|Year : 2017 | Volume
| Issue : 2 | Page : 208-214
Impact of multimodal preoperative preparation program on children undergoing surgery
Priya Reshma Aranha1, Larissa Martha Sams2, Prakash Saldanha3
1 Department of Child Health Nursing, Yenepoya Nursing College, Mangaluru, Karnataka, India
2 Department of Medical Surgical Nursing, Laxmi Memorial College of Nursing, Mangaluru, Karnataka, India
3 Department of Paediatrics, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||15-Dec-2017|
Priya Reshma Aranha
Department of Child Health Nursing, Yenepoya Nursing College, Yenepoya University, Mangalore - 575018, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The advanced era of technological development in child health care has resulted in more pediatric procedures being performed in various settings. Millions of children undergo surgery every year which is a stressful event. Many nonpharmacological strategies are being used to manage the preoperative fear and anxiety in children. The current study aims to assess the effectiveness of multimodal preoperative preparation program (MPPP) on children undergoing surgery in terms of its effect on the psychophysiological parameters. Objective: The aim of this study is to assess the effectiveness of MPPP on the psychophysiological parameters of children undergoing surgery. Materials and Methods: A quasi-experimental study was conducted in a selected multi-specialty hospital. Using the purposive sampling technique, a total of 110 children aged 8–12 years were assigned to nonintervention (n = 55) and intervention (n = 55) groups, respectively. The MPPP was administered to the intervention group. The children in the nonintervention group received the routine preoperative care. Child's fear and anxiety was assessed on admission, prior to shifting the child to operation theater (OT), 24 and 48 h after surgery, whereas child's pulse, respiration, blood pressure (BP), and oxygen saturation was assessed on admission, prior to shifting the child to OT, 6, 12, 24, and 48 h after surgery and pain was assessed at 24 and 48 h after surgery. Results: The mean fear and anxiety scores of children were significantly lower in the intervention group than that of nonintervention group (P < 0.05). Among the physiological parameters, only pulse, respiration, and BP showed significant difference (P < 0.05) between the groups, whereas oxygen saturation and pain scores did not differ significantly (P > 0.05). This study also found that there is a significant association between the psychophysiological parameters of children with the selected demographic variables (P < 0.05). A positive correlation was found between the psychological and physiological parameters of children undergoing surgery. Conclusion: The MPPP is effective on psychophysiological parameters of children undergoing surgery in terms of decreasing the fear and anxiety, stabilizing the physiological parameters of children and can be used in preparing school-aged children for surgery and can be practiced in the clinical setup.
Keywords: Anxiety, children, fear, multimodal preoperative preparation program, physiological parameters
|How to cite this article:|
Aranha PR, Sams LM, Saldanha P. Impact of multimodal preoperative preparation program on children undergoing surgery. Arch Med Health Sci 2017;5:208-14
|How to cite this URL:|
Aranha PR, Sams LM, Saldanha P. Impact of multimodal preoperative preparation program on children undergoing surgery. Arch Med Health Sci [serial online] 2017 [cited 2018 Sep 22];5:208-14. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/208/220839
| Introduction|| |
Technological advancement and changes in health care in the modern era have increased the number of pediatric procedures being performed in variety of settings. One of these procedures is surgery, which becomes a stressful event in the life of a child. When a child undergoes a surgery, it often becomes a very significant and memorable event in the life of the entire family. Unlike other significant events in the child's life, it has an element of threat and fear of the unknown can be overwhelming.
The child may experience tension, apprehension, nervousness, and worry toward the upcoming surgery along with fear of separation from parents and home environment, loss of control, unfamiliar routines, surgical instruments, and hospital procedures. Preoperative anxiety is a distressing feeling that results in adverse physiological and psychological reaction in children. With high level of anxiety, they may exhibit signs of delirium and postprocedure maladaptive behavior. They may have more postprocedural pain and require additional pain control medications.
It has been seen that 75% of children undergoing surgery experience anxiety. Physiological changes such as elevated pulse rate and blood pressure (BP) are also anticipated when there is high level of preoperative anxiety.,
Many strategies have been tried to help children cope with the upcoming surgery and despite these strategies, some children still become distressed during the procedure. Hence, it is important to identify factors that may influence children's responses to painful medical procedures. Preparing children for surgery should be based on their age and developmental status. Therefore, it is essential to plan an individualized preoperative preparation program for children.
