The influence of picture coloring game therapy on anxiety levels of pre- school age children during hospitalization treatment

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1 ADRI International Journal Of Semantic Technology 1 (2017) The influence of picture coloring game therapy on anxiety levels of pre- school age children during hospitalization treatment ISSN : (online) ISSN : (print) Niken Sukesi Widya Husada Nursing Academy, Semarang, Indonesia niken.sukesi@yahoo.com Received February 2017; accepted April 2017; published online may 2017 Abstract. The success of treatment on patients of pre-school age children is highly influenced by their anxiety levels during treatment. In providing nursing care which is mainly to reduce patients' anxiety, the nurses should provide a game therapy. Picture coloring is one of the preferable games that preschool children love. Coloring picture game therapy is expected to be able to reduce the patient anxiety of those pre-school age children that the treatment processes may completely be successful. The purpose of this research is to examine the implementation of picture coloring game therapy on patients of pre-school age children to reduce/lower their anxiety levels. This research uses a quasi-experimental method with pre-post test designs and a total sample of 15 respondents collected with a total sampling technique. To analyze the influence of game therapy on anxiety level of pre-school age children during treatment, a paired test is performed. The research results show that there is a significant difference between anxiety levels of pre-school age children before and after the implementation of game therapy during treatment (p value = smaller than α = 0.05). Thus, it can be concluded that a game therapy may influence the anxiety level of pre-school age children during treatment. Keywords: picture coloring, nurses, pre-school age children, anxiety I. INTRODUCTION The success of treatment on patients of preschool age children is highly influenced by their anxiety levels during treatment. * Corresponding Author. Addres: niken.sukesi@yahoo.com In providing nursing care which is mainly to reduce patients' anxiety, especially children, the nurses should provide a game therapy. Hospitalization treatment may result in stress both for children and the families, which is mainly caused by family separation, control loss, bodily injury and pain [1]. Stress experienced by pre-school age children may influence their healing processes. The reactions of pre-school age children when undergoing treatments at the hospital include protests, despairs, and regressions. It is proven that children tend to be less active, sad, have no interest on the environmental conditions, less communicative, returning to the previous

2 N. Sukesi et al/ ADRI International Journal Of Semantic Technology 1 (2017) behaviors and leading to regressive behaviors such as being more dependent, introvert, and feeling anxious [2]. To solve the problems experienced by both children and parents when the children are hospitalized, some efforts are required to make in order to reduce the anxiety of children who undergo treatments, such as performing a game therapy. Any undertaking action performed to overcome problems faced by the children, should be based on the therapeutic cares as those are intended as therapy for children. Picture coloring is one of a preferable games that pre-school age children love. A picture coloring game therapy is expected to be able to reduce patients' anxiety of pre-school age children that the treatment processes may completely be successful. During the hospitalization treatments, children may experience various unpleasant feelings, such as anxiety. Playing game has various objectives for children undergoing hospitalization treatments, such as reducing fear, anxiety, sadness, stress, and pain [3]. Children who are undergoing hospitalization treatments commonly show anxiety problems, such as crying when medical actions or nursing carers are made, sitting on their parents' arms, not answer any question given by the nurses or strangers that the children have just met, seeming to be afraid of the nurses' coming due to their trauma upon invasive actions performed before. Thus, nurses find it difficult to perform any action on children. The purpose of this research is to examine whether picture coloring game therapy influences the anxiety level of pre-school age children experiencing hospitalization. II. RESEARCH METHODOLOGY This research uses a quasi-experimental method with pre-post test designs. The total sample is 15 patients collected using a total sampling technique with inclusion criteria on patients consciously having the ability to hear, communicate verbally, hold a coloring pencil, willingly participate and being hospitalized for more than 1 X 24 hours at inpatient rooms for children with self-care andpartial care dependence levels. The data collection instruments are questionnaires and observations with a total question of 14 items. Research Results Table 1 Frequency Distribution of Respondents Based on Patients' Age of Pre-School Age Children at Panti Wilasa Citarum Hospital, in August 2016 (n=15) In Table 1, it shows that most respondents age is 3 years old with a total number of 7 respondents (47%). Table 2 Frequency Distribution of Respondents Based on Patients' Sex of Pre-School Age Children at Panti Wilasa Citarum Hospital, in August 2016 (n=15) Meanwhile, Table 2 shows that more than half of respondents sex is male with a total number of 9 respondents (60%) Table 3 Frequency Distribution of anxiety before (pretest) and after (Post-Test) Picture Coloring Game Therapy for Patients of Pre-School Age Children at Panti Wilasa Citarum Hospital, in August 2016 (n=15) In addition, Table 3 shows that before game therapy, more than half of respondents experience anxiety with a total number of 9 respondents (60%), while after game therapy most respondents only experience mild anxiety with a total number of 13 respondents (86%). Thus, the anxiety is decreasing before and after therapy. Table 4. Differential test of anxiety before (pre-test) and after (Post- Test) Picture Coloring Game Therapy for Patients of Pre- School Age Children at Panti Wilasa Citarum Hospital, in August 2016 (n=15)

