapi audiovisual pada pasien

yang dilakukan pemasangan infus,

sebagian besar mengalami kecemasan

ringan yaitu 6 responden (66.7%).


Demikian pula dalam penelitian ini

setelah intervensi audiovisual menonton

film kartun saat prosedur injeksi pada anak

prasekolah, masih didapatkan nilai rata-

rata ketakutan pada skor tertinggi yaitu,

takut diinjeksi dan takut pada orang

asing/perawat. Hal ini selaras dengan teori

yang dikemukakan Kozlowski dkk.,

(2013), salah satu kecemasan yang

dirasakan oleh pasien anak ketika harus

mendapatkan perawatan di rumah sakit

adalah tindakan invasif, seperti pemberian

obat injeksi yang dilakukan oleh tim

kesehatan. Tindakan invasif pemberian

obat injeksi, baik menyakitkan atau tidak

merupakan suatu ancaman bagi anak usia

prasekolah karena mereka menganggap

tindakan invasif merupakan sumber

kerusakan terhadap integritas tubuhnya.

Mott (2005) lingkungan rumah sakit yang

dianggap asing oleh anak akan

meningkatkan kecemasan anak pada saat

dirawat di rumah sakit (Apriliawati, 2011).

Kondisi cemas yang terjadi pada anak

yang menjalani hospitalisasi dan

mendapatkan tindakan invasif harus

mendapat perhatian khusus dan segera

diatasi (Wong, 2009). Intervensi

audiovisual menonton film kartun adalah

sebuah proses yang akan membentuk

imajinasi pada anak, memberikan

kesempatan pada anak untuk lebih

menangkap informasi, edukasi dan hiburan

serta dapat mengekspresikan perasaannya

(Koller dan Goldman, 2012, dalam Patma,

2017).

Anak-anak menyukai unsur-unsur

seperti gambar, warna, cerita pada film

kartun animasi. Unsur-unsur seperti

gambar, warna dan cerita dan emosi

(senang, sedih, seru, bersemangat) yang

terdapat pada film kartun merupakan unsur

otak kanan dan suara yang timbul dari film

tersebut merupakan unsur otak kiri. Unsur

grafis pada sajian anak prasekolah adalah

unsur yang paling penting karena pada

anak prasekolah unsur lisan dan audio

hanya mendapatkan perhatian sebesar 2%

dan 98% sisanya diporsikan pada unsur

visual statis (Evans dkk., 2008 dalam

Wahyuningrum, 2015). Sehingga dengan

menonton film kartun animasi seperti Upin

Ipin, Doraemon ataupun Frozen the Snow,

otak kanan dan otak kiri anak pada saat

bersamaan digunakan dua-duanya secara

seimbang dan anak fokus pada film kartun

(Wahyuningrum, 2015).

Dengan memberikan sajian interaktif

visual (gambar statis) dan video (gambar

dinamis) maka konsentrasi anak terhadap

audiovisual yang dilihat akan meningkat.

Sehingga audiovisual menonton film

kartun dapat memudahkan anak untuk

mendapatkan pembelajaran dengan basis

yang menyenangkan. Sehingga peman-

faatan audiovisual dapat membantu dan




Prasekolah

67

memudahkan perawat dalam mendistraksi

agar anak kooperatif dalam pelaksanaan

prosedur injeksi (Taufik, 2007).

3. Pengaruh Audiovisual Terhadap

Tingkat Kecemasan Saat Prosedur

Injeksi Pada Anak Prasekolah

Hasil uji analisa Paired T Tes untuk

mengetahui Pengaruh Audiovisual

Menonton Film KartunTerhadap Tingkat

Kecemasan Saat Prosedur Injeksi Pada

Anak Prasekolah, pada penelitian ini

didapatkan hasil sig (2-tailed) p = 0.000,

p< 0.05 maka H0 ditolak dan H1 diterima

yang berarti ada pengaruh audiovisual

menonton film kartun terhadap tingkat

kecemasan saat prosedur injeksi pada anak

prasekolah di Ruang Anak Rumah Sakit

Semen Gresik. Hasil penelitian ini sejalan

pada penelitian Wahyuningrum (2015),

bahwa pemberian cerita melalui

audiovisual efektif dalam menurunkan

tingkat kecemasan pada anak usia

prasekolah yang mengalami hospitalisasi.

Berdasarkan tabel 3 tingkat kecemasan

anak sesudah diberikan audiovisual

menonton film kartun saat prosedur injeksi

pada anak prasekolah hampir seluruhnya

tidak mengalami kecemasan, yaitu

sebanyak 23 responden (82,1%). Tingkat

kecemasan yang berbeda pada tiap anak

disebabkan pula karena respon setiap

manusia terhadap stressor memang

berbeda. Hal ini sesuai dengan model

kognitif kecemasan yang menyebutkan

bahwa respon yang berbeda pada tiap

individu antara lain dipengaruhi oleh

adanya kelemahan dalam berbagai proses

informasi (Blackburn, 1990, dalam Juanita,

2017. Namun masih didapatkan 1 respon-

den mengalami kecemasan berat sesudah

intervensi audiovisual menonton film

kartun, meskipun responden kooperatif

saat diberikan intervensi audiovisual

menonton film kartun, dan masih

menunjukkan rasa takut saat akan

diinjeksi, takut pada perawat, gelisah,

tegang, menangis, berteriak dan

memberontak hingga menunjukkan muka

merah dan penurunan nafsu makan. Hal ini

dimungkinkan karena pasien mempunyai

riwayat sudah pernah dirawat dua kali

sebelumnya, sehingga pernah mempunyai

pengalaman yang masih menjadi sumber

kecemasan baginya, diantaranya penga-

laman mendapatkan prosedur injeksi serta

pemasangan infus.

Apabila anak mengalami kecemasan

tinggi saat dilakukan tindakan invasif,

kemungkinan besar tindakan yang

dilakukan menjadi tidak maksimal dan

tidak jarang harus mengulangi beberapa

kali sehingga akan menghambat proses

penyembuhan anak. Kondisi ini memper-

sulit perawat dalam melakukan tindakan

keperawatan (Supartini, 2014). Perlu

adanya upaya dalam menurunkan tingkat


kecemasan terutama saat prosedur injeksi,

diantaranya dengan distraksi audiovisual

(Tamsuri, 2007).

Koller dan Goldman (2012) dalam

studinya menyatakan bahwa pemberian

cerita melalui audiovisual guna menurun-

kan kecemasan termasuk teknik distraksi

kecemasan dengan teknik audiovisual.

Perhatian anak yang terfokus kepada cerita

audiovisual yang disimaknya mendis-

traksikan atau mengalihkan persepsi

kecemasan anak dalam korteks serebral.

Dengan intervensi audiovisual menonton

film kartun akan memberikan rangsangan

distraksi berupa visual, auditory dan

tactile. Perasaan aman dan nyaman yang

dirasakan anak akan merangsang tubuh

untuk mengeluarkan hormon endorphine.

Melalui pemberian audiosivisual

menonton film kartun yang diberikan oleh

perawat diharapkan dapat membantu anak

dalam mengatasi permasalahan dengan

meminta mereka ikut terlibat tentang

kegiatan atau tindakan injeksi yang

diberikan oleh petugas sehingga dapat

membantu membangun pikiran dan

kemungkinan dapat menyelesaikan

masalah yang berhubungan dengan

penyakit, perpisahan selama dirawat,

kecacatan dan keterasingan. Hal ini terlihat

pada saat penelitian anak menjadi fokus

dengan tayangan audiovisual menonton

film kartun dibandingkan prosedur injeksi,

walaupun anak masih tetap harus di

dampingi dan tetap dekat dengan

orangtuanya. Hasil uji analisis statistik

didapatkan adanya perbedaan tingkat

kecemasan pada pre test dan post test pada

anak yang diberikan audiovisual menonton

film kartun saat prosedur injeksi. Ini

berarti bahwa ada pengaruh audiovisual

menonton film kartun dalam menurunkan

tingkat kecemasan saat prosedur injeksi

pada anak prasekolah, baik secara

subyekstif maupun obyektif. Hal tersebut

sesuai dengan teori bahwa salah satu cara

yang dapat dilakukan untuk pengendalian

kecemasan adalah tehnik distraksi

audiovisual untuk mengalihkan perhatian

anak (Tamsuri, 2007, dalam Agustina

2015). Perhatian anak menjadi teralihkan

pada film kartun yang disukai anak, yang

menyebabkan anak tidak lagi memikirkan

prosedur injeksi, anak menjadi rileks dan

nyaman sehingga menurun kecemasannya.

KESIMPULAN

Sebelum diberi intervensi sebagian

responden memiliki kecemasan berat,

sedangkan sesudah diberi intervensi

hampir seluruh responden tidak mengalami

kecemasan. Sehingga Ada pengaruh

pemberian audiovisual menonton film

kartun terhadap penurunan tingkat

kecemasan saat prosedur injeksi pada anak

prasekolah.




Prasekolah

69

DAFTAR PUSTAKA

Agustina, H, (2015). Pengaruh Distraksi

Audiovisual Terhadap Respon

Penerimaan Injeksi Intravena Pada

Anak Prasekolah di RSD Kalisat

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ARTICLE IN PRESS+Model

J Pediatr (Rio J). 2018;xxx(xx):xxx---xxx

www.jped.com.br

ORIGINAL ARTICLE

Psychological preparation reduces preoperativeanxiety in children. Randomized and double-blindtrial�,��

Dânia P. Meletti a,∗, José Fernando A. Melettib, Rodrigo P.S. Camargoc,Leopoldo M. Silvad, Norma S.P. Módoloe

a Faculdade de Medicina de Jundiaí, Ciências da Saúde, São Paulo, SP, Brazilb Faculdade de Medicina de Jundiaí, Departamento de Anestesiologia, São Paulo, SP, Brazilc Faculdade de Medicina de Jundiaí, Departamento de Ginecologia e Obstetrícia, São Paulo, SP, Brazild Universidade Estadual Paulista ‘‘Júlio de Mesquita Filho’’ (UNESP), Departamento de Anestesiologia, São Paulo, SP, Brazile Universidade Estadual Paulista ‘‘Júlio de Mesquita Filho’’ (UNESP), Faculdade de Medicina de Botucatu, Departamento deAnestesiologia, Botucatu, SP, Brazil

Received 26 September 2017; accepted 26 April 2018

KEYWORDSChild;Anxiety;Psychologicalpreparation;Anesthesia;Surgery

AbstractObjective: To verify the effect of psychological preparation on the relief of preoperative anxietyin children and to correlate parents’ and children’s levels of anxiety.Method: After the approval of the institutional Research Ethics Committee and written consentof the children’s parents or guardians, 118 children of both genders were prospectively selected,aged between 2 and 8 years, physical condition classification ASA I, who were treated in thepre-anesthetic evaluation ambulatory of the University Hospital and who underwent ambula-tory surgeries at the same hospital. Two controlled groups of 59 children were randomized:control group basic preparation and psychological preparation group. On the day of surgery,all selected children were evaluated regarding their level of anxiety using the modified YalePreoperative Anxiety Scale and their parents were evaluated regarding their level of anxietythrough the Visual Analog Scale. The evaluator was blinded to which study group the child andfamily member belonged to.
Results: Nine children and their family members were excluded per group when the resultswere analyzed. Children from the prepared group showed significant reductions in their levelof anxiety in relation to the control group (p = 0.04). There was no correlation between thelevel of anxiety of children and their parents’ levels (p = 0.78).
� Please cite this article as: Meletti DP, Meletti JF, Camargo RP, Silva LM, Módolo NS. Psychological preparation reduces preoperativeanxiety in children. Randomized and double-blind trial. J Pediatr (Rio J). 2018. https://doi.org/10.1016/j.jped.2018.05.009

�� Study conducted at the Master’s Degree Program of Faculdade de Medicina de Jundiaí, São Paulo, SP, Brazil∗ Corresponding author.

