Preparing Children for Surgery—an Integrative Research Review

Preparing Children for Surgery—an Integrative Research Review

Susan O’ Conner-Von

Since 1934, the adverse effects of illness and hospitalization on children have been documented in the research literature.(1) In a landmark study conducted in 1966, the effects of hospitalization on 387 children were examined by evaluating changes in their behavior as noted by their parents on an assessment instrument, the Post-hospital Behavior Questionnaire.(2) These researchers summarized the negative effects of hospitalization into five categories: regression, separation anxiety, sleep anxiety, eating disturbance, and serious aggression.

Positive changes. In an attempt to decrease these negative effects, positive changes in children’s health care have been made during the last 30 years. For example, family member visitation and care are now encouraged, child life specialists have become essential members of the health care team, efforts are being made to better prepare children and family members, and the health care environment has become more child-friendly.

Positive changes also have occurred in the surgical care of children by way of the increasing trend in outpatient procedures. In 1980, outpatient surgery accounted for 20% of all procedures performed in children’s hospitals in the United States. The percentage of outpatient surgeries rose to 47% by 1986, and to 56% by 1990. In 1993, researchers estimated that 70% of surgeries would be performed on an outpatient basis by 2000.(3) Outpatient surgery has greatly reduced the negative effects of the pediatric health care experience and provided many advantages, including less parent and child separation, quick return to home, decreased nosocomial infections, and reduction in cost of surgery.(4)

Preparation for surgery still needed.

Unfortunately, some of the factors that contribute to the negative effects of children’s health care remain. These factors include unfamiliarity with the surgical setting, threatening medical equipment, painful procedures, and lack of control over events.(5) Furthermore, children arriving for outpatient surgery have limited time to acclimate to the health care environment, and health care providers have limited time to adequately prepare children and family members for the experience. As a result, preparation of children and family members before surgery is warranted.

Research indicates that all children can benefit from preoperative preparation.(6) In fact, one survey reports that 70% of all pediatric hospitals in the United States provide preparation before surgery.(7) Another survey of 123 pediatric hospitals reports that almost all responding hospitals provide some kind of preparation to the majority of patients.(8)

During the last three decades, research has focused on developing techniques for preparing preschool and school-aged children for surgery. Preparation programs that use coping models, procedural and sensory information, and medical “play” have resulted in less anxiety and increased knowledge in children undergoing surgery.(9) Research is still needed to evaluate the effectiveness of preparation, determine the appropriate match between children and preparation techniques, and identify gaps in the studies.

RESEARCH QUESTIONS

An integrative research review summarizes published studies in an effort to make overall conclusions regarding a particular area of study.(10) For this integrative research review, the following questions were determined.

* What are the methodological and substantive characteristics of the research pertaining to the preparation of children for surgery?

* What does the research during the last three decades show regarding the efficacy of preparation programs for children?

METHODOLOGY

Table 1 outlines the established inclusion and exclusion criteria for the review. Databases searched included CINAHL, from 1982 to 1997; MEDLINE, from 1966 to 1997; and PsycINFO, from 1984 to 1997. Descriptors used in the search were the terms child, children, pediatric, preparation, and surgery. The review included studies of preparation of children for surgery by four disciplines: child health care, medicine, nursing, and child psychology. The descriptors identified 400 articles, which were reviewed using the inclusion and exclusion criteria. A total of 22 studies met the criteria and, therefore, constituted the sample (Table 2).

Table 1

INTEGRATIVE RESEARCH REVIEW

INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria Exclusion criteria

United States-refereed journal Dissertation

Published in English Book chapter

Sample size [is greater than] 20 Review

Experimental or Case study

quasiexperimental design

Preparation of children for surgery

Table 2

INTEGRATIVE RESEARCH REVIEW SAMPLE

* L Abrams, “Resistance behaviors and teaching media for children in day surgery,” AORN Journal 35 (February 1982) 244-258.

* L A Campbell et al, “Preparing children with congenital heart disease for cardiac surgery,” Journal of Pediatric Psychology 20 (June 1995) 313-328.

* J Faust, B G Melamed, “Influence of arousal, previous experience, and age on surgery preparation of same day of surgery and in-hospital pediatric patients,” Journal of Consulting and Clinical Psychology 52 (June 1984) 359-365.