It is estimated that approximately 50%–70% of children undergoing surgery experience severe anxiety and distress prior to surgery. A study identified five dimensions of the surgical experience that can evoke anxiety in children-physical harm or bodily injury in the form of pain, mutilation or even death, separation from parents and absence of trusted adults, fear of the unknown and unfamiliar, uncertainty about “acceptable” and normative behavior in a hospital setting and loss of control, autonomy, and competence.
According to different research studies, severe preoperative fear affects 40%–60% of young children. Around 40%–60% of pediatric patients experience preoperative anxiety which is associated with maladaptive behavior lasting for many weeks after surgery.
It has been seen that developmentally appropriate presurgical educational programs, preoperative visits, humor, and distraction  are effective in relieving preoperative anxiety in children and their parents. Studies have also shown that adequate parental preparation alone may minimize the anxiety in children.
Preoperative preparation of children should be based on their age and developmental stages  and performing surgical procedures in children requires both physical and mental preparation which should include the use of videos, training manuals, brochures, tours, and playing.
Studies have also showed that providing children with information about the hospital stay using films, computer presentations and animations, role-playing with the clown physician, and special books  telling stories or reading books by nurses  may help children in dealing with anxiety. Literature reveals various preoperative preparations for children, which includes role rehearsals with dolls,,,, puppet shows,, the teaching of coping and relaxation skills, orientation tours of the operating room,, as well as educational videos  and books , are effective in preparing children for surgery.
The researcher in her day-to-day practice has seen that despite routine preoperative preparation, nothing much is done to alleviate children's fears and anxiety. The routine preoperative preparation of children includes only verbal instructions given by doctors and nurses. There is a need for developing a preoperative preparation program customized to the needs of children. Therefore, to prepare the school-aged children for surgery, the researcher has developed a multimodal preoperative preparation program (MPPP) based on the needs of school-age children. It is an individualized preoperative preparation program for a child undergoing surgery and the accompanying parent. It includes a combination of audio-visual aids and real-life experience. It was prepared based on the needs and developmental concerns. The program is both for the child and parent and it aims to increase their confidence and bonding.
This study aims to assess the effectiveness of MPPP on children undergoing surgery, in terms of its effect on the psychophysiological parameters, that is, to reduce the fear and anxiety, stabilize physiological parameters, and decrease postoperative pain.
| Materials And Methods|| |
A quasi-experimental study with nonequivalent control group design was conducted in a selected multi-specialty hospital with an exclusive pediatric surgical unit at Mangalore, India. Ethical approval was obtained from the Institutional Ethics Committee. The study population comprised children aged 8–12 years undergoing elective surgery. Following the informed consent process, purposive sampling technique was used to select 110 children and was assigned to nonintervention (n = 55) and intervention (n = 55) groups, respectively.
The intervention in the study was the MPPP, was administered by the researcher to the children in the intervention group. It included audio-visual instructions along with the real-life situations provided to the child and parent, that is, an information video, pamphlet and interactive sessions for children and their parents, medical play and theater tour for children. It includes audio-visual material that may help the child and parent get the information they needed in a more realistic manner. Along with the audio-visual material, the interactive sessions will be more useful as the parent, and the child can interact with the researcher and clear their doubts. Children were oriented to the theater and provided with medical play which is a real-life experience for them and will be helpful to reduce the preoperative fear and anxiety. The children in the nonintervention group received the routine preoperative preparation provided by the hospital staff after admission to the hospital.
