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The Effects of a Therapeutic Play/Play Therapy Program on the Fear and Anxiety Levels of Hospitalized Children After Liver Transplantation

Published:November 03, 2020DOI:https://doi.org/10.1016/j.jopan.2020.07.006

      Abstract

      Purpose

      This study was conducted to analyze the effects of a therapeutic play/play therapy (TP/PT) program on anxiety levels and fear of medical procedures in children with liver transplant.

      Design

      The study had a pretest–posttest quasi-experimental design.

      Methods

      Sixty-five children aged between 6 and 12 years were included in this study. A children's information form, the State-Trait Anxiety Inventory for Children, and the Medical Procedure Fear Scale were used for data collection.

      Findings

      The application of the TP/PT program resulted in a statistically significant decrease in the children's anxiety levels and fears about medical procedures (P = .001).

      Conclusions

      The TP/PT program had a positive effect on the children's fear and anxiety levels regarding certain medical procedures. Pediatric nurses can use the TP/PT program to reduce children's anxiety and fears about medical procedures.

      Keywords

      Liver transplantation has become the standard treatment for acute liver failure or the last stages of liver disease in childhood.
      • Alpert O.
      • Sharma V.
      • Cama S.
      • Spencer S.
      • Huang H.
      Liver transplant and quality of life in the pediatric population: A review update (2013-2014).
      During the past 40 years, pediatric liver transplantation has evolved significantly, and long-term survival after transplantation has increased to 85%.
      • Cuenca A.G.
      • Kim H.B.
      • Vakili K.
      Pediatric liver transplantation.
      As the survival rate and expected length of survival have increased in pediatric liver transplantation, the psychological effects of transplantation on children and their families have gained attention.
      • Alpert O.
      • Sharma V.
      • Cama S.
      • Spencer S.
      • Huang H.
      Liver transplant and quality of life in the pediatric population: A review update (2013-2014).
      ,
      • Parmar A.
      • Vandriel S.M.
      • Ng V.L.
      Health-related quality of life after pediatric liver transplantation: A systematic review.
      Previous studies have shown that children who have undergone transplantation experience many psychosocial problems, such as sleep disorders,
      • Hames A.
      • Matcham F.
      • Joshi D.
      • et al.
      Liver transplantation and adolescence: The role of mental health.
      ,
      • He K.
      • Shen C.
      • Chen X.
      • et al.
      Health-related quality of life and sleep among Chinese children after living donor liver transplantation.
      anxiety, nervousness, fatigue, concentration impairment,
      • Karayurt Ö.
      • Ordin Y.S.
      • Ünek T.
      • Astarcıoğlu İ.
      Immunosuppressive medication adherence, therapeutic adherence, school performance, symptom experience, and depression levels in patients having undergone a liver transplant during childhood.
      and a low quality of life.
      • He K.
      • Shen C.
      • Chen X.
      • et al.
      Health-related quality of life and sleep among Chinese children after living donor liver transplantation.
      Hames et al
      • Hames A.
      • Matcham F.
      • Joshi D.
      • et al.
      Liver transplantation and adolescence: The role of mental health.
      found that depression and anxiety levels were significantly high in adolescents who had undergone liver transplantation. Another study showed that emotional disorders, such as anxiety, depression, and post-traumatic stress disorders, were very high in children who had undergone liver transplantation compared with their healthy peers, and these children also experienced chronic disease after transplantation.
      • McCormick King M.L.
      • Mee L.L.
      • Gutiérrez-Colina A.M.
      • Eaton C.K.
      • Lee J.L.
      • Blount R.L.
      Emotional functioning, barriers, and medication adherence in pediatric transplant recipients.
      Psychological well-being directly affects the results of long-term treatment after transplantation.
      • Bamford J.
      • Wirz L.
      Piloting psychology annual reviews as a method of measuring psychological distress and quality of life in pediatric renal transplant patients.
      In such cases, therapeutic play (TP) can be used to provide both physical and emotional comfort and can contribute to children's recovery. Play, which has been proven to have a high therapeutic value for children during hospitalization, can be applied as both TP and play therapy (PT).
      • Koukourikos K.
      • Tzeha L.
      • Pantelidou P.
      • Tsaloglidou A.
      The importance of play during hospitalization of children.
