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Parental anxiety in the pediatric perioperative setting: an integrative literature review with best practice recommendations for perioperative information delivery to reduce parental anxiety

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Parental anxiety in the pediatric perioperative setting: an integrative literature review with best practice recommendations for perioperative information delivery to reduce parental anxiety

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Content PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING
PARENTAL ANXIETY IN THE PEDIATRIC PERIOPERATIVE SETTING: AN
INTEGRATIVE LITERATURE REVIEW WITH BEST PRACTICE RECOMMENDATIONS
FOR PERIOPERATIVE INFORMATION DELIVERY TO REDUCE PARENTAL ANXIETY
by
Jaclyn Gabbert
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2025

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING ii
Distribution of Work
The following manuscript was contributed in equal parts by Chelsea Chavez and Jaclyn Gabbert

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING iii
Acknowledgements
We would like to thank our families for their endless support. You have been so patient,
generous, and encouraging throughout this process and we could not have done it without you.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING iv
Table of Contents
Acknowledgements.........................................................................................................................iii
Chapter 1 ........................................................................................................................................ 1
Introduction................................................................................................................................. 1
Research Question and Specific Aims........................................................................................ 2
Background and Significance ..................................................................................................... 2
Chapter 2 ........................................................................................................................................ 5
Methods....................................................................................................................................... 5
Chapter 3 ........................................................................................................................................ 7
Literature Review........................................................................................................................ 7
Written Information ................................................................................................................ 7
Virtual Tour........................................................................................................................... 12
Audio-Visual Aid .................................................................................................................. 15
Systematic Reviews, Meta Analyses, and Narrative Reviews.............................................. 18
Chapter 4 ...................................................................................................................................... 23
Results....................................................................................................................................... 23
Practice Recommendations................................................................................................... 25
Chapter 5 ...................................................................................................................................... 28
Discussion................................................................................................................................. 28
References..................................................................................................................................... 30
Appendix A.................................................................................................................................... 36

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 1
Chapter 1
Introduction
Current data estimate 4.7% of children undergo surgical interventions each year, with an
average of 3.9 million surgeries performed annually in the United States (Rabbitts &
Groenewald, 2020). Surgical procedures and the need for anesthesia can be a source of anxiety
for both the pediatric patient and their parents. In addition to coping with their own stress,
parents must also manage the emotions of their child undergoing surgery. Both adult and
pediatric patients experience anxiety in the perioperative period (Pomicino et al., 2018).
Different from generalized or baseline anxiety (trait anxiety), situational anxiety (state anxiety) is
experienced in response to transient and impactful events. The perioperative period, which
includes the preoperative, operative, and postoperative periods, has the tendency to elicit
situational anxiety. Parental anxiety in the perioperative period heavily influences pediatric
patient anxiety because children are impressionable and likely to model both the adaptive and
maladaptive behaviors of their parents (Burstein & Ginsberg, 2010). Pediatric anxiety in the
perioperative period has known deleterious effects and many studies focus on mitigating the
transference of parental anxiety to the pediatric patient (Santapuram et al., 2021).
As research continues to correlate parental anxiety with the degree of pediatric patient
anxiety, the anesthesia provider’s best strategy is to implement measures that address parental
anxiety. Excessive parental anxiety influences the pediatric patient experience and can have an
array of negative consequences, ranging from minor to extreme. An example of a minor
consequence is the hindrance of peripheral intravenous catheter insertion (Thyer et al., 1984)
whereas a major consequence is an increase in postoperative pain (Kil et al., 2010). A reduction
in anxiety is directly proportional to the amount of information and education provided to the

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 2
parent and child prior to the surgery (Landier et al., 2017). Common modalities for information
delivery include: standard verbal communication, written information, virtual tours, and audiovisual aids (AVA). A knowledge gap exists regarding which modality is most effective. This
integrative review attempts to address the best approach for perioperative information delivery
according to current literature.
Research Question and Specific Aims
The research question guiding this literature review is as follows: What is the most
effective evidence-based information modality to reduce parental anxiety in the perioperative
period for pediatric patients? The Population Intervention Outcome (PIO) question guiding this
evidence-based inquiry is defined as follows: population (P) consists of parents of pediatric
patients undergoing elective surgery, the intervention (I) is to synthesize the information
modalities to reduce parental anxiety in the perioperative period, and the outcome (O) is the
identification of the most effective information modality to mitigate parental anxiety in the
perioperative period. This review has no real-time comparison group as part of its strategy, rather
it examines and compares various information modalities used as parental anxiety reduction
techniques.
There are two specific aims of this literature review. The first is to explore the relevant
literature investigating which information modality is most effective in reducing parental anxiety.
The second is to synthesize the findings of this integrative literature review into best practice
recommendations for anesthesia providers in the perioperative setting.
Background and Significance
It is essential to this topic to first discuss the sequelae of parental anxiety and explain
each component. Pathophysiologic effects of anxiety, the impact of parental anxiety on the

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 3
child’s anxiety, and complications of the child’s anxiety on postoperative outcomes will be
discussed in detail. The current information modalities for addressing parental anxiety are further
explored in the literature review.
Definition and Pathophysiologic Effects of Anxiety
Anxiety is a stress induced state that has physiological, psychological, and behavioral
manifestations designed to help cope with actual or perceived threats (Steimer, 2002). Threats
might include situations that result in loss of control, unfamiliarity, change, or the possibility of
physical or psychological pain. The perioperative setting contains many potentially anxietyprovoking situations in which a person is required to surrender control.
The physiologic and behavioral response to anxiety is the activation of the autonomic
nervous system pathways, specifically the sympathetic nervous system (SNS) (Steimer, 2002).
Activation of the SNS results in increased catecholamine release, leading to tachycardia,
hypertension, increased cardiac tone, and tachypnea (Chrousos & Gold, 1992). While the stress
response serves a purpose, it is meant to be acute and short lived. A prolonged stress response
can result in immunosuppression, peptic ulcers, anorexia, weight loss, and depression.
Additionally, Fronk and Billick (2020) describe how these sequelae can alter wound healing and
impair sleep.
Impact of Parental Anxiety
Perioperative parental anxiety directly corresponds to anxiety in the preoperative
pediatric patient, as children learn coping mechanisms from their parents (McGraw, 1994). The
research of Burstein and Ginsburg (2010) describes how children may adopt anxious behaviors
and cognitions by observing similar behaviors in their parents. Children observe parental actions
to look for clues that inform the child’s future response to certain stimuli (Burstein & Ginsburg,

