Author: Jessika Boles, PhD, CCLS
Pediatr Nurs. 2016;42(3):147-149.
On average, more than 4 million children undergo anesthesia for surgery or procedures each year in the United States, a number that has likely continued to grow in the past decade (Kain & Caldwell-Andrews, 2005). Anesthesia can be a complicated and confusing concept for school-age children and younger because it is abstract in nature – one cannot see, hear, feel, or experience for themselves what it is like to be anesthetized. This is contrary to its purpose in the first place! Instead, children must gather information and draw conclusions about anesthesia and procedures based on the information provided by family members and medical providers, ideally prior to the procedure in question. Moreover, it requires a certain level of trust to believe that one is safe in the hands of strangers in an unfamiliar environment – and it can be especially frightening when one is a child and those strangers are medical staff.
For reasons like these, anesthesia is one of the most stressful medical procedures children can experience, and 40% to 60% of children will display significant emotional and behavioral stress prior to surgery (Kain, Caldwell-Andrews, & Wang, 2002). Fifty percent of children will report a high level of anxiety during the induction of anesthesia (Davidson et al., 2006), which some researchers have argued is the single most stressful medical event that children can experience (Perry, Hooper, & Masiongale, 2014). For 16% of children, this increased anxiety level may continue as long as 30 days after the completion of the procedure (Stargatt et al., 2006). More specifically, when asked about receiving anesthesia for a day surgery procedure, children have invoked themes such as “enduring inflicted hospital distress,” “facing an unknown reality,” and oscillating between “losing control” and “trying to gain control” to describe their experiences (Weenstrom, Hallberg, & Bergh, 2008, p. 100).
Parents likewise demonstrate high levels of anxiety prior to surgery and at anesthesia induction, especially when the child will require an inpatient stay or will need high levels of care from the parent prior to and after the procedure (Li, Lopez, & Lee, 2006). Given the connections documented between parental and child stress in health care settings, it is important to consider ways to support both parents and children facing invasive medical procedures and anesthesia (Fortier et al., 2015). When parents are able to better manage their own stress, the child is more likely to demonstrate decreased anxiety in the context of procedures like day surgery, and parents are also more likely to be compliant with care responsibilities (Chahal et al., 2009).
The anxiety that parents and children experience when approaching a surgery or procedure has been consistently observed for many years; health care providers have been developing and evaluating preparation programs for children and families for just as long, with the goal of promoting more effective coping with these encounters. Drawing upon Lazarus and Folkman’s (1984) theory of stress and coping, proponents of preparation argued that if individuals are able to more accurately judge the demands of an experience and make a cognitive appraisal about their abilities to cope with it, more successful coping is likely. Therefore, by providing preparatory information to help children and families know what to expect during a hospitalization or surgery, the hypothesis was that preparation would reduce fears about the unknown while helping children and families to make accurate appraisals about the stressors they may encounter and employ appropriate coping mechanisms to manage them.
Ever since these preparation programs first emerged, the research literature has consistently documented their positive impacts on patient and family coping. Findings from some of the most widely known studies, such as Wolfer and Visintainer (1975), Melamed and Siegel (1975), and Petrillo (1972), emphasize the following key elements of effective preparation programs (Stanford & Thompson, 1981):
Conveying information to the child in a developmentally appropriate manner.
Encouraging the expression of feelings about the information or event.
Including the participation of parents or other significant family members.
Establishing a trusting therapeutic relationship with staff members.
More recently, preparation interventions and programs have continued to focus on parental empowerment and involvement (Bailey, Bird, McGrath, & Chorney, 2015), family-centered preparation for surgery (Fincher, Shaw, & Ramelet, 2012), encouraging the child to learn about the procedure and express his or her concerns through play (Cuzzocrea et al., 2013), and conveying information in ageappropriate ways through developmentally supportive staff members (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006; Li, Chan, Wong, & Lee, 2014).
Some newer studies have investigated the use of novel means for providing age-appropriate preparatory information about procedures, such as through board games (Fernandes, Arriaga, & Esteves, 2014) or interactive puppet shows (Cuzzocrea et al., 2013). Interestingly, even these more creative manners of delivering preparatory information have shown to similarly reduce children’s anxiety related to procedures and anesthesia induction. In keeping with the evolution of technology platforms, other programs such as WebTIPS have been created to provide child-and parent-centered preparation through online modules that can be completed at home at the family’s convenience (Kain, Fortier, Chorney, & Mayes, 2015). When evaluated, parents reported satisfaction with the online program, and both parents and children were less anxious during anesthesia induction when compared with children and families who did not receive the WebTIPS intervention.
At the same time, preparation can just as easily be provided in a clinic room, waiting room, playroom, or other encounter when online programs or specialty materials are not available. Child life specialists, nurses, or other care team members may be involved in providing preparation, or preparation may be led by parents, with support and resources given by the medical team. No matter when or by whom preparation is provided, the most important thing is that preparation is provided at all because preparation makes a positive impact on patient and family coping with anesthesia, surgery, and procedures (MacLaren & Kain, 2007).