      The creation of spontaneous activities using toys without predefined targets is expressed as PT.
      • Lemos I.C.S.
      • da Silva L.G.
      • Delmondes G.
      • et al.
      Therapeutic play use in children under the venipucture : A strategy for pain reduction.
      TP is a nursing education intervention that eases children's fears before surgery, reduces anxiety levels, and provides a positive experience.
      • Coşkuntürk A.E.
      • Gözen D.
      The effect of interactive therapeutic play education program on anxiety levels of children undergoing cardiac surgery and their mothers.
      Toys and equipment can be used in TP to teach children about what happens during medical interventions. Using toys and medical equipment, a therapist plays with the children so that they learn about the stages of the procedure.
      • Nabors L.
      • Kıchler J.
      Play therapy with children experiencing medical illness and trauma.
      TP improves the sense of control and confidence in hospitalized children, thus prepare the child for medical procedures in the hospital and making it easier to cope.
      • Yayan E.H.
      • Zengin M.
      Therapeutic play in child clinics.
      ,
      • Stewart M.W.
      Therapeutic play intervention.
      TP contributes to cognitive, emotional, and social developments in children and has a significant function in communication with children.
      • Büyük E.T.
      • Bolışık B.
      The effect of preoperative training and therapeutic play on children's anxiety, fear, and pain.
      • Yayan E.H.
      • Zengin M.
      • Düken M.E.
      • Suna Dağ Y.
      Reducing children's pain and parents' anxiety in the postoperative period: A therapeutic model in Turkish sample.
      • Caleffi C.C.
      • Rocha P.K.
      • Anders J.C.
      • Souza A.I.
      • Burciaga V.B.
      • Serapião Lda S.
      Contribution of structured therapeutic play in a nursing care model for hospitalised children.
      TP and PT are widely used in relieving pain and anxiety and increasing coping in children.
      • Yayan E.H.
      • Zengin M.
      Therapeutic play in child clinics.
      ,
      • Stewart M.W.
      Therapeutic play intervention.
      Although the TP is not effective in infancy, the game can be played using a doll or a puppet in the preschool period. In school-age children, it can be planned using medical equipment.
      • Yayan E.H.
      • Zengin M.
      Therapeutic play in child clinics.
      The literature shows that TP is an effective method for reducing the anxiety of children and their parents after surgery.
      • Coşkuntürk A.E.
      • Gözen D.
      The effect of interactive therapeutic play education program on anxiety levels of children undergoing cardiac surgery and their mothers.
      ,
      • Orhan E.
      • Yildiz S.
      The effects of pre-intervention training provided through therapeutic play on the anxiety of pediatric oncology patients during peripheral catheterization.
      TP decreases pain
      • Lemos I.C.S.
      • da Silva L.G.
      • Delmondes G.
      • et al.
      Therapeutic play use in children under the venipucture : A strategy for pain reduction.
      ,
      • Orhan E.
      • Yildiz S.
      The effects of pre-intervention training provided through therapeutic play on the anxiety of pediatric oncology patients during peripheral catheterization.
      ,
      • Ullán A.M.
      • Belver M.H.
      • Fernández E.
      • Lorente F.
      • Badía M.
      • Fernández B.
      The effect of a program to promote play to reduce children's post-surgical pain: With plush toys, it hurts less.
      and the negative emotions related to hospitalization
      • Li W.H.C.
      • Chung J.O.K.
      • Ho K.Y.
      • Kwok B.M.C.
      Play interventions to reduce anxiety and negative emotions in hospitalized children.
      and increases the feeling of control, making it easier for children to cope with the situation.
      • Koukourikos K.
      • Tzeha L.
      • Pantelidou P.
      • Tsaloglidou A.
      The importance of play during hospitalization of children.
      ,
      • Stewart M.W.
      Therapeutic play intervention.
      Moreover, a study found that TP for children was related to positive behaviors and instilled trust by increasing cooperation
      • Artilheiro A.P.S.
      • De Amorim Almeida F.
      • Chacon J.M.F.
      Use of therapeutic play in preparing preschool children for outpatient chemotherapy.
      so that the children's fears decreased. Children who undergo major operations and medical procedures have very high anxiety levels. Furthermore, painful interventions are a negative experience for children. Fear levels therefore also increase during other nonpainful interventions.
      This study was conducted to determine the effects of a TP/PT program on anxiety levels and fear of medical procedures in children with liver transplantation.