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 4
2010). Chow et al. (2018) found that when a parent overestimates a threat and becomes
overprotective, it impairs the child’s ability to adapt. Parents interfere with a child’s coping
mechanism by inhibiting their self-confidence and reinforcing their existing anxiety.
Fronk and Billick (2020) investigated the effect of parental presence at anesthesia
induction to alleviate pediatric anxiety. They found parental presence is only beneficial when the
parent is both calm and adequately informed. In the same way that an anxious parent is of no
benefit, a calm parent lacking information also fails to benefit the child (Fronk & Billick, 2020).
A calm but uninformed parent is less prepared to manage the situational anxiety associated with
surgery, thus allowing their uncertainty to transfer to the child. Education and information about
what to expect in the perioperative period is a well-established means of mitigating parental
anxiety (Lim et al., 2011).
Complications of Pediatric Anxiety on Perioperative Outcomes
Increased pediatric anxiety can lead to behavioral and physiological complications. Fronk
and Billick (2020) described some of the behavioral manifestations as lack of cooperation, bad
dreams, disobedience, separation anxiety, temper tantrums, and poor sleep. These behavioral
effects create delays to care and may increase the resources and time needed to care for the child.
The physiological manifestations include nausea and vomiting, higher anesthetic dose
requirement, and increased pain (Kiecolt-Glaser et al., 1998). Laufenberg-Feldmann et al. (2019)
demonstrated a fivefold increase in the odds ratio for post-operative nausea and vomiting in
patients with anxiety. The SNS response of tachycardia and hypertension necessitate larger doses
of anesthetic to achieve loss of consciousness (Kim et al., 2010). Patients with higher anxiety
require greater amounts of propofol to reach light and moderate levels of sedation as seen on
Bispectral Index (BIS) monitors (Kil et al., 2010). In addition, Gras et al. (2010) found that

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 5
anxiety-induced tachycardia leads to increased variability in vital signs on induction of
anesthesia.
The relationship between anxiety and pain is undeniable and research consistently
correlates anxiety levels with intensity of postoperative pain (Kil et al., 2010). Fischer et al.
(2019) found that pain can last for months after the procedure, at which point it becomes chronic.
When parents are overly attentive to the distressing details of their child’s pain experience, the
pediatric patient is more likely to somaticize pain in the postoperative period (Stamenkovic et al.,
2018). As a result of these complications, higher perioperative anxiety can slow recovery and
increase length of stay (Gorini et al., 2022).
Information Modalities
Several interventions aim to address parental anxiety. Currently, verbal communication is
the standard approach to interact with parents and their children, deliver information regarding
the perioperative process, and address parental anxiety. Other modalities include written
information, virtual tours, and AVAs. Researchers often compare each of these modalities against
the standard of verbal communication.
Chapter 2
Methods
The content for the literature review regarding parental anxiety in the perioperative phase
of pediatric surgery was sourced from PubMed and Google Scholar. Keywords and search terms
included: “parental anxiety”, “pediatric surgery”, and “anxiety pediatrics”. The initial search on
PubMed yielded 579 results and when the date range was narrowed to only include articles from
2012-2023 it resulted in 450 articles. Additional filtering for full text systematic reviews, metaanalyses, randomized controlled trials (RCT), and narrative reviews resulted in 87 articles.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 6
Abstracts of these 87 articles were evaluated for outpatient (day) surgical cases, school-aged
children, and objective measurement of parental anxiety using a tool or scale; see Appendix A for
Prisma Flow Diagram. Thirty-four full text articles were assessed for eligibility for literature
review and reference sections were screened for additional articles. Nine articles from the
original search and six sourced from references met criteria for literature review and included the
following interventions on parental anxiety: written handouts, virtual tours, or AVA. The final
literature review includes fifteen articles.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 7
Chapter 3
Literature Review
This literature review evaluates various modalities of perioperative information delivery
and their effect on parental anxiety. Understanding which method is most effective may assist
providers in reducing parental anxiety and improve pediatric patient outcomes. This review is
divided into sections according to the most common modalities used. Characteristics such as
surgical setting (outpatient), American Society of Anesthesiology Classification (I-II), baseline
physiologic status, anesthetic history, and age were similar in all groups.
Written Information
Landier et al. (2017) conducted a randomized controlled trial to examine the impact of
written information on the level of parental anxiety, satisfaction, and comprehension at two
different time points. Their study included 164 parents of pediatric surgical patients. The
experimental group (n= 80) received both verbal information and a four-page leaflet, in brochure
format, that summarized the pathophysiology of the pediatric patient’s disease or condition,
risks, surgical techniques, alternatives, and description of the hospitalization and postoperative
care. The control group (n= 84) received only verbal information. Parental anxiety was measured
at two separate time points (T1, T2): first after initial consultation with the surgeon (T1) and a
second time on the day of hospitalization (T2) using the Visual Analog Scale (VAS) and the
Amsterdam Preoperative Anxiety and Information Scale (APAIS). The VAS is a subjective
assessment tool with a 100-mm line scale where subjects mark their anxiety level, where marks
on the left indicates zero anxiety and marks on the right indicate maximum anxiety (Kindler et
al., 2000). The APAIS is a six-item questionnaire used in adults to assess for anxiety (four items)
and need for information (two items) using a five-point Likert scale (Moerman et al., 1996). This

