RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE.
PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 NAME AND ADDRESS UNNI KRISHNAN R
OF THE CANDIDATE
1 YEAR MSc. NURSING ,
(in block letters)
SOFIA COLLEGE OF NURSING ,

# 63 , CHOKKANAHALLI ,

YELEHANKA HOBLI, BANGALORE.

SOFIA COLLEGE OF NURSING ,
2 NAME OF THE
# 63 , CHOKKANAHALLI ,
INSTITUTION
YELEHANKA HOBLI, BANGALORE.
3 COURSE OF THE MASTER OF SCIENCE IN NURSING
STUDY AND IN
SUBJECT PAEDIATRICS
4 DATE OF ADMISSION 15/10/2010
TO THE COURSE
5 TITLE OF THE TOPIC Assess the effectiveness of play therapy in reducing

PROBLEM anxiety level

STATEMENT
“A DESCRIPTIVE STUDY TO ASSESS THE

EFFECTIVENESS OF PLAY THERAPY IN

REDUCING ANXIETY LEVEL AMONG

HOSPITALISED CHILDREN IN SELECTED

HOSPITALS AT BANGALORE”

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6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

“Achild is precious and beautiful,

A source of joy and happiness,
A focus of love and care,
A subject of dream for the future”
(Child care)
Hospitalization is stressful for children of all ages. During a serious illness, even older

children have a great need for their parents and can tolerate their absence only for short

periods. They need to know that their parents will be there when they need them most and

that they are loved and missed. 1

Play is an essential part of a child’s life and is an important aspect in fostering growth and

development. Toys are the “tools” of play and provide a more “natural” environment for a

child. The proper selection and use of toys can reduce the traumatic effects of a

hospitalization experiences and aid in the recovery phase of illness.1

Play is an integral part of the hospitalized child’s plan of care. Play offers, the child an

opportunity or creative expression, diversion and effective coping. In the hospital a

supervised play program provides warm, friendly atmosphere that will help the child continue

to grow and develop. In larger hospitals a child life specialist may coordinate the play

program. A place to play, suitable materials and other children to play with are essential.

Because play is a child’s way of learning; toys, materials, and equipment are learning tools.2

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Paints modeling clay dolls, blocks, games, books, toys and interactive computer technology

are some of the materials with which children rebuild the world to their size a world they

bring with them of people, special belongings (e.g.: blanket or toys),and feelings. Children

play wherever they are. A child’s play is his or her occupation or work. Designing a play

program buffers. The effects of separation from family. feelings of isolation and painful or

frightening experiences such as intensive procedures.3

Play promotes healing and helps the child to cope with stressful experiences. Children Won

fear treatments are helped to release their feelings in their use of falls and other toys. The

attitudes and feelings that children reveal in their play are full of meaning. Every opportunity

should be afforded the hospitalized childe to use play and other expensive activities to lessen

stress, thus promoting healthy resolution of the negative aspects of the hospital experiences.

The child can find acceptable outlets for hostilities through play activities 3. The proper

selection of toys can provide constructive, educational stimulating relaxing, diversional, or

therapeutic value. Play is an essential element in the development of healthy individuals;

childhood play is an integral part of the developmental process in young children. It occurs

spontaneously in children and gives then an important medium for informal learning play is

not a purposeless activity serving only to pass the childhood hours, it’s a vital factor in

intellectual, social, and emotional development of a child.4

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6.1 NEED FOR THE STUDY

Play - when one thinks of play, one immediately thinks of fun and children. But what one

does not realize is the scope of influence it has on the growth and development of a child

stored within its realms. Play happens to be the business for children. Its purposes are

numerous intellectual and motor developments, creativity and development of higher

functions, play has been known to divert child’s mind. E.g. A crying child will stop crying

when a toy is given to play. The value of play to a sick child in the hospital has long been

recognized and if the hospital is to meet the physical, mental and emotional need of the child.

It must also provide suitable play activity to the child to reduce the fear and anxiety of

hospitalized children.5

Saucier stated that Play activities can be used in a multitude of setting and in multidisciplinary

fashion Ziegler state that one of every four children will be hospitalized at least once before

reaching school age. The physical and psychosocial stress of hospitalization may be

influences by the child developmental level, causing behavior changes, somatic complaints

and a prolonged hospital stay. Through the use of careful developmental assessments,

preoperative tours and therapeutic play techniques, fear can be allayed misconceptions

correlated emotionally charged issues addressed and appositive self image created. Other

purposes of therapeutic play are helps sick children gradually regain independence through

enjoinment of group experiences. Creativity can be developed through playing with toys,

games and group projects during the literature review, the investigator came across studies in

relation to play activity and its effectiveness, in reducing the child anxiety, which are done in

foreign settings. Studies done regarding the relationship between play activities and anxiety

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of hospitalized children are very few in India. Thus the investigators were motivated to carry

out this study.6

6.2 REVIEW OF LITERATURE

Review of literature is a systematic identification, location, scrutiny and summary of written

materials that contain information on research problems.

