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PEDIATRIC ANESTHESIA

Use of a Preanesthetic Video for Facilitation of Parental Education and Anxiolysis Before Pediatric Ambulatory Surgery

Joseph F. Cassady, Jr., MD^,¶, Timothy T. Wysocki, PhD^*,||, Kathryn M. Miller, PhD^*, Dawn D. Cancel, MA, and Neil Izenberg, MD^§

*Division of Behavioral Pediatrics and Psychology, Department of Anesthesiology, Nemours Children's Clinic, Jacksonville, Florida, §Nemours Foundation Center for Children's Health Media, Wilmington, Delaware; and Departments of ||Psychology and ¶Anesthesiology; Mayo Medical School, Jacksonville, Florida

Address correspondence and reprint requests to Joseph F. Cassady, Jr., MD, Department of Anesthesiology and Critical Care, Nemours Children's Clinic, 807 Nira St., Jacksonville, FL 32207.

	Abstract

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In this study, we evaluated the effects of viewing an educational videotape about pediatric anesthesia on measures of parental knowledge of anesthesia and preoperative anxiety using a randomized, controlled design. During their routine preoperative visit, 85 parents of children scheduled to undergo ambulatory surgical procedures under general anesthesia were randomized to view either the experimental videotape about pediatric anesthesia or a control videotape with no medical content. Before and immediately after viewing the assigned videotape, parents completed measures of situational anxiety (State-Trait Anxiety Inventory-State), preoperative anxiety and need for information (Amsterdam Preoperative Anxiety and Information Scale), and anesthesia knowledge (Standard Anesthesia Learning Test). Repeated-measures analyses of variance showed that parents who viewed the experimental videotape showed a significant increase in anesthesia knowledge (P < 0.022) and a significant reduction in their state of anxiety (P < 0.031), anesthesia-specific anxiety, and need for information (P < 0.0001) compared with the control group. These results demonstrated that viewing a preoperative educational videotape about pediatric anesthesia can provide immediate educational and anxiolytic benefits for parents of children undergoing ambulatory surgery. The duration of these benefits remains to be determined.

Implications: In this study, we demonstrated the benefits of viewing an educational videotape about pediatric anesthesia on measures of parental knowledge of anesthesia and preoperative anxiety using a randomized, controlled design. We found that videotape viewing facilitated preoperative preparation and lessened preoperative anxiety.

	Introduction

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The anxiolytic value of the routine preanesthetic visit was demonstrated for adult patients >30 yr ago (1) and has been confirmed.¹ For pediatric patients and their parents, supplemental preoperative preparation is recommended (3,4). Such preparation programs have demonstrated a reduction in anxiety for the parent (3,5–7), as well as for the child (3,5). Preoperative anxiolysis for parents is important because parental anxiety has been identified as a risk factor for preoperative anxiety and postoperative maladaptive behavior in children (8–9).

Supplemental preoperative preparation may take many forms. Typically, preparation provides the patient and family with information about the perioperative experience. However, adult patients often do not retain basic and essential elements of information from routine preanesthetic visits (10,11). For parents of pediatric ambulatory surgery patients, an understanding of anesthesia and specific preoperative instructions is a prerequisite for their child's care (12). Indeed, the need for detailed information is overwhelmingly recognized by parents of children scheduled for surgery (13).

The need for information and anxiety are not independent factors in the preoperative phase. A positive relationship has been demonstrated between preoperative anxiety and the need for information (14). However, there are little data regarding whether the information provided preoperatively actually increases parental knowledge of anesthesia. Explicit conveyance of accurate anesthesia information is intended to satisfy the parental need for information, reduce anxiety, improve compliance with specific preoperative instructions, and assist in fulfilling the anesthesiologist's ethical and legal requirements for obtaining informed consent.

A single study has assessed the effects of a videotape specifically targeted to parents on parental anxiety and knowledge of pediatric anesthesia. Karl et al. (7) described the preoperative use of a videotape that illustrates the induction of anesthesia and offers information, including a discussion of pediatric anesthesia risks. Parents considered certain aspects of the videotape helpful, although only those bringing a child to surgery for the first time exhibited a demonstrable reduction in concerns about anesthesia. Nearly half of the parents reported that the videotape reminded them of issues to discuss with the anesthesiologist. Although this study provides insight into the effects of preoperative preparation on parental anxiety and education, the authors did not use validated measures of anxiety and anesthesia knowledge. Control subjects were not used, and the actual conveyance of information was not demonstrated. These authors recommended additional investigation to determine the usefulness of preoperative videotapes for parents. Therefore, our investigation was designed to assess the effects of viewing a preanesthetic educational videotape on parental anesthesia knowledge and anxiety using validated measures in a randomized, controlled fashion.

