In this follow-up dismantling report, we found that greater parental adherence to components of the ADVANCE family-centred preparation programme was associated with lower child anxiety before surgery. Through dismantling the multi-component intervention and examining each specific component independently, we determined that practising with the anaesthesia mask at home and parental planning and use of distraction in the holding area were the two components that emerged as having a significant impact on children's anxiety. However, not only did children experience significantly less preoperative anxiety when their parents were adherent to mask practise and use of distraction, their anxiety tended to remain stable and relatively low throughout the preoperative period. In contrast, those children whose parents were not adherent to these intervention components experienced escalating anxiety as they progressed from holding to introduction of the mask.
Considering the detrimental effects of preoperative anxiety on children's clinical and behavioural recovery from surgery,5,17
identification of critical components of interventions to reduce preoperative distress is needed. This is particularly important because children are seldom provided with comprehensive preoperative preparation in the hospital setting. In fact, recent research by our group illustrated that on the day of surgery, anaesthesiologists and nurses spent just minutes with families before surgery.18
Also, although presurgical sedatives, such as midazolam, are effective interventions for preoperative distress, administration is not always possible, given the timing in onset of action in the context of a busy surgical setting. Alternatively, our group developed and examined the efficacy of a comprehensive behavioural, family-centred preparation programme (ADVANCE) that was shown to be as effective as midazolam in reducing children's preoperative anxiety.6
Although this multi-component intervention was effective, parental use of distraction in the preoperative holding area and practise with the anaesthesia mask at home emerged as two components of the programme that were associated with lower child anxiety. Distraction has consistently been shown to be an effective intervention in managing children's anxiety in the medical setting.7
Similarly, mask practise at home before exposure to anaesthesia induction combines the behavioural training features of exposure to the potentially feared stimulus and shaping of the children's adaptive responses when presented with the mask in the OT before induction.7,10
These features of the ADVANCE programme seem crucial to its efficacy, and should be strongly emphasized during training.
Although this report supports the necessity of distraction and practise with the mask at home, it does not specifically address the sufficiency of those components when used alone for reducing children's preoperative anxiety. These components were presented within the context of a family-based intervention package. Additional research should address which of the other intervention components can be eliminated in an effort to streamline the intervention without detrimental effects. We also note that while most parent and child characteristic and psychological factors, such as child temperament and parent anxiety, were not associated with adherence to the treatment programme, child gender and parental education were two factors that did demonstrate such a relationship. Therefore, it may be prudent to determine whether aspects of these patient characteristic variables impacted adherence. For example, perhaps level of education was a barrier to optimally implementing the intervention and therefore may require modifications to the intervention itself.
The process of development, testing, and refinement of interventions that decrease children's preoperative anxiety includes multiple stages. Dismantling reports like this one in which necessary components are identified is a valuable step that helps inform the development of streamlined and therefore more easily disseminated interventions. This intervention refinement process is essential for the production of cost-effective interventions for reducing anxiety and anxiety-related post-surgical complications in children undergoing surgery.
This dismantling analysis is an important step in that process and highlights shaping and exposure (i.e. practise with the anaesthesia mask) and parental use of distraction in the surgical setting as two beneficial components to any preoperative preparation programme that will be designed in the future. When these particular intervention components are implemented, children are not only taken into the OT in a significantly calmer state, their anxiety remains relatively stable throughout the preoperative process. Given the strong relationship between preoperative anxiety and postoperative recovery, effective means of preventing high anxiety in the surgical setting are needed.