Research Article :
Mohebbi Kharrati, Sadat
Hoseini Akram Sadat, Pour Abouli Batol and Kazemnejad
A Introduction:
Surgery creates anxiety for children, whose control and reduction are among the
objectives of nursing care. Nurses have always sought scientific evidence for
the use of innovative techniques appropriate for the level of understanding,
recognition, and need of children, such as the use of poetry to reduce childrens
anxiety. Therefore, the present study aimed to investigate the effects singing
songs about preoperative care for tonsillectomy on the anxiety of children
undergoing tonsillectomy. Method:
This quasi-experimental non-random study recruited 76 children aged 7-12 years
old presenting to the hospital for tonsillectomy were selected with a
convenience sampling method. In addition to the routine care, some songs were
sung to children in the intervention group about pre- and post-operative
procedures before, on the day of, and after the surgery. Hamilton Anxiety
Rating Scale (HAM-A) was filled out before and after the surgery and on the day
of discharge in the intervention and control groups in order to measure
childrens anxiety. Data were analyzed in SPSS software using Chi-square,
Mann-Whitney, and Fishers exact tests. Results:
The results showed that the mean and standard deviation of anxiety in both
groups (control=19.57 ± 3.65; intervention=19.78 ± 4.87) were not significantly
different before the intervention (P=0.48), while a significant difference
(P<0.001) was observed on the day of surgery between the two groups (control=34.28
± 5.68; intervention=26.97 ± 4.6). Nurses can sing songs about pre- and
post-operative procedures as an easy, inexpensive way appropriate for childrens
level of development to reduce their anxiety. Furthermore, the familys
engagement in pre-operative training in an innovative manner can be a step
forward in the development of family-based care. As a common feeling in children
during the pre-operative period, anxiety incurs harmful effects on the childrens
body and mind, causes negative behaviors, and increases pain scores after
surgery [1,2]. Anxiety causes children to resist against and not to cooperate
in the pre- and post-operative
care [3,4]. Therefore, reducing child
anxiety is one of the important nursing tasks. One way to reduce anxiety in
children is their physical, emotional and cognitive preparation before performing
care procedures [5,6]. Research suggests that informing children and trying to
reduce anxiety and fear of surgery results in better adaptation to the care and
treatment process such that the proper pre-operative preparation of children
reduces anxiety and creates a better memory of the surgery and leads to faster
recovery after the surgery [5,7,8]. There is little clinical
evidence about the effectiveness of preparing
children for care and treatment procedures using joyful, innovative, artistic and creative
practices although they are welcomed by nurses [5,7,8]. Meanwhile, singing can
be effective in reducing childrens anxiety as it is
desirable for them, is appropriate for their cognitive, growth, and mental
development needs, and creates a cheerful
environment for them [9]. Singing has proved effective due to its systematic
and artistic nature in transmitting educational messages especially in
children; therefore, training through singing has a great effectiveness [10-13].
Singing is a verbal art, and if it is beautiful, it can attract the audience
and become a good tool for training [1]. Several studies have applied singing
for changing students irrational beliefs, decreasing post-traumatic
anxiety, decreasing childrens aggression,
boosting the immune system, and increasing the self-esteem of children and have
proved its efficacy; hence it is considered a way to influence the psychological
behaviors of children [14-19]. Singing is suggested for teaching especially in
children, which may affect their psychological state, too [20,21]. The aim of
this study was to integrate the two functions of singing (educational and
psychological) and investigate the effect of familiarization with pre- and
post-operative care procedures through singing on the anxiety of children
undergoing tonsillectomy. The present study was a
non-randomized, quasi-experimental study, with intervention and control groups,
conducted on 76 children aged 7-12, who were candidates of tonsillectomy
at ENT clinic of Imam Khomeini Hospital in Tehran, Iran. The participants were
selected by convenience method and were non-randomly divided into intervention
(n=38) and control (n=38) groups. In order to prevent the effect of the
intervention on the control group, subjects in the control and intervention
groups were in separate rooms, and given the short duration of hospitalization
prior to surgery, the two groups did not actually interact or exchange any
information. The inclusion criteria were being 7-12 years old, tonsillectomy
being their first surgery experience, no underlying diseases, no history of
psychological illness, experiencing no other crises in the last six months, no hearing
disorders, no mental
retardation, and obtaining a HAM-A score above 17.
