Reducing preoperative anxiety with Child Life preparation prior to intravenous induction of anesthesia: A randomized controlled trial

Ethical and practical considerations of pediatric refusal in clinical anesthesia: An educational review

Children commonly refuse induction of anesthesia. Anesthesia providers must then decide whether to honor the child's dissent or to proceed over objection. In some circumstances, a forced induction involves restraining the child, incurring both practical and ethical harms to the patient-provider encounter. This educational review explores the practical dilemma encountered when a child dissents to induction of anesthesia. In the course of exploring this dilemma, dissent and associated terms are defined and compared, and the prominent ethical underpinnings regarding pediatric decision-making are described to clarify dissent as an ethical and practical concept. Important legal and professional standards are summarized, and practice trends are discussed to depict the current state of practice, including novel approaches to honoring pediatric dissent for elective surgeries. This information is then used to invite providers to consider where they ethically situate themselves within a legally and professionally defined space of acceptable practice. Finally, these considerations are synthesized to discuss important nuances regarding pediatric refusal, and some key questions are presented for clinicians to ponder as they consider their practice of choosing whether to honor pediatric dissent at induction.

Effective dose of intranasal remimazolam for preoperative sedation in preschool children: a dose-finding study using Dixon's up-and-down method

Background

Most preschool children are distressed during anesthesia induction. While current pharmacological methods are useful, there is a need for further optimization to an "ideal" standard. Remimazolam is an ultra-short-acting benzodiazepine, and intranasal remimazolam for pre-induction sedation may be promising.

Methods

This study included 32 preschool children who underwent short and minor surgery between October 2022 and January 2023. After pretreatment with lidocaine, remimazolam was administered to both nostrils using a mucosal atomizer device. The University of Michigan Sedation Score (UMSS) was assessed for sedation 6, 9, 12, 15, and 20 min after intranasal atomization. We used Dixon's up-and-down method, and probit and isotonic regressions to determine the 50% effective dose (ED50) and 95% effective dose (ED95) of intranasal remimazolam for pre-induction sedation. Results: Twenty-nine pediatric patients were included in the final analysis. The ED50 and ED95 of intranasal remimazolam for successful pre-induction sedation, when processed via probit analysis, were 0.65 (95% confidence interval [CI], 0.59-0.71) and 0.78 mg/kg (95% CI, 0.72-1.07), respectively. In contrast, when processed by isotonic regression, they were 0.65 (95% CI: 0.58-0.72 mg/kg) and 0.78 mg/kg (95% CI: 0.69-1.08 mg/kg), respectively. At 6 min after intranasal remimazolam treatment, 81.2% (13/16) of "positive" participants were successfully sedated with a UMSS ≧ 1. All the "positive" participants were successfully sedated within 9 min.

Conclusion

Intranasal remimazolam is feasible for preschool children with a short onset time. For successful pre-induction sedation, the ED50 and ED95 of intranasal remimazolam were 0.65 and 0.78 mg/kg, respectively.

Evaluación enfermera de la ansiedad prequirúrgica pediátrica: estudio cualitativo

Resumen Objetivo: explorar y describir cómo las enfermeras perioperatorias evalúan e interpretan el comportamiento del niño antes de entrar a quirófano, identificando las estrategias que utilizan para minimizar la ansiedad y las propuestas de mejora. Método: estudio cualitativo descriptivo mediante entrevistas semiestructuradas y observación participante de las rutinas diarias. Análisis temático de los datos. El estudio sigue las recomendaciones de criterios para la publicación de artículos de metodología cualitativa Consolidated Criteria for Reporting Qualitative Research. Resultados: cuatro temas surgieron de los datos: a) evaluación de la ansiedad o comunicación estrecha con el niño y su familia; b) valorando lo observado; c) manejando la ansiedad y d) mejorando la evaluación o propuestas de mejora para la práctica diaria. Conclusión: enfermeras evalúan la ansiedad en su práctica diaria de forma observacional utilizando el juicio clínico. La experiencia de la enfermera es determinante en la adecuada evaluación de la ansiedad prequirúrgica del niño. La falta de tiempo entre la espera y el momento de entrar a quirófano, la mala información que tiene el niño y los padres sobre el proceso quirúrgico y la ansiedad de los padres dificultan la evaluación y el manejo correcto de la ansiedad.

Avaliação de enfermagem da ansiedade pré-operatória pediátrica: um estudo qualitativo?