The researcher collected data using the reliable tools. The demographic pro forma was used to collect the sociodemographic data of children. Child's fear (measured using children's fear scale) and anxiety (measured using numerical 0–10 state anxiety scale) were assessed on admission, prior to shifting the child to operation theater (OT), 24 and 48 h after surgery whereas child's pulse and BP (measured using Omron digital BP monitor), respiration and oxygen saturation (measured using Nidex fingertip pulse oximeter) were assessed on admission, prior to shifting the child to OT, 6, 12, 24, and 48 h after surgery and pain (measured using Faces Pain Scale-Revised) was assessed at 24 and 48 h after surgery.
| Results|| |
The majority (67.3%) of children in the intervention group was in the age group 10–12 years and majority (63.6%) in the nonintervention group was in the age group of 8–10 years. The majority (59%) of the study sample were males. The majority (65.5% in nonintervention and 76.4% of intervention group) of children underwent general surgery. The majority (52.7% in nonintervention group and 69.1% in intervention group) of children was admitted only 1 day prior to surgery and majority (87.3%) had not been hospitalized earlier.
The comparison of fear [Table 1] and anxiety [Table 2] scores of children within the groups is done by Friedman test which showed the difference in the scores is statistically significant (P < 0.001). Further pair-wise comparison by Wilcoxon signed rank test showed that in both the groups, reduction of fear as well as anxiety scores were significant prior to shifting to OT and subsequently it showed the significant reduction at 24 h after surgery and 48 h after surgery (P < 0.001). To find the difference in the fear scores as well as the anxiety scores between the intervention and nonintervention groups, Mann–Whitney's test was computed. It showed that there is a significant difference in the mean scores of both fear and anxiety between intervention and nonintervention groups at prior to shifting (P < 0.001), at 24 h after surgery (P < 0.001), and also at 48 h after surgery (P < 0.001). The change was significantly higher in intervention group compared to nonintervention groups at all the time points.
|Table 1: Comparison of fear scores of children within intervention and nonintervention groups at different time intervals (n=55+55)|
Click here to view
|Table 2: Comparison of anxiety scores of children within intervention and nonintervention groups at different time intervals (n=55+55)|
Click here to view
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] depict the comparison of physiological parameters of children between the groups. It was observed that, at every time point reduction in the mean pulse, respiration, BP, and oxygen saturation scores in both intervention and nonintervention groups is minimal. However, the computed ANOVA test showed that reduction was statistically significant within the intervention (pulse: F(5,270)= 23.18, P < 0.001; respiration: F(5,270)= 11.44, P < 0.001; systolic BP: F(5,270)= 25.04, P < 0.001; diastolic BP: F(5,270)= 17.48, P < 0.001; oxygen saturation: F(5,270)= 17.60, P < 0.001) and nonintervention (pulse: F(5,270)= 24.84, P < 0.001; respiration: F(5,270)= 28.93, P < 0.001; systolic BP: F(5,270)= 7.53, P < 0.001; diastolic BP: F(5,270)= 3.60, P < 0.01; oxygen saturation: F(5,270)= 10.92, P < 0.01) groups. Further, post hoc analysis is done using Bonferroni test to compare the effect between different times of observation. The Bonferroni test showed significant changes (P < 0.05) in mean difference over different time points in both the groups in most of the times for all the physiological parameters.
|Figure 1: Comparison of pulse scores of children between the groups at different time points|
Click here to view
|Figure 2: Comparison of respiration scores of children between the groups at different time points|
Click here to view
|Figure 3: Comparison of systolic scores of children between the groups at different time points|
Click here to view
|Figure 4: Comparison of diastolic scores of children between the groups at different time points|
Click here to view
|Figure 5: Comparison of oxygen saturation scores of children between the groups at different time points|
Click here to view
To find the difference in the scores of physiological parameters between the two groups, t-test was computed. It was seen that there is a significant difference in the mean change pre- and posttests scores of pulse, respiration, and systolic as well as BP of children between intervention and nonintervention groups at different point of time (P < 0.05) but not in oxygen saturation scores.