* J Faust, R Olson, H Rodriguez, “Same-day surgery preparation: Reduction of pediatric patient arousal and distress through participant modeling,” Journal of Consulting and Clinical Psychology 59 (June 1991) 475-478.

* B F Ferguson, “Preparing young children for hospitalization: A comparison of two methods,” Pediatrics 64 (November 1979) 656-664.

* C Kennedy, I I Riddle, “The influence of the timing of preparation on the anxiety of preschool children experiencing surgery,” Maternal-Child Nursing Journal 18 (Summer 1989) 117-132.

* M Lynch, “Preparing children for day surgery,” Children’s Health Care 23 (Spring 1994) 75-85.

* M E Mansson, B Fredrikzon, B Rosberg, “Comparison of preparation and narcotic-sedative premedication in children undergoing surgery,” Pediatric Nursing 18 (July/August 1992) 337-342.

* M M McGrath, “Group preparation of pediatric surgical patients,” Image 11 (June 1979) 52-62.

* B Melamed, M Dearborn, D A Hermecz, “Necessary considerations for surgery preparation: Age and previous experience,” Psychosomatic Medicine 45 (December 1983) 517-525.

* B Melamed et al, “The influence of time and type of preparation on children’s adjustment to hospitalization,” Journal of Pediatric Psychology 1 no 4 (1976) 31-37.

* B Melamed, L Siegel, “Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling,” Journal of Consulting and Clinical Psychology 43 (August 1975) 511-521.

* L Peterson, C Shigetomi, “The use of coping techniques to minimize anxiety in hospitalized children,” Behavior Therapy 12 (1981) 1-14.

* L Peterson et al, “Comparison of three modeling procedures on the presurgical and postsurgical reactions of children,” Behavior Therapy 15 (1984) 197203.

* R P Pinto, J G Hollandsworth, Jr, “Using videotape modeling to prepare children psychologically for surgery: Influence of parents and costs versus benefits of providing preparation services,” Health Psychology 8 no 1 (1989) 79-95.

* C K Schmidt, “Pre-operative preparation: Effects on immediate pre-operative behavior, post-operative behavior, and recovery in children having same-day surgery,” Maternal-Child Nursing Journal 19 (Winter 1990) 321-330.

* S Twardosz et al, “A comparison of three methods of preparing children for surgery,” Behavior Therapy 17 (1986) 14-25.

* D T Vernon, W C Bailey, “The use of motion pictures in the psychological preparation of children for induction of anesthesia,” Anesthesiology 40 (January 1974) 68-72.

* M A Visintainer, J A Walter, “Psychological preparation for surgical pediatric patients: The effects on children’s and parents’ stress responses and adjustment,” Pediatrics 56 (August 1975) 187-202.

* J A Walter, M A Visintainer, “Pediatric surgical patients’ and parents’ stress responses and adjustment as a function of psychologic preparation and stress-point nursing care,” Nursing Research 24 (July/August 1975) 244-255.

* J A Walter, M A Visintainer, “Prehospital psychological preparation for tonsillectomy patients: Effects on children’s and parents’ adjustment,” Pediatrics 64 (November 1979) 646-655.

* T R Zastowny, D S Kirschenbaum, A L Meng, “Coping skills training for children: Effects on distress before, during, and after hospitalization for surgery,” Health Psychology 5 no 3 (1986) 231-247.

RESULTS

Each of the 22 studies was examined to identify the methodological and substantive characteristics.

Methodological characteristics. The methodological characteristics addressed were design, sampling method, and sample size.(11) Seventy-two percent (n = 16) of the studies were experimental in design; the remaining six were quasiexperimental. The experimental studies used random sampling, and the quasiexperimental studies used convenience sampling methods or lacked a control group. The sample for each reviewed study corpus ranged from 23 to 163, for a total sample of 1,263 subjects.

Substantive characteristics. Substantive characteristics included

* demographic characteristics (eg, age, gender, socioeconomic status, race);

* health event and setting;

* theory;

* intervention;

* cost factor;

* instruments; and

* outcomes.(12)

Demographic characteristics. The sample age range was two to 17 years. The sample comprised 480 female subjects and 496 male subjects. Gender was not reported in five studies. Socioeconomic status was not reported in 16 of the studies; five studies reported that all of their subjects were middle-class, and one study reported that 66% of its subjects were middle-class. Children’s race was not reported in 13 studies; nine studies did report the children’s race (ie, Caucasian [n = 429], African American [n = 44], Hispanic [n = 10], and Asian [n = 2]).