The inclusion criteria regarding the childrens mothers were being able to hear
and speak, being literate, and having no history of psychological illnesses.
The exclusion criteria were changes in the process of child
care and treatment, and parents or childrens
failure to cooperate. The age group of 7-12 years old
was selected due to the prevalence of tonsillectomy and also the better ability
of measuring anxiety in this age group. However, the main reason for selecting
this group was their ignored need of a happy environment and training through
playing. Data
collection tool In this study, a demographic
questionnaire was used to collect the demographic data of the subjects and
their mothers. The face validity of this researcher-made questionnaire was
confirmed by ten faculty members of universities of medical sciences in Iran.
The reliability of the questionnaire was confirmed by test-re-test method
resulting in a 100% correlation. The Hamilton
Anxiety Rating Scale (HAM-A) was used to assess childrens
anxiety. HAM-A was filled out by the researcher through interviewing the child
and the parents simultaneously, on the day of admission to the clinic, before
the surgery and on the discharge day. On the day after the surgery, questions
were only asked of mothers because the children were ill. HAM-A has 14
components, each covering a set of symptoms. Each of these components is scored
from 0 (no symptoms) to 4 (very severe). The overall score ranges from 0-56. A
score of 0-17 indicates mild anxiety, 18-24 indicates moderate anxiety, 25-30
indicates severe anxiety, and a score above 30 indicates extremely severe
anxiety. Several studies have reported the validity of this test in Iran as
0.84, including Gharayi & Tashakkori, and Arabgol & Panaghi [7]. The
reliability of this test was confirmed in the present study by Cronbachs alpha
method (0.754). HAM-A was filled out by the researcher in four phases. First,
it was filled out in the clinic for enrolling the subjects, then on the day
before the operation and after the intervention, then on the day of operation,
and finally on the day of discharge from the hospital. HAM-A was not filled out
after admitting the subjects and before the intervention, which can be considered
a limitation of the study. The reason for this limitation was that we could not
complete the questionnaire before the intervention because the child was
admitted in the afternoon of the day before the surgery and, upon admission;
the intervention had to be started because care and interventions such as
venipuncture, the onset of intravenous nutrition, and fasting for the surgery
would start immediately. As a result, there was practically not much time
before the intervention to complete HAM-A. Furthermore, frequent filling of the
questionnaire would result in fatigue and familiarity of the subjects and their
parents, which would undermine the accuracy of the findings. Ethical
considerations First, the Joint Ethics Committee
of the Faculty of Nursing and Midwifery
of Tehran University of Medical Sciences approved the study
(IR.TUMS.FNM.REC.1396.2207), and it was registered in IRCT (201708285163N5).
