The current study examined adult behaviors during induction of anesthesia in children when parents are present. To our knowledge, this was the first study to examine multiple individuals who interact with children during induction of anesthesia and evaluate the relation between discrete, trainable, behaviors and children’s distress and coping.
Six hypothesis-driven adult behaviors were examined based on previous literature in pediatric procedural pain. Overall, nurses engaged in the lowest rates of all behaviors when compared to anesthesiologists and parents. Parents and anesthesiologists displayed relatively comparable rates of most behaviors. In terms of differences, anesthesiologists used more medical reinterpretation than parents and parents used more empathic touch than anesthesiologists. Correlations indicated that anesthesiologists’ and parents’ rates of most behaviors were correlated as were rates of nurses’ and parents’ behaviors. Taken together, these findings highlight the interactive nature of anesthesia induction with parents present. It is likely that parents take their cues from anesthesiologists and nurses on how to behave during the induction; when anesthesiologists use more nonprocedural talk and humor, so do parents. It is also possible that children drive these relations; adults may behave similarly because they are responding to the same behaviors from the child. These findings could have important implications for intervention. Training each parent who will be present at anesthesia induction is a time consuming process. Results presented here suggest that healthcare personnel may be able to directly affect parents’ behavior by engaging in higher rates of desirable behaviors themselves.
The current study also examined relations among adults’ behaviors and children’s distress and coping during anesthesia induction. Two commonly co-occuring distracting behaviors, nonprocedural talk and humor were significantly positively related to children’s coping and negatively related to children’s distress. Both nonprocedural talk and humor may reduce children’s distress through extinction (i.e., by ignoring the behavior thus removing any positive consequences such as attention) and have the added benefit distracting children by directing attention away from the potentially distressing medical procedure.
One of the most striking findings of the current report is the strong positive relation between adults’ emotion-focused behaviors (reassurance, empathy, empathic touch) and children’s distress. This finding is likely to incite discussion as it is both counter intuitive and contradictory to typical training of physicians in communication skills.18
This finding is consistent, however, with at least four randomized controlled trials of emotion-focused type behavior on children’s acute distress.7,8,9,19
Each of these studies was conducted by a different research group, used a different methodology, and three of the four included a different pain stimulus thereby supporting the generalizability of these results. In terms of an explanation of this effect, authors have hypothesized that reassurance may cue children to be distressed by communicating to the child that the situation should be of concern or may serve to direct attention toward the unpleasantness of the situation, thereby increasing distress.20
This study also examined the behavior of medical reinterpretation which is defined as attempts to provide information on the induction procedure while reframing the procedure as less threatening (perhaps even fun). Not surprisingly, this behavior was more commonly engaged in by anesthesiologists than parents or nurses. Interestingly, this behavior showed little concordance across adults: parents were not necessarily more likely to use reinterpretation when anesthesiologists were (or vice versa). In terms of outcomes, anesthesiologists’ use of reinterpretation was related to children’s regulating behaviors; children displayed a higher rate of regulating behaviors when anesthesiologists used more reinterpretation. The somewhat contradictory results of reinterpretation being used by parents rather than anesthesiologists were surprising. There was a positive association between parent rate of reinterpretation and children’s distress. The explanation for this finding is unclear. It is possible that parents are unfamiliar with equipment in the operating room and therefore are less successful in interpreting it as non-threatening. Alternatively, it is possible that parents become more involved in reinterpretation when the child is more distressed. To our knowledge, this is the first time that medical reinterpretation has been described in the literature and thus more research on this behavior and its impact on children’s distress is needed.
Several methodological issues with the current study should be noted. First, although measures were taken to reduce reactivity (e.g.., participants were informed only of the general nature of the study, length of study), it may be that participants’ behavior changed as a result of being observed. Second, this study was carried out in one pediatric surgery center and thus results may not be widely generalizable outside such a center or to centers with different standards of practice. For example, although nurses showed significantly lower rates of the coded behaviors in this study, we are aware of other surgery centers in which nurses play the most prominent role in the induction. Third, this study did not take into account adult behaviors in the waiting area or at other times prior to surgery. There is little question that the behaviors of adults in these time periods influence children’s distress and we do not intend to minimize these effects here. However, given the relatively large effect sizes found in this study, we assert that interactions during the induction can affect children’s experiences with this procedure. Fourth, this study was conducted with children who did not receive sedative premedication. Although it is our impression that the efficacy of specific anesthesiologist and nurse behaviors would generalize to children who were premedicated, further studies should be conducted to examine interactions with children who have received this intervention. Finally, it is also important to note that given the correlational nature of the current data, it is impossible to conclude that it is adults who are affecting children, as opposed to the children affecting adults. Future work in this area should consider sequential analysis to gather support for causation.21
Experimental intervention studies will be needed to confirm these hypotheses. Despite these limitations, this study has methodological strengths which support the validity of the findings. Specifically, this is the largest scale study collecting observational data of healthcare providers, parents, and children during acute medical procedures. Further, the examination of discrete behaviors strengthens the clinical utility of the findings.
In sum, the current study examined adults’ behaviors during anesthesia induction. Behaviors were identified that were related to increased and decreased distress and coping in children. These behaviors were relatively straightforward and should be easy to teach and incorporate in practice. These results should be considered preliminary, however and should be confirmed via sequential analyses and randomized controlled trials. Further, future work should consider potential moderators of effects (e.g., child temperament, previous surgical experience). Once confirmed, these behaviors could be easily incorporated into standard practice and effectively influence children’s distress prior to and during anesthesia induction.