Health event and setting. Ninety-four percent (n = 1,185) of the sample subjects underwent elective surgery. Only two studies pertained to surgeries that were not elective. One set of researchers examined children who were undergoing emergency appendectomy procedures,(13) and another set of researchers examined children who were undergoing cardiac procedures.(14) Four of the studies did not report the setting of their research, and eight reported the setting was a children’s hospital. Ten studies reported the setting for their research was a pediatric unit in a general or community hospital.

Theory. Few studies reported a theoretical basis or conceptual framework. Two studies referred to Bandura’s studies regarding extinction of avoidance behaviors.(15) One researcher referred to Selye’s theory of stress,(16) and another set of researchers referred to Lazarus and Folkman’s coping theory.(17) It must be recognized, however, that space limitations often exclude extensive theoretical background in published research.

Intervention. The intervention for each study involved individual or group preparation of children undergoing surgery. Fourteen studies reported individualized preparation, three studies reported group preparation, and five did not specify. Preparation was conducted at various times. Reported preparation occurred two weeks before surgery (n = 2), one week before surgery (n = 10), four days before surgery (n = 10), the day before surgery (n = 10), and one hour before surgery (n = 5). One study did not specify the time of preparation. Twelve studies reported that parents were present during preparation, six reported that parents were absent, and four did not specify.

Sixty-eight percent (n = 15) of the studies reported the use of videotapes to prepare children and their family members. Other methods of intervention reported were stress point preparation (ie, preparation and support provided during stressful times such as blood tests and separation from parents) (n = 4), and written or verbal explanations of procedural or sensory information (ie, showing the OR attire or explaining that they will wake up with an IV line inserted) (n = 3). Several studies used more than one type of preparation to compare the effectiveness of each.

Cost. Preparation program cost was reported in only one study, which completed a cost-benefit analysis of developing and producing a preparation videotape.(18) In addition to analyzing videotape costs, this study calculated the hospital and medical costs per child. After comparing the treatment group costs to the control group costs, it was determined that the prepared treatment group saved the hospital $187.17 per child, yielding a total savings of $7,326.80. In this era of cost containment, it is recommended that a cost-benefit analysis be included in all preparation studies. Preparation programs often are not used because of their cost;(19) however, they can significantly reduce the medical expenses related to pediatric surgery.

Instruments. When preparation programs were initially developed, the goal of preparing children for surgery was to reduce anxiety and increase cooperation.(20) To evaluate the effectiveness of psychological preparation programs, instruments were developed to measure children’s anxiety and cooperation levels. The most frequently used instruments were the Hospital Fears Rating Scale, Observer Rating Scale of Anxiety,(21) Manifest Upset Scale and Cooperation Scale,(22) and the Post-hospital Behavior Questionnaire.(23)

The Hospital Fears Rating Scale was used in eight of the studies.(24) This self-report scale was developed to reflect situational or “state” anxiety in children during hospitalization for elective surgery. Developed from the Medical Fears Subscale of the Fear Survey for Children, this scale contains 16 fear-related items and nine nonfear-related items.(25) Children rate their fear from one (ie, not afraid at all) to five (ie, very afraid). The total score reflects the sum of the 16 items related to fear.

Seven of the studies used the Observer Rating Scale of Anxiety.(26) Like the Hospital Fears Rating Scale, this scale reflects situational or “state” anxiety of children during hospitalization for elective surgery. The scale is constructed of 29 categories of verbal and skeletal-motor behaviors (eg, crying, trembling hands, talking about hospital fears) that are believed to be reflective of child anxiety. Each observer uses a time sampling procedure to note the presence or absence of each category.

In seven of the studies, the behavioral observational Manifest Upset Scale was used, which rates children’s emotional states during the surgical experience.(27) Based on a five-point scale, a rating of one indicates no fear or anxiety (ie, calm appearance, no crying). A rating of three indicates a moderate amount of anxiety (ie, whimpering, mild protesting), and a rating of five indicates extreme emotional distress (ie, hard crying, strong verbal protest).