Literature review is based on an extensive survey of books, journals and international

nursing indices. It provides basis for future investigation, justifies the need for the study,

reveals constrains of data collection and establish a comprehensive study of scientific

knowledge in a professional discipline, and from which valid and theories may be developed.

“The review of literature is defined as a broad, comprehensive in-depth. Systematic and

critical review of scholarly publications, unpublished scholarly print materials, audiovisual

material and personal communication”.

Review of literature is the systematic and critical reviews of the most important published

scholarly literature on a particular topic. This helps the investigator to find what is already

known, and what problems remain to be solved. Since effective research is based upon past

knowledge this exercise provides useful hypothesis and helpful suggestion for significant

investigations

The related studies are presented under the following sub – headings.

1. Studies related to anxiety.

2. Studies related to play activities.

3. Studies related Play activities and its therapeutic value in reducing anxiety among the

hospitalized children.

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1. Studies Related To Anxiety

.Stress response after pediatric Bone Marrow Transplantation. The study was to assess the

stress response after pediatric bone marrow transplantation. Data were collected during the

pre transplant stage and at 3, 6, 12 months post transplant stage using scale. At the initial

assessment children were found to demonstrate fewer symptoms. The symptoms observed in

the majority of the subject, were the presence of intrusive thoughts demonstrate fewer

symptoms. The symptoms observed in the majority of the subjects were the presence of

intrusive thoughts demonstrated through preservative play with medical equipment and doll

play containing prominent themes of death, mutilation and abandonment set in hospital

rooms. Denial and avoidance of reminders were common and intense. Irritability and sleep

disturbances were common as compared to regressive behaviors, exaggerated startle response

hypervigilence orattentional problems. Scores were not significantly different at 3 months

aftermath (range 60 – 90, Mean = 78). All scores were 80 – 100 by months aftertransplant

and remained at the level or improved by 12 months.It is indicated that intensive and for

intrusive procedure like transplant areknown to cause short term psychological morbidity with

acute stress relatedbehavioral and emotional responses in children and their parent. The

resultdocuments the need for children to be restored to a normal life as quickly aspossible,

setting the BMT experience behind them.8

Pereira conducted study to find out the emotional reactions of hospitalisedchildren identified

that anxiety fear, anger more prominent emotional reactionsamong hospitalized preschool

among school aged children Conducted a study on behavioral changes in peadiatric intensive

care units. The trauma ofhospitalization for children is similar in many aspects to the trauma

of a natural disaster such a flood. compared the frequency and severity of behavioral

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manifestations of anxiety in peadiatricpatients hospitalized in intensive care unit us ward

setting using a prospective patient’s series at Arkansan children’s hospital. A sample of 43

subjects aged 6 –17 years was consecutively selected for the study. The hospital observed

scale (HOBS) developed for this study was used to describe objectively the subject’s

manifestations of anxiety depression, delirium and with drawl subjects in the intensive care

unit exhibited apprehension and withdrawal. Subjects in the intensive care unit exhibited

apprehension. Anxiety, detachment, sadness and weeping more often than did patients in the

ward [P<0.05]. Behavior was significantly influenced by severity of illness [r= 0.39],

[P<0.01], duration of hospitalization [r = 0.42], [P<0.01], number of previous hospitalization

[r = 0.44],[P< 0.01], and presence of a preexisting anxiety and mood disorders [P< 0.05].The

data indicated that critically ill children in the intensive care unit, children with prolonged or

repeated hospitalization and children with preexisting anxiety and mood disorders are at

greater risk than other hospitalized pediatric patients for psychological trauma and for

behavioral problems that many warrant psychiatric intervention. conducted study on factors

influencing the coping of hospitalized school aged children . Indicated that a priority area of

pediatrics nursing intervention is the alleviation of fears and anxieties of hospitalized children

and their parents. Knowing more about the specific stressors and the relationship of the

reaction could provide a rationale. The information comes from investigating children’s

response to hospitalization this will allow nurse to individual supportive interventions for

hospitalized children conducted study on The major anxiety for children are separation

anxiety, loss of control, bodily injury and pain and uncertainty about limits. Separation from

their parents has been long recognized as the greatest source of anxiety for children under 7

years of age. conducted study on “coping with unplanned childhood hospitalization effects of