      Methods

      Design and Sample

      This quasi-experimental study was implemented in one group and a pretest–posttest design. The study sample comprises children who had already undergone transplantation and were hospitalized in the Pediatric Organ Transplantation Service of a university research hospital between February 2017 and March 2018. The inclusion criteria were as follows: aged 6 to 12 years; who have had the liver transplant and on the second postoperative day; whose general condition is stable; did not have a systemic disease that had caused developmental impairment; and did not have learning disabilities or attention-deficit disorder. Those children who met the inclusion criteria and volunteered to participate were included in the study. The exclusion criteria were as follows: children who were reluctant to play and who had developmental impairment.
      A power analysis was performed using the G∗Power (Version 3.1.9.2; Franz Faul, Universität Kiel, Germany) software program to determine the sample size. The power analysis showed a required sample size of 72 participants with a representation power of 95% at a 0.80 effect size and a 0.05 significance level. Of the initial 72 children in the study sample, four did not agree to participate in the study, and three children who had developmental impairment were excluded. Accordingly, 65 children participated in the study.

      Ethical Considerations

      Ethical approval (number 2017/23-2) was obtained from the IU Scientific Research and Publication Ethics Committee. Institutional approval was also obtained from the hospital where the study was conducted. The information about the participants was collected for academic purposes and not shared with third parties. Written consent was obtained from the voluntary participants (both the children and their parents) after they were given information about the aim of the study and its length. The study consent forms were completed by the children and their parents in the preoperative period after they had had the opportunity to ask questions about the study. The data were stored in a locked cabinet in an office to maintain confidentiality. No honoraria were distributed among the participants or the researcher.

      Data Collection

      A children's information form, the State-Trait Anxiety Inventory for Children (STAIC), and the Medical Procedure Fear Scale were used for data collection. The data were collected by the research assistants in an average of 60 minutes per participant.

      Children's Information Form

      The children's information form consisted of questions regarding the characteristics of the children. This form comprises five questions that addressed the child's age and gender, the existence of any health problems and their nature, the degree of closeness of the patient with the donor (eg, mother, father, foreigner), and any complications experienced.

      State-Trait Anxiety Inventory for Children

      The STAIC was developed by Spielberger and Edwards in 1973 and translated into Turkish by Özusta, who also performed a validity and reliability test, in 1995. Chieng et al confirmed the validity and reliability of STAIC for the age group 6 to 14 years (Cronbach alpha = 0.88). The scale consists of 20 questions, with three possible answers for each question (almost never, sometimes, and often). High scores on the scale indicate high levels of anxiety, whereas low scores suggest low levels of anxiety.
      • Coşkuntürk A.E.
      • Gözen D.
      The effect of interactive therapeutic play education program on anxiety levels of children undergoing cardiac surgery and their mothers.
      ,
      • Özusta Ş.
      State-trait anxiety inventory for children: A study of reliability and validity.