Resumo Objetivo: explorar e descrever como as enfermeiras perioperatórias avaliam e interpretam o comportamento da criança antes de entrar na sala de cirurgia, identificando as estratégias que utilizam para minimizar a ansiedade e as propostas de melhoria. Método: estudo qualitativo descritivo utilizando entrevistas semiestruturadas e observação participante das rotinas diárias. Análise temática dos dados. O estudo segue os critérios recomendados para publicação de artigos da metodologia qualitativa Consolidated Criteria for Reporting Qualitative Research. Resultados: quatro temas emergiram dos dados: a) avaliação da ansiedade ou comunicação próxima com a criança e sua família; b) analisando o que foi observado; c) controlando a ansiedade e d) melhorando a avaliação ou propostas de melhoria na prática diária. Conclusão: as enfermeiras avaliam a ansiedade em sua prática diária por meio da observação e usando julgamento clínico. A experiência da enfermeira é decisiva na avaliação adequada da ansiedade pré-operatória da criança. A falta de tempo entre a espera e o momento de entrar na sala de cirurgia, a escassez de informação que a criança e os pais têm sobre o processo cirúrgico e a ansiedade dos pais, dificultam a avaliação e o controle adequado da ansiedade.

Exploration and Application of the Peri-anesthesia Nursing Management Mode of the Five-Sphere Integrated Plan

Objectives: The objective of this research was to test the application of peri-anesthesia nursing management (anesthesia preparation room, operating room, recovery room, post anesthesia visit, and anesthesia general management) on hospital services. Methods: We used a quantitative research design to collect data from 311 nurses, with structural equation modeling used for data analysis. Results: The application of the peri- anesthesia nursing management mode of the five-sphere integrated plan impacted hospital services for patients. Conclusion: The practice of the five-sphere integrated mode not only highlighted the professional characteristics of anesthesia nursing, but also ensured the quality of medical treatment of patients during peri-anesthesia, and provided new ideas and references for nursing management of other specialties.

Nursing evaluation of pediatric preoperative anxiety: a qualitative study

OBJECTIVE

to explore and describe how perioperative nurses assess and interpret the child's behavior before entering the operating room, identifying the strategies they use to reduce anxiety and the proposals for improvements.

METHOD

descriptive qualitative study using semi-structured interviews and participant observation of daily routines. Thematic analysis of data. This study follows the recommended criteria for publication of articles of the qualitative methodology Consolidated Criteria for Reporting Qualitative Research.

RESULTS

four topics emerged from the data: a) assessment of anxiety or close communication with the child and their family; b) evaluating what was observed; c) managing anxiety and d) improving the assessment or proposals for improvements in daily practice.

CONCLUSION

nurses assess anxiety in their daily practice through observation using their clinical judgment. The nurse's experience is decisive for the appropriate assessment of the preoperative anxiety in child. Insufficient time between waiting and entering the operating room, lack of information from child and their parents about the surgical procedure, and parental anxiety make it difficult to assess and properly manage anxiety.

Foster children's perspectives on participation in child welfare processes: A meta-synthesis of qualitative studies

The objective of this meta-synthesis was to systematically synthesise qualitative research that explores foster children's perspectives on participation in child welfare processes. Searches were conducted in Medline (OVID), Embase, PsycINFO, and Social Science Citation Index. Children in non-kinship foster care in any setting (high-income, middle-income, low-income countries) who self-reported their experiences of care (removal from home, foster family processes, placement breakdown) were eligible for inclusion. Selected studies took place in 11 high-income countries. A total of 8436 citations were identified and 25 articles were included in this meta-synthesis. Studies summarized the views of 376 children. Children had been in foster care between two weeks and 17 years. Findings synthesize 'facets' of children's participation (e.g., being asked vs making decisions), as well as children's perceived barriers and facilitators to participation. A main priority for children was the quality of their relationships, especially in terms of values (e.g., fairness, honesty, inclusivity). No one way of participating in child welfare processes is better than another, as some children more clearly expressed a desire for passive listening roles and others indicated a desire for active roles in decision-making. However, meaningful adults in foster children's lives have a responsibility to act in a way that strengthens the emphasis on children's needs and voices.