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informational interventions on mothers and children. Unexpected hospitalizations of young

children under 6 years. Constitute the bulk of pediatric hospital admissions. Lack of

preparation results in heightened Anxiety and high risk for negative outcomes.9

conducted study on “Child Drawing Hospital: An Instrument Designed to Measure the

Emotional Status of Hospitalization School Aged Children”. The degree of anxiety

experienced by any hospitalized child is unknown. The physiological status (temperature,

pulse, respiration, blood pressure etc) can be measured on hospital admission and at routine

intervals. Behavioral indicator of anxiety such as crying or aggression may be recorded. But

children may or may not have the ability or the vocabulary to express their feelings fears,

worries and concerns verbally.10

Conducted study on “Child Drawing Hospital: An Instrument Designed to Measure the

Emotional Status of Hospitalization School Aged Children”. Stated that anxiety fear and

anger frustration were more prominent emotional reaction among hospitalized scholars than

among school aged children. Stated that school age children experience decreased anxiety

with longer hospital stay. Whereas preschoolers do not show and any changes in the anxiety

status.11

Conducted study on children and illness: psychological aspect of children. Identified the

psychological aspect of hospitalization in children. Hesitated that hospitalization affects body

image and perception, as well as thesocial and family relationship, of children. The resulting

psychological disturbances may influences the course of diseases and the efficiency of the

care conducted a study on anxiety reaction in children during removal of their plaster cast

with a saw inschneider children’s medical center, at Petah Tiqua, Israel.We have had

experience of an 18 months old boy with a cardio my path who died a few minutes after

8
removal of his cast with a saw, apparently from malignant cardiac arrhythmia triggered by

anxiety. We therefore examined the anxiety to this method of removal of a plaster cast in 20

healthy children; ten were provided with hearing protectors and ten were not. The level of

anxiety was assessed by measuring the heart rate. A known physiological indicators of

anxiety, before, during and five minutes after removal of the cast. The noise level was also

measured. The results showed a mean increase in heart rate during the procedure of 27.9

beats per minute (bum) (26.9%) in the children with no hearing.12

2. Studies Related To play activities:

Conducted an experimental study to explain the effectiveness of Play activities on

development achievement levels of abused children. She defined Play activities as an

opportunity for the child to experience growth and development under the most favorable

conditions. The sample size was 60.There was a significant difference noted between abused

children receiving play and the other children. The result revealed that there is a difference in

the development of the abused children after Play activities.13

Conducted an experimental study to examine the role that play occupies within current

occupational therapy practice with preschoolers. The sample consists of two hundred and

twenty four pediatric occupational therapists completed mail questionnaires designed to

ascertain how they used play in their practice, their used of play assessments, and potential

constrains on their used of play. The results suggested that although respondents indicated that

play was important in motivating children and frequently used play as a treatment modality or

reinforces, they less frequently assessed between school based and non school based

respondents regarding the discipline or model that addresses play in the work setting. He

results suggested a need for increasing the emphasis on play in entry level curricular

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continuing education improving clinician access to valid and reliable play assessments, and

designed studies to examine the use and efficiency of play in occupational therapy designed

studies to examine the use and efficiency of play in occupational therapy intervention.14

Conducted experimental comparative study in the effectiveness of Play activities in gaining

the cooperation of the children during painful procedures like blood sampling IV infusions.

Etc. Among the hospitalized children. The sample size was 80 members. The tool used was

observation rating scale to observe to reaction of the children during painful procedure. The

result revealed that there was an effectiveness of play activities in gaining the cooperation of

the children during painful procedures.16

Conducted an experimental study on the effectiveness of Play activities in helping children

between three to twelve years in coping with painful procedures. The findings revealed that

adequate coping ability was shown by62.5% of the children in verbal responses 3.1% in facial

expression 34.4% imposture and 16.9% in physical activities rating scale. Play activities had

helped in improving coping ability of children during painful procedures and children with

Play activities copied better than children without Play activities

Conducted an experimental study concerning effect of play on immobilized children in the

hospital. It aimed to determine whether any difference existed in the perception of time,

social space and self for the two groups of immobilized children in the hospital. Sixty

immobilized children wererandomelly assigned to the experimental and control groups;

children in the control group were exposed to the regular ward stimuli while the experimental

group participated in four periods of planned play. Findings indicated that the immobilized

children exposed to planned play periods expressed more positive feelings towards

themselves than the control group.17

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 Conducted an experimental study on children with leukemia and found that day undergo

painful procedures such as lumbar puncture and bone marrow aspiration. To overcome pain,

certain units offer total anesthesia. Others offer generic supports: others offer no preparation

at all. Since September 1997, we have provided leukemia children with Play activities a non

verbal and creative modality that develops coping skills. Our goal is to prevent anxiety and

fear during painful interventions as well prolonged emotional distress. We treated 32children

aged 2 – 14 years. The modes of Play activities before, during and after the punctures were as

follows: clinical dialogue to calm children and help them.18

Cope with painful procedures; visual imagination to activate alternative sensitivity