The Cooperation Scale also was used in seven of the studies.(28) This behavioral observational scale rates children’s cooperation during the surgical experience. A rating of one indicates complete cooperation, a rating of three indicates mild resistance or passive participation, and a rating of five indicates extreme avoidance and the necessity to restrain the child.

Seven studies used the Post-hospital Behavior Questionnaire,(29) which comprises a checklist of 27 of the most frequently reported behaviors occurring in children after hospitalization. Parents compare their child’s behavior one week after hospitalization with the child’s typical behavior before hospitalization. Five responses are provided regarding the frequency of the child’s postoperative behaviors: much less than before (one point), less than before (two points), same as before (three points), more than before (four points), and much more than before (five points). A total score of 81 indicates no change in the child’s behavior, more than 81 indicates poorer adjustment, and less than 81 indicates an improvement in behavior. This questionnaire is the most commonly used method of examining postoperative behavior, however, its validity has not been firmly established.(30)

Outcomes. Outcomes were used to determine the effectiveness of each program and were presented in terms of

* information acquisition,

* self report of anxiety or fear,

* observed behavior changes or verbalization, or

* physiologic changes.

DISCUSSION

Results of this integrative review are discussed in terms of a classic 1965 review, which focused on the psychological effects of surgery or hospitalization on children and described the initial preparation studies.(31) In this review, researchers reviewed 208 articles, of which only a small percentage were formal research studies. As a result of their comprehensive review, they concluded that the three key components of preparation were

* providing information to children about the experience,

* encouraging emotional expression of concerns, and

* establishing a trusting relationship with the health care provider.

They also delineated seven primary weaknesses of the research, including

* inadequate description of procedures,

* failure to control observer bias,

* little use of statistical tests,

* confounding of theoretical implications,

* failure to measure direct effect of experimental conditions,

* disregard of psychological benefit, and

* little concern with reliability and validity.(32)

Twenty years later, these seven primary weaknesses were used as a critique framework by another researcher in an analysis of 63 preparation studies published since the 1965 review. This researcher further discovered a lack of research involving fathers and siblings of pediatric patients and involving sample populations of children undergoing nonelective surgery.(33)

Inadequate description of procedures. The 1965 review revealed that the majority of the studies failed to fully describe the procedures followed in each study. Of particular concern was the inadequate description of sample characteristics, measures, data collection methods, and preparation interventions. This inadequacy prohibited further evaluation or replication studies.(34)

In contrast to the 1965 review, 81% (n = 18) of the studies in this current review included descriptions of measures, data collection methods, and interventions that were sufficient for evaluation and replication. Unfortunately, 86% did not fully describe their sample characteristics and did not mention children’s socioeconomic status, race, or gender. Only three studies fully described their sample with respect to these characteristics.(35)

The 1965 review also noted the omission of children’s assent to participate in each study. Although 72% (n = 16) of the studies in the current review reported that parental informed consent was obtained, none of the studies specifically addressed the issue of child assent.

Failure to control observer bias. The earlier review reported that multiple observers and blind ratings were infrequently used in the studies.(36) Researchers noted that it was common in the studies for the same investigator to interview the parents, perform the intervention, and rate the children’s behavior. As a result, the possibility of investigator bias posed a serious effect on the accuracy of the data and threatened the reliability and validity of the studies.

In the current review, 77% (n = 17) of the studies reported that the observers were blind to the experimental and control group conditions. In three of the 17 studies, however, there was a possibility for the observers to become aware of the children’s conditions due to the study design. Four studies did not report using blind observers, and one study reported that the researcher performed the rating for all 60 research subjects.

Interestingly, a variety of staff members served as observers in these studies. Most of the observers were health care staff members; however, undergraduate and graduate psychology students also were employed. Only four of the studies reported that observer training was performed to ensure interrater reliability.

Little use of statistical tests. The 1965 review found that many studies did not use nor report the results of statistical tests. As a result, many of the studies failed to describe the relationships between variables and the differences among groups.(37) In contrast, all of the studies in the current review reported use of statistical analyses. In general, as the sophistication of study designs increased, so did the need for advanced statistical procedures.