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 8
scale can have a score ranging from 4 (not anxious) to 20 (highly anxious). The need for
information scale can score a range of 2-10; no or little information requirement (2-4), average
information requirement (5-7), and high information requirement (8-10). High information
requirement correlates with high levels of anxiety. Both tools have been validated for measuring
anxiety against the most common anxiety measurement tool, the Spielberger’s State-Trait
Anxiety Inventory (STAI) (Spielberger et al., 1983), which will be later defined in further detail.
The authors of this study reported a statistically significant benefit to the written leaflet but only
at T2. The VAS and APAIS scores between the control group (39.5/100 VAS, APAIS 11.6/20)
and experimental group (33.12/100, 10.9/20) were not statistically significantly different at TI.
However, at T2, anxiety scores were significantly higher in the control group (54.1/100, 12.4/20)
than the experimental group (39.03/100, 10.9/20) (VAS: p < 0.001; APAIS: p = 0.015). The
authors also highlighted that 61.7% of parents stated that anesthesia was the biggest cause of
anxiety at T1 (58.6% at T2). Moreover, 20% of parents in the control group asked for written
information regarding anesthesia and the procedure. There are some limitations to this study. The
first is the inability to reproduce findings, as the authors did not include the leaflet, nor did they
include any information on which statistical tests were used to compare findings among groups.
Additionally, there was variability in length of time between T1 and T2. In the experimental
group, 35% of subjects waited less than two months, 43.8% waited 2-4 months, and 21.3%
waited more than 4 months. In the control group, 28.6% of subjects waited less than two months,
42.7% waited 2-4 months, and 28.6% waited more than four months. Also, the authors did not
collect baseline anxiety levels since T1 was measured after the initial consultation which can be
anxiety provoking. It would have been informative to measure anxiety at a third time point after
surgery because the second time point data is reflective of peak anxiety.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 9
Afzal et al. (2022) conducted a randomized controlled trial to assess the effects of a
printed brochure on mean anxiety levels of 72 parents of pediatric patients in the outpatient
surgery setting. The experimental group (n= 36) was provided a printed brochure in addition to
verbal information, and the control group (n= 36) received only standard verbal information. The
printed brochure contained details regarding the perioperative process including anesthesia
induction, emergence, post-operative care, and discharge criteria. Parental preoperative anxiety
was measured at 3 different time points using the VAS. The VAS scores were taken first on the
day of surgery after consultation but before intervention with brochure (T1), then a second time
after intervention but before separation from the child (T2), and a third time in the recovery room
upon the child’s arrival (T3). It is important to note that mean baseline anxiety (T1) in the
experimental group was statistically significantly higher than the control group using
independent sample t-tests (6.69 versus 5.69; p = 0.017). Despite having higher T1 anxiety
scores, the experimental group had lower mean VAS scores at T2, resulting in a more significant
decrease when compared to the control group (4.08 versus 6.08; p < 0.001). The two groups did
not show significant differences at T3. Some limitations of this study are small sample size and
lack of true baseline anxiety measurement. The authors refer to T1 as baseline anxiety; however,
anxiety was measured after the consultation with the surgeon. As previously discussed, surgical
consultation can be anxiety provoking. Additionally, all VAS scores were taken on the day of
surgery which allows little time for parents to process the information.
Bartik and Toruner (2018) performed a quasi-experimental study to examine the effects
of a preoperative program on the anxiety levels of children and their parents in the outpatient
surgery setting. The experimental group (n= 36) received both verbal information and an
instruction booklet titled, “The Care of Your Child in Outpatient Surgery”, the day before

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 10
surgery. Some of the content included in the booklet was related to preparing a child for surgery,
what items to take to the hospital, the admission process, post-surgical monitoring, and home
care. The control group (n= 37) received only the standard verbal preoperative communication.
Both groups had anxiety measured with the State Anxiety Inventory (SAI) scale at two time
points: 1 day before surgery (T1) and again before discharge (T2). The State Anxiety Inventory is
a component of the Spielberger’s State-Trait Anxiety Inventory (Spielberger et al., 1983). It is a
20-item questionnaire on a 4-point likert-type scale (1= no, 4=completely) that is intended to
measure how a person feels about themself in that moment. The SAI is often used alone because
it pertains to situational anxiety whereas the Trait Anxiety Inventory (TAI) scale is the
component that assesses for underlying anxiety unrelated to a particular situation. The total point
value ranges from 10–40 with a high score indicating high levels of anxiety. Authors compared
scores between groups using the χ! test, Fisher’s test, and the Mann-Whitney U test. They found
a statistically significant difference in SAI scores between the experimental group (38.27 ± 8.93)
and control group (53.81 ± 6.92) (U= 1,191.50; p= .001) at T2. Additionally, the average SAI
scores in the experimental group decreased significantly from T1 (48.08 ± 9.52) to T2 (38.27 ±
8.93; W= 41.00; p= .001). Some limitations of this study include small sample size, lack of
randomization due to the quasi-experimental study design, and poorly defined and executed time
points. The authors were unclear regarding when the T1 measurement took place. They simply
stated that it was done one day before surgery without defining if that meant before or after
initial consultation with the surgeon. Clear definition of T1 is important to understand if baseline
anxiety was measured. Additionally, there was limited data regarding anxiety around the time
leading up to the surgery or around the actual surgery since T2 was taken postoperatively. The
authors did not specify the time variable between T1 and T2.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 11
Cumino et al. (2013) conducted a randomized controlled trial to assess the effect of a
leaflet on anxiety levels of 72 parents and children. The experimental group (n= 36) received a
leaflet in addition to verbal information while the control group (n= 36) received standard verbal
information only. The experimental group’s leaflet contained 17 frequently asked questions and
answers pertaining to the perioperative process, such as type of anesthetic, need for fasting,
whether to discontinue regular medications, and how the parent or guardian could contribute to a
safe anesthetic process. The authors measured parental anxiety at only one time point using the
Hamilton Anxiety Rating Scale (HAM-A scale). The HAM-A is a highly reliable 14-item
questionnaire divided into 2 categories: 7 items regard an anxious mood, and 7 items are related
to the physical symptoms of anxiety (Hamilton, 1959). The scores range from 0-56 and are
classified into 5 degrees (0 = none present and 4 = very severe). Scoring 0 means absence of
anxiety; 1–17 points is mild anxiety, 18–24 points mild to moderate anxiety, and 25–30 points is
moderate to severe anxiety. Parental anxiety was measured at the end of the preanesthetic
evaluation, after information was given and at least 30-minutes before the child and parent
entered the operating room. In this study, the parents accompanied the children until the end of
induction. According to the authors, the HAM-A scores in the experimental group (9, 3.25 –
17.75) and control group (8, 5.25 - 16) were not significantly different using median anxiety
scores and χ! test. There are several limitations to this study. First, parental anxiety was only
measured at one time point although parents remained with the child through the time of
induction and child anxiety was measured twice. Second, is how the authors presented their data
regarding HAM-A scores. The authors defined the HAM-A scores of parents as either no anxiety
(score < 18) or anxious (≥ 18). However, the HAM-A was intended to differentiate three levels
of anxiety as mild, moderate, and severe. A score of < 18 does not mean the person is without