E-mail: [email protected] (D.P. Meletti).

https://doi.org/10.1016/j.jped.2018.05.0090021-7557/© 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

JPED-686; No. of Pages 7

https://doi.org/10.1016/j.jped.2018.05.009

http://www.jped.com.br




http://creativecommons.org/licenses/by-nc-nd/4.0/


2 Meletti DP et al.

Conclusion: The psychological preparation was effective in reducing the level of anxiety ofchildren. However, there was no relation between the level of anxiety of children and theirparents’ level.© 2018 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This isan open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVECrianca;Ansiedade;Preparacãopsicológica;Anestesia;Cirurgia

Preparacão psicológica reduz ansiedade pré-operatória de criancas. Ensaiorandomizado e duplamente encoberto

ResumoObjetivos: Verificar o efeito da preparacão psicológica no alívio da ansiedade pré-operatóriade criancas e avaliar se há correlacão com a ansiedade dos pais.Método: Após a aprovacão do Comitê de Ética e Pesquisa da Faculdade de Medicina e obtencãodo consentimento pelos responsáveis dos pacientes, foram selecionadas prospectivamente 118criancas, de ambos os sexos, com idade entre dois e oito anos, classificacão de estado físico ASAI, atendidas no ambulatório de avaliacão pré-anestésica do Hospital Universitário e submetidasa cirurgias ambulatoriais. Foram randomizados dois grupos controlados de 59 criancas: grupo depreparacão básica e grupo preparacão psicológica. No dia da cirurgia, todas as criancas foramavaliadas em relacão ao seu grau de ansiedade através da Escala de Ansiedade Pré-operatóriade Yale Modificada e seus pais, avaliados quanto ao seu nível de ansiedade pela Escala VisualAnalógica. O avaliador era cego sobre qual grupo do estudo a crianca e seu familiar pertenciam.Resultados: Na análise dos resultados, foram excluídas 9 criancas e familiares de cada grupo.As criancas do grupo preparado tiveram reducões significativas no grau de ansiedade em relacãoao grupo controle, (p = 0,04). Não houve correlacão entre os graus de ansiedade das criancas eseus pais (p = 0.78).Conclusão: A preparacão psicológica foi eficaz na reducão do grau de ansiedade das criancasno momento da cirurgia. Não houve, entretanto, relacão entre os graus de ansiedade dos paise seus filhos.© 2018 Sociedade Brasileira de Pediatria. Publicado por Elsevier Editora Ltda. Este éum artigo Open Access sob a licença de CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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nxiety is present in approximately 50% of patients whondergo an anesthetic-surgical procedure.1 The prospect ofostoperative pain, separation from family members, expo-ure to strangers, fear of the surgery and anesthesia, and theossibility of becoming incapacitated are factors that mayncrease the degree of anxiety in pediatric patients.2 In thereoperative period, anxiety tends to manifest as feelings ofension, nervousness, worry, apprehensiveness, or psycho-ogical stress.3 Some children verbalize their dreads, whilethers demonstrate anxiety through behavioral changes,uch as becoming restless, trembling, breathing deeply,easing to speak, crying, or becoming, in some cases, dif-cult to control.4 In relation to anesthesia, high levelsf anxiety can have negative effects, such as difficultyn achieving anesthetic induction, reduction in defensesgainst infections, and increase in intraoperative anestheticonsumption and postoperative analgesics.5

Diverse ways to alleviate preoperative anxiety have beenidely studied, such as preanesthetic medications, dis-

raction techniques, presence of parents during anesthesianduction, and preoperative psychological and educationalnterventions.6 The non-pharmacological management ofnxiety has advantages when compared to anxiolytics, as

dapd

hey do not have adverse events; however, further studiesre required to demonstrate the efficacy of distraction tech-iques such as the use of medical clowns, videogames, andartoons, among others.7,8 Psychological preparation is seens expensive due to the need for several sessions;9 however,t has good results in reducing preoperative anxiety, as wells in the psychological recovery of the children and theiramily members after the surgery.10,11

Thus, the authors propose a single-session model of psy-hological preparation for parents and children, with theain objective of verifying the effect of anxiety reduction

n children at the time of the surgery. Moreover, the authorsroposed to investigate whether there would be a correla-ion between parents’ and children’s anxiety.

ethods

linical study description and participants

fter approval by the Research Ethics Committee of Facul-
ade de Medicina de Jundiaí (CAEE: 16288513.2.0000.5412)nd after the informed consent form was signed by theatients’ parents or guardians, 118 children of both gen-ers, aged between 2 and 8 years, with physical status




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ARTICLEPreparation reduces preoperative anxiety in children

classification according to the American Association ofAnesthesiologists (ASA) I, treated at the pre-anestheticoutpatient clinic of the University Hospital of Faculdadede Medicina de Jundiaí, and who underwent outpatientsurgeries at that hospital were selected. A randomized,parallel-controlled, prospective, and double-blinded trialwas carried out to evaluate the effect of psychologicalpreparation on the preoperative anxiety levels of childrenand their parents. The methodology was not changed afterthe study was started.

Allocation

Participants were randomly allocated using the List random-izer program (Randomness and Integrity Services Ltd, Schoolof Computer Science and Statistics at Trinity College, Dublin,Ireland). This allocation was implemented by two anesthe-siologists responsible for the pre-anesthetic consultation:they enrolled the participants, applied the exclusion cri-teria and directed the participants to intervention whennecessary. The exclusion criteria were children with provenbehavioral and cognitive alterations; history of previoussurgeries and general anesthesia; users of psychoactivemedications; and history of seizures, mental illness, orchronic pain. Five children were excluded for these reasonsand three patients were excluded because their parents didnot agree to their participation in the study (Fig. 1).

Interventions

From November 6, 2014 to October 5, 2015, two groupsof children and their parents or guardians were randomlyassigned, as described below:

Basic preparation group (BPG): a group that receivedthe standard preparation at the pre-anesthetic consulta-tion, where parents could have their questions answered andreceive explanations from the anesthesiologist; as for thechildren, on the day of surgery, they waited for the momentof surgery in the toy library, a place with toys and booksreserved for them and their family members.

Psychological preparation group (PPG): a group that, inaddition to the basic preparation, underwent a psycholog-ical interview always performed by the same psychologist,after the pre-anesthetic consultation, with the presence ofthe family member and the child. Parents were briefed onthe aspects of the surgery and the separation that wouldoccur when the child entered the operating room, aiming tohelp them cope with these situations. A story was told to thechild, with the support of a children’s book entitled ‘‘Gasparin the hospital’’ by Anne Gutman and Georg Hallensleben,published by Cosacnaif. Gaspar is a child character whosuffers an accident and needs to undergo an emergencysurgery.12 He was at school and is taken to the hospital byambulance alone. He needs to be operated on and duringanesthesia he sleeps and has a good dream. The book high-lights Gaspar’s courage and independence, how happy he
is with his dream and when he wakes up, how happy he isto see his mother. The approach used with the child is thatof coping with a new situation without the presence of theparents.
6llt

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sychological preparation

our main questions were addressed with the parents oramily members present in the psychological session using

semi-open interview model, i.e., the questions were nec-ssarily the same, but the interview varied according to theamily responses and demands. The first question addressedhe feelings about the surgery by the parent and the child;pecifically asking for the verbalization of feelings such asear, anxiety, concern and others as an initial approach.n the second question, adult aspects were questionedegarding the mother-child, or father-child separation, fromimple separations such as leaving the child with a relativeor a few hours, adaptation to school, and other separationxperiences. The third question addressed how the motherr father perceived and dealt with the child’s health and ill-ess situations, and the last question addressed the child’sttachment to objects. This session with the parents wassed to guide and to calm them down regarding the anesthe-ia and surgery aspects, as well as to support the children’separation from their parents, so they would feel confidentoing into the operating room.

easures

t the pre-anesthetic evaluation outpatient clinic, on theay of the consultation, the following tools were applied tohe parents: a questionnaire to assess the sociodemographicrofile, a questionnaire about the role of the anesthe-iologist, the parents’ apprehensions and fears relatedo anesthesia and assessment of their degree of anxietyhrough the visual analogue scale (VAS). Such scale, used as

secondary outcome measure, was also applied to parentsr guardians at the time of the surgery. The scale mea-ured 100 mm, where 0 (zero) was equivalent to ‘‘calm’’nd 100 mm meant ‘‘very anxious.’’13 Mild anxiety wasxpressed by the scores 0, 1, and 2; moderate anxiety, 3,, 5, 6, and 7; and intense anxiety, 8, 9, and 10.

On the day of the surgery, all children selected from bothroups were referred to the toy library attached to the surgi-al center, where their anxiety levels were assessed throughhe modified Yale Preoperative Anxiety Scale (m-YPAS).his observational scale consists of 27 items divided intove categories: activity, vocalization, emotional expression,pparent awakening state, and family interaction. The scoreanges from 23.5 to 100; when above 30, the higher thecore, the greater the anxiety.14 The m-YPAS Scale waspplied continuously, from the pre-anesthetic preparationoom at the time of the child’s separation from the parentso the moment of anesthetic induction, and was performedy a single and the same resident physician in anesthesiol-gy, under the supervision of the anesthesiologist in chargeor the division, after previous training. The evaluator waslinded to the child’s group.

The basic protocol of anesthetic induction was performedn a closed-loop anesthesia delivery system with 33% O2 and
6% N2O, with a total flow of 5 L.min-1 for one minute, fol-owed by administration of sevoflurane at 8%. After the childost consciousness, the gas flow was reduced to 2 L min−1 andhe anesthetic concentration, to 2---3%.


4 Meletti DP et al.

50 children were ana lyz ed for thebasic preparation group

Eligible patients: 118

Excluded: 8

Did not meet the inclusioncriteria: 5

Refused to participate: 3

Randomized: 110

Allocated to the psychologicalpreparation group (PPG): 55

Allocated to the BasicPreparation Group (BPG): 55

Exclu ded aft er all ocation:

Yale scale was not applied: 4

Surgery was cancelled: 1

Exclude d aft er all ocation:

Yale sc ale was not applied: 3

Surgery was cancelled: 2

50 chil dren were analyz ed for thepsychological prepa ration group

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ample size determination and statistical analysis

fter the 110 children were allocated in both groups, fivehildren from each group were lost to follow-up due tourgery cancellation or non-application of the anxiety scalen the day of the surgery. The final analysis was restrictedo 50 children from each studied group.

Considering that the prevalence of anxiety in the oper-ting room in children is 50%1 and that the proposedntervention was able to reduce children’s anxiety by 20%fter a pilot study with 20 children, and using an �-errorf 5%, �-error of 20%, and 95% confidence interval (95%I), the number of patients was determined at 42 in eachroup, totaling a number of 84 participants in the proposedtudy.

The statistical analysis was performed using the soft-are Stata/SE version 9.0 for Windows (Stata Corporation

-- College Station, Texas, USA). In the analysis of groups,edians and the 25---75% percentiles were used as aeasure of central tendency and variability due to

he non-normal distribution trend of the sample sep-rated in groups. Categorical variables were shown asbsolute values and percentages. Histograms and thehapiro---Wilk test were used to verify the symmetry of dataistribution.

The chi-squared test and Fisher’s exact test were usedor categorical variables, and the chi-squared partition waserformed if p-value was less than 0.05 (significance levelsed). The comparisons between two groups for continuous
r ordinal variables were performed using the Mann-Whitneyest.
Spearman’s correlation was used to evaluate the associ-tion intensity of ordinal variables in the same individual.

D

Tp

domization guidelines and participants’ study.

esults

he groups were homogeneous regarding gender, age, levelf schooling, and type of surgery. In both groups, a preva-ence of boys for both groups and children attendingreschool was observed (Table 1).

No significant differences were found regarding thearents’ characteristics (chi-squared test) when the tworoups were compared regarding gender (p = 0.76), school-ng (p = 0.39), income (p = 0.32), occupation (p = 0.20), andarital status (p = 0.36). Most interviewees were women

87%), who were generally the mothers, had finished highchool (39%), belonged to the middle class (57%), and weremployed (58%) and married (77%).

When comparing the groups, both parents and childrenrom the PPG group had significantly lower anxiety levels athe time of surgery when compared with parents and chil-ren from the BPG. There was no difference between thearents’ level of anxiety assessed by the VAS at the time ofhe preanesthetic consultation (Table 2).

There was no correlation between parental anxiety at theime of surgery and the children’s anxiety the two studiedroups (r = 0.0276, p = 0.78; Fig. 2).

