Case Studies of Hospital Play in Japan No.3

Preparation Practiced wiht a Child and His family experiencing Great Anxiety
Masumi Mochiduki*
Ⅰ. Introduction
In the hospital that I work for, the out-patient department, pediatric wards and the operating
room coordinate their support for children according to their medical situations. Once the date ofsurgery is determined, the HPS is informed through the out-patient department of the dates ofadmission, surgery and other related schedule. In a case where a patient (hereinafter referred to as“the child”) undergoes a one-day outpatient procedure, the HPS provides preparation on that day or
any previous day with a surgical nurse when the child comes to hospital. HPS stays with the childfrom admission to the operation room. When the child requires hospitalization, HPS tries to build agood relationship as soon as possible, and provides preparation with nurses in the operation roomand in pediatric ward.
This report is about preparation and its result when provided for a mother and a child who had a
traumatic experience during previous surgery in a different hospital that caused them great
anxiety about the upcoming surgery. Preparation here is referred to as interventions to reduce thedistress of children suffering from a certain disease and/or staying in a hospital througharrangements. It provides psychological care and involves efforts to create conditions forchildrenand their families to cope with their situations. Through preparation, HPS 1) provides the correctknowledge of a treatment, 2) provides children opportunities to express their true feelings andemotions, and 3) builds up a relationship built on trust between children and healthcare
professionals through psychological preparation1).
Ⅱ．Method
１．Procedure of preparation after the admission to the hospital and before the operation
The HPS visits a child once he is admitted to the hospital. The HPS then asks requests from him
while practicing preparation for the upcoming surgery. Once the initial greeting and preparation
with the child are done, HPS communicates with surgical nurses and plans the future schedule.
Either in his room or in a playroom, explanations for the day of surgery are given while showing apreparation booklet and a stamp rally map. The HPS asks him to stamp on the map the route to thesurgery room. The child, his family, an attending nurse and HPS then take the actual route to thesurgery room together.
At the reception of the surgery room, he is asked to search a bear who is wearing a hospital gown.
He is greeted by a nurse at the reception and is asked his name and which part of his body thesurgery will be performed on. He is then shown the actual operation room, and asked to wear a
medical cap of which he can choose a color. He is then told that healthcare staff will ask him hisname even though they will often know his name. In each step, he will put a stamp on the map.
After everyone. Including a surgical nurse goes back to his room, he is allowed to touch an actual
anesthetic mask and an electrocardiogram. The explanation of surgery is given to the child again
while playing with a bear doll and reading a preparation booklet. The HPS asks if he has anyquestions or requires re-explanation about the surgery. After the child puts the last stamp on themap, preparation is done and the HPS records all the events.

Mochizuki：Preparation Practiced to a Child and His family with Great Anxiety

Pic.１. During preparation
2．Case subject
1) Subject: Boy, 6 years and 8 months old, first grader. Physical/mental development wasappropriate for his age.
2) Family：Father, Mother and a sister (9 y/o)3) Surgery：Epiglottic cyst removal (otorhinology)。
4) Length of hospitalization：May 2012 (7 days in total) : Subject’s mother was with the subject for
the entire period.
Ⅲ．Result
1. The work of the HPS１）The first day of hospitalization
The HPS visited the boy soon after the boy was admitted to hospital the day before his surgery.
After the introduction, the HPS asked him if he had any request regarding preparation for thesurgery and scheduled with nurses in the ward and in the surgery room.
While playing together with the boy and his parent in the playroom, his mother told the HPS thatthe boy was crying uncontrollably at the previous surgery that was held three years ago. The boy
also said “I remember it. I did not like the surgery room”. The HPS informed his status in theprevious surgery to his attending nurse before our preparation.
(1) Surgical preparation
After a brief explanation in the playroom, the boy, his mother, his attending nurse and the HPS
went to the surgery room by taking the same route as the day of surgery. The boy happily kept on
looking at a provided stamp rally map
At the reception of the surgery room, a nurse was waiting and greeted us. The nurse asked thechild his name and what kind of surgery he was having. Though the boy looked nervous, he replied
clearly.
After everyone went back to the playroom, the HPS explained about the procedure of the surgery
while showing a preparation booklet. The boy was allowed to touch an anesthesia mask and anelectrocardiogram and he was playing with a bear doll by putting on plasters seals and applying
apparatu on the bear. The boy was saying “I did it before” while touching an anesthesia mask
nervously. HPS also explainedthat securing vascular access would be necessary before thesurgery and explained about the procedure using the actual equipment.
The boy’s mother said “ During the previous surgery, we were too anxious about the surgery tothink clearly, and we were both crying and just wondering what to do. Of course we are anxious thistime as well, but much calmer than before as we have received preparation. I wish that we could
have had a similar explanatory session before the previous surgery”
The HPS recorded the responses of the boy and his mother and later shared the information withother healthcare staff