Then, necessary permissions were obtained for sampling, and the researcher
visited the ENT clinic of Imam Khomeini Hospital in Tehran. After examining the
children by a physician and scheduling an appointment for surgery, the
researcher performed sampling by introducing themselves to the subjects,
obtaining written consent from the childrens parents, and oral consent from the
children. First, the demographic questionnaire and then HAM-A were completed by
the researcher, and the children entered the study according to the inclusion
criteria. Preparation
of the familiarization songs booklet Using reliable textbooks and
articles, the contents and subjects needed for the song booklet were collected
for pre- and post-operative preparation. The subjects and scientific accuracy
of the collected materials for writing the songs were approved by three faculty
members of the School of Nursing
and Midwifery of Tehran University of Medical Sciences. Then the songs were
written by the researchers and were approved by three specialists in children
poetry in terms of observing the rhyme and rhythm rules of poetry. The songs
were then compiled in a booklet. They were also sung by the researcher in a
studio and recorded as a digital file. Intervention The control group received the
routine intervention of the ward, which included an educational pamphlet and
the nurses explanation about the pamphlet for the child and the family on the
day before the operation. Everything was the same for the two groups except for
singing. In addition to the routine care, the intervention group received a
booklet including information on the method of and need for venipuncture, pre-
and post-operative preparation for tonsillectomy, the concept of the operating
room and its environment, and anesthesia
in form of songs on the day before the surgery. First, the researcher sang the
songs for the children. Then the mothers sang the songs for the children during
the transfer of the child to the operating room and at the time of the childs
presence in the ward after the surgery or whenever the child requested. HAM-A
was completed through interviews with children and their mothers by the
researcher at the time of sampling (for the inclusion of subjects with an
anxiety score of above 17), the night before surgery, after surgery (after
recovery and start of feeding) and on the day of discharge (the day after the
surgery). Data were analyzed in SPSS-16
software using Chi-square for child gender, Mann-Whitney for anxiety score,
Fishers exact test for literacy of mothers and childrens rank of birth and
Friedman test for intra-group comparison of anxiety score. It should be noted
that the electronic file was provided to both groups in order to observe
ethical considerations. In addition, according to the positive results, the
file was provided to the ward for use in familiarizing children with
tonsillectomy procedures. The mean age of the subjects was
8.63 ± 1.69 in the control group and 8.42 ± 1.67 in the intervention group. The
analysis revealed that the two groups did not have a significant difference in
demographic characteristics and anxiety scores in the time of sample collection
(Table 1). Table
1: Comparison of demographic variables in the time of
sample collection. The results of the comparison of
the anxiety level by the Mann-Whitney test indicated that the anxiety
level of the intervention group in all phases
was significantly lower than that of the control group. Although Friedmans test
in intra-group comparison showed that anxiety level decreased in both groups,
this level was significantly lower in the intervention group (Table 2). Comparison of mean anxiety differences showed
that there was a significant difference between the day before surgery and the
day of surgery, the day before surgery and the day of discharge, and the day of
surgery and the day of discharge in the intervention group, while there was no
significant difference in the control group between the day before surgery and
the day of discharge (Table 3). Table
2: Comparison of the score of anxiety. Table
3: Comparison of mean and SD of anxiety score between
days. The results of this study showed
that singing songs about preoperative care for tonsillectomy is effective on
the anxiety level of 7-12 year-old children, that is, it led to a greater
reduction of anxiety in the intervention group as compared with the control
group. Tunney & Boor, showed the role of using storybooks on reducing
childrens preoperative
anxiety in a study on 80 children aged 5-11
years undergoing tonsillectomy. Their study showed that children undergoing
tonsillectomy experience some degrees of anxiety, which is in line with the
present study, and also showed that reading a storybook was effective in
reducing their anxiety [19]. Tavassoli et al., reported the effect of
familiarization with the disease, treatment, and care of thalassemia on the
severity of anxiety in pre-school children with thalassemia. During the
familiarization game, childrens anxiety reduced by using syringes, drug vials,
wet cotton balls, and dolls, which were the sources of anxiety
in children [15]. Their study showed that the
familiarization of children with procedures and equipment used in the hospital
can reduce their anxiety. Majzoobi et al. showed that childrens psychological
preparation for surgery had a significant effect on reducing their preoperative
anxiety symptoms. They psychologically prepared children by familiarizing them
with the operating room, surgery equipment, and surgery team on the day before
surgery. The results showed that psychological preparation significantly
reduced their preoperative anxiety, and that children in the intervention group
showed less preoperative anxiety than those in the control group [7]. Shoja et
al., also showed that preoperative preparation can reduce childrens anxiety
[18]. In a familiarization program with
hospital procedures, Talebi et al., compared the effect of face-to-face
training methods and visual conceptual posters (illustrated songbooks) about
the procedures that children face in the hospital and examined their effects on
childrens fear and anxiety. Their study had three groups. They concluded that
the use of visual conceptual posters was more effective than the face-to-face
approach in reducing the trait and total anxiety of hospitalized children.