None of the children’s demographic data, such as genderp = 0.20), age (p = 0.88), and level of schooling (p = 0.52;hi-squared test) presented a significant association withnxiety.

iscussion

his clinical trial demonstrated that the children and theirarents who received psychological preparation care in a


Preparation reduces preoperative anxiety in children 5

Table 1 Characteristics of the study children: comparison by group.

Variables Basic Preparation GroupBPGFrequency and percentage

Psychological PreparationGroupPPGFrequency and percentage

p-value

Gender 0.76a

Male 44(88) 43(86)Female 6 (12) 7 (14)

Child’s age 0.19a

≥2 and ≤4 27 (54) 18 (36)>4 and ≤6 1 5(30) 21 (42)>6 and ≤8 8 (16) 11 (22)

Child’s level of schooling 0.59a

No schooling 5 (10) 5 (10)Daycare 10 (20) 5 (10)Pre-school 21 (42) 20 (40)First grade 8 (16) 12 (24)Second grade 6 (12) 8 (16)

Type of surgery performedPostectomy 19 (38) 22 (44) 0.684a

Thyroglossal cyst correction 0 3 (6) 0.242b

Inguinal herniorrhaphy 4 (8) 7 (14) 0.523a

Umbilical herniorrhaphy 7 (14) 5 (10) 0.758a

Nevus excision 3 (6) 1 (2) 0.617b

Adenoamigdalectomy 17 (34) 12 (24) 0.378a

a Yates’ chi-squared test.b Fisher’s exact test.

Values expressed as frequency and percentage (%); p < 0.05.

Table 2 Parents’ and children’s anxiety: comparison bygroup.

Scales BPGMedian andpercentiles

PPGMedian andpercentiles

p-value

VAS (consulta-tion)

8 (6.75---10) 7 (5---10) 0.12

VAS (surgery) 9 (7---10) 7 (5---10) 0.01m-YPAS 33.4

(23.4---45.85)26.6(23.4---33.4)

0.04

120

100

80

60

40

201 3 5

Visual Analogue Scale – Anxiety before the surgery

Mod

ified

Yal

e P

reop

erat

ive

Anx

iety

Sca

le

7 9 11

Figure 2 Correlation between the parents’ anxiety (VAS)scale at the time of surgery and the modified Yale Preoper-ac

si

In his review article, Moro discusses the question of age

Mann---Whitney test.Values expressed as medians and percentiles (25---75%).

single session had their preoperative degree of anxiety sig-nificantly reduced when compared with the group that didnot receive this care (p = 0.04 for the children and = 0.01 forparents at the time of surgery).

The preparation was focused on alleviating separationanxiety in young children. According to the care protocolused at the University Hospital where this study was per-formed, the parents did not accompany their children duringanesthetic induction, and the separation took place at thetoy library attached to the surgical ward. The authors con-
sider the age limit of 8 years as a predisposing factor to thisanxiety,15 due to the peculiar fact that children between 6months and 4 years of age manifest a greater intensity of
rss

tive Anxiety Scale (m-YPAS) applied in children. Spearman’sorrelation: p = 0.78.

eizures and the fear of separation from parents still remainn some children between the ages of 4---8 years.15

16

elated to preoperative anxiety and concludes that there istill no consensus on the subject. The literature containsome assertions that younger children, up to 6 years of age,

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re more likely to suffer from preoperative anxiety relatedo separation. Older children, however, would be more con-erned with the surgery itself. Some studies have reportedhat older children are more anxious, and other authors didot find any evidence related to age.16 In the present study,o differences regarding an age-related degree of anxietyere observed; younger children between 2 and 4 years,r those aged 5 and 6 years, were no more anxious thanhose aged 7 and 8 years (p = 0.08). Similarly to the presentesults, Wollin et al.17 found no significance in the associa-ion between anxiety and the children’s age between 5 and2 years --- they divided the children into age groups: 5---6ears, 7---10 years, and 11---12 years. The present authorsherefore believe that maintaining the focus on the separa-ion anxiety approach for the age group of 2---8 years reducedhe number of consultations to a single session.

Kain et al. performed a family-centered preparation.9

n this intervention, parents received counseling throughideos, booklets, or by telephone, and the children received

surprise box at the time of anesthetic induction; their par-nts were monitored by a researcher who asked them to uselanned distraction strategies for children, if necessary. Thisdvanced preparation group presented superior results ineducing the children’s anxiety in comparison with the othertudy groups that were not submitted to this preparation.

Although the trial concluded that the psychologicalreparation significantly contributed to the reduction ofreoperative anxiety in children, the program was expensivend feasible only in large hospitals. Moreover, because ofhe complexity involved, it was not clear which componentould be essential in this preparation.

Another study, comparing children who underwent a pre-perative psychological preparation to a group of childrenho did not receive this type of care showed that theroup of children trained by the psychologist had lowernxiety levels than those who underwent only distractionechniques.18 Another trial19 evaluated the psychologist’sresence at the time of anesthetic induction and concludedhis method was more effective in reducing anxiety in chil-ren when compared with distraction techniques. In thattudy, it was necessary to have the presence of a profes-ional psychologist, who is part of the surgical team, onlyor this in-person support during anesthetic induction. In theresent study, the preparation aimed to enable the child toace the moment of surgery alone, but with the support ofhe existing team.

Regarding the aspect of an association between theegree of anxiety of the parents and their children inhe preoperative period, the present* study did not showuch correlation. Another clinical trial20 also failed tobserve such association, but its result was attributed tohe restricted number of participants. Cui et al.21 demon-trated a correlation between the anxiety of parents andheir children younger than 4 years during anesthetic induc-ion. It could be suggested that this difference in resultsas due to the fact that the mean age of the children in theresent study was higher. According to Nascimento,22 thereay be differences in the correlations between parents’ and

hildren’s anxiety levels regarding their age group.The present study had some limitations. In the postop-

rative period, the children’s behaviors and need for painedication were not assessed and, therefore, it was not

PRESSMeletti DP et al.

ossible to verify the extent of the benefits in this psycho-ogical preparation model. It was also not possible to matchhe genders in the studied groups, which predominantly con-isted of boys, due to the high frequency of postectomies inhe service. The psychological preparation for preanestheticedication use was not compared, and ethical reasonsrevented the creation of a control group without any pre-nesthetic preparation. Children who received psychologicalreparation were compared with children awaiting surgeryn a toy library, since it has already been shown that toyselp reduce anxiety.3,23,24

Finally, the study could have selected parents and chil-ren with a high risk of anxiety based on the informationollected during the psychological consultation and comparehem to the anxiety assessed by VAS and YALE scale at theime of surgery. This prognosis would have been useful instimating which parents and children would need a moreomprehensive approach with more than one session. Theuthors suggest this approach for future studies.

Children in the PPG and their parents benefited from thenxiety reduction when compared to the group that did noteceive this preparation. Therefore, the authors concludehat a single psychological session was effective in preparingarents and children for separation anxiety and coping withhe surgical procedure in most cases. This result has prac-ical and clinical importance and thus, this approach washown to be as effective as programs that rely on multipleessions.

unding

he study was registered in the Registro de Ensaios Clínicosrasileiros. Primary Identifier: RBR-5jh9sf.

onflicts of interest

he authors declare no conflicts of interest.

eferences

1. Davidson AJ, Shirivastava PP, Jansen K, Huang GH, CzarnekiC, Gibson MA, et al. Risk factors for anxiety at induction ofanesthesia in children: a prospective cohort study. PaediatricAnaesth. 2006;16:919---27.

2. Maranets I, Kain ZN. Preoperative anxiety and intraoperativeanesthetic requirements. Anesth Analg. 1999;89:1346---51.

3. Weber FS. The influence of playful activities on children’s anx-iety during the preoperative period at the outpatient surgicalcenter. J Pediatr. 2010;86:209---14.

4. Kain ZN, Mayes LC. Anxiety in children during the perioperativeperiod. In: Borenstein M, Genevro JL, editors. Child devel-opment and behavioral pediatrics. Mahwah, New Jersey: L.Erlbaum Associates; 1996. p. 85---103.

5. Guaratini AA, Marcolino JA, Teixeira AB, Bernardis RC, PassarelliML, Mathias L. Estudo transversal de ansiedade pré-operatóriaem criancas: utilizacão da Escala de Yale modificada. Rev Bras
Anestesiol. 2006;56:591---601.
6. Ahmed MI, Farrel MA, Parrish K, Karla A. Preoperative anxiety inchildren --- risk factors and non-pharmacological management.M E J Anesth. 2011;21:153---70.

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7. Yip P, Middleton P, Cyna AM, Carlyle AV. Non-pharmacologicalinterventions for assisting the induction of anaesthesia in chil-dren. Evid Based Child Health. 2011;6:71---134.

8. Manyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non-pharmacological interventions for assisting the inductionof anaesthesia in children. Cochrane Database Syst Rev.2015:CD006447.

9. Kain ZN, Caldwell-Andrews AA, Mayes LC, Weinberg ME, WangSM, MacLaren JE, et al. Family-centered preparation for surgeryimproves perioperative outcomes in children. Anesthesiology.2007;106:65---74.

10. Gorayeb RP, Petean EB, Pileggi FO, Tazima MF, Vicente YA,Gorayeb R. Importance of psychological intervention for therecovery of children submitted to elective surgery. J PediatrSurg. 2009;44:1390---5.

11. Hilly J, Hörlin A-L, Kinderf J, Ghez C, Menrath S, DelivetH, et al. Preoperative preparation workshop reduces postop-erative maladaptive behavior in children. Paediatr Anaesth.2015;25:990---8.

12. Gutman A, Hallensleben G. Gaspar no Hospital. 2nd ed. SãoPaulo: Cosac Naify; 2010.

13. Kindler CH, Harms C, Amsler F, Ihde-School T, Scheidegger D.The visual analog scale allows effective measurement of pre-operative anxiety and detection of patients. Anesth Analg.2000;90:706---12.

14. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofs-
tadter MB. The Yale Preoperative Anxiety Scale: does it comparewith a ‘‘gold standard’’? Anesth Analg. 1997;85:783---8.
15. Ghazal EA, Mason LJ, Coté CJ. Preoperative evaluation pre-medication and induction of anesthesia. In: Cote CJ, Lerman

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J, Anderson B, editors. A practice of anesthesia for infants andchildren. 5th ed. Canada: Saunders; 2013.

6. Moro ET, Módulo NS. Children, parents and anxiety. Rev BrasAnestesiol. 2004;54:728---38.

7. Wollin SR, Plummer JL, Owen H, Hawkins MF, Materazzo F. Pre-dictors of preoperative anxiety in children. Anaesth IntensiveCare. 2003;31:69---74.

8. Cuzzocrea F, Costa S, Gugliandolo MC, Larcan R. Psychologistsin preoperative programmes for children undergoing surgery. JChild Health Care. 2016;20:164---73.

9. Cuzzocrea F, Gugliandolo MC, Larcan R, Romeo C, Turi-aco N, Dominici T. A psychological preoperative program:effects on anxiety and cooperative behaviors. Paediatr Anaesth.2013;23:139---43.

0. Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as atreatment for preoperative anxiety in children: a randomized,prospective study. Pediatrics. 2005;116:563---7.

1. Cui X, Zhu B, Zhao J, Huang Y, Luo A, Wei J. Parental state anx-iety correlates with preoperative anxiety in Chinese preschoolchildren. J Paediatr Child Health. 2016;52:649---55.

2. Nascimento CR [dissertation] Relacões entre a resposta deansiedade de pais e a resposta de ansiedade de seus filhos. PortoAlegre (RS): Universidade Federal do Rio Grande do Sul; 1998.

3. Golden L, Pagala M, Sukhavasi S, Nagpal D, Ahmad A, MahantaA. Giving toys to children reduces their anxiety about receivingpremedication for surgery. Anesth Analg. 2006;102:1070---2.