      Medical Procedure Fear Scale

      Developed in 1985, the Medical Procedure Fear Scale measures children's fear levels about medical procedures and applications.
      • Broome M.E.
      • Hellier A.P.
      School-age children's fears of medical experiences.
      The scale consists of 29 questions and 4 subscales. The fear levels of children for procedures, such as needle, body temperature measurement, and drinking drugs, are evaluated with a nine-question operational subscale. The level of fear for going to the hospital and lying the examination table is evaluated with a six-item environmental subscale. A four-question personal subscale is used to identify some personal fears, such as vomiting and fear of being hurt. A nine-question interpersonal subscale is used to identify intrapersonal fears, such as communication with nurses and doctors. There are three different answers and scores in the scale for each question: I am not afraid = 1; I am a little afraid = 2; and I am very afraid = 3. The scores that can be obtained from the scale vary between 29 and 87. High scores on the scale indicate high levels of medical fear. The lowest score that can be attained is 29, whereas the maximum score on the scale is 87. A validity and reliability study of the scale was conducted by Alak.
      • Alak V.
      Fears of 7–14 age group children who are hospitalized for surgery and nursing practices.
      The Cronbach alpha for the present study was found to be 0.89, indicating good reliability.

      Procedure

      The study was conducted in two stages. The children's medical procedure fear and STAIC levels were determined in the first stage using the pretest, and the TP/PT program was conducted after the pretest. In the second stage, which commenced 1 day after the TP/PT program, the children's fear and STAIC levels about medical procedures were determined. The TP/PT program was applied in two stages by the researcher.

      TP/PT Program

      In line with the literature,
      • Li W.H.C.
      • Chung J.O.K.
      • Ho K.Y.
      • Kwok B.M.C.
      Play interventions to reduce anxiety and negative emotions in hospitalized children.
      ,
      • He H.-G.
      • Zhu L.
      • Chan S.W.-C.
      • et al.
      Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: A randomized controlled trial.
      • Stulmaker H.L.
      • Ray D.C.
      Child-centered play therapy with young children who are anxious: A controlled trial.
      • Mohan S.
      • Nayak R.
      • Thomas R.J.
      • Ravindran V.
      The effect of Entonox, play therapy and a combination on pain relief in children: A randomized controlled trial.
      the TP/PT program was prepared by a researcher who had both TP and PT certification and sent to four reputable academic professionals for their opinions. Two experts were experienced in pediatric health disease nursing, whereas the other two worked in the pediatric development department. Necessary revisions were made in line with their opinions. The study was applied after the program was revised into its final form. The certified researcher whose profession is nursing conducted the program and played with the children. It can be applied by all nurses working in pediatric transplantation clinics without the need for a certificate or a special training.
      The following processes were completed with the children who participated in the study:

      Stage 1

      The children's medical procedure fear and STAIC levels were determined using the pretest. First, the researchers asked the children their opinions about the medical procedures they had experienced. Because the Medical Procedure Fear Scale was composed of questions to determine children's fear causes, the scale revealed the fear causes of children. The reasons the children gave for their fear (eg, fear of intravenous and intramuscular injections, catheterization fear, health care provider fear) were recorded to plan the play that would be appropriate for the children. Some of the questions of the scale were as follows: I am afraid of a needle; I am afraid of bleeding from my finger; I am afraid of going to the hospital; I am afraid to lie on the examination table; I am afraid of being hurt (injured); I am afraid that the doctor will not explain what to do to me; and I am afraid of not going to school when I am ill.

      Stage 2

      Individualized play relating to each child's specific fear and anxiety levels was provided to the child. TP was developed within the framework of dramatic play with the active participation of the children. The TP was started with preparation play that children were made to start the play with a toy chosen by them among the toys suitable for their ages. Children were made to play with toys, such as baby dolls and plastic animal figures. Children engaged in activities, such as singing, puzzles, computer games, and watching videos. The play program was conducted using clinical materials, such as a branula (cannula) without a needle injector, cotton, a plaster serum set and prop, and a medical play doll. Children were allowed and oriented to make their own toys with clinical materials, such as fish figures using serum sets, and trucks, cars, babies using medicine boxes, cotton, or other clinical materials. The play program was completed within 40 to 45 minutes. The researcher then applied the posttest and completed the questionnaire.