This study also revealed that [Table 3] the mean difference in pain scores of children between 24 and 48 h of surgery is more in the intervention than that of nonintervention group. However, Wilcoxon signed rank test Z value shows that in both the groups, the mean difference is statistically significant (P < 0.001). When compared the scores between the groups [Table 4], computed Mann–Whitney's Z value was not statistically significant (Z = 1.032, P > 0.05).
|Table 3: Pair-wise comparison of pain scores at different time points within the groups (n=55+55)|
Click here to view
|Table 4: Comparison of pain scores of children at different time points between the groups (n=55+55)|
Click here to view
This study findings also revealed that there is a significant association between the age and anxiety of children (χ2 = 9.73; P < 0.05), anxiety and type of surgery underwent (χ2 = 9.57; P < 0.05), pulse and type of surgery (χ2 = 23.10; P < 0.05), systolic BP and duration of admission prior to surgery (χ2 = 29.57; P < 0.05), diastolic BP and type of surgery (χ2 = 83.33; P < 0.001), diastolic BP and duration of admission prior to surgery (χ2 = 35.25; P < 0.05).
This study also found that there is a statistically significant positive correlation between the psychological and physiological parameters of children undergoing surgery (P < 0.05).
| Discussion|| |
The present study showed that MPPP is effective in reducing the preoperative fear and anxiety of children (P < 0.05). This finding is consistent with the previous research studies which proved that children prepared for surgery were less anxious  and preoperative anxiety was less in children who were prepared psychologically. At the same time, hospital tours, play therapy, information videos, surgical brochures, preoperative cognitive behavioral program, preoperative education programs, viewing animated cartoons and phone interviews, and therapeutic play intervention  were also proved effective in reducing preoperative anxiety of children. Moreover, even if it was not studied here, the reduction in anxiety has positive impact on postoperative recovery and it was seen that children who were prepared for surgery had a speedy recovery and fewer emotional problems than those who were not prepared.
The present study evaluated that MPPP of children is effective in stabilizing pulse, respiration, and BP (P < 0.05). It was studied earlier that children who had an influence of adult behavior had significantly lower mean value for pulse rate and BP during invasive procedure. However, with regard to the mean pulse score, the current study findings contradict with a study  where although the mean scores of physiological parameters in the experimental group were less than that of control group, the pulse score did not achieve the statistical significance, but there was a significant difference found in the mean BP scores between the experimental and control groups.
There was a significant association between the psychophysiological parameters of children and selected demographic variables (P < 0.05). This finding is consistent with the studies which showed that child's anxiety was associated with age of the child, age and socioeconomic status influence the occurrence of preoperative anxiety. The current study found that psychological and physiological parameters of children undergoing surgery were correlated. A previous study results also showed that the anxiety, fear, and pain had an effect on hemodynamic, ventilator, and cardiovascular parameters during the extraction procedure. It was also seen that during all routine dental procedures, the pulse rate values increased intraoperatively from the preoperative baseline values and then decreased in the postoperative phase. Hence, it concluded that dental anxiety and fear may have an effect on the normal physiologic parameters during routine dental procedures.
Several implications for nursing education, nursing practice, nursing administration, and nursing research can be stated based on the findings of the study.
In the child health nursing curriculum, pre- and postoperative care of children is an important topic but the preoperative education programs used in preoperative preparation of children is given least importance. It is essential to help students to develop knowledge, skill, and attitude toward these programs and the nursing faculty can be oriented regarding the same. Students should be taught to assess preoperative fear and anxiety of children and their parents and also should be encouraged to develop and use various preoperative education programs during their clinical postings. Nurses working in the pediatric surgery units need to develop the practice of routine assessment of preoperative fear and anxiety and use preoperative preparation programs in preparing children and their parents for surgery. Other than providing routine information regarding surgery, no other special programs for preoperative preparation of children as a routine are available in the hospitals in India. But in abroad, such facilities are available in many of the hospitals. Therefore, nursing administrators in India should develop nursing practice standards, protocols, and manuals for the assessment of preoperative fear and anxiety of children and parents and incorporate various preoperative preparation programs for children and parents. Nursing administrators should make a policy for using preoperative education programs routinely. Administrators should ensure the availability of a variety of age-appropriate preoperative preparation programs for children and parents and provide training for nurses regarding this matter. Hospital authorities can also develop a customized preoperative preparation program exclusively for their hospital and involve the entire surgical team in the same. Preoperative anxiety is common among children undergoing surgery and their parents and various preoperative preparation programs have been developed and tested to see its effectiveness. Further research in this area will help nurses to find out other effective preoperative preparation programs to reduce the fear and anxiety of children and parents and also enhance parental satisfaction regarding preoperative preparation of children. Emphasis should be given to the utilization of research findings. Appropriate utilization of research helps nurses to make evidence-based decisions regarding care of the children. Nurses can develop customized preoperative preparation programs and test its effectiveness and use this evidence in providing nursing care to children and their parents.