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 12
anxiety, it is intended to mean the person has a normal level of anxiety. Lastly, the authors did
not establish a baseline level of anxiety in parents.
Virtual Tour
Eijlers et al. (2019) conducted a randomized controlled trial to assess the impact of
preoperative virtual reality exposure (VRE) on anxiety. The primary outcome was to assess
anxiety levels of children receiving outpatient surgery and the secondary outcome was to assess
parental anxiety. A total of 191 parents and children were included in the study. The experimental
group (n = 94) received VRE, and the control group (n = 97) received standard verbal
information. The VRE was a child-friendly version of the operating theater, with the aim of
familiarizing the child with the environment and anesthesia procedures. Parental anxiety was
measured by researcher observation using the VAS and parents’ self-report using the SAI
component of the STAI. Parents in both groups completed the SAI at two time points, upon
hospital admission on the day of surgery before the intervention (T1), and directly after induction
of anesthesia (T2). The study’s findings revealed no statistically significant differences in
parental anxiety between groups when observed using the VAS (p = 0.418) or when self-reported
using the SAI (p = 0.753) between groups. However, the authors found preoperative SAI to be a
primary predictor of child anxiety during induction of anesthesia (F (1,85) = 5.05, p = 0.027).
Higher levels of anxiety exhibited by parents before the surgical procedure were significantly
associated with increased anxiety levels experienced by children during the anesthesia induction
process in the VRE group. A limitation of this study is that 21 children removed the VRE headset
which could lead to additional anxiety in the parent if they presume the child to be dissatisfied.
Additionally, wearing the bulky VRE headset could have caused physical discomfort to the child,

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 13
which is also potentially anxiety provoking in the parent. Another limitation of this study is the
lack of reproducibility, as it may not be feasible to recreate a VRE of this caliber.
Park et al. (2019) conducted a randomized controlled trial to evaluate the effect of a
virtual reality (VR) tour of an operating room through a VR mirroring device on preoperative
parental anxiety. For the experimental group (n= 40), parents watched the child's 4-min VR tour
of the operating theater on a mirroring device (computer monitor) as the child watched through
the VR device. The VR tour depicted a popular cartoon detailing the perioperative process
including the operating room and anesthetic induction with a face mask. The control group (n=
40) did not concurrently watch the VR alongside the child. Parental preoperative anxiety was
measured at two time points. The first measurement was on admission (T1), to establish a
baseline anxiety level before any intervention, and the second was after induction of anesthesia
(T2). Anxiety was measured using a 101 Numerical Rating Scale (NRS) with a score of 0
defined as no anxiety and a score of 100 defined as a high level of anxiety. Parents were present
in the operating room for induction. There was no difference in T1 anxiety scores between the
two groups. The T2 anxiety scores of the parents in the experimental group (30 [10–62.5]) were
lower than the parents in the control group (55 [40–80]; p = 0.025). The researchers also
measured anxiety levels of children in both groups and found a significantly lower mean anxiety
score in the experimental group. They suggest this may be due to parental empathy and
communication that was unavailable in the control group. Some limitations of this study are
small sample size, lack of a true control group, and measurement of anxiety at only two time
points. The children in the control group also received the VR intervention with the only
difference being that the parents did not simultaneously view on a mirroring device. A true
control group would have received the standard of care without intervention. Additionally, the

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 14
researchers did not measure postoperative anxiety. While the research showed a statistical benefit
to the VR tour, it is important to consider the whole perioperative period which should include
postoperative outcomes.
Phaneendra et al. (2022) conducted a randomized controlled trial to assess the effect of
video-based, preoperative preparation on parental anxiety when compared to standard
preparation. The experimental group (n= 36) was shown a short video of the operating room
setup and equipment on a smart phone, along with traditional verbal information. The control
group (n= 34) received standard verbal preoperative information. Parental anxiety was measured
at two time points using the APAIS questionnaire. The first measurement of anxiety (T1) was
upon arrival to the preoperative area before any intervention was done, while the second
measurement (T2) was done one hour after the child returned from the procedure in the recovery
room. The APAIS scores were significantly decreased at T2 in the experimental group (T1 25.47;
T2 14.92) using the Wilcoxon-Mann-Whitney U test (p < 0.001). The control group did not have
statistically significant reductions (T1 25.26; T2 24.56). Limitations of this study include small
sample size, and lack of an anxiety measurement between baseline and postoperative time points.
Berghmans et al. (2012) conducted a randomized controlled trial with two aims. The first
was to determine if a virtual tour shown the day of surgery could positively impact parental
anxiety levels. The second aim was to measure if the intervention had any effect on parental
assessment of their child’s anxiety when compared to the anesthesia provider’s assessment. The
experimental group (n= 60) viewed the virtual tour in the holding area before entering the
operating room and the control group (n= 60) received standard verbal information. The 4-
minute-long virtual tour depicted a fairy-tale-like story of a boy that outlined the admission
process. It displayed entrance to the operating theater, inhalation induction, and discharge from