Confounding of theoretical implications. A concern addressed in the 1965 review was the lack of consideration of the changes occurring in the health care environment during the time period of the several studies. This lack of attention made it difficult to examine the effects of each intervention because of the possible presence of confounding variables.(38)

Researchers of the previous review also noted the failure to use control groups–an essential element of experimental research. Similarly, the majority of the studies in the current review are considered to be experimental; however, few can be considered purely experimental because of the nature of psychosocial research. The purpose of experimental research is to investigate cause-and-effect relationships between independent and dependent variables in a highly controlled environment.(39) Use of a pure control group (ie, having no preparation before surgery) would be considered unethical practice.

Eight-six percent (n = 19) of the studies in the current review conscientiously used control groups. For example, in the studies using videotape preparation, a control film that was not related to hospitalization or surgery was used. Similarly, in the studies using stress point preparation, a supportive nurse stayed with the children in one group throughout the study but did not provide stress point preparation. This type of control is referred to as attention control (ie, one group does not receive the preparation intervention but maintains close contact with a health care provider).(40) This allows for comparison of the effects of contact alone with a health care provider to the effects of the preparation intervention.

Failure to measure direct effects of experimental conditions. It was noted in the 1965 review that no study measured the degree to which preparation increased children’s knowledge regarding surgery.(41) In the current review, only two studies assessed the amount of information children retained after receiving preparation for surgery.(42) In one study, the Hospital Information Test was administered to children immediately after watching a preparation film and after one month. The study found that children who viewed a hospital-relevant film retained more information regarding hospital procedures than children who viewed a control film. In addition, children older than seven years of age who saw the hospital-relevant film were more knowledgeable about hospital procedures than younger children. Arguably, children’s change in behavior, rather than their acquisition of knowledge, may be a more valid measure of the direct effects of preparation.

Disregard of psychological benefit. In the 1965 review, most of the studies excluded any mention of psychological benefit in their respective analyses.(43) The studies showed, however, that the hospital experience is not always upsetting to children and actually may promote a positive sense of mastery and accomplishment. This was illustrated in one-year follow-up interviews in which 62% of mothers reported that their child recalled positive aspects of hospitalization, such as watching color television and eating ice cream, compared to 22% who recalled the negative aspects, such as receiving injections and having pain.(44)

Likewise, postoperative interviews of children who received psychological preparation for emergency appendectomy procedures indicated a more realistic view of their hospital experience. Researchers surmised that the children had dealt adequately with their anxiety and fears while in the hospital.(45)

Little concern with reliability and validity. The 1965 study reported an absence of data that addressed reliability and validity. Of grave importance was the lack of data pertaining to interrater reliability and validity of global measures of psychological upset.(46)

Issues related to reliability. In the current review, there was notable concern regarding the reliability of the instruments used in 82% (n = 18) of the studies; 64% (n = 14) of these studies reported interrater reliability. Although there is no established unacceptable value of interrater reliability, any value below 80% should be cause for concern about the reliability of the data.(47)

Of the seven studies that reported test-retest reliability, four studies used the Post-hospital Behavior Questionnaire and reported an overall reliability coefficient of 0.65. Two studies used the Hospital Information Test and reported a reliability coefficient of 0.60. Finally, one study used the Hospital Fears Rating Scale and reported a coefficient of 0.75. Reliability coefficients can range from 0.0 to 1.0. Reliability coefficients higher than 0.70 are considered satisfactory.(48)

Issues related to validity. Consistent with the 1965 findings, the current review found a lack of consideration in addressing the validity of instruments. Only 32% (n = 7) of the studies reported instrument validity, and 68% (n = 15) did not.(49)

Of the seven studies that reported validity, two reported the construct validity of the Post-hospital Behavior Questionnaire.(50) One of these studies reported that the construct validity of the questionnaire is based on its detection of previously predicted changes in behavior.(51)

Other researchers reported the construct validity of the Global Mood Scale, citing that research since 1966 has supported the validity of the scale.(52) Four studies reported adequate validity.

In terms of internal validity, it can be difficult to use an experimental design when conducting behavioral research with children; however, 72% (n = 16) of the studies were reported to be experimental, and 28% (n = 6) studies were quasiexperimental. As randomization was not used in some of the quasiexperimental studies, biases could have resulted from the differences in the groups. Furthermore, parents who chose to attend a preparation program could have been more motivated to learn.