4. Aydin GB, Yuksel S, Ergil J, Polat R, Akelma FK, Ekici M,et al. The effect of play distraction on anxiety before pre-medication administration: a randomized trial. J Clin Anesth.2016;36:27---31.




































































































































































































































































































































































































































































































































































































Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.778 www.anesthesia-analgesia.org September 2015 • Volume 121 • Number 3

Copyright © 2015 International Anesthesia Research SocietyDOI: 10.1213/ANE.0000000000000839

Preschool children undergoing surgery are particularly vulnerable to separation anxiety before anesthesia because they are dependent on their parents and are

old enough to recognize parental absence.1–3 Furthermore, the placement of a mask on the face and the inhalation of volatile anesthetics in the absence of parents further dis-tresses young children, sometimes to the extent of refusal of mask induction.1,2,4,5 A more anxious state preoperatively results in poor cooperation at anesthetic induction and may be associated with emergence delirium and negative behavioral change after surgery.6,7 Therefore, the transfer of children from a preoperative holding area to the operating

room (OR) and the smooth induction of anesthesia without heightened anxiety may be of paramount importance in terms of minimizing perioperative distress and improving behavioral outcome.

Portable multimedia devices, such as smart phones, tablet computers, and handheld DVD players, are readily available at low cost. Age-appropriate video clips and video games are commonly used as effective distraction tools for medical and surgical procedures in children.8,9 In anesthetic practice, active distraction by a handheld video game with parental presence was found to be more effective than pre-medication or parental presence only for reducing anxiety and improving cooperation during mask induction in chil-dren aged 4 to 12 years.10 In younger children, whose cog-nitive and motor development were not advanced enough to play interactive video games, passive viewing of an animated cartoon also proved a more effective distraction than traditional storytelling, game-playing, nonprocedural talking, or humor during mask induction.11 However, pre-vious studies did not completely control for parental pres-ence or used parents to keep children relaxed during video distraction.9–11

Thus, we performed this study to determine whether video distraction per se is capable of alleviating preoperative

BACKGROUND: The anxiolytic efficacy of video watching, in the absence of parents, during the mask induction of anesthesia in young children with high separation anxiety has not been clearly established. We performed this study to determine whether the effect of video distrac-tion on alleviating preoperative anxiety is independent of parental presence and whether a combination of both interventions is more effective than either single intervention in alleviating preoperative anxiety and postoperative behavioral disturbance in preschool children.METHODS: In this prospective trial, 117 children aged 2 to 7 years scheduled for elective minor surgery were randomly allocated to 1 of 3 groups, a video distraction group (group V), a parental presence group (group P), or a combination of video distraction plus parental presence group (group VP) during induction of sevoflurane anesthesia. The Modified Yale Preoperative Anxiety Scale (mYPAS) was used to assess anxiety in the preoperative holding area (baseline), immediately after entry to the operating room, and during mask induction. Compliance during induction, emergence delirium during recovery, and negative behavioral changes at 1 day and 2 weeks postoperatively were also assessed.RESULTS: The mYPAS scores were comparable (P = 0.558), and the number of children exhibit-ing baseline anxiety (an mYPAS score > 30) were not different among the 3 groups in the preop-erative holding area (P = 0.824). After intervention, the changes in mYPAS scores from baseline to induction were not different among the 3 groups (P = 0.049). The proportion of children with increased mYPAS scores was higher in group P compared with group V from baseline to operat-ing room entry (Bonferroni-adjusted 95% confidence interval for difference, 2 to 49) but similar from baseline to induction in all 3 groups. Although children in group V were more cooperative during mask induction than those in the other 2 groups (P < 0.001 versus group P and P = 0.001 versus group VP), no significant intergroup differences were observed in the incidence of emergence delirium or new-onset negative behavioral change after surgery.CONCLUSIONS: Video distraction, parental presence, or their combination showed similar effects on preoperative anxiety during inhaled induction of anesthesia and postoperative behav-ioral outcomes in preschool children having surgery. (Anesth Analg 2015;121:778–84)

From the Department of Anesthesiology and Pain Medicine, Yeungnam University School of Medicine, Daegu, Republic of Korea.

Accepted for publication April 15, 2015.

Funding: This work was funded by Yeungnam University Grant-in-Aid of 2012.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Sung Mee Jung, MD, Department of Anesthe-siology and Pain Medicine, Yeungnam University School of Medicine, 170, Hyeonchung-ro, Nam-gu, Daegu 705-703, Republic of Korea. Address e-mail to [email protected].

Video Distraction and Parental Presence for the Management of Preoperative Anxiety and Postoperative Behavioral Disturbance in Children: A Randomized Controlled TrialHyuckgoo Kim, MD, Sung Mee Jung, MD, Hwarim Yu, MD, and Sang-Jin Park, MD, PhD

Section Editor: James DiNardo

Society for Pediatric Anesthesia


Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.

September 2015 • Volume 121 • Number 3 www.anesthesia-analgesia.org 779

anxiety and improving cooperation independent of paren-tal presence and whether a combination of video distrac-tion and parental presence is more effective than either intervention in preschool children during mask induction of anesthesia. The primary end point of this study was a change in anxiety level from baseline to induction. In addi-tion, we investigated the effect of each proactive interven-tion on postoperative behavioral outcomes, that is, on the incidences of emergence delirium and new-onset maladap-tive behavioral changes.

METHODSThis prospective, randomized study was approved by the IRB of Yeungnam University Hospital in South Korea and was registered with ClinicalTrials.gov on the December 30, 2013 (NCT02027844). One hundred seventeen children aged between 2 and 7 years, ASA physical status I or II scheduled for elective minor surgery under general anesthesia were enrolled. Children with a chronic illness, developmental delay, a neuropsychiatric disease, cancer, experience of a recent stressful life event, previous anesthetic experience, sedative medication, or emergency surgery were excluded. Written informed consent was obtained from parents, and verbal assent was obtained from children older than 6 years before the day of surgery.

No participant received sedative premedication before anesthesia. After arriving in the preoperative holding area, participants were allocated to 1 of the 3 study groups: group V (distraction by watching an animated cartoon video), group P (parental presence), or group VP (video distraction plus parental presence), throughout induction of anesthesia, using a computer-generated random assignment scheme. In group V, children were allowed to select 1 animated cartoon video in a smartphone offered by the researcher or parents and started to watch it with or without parents while wait-ing in the preoperative holding area. Children in group V were separated from their parents in the preoperative hold-ing area and transported to the OR. Anesthesia was induced while children continued to view the chosen video. In group P, 1 parent accompanied the child to the OR and stayed dur-ing the induction of anesthesia, and in group VP, children watched a cartoon video with their parents throughout the whole anesthesia induction process.

After arrival in the OR, children were given the choice to sit up or lie down on the operating table. All participants were introduced to the facemask, which was detached from the anesthetic circuit, before induction. The anesthesiolo-gist explained the anesthesia induction process to children and gently asked them to breathe deeply. A pulse oximeter and electrocardiogram were used for continuous monitor-ing during induction. Anesthesia was induced by mask inhalation with incrementing sevoflurane up to 8% with N2O (4 L/min) and oxygen (2 L/min). The anesthesiologist carefully positioned the facemask/anesthesia circuit so as not to interfere with video watching or the parent. When a participant closed his/her eyes and failed to respond to his/her name, the video was discontinued and the parent was escorted out of the OR by a nurse. Noninvasive arte-rial blood pressure was measured as soon as possible. After endotracheal intubation, anesthesia was maintained by sevoflurane inhalation at an end-tidal concentration of 1.5%

to 3.0% in 50% oxygen and by IV remifentanil infusion at a rate of 0.05 to 0.1 μg/kg/min during surgery. At the end of surgery, sevoflurane administration was discontinued, and after awakening with adequate spontaneous ventila-tion, children were tracheally extubated and transferred to the postanesthesia care unit (PACU). Heart rate, Spo2, and respiratory rate were monitored in the PACU. Parents were allowed to rejoin their children in the PACU. If a child com-plained of pain or exhibited signs or symptoms of pain, IV fentanyl 1 μg/kg was administered in the PACU. All clinical management decisions were made by the anesthesiologist responsible for the care of the patients.

Children’s anxiety levels throughout anesthesia induc-tion were assessed using the modified Yale Preoperative Anxiety Scale (mYPAS) at 3 time points, that is, while wait-ing in the preoperative holding area (T0; baseline), on enter-ing the OR (T1), and during mask induction (T2). mYPAS scores are obtained by summing the scores of 22 items in 5 behavioral categories: activity, state of apparent arousal, vocalization, emotional expression, and the use of parents.12 In group V, the interaction with the parent was assessed by slightly modifying the original components of the “use of parents” because of parental absence.

An mYPAS score of >30 indicates the presence of signifi-cant anxiety.12 The induction compliance checklist (ICC) was used to assess cooperation during induction.13 Both mYPAS and ICC scores were assessed by a trained observer in real time during the perioperative period. Before patients were enrolled in this study, the observer was trained in how to perform mYPAS and ICC scoring by reviewing videotapes of children at induction of anesthesia until 80% agreement with the scores allocated by a psychologist was achieved consistently, as suggested by Sadhasivam et al.14

Parental anxiety was assessed using the Korean version of Spielberger’s State-Trait Anxiety Inventory (STAI), which evaluates trait (baseline) and state (situational) anxiety.15 In the preoperative holding area, both trait and state anxiety scores were measured to investigate the effect of parental anxiety on child anxiety. State anxiety scores after induction were obtained to assess the effect of the 3 interventions on situational anxiety changes in parents.

After surgery, postoperative pain was assessed using the Children’s Hospital of Eastern Ontario Pain (CHEOP) scale.16 Emergence delirium was evaluated using the Pediatric Anesthesia Emergence Delirium (PAED) scale at 10-minute intervals for 30 minutes after arrival in the PACU.17 When the highest PAED score recorded at any time exceeded 10, emergence delirium was deemed to be present.

An investigator, unaware of group assignments, con-tacted parents and requested that they complete the Post-Hospitalization Behavior Questionnaire (PHBQ) at 1 and 14 days postoperatively by phone. The PHBQ contains 27 items in 6 categories: general anxiety, separation anxiety, anxiety about sleep, eating disturbance, aggression toward author-ity, and apathy/withdrawal.18 Negative behavioral change development after anesthesia and surgery was recorded. Both CHEOP and PAED scores and PHBQ interviews were performed by an independent observer unaware of group assignments.

Power analysis was conducted using G*Power ver. 3.1.5. An effect size of 0.31 was estimated from the variance of

Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.780 www.anesthesia-analgesia.org aNeStheSia & aNalgeSia

Video Distraction and Parental Presence in Children

mean mYPAS differences between the baseline and the induction of anesthesia among the 3 groups and the square of the common SD within each group based on the results of a pilot study conducted on 27 children. The data of the pilot study were not included in data analysis in the current study. A sample size of 35 participants per group was calculated by 1-way analysis of variance (ANOVA) to yield an 80% power to detect this effect size at a set α value of 0.05 among the 3 groups. Thirty-nine participants per group were recruited to account for a 10% dropout rate due to withdrawal of con-sent, a change in anesthetic/surgical plan, or follow-up loss.

Statistical analysis was performed using SPSS version 19 (SPSS Inc., Chicago, IL). The Kolmogorov-Smirnov Lilliefors goodness-of-fit test was used to verify normalities of the residuals of all continuous variables. When P values of the data were >0.05, they were considered normally distrib-uted. The normally distributed continuous variables, such as age, weight, and duration of anesthesia, were presented as the means ± SDs and were compared using the 1-way ANOVA. Statistical significance was accepted for P values <0.05. Nonnormally distributed continuous variables, such as mYPAS scores at each time point and ICC, were presented as medians and ranges and compared using the nonpara-metric Kruskal-Wallis test. The test was followed the Mann-Whitney U test with Bonferroni adjustment for multiple pairwise comparisons (3 comparisons) if a significant inter-group difference was found. A Bonferroni-adjusted P value <0.017 (0.05/3) was considered statistically significant. The change in mYPAS scores over time among the 3 groups was compared using the repeated measures ANOVA.

Categorical variables were analyzed using the χ2 test or the Fisher exact test. Wilson score interval without continu-ity correction19 was used to compare Bonferroni-adjusted 95% confidence interval for differences in proportion of participants with increased anxiety from baseline to OR entry and induction of anesthesia among interventions. Statistical significance was considered for P < 0.017 after Bonferroni adjustment for 3 comparisons (0.05/3). The McNemar test was used to compare the incidence of newly developed maladaptive behavior 1 day and 2 weeks after surgery. Correlations between mYPAS score during induc-tion of anesthesia and PAED scores or numbers of patients exhibiting a postoperative negative behavioral change were assessed using the Pearson correlation or the Spearman rank correlation coefficients, respectively. Statistical signifi-cance was accepted for P values <0.05.

