Effect of Play Activities Versus Passive Distraction Technique on Preoperative Anxiety and Fear Levels among Children Undergoing Surgeries

Background: Illness, hospitalization, and surgery are the first crises that children face especially during the early years. The play and passive distraction technique are non ‐ pharmacological approach used to control emotions. They are considered an anxiety-reducing strategies that divert children’s attention away from noxious or unpleasant stimuli and subsequently minimizes their anxiety and fear. Objective : To determine the effect of play activities versus passive distraction techniques on preoperative anxiety and fear levels among children undergoing surgeries. Setting: The study was conducted in the general pediatric surgical units at Alexandria University Children at El-Shatby and Smouha Specialty Hospitals. Subjects : A convenience sampling of 90 hospitalized school-age children undergoing general surgeries were included from the previously mentioned settings. Tools : Three tools were used; Socio-demographic and medical data of Children's structured Interview Schedule, State trait anxiety inventory for children (STAIC), and the children’s fear scale (CFS). Results : These results revealed that 66.7% of school-age children in the play activities group and 30% of children in the passive distraction group had low anxiety compared to none of them in the control group (0.0%). In addition, 66, 7% of school-age children in the control group had extreme fear compared to none of those children in both the play activities group and the passive distraction group. A highly statistically significant difference was detected for the preoperative anxiety and fear between school-age children in both groups (I and II) one hour before surgery. Where 50% of children in study group II mentioned that they had average anxiety compared to 33.3% of them in study group I. In addition, nearly half of the children in study group II reported that they had medium fear (46.7%) compared to 16.7% of them in study group I. Conclusion : Practicing the play activities and passive distraction technique for school-age children preoperatively minimized their level of anxiety and fear. In addition, the play activities were more effective in decreasing children's level of anxiety and fear than the passive distraction technique. Recommendations: It was recommended that play activities should be applied preoperatively to children undergoing surgeries in hospitals.


Introduction
Hospitalization for medical illness or surgical procedures is experiencing various emotions due to the unknown environment, unfamiliar people, and various frightening equipment.The effects of the disease, changes in the environment and habits as well as separation from family members and friends can lead to stress particularly during painful procedures (Al-Yateem et al., 2015;Kapkın et al., 2020).Surgical operations are situations that provoke anxiety, fear and varying levels of distress not only for the child who is unwell but also for the parents.Varying degrees of anxiety and fear may be experienced by children depending on the seriousness of the health problem and the level of parental ; anxiety and concern exhibited Chow et al., 2016).Anxiety is defined as a psychological, physiological, and behavioral state induced in human beings by a threat to well-being or survival, either actual or potential.Preoperative anxiety (PA) is of utmost concern in pediatrics.It was documented that 40% to 60% of children undergoing surgical procedures experience high levels of preoperative anxiety (Fortier & Kain, 2015).
Fear is a natural, powerful, and inherent human emotion.It involves a universal biochemical reactions as well as a high individual emotional response.Fear refers to the presence of danger or the threat of harm, whether that danger is physical or psychological (Fritscher, 2020).Anxiety and fear in children undergoing hospitalization can be reduced by several measures in the form of play activities and passive distraction technique.In accordance with the stage of development of play for children aged 6-12 years, the game that can be done is constructive play.In this playing activity, the child will create something, create a particular building with the available game tools (Supartini, 2014;Kaluas, 2015(.Play activities are playing technique used to reduce anxiety and fear among hospitalized children.They evaluate their feelings and misunderstandings toward treatments and procedures and help them develop positive coping methods (Kapkın ,2020).Several studies have shown that play activities can help establish a bond and communication with the hospitalized children.The expression of feelings among children, relieve stress and anxiety and prepare them for invasive interventions (Caleffi et al ., 2016).
Passive distraction technique means that the children usually remain silent during the procedure through watching a stimulant rather than the active participation.It is hypothesized to be an effective strategy for decreasing procedural pain, fear, anxiety by reducing the sensory and affective components of pain, anxiety and fear and the diversional capacity left to process that pain.In addition, when an individual is distracted, regional cerebral blood flow associated with processing a painful event is reportedly reduced.Likewise, when an individual's attention is occupied by a distracting task, activation is reduced to the areas of the brain associated with pain such as the thalamus, insula and the anterior cingulate cortex producing correspondingly lower pain and anxiety scores (Guzzetta et al .,2007).
Pediatric nurse has a crucial role in reducing anxiety and fear among children in preoperative period.Some hospitals provide preoperative preparation programs to reduce anxiety in children and their parents.Preoperative preparation programs allow children and their parents the chance to familiarize themselves with the hospital environment and procedures, some days before the operation.By doing this, they can increase their knowledge, learn coping strategies and lower anxiety (Olson, 2018).
Pediatric nurse also can reduce the negative effects of hospitalization through prepare the child and family for this process such as; establish a trusting relationship, provide information about procedures, help children to express emotions, support coping strategies and distraction techniques.Previous experiences of the child and family should also be considered to establish communication appropriate for the age of the child, answer questions carefully, and eliminate needless worries (Çelebi et al ., 2015;Kapkin , 2020).Spielberger, (1964) and adopted in the current study.Validity and reliability has been done for this scale again by Levent Kirisci and Duncan B. Clark, (1996).Cronbach's reliability coefficients for the STAIC ranging from 0.82 to 0.89.The STAIC is self-reported instrument used to evaluate children's anxiety between the ages of 7 to 11years .The scale consists of 20 items that ask children how they feel at a particular time.Children were instructed to respond according to how they feel about their surgeries.They resonded to the STAIC by selecting one of three scores (Hardly ever, often , always).