Gate; medical play to clarify structured drawing to contain anxiety by offering a structured,

predictable reality (the drawing) that was controllable by children; free drawing to allow

children to externalize confusion and fears: and dramatization to children expect and reconcile

themselves body changes. The results revealed children hospitalized before September 1997,

exhibited resistance and anxiety during and after painful procedures.

3. Studies Related Play activities and its Therapeutic Value in Reducing

Anxiety among the Hospitalized Children.

Conducted a study on therapeutic play and hospitalized child. It has long been recognized that

there are many and varied definitions of play. This article briefly reviews normative play theory,

differentiating it. from its counterpart, therapeutic play. Three forms of therapeutic play

(emotions outlet play, instructional play, and physiologically enhancing play) are described and

clinical examples are given.19

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Conducted a study on the effect of the use of therapeutic play by the pediatric nurse on the

behavior of recently hospitalized children. This work describes the realization and the results of

one experimental research accomplished with children from 3 to 5 years age, recently -

hospitalized using the therapeutic play. The results showed that it helped children behave more

according to what is expected of this 3 – 5 age group, as well as show signs that they had adapted

or presented ego strength.17

Conducted a study on medical play and preparation: question and issues. Medical play and

preparation have become increasingly visible components of psychosocial programming for

children in health care settings. Each strategy varies to the extent to which adults structure and

direct, which may influence children’s responses and post hospital adjustment. Medical play and

preparation represent different philosophies and theories on children’s learning. Adaptation, and

development, the ever changing medical environment may currently favor adult- directed

experiences over those that are spontaneous or child initiated, with potentially differing impacts

on children.

6.3 Statement of problem

A descriptive study to assess the effectiveness of play therapy in reducing anxiety level among

hospitalized children in selected hospitals in Bangalore.

6.4 Objectives

1. To assess level of anxiety among hospitalized children before administering

Play activities in experimental and control group.

2. To determine the effectiveness of play activities among hospitalized children

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 In experimental group.

3. To find out the association in anxiety level among hospitalized children with selected

demographic variables.

Hypotheses

H1: There will be a significant difference between the pre test and post test level of anxiety

among hospitalized children after play activities.

H2: there will be a significant association in the pretest level of anxiety with the selected

demographic variables.

Assumption

The study was based on the following assumptions:

 It will highlight those areas in children’s development which require genuine care and

support.
 Identification of reaction will motivate the health team to create a healthy care encounter

with children.
 It will help the team members to understand hospitalized children as unique & whole and

therefore provide them improved quality care.

 It will promote sensitive care in order to meet effectively the needs of ill and hospitalized

children and thus promote more positive health outcomes.

DELIMITATIONS

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The study is delimited to

 Hospitalized ill children and their mothers who are willing to participate in the study.
 Observation of the children by the investigator is limited only to day time.
 Children who are admitted in general pediatric unit and during the period of data

collection.
 The children whose mothers can speak Kannada.

Operational definition

1. Children:

Refers to children admitted to the medical ward in age groups of 3-6 both

Male and female children were included in the study.

2. Effectiveness:

Effectiveness is defined in term of reduction in anxiety offer the

Intervention through Play activities.

3. Play activities:

Play activities is the process for treatment where the concept of

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Play is used as diversion. It includes the opportunity provided for children to manipulate create

draws interact and involve themselves with selected activities or object. The following types of

play were include in Play activities i.e. toys, balls, paints, drawing materials building blocks,

videogames and snake and ladder.

4. Anxiety:

A chronic state of tension, which effects both mind and body.

5. Hospitalization:

Admission in to an institution providing medical and surgical

Treatment and nursing care for sick or injured people [oxford dictionary, 1994] in this study it

refers to the admission of the child to the pediatric medical unit of the hospital for treatment

7. MATERIALS AND METHODS;

7.1 SOURCE OF DATA;

Hospitalized preschool children admitted in medical ward in India Gandhi Institute of Child

Health at Bangalore will be selected through convenient sampling technique through non

probability sampling technique

INCLUSIVE CRITERIA:

 Children admitted in hospital during June 2005

 Children admitted in medical ward
 Children who could understand Kannada.