RESULTSOne hundred seventeen children were initially enrolled. Eleven children were excluded because of withdrawal of consent, incomplete data, or loss to follow-up (Fig. 1). Two children in group P were excluded because they viewed an animated cartoon with their parents while waiting in the preoperative holding area after random allocation. Thus, 104 participants completed the study, and they were included in the data analysis. No significant intergroup dif-ferences in demographic or surgical characteristics were observed (Table 1). Mothers predominantly accompanied children to the OR and stayed during anesthesia induction in groups P (n = 27, 81.8%) and VP (n = 26, 70.3%).

Eligibility

(n = 125)

Not meeting inclusion criteria (n = 6)

Decline to participate (n = 2)

Randomization

(n = 117)

Group V

(n = 39)

Group P

(n = 39)

Group VP

(n = 39)

Withdrawal of consent (n = 3)

Incomplete data (n = 2)


Noncompliance to protocol

(n = 2)

Loss of follow-up (n = 2)


Loss of follow-up (n = 1)

Completion of the study

(n = 34)


(n = 33)


(n = 37)

Data analysis

(n = 104)

Figure 1. Flow diagram of participants. Group V = video distraction; group P = parental presence; group VP = com-bination of video distraction and parental presence.



The median mYPAS scores were comparably lower than 30 at T0 (P = 0.558), and the number of children exhibiting baseline anxiety (an mYPAS score > 30) was not different among groups (Table 2, P = 0.824) before intervention. After intervention, mYPAS scores were different among the 3 groups at T1 (P = 0.002) and T2 (P = 0.012). Specifically, chil-dren in group V exhibited lower mYPAS scores compared with the other 2 groups at both T1 (P < 0.001 versus group P and P = 0.015 versus group VP) and T2 (P = 0.012 ver-sus group P and P = 0.008 versus group VP). However, the overall changes in mYPAS scores from baseline to induc-tion of anesthesia were not different among the 3 groups (P = 0.049). The proportion of children who increased their mYPAS scores was higher in group P compared with group V from T0 to T1 (Bonferroni-adjusted 95% confidence inter-val for difference 2 to 49) but was similar in all groups from T0 to T2 (Fig. 2, Table 3).

The compliance of children at mask induction was signif-icantly different among groups (P = 0.001; Table 2). Children in group V were more cooperative during mask induction than children in the other 2 groups (P = 0.0005 versus group P and 0.001 versus group VP). ICC scores were found to be significantly correlated with mYPAS scores at each time point (P < 0.001, r = 0.338, 0.531, and 0.869 at T0, T1, and T2, respectively) and with the amount of mYPAS score change (P = 0.042, r = 0.199 from T0 to T1; P < 0.001, r = 0.702 from T0 to T2).

Parent anxiety was assessed using STAI before interven-tion and after completing anesthesia induction in all groups. Both trait and state anxiety scores in the preoperative hold-ing area and changes in state and anxiety scores over the peri-induction period were not different in the 3 groups (Table 2). Parent state anxiety score changes were found to be weakly correlated with the mYPAS score changes from T0 to T2 (P = 0.025, r = 0.221) and with ICC scores at mask induction (P = 0.035, r = 0.207). However, parent trait anxiety scores were not found to affect children’s anxiety

scores during the perioperative period. The majority of par-ents (75%) stated that they would prefer to be present dur-ing anesthesia induction in the future if their child had to undergo surgery. However, a significant intergroup differ-ence was found in this respect (P < 0.001), and fewer parents of group V children (39.1%) favored parental presence at the induction of anesthesia for any future surgery than parents of group P (95.8%, P < 0.001) or group VP (86.2%, P < 0.001) children.

Emergence statuses were comparable except for pain scores among groups (P = 0.041). Postoperative pain scores were weakly correlated with changes in anxiety scores among children between T0 and T2 (P = 0.041, r = 0.200). Median PAED scores and incidences of significant emer-gence delirium were comparable in the 3 groups and were not linked to the anxiety levels of children or parents at any of the 3 time points (Table 4). Number of children who developed new-onset negative behavior over the 2 weeks after surgery were comparable in all groups. Eating distur-bance (31.7%), separation anxiety (14.9%), and aggression toward authority (13.9%) were common on the first post-operative day but decreased significantly with time over the next 2 weeks (7.0%, P < 0.001, 7.0%, P = 0.02 and 8.0%, P = 0.07, respectively). The incidence of newly developed negative behavior was not found to be related to the anxi-ety levels of children or parents, postoperative pain scores, or the number of children who experienced emergence delirium in the PACU.

DISCUSSIONIn the present study, video distraction, parental presence, or a combination of both had a similar effect on preoperative anxiety during inhaled induction of anesthesia in preschool children undergoing surgery. We found that the overall changes in anxiety levels from preoperative holding area to induction of anesthesia were not different among the 3 groups although children with video distraction had lower anxiety levels compared with those with parental presence only or their combination at entry to the OR and during induction of anesthesia.

Our results suggest that video distraction and paren-tal presence appeared to have different anxiolytic mecha-nisms in the perioperative setting. Video distraction makes children oblivious to the unfamiliar OR environment and absorbs them in a familiar imaginary world, whereas parental presence simply relieves the distress associated with separation from parents. Previous studies demon-strated that the addition of viewing age-appropriate video provided greater reduction of anxiety than control or con-ventional distraction techniques in children accompanied by their parents during induction of general anesthesia.11,20 However, the changes in anxiety levels from holding area to anesthetic induction were similar not only between parental presence and video distraction, but also between each single intervention and combination of both interven-tions in the present study. This inconsistency in the results may be explained by different study designs. Allowing that parental presence and type of anesthetic induction were different. Mifflin et al.11 demonstrated that video distraction more effectively reduced preoperative anxi-ety compared with control during inhaled induction of

Table 1. Demographic and Surgical Characteristics of Patients

Group V Group P Group VP P(n = 34) (n = 33) (n = 37)

Age (y) 5.5 ± 1.0 5.3 ± 1.4 5.0 ± 1.3 0.097Sex (M/F) 15/19 12/21 18/19 0.581Weight (kg) 20.7 ± 4.1 22.4 ± 6.5 20.6 ± 6.0 0.372Height (cm) 114.9 ± 10.6 114.0 ± 10.1 111.7 ± 9.3 0.494ASA PS (I/II) 34/0 32/1 37/0 0.317Type of surgery,

n (%)0.250

Eye surgery 17 (50.0) 21 (63.6) 23 (62.2) Tonsillectomy 9 (26.5) 8 (24.2) 10 (27.0) Herniorrhaphy 5 (14.7) 0 3 (8.1) Excision of

neck mass3 (8.8) 4 (12.1) 1 (2.7)

Duration of surgery (min)

37.0 ± 16.5 40.9 ± 10.1 39.1 ± 10.6 0.449

Duration of anesthesia (min)

60.0 ± 19.3 62.9 ± 14.5 61.7 ± 11.5 0.748

Values are mean ± SD and number of patients (%).V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; ASA PS = American Society of Anesthesiologist physical status.



anesthesia in children who had parents absent. However, Lee et al.20 demonstrated that animated cartoon distraction produced a greater reduction of anxiety compared with control or toy distraction during IV induction of anesthesia in children who had parental presence and an IV cannula in situ. In addition, both previous studies compared the change in anxiety levels from holding area to induction by subtracting holding area mYPAS from induction mYPAS to determine the anxiolytic effect of each intervention. In

this study, the anxiety levels were significantly different at each time point after intervention, but the changes in anxiety levels through 3 different time points (from hold-ing area to induction) were not different among groups. In addition, the proportions of children who had increased anxiety from baseline to induction of anesthesia were simi-lar in all 3 groups although children had increased anxiety levels from baseline to transport in the video distraction group compared with the parental presence only group. Our findings indicate that by diverting a child’s attention, audiovisual distraction is more effective in alleviating anx-iety from the stress of separation from parents, but not dur-ing induction of anesthesia, than parental presence. Also parental presence does not seem to augment the anxiolytic efficacy of video distraction in children during transport

Table 2. Anxiety Levels in Children and Parents in the Perioperative PeriodGroup V Group P Group VP P(n = 34) (n = 33) (n = 37)

Children’s anxiety mYPAS 0.049a

T0 28.4 (23.4 to 36.6) 28.4 (23.4 to 46.6) 23.4 (23.4 to 65.3) 0.558b

T1 23.4 (23.4 to 31.6) 33.4 (23.4 to 50.0)† 28.4 (23.4 to 46.6)* 0.002b

T2 28.4 (23.4 to 46.6) 43.4 (23.4 to 65.0)*‡ 43.4 (23.4 to 70.0)*‡§ 0.012b

Baseline anxiety, n (%) 14 (41.2) 15 (45.5) 14 (37.8) 0.824c

ICC 0.0 (0.0 to 0.0) 1.0 (0.0 to 3.0)† 1.0 (0.0 to 5.0)† 0.001b

Parental anxiety STAI, trait 41.8 ± 4.5 41.0 ± 6.8 38.4 ± 7.8 0.465d

STAI, state 0.911a

Before intervention 44.0 ± 9.4 44.2 ± 9.0 42.8 ± 8.2 0.446d

After intervention 43.1 ± 8.0 44.0 ± 9.6 43.6 ± 8.9 0.465d

Change of score 0.0 (−6.0 to 3.0) 0.0 (−3.0 to 3.0) 0.0 (0.0 to 3.0) 0.543b

Values are median (interquartile ranges) or mean ± SD for continuous variables and number of patients (%) for categorical variables.V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; mYPAS = modified Yale preoperative anxiety scale; T0 = preoperative holding area; T1 = entry to the operating room; T2 = induction of anesthesia; ICC = induction compliance checklist; STAI = state and trait anxiety inventory.*Bonferroni-adjusted P < 0.017 versus group V after Mann-Whitney U test.†Bonferroni-adjusted P < 0.003 versus group V after Mann-Whitney U test.‡P < 0.05 versus T0 within group.§P < 0.05 versus T1 within group.aRepeated measures analysis of variance (ANOVA).bKruskal-Wallis test.cχ2 test.dOne-way ANOVA.

V P VP V P VP0

10

20

30

40

50 No increase

Increase

Group

T0T1 T0T2

*

Num

ber o

f Pat

ient

s

Figure 2. The proportions of children with changes in anxiety lev-els in the perioperative period. Anxiety level in children was mea-sured using modified Yale Preoperative Anxiety Scale (mYPAS). *Bonferroni-adjusted P < 0.017 versus group V. V = video distrac-tion; P = parental presence; VP = combination of video distraction and parental presence; T0T1 = from preoperative holding area to operating room entry; T0T2 = from preoperative holding area to induc-tion of anesthesia.

Table 3. Group Differences for Proportions with Increased Anxiety from Baseline to Operating Room Entry and Induction of Anesthesia

T0T1 T0T2

mYPAS change

95% CI of proportion differences P

95% CI of proportion differences P

Group P to group V

2 to 49 0.009* −9 to 44 0.112

Group P to group VP

−19 to 32 0.542 −33 to 19 0.503

Group VP to group V

−3 to 42 0.038 −1 to 50 0.022

Data are Bonferroni-adjusted confidence interval for difference in proportions (%) between groups.V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; mYPAS = modified Yale preoperative anxiety scale; T0T1 = from preoperative holding area to the operating room entry; T0T2 = from preoperative holding area to induction of anesthesia; CI = confidence interval.*Bonferroni-adjusted P < 0.017 between groups.



and induction of anesthesia. Thus, each intervention or a combination of both interventions may result in similar effects on preoperative anxiety in children undergoing inhaled induction of anesthesia.