Scoring system:
The total scores 60 are summation of the item scores; For statistical purposes, scores ranged from 20 to less than 30 were considered low anxiety, 30 to less than 40, indicating average; 40 to less than 50, indicating above average; and 50 to 60 suggesting very high level of anxiety.

Tool III: The children's fear scale (CFS):
It is self-reported scale that was developed by McMurtry et al (2011)

Statistical Analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp) Qualitative data were described using number and percent.The Shapiro-Wilk test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation, median.Significance of the obtained results was judged at the 5% level.The used tests were: 1-Chi-square test: For categorical variables, to compare between different groups 2-Fisher's Exact or Monte Carlo correction: Correction for chi-square when more than 20% of the cells have expected count less than 5 3-Paired t-test: For normally distributed quantitative variables, to compare between two periods.4-Kruskal Wallis test: For abnormally distributed quantitative variables, to compare between more than two studied groups.5-Wilcoxon signed ranks test: For abnormally distributed quantitative variables, to compare between two periods.

Results:
Table ( The relationship of the preoperative level of anxiety between the school-age children in study group one and control group through one hour before surgery is shown in (Table 2).It was found that the level of anxiety for 46.7% of children was very high in control group compared to none of children in the study group one (0.0%).In addition, the anxiety level for 66.7% of children in study group one was on low level compared to none of them on the control group (0.0%) and the difference statistically significant, where p= <0.001.
Table (3) presents the relationship of the preoperative level of fear between the school-age children in study group one and control group through one hour before surgery.Significant difference was found between the two groups (p= <0.001) where the majority of children in study group one reported that they had simple fear (83.3%) compared to none of those in control group (0.0%).Furthermore, 66.7% of children in control group mentioned that they had extreme fear compared to none of those in study group one (0.0%).