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 15
the hospital. Parental anxiety levels were measured with the STAI and APAIS at three different
time points: baseline upon admission before intervention (TI), in the holding area after education
but before entering the operating theater (T2), and after leaving the operating theater
immediately after induction (T3). The researchers found the STAI scores gradually increased
over time in both control (T1 41.9; T2 43.6 (p < 0.05); T3 46.5 (p < 0.05)) and experimental
groups (T1 38.6; T2 38.3 (p < 0.05); T3 41.5 (p < 0.05)). By contrast, the APAIS only increased
in the control group (T2 10.9; T3 11.4 (p < 0.05) at T3 but not in the experimental group (T2 9.2;
T3 9.4). Intergroup comparisons between experimental and control groups at T2 and T3 showed
significant differences in both STAI and APAIS scores using the Bonferroni-corrected multiple
Mann–Whitney U-test. There was no statistical significance to show parental anxiety influenced
perception of the child's anxiety. Some limitations of this study are small sample size, and lack of
a true control group. The authors did not establish a control group devoid of intervention because
instead of providing the control with only standard verbal information, both groups received
written information. This was only mentioned in the discussion portion of the study not the
methodology. This heavily influences the outcomes of the control group as written information is
an intervention. The authors refer to the virtual tour in the study as an AVA but after
consideration for the content of the AVA and for the purposes of this paper, this intervention is
best classified as a virtual tour.
Audio-Visual Aid
Ji et al. (2015) conducted a randomized controlled trial to evaluate the effects of an online
AVA titled the drawMD APP on parental anxiety. This AVA is a supplementary tool that provides
a customizable drawing specific to the pediatric patient and their condition or procedure. The
primary objective of this study was to determine if using the AVA as an educational tool before

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 16
surgery would reduce preoperative anxiety in children and parents. The experimental group (n=
51) was given access to the online AVA and the control group (n= 51) only received standard
verbal information. Parental anxiety was measured at three different time points using APAIS
and STAI. The APAIS was completed before preoperative information (T1) and was reassessed
immediately after (T2) whereas the STAI was completed 6-24 hours postoperatively (T3). The
authors found no significant difference in T1 APAIS between both groups using independent
sample t-tests. However, at T2 there was a statistically significant difference in APAIS between
groups (18.92 ± 7.23 vs 25.18 ± 7.43; p <0.01). The authors found no difference in trait
(baseline anxiety) using the TAI but there was a difference in state (situational anxiety) using the
SAI. At T3, the authors found statistically significantly lower mean SAI scores in the
experimental group (30.10 ± 8.78) than the control group (36.25 ± 12.9; p < 0.05). Some
limitations of this study are small sample size, and lack of clarity regarding the time spent with
the AVA.
Fortier et al. (2015) conducted a randomized controlled trial to assess the efficacy of an
AVA on parental anxiety. The AVA was titled Web-based Tailored Intervention Preparation for
parents and children undergoing Surgery (WebTIPS). The authors validated the usability of
WebTIPS on 13 parent-child dyads prior to using it in the RCT. Parents in the experimental
group (n= 38) received unlimited access to the AVA seven days prior to surgery and seven days
post-surgery. Parents in the control group (n= 44) received standard verbal care. Anxiety was
measured using the STAI at two time points during this study: on the day of surgery in the
preoperative holding area after education (T1), and again upon separation from their child (T2).
Using independent sample t-tests and repeated-measures ANOVA, the experimental group had
significantly lower anxiety levels at T1 compared to parents in the control group (p = 0.02). No

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 17
significant differences were observed in parental anxiety levels at T2. Both groups experienced
an increase in anxiety from T1 to T2. Some limitations of this study are small sample size, lack
of baseline anxiety measurement, and lack of postoperative anxiety measurement. The authors
were unable to establish baseline anxiety because the parents had access to the AVA one week
prior to surgery. They were also given access to the AVA up to 7 days postoperatively, but no
measurement of postoperative anxiety was ever assessed. It could have been beneficial to track
how many parents revisited the AVA content postoperatively.
Shreyas et al. (2023) conducted a randomized controlled trial to measure the impact of a
multi-media tool on parental anxiety, comprehension, and satisfaction. This AVA was a
PowerPoint presentation shown during preoperative counseling and addressed all the
components of a surgical consent with photographs, tables, graphs, and details regarding the
procedure. Standard consent items were included in the AVA like the risks, benefits, alternatives,
length of stay, pre and postoperative course, follow-up, and complications. The outcomes were
measured using the STAI for parental anxiety, a 5-question knowledge-based test for
comprehension, and a 4-point Likert-based questionnaire for satisfaction. The experimental
group (n= 61) was given the AVA as preoperative teaching, whereas the control group (n = 61)
received only standard verbal education. Parental anxiety was measured at two time points using
the STAI. The first measurement (T1) was taken at the initial encounter with the surgical team,
but before education, and the second measurement (T2) was taken after surgical consent. Data
was analyzed using the χ! test, Fischer Exact, Mann Whitney U, and Independent Sample t-tests.
The T1 scores were not significantly different between the experimental and control groups.
Both groups showed a decrease in SAI from T1 to T2, however, the mean percent reduction in
the experimental group (44.64 ± 10.14) was statistically significantly more than the control