Their study is consistent with the present study in terms of investigating the
effect of familiarization through song booklets and its effect on anxiety [22].
Therefore, all studies have shown that familiarization with surgical and care
procedures reduce anxiety, which is consistent with the present study. Singing
was used for the familiarization of the children in the following study. A study titled “Childrens poetry
meaning: A methodology” by Coat, showed that childrens poetry can be considered
as a means of playing and participating in social life by preserving the rhythm
and pleasure of body language and facilitating emotional and physical alignment
with others, and can control the emotional environment and reduce anxiety in
children [9]. Shamshiri et al., suggested that training children through art is
not merely for the sake of their entertainment, rather with such education,
they can face their own self [21]. Art is a kind of treatment and development,
and it is a great way to discover the identity. Sao and Mauerya also
acknowledged the role of art in reducing the anxiety of hospitalized children
in their study [23]. Khoshrange quoted Muriaty et al., that they studied the
effects of game-therapy and art-therapy in preschool children [5]. Their
results emphasized the role of art in decreasing the anxiety of hospitalized
children, too. Considering the use of poetry as a branch of art in this study,
it can be concluded that the results of abovementioned studies are consistent
with the present study in terms of using art to reduce anxiety. According to
these studies, the use of art at the bedside can have an irrefutable effect on
the anxiety of hospitalized children. Therefore, despite the fact that
familiarization has reduced the anxiety in both groups, it appears that a
greater reduction in anxiety in the intervention group than that in the control
group was due to the influence of poetry as an innovative method appropriate to
the level of growth and development of school-age children. The most important limitation of
the present study was the non-random allocation of samples into two groups. In
order to prevent the effect of the intervention on the control group, the two
groups were hospitalized in two separate rooms and the allocation of the
samples to the two groups was based on their hospitalization room. Another
limitation was the fact that the questionnaire was not filled out before the
intervention, which was practically impossible because the procedures were
performed quickly after hospitalization and the children had to be familiarized
with them in the shortest possible time. In order to provide more evidence, it
is recommended that further studies measure mothers anxiety in addition to
childrens anxiety to determine whether the intervention and participation of
the mother in familiarization of the child has any effect on their anxiety. According to the results of the
abovementioned studies, art is the common and familiar language in all
cultures. Using the language of art is a safe method that has positive psychological
effects. Nurses can use the language of art as
an acceptable and innovative non-pharmacological approach for care processes,
especially for familiarization and education of patients. In this way,
establishing an effective communication and mitigating the psychological
effects of the hospital environment, they can improve the psychological health
of patients. Therefore, it is recommended that nurses use songs to familiarize
children with pre- and post-operative procedures, such that, in addition to
receiving the necessary training, children and their family experience a happy
and pleasant environment, which reduces childrens anxiety. Furthermore, signing
is associated with good memories in children and it appears that this
association helps reduce the psychological complications of surgical procedures
in children. It is also recommended that further studies investigate the
long-term effects of this method and its effect on the satisfaction of the
child and the family. The researchers also suggest that the effects of mothers
signing for children be examined on maternal
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Hoseini Akram Sadat, Associate
Professor, Department of pediatrica and NICU, School of Nursing and Midwifery,
Tehran University of Medical Sciences, Tehran, Iran, Tel: 0989122094828,
Email: ashoseini@tums.ac.ir Mohebbi K, Sadat
HAS, Batol PA and Kazemnejad A. Effects of singing songs about preoperative
care for tonsillectomy on the anxiety of children undergoing tonsillectomy (2019)
Nursing
and Health Care 4: 17-20 Anxiety, Singing, Tonsillectomy, ChildrenEffects of Singing Songs about Preoperative Care for Tonsillectomy on the Anxiety of Children Undergoing Tonsillectomy
Abstract
Full-Text
Introduction
Materials and
Method
Results
Discussion
Limitations
Conclusion
References
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