      Data Analysis

      The data were analyzed using the SPSS 21.0 package program (IBM Corporation, Armonk, NY). The mean, SD, frequency, percentage distribution, and one-sample t test analysis methods were used to evaluate the data. A linear regression analysis was conducted to determine the anxiety level predictors. The mean anxiety score was used as the dependent variable, and the mean medical procedure fear score was used as the independent variable.
      The effect size of the study was determined as (Cohen d = 2.53) 0.78 (moderate) for the children's anxiety levels after the TP/PT intervention. The effect size of the medical procedure fear was calculated as (Cohen d = 2.85) 0.81 (high). A P-value less than .05 was considered statistically significant.

      Results

      Most participants (63.1%) were male, and 25% did not have any other health problems. Among the children, 17.5% had received organ transplantation from a cadaver, whereas 32.5% of the children's mothers, 15% of their fathers, and 27.5% of their relatives had donated their organs. Almost all the children (97.5%) experienced complications after transplantation. The mean pretest and posttest STAIC-level scores were 49.1 ± 8.5 and 31.5 ± 4.9, respectively (Table 1). There was a significant decrease in the mean trait anxiety scores, and this difference was statistically significant (P = .001).
      Table 1Comparison of STAIC Pretest and Posttest Mean Scores (N = 65)
      ScaleMean ± SDTest Value
      One-sample t test value.
      P
      PretestPosttest
      Total scores of STAIC49.1 ± 8.531.5 ± 4.917.172.001
      STAIC, State-Trait Anxiety Inventory for Children.
      P < .05.
      One-sample t test value.
      The mean pretest and posttest fear scale scores were 69.7 ± 13.5 and 38.9 ± 7.1, respectively (Table 2). The mean posttest score decreased after the program, and this change was statistically significant (P = .001).
      Table 2Comparison of Medical Procedure Fear Level Pretest and Posttest Mean Scores (N = 65)
      SubscalesMean ± SDTest Value
      One-sample t test value.
      P
      PretestPosttest
      Operational21.5 ± 5.011.2 ± 2.214.600.001
      Environmental16.9 ± 3.010.4 ± 2.214.034.001
      Personal9.5 ± 1.95.0 ± 1.214.279.001
      Interpersonal21.9 ± 4.812.3 ± 3.211.190.001
      Total of Medical Procedure Fear Scale (score range, 29-87)69.7 ± 13.538.9 ± 7.114.560.001
      P < .05.
      One-sample t test value.
      The results of the linear regression analysis showed that pretest medical fear levels were a significant predictor of pretest anxiety levels (R = 0.727; R2 = 0.528; P = .000). The regression analysis found that posttest medical fear levels were not a predictor of posttest anxiety levels (R = 0.098; R2 = 0.010; P = .439; Table 3).
      Table 3Linear Regression Analyses for Preanxiety and Postanxiety Levels of Children (N = 65)
      BSEβTest ValueP
      Pretest
       Constant17.0633.8854.392.000
       Medical procedure fear level0.4600.0550.7278.402.000
      R = 0.727; F = 70.593; R2 = 0.528; P = .000
      Posttest
       Constant34.0743.36810.116.000
       Medical procedure fear level−0.066.085−0.098−0.779.439
      R = 0.098; F = 0.607; R2 = 0.010; P = .439
      B, unstandardized coefficient of regression; SE, standard error; β, standardized coefficient of regression; R2, coefficient of determination.