The limitations of the study were – this study was conducted in a single study setting at a geographical area and MPPP is administered just 24 h prior to surgery.
| Conclusion|| |
Preparing children and parents for surgery is an essential responsibility of health-care professionals. The preoperative fear and anxiety can negatively affect the postoperative recovery of children, the preoperative preparation of children and parents should be tailor-made according to their level of understanding. When the children and parents received the MPPP, the knowledge gained regarding the pre-, intra-, and postoperative events, enabled them to prepare well for the upcoming surgery. Therefore, it is concluded that MPPP is effective and can be successively implemented in pediatric surgery units to prepare children and parents for the surgery.
The authors express sincere thanks to the administrators, doctors, nurses, and other hospital staff of Yenepoya Medical College Hospital, Mangalore, Karnataka, for all the support rendered during the study and the parents for being a part of the study.
Financial support and sponsorship
Yenepoya University, Mangalore, has partly funded this project.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chari P, Sen I. Perioperative concerns. Indian J Anaesth 2004;48:387-93. [Full text]
Wilson D, Hockenberry MJ. Nursing Care of Infants and Children. 8th
ed. New Delhi: Elsevier Private Limited; 2007.
Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as a treatment for preoperative anxiety in children: A randomized, prospective study. Pediatrics 2005;116:e563-7.
Shirley PJ, Thompson N, Kenward M, Johnston G. Parental anxiety before elective surgery in children. A British perspective. Anaesthesia 1998;53:956-9.
Debora DO, Guilherme C, Vinícius FZ, Schapira W, Lígia AD. Impact of preanesthetic information on anxiety of parents and children. Rev Bras Anestesiol 2013;63:473-82.
Rayen R, Muthu MS, Chandrasekhar Rao R, Sivakumar N. Evaluation of physiological and behavioral measures in relation to dental anxiety during sequential dental visits in children. Indian J Dent Res 2006;17:27-34.
] [Full text]
Kain A. Preoperative anxiety and post operative nausea and vomiting in children: Is there an association? Pediatr Anesth 2000;90:571-5.
Taylor C, Sellick K, Greenwood K. The influence of adult behaviors on child coping during venipuncture: A sequential analysis. Res Nurs Health 2011;34:116-31.
Kain ZN, Wang SM, Mayes LC, Krivutza DM, Teague BA. Sensory stimuli and anxiety in children undergoing surgery: A randomized, controlled trial. Anesth Analg 2001;92:897-903.
Visintainer MA, Wolfer JA. Psychological preparation for surgical pediatric patients: The effect on children's and parents' stress responses and adjustment. Pediatrics 1975;56:187-202.
Litke J, Pikulska A, Wegner T. Management of perioperative stress in children and parents. Part I – The preoperative period. Anaesthesiol Intensive Ther 2012;44:165-9.
Kain ZN, Mayes LC, O'Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996;150:1238-45.
Berger J, Wilson D, Potts L, Polivka B. Wacky Wednesday: Use of distraction through humor to reduce preoperative anxiety in children and their parents. J Perianesth Nurs 2014;29:285-91.
O'Shea M, Cummins A, Kelleher A. The perceived effectiveness of a pre-admission visit for children (and their parents) undergoing day surgery procedures. J Perioper Pract 2011;21:244-8.
Schwartz BH, Albino JE, Tedesco LA. Effects of psychological preparation on children hospitalized for dental operations. J Pediatr 1983;102:634-8.
Broome ME, Lillis PP, Smith MC. Pain interventions with children: A meta-analysis of research. Nurs Res 1989;38:154-8.
Cassady JF Jr., Wysocki TT, Miller KM, Cancel DD, Izenberg N. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999;88:246-50.
Rassin M, Gutman Y, Silner D. Developing a computer game to prepare children for surgery. AORN J 2004;80:1095-6, 1099-102.