Discussion
Surgical operations are situations that develop for multiple reasons causing stress for both children and their families.This stress is reflected as anxiety, fear and anger that initiating mainly from Parental separation and a strange environment.The identification and treatment of these clinical phenomena are very important to prevent both psychological and physiological side effects (Aytekin et al., 2016).The most significant advantage of nonpharmacological methods is that they reduce the use of analgesics and inhence children's adaptation to the stressful situations and fears.Play activities and passive distraction technique are types of these non-pharmacological methods (Inan & Inal, 2019).
The findings of the present study revealed that the school-age children who received play activities exhibit lower anxiety and fear than those who don't (table 2& 3).The positive effect of play activities in the present study could be explained in the light of certain issues; it was stated that play activities are an effective strategy for decreasing procedural pain, fear, anxiety and distress where it reduces the sensory and affective components of these feelings.Play activities will be also a vehicle to modify how noxious and fearful stimuli are processed (Guzzetta et al., 2007).
It was revealed from the results of the present study that the use of passive technique for children preoperatively has a positive effect in reducing their anxiety and fear (table 4&5).This could be related to passive distraction technique (e.g.watching cartoon games) leads to endorphin secretion and thus, can lead to the modifications of emotions, increase children's comfort and reduce pain, fear and anxiety (Kazemi et al., 2012).
The results of current study were congruent with the findings that have been done by Amer et al. ( 2021) who recommended the use of storytelling technique (a type of passive distraction technique) beside routine hospital programs for children undergoing surgery.They found that children who were exposed to storytelling experienced low anxiety and fear scores compared to those children who received the routine hospital care only.
The findings of the current study revealed that play activities is more effective than passive distraction technique in minimizing level of anxiety and fear for school-age children preoperatively as illustrated in tables 6 & 7.The superiority effect of play activities in this study could be related to, the school -age children in play activities group act as an active participant in which they were completely involved, immersed and occupied with the play games.So, they focused all their attention that help them to reduce their feelings of anxiety and fear.While, with passive distraction technique the children act as passive participant and they were only just viewers (Elsayed, 2020) The findings that have been shown by Arıkan & Esenay 2020 regarding their study on "active and passive distraction interventions in an emergency pediatric department to alleviate the pain and anxiety during venous blood sampling" supported the findings of the present study as they cited that the active distraction group had lower levels of procedural pain, fear, and anxiety than those in other groups.
Inan & Inal, 2019 in their study findings about a clinical trial to evaluate the Impact of 3 different distraction techniques on the pain and anxiety levels of children during vein puncture were parallel with the findings of the current study that the anxiety levels of the group playing video games (as active distraction method) during the venipuncture procedure were significantly lower than those who don't.
On the contrary, Many authors ( Millett and Gooding, 2017;Gul, U. 2021;Shekhar et al., 2022) stated that there was no significant difference between the groups of active and passive distraction techniques in reducing pain, anxiety and fear.In addition, the findings that have been shown by Durak &Uysal, 2022 andUgucu et al., 2022 reported that cartoon watching (a type of passive distraction) was more effective in reducing pain, anxiety, and fear in children than distraction card (a type of active distraction).
Unfortunately, children's previous experience of hospitalization in the current study doesn't have any effect regarding their anxiety and fear levels.Where, children who hadn't previous experience of hospitalization had lower anxiety and fear levels than those who don't.

Conclusion:
It is concluded from the present study that practicing the play activities and distraction technique for school-age children preoperatively minimized their level of anxiety and fear.In addition, the play activities were more effective in decreasing the children's level of anxiety and fear than passive distraction technique.

Recommendations:
1.An educational training program should be conducted to pediatric nurses about various methods of distraction to minimize children's anxiety and fear preoperatively.2. Play activities as a non-pharmacological anxiety and fear management should be used as a routine in daily care in pediatric hospitals.3. Play activities should be used to children before surgical procedures in hospitals.4. Establishment of playing rooms with interacting toys in surgical units and demonstrate to children how to use it.
to measure fear among children.The child's version consists of 5 faces.The first face (from the left) is not scared at all, represents no fear.The next 4 show incremental amounts of fear ranged from low fear to very fearful and the last face is representing the extreme fear.These faces are showing different amounts of being scared.This face [point to the left-most face] is not scared at all, this face is a little bit more scared [point to second face from left], a bit more scared [sweep finger along scale], right up to the most scared possible [point to the last face on the right].For statistical purposes, each face is assigned a numerical value from 0 to 4 (Zero indicating no fear, while 4 indicating extreme fear).

Figure 1 :
Figure 1: children's fear scale (McMurtry, C.M., Noel, M., Chambers, C.T., McGrath, P.J. (2011).Children's fear during procedural pain: Preliminary investigation of the Children's Fear Scale.Health Psychology, Advanced Access Online.)Method 1. Approval from Research Ethics Committee, Faculty of Nursing, Alexandria University was obtained.2.An official letter was sent from the Faculty of Nursing to the directors of the previously mentioned settings to facilitate research implementation after explanation of the aim of the study.3. Tool I was developed by the researcher.4. Tool II & III were translated into Arabic.5. Tool I & II & III were tested for content validity by five experts in the pediatric nursing field and necessary modifications were done and it was 94.8%. .

 2 : 2 : 2 :
Chi square test MC: Monte Carlo*: Statistically significant at p ≤ 0.05Table (3): The relationship of the preoperative level of fear between the school-age children in study group one and control group through one hour before surgery Chi square test MC: Monte Carlo*: Statistically significant at p ≤ 0.05 Table (4): The relationship of the preoperative level of anxiety between the school-age children in study group two and control group through one hour before surgery.Chi square test MC: Monte Carlo*: Statistically significant at p ≤ 0.05

Tool II: State trait anxiety inventory for children (STAIC):
This scale was developed by Charles D.