3 N. Sukesi et al/ ADRI International Journal Of Semantic Technology 1 (2017) Furthermore, Table 4 shows the average difference of before and after game therapy. On the average value of before game therapy is 2.7 while after game therapy is 2.0 that the average difference is 0.7. From the analytical results, it is found that the t-value is (more than t-table of 2.114). It means that game therapy influences the anxiety level, while p value of is less than the significance level of α = It shows that there is a significant difference. III. DISCUSSIONS The average age of pre-school age children is three years old. Those who are sick and should be hospitalized result in separation with their parents, siblings, and mates at a similar age as well as factors triggering children's anxiety. Supartini (2004) states that children's reactions to pain are variously based on their level of development [3]. The younger the children the more difficult they adjust themselves upon hospitalization experiences [4]. Alimul (2007) states that anxiety experienced by pre-school age children (3-5 years) appear when they are undergoing treatments at a hospital that result in reaction upon their separation by refusing to eat, frequently asking questions, crying even just slightly, and being not cooperative with the health workers [5]. Children experiencing stress may adapt or adjust themselves to overcome their stress [6]. Children experiencing stress and anxiety require therapeutic measures required to reduce anxiety. If not eliminated or reduced, the anxiety may cause children's refusal on the given nursing measures. One nursing measure considered possible to overcome or reduce anxiety is in the forms of the game. This game is certainly determined by children's age. The therapeutic games based on children's age may improve children's emotional disorders and overcome their physical condition experiencing sickness [7]. The respondents of this research consist of 6 males (60%) and six females (40%). Sex certainly influences children s anxiety level. Female respondents are more susceptible to experience anxiety than the male ones as females' estrogen hormones are males' [8]. Similarly, Hockenberry & Wilson (2009) also state that children's reaction to hospitalization is influenced by sex [9]. Males tend to be more active and explorative, while females are more sensitive [10]. Soetjiningsih (1995) in Samiasih Amin (2007) explains that boys are more susceptible to experience illness than girls, yet no scientific reason is found [11]. Although sex is not a dominant factor in the presence of anxiety, there are studies mentioning that the highest anxiety level is experienced by females with a comparison of 2: 1 to males [12]. Thus, females are more susceptible to experience anxiety than males. The results of this research show that children who are mostly influenced by hospitalization are at the age of 3 years old with a total number of 37% and those are males with a total number of 60%. It shows that respondents experience hospitalization anxiety due to the facts that patients with the age of 3 and 4 years old experience severe anxiety level as they are unable to well communicate in a sophisticated language and may not be separated from their parents. Severe anxiety level is experienced by many children who have never been hospitalized before as they are crying, losing appetite, feeling unstable, having the convulsive face, and restless. The anxiety level of male children is higher than that of female children as males find it difficult to control themselves characterized by aggressiveness such as biting, kicking, and even hitting 13]. High anxiety level experienced by children during hospitalization is supported by a research conducted by Samidah (2012) who finds that 84.4% of children experience mild anxiety during hospitalization [14]. Accordingly, a research conducted by Wowiling, et al., (2014) shows that 42.43% of children experience anxiety during hospitalization [15]. Preschool age children consider that hospitalization is a frightening experience [11]. The research results show that of 15 respondents, 5 (33%) children experience mild anxiety, 9 (60%) experiences medical anxiety, 1 (7%) experienced severe anxiety before game therapy while after game therapy 1 (7%) experiences no anxiety, 13(86%) experienced mild anxiety, and none experienced severe anxiety. Guyton (2002) states that the anxiety experienced by pre-school age children may activate hypothalamus and then subsequently release Corticotropin Releasing Hormone (CRH) which encourage anterior hypo-phase releasing Adrenocorticotropic Hormone (ACTH)[16]. ACTH stimulates adrenal cortex to release cortisol. Cortisol encourages resistance to stress, helps muscle growth and formation of new glucose (gluconeogenesis) to be converted into energy against stress. In addition, cortisol also plays an important role in lipid metabolism, protein metabolism, lysosome stability, preventing a body from allergic reactions and inflammations. The psychological anxiety responses include restlessness, nervousness, convulsiveness, worried, cautious, and guilty feeling or ashamed 17]. Children at the age of fewer than