Glazebrook CP, Lim E, Sheard CE, Standen PJ. Child temperament and reaction to induction of anaesthesia: Implications for maternal presence in the anaesthetic room. Psychol Health 1994;10:55-67.
Robinson S. Children's books: A resource for children's nursing care. Paediatr Nurs 2002;14:26-31.
Kain ZN, Caramico LA, Mayes LC, Genevro JL, Bornstein MH, Hofstadter MB, et al
. Preoperative preparation programs in children: A comparative examination. Anesth Analg 1998;87:1249-55.
Zahr LK. Therapeutic play for hospitalized preschoolers in Lebanon. Pediatr Nurs 1998;24:449-54.
Schulz JB, Raschke D, Dedrick C, Thompson M. The effects of a preoperational puppet show on anxiety levels of hospitalized children. Child Health Care 1981;9:118-21.
LaMontagne L, Hepworth JT, Salisbury MH, Cohen F. Effects of coping instruction in reducing young adolescents' pain after major spinal surgery. Orthop Nurs 2003;22:398-403.
LaMontagne LL, Hepworth JT, Cohen F, Salisbury MH. Cognitive-behavioral intervention effects on adolescents' anxiety and pain following spinal fusion surgery. Nurs Res 2003;52:183-90.
Durst LM. Preoperative teaching videotape. The effect on children's behavior. AORN J 1990;52:576-84.
Margolis JO, Ginsberg B, Dear GL, Ross AK, Goral JE, Bailey AG, et al
. Paediatric preoperative teaching: Effects at induction and postoperatively. Paediatr Anaesth 1998;8:17-23.
Felder-Puig R, Maksys A, Noestlinger C, Gadner H, Stark H, Pfluegler A, et al
. Using a children's book to prepare children and parents for elective ENT surgery: Results of a randomized clinical trial. Int J Pediatr Otorhinolaryngol 2003;67:35-41.
Hockenberry MJ, Wilson D. Wong's Nursing Care of Infants and Children. 8th
ed. St. Louis: Mosby Elsevier; 2007.
Peterson L, Shigetomi C. The use of coping techniques to minimize anxiety in hospitalized children. Behav Ther 2006;12:1-14.
Brewer S, Gleditsch SL, Syblik D, Tietjens ME, Vacik HW. Pediatric anxiety: Child life intervention in day surgery. J Pediatr Nurs 2006;21:13-22.
Karimi R, Fadaiy Z, Nikbakht Nasrabadi A, Godarzi Z, Mehran A. Effectiveness of orientation tour on children's anxiety before elective surgeries. Jpn J Nurs Sci 2014;11:10-5.
Lee J, Lee J, Lim H, Son JS, Lee JR, Kim DC, et al
. Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg 2012;115:1168-73.
Fernandes SC, Arriaga P, Esteves F. Providing preoperative information for children undergoing surgery: A randomized study testing different types of educational material to reduce children's preoperative worries. Health Educ Res 2014;29:1058-76.
Preethy D, Aparna B, Anice G, Renu G, Ashley D. Parental anxiety during children's surgery: The effect of preoperative cognitive behavioural programme. Int J Law Psychol Human Life 2013;2:1-7.
Hee HI, Lim EH, Tan QC, Bao ZY, Loh KW. Effect of preoperative education on behaviour of children during induction of anaesthesia: A randomised clinical trial of efficacy. Anaesth Intensive Care 2012;40:795-802.
McEwen A, Moorthy C, Quantock C, Rose H, Kavanagh R. The effect of videotaped preoperative information on parental anxiety during anesthesia induction for elective pediatric procedures. Paediatr Anaesth 2007;17:534-9.
Mamatha SP, Kumar V, Santhosh P, Sundeep PT. Effectiveness of hospital based intervention on parenting stress among mothers of pediatric surgery children in South India. Int J World Res 2014;1:25-34.
Cagiran E, Sergin D, Deniz MN, Tanattı B, Emiroglu N, Alper I, et al
. Effects of sociodemographic factors and maternal anxiety on preoperative anxiety in children. J Int Med Res 2014;42:572-80.
Hall A. Client education. In: Fundamentals of Nursing. St. Louis, MO: Elsevier; 2009.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]