      Discussion

      The present study analyzed the effects of a TP/PT program on children's anxiety and fear levels regarding medical procedures and found that the anxiety and medical procedure fear levels of children who had undergone liver transplantation may be decreased after the TP/PT program. Liver transplantation causes many complications, including acute or chronic organ rejection and infection because of immunosuppressive treatment post-transplantation.
      • Cuenca A.G.
      • Kim H.B.
      • Vakili K.
      Pediatric liver transplantation.
      In this study, almost all the children (97.5%) experienced complications after transplantation.
      The medical environment has iatrogenic sides that cause children to experience fear. Injections, blood, and being touched by strangers are among the factors that cause these fears.
      • Mahat G.
      • Scoloveno M.A.
      • Cannella B.
      Comparison of children's fears of medical experiences across two cultures.
      The pretest measurement in this study showed that the children's fear of medical procedures was quite high (69.7 ± 13.5). Maraşuna and Eroğlu determined that the fear of medical procedures among the secondary school students in their study was 42.14 ± 9.73. In our study, the children's sense of fear was at critical levels because the children were facing major surgical interventions, they had been hospitalized, and painful and frequent interventions were being applied for diagnosis and treatment.
      Medical interventions are painful and distressful for children,
      • Uman L.S.
      • Birnie K.A.
      • Noel M.
      • et al.
      Psychological interventions for needle-related procedural pain and distress in children and adolescents.
      and a fear of medical procedures negatively affects participation in the treatment process.
      • Maraşuna A.O.
      • Eroğlu K.
      The fears of high school children from medical procedures and affecting factors.
      In our study, the children's medical procedure fear levels were quite high; however, there was a significant decrease in the mean scores after the application of the TP/PT program (Table 2). Similarly, a study by Büyük and Bolışık
      • Büyük E.T.
      • Bolışık B.
      The effect of preoperative training and therapeutic play on children's anxiety, fear, and pain.
      conducted with 300 children found a significant decrease in children's medical procedure fears compared with the control group after education and training had been conducted and TP groups had been held. In their systematic compilation, Uman et al
      • Uman L.S.
      • Birnie K.A.
      • Noel M.
      • et al.
      Psychological interventions for needle-related procedural pain and distress in children and adolescents.
      noted that psychological interventions, such as attention distraction, hypnosis, and coping skills training, could decrease the fear experienced by children and adolescents during medical procedures.
      • Uman L.S.
      • Birnie K.A.
      • Noel M.
      • et al.
      Psychological interventions for needle-related procedural pain and distress in children and adolescents.
      Unlike in previous studies, we determined the reasons for the children's fear. The TP was structured based on the reasons for the children's fears, and a structured TP/PT program was applied and found to be effective.
      A study by Karayurt et al
      • Karayurt Ö.
      • Ordin Y.S.
      • Ünek T.
      • Astarcıoğlu İ.
      Immunosuppressive medication adherence, therapeutic adherence, school performance, symptom experience, and depression levels in patients having undergone a liver transplant during childhood.
      found that the most common symptoms experienced by children aged 0 to 18 years who had undergone liver transplantation were anxiety, nervousness, fatigue, and difficulties with concentration. The pretest anxiety levels of the children in our study were determined to be very high. A high level of anxiety is serious because it complicates adherence to medical treatment after transplantation. It is therefore necessary to approach young patients with interventions that decrease their anxiety. These interventions require an integrated care approach.
      TP with toys in hospital and educating parents on how to prepare children for hospitalization can decrease negative reactions to hospitalization.
      • Nabors L.
      • Kıchler J.
      Play therapy with children experiencing medical illness and trauma.
      There was a significant decrease in the mean STAIC score after our TP/PT program had been completed, and the difference in the pretest and posttest scores was statistically significant (P = .001; Table 1). Although we did not find any studies on the application of TP for children who had undergone organ transplantation or were going to have organ transplantation, there were many studies in which TP had been applied and its efficacy assessed. Coşkuntürk and Gözen
      • Coşkuntürk A.E.
      • Gözen D.
      The effect of interactive therapeutic play education program on anxiety levels of children undergoing cardiac surgery and their mothers.
      stated that interactive TP programs applied to children aged 6 to 12 years who were facing surgery because of congenital heart disease were effective in decreasing the postoperative anxiety of the children and their mothers. In their study, Yayan et al
      • Yayan E.H.
      • Zengin M.
      • Düken M.E.
      • Suna Dağ Y.
      Reducing children's pain and parents' anxiety in the postoperative period: A therapeutic model in Turkish sample.
      determined that their TP/PT program reduced children's pain after surgery. In the same study, the pain level of children was found to be related to the level of parental anxiety, and it was found that the anxiety level of the parents decreased after the program.
      • Yayan E.H.
      • Zengin M.
      • Düken M.E.
      • Suna Dağ Y.
      Reducing children's pain and parents' anxiety in the postoperative period: A therapeutic model in Turkish sample.
      In another study, TP was applied to pediatric oncology patients during peripheral catheterization, and the application of TP before catheterization decreased the children's anxiety and pain.
      • Orhan E.
      • Yildiz S.
      The effects of pre-intervention training provided through therapeutic play on the anxiety of pediatric oncology patients during peripheral catheterization.
      Previous studies have also shown that TP is effective
      • Mohammadi A.
      • Mehraban A.
      • Damavandi S.
      Effect of play-based occupational therapy on symptoms of hospitalized children with cancer: A single-subject study.
      in decreasing children's fear, anxiety, and negative thoughts.
      • Büyük E.T.
      • Bolışık B.
      The effect of preoperative training and therapeutic play on children's anxiety, fear, and pain.
      ,
      • Li W.H.C.
      • Chung J.O.K.
      • Ho K.Y.
      • Kwok B.M.C.
      Play interventions to reduce anxiety and negative emotions in hospitalized children.
      ,
      • He H.-G.
      • Zhu L.
      • Chan S.W.-C.
      • et al.
      Therapeutic play intervention on children's perioperative anxiety, negative emotional manifestation and postoperative pain: A randomized controlled trial.
      ,
      • He H.G.
      • Zhu L.
      • Chan S.W.C.
      • Klainin-Yobas P.
      • Wang W.
      The effectiveness of therapeutic play intervention in reducing perioperative anxiety, negative behaviors, and postoperative pain in children undergoing elective surgery: A systematic review.
      In the present study, it was determined that the children's pretest medical fear levels were significant predictors of their pretest anxiety levels, but their posttest medical fear levels were not a predictor of their posttest anxiety levels. As a result of the regression analysis, it can be said that the level of fear of medical procedure in children is the most important predictor of pretest anxiety. Children's medical procedure fear level explains 50% of anxiety (Table 3). In our study, anxiety was reduced by interfering with the most important predictor of anxiety. TP/PT programs are thus effective in reducing fear and anxiety in children facing liver transplant in which various medical procedures are performed.