	Methods

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The investigation was approved by The Nemours Children's Clinic Clinical Research Review Committee and the Baptist Medical Center Institutional Review Committee. Written consent was obtained from all subjects. Participants were parents of children scheduled for ambulatory surgery under general anesthesia at Wolfson Children's Hospital, Jacksonville, FL. Participants presented for a preanesthetic visit before their children's date of surgery. Parents were eligible to participate if they had a healthy child (ASA physical status I or II) scheduled for ambulatory surgery. Parents employed in the healthcare field and parents of any child who had received general anesthesia in the previous 3 yr were excluded. Only one parent was enrolled per child. If both parents were present, the mother was asked to participate. Parents received a $25 volunteer stipend for participation in the study. No demographic data were collected for parents not wishing to participate in the investigation.

The experimental group viewed the videotape Your Child's Anesthesia (15). The 22-min professionally narrated videotape provides detailed descriptions of anesthetic information while the simulated perioperative experiences of several children are depicted. The preanesthetic visit, induction of anesthesia, and postanesthesia care unit are presented visually, as are scenes from the surgical waiting room and other pertinent hospital areas. Accurate anesthetic information is conveyed to parents in a supportive and reassuring manner. The control videotape, Nature Series: Penguins (16) is an educational program lasting approximately 25 min. It includes no medical information or references.

Dependent Measures
The State-Trait Anxiety Inventory (STAI-State) (17) is a well validated and widely used instrument that provides separate measures of stable, dispositional anxiety (Trait Anxiety), as well as transient, situational anxiety (State Anxiety). Each scale is comprised of 20 statements. Respondents are asked to indicate on a four-point scale to what degree each statement applies to them. A score from 20 (low anxiety) to 80 (high anxiety) is generated. Because parents' anxiety in response to a discrete stressful event (i.e., their child's surgery) was the focus of this study, participants completed only the 20 State Anxiety items describing how they felt at the time of the test.

The Amsterdam Preoperative Anxiety and Information Scale (APAIS) (14) is a recently developed self-report measure consisting of six items designed to assess anxiety levels and need for information related specifically to anesthesia and the surgical procedure. Each item is scored using a Likert scale from 1 to 5. The scale was originally validated for administration to adult surgery patients; however, we have demonstrated that the APAIS is valid and reliable for administration to parents of pediatric surgery patients (18). Moerman's factor analysis showed that the APAIS measures two independent constructs, which could be labeled "anxiety" (four items) and "need for information" (two items) (14).

Because no validated measure could be identified in the anesthesiology literature for use in assessing the educational benefit of the videotape, we created the Standard Anesthesia Learning Test (SALT) (18). The 15-item self-administered SALT assesses factual knowledge of anesthesia procedures and risks in a multiple-choice and true/false format. Two equivalent versions of SALT were constructed for use in pretest/posttest format. Topics tested in a multiple-choice format on SALT I were tested in a true/false format on SALT II, and vice versa. The order of administration of the two forms was counterbalanced across time so that each SALT form was administered first to half of the participants and second to the other half of the participants.

Procedure
Parents were invited to participate in the study before commencement of their routine preanesthetic visit. One author (KMM) interviewed each participating parent to obtain demographic data, parental educational level, and socioeconomic status. Participants were randomly assigned to either the experimental or control group. Each participant completed two self-report measures of anxiety, STAI-State and APAIS, followed by SALT, a self-report measure of anesthesia knowledge. After completion of the three measures, the participant viewed the assigned videotape. Immediately after viewing the assigned videotape, each participant completed all measures in the same order. After the postvideo assessment, parents and children proceeded with the routine preanesthetic visit. All activities were conducted in a quiet, private room.

Data Analysis
A separate 2 x 2 repeated-measures analysis of variance (ANOVA) was completed for each of the measures of anxiety and knowledge using group as the between-subjects variable and the time of measurement as the within-subjects variable. The key contrast of interest in each case was the group x time interaction, which, if significant, would indicate that a change in the dependent measure differed significantly as a function of group assignment. Statistical significance was assumed at the P < 0.05 level.

	Results

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Of the 276 parents who were approached, 142 met all eligibility criteria. Of those eligible, 57 declined to participate, most (98%) because of time constraints. Characteristics of the 85 parents who participated in the study are presented in Table 1. Forty-three parents were randomly assigned to the experimental group; 42 parents were assigned to the control group. There were no statistically significant differences between groups with regard to demographic and socioeconomic characteristics or type of surgery.

The APAIS Anxiety Scale, Need for Information Scale, and mean total scores were analyzed for each group. In each case, a significant group x time interaction was obtained (P < 0.0001). Further analysis revealed that the experimental group demonstrated a reduction in anxiety (effect size 0.9), need for information (effect size 0.7), and total scores (effect size 0.9), as measured by the APAIS, compared with controls.

Analysis of change in SALT scores for the two groups revealed a significant group x time interaction (P < 0.022). Further analysis indicated that the experimental group performed better on anesthesia knowledge postvideo, compared with the control group. Parents in the experimental group answered 84.9% of the questions correctly on the postintervention SALT compared with 75.4% in the control group (effect size 0.7).