Case Studies of Hospital Play in Japan No.3

Pic. 2. Preparation booklet and tools
Later, the vascular access practice was given to the boy while he was distracted with a children’s book at hisrequest. Throughout the time, he was calm and the procedure went smoothly. Though he was a little nervous about
the apparatus for the vascular access attached to his body while playing in the playroom, he was playing with one
toy after another restlessly and was not disturbed too much by the apparatus.
2) Day 2 (The day of surgery)
From 8:30 a.m. to the time of the surgery that would be held during the afternoon, the HPS andthe boy continuously played as follows:(1) Rolled ball down a jumbo slope.
(2) Played doctors and nurses with Playmobil toys. The boy was carrying a doll on a stretcher,placing doctors around a bed and letting the doll sit in a chair. When the HPS asked him “Is hehaving surgery?” he replied “Yes, it’s his leg” with a smile.
(3) He found building blocks, the same as the one that he played with in a kindergarten. Thebuilding blocks became his favorite until he left the hospital. He was building cars and airplanes,
and he put passengers in them.
(4) Though he was a little nervous while he was receiving an IV, he played bowling and enjoyedlining up pins in different ways.
His mother was a little worried whether he would forget how to play Electone (a type of electronicorgan produced by Japanese company, Yamaha), yet a recital was coming soon. At the time there
was no Electone in the playroom. When the HPS asked the boy if he would like to play the keyboard,
he said yes. The HPS promised him that she would prepare the keyboard after the surgery (the HPS
borrowed the keyboard from a daycare center located inside of the hospital. The HPS placed thekeyboard in the playroom for the boy so that he was able to play it whenever he wished to play).
When he was about to go to have his surgery, he smiled and said “I’m going now”. His motherseemed nervous. He was asleep peacefully in the surgery room while his mother was watching him.
His mother recalled later “ I was more nervous than he was, but it went well”.
3) Day 3 (A day after the surgery)
When asked about the surgery, he said “It wasn’t that bad. It was alright”. He then played thekeyboard and enjoyed the sound that he made. He played music that he would perform in an eventto the HPS. When the HPS praised his music, he looked happy.

Mochizuki：Preparation Practiced to a Child and His family with Great Anxiety4) Day 4 and Day 5
The HPS was absent. Later the HPS was reported that the boy was playing long in the playroom.
5) Day 6 and Day 7
He was playing in the playroom with the HPS. He played with his favorite toys calmly andpracticed his music on the keyboard. Though he was initially shy, he gradually showed his active
characteristics. He said “ I don’t want to go home. I want to play more” when he left the hospital.
His mother said, with tears when she left the hospital “ I was really worried for the surgery becauseof our previous experiences, but
this time, we went through the wholeprocedure with peace ofmind”.
IV. Discussion
When healthcare professionals receive information about a patient with a history of surgery andhospitalization, they tend to expect that the patient shall be OK since he/she has been through theprocedure before. In some cases however, children with previous surgical experiences are moreanxious about the upcoming surgery when they have their previous experiences as “bad memory”
than children who have no such history. The same goes for families. Families of children who have
had bad experiences in hospital tend to have higher anxiety than other families. It also appears
that such families’ anxieties are often not properly conveyed to healthcare staff.
In this report, though the boy did not express his feelings initially, he told the HPS and staff “Iremember it. I did not like the surgery room” when he was asked about his past experience. Inaddition, since the HPS came to know that his mother was also highly anxious about her son’ssurgery right after he was admitted to the hospital, detailed preparation was carefully given
working together with the nurses.
Through a preparation booklet and a stamp rally game, explanations of a route to the surgery
room, and the process of anesthesia were given while playing with a bear doll, and things after thesurgery were provided. On the day of the surgery, he was able to clearly imagine what the a surgery
would be about in his own way, through touching real apparatus and using them on a doll.
Eventually his anxiety was reduced.
During the preparation, his mother, apparently worried about her son’s surgery, asked aboutanesthesia, and a nurse who was going to attend the surgery replied immediately, and this seemed
one of the factors that had considerably reduced the mother’s anxiety.
Shima stated (2010) “ No matter how old a patient is, to introduce elements of “play” into apatient’s everyday life in hospital provides better understanding of the seemingly unfamiliar
medical environment because play transforms things to one’s familiar environment”. Throughpreparation, it is also important to use “play” in order to convey correct information both to apatient and to healthcare staff.
Things mentioned above indicate that mere preparation may not be sufficient to support a patient.
It seems necessary to build a good relationship with children through playing before/aftertreatments and to encourage them to take a step forward. Most importantly, information received
during play shall also come to contribute to our future work as HPS.

Case Studies of Hospital Play in Japan No.3

V. Conclusion
Previously in our hospital, preparation had been given to a patient at an out-patient department,
pediatric ward, and the surgery room separately, and often overlapping. To provide clear
information to patients and families and to reduce unnecessary anxieties, preparation has been
provided in collaboration with those three departments over the past two years.
Since nurses of pediatric ward/ surgery room and HPS work together, the purposes of preparation
was: 1) to provide correct information, 2) to provide opportunities to express feelings and 3) to build
up a trust relationship with patients which was accomplished. Consequently, anxiety, worry andrequests of patients and families were properly expressed and actions were taken rapidly to solve
issues.
Many nurses in the surgery room reported that children were calm when they entered theroom. Since family’s anxiety tends to be passed on to the child and he/she also becomes anxious, toreduce family’s anxiety is also an important consideration. To provide preparation that fulfills thepersonal needs of a patient is still a challenge, but it should be possible
through collaboration
and working together with other departments in the hospital.
References1) Ikuko Oikawa (2007). Preparation, Pediatric Nursing Dictionary, Health Press: p.735
2) Hideki Shima (2010). Surgical Preparation for older Children – An introduction and theeffect of backstage tour of the operation room, Pediatric Surgery 42: 342