4 N. Sukesi et al/ ADRI International Journal Of Semantic Technology 1 (2017) five years old are unable to well communicate using a sophisticated language and still have a limited sense of reality. Mother and children relationship is very close that separation may result in children's feeling of loss to a person that they consider as the closest one as well as the environment they are acquaintance with that eventually leads to their feeling of insecurity and anxiety [18]. Anxiety is an individual response to unpleasant conditions and those are experienced by all living things in the daily life [19]. Anxiety and stress experienced by children during hospitalization are influenced by several factors, such as health workers (nurses, doctors, and others), new environment, and the accompanying family during treatment [18]. The research results show that game therapy for children may help them express their thoughts, feelings, fantasies, and develop their creativity, and adapt more effectively against stress [20]. Game therapy for children is expected to be able to prevent and even reduce the impact risks resulted from their anxiety. Anxiety may lead to children's refusal against nursing measures. Supartini (2004) states that game therapy may reduce hospitalization influence on children [3]. The therapeutic game is based on views that games for children are healthy activities and necessary for the sustainability of children's growth and enable them to explore and express their feelings and thoughts, transferring pain, and relaxing. Game activities should be an integrated part of children health care at hospitals [3]. Hospitalization impacts may be reduced with a therapy of games. Supartini (2004) mentions that game therapy may reduce children's hospitalization impacts [3]. A therapeutic game is based on views that for children, games are healthy activities required for their growth sustainability and to enable them to explore and express their feelings or thoughts as well as to replace pain into relaxation. Game activities should be an integrated part of children nursing care processes at a hospital. Game therapy is provided to reduce children's anxiety on hospitalization. Game therapy is required by the hospitalized children to improve their health [5]. Playing game is very essential for children s mental health and emotion as well as their welfare, including their unstoppable needs to grow and to even then they are sick or hospitalized [21]. In addition, children s developmental compliance requires game therapy to generate other advantages, such as children s pleasure and excitement. The anxiety average level before game therapy is 2.7 while after game therapy is 2.0 that the average difference is 0.7. The analytical results find that t value is (greater than t table of 2.114). It means that game therapy influences anxiety level, while the p value of is less than the significance level of α = It shows that there is a significant difference. Game therapy has a strong and significant influence on stress. It means that game therapy programs based on age are greatly necessary. Well, programmed game Activities may soon restore children's independence feeling. Games for children at a hospital may not only provide pleasures but also help them express their thoughts, anxiety, fear, sadness, stress, and pain [14]. Picture coloring game therapy may help children to positively explore themselves that children feel proud of their own works. This is consistent with the theory of psychosocial development stages for pre-school children suggesting that pre-school children begin to develop their wishes by exploring their surrounding environment. The children may also feel satisfied and proud of their ability to produce something as their achievements [3]. In addition, creativity in arts may increase pleasure, self-esteem, and self-awareness as well as reduce anxiety [10]. Therapeutic games may improve children's ability to have positive behaviors [14]. Children may obtain various advantages in the forms of pleasure and excitement that their health recovery may be realized or, at least, there is no objection to any given nursing measures. The pleasure that the children obtain, in facts, may reduce their anxiety and readiness when nursing measures are undertaken and recover those with emotional disturbances [7]. A game therapy approach to overcome trauma resulted from hospitalization is also explained by Lamotte (2011), that an appropriate combination of psychotherapeutic approach and game therapy is greatly recommended as an alternative way to overcome children s traumas of being hospitalized [22] IV. CONCLUSIONS AND RECOMMENDATIONS Conclusions Based on research results, the influence of game therapy on anxiety decrease of preschool age students at Panti Wilasa Citarum Hospital, most patients are males with the age of three years old. The analytical results show that children's anxiety before and after therapy treatments is decreasing. Game therapy influences children's anxiety decreased.