The similar changes in anxiety levels from baseline to induction among the 3 interventions in the present study sug-gest 2 interesting possibilities. First, contrary to the general belief, separation from parents may not be the most important cause of preoperative anxiety in preschool children. Although children accompanied by their parents did not experience sep-aration anxiety, their changes in anxiety levels until induction of anesthesia were similar to children with video distraction (parental absence) in this study. In fact, parental presence was shown to be briefly effective in reducing a child’s anxiety only at separation from parents but not at induction of anesthesia.21 Our data are consistent with previous reports that placement of a mask for anesthetic induction caused the greatest distress to children undergoing surgery.5,6,22 Next, the anxiety levels at the separation time point (transport to the OR) were lower in children with video distraction than parental presence only or a combination of both despite similar changes in anxiety lev-els over time. In addition, the proportion of children who had increased anxiety levels from baseline to OR entry was higher in children with parental presence than video distraction. Our data suggest that parental presence is unlikely to be a more effective intervention to reduce separation anxiety than video distraction even in preschool children at greatest risk of devel-oping a separation anxiety reaction.3 Lee et al.20 demonstrated that, in preschool children accompanied by their parents, the cartoon distraction group showed less change in anxiety lev-els at separation from parents compared with a control group. In contrast, the addition of video distraction did not provide additional benefit in reducing separation anxiety in children with parental presence in this study.

Increased parental anxiety can increase child anxiety and prolong anesthetic induction by generating interactions between children and parents.23,24 We found that a change in parent situational anxiety was influenced by a change in child anxiety or compliance at anesthetic induction and vice versa. Although no significant differences in parental anxiety change were found with respect to intervention, a few parents in both groups that had a parent present (group P and VP) left the OR in tears. However, no parent in the video distraction group

showed an emotional reaction at separation. In this study, the number of parents who reported their presence helped their child during transport to the OR and induction of anesthesia and would be present during the induction of anesthesia if required in the future was significantly higher in both paren-tal presence groups than in the video distraction group. These findings suggest that parental anxiety interacts with child anx-iety during induction of anesthesia and that a more objective instrument may be required to measure parental anxiety.

Although the pathogeneses of postoperative emergence delirium and negative behavioral changes remained unde-fined, preschool children, sevoflurane anesthesia, and high anxiety levels in the preoperative holding area and at induc-tion of anesthesia are considered potential risk factors.6,7,22 This means that postoperative emergence delirium and negative behavioral change might be reduced by a preoper-ative intervention targeting anxiety reduction. The addition of active distraction with a handheld video game effectively reduced the change of anxiety from holding area to mask induction of anesthesia but did not improve postoperative behavioral change compared with children accompanied by their parents.10 In this study, emergence delirium occur-ring within the first 30 minutes after anesthesia occurred similarly among the 3 groups and largely resolved in 10 to 20 minutes. New-onset negative behavior occurred in 49% of children on the first day after surgery and persisted for 2 weeks after surgery in 14%.

Several limitations related to this study should be dis-cussed. First, parental anxiety was assessed using a self-report-ing rating scale. Although the state-trait anxiety inventory is a validated anxiety assessment instrument for adults, we found some discrepancies between subjective reports and objective behaviors. Second, we did not measure the baseline temperament of children using a validated behavioral assess-ment tool, and baseline temperament characteristics can affect the effectiveness of an anxiolytic intervention by influencing how a child will respond emotionally in a stressful situation. Third, blinding was impossible in this study because video watching and parental presence were visible to investigators and participants, and thus, observer bias may have influenced assessments of anxiety levels and compliance at induction of anesthesia. Fourth, we were unable to calculate the use of par-ents’ item of the mYPAS accurately because parental presence

Table 4. Postoperative Emergence Delirium and Negative Behavioral Changes in ChildrenGroup V Group P Group VP

P(n = 34) (n = 33) (n = 37)Awakening time (min) 9.0 ± 3.9 12.2 ± 7.0 10.7 ± 5.0 0.056CHEOP score 7.0 (6.0–8.3) 8.0 (6.5–9.5) 9.0 (7.0–10.0)* 0.041Peak PAED score 7.9 ± 6.3 8.0 ± 5.5 9.3 ± 6.0 0.517Emergence delirium, n (%) 13 (38.2) 13 (39.4) 20 (43.5) 0.324Negative PHBC, n (%) ≥1 1 d 17 (50.0) 19 (57.6) 15 (40.5) 0.354 2 wk 7 (21.2) 5 (15.2) 3 (5.2) 0.299 ≥4 1 d 1 (2.9) 1 (3.0) 4 (11.4) 0.224 2 wk 2 (6.1) 1 (3.0) 0 0.551

Values are median (interquartile ranges) or mean ± SD for continuous variables and number of patients (%) for categorical variables.V = video distraction; P = parental presence; VP = combination of video distraction and parental presence; CHEOP = Children’s Hospital of Eastern Ontario Pain Scale; PAED = Pediatric Anesthesia Emergence Delirium scale; PHBC = post-hospital behavior change.*Bonferroni-adjusted P < 0.017 versus group V.



was lacking in group V. Although we matched children’s responses in group V with the components of the use of par-ents, this may have affected the psychometric integrity of the mYPAS. Finally, the inability to relate the anxiolytic effects of video distraction and parental presence on the short- and long-term postoperative behavioral outcomes in children may be related to sample size. We calculated sample size based on a change in anxiety levels from baseline to induction of anesthesia, the primary end point of this study, and thus, the number of children recruited may have been insufficient to detect the effects of the 3 different interventions on postop-erative behavioral changes.

In conclusion, we found that video distraction, parental presence, or combination of both interventions had a simi-lar effect on preoperative anxiety during inhaled induction of anesthesia and postoperative behavioral outcomes such as emergence delirium and new-onset negative behavioral changes in preschool children. A further large-scale study is required to determine the ability of video distraction to improve postoperative behavioral outcomes. E

DISCLOSURESName: Hyuckgoo Kim, MD.Contribution: This author helped design and conduct the study, acquire the data, review and analyze the data, and draft and revise the manuscript.Attestation: Hyuckgoo Kim has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.Name: Sung Mee Jung, MD.Contribution: This author helped design and conduct the study, acquire data, analyze and interpret the data, draft and revise the manuscript, and is the corresponding author.Attestation: Sung Mee Jung has seen the original study data, reviewed the analysis of the data, approved the final manu-script, and is the archival author.Name: Hwarim Yu, MD.Contribution: This author helped design and conduct the study, acquire the data, and prepare the manuscript.Attestation: Hwarim Yu has seen the original study data and approved the final manuscript.Name: Sang-Jin Park, MD, PhD.Contribution: This author helped design the study, analyze and interpret the data, and revise the data.Attestation: Sang-Jin Park has seen the original study data, analyzed and interpreted the data, and approved the final manuscript.This manuscript was handled by: James A. DiNardo, MD.

ACKNOWLEDGMENTSThe authors thank Ji Eun Jang, Department of Statistics, Yeungnam University, for assistance with statistical analysis.

REFERENCES 1. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative

anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996;150:1238–45

2. Kain ZN, Mayes LC, Caramico LA, Silver D, Spieker M, Nygren MM, Anderson G, Rimar S. Parental presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 1996;84:1060–7

3. Vetter TR. The epidemiology and selective identification of children at risk for preoperative anxiety reactions. Anesth Analg 1993;77:96–9

4. Przybylo HJ, Tarbell SE, Stevenson GW. Mask fear in children presenting for anesthesia: aversion, phobia, or both? Paediatr Anaesth 2005;15:366–70

5. Fortier MA, Del Rosario AM, Martin SR, Kain ZN. Perioperative anxiety in children. Paediatr Anaesth 2010;20:318–22

6. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal D, Mayes LC, Feng R, Zhang H. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg 2004;99:1648–54

7. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006;118:651–8

8. Low DK, Pittaway AP. The ‘iPhone’ induction—a novel use for the Apple iPhone. Paediatr Anaesth 2008;18:573–4

9. Burk CJ, Benjamin LT, Connelly EA. Distraction anesthe-sia for pediatric dermatology procedures. Pediatr Dermatol 2007;24:419–20

10. Patel A, Schieble T, Davidson M, Tran MC, Schoenberg C, Delphin E, Bennett H. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth 2006;16:1019–27

11. Mifflin KA, Hackmann T, Chorney JM. Streamed video clips to reduce anxiety in children during inhaled induction of anesthe-sia. Anesth Analg 2012;115:1162–7

12. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a “gold standard”? Anesth Analg 1997;85:783–8

13. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology 1998;89:1147–56

14. Sadhasivam S, Cohen LL, Hosu L, Gorman KL, Wang Y, Nick TG, Jou JF, Samol N, Szabova A, Hagerman N, Hein E, Boat A, Varughese A, Kurth CD, Willging JP, Gunter JB. Real-time assessment of perioperative behaviors in children and parents: development and validation of the periopera-tive adult child behavioral interaction scale. Anesth Analg 2010;110:1109–15

15. Spielberger CD, Gorsuch RL, Lushene PR, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory STAI (Form Y) (“Self-Evaluation Questionnaire”). Palo Alto, CA: Consulting Psychologists Press, Inc., 1983

16. McGrath PJ, Johnson G, Goodman JT, Schillinger J, Dunn J, Chapman J. CHEOPS: A Behavioral Scale for Rating Postoperative Pain in Children. New York, NY: Raven Press, 1985

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Jurnal Keperawatan Silampari

Volume 3, Nomor 1, Desember 2019

e-ISSN: 2581-1975

p-ISSN: 2597-7482

DOI: https://doi.org/10.31539/jks.v3i1.837

332

VIDEO KARTUN DAN VIDEO ANIMASI DAPAT MENURUNKAN TINGKAT

KECEMASAN PRE OPERASI PADA ANAK USIA PRA SEKOLAH

Ajeng Dwi Retnani1, Titin Sutini2, Suhendar Sulaeman3

Program Studi Magister Keperawatan, Universitas Muhammadiyah Jakarta1

Program Studi Keperawatan, Universitas Muhammadiyah Jakarta2

Program Studi Manajemen, Universitas Muhammadiyah Jakarta3

[email protected]

ABSTRAK

Tujuan penelitian ini ialah menganalisis pengaruh video kartun dan video animasi

terhadap penurunan tingkat kecemasan pre operasi pada anak usia pra sekolah. Metode

penelitian ini menggunakan quasiaeksperimental dengan pendekatan pre and post-

testawithout control. Hasil penelitian menunjukkan bahwa penurunan tingkat

kecemasan pre operasi pada anak usia pra sekolah setelah diberikan intervensi video

kartun sebesar 4,20, setelah diberikan intervensi video animasi sebesar 4,70 dan setelah

diberikan intervensi kombinasi antara video kartun+video animasi sebesar 7,20.

Berdasarkan hal tersebut, tingkat kecemasan pre operasi menggunakan intervensi

kombinasi video kartun+video animasi menunjukkan penurunan paling besar. Hasil

penelitian juga didapatkan p value > 0,000. Simpulan, adanya pengaruh video kartun

dan video animasi terhadap penurunan tingkat kecemasan pre operasi pada anak usia pra

sekolah.

Kata Kunci: Animasi, Kecemasan, Pre Operasi, Video Kartun

ABSTRACT

The purpose of this study was to analyze the effect of cartoon videos and animated

videos on reducing preoperative anxiety levels in pre-school age children. This

research method uses quasi-experimental with a pre and post-test approach with out

control. The results showed that the reduction in preoperative anxiety levels in pre-

school children after being given a cartoon video intervention by 4.20, after being given

an animated video intervention by 4.70 and after being given a combination

intervention between cartoon videos + animated videos by 7.20. Based on this, the level

of preoperative anxiety using a cartoon video + animated video combination

intervention showed the greatest decrease. The results of the study also obtained p

value> 0,000. Conclusions, the influence of cartoon videos and animated videos on the

reduction of preoperative anxiety levels in pre-school age children.

Keywords: Animation, Anxiety, Pre Operation, Cartoon Video

https://doi.org/10.31539/jks.v3i1.837

2019. Jurnal Keperawatan Silampari 3 (1) 332-341

333

PENDAHULUAN

Anak usia pra sekolah merupakan anak yang berusia 3 sampai 5 tahun yang

memiliki kemampuan berinteraksi dengan sosial dan lingkungannya sebagai tahap

menuju perkembangan selanjutnya (Astarani, 2017). Anak usia pra sekolah memiliki

resiko besar untuk mengalami masalah kesehatan jika dikaitkan dengan respon imun

dan kekuatan pertahanan dirinya yang belum optimal (Papalia, et al, 2010). Alini (2017)

juga menyatakan bahwa pada masa usia pra sekolah aktifitas anak yang meningkat

menyebabkan anak kelelahan dan menjadikan anak rentan terhadap penyakit akibat

daya tahan tubuh yang lemah sehingga anak diharuskan menjalani hospitalisasi,

termasuk operasi.