EXCLUSIVE CRITERIA:

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 Who are critically ill children?
 Children who were treated as our patients
 Children with complications.

DEPENDENT VARIABLE:

Anxiety level of hospitalized children

INDEPENDENT VARIABLE:

Structured teaching programmed

STUDY DESIGN:

One group pre and post test approach will be used for the study.

7.2 METHOD OF COLLECTION OF DATA;

 Closed ended questionnaire

 Interview methods

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED PATIENTS OR OTHER HUMANS

OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY:

The study will be done on mothers with hospitalized children who are willing to participate.

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

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. Ethical clearance has been done by obtaining permission from the principal of

Sophia College of nursing, from hospital administrative, ward in charge and the participants of

the mothers with hospitalized children.

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8. LIST OF REFERENCE

1. Ingalls, saleroom. Maternal and child health nursing. 9th edition. Network: Mosby; 1999.

2. Sadler C. child’s play nurses times. 1990; 86 (11): 16 –17.

3. Saucier Bl... Play activities a nursing intervention. Advanced clinical care. 1989

4. Ziegler Debbie Michelle. Preparation for surgery and adjustment to

Hospitalization. Nurses clinician of North America. 1994; 29 (4):655-59.

5. Denise F. Polite, Bernadette P. Hunger. Nursing research – principles and methods.

2ndedition. Philadelphia: Lippincott publishers; 1999.

6. Mariner. A nursing theorists and their work. 1st edition. Toronto C.V. Company

1986.

7. Chirstense P.J, Kenny. J.N. Nursing process. Application of conceptual framework. 1 st

edition. Philadelphia: Mosby. 1989.

8. Nancy Burns, Susan K Grove. Understanding nursing research 1 st edition.

Philadelphia: saunders publishers : 2002.

9. Laura A Talbot. Principles and practice of nursing research. 1 st

edition Missouri:Mosby – publishers: 1995.

10. Denise F. Polit, Cheryl tatano Beck. Nursing reaserach priniciples and methods.

7 th edition. Philadelphia: Lippincott publishers; 2003.

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11. Basavanthappa BT. Nursing research 1 st edition. Bangalore: Jaypee Brothers

medical publishers; 2003.

12. Stuber M.L, Nader K D S W, Yasuda P, Pynoos R S, Cohen S. Stress responses

after paediatric bone marrow transplantation: preliminary results of a prospective longitudinal

study. Journal of American academy of child- Adolescent psychiatry. 1991: 30 (6):952 –957.

13. Perelra, M.A. A study to find out the emotional reactions of hospitalized children.

Published dissertation SNDT Women’s University Mumbai 1992

14. Jones S M, Fiser H.D, Living Stone R. L. Behaviour changes in paediatrics intensive care

units. American journal of disease children. 1992; 146 : 375 –379.

15. Bossert E. Factors influencing the coping of hospitalized school aged children.

Journal of paediatrics nursing. 1994; 9(5): 299-306.

16. Zingler Debbie Michelle. Preparation for surgery and adjustment to

hospitalization. Nurse clinician or North America. 1994; 29 (4) : 655–59.

17. Melynk. M.B. Coping with unplanned child hood hospitalization effects of informational

interventions on mothers and children. Nursing research. 1994; 43(1): 50–55.

18. Clatworthy S, Simon K, Tiedman M E. Child drawing hospital. An instrument

19
designed to measure the emotional status of school aged children. Journal of Paediatric Nursing.

1999; 14 (1): 2 – 18.

19. Bastin T. Children and illness psychological aspect of children. Archieves of paediatrics.

2000; 7 (4): 405 –9.

20. Katz K, Fogelman R, Attias J, Baron E, Soudry M. Anxiety reaction in children during

removal of their plaster cast. Journal of bone joint surgery. 2001; 83 (3):

388 – 90.

21. Bonnie N. The effectiveness of play therapy on development achievement level

so of abused children. IPT journal . 2000;14(2):6-8.

22. Couch. Promoting Play activities . I PT Journal. 1999; 347 –349.

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9 SIGNATURE OF THE STUDENT
10 REMARKS OF THE GUIDE it is a seasible study

11 NAME AND DESIGNATION Professor in pediatrics

11.1 GUIDE
11.2 SIGNATURE
11.3 HEAD OF THE DEPARTMENT
11.4 SIGNATURE
12.1 REMARKS OF THE PRINCIPAL findings of the study will be use full in

reducing anxiety level using play therapy

12.2 SIGNATURE

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