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 18
group (26.6 ± 11.91; p = 0.0001). A limitation of this study is the lack of postoperative anxiety
measurement.
Jin et al. (2021) conducted a randomized controlled trial to determine the effect of an
animated cartoon on anxiety in the perioperative period. The experimental group (n= 50)
watched an AVA, while the control group (n= 50) received standard verbal information. The AVA
depicted a popular cartoon tiger named Qiaohu, who detailed the anesthetic and surgical process
including operative risk and disease outcomes. It was shown to parents and children in the
experimental group three times, for 10 minutes at a time, because a pre-experiment trial
concluded that children who watched the AVA once were not captivated. Parental anxiety was
measured using the STAI scale at three time points. All subjects were admitted to the hospital
one day prior to surgery at which time the researchers conducted an initial preoperative interview
and measured baseline anxiety scores (T1). After education, anxiety was measured again in the
pre-anesthetic holding area the morning of surgery (T2). Anxiety was measured a third time just
prior to anesthesia induction (T3). Scores were analyzed between groups using two-sample ttests and Kruskal-Wallis test. Parental anxiety increased from T1 to T3 in both groups. However,
the authors found statistically significantly higher increases in anxiety scores of the control group
(T1 40.6 ± 6.28, T2 45.3 ± 9.75, T3 47.4 ± 13.4) when compared to the experimental group (T1
39.4 ± 7.06, T2 40.2 ± 10.45, T3 43.3 ± 8.58; p < 0.05). Overall, parents in the experimental
group had significantly less anxiety when compared to parents in the control group. A limitation
of this study lies in the difficulty to reproduce results with the AVA. It requires multiple viewing
times, and it is tailored to meet the needs of preschool-aged children.
Systematic Reviews, Meta Analyses, and Narrative Reviews
Kim et al. (2019) conducted a systematic review of 38 research studies (33 randomized

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 19
controlled trials and 5 non-randomized controlled trials). The goal was to synthesize findings
regarding the effectiveness of technology-based preoperative preparation programs on anxiety of
children and their parents. Studies were reviewed if they used the following technological
interventions: video (n = 15), videos with additional teaching material (n = 7), tablet-based
technologies (n = 12), internet or web-based technologies (n = 3), and VR programs (n = 1).
Parental anxiety was measured in 21 of the 38 studies. Fifteen studies used preoperative video
preparation, and nine of those measured parental anxiety. Seven of those nine studies found a
significant reduction in parental anxiety levels when compared to a control group. Of the seven
studies that compared the use of a video with additional teaching material, five measured
parental anxiety and three found a decrease. The additional practices compared to video included
written information, operating room tour, coping mechanisms, or a peer modeling video. One of
the effective studies compared three modalities against each other (video, written, and standard
verbal teaching). That study found anxiety was significantly decreased in both video and written
information groups. Additionally, that study found a video intervention 24-hours before an
operation to be most effective. Ultimately, researchers found the greatest decrease in anxiety in
the parents who received the most extensive preoperative education program (i.e. video + tour or
peer modeling, video + complementary booklet, etc.). Twelve studies assessed the efficacy of
tablet-based technologies and five measured parental anxiety. However, only one found a
significant reduction in anxiety. Three studies examined the effect of internet or web-based
technologies but only two measured parental anxiety. Of those two, only one study found webbased intervention to significantly reduce parental anxiety while the other did not. The authors
only examined the efficacy of VR intervention from one study which did not measure parental
anxiety. Ultimately, the authors concluded that video education is more effective than written

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 20
information, non-medical videos, or standard verbal information. They suggested that videos
alone may suffice as preoperative preparation to reduce parental anxiety. Some limitations of this
systematic review include high variability between studies, and overgeneralization of the term
video. Examples of variability among studies included lack of consistency on time points
measured, differences in sample size, and a 43-year range of studies reviewed. The authors
attempted to organize the studies by intervention, but several intervention categories overlapped.
For example, one study using a YouTube video was categorized under tablet, but not under video
or web-based intervention. Additionally, almost half of the studies in the video category were
older than 1990, which means video use in the preoperative area was a novel concept. It is
inappropriate to compare the effect of a video on parents in the 1980’s to the effect of a video on
modern parents, given the advances in technology that have taken place during the intervening
years. None of the randomized controlled trials had a high risk of bias, however, all five nonrandomized controlled trials showed high levels of potential for bias.
Nytun et al. (2022) conducted a systematic review and meta-analysis of eight randomized
controlled trials to evaluate the effect of a web-based preoperative preparation program on
parental anxiety. Web-based interventions are combined digital interventions that include some
or all the following elements: text, sound, graphics, animations, and/or video. Of the eight
studies, five used either STAI or the APAIS to measure parental anxiety and only 2 studies
obtained baseline anxiety levels. The meta-analyses of four studies reported as standardized
mean difference showed web-based preoperative information significantly decreased parental
anxiety (p = 0.002). The authors found that differences in time points affected statistical
significance of the data. There was statistical significance when the post intervention anxiety
measurement was taken before separation of the child or after surgery (p < 0.001; p = 0.01,

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 21
respectively). However, such statistical significance was not demonstrated if the postintervention measurement was taken at or immediately after separation from their child (p=
0.35). The biggest limitation of this meta-analysis is the small number of articles examined.
Santapuram et al. (2021) conducted a narrative review of 33 articles on targeted
interventions for reducing preoperative parental anxiety. Interventions were included if there was
preliminary evidence of positive outcomes in reducing parental anxiety. The interventions
included education, play, music, parental presence, and integrative preparation programs. This
literature review only examined the education and integrative preparation programs. The
education category was subdivided into either paper-based information or audiovisual
information. Several studies showed information without an interactive component, such as a
booklet or leaflet, may demonstrate mixed efficacy, meaning it was effective in some studies, and
ineffective in others. Moreover, variation in the types of materials provided, delivery style, and
surgical populations make it difficult to ascertain conclusions regarding efficacy. Results were
found to be inconclusive regarding written information. The use of audiovisual devices was
found to be most effective when directed at the parent alone and delivered before the day of
surgery. Video education appeared to be more effective than booklets and standard methods,
whereas virtual reality tours were found to have mixed effectiveness. Interactive preoperative
programs combined multiple interventions from different categories such as written information,
play therapy, and video. These programs were found to significantly reduce parental anxiety but
are difficult to reproduce for several reasons. These include variety of interventions, extent and
timing of the interactions, and difference in anxiety measurement tools. One preparation
program, ADVANCE, was compared against three other interventions (oral midazolam, parental
presence, and standard of practice). It targeted parents and consisted of: anxiety-reduction,