ADV6209 for Premedication in Pediatric Anesthesia: A Double-Blinded, Randomized Controlled Trial

ADV6209, a new formulation of midazolam with the addition of γ-cyclodextrin for oral use, has recently been licensed as the first pediatric sedative in the European Union. We compared the clinical efficacy of ADV6209 to the standard formulation of midazolam in premedication to reduce anxiety in children before anesthesia induction in a randomized, double-blinded controlled trial. Eighty children (ASA I/II; age: 2–8 years) scheduled for elective surgery were randomized to receive 0.25 mg kg−1 of either conventional midazolam or ADV6209. Assessment tools included the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) as well as scores for oral acceptance of the premedication and facemask acceptance during inhalational anesthesia induction. Mann–Whitney U and Pearson’s chi-square tests were used for comparisons of outcome parameters. The primary outcome parameter of the study (mYPAS-SF anxiety score 30 min after the drug administration) did not reveal any significant intergroup difference between the ADV6209 group and the conventional midazolam group. Both drugs revealed their efficacy in reducing anxiety and in providing adequate sedation. The premedication dose was accepted by all children in the ADV6209 but rejected by 15% in the conventional midazolam group (p = 0.037). Acceptance of facemask placement was not found to differ significantly. No adverse events related to the study medications were noted. ADV6209 was better orally accepted than the conventional midazolam preparation and proved its efficacy in reducing preoperative anxiety. This clinically interesting preparation may alleviate the premedication process of 2−8 year-old children and obviates off-label drug use.

Role of information and preparation for improvement of pediatric perioperative care

The perioperative period is a significant and stressful experience that may cause negative consequences in children, both in a short-term and long-term perspective. Despite a wide base of evidence stating the importance of adequate preparation to reduce anxiety, improve coping, cooperation and enhance recovery, many children continue to report that they feel unprepared for their perioperative experience. To secure children's right to request and need for preparation, the content, format, and availability of existing programs need to be scrutinized. Preparation programs in perioperative care must change from simply providing information to embracing the importance of children's need to process the information provided in order to learn and understand. Interactive web-based technology can function as a significant resource for preparation of children for perioperative procedures. By changing perspective from children's need for information to their need for learning and by developing preparation programs including adequate educational principles, web-based technology can be used to its fullest advantage as a healthcare learning and preparation resource.

Children's informed signified and voluntary consent to heart surgery: Professionals' practical perspectives

Background:

The law and literature about children’s consent generally assume that patients aged under-18 cannot consent until around 12 years, and cannot refuse recommended surgery. Children deemed pre-competent do not have automatic rights to information or to protection from unwanted interventions. However, the observed practitioners tend to inform young children s, respect their consent or refusal, and help them to “want” to have the surgery. Refusal of heart transplantation by 6-year-olds is accepted.

Research question:

What are possible reasons to explain the differences between theories and practices about the ages when children begin to be informed about elective heart surgery, and when their consent or refusal begins to be respected?

Research design, participants and context:

Research methods included reviews of related healthcare, law and ethics literature; observations and conversations with staff and families in two London hospitals; audio-recorded semi-structured interviews with a purposive sample of 45 healthcare professionals and related experts; interviews and a survey with parents and children aged 6- to 15-years having elective surgery (not reported in this paper); meetings with an interdisciplinary advisory group; thematic analysis of qualitative data and co-authorship of papers with participants.

Ethical considerations:

Approval was granted by four research ethics committees/authorities. All interviewees gave their informed written consent.

Findings:

Interviewees explained their views and experiences about children’s ages of competence to understand and consent or refuse, analysed by their differing emphases on informed, signified or voluntary consent.

Discussion:

Differing views about children’s competence to understand and consent are associated with emphases on consent as an intellectual, practical and/or emotional process. Conclusion: Greater respect for children’s practical signified, emotional voluntary and intellectual informed consent can increase respectful understanding of children’s consent. Nurses play a vital part in children's practitioner-patient relationships and physical care and therefore in all three elements of consent.

Effects of advance exposure to an animated surgery-related picture book on preoperative anxiety and anesthesia induction in preschool children: a randomized controlled trial

BACKGROUND

Our aim was to investigate whether early surgical preparation by reading an animated picture book about procedure-related events could reduce the preoperative anxiety in preschoolers.

METHODS

131 patients, aged 3-6 years and underwent elective minor surgery were randomized either to a control or a picture book group. Both groups received general information about surgery and anesthesia in pre-anesthesia clinic. Patients in study group also received a surgery-depicting picture book for them to read at home a week earlier before surgery. Child anxiety was evaluated with the modified Yale Preoperative Anxiety Scale Short Form in six observing time points before anesthesia induction, and the compliance of anesthesia induction was assessed with the Induction Compliance Checklist (ICC).