External validity also could have been compromised, as the majority of study participants were healthy Caucasian children undergoing elective surgery. This seriously threatened the ability to generalize beyond the sample of these studies; however, it has provided a foundation for future studies.

RECOMMENDATIONS

Recommendations emerging from this review address preparation strategies, population sample, and parent involvement.

Preparation strategies. Many preparation strategies have been shown to be effective in reducing anxiety for children undergoing surgery; however, flexible strategies are needed for children and family members of diverse cultural backgrounds. In addition, strategies need to be developed that can be adapted for children undergoing emergency or repeat surgery. Equally needed is a method of soliciting patients’ and parents’ satisfaction with the preparation strategy, along with a means to determine each strategy’s effectiveness.

Population sample. The majority of research has been conducted on healthy, Caucasian children experiencing elective surgery for the first time.

Health status. Future research must address children with acute and chronic illnesses, as well as those undergoing repeat or emergency surgery. Children who have chronic illnesses or who are undergoing repeat surgery may have developed their own coping techniques, which need to be integrated into their care plans. In contrast, children who have acute illnesses or medical emergencies may not have time to deal with the events and may need individualized preparation.

Demographic characteristics. African American, Hispanic, and Asian children are underrepresented in the research. Moreover, the majority of children studied are from middle-class families. Future research is needed to include children from all ethnic, cultural, and socioeconomic groups, with particular attention to children and family members whose second language is English.

The majority of children involved in this research are school-aged. Children less than three and more than 12 years of age are not included in the majority of studies, yet these children have unique cognitive and emotional needs.

Cognitive development. In the clinical setting, nursing staff members frequently prepare children for outpatient surgery.(53) It is imperative, therefore, for nurses to be knowledgeable about the methods of assessing children’s level of understanding of the surgical experience. As one type of preparation may not benefit all children equally, nurses may need to try a variety of strategies. Effective strategies need to be documented and communicated to the health care team members.

Parent involvement. With the increased use of outpatient surgery, parents are bearing the responsibility of addressing their child’s concerns before surgery, as well as caring for their child postoperatively. According to this review, most parents are not encouraged to take an active role in preparing their child for surgery. Parents, however, hold the key to understanding how their child responds to and copes with stress. Parents must be considered an integral part of the child’s preparation for surgery and need to be included during preparation.

CONCLUSION

The importance of preparing children for surgery cannot be overemphasized.(54) The results of this integrative research review confirm that children and their parents need preparation before the surgical experience. It is the responsibility of nurses, therefore, to develop and evaluate preparation strategies that will enhance children’s and parents’ ability to cope with surgery. Continued efforts must be made to develop preparation strategies that will meet the unique needs of children and to determine the role of parents in the preparation of their child for surgery.

Considering the changes in health care, it is reasonable to expect a continued increase in outpatient surgery. Future preparation strategies need to document outcomes and cost-effectiveness.(55) In addition, as many of the preparation strategies were developed for children undergoing inpatient surgery, new strategies must take into account the limited time available to spend with children and parents before surgery and the increased responsibility on parents for postoperative home care.(56)

The author thanks the following people for their assistance in the preparation of this article: M. Broome, RN, PhD, FAAN; M. Faut-Callahan, RN, DNSc, CRNA, FAAN; K. Delaney, RN, DNSc; M. Kremer, RN, DNSc, CRNA; V. Maikler, RN, PhD; J. Paice, RN, PhD, FAAN; and K. Kalb, RN, PhD. NOTES

(1.) A H Chapman, D G Loeb, M J Gibbons, “Psychiatric aspects of hospitalizing children,” Archives of Pediatrics 73 (March 1956) 77-78; D Forsyth, “Psychological effects of bodily illness in children,” Lancet 227 (July 7, 1934) 15-18; R Jensen, “The hospitalized child: Round table, 1954” American Journal of Orthopsychiatry 25 (April 1955) 293-318; D G Prugh et al, “A study of the emotional reactions of children and families to hospitalization and illness,” American Journal of Orthopsychiatry 23 no 1 (1953) 70-106; D T Vernon, J L Schulman, J M Foley, “Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates,” American Journal of Disease of Children 111 (June 1966) 581-593.

(2.) Vernon, Schulman, Foley, “Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates,” 581-593.