      Implications for Practice

      Nurses play a key role in health care. It is critically important to evaluate patients holistically and to apply holistic nursing care in this direction. Particularly in pediatric clinics, decreasing children's fear and anxiety is the first stage in holistic nursing care because children experience high anxiety when hospitalized. It is critical to ameliorate this situation as it can significantly negatively affect the recovery process of many children. The application of therapeutic play is therefore an appropriate and effective method for pediatric nurses to apply in practice.
      A traumatic experience can result in fear, and the transplantation process is a period during which intensely painful medical interventions are undertaken. This may be the reason for the increased medical fear levels of children undergoing organ transplantation. To this end, it was determined that therapeutic play program applied after liver transplantation can decrease trauma in children who have had transplantation surgery.

      Limitations

      Fear and anxiety impose significant limitations on a study because of their cultural characteristics; however, sociocultural characteristics were not considered in the sample selection for this study. This is the major limitation of this study.

      Conclusions

      The TP/PT program applied to the children with liver transplant in this study was effective in reducing their anxiety and fear of medical procedures. It is recommended that a structured TP/PT program be used as a nonpharmacologic method to decrease children's fear of medical procedures, particularly among children who must undergo multiple medical procedures. Nevertheless, it must be emphasized that TP must be individualized because the reason for the fear can be different for each child.
      In this study, TP was applied to children after liver transplant, which is a specific group, and its effect on fear and anxiety levels was revealed. Considering that similar procedures are followed in other types of transplantation, it may be suggested to use the TP in reducing anxiety and fear in children after transplantation, but this situation should be based on evidence with further studies.

      Acknowledgments

      The authors thank the children who underwent liver transplantation and their parents for their kind participation in this study.

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