RESULTS

There were significantly lower anxiety scores in picture book group than in control group at the time of ready for intravenous cannulation in operating room [51.9 (23.6) vs. 67.2 (22.0); mean difference 15.3; 95% confidence interval (CI) 6.4-24.1; P = 0.001] and at the time of pre-anesthesia visit [27.8 (7.6) vs. 33.2 (13.6); mean difference 5.3; 95%CI 0.93-9.8; P = 0.018]. No significant differences of anxiety levels were found between two groups at other observed time points: in the anesthesia outpatient clinic, in the holding area, at separation from parent to operating room (OR), and on entrance to OR (P = 0.584, 0.335, 0.228, 0.137, respectively). The percentage of children with poor induction compliance (i.e., ICC ≥ 6) was higher in control group compared with that in picture book group [38% vs.21%; odds ratio(95%CI): 0.78(0.61-0.99); P = 0.041].

CONCLUSIONS

Home-reading an animated picture book to get familiar with the perioperative events earlier prior to surgery could effectively reduce the preoperative anxiety level and increase the compliance during the induction of anesthesia in preschool children.

TRIAL REGISTRATION

ChiCTR2000033583, 06/06/2020 www.chictr.org.cn .

Healthcare staff as promoters of parental presence at anesthetic induction: Net Promoter Score survey

BACKGROUND

Surgical intervention is usually a traumatic event that causes stress and anxiety in the pediatric patient and the family environment. To reduce the harmful effects of presurgical anxiety, parental presence during induction of anesthesia (PPIA) is one of the more notable interventions used in medical centers. However, data on this measure are difficult to evaluate and often face resistance from healthcare staff.

AIM

To analyze the perception of the healthcare workers after the implementation of a PPIA program.

METHODS

A survey was developed and sent by email to all the healthcare staff working in the children’s area of a tertiary hospital. It consisted of 14 items divided into positive aspects of PPIA and negative aspects of PPIA evaluated with the use of a Likert scale (1 to 5). The demographics of the respondents were included in the data collected. The answers to the questions were interpreted through the Net Promoter Score (NPS). The statistical analysis compared the differences in the responses to each question of the survey made by the different groups of health personnel included.

RESULTS

A total of 141 surveys were sent out, with a response rate of 69%. Of the total number of responses, 68% were from women and 32% from men. The average age of the participants was 42.3 ± 10.6 years. As for the positive questions about the PPIA, 83% had an NPS > 50, and only one had a score between 0 and 50, which means that the quality of the service was rated as excellent or good by 100% of the respondents. On the other hand, 100% of the negative questions about the PPIA had a negative NPS. Responses to the question “PPIA increases patient safety” were significantly different (P = 0.037), with a lower percentage of pediatric surgeons (70%) thinking that PPIA increased patient safety, compared with anesthesiologists (90%), nursing (92%), and other medical personnel (96%).

CONCLUSION

The personnel who participated in the PPIA program at our center were in favor of implementation. There were no validated arguments to support worker resistance to the development of the PPIA.

Reducing Children's Preoperative Fear with an Educational Pop-up Book: A Randomized Controlled Trial

OBJECTIVE

Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Pediatric outpatient surgery center.

METHODS

Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction.

RESULTS

In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients' fear of anesthesia induction (Cohen's d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery (d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations (P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies (P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups (P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience (P≤ .02).

CONCLUSION

The educational pop-up book offers a child-focused resource that helps alleviate children's preoperative fears, encourages positive coping, and improves caregivers' perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

A systematic scoping literature review on the use of child life therapy (CLT) in the perioperative setting

BACKGROUND

Children and their caregivers often experience anxiety related to a perioperative admission. A systematic scoping review was conducted to map the evidence for child life therapy, including the professional background of treating clinicians.

METHODS

A scoping review was conducted using the Arksey and O'Malley methodology. Six databases: PubMed, CINAHL, PsychINFO, Cochrane Library, EMBASE and Web of Science were searched.

RESULTS

After reviewing 578 titles and abstracts, and 55 full texts, 11 studies were retained. Included studies were randomised controlled trials (n = 5), retrospective studies (n = 3), descriptive studies (n = 1) and clinical studies (n = 2). Child life therapy was effective for anxiety, anaesthetic induction quality, child cooperation and parental satisfaction. Professions delivering interventions included Child Life Therapists, nurses and a multidisciplinary team.

CONCLUSION

There is emerging evidence for child life therapy which may be used to guide delivery of paediatric procedural support in perioperative settings. Further studies are needed to inform practice.

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

A practical and ethical toolkit for last-minute refusal of anesthetic in children

Children's fear of a procedure, including the anesthetic, is a common issue that operating theatre staff face. This fear is generally mitigated by preesthetic preparation and information sharing. Last-minute refusal of a procedure creates unique difficulties for the anesthetist and proceduralist. Refusal for a procedure raises issues of whether the dissent is binding, and if not, how best to get the child to theatre without creating moral injury. In this case review of a young adolescent who refuses to go to the operating theatre, we explore practical and ethical options to resolve the situation. We discuss respect for persons (including assent and consent), best interests, truth-telling, harm minimization, and restraint. The importance of a postevent debrief is discussed. We also assess the value of a clinical ethics service with team members embedded in clinical teams.