(3.) M Geisz, “Bringing health care to children: The importance of ambulatory care,” Journal of Ambulatory Care Management 16 (January 1993) 1-10.

(4.) A L Zuckerberg, “Perioperative approach to children,” Pediatric Clinics of North America 41 (February 1994) 15-29.

(5.) L Peterson, L Mori, “Preparation for hospitalization,” in Handbook of Pediatric Psychology, ed D K Routh (New York: Guilford, 1988) 460-491.

(6.) B Melamed, R Robbins, S Graves, “Preparation for surgery and medical procedures,” in Behavioral Pediatrics: Research and Practice, eds D C Russo, J W Varni (New York: Plenum Press, 1982) 225-267.

(7.) L Peterson, R Ridley-Johnson, “Pediatric hospital response to survey on prehospital preparation for children,” Journal of Pediatric Psychology 5 (March 1980) 1-7.

(8.) K K O’Byrne, L Peterson, L Saldana, “Survey of pediatric hospitals’ preparation programs: Evidence of the impact of health psychology research,” Health Psychology 16 (March 1997) 147-154.

(9.) A L Meng, “Parents’ and children’s reactions toward impending hospitalization for surgery,” Maternal-Child Nursing 9 (Summer 1980) 83-98.

(10.) H Cooper, Integrating research: A guide for literature reviews, second ed (Newbury Park, Calif: Sage Publications, 1989).

(11.) Ibid.

(12.) E Mumford, H J Schlesinger, G V Glass, “The effects of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature,” American Journal of Public Health 72 (February 1982) 141-151.

(13.) M E Mansson, B Fredrikzon, B Rosberg, “Comparison of preparation and narcotic-sedative pre-medication in children undergoing surgery,” Pediatric Nursing 18 (July/August 1992) 337-342.

(14.) L A Campbell et al, “Preparing children with congenital heart disease for cardiac surgery,” Journal of Pediatric Psychology 20 (June 1995) 313-328.

(15.) D T Vernon, W C Bailey, “The use of motion pictures in the psychological preparation of children for induction of anesthesia,” Anesthesiology 40 (January 1974) 68-72; B Melamed, L Siegel, “Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling,” Journal of Consulting and Clinical Psychology 43 (August 1975) 511-521.

(16.) C K Schmidt, “Pre-operative preparation: Effects on immediate preoperative behavior, post-operative behavior, and recovery in children having same-day surgery,” Maternal-Child Nursing Journal 19 (Winter 1990) 321-330.

(17.) Campbell et al, “Preparing children with congenital heart disease for cardiac surgery,” 313-328.

(18.) R P Pinto, J G Hollandsworth, Jr, “Using videotape modeling to prepare children psychologically for surgery: Influence of parents and costs versus benefits of providing preparation services,” Health Psychology 8 no 1 (1989)79-95.

(19.) L Peterson, C Shigetomi, “The use of coping techniques to minimize anxiety in hospitalized children,” Behavior Therapy 12 (1981) 1-14.

(20.) Melamed, Robbins, Graves, “Preparation for surgery and medical procedures,” 225-267.

(21.) Melamed, Siegel, “Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling,” 511-521.

(22.) J A Wolfer, M A Visintainer, “Pediatric surgical patients’ and parents’ stress responses and adjustment as a function of psychologic preparation and stress-point nursing care,” Nursing Research 24 (July/August 1975) 244-255.

(23.) Vernon, Schulman, Foley, “Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates,” 581-593.

(24.) Melamed, Siegel, “Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling,” 511-521.

(25.) M W Scherer, C Y Nakamura, “A fear survey schedule for children (FSS-FC): A factor analytic comparison with manifest anxiety (CMAS),” Behavior Research and Therapy (May 1968) 173-182.

(26.) Melamed, Siegel, “Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling,” 511-521.

(27.) Wolfer, Visintainer, “Pediatric surgical patients’ and parents’ stress responses and adjustment as a function of psychologic preparation and stress-point nursing care,” 244-255.

(28.) Ibid.

(29.) Vernon, Schulman, Foley, “Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates,” 581-593.

(30.) D T Vernon, R H Thompson, “Research on the effect of experimental interventions on children’s behavior after hospitalization: A review and synthesis,” Journal of Developmental and Behavioral Pediatrics 14 (February 1993) 36-44.