5 N. Sukesi et al/ ADRI International Journal Of Semantic Technology 1 (2017) Recommendations 1. The hospital should provide game therapy programs to reduce anxiety. 2. The researchers are expected to conduct researches with different methods and also with more representative number of samples and characteristics REFERENCES [1] Nursalam. Konsep dan Penerapan Merodologi Penelitian IlmuKeperawatan: Pedoman Skripsi, Tesis dan Instrumen Penelitian Keperawatan. Jakarta: Salemba Medika [2] Wong, D., L.. Whaley and Wong s nursing care of infants and children. (7th ed.). St. Louis: Mosby [3] Supartini. Buku Ajar Konsep Dasar Keperawatan Anak. Jakarta [4] Elfira, Eqlima. (2011). Pengaruh Terapi Bermain Dengan Teknik Bercerita Terhadap Kecemasan Akibat Hospitalisasi Pada Anak Usia Prasekolah di Ruang Perawatan RSUP H Adam Malik Medan. USU InstitutionalRepository Diakses pada 20 Februari 2017 [5] Alimul. A. Pengantar Ilmu Keperawatan. Anak Jilid 1. Salemba Medika. Jakarta, 2007 [6] Hawari D. Manajemen stres cemas & depresi. Jakarta: FKUI [7] Mahon, L.M. The handbook of game therapy and therapeutic game (2rd ed). London: Wiley Inter Science [8] Stuart GW. Buku saku keperawatan jiwa. Jakarta: EGC [9] Hockenberry, M.J., & Wilson, D. Essentials of paediatric nursing. St.Louis: Mosby [10] Little, B.(2006). How viewing art therapy can help? Accessed from apy/art- therapy.php. on 11 February 2016 [11] Samiasih, Amin. (2007). Pengaruh Terapi Bermain Terhadap Tingkat Kecemasan Anak Usia Prasekolah Selama Tindakan Keperawatan di Ruang Lukman Rumah Sakit Roemani Semarang /PENGARUH_TERAPI_BERMAIN_ TERHA DAP_TINGKAT_KECEMASAN_ANAK_US IA_PRA SEKOLAH_SELAMA_TINDAKAN_KEPER AWATA N_DI_RUANG_LUKMAN RUMAH SAKIT ROEMANI SEMARANG. Diakses pada tanggal 20 Februari 2017 [12]Hawari, D. Manajemen Stress, Cemas Dan Depresi. Jakarta: Balai Penerbit FKUI [13] Alkhusari (2013). Analisis Terapi Bermain Mewarnai Terhadap Penurunan Kecemasan Akibat Hospitalisasi Pada Anak Usia Prasekolah (3-6 Tahun) Di Ruang Anak RSUD Sobirin Lubuk Linggau Tahun Vol.1. No.2. Desember Jurnal Harapan Bangsa. ISSN kecemasa n.pdf. Diakses tanggal 20 Februari 2017 [14] Samidah Ida. (2012). Pengaruh Terapi bermain terhadap penurunan kecemasan pada anak usia 3-5 tahun yang dirawat di rsud labuang baji makasar. Accessed on 29 January 2017 from c=s&ur ce=web&cd=1&cad=rja&uact=8&ved=0ahuk Ewjhg8 jcnobrahujk48khs75ar4qfggzmaa&url =http%3a %2F%2Fv1.stikesdehasen.ac.id%2Fdownlot.p hp%3ffil e%3dida%2520samidah.pdf&usg=afqj CNEMXmr Qs00uGUJi5Pb3lXlq1v8B_w&bvm=bv ,d.c2 I [15]Wowiling, F. E., Ismanto, A. Y., & Babakal, A. (2014): Pengaruh TerapiBermain Mewarnai Gambar Terhadap Tingkat Kecemasan Pada Anak PraSekolah Akibat Hospitalisasi Di Ruangan Iriana E Blu RSUP. Prof. Dr. R.D. Kandou Manado. diunduh tanggal 20 Februari 2017 [16] Guyton H. Fisiologi kedokteran. Jakarta:EGC [17]Struart & Sundeen. Buku Saku Keperawatan Jiwa. Jakarta:EGC [18] Nursalam. Konsep dan Penerapan Metodologi Penelitian Ilmu Keperawatan. Edisi 2. Jakarta: Salemba Medika. 2008