Virtual reality for pediatric periprocedural care

PURPOSE OF REVIEW

Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.

RECENT FINDINGS

In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.

SUMMARY

Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

Behavioral and Emotional Disorders in Children and Their Anesthetic Implications

While most children have anxiety and fears in the hospital environment, especially prior to having surgery, there are several common behavioral and emotional disorders in children that can pose a challenge in the perioperative setting. These include anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. The aim of this review article is to provide a brief overview of each disorder, explore the impact on anesthesia and perioperative care, and highlight some management techniques that can be used to facilitate a smooth perioperative course.

Intravenous cannula placement in children for induction of general anesthesia: Prospective audit and identification of success factors

BACKGROUND

Approaches to pediatric induction of anesthesia vary widely. While oral sedative premedication and inhalational induction are common, total intravenous anesthesia is becoming increasingly popular. Total intravenous anesthesia without anxiolytic premedication, which is the most commonly used technique in our hospital, requires intravenous (IV) cannula placement in an awake child.

AIMS

To quantify the success rate of IV cannula placement in 1 or 2 attempts and to identify success factors and barriers.

METHODS

With ethical approval and written informed consent from participating anesthesiologists, a prospective audit of IV cannulation was undertaken over a 1-month period. The attending anesthesiologist captured basic demographics, IV insertion characteristics, setting, distraction techniques, the behavior of the child, number of attempts, and success/failure. A logistic regression model for successful IV cannulation was created. Anesthesiologists and procedural suite nurses participated in semi-structured interviews to identify success factors, barriers, and teaching approaches.

RESULTS

Data from 984 cases were analyzed. IV induction was planned in 562 cases, and IV cannulation was successful in 90% of these patients. Anxiolytic premedication was given in 6% of cases. Observations indicated that 64% of children were pain- and reaction-free, and 90% experienced minimal or no reaction. Predictors for success included older child's age and child behavior at first encounter. Qualitative interview data from 13 participants suggested success factors included effective distraction, preparing the family for IV induction, parental presence, support of the operating room team, effective use of local analgesic cream, adapting the approach to the individual child, and the anesthesiologist's efficiency. Barriers included needle phobia, uncooperative child, anxious parents, ineffective use of analgesic cream, and unfavorable anatomy. Distraction techniques varied by age and developmental stage of the child.

CONCLUSIONS

Cannulation for planned IV induction is feasible for most children, enabling increased use of total intravenous anesthesia as an institutional anesthetic strategy.

How Hospital Tours Affect Preoperative Anxiety in Mothers with Children Undergoing Open-Heart Surgery in Iran: A Quasi-Experimental Study

Background:

Parents tend to experience considerable amounts of anxiety before their children undergo open heart surgery. This study was conducted to assess the effects of taking a hospital tour on preoperative anxiety in the mothers of children undergoing open heart surgery.

Methods:

In this quasi-experimental study, 96 mothers from Shahid Modarres Hospital in Tehran, Iran, during April to December 2018, were selected through convenience sampling and were assigned to three groups using simple randomization. The oral instruction group (N=32) attended two oral instruction sessions; the hospital tour group (N=32) participated in tours of the operation room and intensive care unit; the control group (N=32) was prepared according to the ward’s routine. Preoperative anxiety was evaluated using the Amsterdam Preoperative Anxiety and Information Scale and the State Trait Anxiety Inventory. Data were analyzed in SPSS-20. The ANOVA, paired t-test and Tukey’s test were used for the data analysis. The level of statistical significance was set at P<0.05.

Results:

The mothers’ anxiety about surgery (F=30.99, P≤0.001) and their scores of state anxiety (F=6.02, P<0.001) differed significantly among the three groups after the intervention. A significant difference was observed between the oral instruction and control groups (P<0.001) and the hospital tour and control groups (P<0.001) regarding the surgery-related anxiety scores. A significant difference was also observed between the oral instruction and control groups (P=0.002) regarding the mothers’ state anxiety scores.

Conclusions:

The results suggest the greater efficiency of oral instructions versus hospital tours. Nurses can use oral instructions for reducing surgery-related anxiety and state anxiety of mothers before their toddlers’ open heart surgery.

Trial Registration Number: IRCT20180904040944N1.