(31.) T A Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature (Springfield, Ill: C C Thomas, 1965).

(32.) Ibid.

(33.) R H Thompson, Psychosocial Research on Pediatric Hospitalization and Health Care: A Review of the Literature (Springfield, Ill: C C Thomas, 1985).

(34.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(35.) Campbell et al, “Preparing children with congenital heart disease for cardiac surgery,” 313-328; Peterson, Shigetomi, “The use of coping techniques to minimize anxiety in hospitalized children,” 1-14; S Twardosz et al, “A comparison of three methods of preparing children for surgery,” Behavior Therapy 17 (1986) 14-25.

(36.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(37.) Ibid.

(38.) Ibid.

(39.) N Burns, S K Grove, The Practice of Nursing Research: Conduct, Critique, and Utilization, third ed (Philadelphia: W B Saunders Co, 1997) 60.

(40.) Thompson, Psychosocial Research on Pediatric Hospitalization and Health Care: A Review of the Literature.

(41.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(42.) B Melamed, M Dearborn, D A Hermecz, “Necessary considerations for surgery preparation: Age and previous experience,” Psychosomatic Medicine 45 (December 1983) 517-525; J Faust, B G Melamed, “Influence of arousal, previous experience, and age on surgery preparation of same day of surgery and in-hospital pediatric patients,” Journal of Consulting and Clinical Psychology 52 (June 1984) 359-365.

(43.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(44.) L Peterson, C Shigetomi, “One-year follow-up of elective surgery child patients receiving preoperative preparation,” Journal of Pediatric Psychology 7 (March 1982) 43-48.

(45.) Mansson, Fredrikzon, Rosberg, “Comparison of preparation and narcotic-sedative premedication in children undergoing surgery,” 337-342.

(46.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(47.) Burns, Grove, The Practice of Nursing Research: Conduct, Critique. and Utilization, third ed, 60.

(48.) D Polit-O’Hara, B P Hungler, Nursing Research: Principles and Methods, sixth ed (Philadelphia, J B Lippincott Co, 1999).

(49.) Vernon et al, The Psychological Responses of Children to Hospitalization and Illness: A Review of the Literature.

(50.) J A Wolfer, M A Visintainer, “Prehospital psychological preparation for tonsillectomy patients: Effects on children’s and parents’ adjustment,” Pediatrics 64 (November 1979) 646-655; C Kennedy, I Riddle, “The influence of the timing of preparation on the anxiety of preschool children experiencing surgery,” Maternal-Child Nursing Journal 18 (Summer 1989) 117-132.

(51.) Kennedy, Riddle, “The influence of the timing of preparation on the anxiety of preschool children experiencing surgery,” 117-132; Vernon, Schulman, Foley, “Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates,” 581-593; Wolfer, Visintainer, “Pediatric surgical patients’ and parents’ stress responses and adjustment as a function of psychologic preparation and stress-point nursing care,” 244-255.

(52.) Vernon, Bailey, “The use of motion pictures in the psychological preparation of children for induction of anesthesia,” 68-72.

(53.) P Azarnoff, “Teaching materials for pediatric health professional s,” Journal of Pediatric Health Care 4 (November/December 1990) 282-289.

(54.) A P Wong, J S Jahr, “Outpatient anesthesia in the pediatric patient: A review,” Journal of the Louisiana State Medical Society 145 (June 1993) 271-273.

(55.) M Lynch, “Preparing children for day surgery,” Children’s Health Care 23 (Spring 1994) 75-85.

(56.) Schmidt, “Pre-operative preparation: Effects on immediate preoperative behavior, post-operative behavior, and recovery in children having same-day surgery,” 321-330.

Susan O’Conner-Von, RN, MS, C, is a staff nurse at Children’s Hospital, St Paul, and an assistant professor at the College of St Catherine, St Paul.

The author thanks the following people for their assistance in the preparation of this article: M. Broome, RN, PhD, FAAN; M. Faut-Callahan, RN, DNSc, CRNA, FAAN; K. Delaney, RN, DNSc; M. Kremer, RN, DNSc, CRNA; V. Maikler, RN, PhD; J. Paice, RN, PhD, FAAN; and K. Kalb, RN, PhD.

COPYRIGHT 2000 Association of Operating Room Nurses, Inc.

COPYRIGHT 2001 Gale Group