Menurut Utami (2014) anak merupakan populasi yang sangat rentan terutama saat

menghadapi situasi yang membuat stress. Hal ini dikarenakan kondisi koping yang

digunakan oleh orang dewasa belum berkembang sempurna pada anak-anak. Anak usia

prasekolah menerima keadaaan masuk rumah sakit dengan rasa ketakutan. Jika anak

sangat ketakutan dapat menampilkan perilaku agresif, dari menggigit, menendang-

nendang bahkan berlari ke luar ruangan.

Tindakan operasi merupakan hal yang sangat beresiko. Lebih dari 230 juta operasi

mayor dilakukan setiap tahun di dunia yang menyebabkan keadaan pasien saat operasi

akan lemah, meningkatkan komplikasi setelah operasi dilakukan bahkan dapat

menyebabkan kematian (Priece, Moreno, 2012). Tindakan operasi memerlukan sebuah

tindakan keperawatan pre operasi yang merupakan tahapan awal dari keperawatan

operatif yang dimulai sejak pasien diterima masuk di ruang terima pasien dan berakhir

ketika pasien dipindahkan ke meja operasi untuk dilakukan tindakan pembedahan

(Wijayanti, 2011). Salah satu persiapan pre operasi ialah persiapan mental/psikis.

Persiapan mental merupakan hal yang tidak kalah pentingnya dalam proses

persiapan operasi karena mental pasien yang tidak siap atau labil dapat berpengaruh

terhadap kondisi fisiknya dan kelancaran proses operasi. Perawat perlu mengkaji

mekanisme koping pasien dalam menghadapi stres, dimana tindakan operasi merupakan

salah satu keadaan pemicu kecemasan dan stress pada pasien terutama pada pasien anak

(Sjamsuhidajat, De Jong, 2010). Terdapat sekitar 50%-70% dari anak-anak yang

menjalani operasi mengalami kecemasan dan kesusahan yang parah sebelum operasi

(Alini, 2017).

Kecemasan merupakan suatu kondisi yang tidak menyenangkan yang dapat

mempengaruhi perilaku pasien yang melakukan perawatan (Gracia, 2012). Kecemasan

dental pada pasien anak usia 6-8 tahun biasanya timbul karena belum adanya

pengalaman ke dokter gigi. Kecemasan dental pada anak tersebut menyebabkan anak

sering menunda bahkan menolak untuk dilakukan perawatan di dokter gigi yang juga

mengakibatkan betambah parahnya kondisi kesehatan gigi dan mulut pada anak

(Rehatta dkk, 2014). Kecemasan pada tindakan dental disebabkan oleh banyak hal, di

antaranya penggunaan alat dental yang dimasukan secara berurutan dan bergantian ke

mulut dan suara yang ditimbulkan dari alat-alat tersebut (Gracia, 2012). Setiap orang

menunjukkan tanda-tanda kecemasan berbeda-beda, di antaranya ditandai dengan

meningkatnya denyut nadi (Pontoh dkk, 2015). Penelitian yang dilakukan oleh Collip’s,

menyatakan bahwa terjadi peningkatan denyut nadi pada saat anak diberikan tindakan

medis (Stuart, Laira, 2005).

Kecemasan yang dialami anak usia pra sekolah jika tidak segera ditangani akan

mengakibatkan tubuh menghasilkan hormon yang menyebabkan kerusakan pada

seluruh tubuh termasuk menurunkan kemampuan sistem imun (Putra, 2011). Anak yang


334

mengalami cemas juga cenderung menolak perawatan dan pengobatan yang sedang

dijalani (tidak kooperatif). Anak yang tidak kooperatif akibat kecemasan akan

menyebabkan terjadinya delay terhadap tindakan operasi yang akan dilakukan.

Hasil studi pendahuluan di ruang rawat inap RS Islam A. Yani Surabaya melalui

wawancara dengan perawat ruang anak didapatkan data bahwa 4 dari 5 perawat ruangan

mengalami kesulitan dalam menghadapi pasien anak yang akan menjalani operasi. Anak

cenderung melakukan penolakan saat perawat akan mengukur tanda-tanda vital,

menginjeksi obat atau mengganti cairan infus. Hal lain juga dikemukakan oleh perawat

bedah RS Islam A. Yani Surabaya yaitu untuk melakukan tindakan operasi pada pasien

anak cenderung membutuhkan waktu yang sedikit lebih lama daripada pasien dewasa.

Mereka perlu menunggu hingga anak berhenti menangis dan mau untuk didekati

perawat. Kecemasan ini memberikan dampak negatif jangka panjang pada anak-anak

terhadap tindakan medis di kemudian hari. Kecemasan pre operasi pada anak usia pra

sekolah ini perlu diatasi dengan melakukan persiapan psikologis berbasis caring dan

diharapkan dapat menurunkan kecemasan pre operasi pada anak usia pra sekolah seperti

teori model keperawatan yang digambarkan oleh Kristen Swanson dalam teori caring.

Perawat memerlukan teknik komunikasi terapeutik yang efektif dalam setiap

tindakan yang akan diberikan kepada klien, selain itu diperlukan pula teknik non

farmakologis agar anak dapat bersikap kooperatif misalnya dengan teknik distraksi

(pengalihan) (Prasetyo, 2010). Salah satu teknik distraksi yang bisa dilakukan pada anak

adalah menonton kartun animasi (Wong, 2009). Ketika anak lebih fokus pada kegiatan

mononton film kartun, hal tersebut mengakibatkan impuls nyeri yang disebabkan

adanya cedera tidak mengalir melalui tulang belakang, pesan nyeri tidak tersampaikan

ke otak sehingga anak tidak merasakan nyeri (Brannon, 2013)

Terdapat beberapa macam persiapan psikologis guna mengurangi kecemasan pre

operasi pada anak pra sekolah, salah satunya ialah teknik non-farmakologi, seperti

kehadiran orang tua, musik, akupunktur, terapi bermain, bermain dengan mainan yang

sudah dikenal, dan menonton kartun (Potter, Perry, 2012). Amerika Academy of

Pediatrics merekomendasikan beberapa cara untuk mengurangi kecemasan dan

membantu anak-anak mengatasi stres rawat inap dan operasi, yaitu dengan pemberian

informasi, pendidikan kesehatan, dan membina hubungan saling percaya dengan anak-

anak dan orang tua mereka dengan menggunakan beberapa alat, seperti gambar,

diagram, boneka, orientasi tour area operasi atau ruang perawatan (Brown, 2012).

METODE PENELITIAN

Penelitian ini menggunakan desain quasi eksperimental dengan pendekatan pre

and post-test without control. Populasi yang digunakanadalam penelitian ini adalah

anak usia pra sekolah yang akan menjalani operasi di RS Islam A. Yani Surabaya.

Teknik pengambilan sampel menggunakan purposive sampling. Sampel dalam

penelitian ini ialah anak yang akan menjalani operasi di RS Islam A. Yani Surabaya

yakni sebanyak 30 anak yang dibagi menjadi 3 kelompok. Proses pengambilan data

dilakukan selama empat bulan. Instrumen yang digunakan ialah kuesioner HARS untuk

mengukur kecemasan anak usia pra sekolah.

Kriteria inklusi pada penelitian ini diantaranya anak usia 3-5 tahun, anak

menjalani rawat inap di rumah sakit minimal 1 hari sebelum jadwal operasi, anak yang

akan menjalani operasi sedang dan orang tua bersedia anak menjadi responden. Untuk

kriteria ekslusi pada penelitian ini adalah anak yang dilakukan operasi cito, anak yang

memiliki kelainan konginetal dan penyakit lainnya seperti sindrom down, tuna netra,


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dan sebagainya, serta kondisi anak sangat lemah sehingga tidak memungkinkan untuk

menonton video.

Penentuan kelompok kartun, animasi dan video+animasi dilakukan dengan cara

acak. Anak dengan jadwal operasi awal akan masuk dalam kelompok video kartun, anak

kedua akan masuk dalam kelompok video animasi, anak ketiga akan masuk dalam

kelompok video kartun+animasi, dan anak keempat akan masuk ke dalam kelompok

video kartun, begitu seterusnya. Sebelum dilakukan proses pengambilan data, orang tua

calon responden diberikan informasi tentang penelitian yang akan dilakukan,

keuntungan dan dampak yang mungkin dapat ditimbulkan selama proses penelitian, bila

orang tua calon responden menyetujuinya maka dilanjutkan dengan pengisian lembar

persetujuan menjadi responden. Kemudian dilakukan pengukuran kecemasan anak

sebelum intervensi menggunakan skala HARS 40 menit sebelum anak dibawa ke ruang

operasi.

Pada kelompok video kartun, anak diberi kesempatan memilih salah satu kartun

(bobo boy, tayo the little bus dan marsha and the bear) kemudian dilakukan pemutaran

video kartun selama 15 menit. Pada kelompok video animasi, dilakukan pemutaran

video animasi selama 15 menit. Pada kelompok kombinasi video kartun+video animasi,

anak diberi kesempatan memilih salah satu kartun (bobo boy, tayo the little bus dan

marsha and the bear) kemudian dilakukan pemutaran video kartun 15 menit dan video

animasi 15 menit. Setelah pemutaran video dilakukan pengukuran kecemasan anak

setelah dilakukan intervensi menggunakan skala HARS 5 menit sebelum anak masuk ke

ruang operasi.

HASIL PENELITIAN

Tabel. 1

Distribusi Frekuensi Responden (n=30)

No. Variabel Frekuensi Persentase (%)

1. Jenis Kelamin

- Video kartun

a. Laki-laki

b. Perempuan

- Video animasi

a. Laki-laki

b. Perempuan

- Video kartun+video animasi

a. Laki-laki

b. Perempuan

6

4

5

5

6

4

60

40

50

50

60

40

2. Riwayat operasi

- Video kartun

a. 0 b. 1

c. >1

- Video animasi

a. 0

b. 1

c. >1

- Video kartun+video animasi

a. 0

b. 1

c. >1

10 0

0

10

0

0

10

0

0

100 0

0

100

0

0

100

0

0


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Tabel 1 menunjukkan bahwa sebagian besar anak berjenis kelamin laki-laki. Pada

data riwayat operasi, seluruh responden belum memiliki riwayat operasi sebelumnya

yang artinya semua responden baru pertama kali menjalani operasi.

Tabel. 2

Distribusi Frekuensi Tingkat Kecemasan Sebelum Intervensi

Berdasarkan Jenis Kelamin (n=30)

Jenis

kelamin

responden

Kecemasan responden Total

Kecemasan sedang Kecemasan Berat

F % F % N %

Laki-laki 17 100 0 0 17 100

Perempuan 9 69,2 4 30,8 13 100

Total 26 86,7 4 13,3 30 100

Sumber : data primer, 2019

Tabel 2 menunjukkan terdapat 17 anak berjenis kelamin laki-laki termasuk dalam

kecemasan sedang. Pada anak yang berjenis kelamin perempuan, terdapat 9 anak

termasuk dalam kecemasan sedang dan 4 anak termasuk dalam kecemasan berat.

Tabel. 3

Perbedaan Rata-Rata Tingkat Kecemasan Pre Operasi pada Anak Usia Pra Sekolah

Sebelum dan Setelah Intervensi Menonton Video Kartun, Video Animasi,

Serta Kombinasi Video Kartun+Video Animasi (n=30)

Variabel Mean SD 95% CI p value n

a. Menonton video kartun

Tingkat kecemasan sebelum

Tingkat kecemasan setelah

Selisih

24,70

20,50

-4,20

2,111

2,506

3,258-5,142 0,000 10

b. Menonton video animasi


Tingkat kecemasan setelah

Selisih

24,40

19,70

-4,70

1,767

2,058

3,529-5,871 0,000 10

c. Menonton video kartun+video animasi


Tingkat kecemasan setelah Selisih

24,90

17.70 -7,20

1,729

1,567

5,947-8,453 0,000 10

Berdasarkan tabel 3 menunjukkan bahwa pada kelompok anak yang diberikan

intervensi menonton video kartun mengalami penurunan tingkat kecemasan pre operasi

sebesar 4,20. Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat

kepercayaan 95% (3,258-5,142), sehingga dapat disimpulkan bahwa ada perbedaan

antara tingkat kecemasan pre operasi pada anak sebelum dan setelah diberikan

intervensi menonton video kartun.