	Discussion

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The results of this investigation demonstrate that viewing a preanesthetic educational videotape about pediatric anesthesia can facilitate education and anxiolysis for parents of pediatric ambulatory surgery patients. This is the first investigation to demonstrate a measurable increase in anesthesia knowledge produced by a videotape targeted specifically to parents of pediatric surgery patients. Few previous studies in the adult and pediatric literature have examined the ability of preoperative educational videotapes to improve anesthesia knowledge. Zvara et al. (10) found little difference in factual knowledge and no differences in perceived knowledge when comparing patients who viewed a videotape about anesthesia and surgery with patients who did not view the videotape. Although an objective questionnaire containing knowledge-based items was used in that study, the measure was not validated, and the authors acknowledged that the testing instrument may not have been sensitive enough to detect a difference.

Our findings support those of Karl et al. (7), which suggest that a preoperative videotape can decrease parental concerns regarding pediatric anesthesia and perioperative management. Furthermore, by using a randomized, controlled design, we eliminated the possible effect of additional interaction with the interviewer in reducing anxiety and parental self-assignment to a treatment group.

Supplemental preoperative preparation programs that inform parents and children about the perioperative experience have been advocated in the medical literature (6,19). Although our study confirms previous findings that supplemental preoperative preparation decreases parental anxiety (3,5–7), the precise manner in which preoperative preparation decreases anxiety is unclear.

Previous studies have examined anxiety related to the need for information. Moerman et al. (14) found that adult patients with a great need for information also had a high level of anxiety. This study demonstrated that viewing an educational preoperative videotape reduced the perceived need for information for parents of pediatric patients. Although perceived need for information seems to be a critical factor in the preoperative preparation of adult patients and parents of pediatric patients (13), need for information may be unrelated to parents' actual factual knowledge. Although parental perception of anesthesia knowledge may influence perioperative anxiety, only factual knowledge of anesthesia can improve compliance with perioperative instructions and facilitate informed consent.

Although this study confirms the parental anxiolytic and educational benefits of a preanesthetic videotape, its design has several inherent theoretical limitations. This investigation presents the possibility of self-selection bias. Of the parents eligible for this study, 40% declined to participate, most often citing lack of time. Parents unwilling to participate may have been the most anxious or least desirous of information. In a study to determine the effect of anxiety on the granting of informed consent to participate in a study of anxiolytic premedication, Antrobus (20) found that patients with high preoperative anxiety levels were more likely to withhold consent than those who were less anxious. Although we did not assess this dimension, the exclusion of parents with high anxiety levels may have reduced the anxiolytic and/or educational effect realized in this study.

Additionally, the time at which the preanesthetic videotape was presented may have been a significant variable. We evaluated the videotape intervention immediately before the routine preanesthetic visit, i.e., <1 wk before the day of surgery. The time elapsed between that day and the surgery was not controlled. No time was available for viewing the videotape or data collection on the morning of surgery because of the implementation of a fast-track day of surgery timeline for rapid admission and discharge by a quality assurance committee at our hospital. Kain et al. (19) found that both parents and children were most anxious when a preoperative preparation program was given 1 day before surgery. Preoperative preparation was most beneficial in reducing anxiety when it was implemented >5–7 days before surgery. Furthermore, in our study, anxiety and knowledge were assessed immediately before and after viewing the videotape. Our study did not actually examine the effects of such preparation on the day of surgery. Therefore, whether the anxiolytic and educational effects of the videotape were sustained throughout the perioperative period was not evaluated. In view of the tendency for increased anxiety as the time of surgery nears (21) and the significance of the timing of the preoperative program (8,19), future studies should evaluate the timing of supplemental preanesthetic preparation and the long-term effects of such preparation.

Another possible limitation of this study is the videotape itself. Previous studies assessing the benefits of preoperative preparation videotapes have rarely described the setting for filming of the videotape. The videotape used in this study was produced in our institution's ambulatory surgical facilities. Participating parents had not previously experienced this setting. We do not know whether the same anxiolytic and educational benefits found in our institution would be recognized in another institution.

Future studies should also take into account the cost and benefits of supplemental preparation programs. The planning and production of a high-quality videotape may cost $10,000–$50,000, depending on the use of professional producers and actors and the time expended. Previous research has supported the cost-effectiveness of videotape preparation in reducing individual and overall medical costs (5). Additional parental measures, such as compliance with preoperative instructions (specifically nothing by mouth instructions) and informed consent, should also be evaluated because facilitation of either of these measures may result in additional cost-savings.

In summary, in this study, we demonstrated that a preanesthetic educational videotape can reduce preoperative parental anxiety and need for information and improve parental knowledge regarding anesthesia before pediatric ambulatory surgery.

	Acknowledgments

 
This investigation was funded by a grant from the Nemours Foundation.

The authors thank Bebe Burney and Amy Whaley, without whose diligence and commitment this project could not have been completed.

	Footnotes

 
¹ Kern C, Martensson M, Klopfenstein CE, et al. Influence of different types of preanesthetic visits on preoperative anxiety: Egbert revisited [abstract]. Anesthesiology 1994;81:A1258.

	References

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999