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 22
distraction, video modeling and education, adding parents, no excessive reassurance, coaching,
and exposure/shaping. This group had the most significant reduction of parental anxiety in the
preoperative area and after anesthesia induction. Moreover, the children in this group also had
significantly reduced delirium, hospital stay, and analgesic requirement. This may be attributed
to the significant reduction in parental anxiety. While these types of programs are effective, they
are costly because they are multifaceted. Further research on the individual components of
preparation programs like ADVANCE are warranted. A limitation of this review is the lack of
statistical comparison between studies. This makes it difficult to distinguish which methods are
superior to others.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 23
Chapter 4
Results
This literature review examined 15 articles to address two specific aims. The first was to
identify the information modality that is most effective in reducing parental anxiety. The second
was to synthesize these findings into best practice recommendations for anesthesia providers in
the perioperative setting. Included were 11 randomized controlled trials, one quasi-experimental
study, one systematic review, one meta-analysis, and one narrative review. The most common
modalities in the literature were written information, virtual tours, and AVAs. Four studies were
included for each modality and were analyzed based on statistical significance.
Among the four articles that compared written information to standard verbal
preoperative information, written information proved effective in reducing parental anxiety in at
least one time point in three studies (Landier et al. 2017; Afzal et al. 2022; Bartik & Toruner
2018). Two of the three studies that demonstrated effectiveness of written intervention measured
anxiety using VAS. Landier et al. (2017) compared the effect of a written brochure versus verbal
education on parental anxiety levels at two time points. Afzal et al. (2022) compared the effect of
a printed brochure versus verbal education on parental anxiety levels at three different time
points. At the second time point, anxiety scores of parents in the experimental group were
significantly lower than the scores of parents in the control group. However, mean baseline
anxiety scores of parents in the experimental group were significantly higher and there was no
difference in scores at time point three in the postoperative care unit between groups. Bartik and
Toruner (2018) compared the effect of a written booklet versus verbal education on parental
anxiety. There was a significant difference in mean SAI scores between the experimental group
and control group in favor of the written intervention. Unlike the previously mentioned studies,

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 24
Cumino et al. (2013) did not find any difference in anxiety levels amongst parents in their study.
They only measured parental anxiety at one time point immediately after preoperative teaching
without having established baseline parental anxiety scores for comparison. Landier et al. (2017)
had two pertinent findings, first, 20% of parents in the control group requested a written handout
to reference later. Second, only half of the information conveyed verbally was actually retained
and understood.
In the four articles examining the efficacy of a virtual tour versus standard verbal
information, three articles showed significant reductions in parental anxiety against the control
group (Park et al., 2019; Phaneendra et al., 2022; and Berghmans et al., 2012). Two of the three
studies demonstrated effectiveness of a virtual tour using the APAIS to measure parental anxiety.
Park et al. (2019) studied the effect of a 4-minute virtual reality experience on children with a
virtual reality headset while parents simultaneously co-experienced by watching on a computer
monitor. The experimental group saw a dramatic reduction in parental anxiety. The statistical
significance of the parental anxiety reduction speaks to an important finding: co-experienced
interventions may be more efficacious than parent or child experience alone. Phaneendra et al.
(2022) measured the effect of viewing a short informative video via smartphone during the
preoperative period against standard verbal instruction. Parents in the experimental group saw
dramatic reductions in anxiety scores compared to the control group. Berghmans et al. (2012)
studied the effect of a 4-minute virtual tour. Both groups saw increases in STAI scores as time
points progressed, but the APAIS only significantly increased in the control group. One article
pertaining to virtual tours did not show statistical benefit. Eijlers et al. (2019) was the largest of
these four studies and was similar to Park et al. (2019) in that it was a co-experienced mirroring
displayed video for the parent. The authors found no statistically significant reduction of parental

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 25
anxiety in the experiment group.
Lastly, four articles assessed the efficacy of AVAs to reduce parental anxiety compared
to standard verbal information. Of the four, three showed a reduction in anxiety (Ji et al. 2015;
Shreyas et al. 2023; Jin et al. 2021). One of the four studies did not show statistically significant
differences in anxiety levels between groups (Fortier et al. 2015). All studies that examined the
effectiveness of an AVA used STAI to measure parental anxiety. Ji et al. (2015) evaluated the
effect of an AVA on parental anxiety against standard verbal preoperative information. Their AVA
was a supplementary tool with customized drawings specific to the pediatric patient and their
condition or procedure. There was no difference in APAIS between groups at baseline, and there
was a significant decrease in anxiety in the experimental group throughout time points.
Additionally, the experimental group had a lower STAI. Shreyas et al. (2023) studied the effect
of a multimedia tool on parental anxiety. Baseline anxiety scores were not significantly different
between the experimental and control group. Both groups had a reduction in SAI, however, the
experimental group had a more significant reduction. Jin et al. (2021) examined the effect of an
AVA on parental anxiety against standard verbal preoperative information. The AVA depicted the
process of anesthesia and surgery. The control group had significantly higher increases at each
time point. Fortier et al. (2015) assessed the effect of an AVA for parents and children undergoing
surgery on reducing preoperative anxiety against standard verbal information on 82 subjects.
This AVA contained standardized information regarding the perioperative period. The
intervention group had lower anxiety after education compared to the control group, however,
there were no significant differences in anxiety levels upon separation to the OR.
Practice Recommendations
While standard verbal communication may convey all the pertinent information