Tabel 3 juga menunjukkan bahwa pada kelompok yang diberikan intervensi

menonton video animasi terjadi penurunan tingkat kecemasan pre operasi sebesar 4,70.

Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat kepercayaan 95%

(3,529-5,871), sehingga dapat disimpulkan bahwa ada perbedaan antara tingkat

kecemasan pre operasi anak sebelum dan setelah diberikan intervensi menonton video

animasi.


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Tabel di atas juga menunjukkan bahwa pada kelompok anak dengan intervensi

kombinasi video kartun+video animasi terjadi penurunan tingkat kecemasan pre operasi

sebesar 7,20. Hasil uji statistik didapatkan nilai p value = 0,000 dengan derajat

kepercayaan 95% (5,947-8,453), sehingga dapat disimpulkan bahwa ada perbedaan

antara tingkat kecemasan pre operasi anak sebelum dan setelah diberikan intervensi

kombinasi video kartun+video animasi.

Berdasarkan penjelasan di atas, dapat diketahui bahwa penurunan tingkat

kecemasan pre operasi anak setelah diberikan video kartun lebih kecil daripada

penurunan tingkat kecemasan pre operasi anak setelah diberikan video animasi. Maka,

pemberian video animasi lebih efektif daripada video kartun dalam menurunkan tingkat

kecemasan pre operasi pada anak usia pra sekolah.

Untuk penurunan tingkat kecemasan pre operasi anak setelah diberikan video

kartun juga lebih kecil daripada penurunan tingkat kecemasan pre operasi anak setelah

diberikan kombinasi video kartun+video animasi. Maka, kombinasi video kartun+video

animasi lebih efektif daripada video kartun dalam menurunkan tingkat kecemasan pre

operasi pada anak usia pra sekolah. Untuk penurunan tingkat kecemasan pre operasi

anak setelah diberikan video animasi lebih kecil daripada penurunan tingkat kecemasan

pre operasi anak setelah diberikan kombinasi video kartun+video animasi. Maka,

kombinasi video kartun+video animasi lebih efektif daripada video animasi dalam

menurunkan tingkat kecemasan pre operasi pada anak usia pra sekolah.

Berdasarkan, ketiga intervensi di atas dapat disimpulkan bahwa intervensi

kombinasi video kartun+video animasi memiliki penurunan yang paling besar daripada

dua intervensi yang lain, sehingga intervensi kombinasi video kartun+video animasi

lebih direkomendasikan untuk digunakan dalam menurunkan tingkat kecemasan pre

operasi anak usia pra sekolah.

PEMBAHASAN

Jenis Kelamin

Hasil analisis didapatkan bahwa anak laki-laki yang termasuk dalam kecemasan

sedang ialah sebanyak 17 anak dan tidak ada yang termasuk dalam kecemasan berat,

sedangkan pada anak perempuan yang termasuk dalam kecemasan sedang ialah

sebanyak 9 anak dan yang termasuk dalam kecemasan berat sebanyak 4 anak. Potter,

Perry (2012) menyebutkan bahwa salah satu faktor yang mempengaruhi kecemasan

ialah jenis kelamin. Kecemasan lebih sering terjadi pada anak perempuan dibandingkan

anak laki-laki.

Hal ini karena laki-laki lebih aktif dan eksploratif sedangkan perempuan lebih

sensitif dan banyak menggunakan perasaan. Pada perempuan juga lebih mudah

dipengaruhi oleh tekanan-tekanan lingkungan daripada laki-laki, kurang sabar dan

mudah menggunakan air mata. Mudatsir (2010) menyatakan bahwa anak harus

mendapatkan penanganan medis dan tindakan operasi di rumah sakit yang mampu

menimbulkan kecemasan akan suasana rumah sakit.

Riwayat Operasi

Hubungan riwayat operasi dengan tingkat kecemasan pre operasi anak usia pra

sekolah dalam penelitian ini tidak dapat dianalisis karena semua responden belum

pernah menjalani operasi sehingga kali ini merupakan pengalaman pertamanya. Maka,

perlu adanya penelitian yang menggunakan responden yang variatif. Menurut Supartini

(2013) anak yang baru mengalami perawatan di rumah sakit akan berisiko menimbulkan


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perasaan cemas yang ditimbulkan baik oleh anak maupun orang tua. Berbagai kejadian

dapat menimbulkan dampak atraumatik terutama pada anak yang baru pertama kali

mengalami perawatan di rumah sakit, salah satunya karena adanya pengalaman interaksi

yang tidak baik dengan petugas kesehatan.

Hockberry, Wilson (2010) juga menyebutkan bahwa anak yang mempunyai

pengalaman sebelumnya akan mulai membentuk respon koping dibandingkan dengan

anak yang belum mempunyai pengalaman. Hal ini disebabkan karena anak yang pernah

dirawat sebelumnya di rumah sakit yang sama akan merasa lebih terbiasa dibandingkan

dengan yang baru pertama kali dirawat serta anak akan merespon sakitnya dengan lebih

positif. Hal ini juga didukung oleh Pelander, Leino-Kilpi (2010) menyebutkan bahwa

semakin sering anak berhubungan dengan rumah sakit maka semakin kecil bentuk

kecemasan atau sebaliknya.

Pengaruh Video Kartun terhadap Penurunan Tingkat Kecemasan Pre Operasi

pada Anak Usia Pra Sekolah

Hasil penelitian menunjukkan bahwa ada perbedaan tingkat kecemasan anak

sebelum dan setelah diberikan intervensi video kartun (p value = 0,000) dengan

penurunan nilai rata-rata tingkat kecemasan pre operasi anak sebesar 4,20. Video kartun

cocok digunakan untuk mendistraksi/mengalihkan rasa cemas anak menjelang operasi

(Noorlaila, 2010). Teknik distraksi yang dapat dilakukan untuk mengatasi kecemasan

anak yaitu melibatkan anak dalam permainan, karena bermain merupakan salah satu alat

komunikasi yang natural bagi anak-anak (Suryanti et al, 2011). Penelitian oleh Lee

(2012) menyatakan bahwa menonton video kartun oleh pasien bedah anak adalah

metode yang sangat efektif untuk mengurangi kecemasan pra operasi. Intervensi ini

merupakan metode yang murah, mudah dikelola, dan komprehensif untuk mengurangi

kecemasan dalam populasi bedah pediatrik.

Pengaruh Video Animasi terhadap Penurunan Tingkat Kecemasan Pre Operasi

pada Anak Usia Pra Sekolah


sebelum dan setelah diberikan intervensi video animasi (p value = 0,000) dengan

penurunan tingkat kecemasan pre operasi anak sebesar 4,70. Penurunan tingkat

kecemasan pre operasi menggunakan video animasi ini lebih besar daripada pemberian

video kartun. Kecemasan pada anak timbul karena menghadapi sesuatu/lingkungan

yang baru dan belum pernah ditemui sebelumnya, serta ketidaknyamanan/ketakutan

terhadap sesuatu karena merasa bahaya dan menyakitkan (Townsend, 2009 dalam

Suprobo, 2017). Pada anak usia pra sekolah, ia akan beranggapan bahwa saat

dipindahkan ke ruang operasi hal tersebut merupakan sebuah hukuman baginya

sehingga timbul perasaan malu dan bersalah, merasa dipisahkan, merasa tidak aman dan

kemandiriannya terhambat (Hockenberry & Wilson, 2010).

Salah satu cara yang dapat digunakan perawat untuk mengurangi kecemasan pre

operasi anak ialah dengan pemberian informasi menggunakan beberapa alat, seperti

gambar, diagram, boneka, orientasi tour area operasi atau ruang perawatan (Brown,

2012). Tour area operasi yang dimodifikasi dengan menggunakan media video animasi

dapat memudahkan anak usia pra sekolah yang memiliki daya imajinasi tinggi untuk

mendapatkan informasi ringan berbasis menyenangkan, sekaligus menurunkan

kecemasan pre operasinya.


339

Pengaruh Kombinasi Video Kartun+Video Animasi terhadap Penurunan Tingkat

Kecemasan Pre Operasi pada Anak Usia Pra Sekolah


sebelum dan setelah diberikan intervensi video animasi (p value = 0,000) dengan

penurunan tingkat kecemasan pre operasi anak sebesar 7,20. Intervensi kombinasi video

kartun+video animasi ini memiliki penurunan tingkat kecemasan paling besar daripada

pemberian video kartun maupun video animasi.

Intervesi ini memiliki jenis video yang lebih bervariasi dan waktu penayangan

yang lebih lama, sehingga mampu lebih efektif dalam menurunkan tingkat kecemasan

pre operasi pada anak usia pra sekolah. Hal tersebut dikarenakan video kartun

menayangan tokoh kartun yang lucu dan disukai anak-anak sehingga membuat anak

merasa senang, terhibur dan melupakan rasa cemasnya menjelang operasi. Kemudian

penayangan video kedua yaitu video animasi tour area operasi dimana memudahkan

anak usia pra sekolah yang memiliki daya imajinasi tinggi untuk mendapatkan

informasi ringan mengenai situasi dan kondisi ruang operasi atau ruang perawatan

berbasis menyenangkan, sekaligus menurunkan kecemasan pre operasi anak dengan

mengatasi ketidaktahuan dan kewaspadaan anak terhadap ruang operasi/ruang

perawatan.

Sejalan dengan penelitian yang dilakukan oleh Fatmawati, Syaiful & Ratnawati

(2019) yang menyatakan bahwa ada pengaruh audiovisual menonton film kartun

terhadap tingkat kecemasan saat prosedur injeksi pada anak prasekolah. Hasil penelitian

ini juga sejalan dengan penelitian Wahyuningrum (2015) yang menyatakan bahwa

pemberian cerita melalui audiovisual efektif dalam menurunkan tingkat kecemasan pada

anak usia prasekolah yang mengalami hospitalisasi.

Apabila anak mengalami kecemasan tinggi saat dilakukan tindakan invasif,

kemungkinan besar tindakan yang dilakukan menjadi tidak maksimal dan tidak jarang

harus mengulangi beberapa kali sehingga akan menghambat proses penyembuhan anak.

Kondisi ini memper-sulit perawat dalam melakukan tindakan keperawatan (Supartini,

2014).

Koller, Goldman (2012) dalam studinya menyatakan bahwa pemberian cerita

melalui audiovisual guna menurun-kan kecemasan termasuk teknik distraksi kecemasan

dengan teknik audiovisual. Perhatian anak yang terfokus kepada cerita audiovisual yang

disimaknya mendis-traksikan atau mengalihkan persepsi kecemasan anak dalam korteks

serebral. Dengan intervensi audiovisual menonton film kartun akan memberikan

rangsangan distraksi berupa visual, auditory dan tactile. Perasaan aman dan nyaman

yang dirasakan anak akan merangsang tubuh untuk mengeluarkan hormon endorphine.

SIMPULAN

Berdasarkan hasil penelitian dapat disimpulkan bahwa terdapat perbedaan rata-

rata tingkat kecemasan pre operasi anak sebelum dan setelah diberikan video kartun (p

value = 0,000, selisih = 4,20), setelah diberikan video animasi (p value = 0,000, selisih

= 4,70), dan setelah diberikan kombinasi video kartun+video animasi (p value = 0,000,

selisih = 7,20).


340

SARAN

Perawat diharapkan dapat menerapkan pemberian kombinasi video kartun+video

animasi untuk anak usia pra sekolah yang akan menjalani operasi. Intervensi ini

merupakan salah satu tindakan atraumatic care berbasis caring. Bagi peneliti

selanjutnya diharapkan dapat mempertimbangkan jumlah sampel yang lebih besar,

karakteristik responden yang lebih variatif dari sisi pengalaman operasi sebelumnya,

jenis operasi yang sama dan penggunaan instrumen lain untuk mengukur tingkat

kecemasan pada anak.

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