20 set 2016

artigos_definitivoJessika Boles, PhD, CCLS

Pediatr Nurs. 2016;42(3):147-149.

Abstract and Introduction

Introduction

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).

Elements of Successful Preparation Interventions

According to Wright, Stewart, Finley, and Buffett- Jerrott (2007), “the most effective components of preparation programs include modeling, parental involvement, child life preparation, and coping skills instruction” (p. 70). Thirty years and 100 studies later, recommendations by Wolfer and Visintainer (1975), Melamed and Siegel (1975), and Petrillo (1972) have been corroborated by evidence from a variety of populations and settings. Further, the literature base suggests that preparation is most useful when each of these components is provided in conjunction with one another, rather than in isolated interventions. Techniques for providing these four crucial components are discussed in more detail below.

Modeling

Originally attributed to Albert Bandura (1971), modeling is the process by which individuals learn vicariously through observing and potentially imitating the behaviors of others. Children are constantly exposed to models, whether they are parents, siblings, peers, teachers, or healthcare professionals. In the hospital environment, when a child is facing an unfamiliar procedure or even anesthesia induction, modeling may be the most readily available preparation technique. This may take the form of talking with another patient who has undergone the same procedure, watching a video in which a child experiences the procedure at hand, or even using a doll or stuffed animal to observe the steps of the procedure and what the child may see, hear, feel, taste, or smell along the way. If the child seems comfortable, he or she can act as the model, such as in the case of “practicing” lying still on the MRI table, entering the OR with a parent to practice what will happen during induction, or attaching electrodes to his or her skin to see what it will feel like. In each of these instances, the child and parent learn more about the procedure vicariously, which gives them increased knowledge about what to expect and can thereby promote increased feelings of control.

Parental Involvement

As discussed above, parents are the first models in children’s lives. If the parent is exhibiting signs of anxiety or distress, children can pick up on these emotional cues and begin to demonstrate similar behaviors and reactions. When parents are able to receive adequate information for themselves (Melnyk, Small, & Carno, 2004), participate in educating their child about the procedure (Wakimizu, Kamagata, Kuwabara, & Kamibeppu, 2009), and function as an active participant in other preparatory activities, such as play-based interventions or surgical tours, they are able to demonstrate less distress during anesthesia induction (Kain et al., 2007). Parents should be given many opportunities to ask questions, to make decisions about their child’s care, and to think about and rehearse coping strategies for themselves and with their child. In addition, when in the operating room or procedure room, parents can benefit from coaching about where they can stand, the sequence of events, and what they can do to help their child (Bailey et al., 2015). Finally, during the procedure, parents can benefit from timely and honest communication and updates, as well as social support through family and friends or hospital staff if appropriate.

Child Life Preparation and Coping Skills Instruction

Child life specialists, as professionals trained in developmentally appropriate techniques for helping children and their families cope with stressful life experiences, can be a valuable resource when providing preparation for procedures or surgery. Child life specialists make individualized assessments based on the child and family’s coping, previous experiences, and the family’s goals for their child’s up-coming medical experience. Using this information, child life specialists provide age-appropriate preparation using developmentally targeted language and play-based techniques, such as medical play, modeling, and role rehearsal (Brewer et al., 2006). They aim to provide children with two types of developmentally appropriate information: sensory, which encompasses what the child will experience through their five senses, and procedural, which describes the expected step-by-step sequence of events of the procedure.

Beyond providing education about the upcoming procedure, child life specialists and other professionals may assist children and families in developing, rehearsing, and employing coping strategies as the day of the procedure approaches or during the procedure itself. Also based on individualized assessment, recommended coping techniques are based on the child’s needs and preferences, and can include strategies such as distraction, deep breathing, guided imagery, or alternative focus (Thompson, 2009). In addition, child life specialists can be useful supports during the induction of anesthesia or during procedures to remind children of the preparatory information they received, narrate the sequence of events to promote predictability, and coach the child and parent through their previously rehearsed coping plan (Brewer et al., 2006).

Conclusion

Fear and anxiety are understandable emotions when facing an unknown experience, and are even moreso expected when the experience in question is a potentially invasive, painful, and unfamiliar procedure or surgery. When a child faces these circumstances, they require developmentally appropriate intervention to help them understand the medical encounter, predict the steps that will occur and how they might feel, and develop a plan to help themselves manage feelings of stress or anxiety leading up to and on the day of the procedure. This requires interdisciplinary collaboration because there are multiple elements of successful preparation programs, namely modeling opportunities, parental involvement, preparation provided by child life specialists, and coping skills instruction. When these components are provided in the context of supportive health care relationships, even though the fear and anxiety may not disappear completely, the child and family may feel more empowered to manage the demands ahead – those of the upcoming procedure and those of future medical experiences throughout their lifetimes.

Sidebar

The Children’s Corner: Perspectives on Supportive Care focuses on exploring ways to support children undergoing healthcare experiences. Drawing on the documented thoughts and perspectives of children in the research literature, The Children’s Corner aims to provide practitioners with high-quality evidence-based care practices that also promote the coping and development of children of all ages and their families.

If you are interested in submitting material for this column, please contact: Jessika Boles, MEd, CCLS; Pediatric Nursing; East Holly Avenue/Box 56; Pitman, NJ 08071-0056; pnjrnl@ajj.com

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