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 26
necessary, only half is retained and understood (Landier et al., 2017). Written information is
inexpensive, reproducible, and easily referenced. Some common forms of written information
include leaflets, pamphlets, and brochures. All these offer standardization and consistency of
information between facilities and can be referred to by the parent in the future should any
anxiety-provoking questions arise. Written information is easily customizable to different
procedures allowing for appropriate use between patients and situations.
While virtual tours proved to be highly efficacious, this modality is not easily transferable
to other sites because it is customized to depict the originating facility. It may be difficult for
some facilities to recreate a high-quality tour with custom content for various procedures and
patient populations. This may necessitate additional tools like written documents to supplement
missing information. The requirement for provision and utilization of supplemental written
material undermines the effectiveness of spending time and resources to design a virtual tour.
Although technology-based interventions provide an immersive level of education, many
of the AVAs, like the virtual tours, were customized to a particular site. This limits the use of the
AVA to the original content creator’s facility. Additionally, it may not be feasible for most sites to
fund the development of a customized AVA. Use of technology-based interventions may also
impact reproducibility and require the need for other information modalities like written or
verbal education.
Best Practice Recommendations:
1. Written leaflet, pamphlet, or brochure should be used alongside standard
preoperative verbal education as a tool for the provider to ensure no key points are
missed.
2. Written leaflet, pamphlet, or brochure with procedure specific information should be

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 27
given at the end of standard preoperative verbal education at either the consultation
or day of surgery interview.
3. Written leaflet, pamphlet, or brochure should include the following content:
o Preoperative information regarding fasting, arrival time, and medication
adherence
o Procedure specific instructions
o Postoperative instructions on when to resume medications and feeding,
wound care, and when to follow up with the physician
o Explanation of different types of anesthetics, risks and benefits,
intraoperative monitoring, and complications

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 28
Chapter 5
Discussion
Through a review of the recent literature, there is evidence to support the need for
providing parents of pediatric patients with more than standard verbal information regarding the
perioperative process. Studies show information and anxiety are inversely related. Appropriate
information, education, and preparation before surgery results in decreased parental anxiety.
Well-informed parents are better able to cope with stressors of the perioperative period and thus
less likely to experience heightened levels of anxiety, which could potentially transfer to the
child.
The literature analyzed in this review showed strength in its low likelihood of bias due to
the inclusion of many randomized controlled trials and high-level evidence. Of the 12 articles
organized into the 3 categories of interventions, only one article, Bartik and Toruner (2018), was
not a randomized controlled trial. The studies shared similar patient populations, demographics,
age, ASA physical status, and surgical setting, which improves generalizability of the findings.
A primary limitation of the data is the use of various scales to measure parental anxiety.
The majority (n= 7) of the 12 randomized controlled trials used the STAI. The STAI is ideal
because it measures both state and trait anxiety which highlights the presence of baseline anxiety.
The other studies used the VAS (n= 2), NRS (n= 1), HAM-A (n= 1), and APAIS (n= 3) to
measure anxiety. The use of different scales makes it difficult to compare studies against each
other. Cumino et al. (2013) modified the HAM-A scale to their own preference, therefore,
potentially threatening the validity of the data by manipulating the anxiety scale to produce more
favorable results. Another limitation posed in the literature includes small sample sizes. Half of
the research studies (n= 6) had sample sizes less than 100, and half (n= 6) had greater than or

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 29
equal to 100. Lastly, another common deficit in all studies was the time points in which the data
was collected. There was inconsistency in the presence of a baseline anxiety measurement, how
many overall anxiety time points were measured, and variability between time point intervals.
Nytun et al. (2022) discussed the importance of timing on outcome measurements. Some
researchers would forgo measuring anxiety at the time of parent and child separation while
others would use this time as their final measurement of anxiety. This inconsistency can
drastically alter the study results because the time in which parent and child are separated
represents the highest stress and anxiety time. Thus, data must be collected at this time point
rather than ending at this time. Ideally, anxiety should be measured at the following time points:
T1 should be a baseline anxiety measurement, T2 should be measured after education delivery
when in the preoperative holding area and before separation from the child, and T3 should be
measured after the procedure once the child is back with the parent in recovery.
Although the evidence may suggest one intervention to be superior to another, the data
indicate that any information is superior to none. If a facility can provide additional parent
education in either written, virtual-tour, or AVA form, they should implement that over the
current standard of practice. More research should explore using written information to educate
and inform parents. Written information is often overlooked for more creative information
modalities, but it is easily reproducible, inexpensive, and effective at disseminating information
when timed appropriately. The provider must consider the limitations of written information,
such as literacy, culture, education level, and language.

PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 30
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PARENTAL ANXIETY IN PEDIATRIC PERIOPERATIVE SETTING 36
Appendix A

Abstract (if available)

Abstract There are many factors that influence the outcomes of pediatric patients during the perioperative process. One of those factors is the level of anxiety experienced by parents. Parental anxiety in the pediatric perioperative setting is directly correlated with the level of pediatric patient anxiety and anxiety has deleterious effects on the child. Some of those effects are increased anesthetic requirement, increased postoperative pain, and increased postoperative nausea and vomiting. All of these can lead to an overall increased hospital length of stay. Current research in this area is exploring ways to mitigate parental anxiety through the modality in which information is delivered to parents. While information delivery has traditionally been given verbally to parents, the evidence shows that this is insufficient. Some common alternative information modalities aimed at reducing parental anxiety are written formats, virtual tours, and audiovisual aids. These are all affective at reducing parental anxiety because the more education and preparation provided to parents decreases the level of anxiety they will experience. However, of the three aforementioned information modalities, the use of a written tool is easily reproducible, cost effective, and standardizable across many facilities.

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Creator Gabbert, Jaclyn (author)

Core Title Parental anxiety in the pediatric perioperative setting: an integrative literature review with best practice recommendations for perioperative information delivery to reduce parental anxiety

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Degree Conferral Date 2025-05

Publication Date 11/18/2024

Defense Date 10/09/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag Anxiety,anxiety pediatrics,parental anxiety,pediatric surgery,Pediatrics,perioperative anxiety,perioperative education,perioperative information delivery

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