Rev. Latino-Am.

Enfermagem
2023;31:e3738
DOI:10.1590/1518-8345.6230.3738
www.eerp.usp.br/rlae

Original Article

Nursing evaluation of pediatric preoperative anxiety: a qualitative

study*

Carmen Jerez Molina1,2

https://orcid.org/0000-0003-2402-6785
Highlights: (1) Assessment of pediatric preoperative
Laura Lahuerta Valls3
https://orcid.org/0000-0001-7916-2317 anxiety. (2) Management of pediatric preoperative anxiety.
(3) Appropriate information on the procedure for both parents
Victoria Fernandez Villegas 2

https://orcid.org/0000-0001-5534-7157
and children. (4) Low reliability of the current assessment of
pediatric preoperative anxiety. (5) Necessary involvement
Susana Santos Ruiz 1

https://orcid.org/0000-0002-7491-5911
of surgical administrators.

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.
*
Supported by Departament de Salud de la Generalitat de Conclusion: nurses assess anxiety in their daily practice through
Catalunya (PERIS) # SLT006/17/00196, # 22.355, Spain. observation using their clinical judgment. The nurse’s experience is
1
Campus Docent Sant Joan de Déu, School of Nursing, decisive for the appropriate assessment of the preoperative anxiety
Barcelona, Spain.
in child. Insufficient time between waiting and entering the operating
2
Hospital Sant Joan de Déu, Nursing Department,
Ambulatory Surgery, Barcelona, Spain. room, lack of information from child and their parents about the
3
Hospital Sant Joan de Déu, Nurse Research Department, surgical procedure, and parental anxiety make it difficult to assess
Barcelona, Spain. and properly manage anxiety.

Descriptors: Preoperative Care; Perioperative Nursing; Preoperative

Assessment; Anxiety; Child; Qualitative Research.

How to cite this article

Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S. Nursing evaluation

of pediatric preoperative anxiety: a qualitative study. Rev. Latino-Am. Enfermagem. 2023;31:e3738.
[Access ]; Available in: . https://doi.org/10.1590/1518-8345.6230.3738
month day year URL
2 Rev. Latino-Am. Enfermagem 2023;31:e3738.

Introduction act accordingly. The assessment of preoperative anxiety

in the daily routine is currently performed through the
Anxiety is a psychological reaction that can be clinical judgment by health professionals(16). However, we
observed in health users who are about to undergo a have not found in the literature how health professionals
surgery. A surgical intervention can be very stressful, interpret the behaviors and actions of the child before
especially for children and their families, which can cause entering the operating room. The objective of this study
high levels of preoperative anxiety and postoperative was to explore and describe how perioperative nurses
behavioral changes(1). Recent studies report a prevalence assess and interpret the child’s behavior before entering
of anxiety of 67-75% in children aged 2-12 years(2-3). the operating room, identifying the strategies they use
Age, personality, developmental status and previous to minimize anxiety and proposals for improvements.
experiences can be triggering factors(2), and high parental
anxiety can also influence the child’s anxiety(4). Method
It is known that an effective reduction in
preoperative anxiety can improve the child’s cooperation Design
with the care team(3), promote a better postoperative
A descriptive qualitative study. The qualitative
response(5), increase parental satisfaction with the
design was considered as the most appropriate to know
procedure and improve the quality of care(6). In children,
how the nurses in their daily practice assess the child’s
strategies such as the administration of anxiolytic
preoperative anxiety as it provided the researchers with
medication, the use of videos, hospital clowns, music
a rich descriptive content from the perspective of the
therapy and allowing the presence of their parents/
study subjects(17-18). The manuscript has been prepared
caregivers during anesthetic induction are some of the
according to COREQ checklist (Consolidated Criteria For
interventions that aim to reduce anxiety and, thus,
Reporting Qualitative Research)(19).
promote a more cooperative child during anesthetic
induction(7-9). However, we cannot only focus on reducing Place of study
the child’s anxiety, as their parents can also be the
The study was carried out in the pediatric outpatient
cause of their children’s anxiety, as we have already
surgery unit of a hospital in Barcelona. A third-level
mentioned. Therefore, strategies such as music, clowns,
University Hospital specialized in the health of children
preopertative programs and educational materials have
and pregnant women and the first pediatric center in
also been shown to reduce parental anxiety(10), thereby
Spain to implement an Outpatient Surgery Unit. The unit
contributing to a holistic and comprehensive care, which
has 23 armchairs/individual beds with enough space for
is centered on the children and their family.
two accompanying persons (father/mother) to be with
Child- and family-centered care can help to humanize
the child during the preparation and after the surgical
the surgical process, which must be centered not only on
procedure. Four surgical procedures are performed (two
the child, but also on the family and on the relationship
in the morning and two in the afternoon), which can be
established between them and the health professional. In
in the specialty of surgery, ophthalmology, traumatology,
this approach, the family is an active part of the surgical
otorhinolaryngology, dermatology and dentistry, depending
process and the need for information is increasingly
on the surgical schedule.
important, parents need information about the process
and children must be involved to answer their questions, Study period
consider their fears, turn their attention to others and
talk to them(11-12). A recent study demonstrates how Interviews and participant observation were carried

a child- and family-centered program decreases the from October 2018 to January 2019.

administration of preoperative sedation, increases the

Population
satisfaction of parents and health professionals, and
decreases the anxiety of parents and children, in addition It was proposed the participation of all perioperative
to not modifying the surgery times .
(13)
nurses from the outpatient surgery unit of the two shifts,
On the one hand, it is known that the causes of about 15 nurses. All nurses in charge of care for children
preoperative anxiety are multiple and its effects can last who were admitted to the unit on the day of their surgical
up to months after the surgical intervention(14), and on intervention. Participants were selected by maximum
the other hand, it is known that there is a high prevalence variation sampling(20), which ended when data saturation
of children with preoperative anxiety(15). Both statements was reached(21). Two evaluators decided by consensus
should lead us to think about how we are assessing when the data saturation was reached. The participants
anxiety and how we are going to minimize anxiety and were chosen taking into account that they worked in the

www.eerp.usp.br/rlae
 Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S. 3

unit and were in charge of care for child and, therefore, for a event sampling and involved the selection of the events
the assessment of anxiety before the surgical intervention; to be observed(23). Thus, the first contact with the child
and that there was representation of nurses from both and their parents and the assessment and management
shifts (morning and afternoon). The final sample included of anxiety by the nurse were observed. The observations
nine participants. The first author invited personally and were carried out during ten non-consecutive days in both
individually all the nurses of the unit to participate. One shifts and in different times of the day.
of the selected nurses who met the eligibility criteria did
Data analysis
not agree to be interviewed and/or observed in their daily
practice for personal reasons. The proposed thematic analysis(24), was carried
out in line with the recommendations and consisted of
Data collection
six phases: a) familiarization: the interviews and field
Semi-structured interviews and participant notes collected during the participant observation were
observation were conducted. The interviews, which lasted transcribed. Next, the data were read and reread and the
about thirty minutes, were conducted in a distraction- information was redefined taking into account semantic
free office in the surgical unit by the main author, who cohesion, b) codes creation: the most relevant data
worked as a research nurse for a year. The researcher characteristics were coded and each code was conceptually
had knowledge in conducting interviews because of defined, c) search for themes: the codes were grouped
previous studies and her academic career. To start the and four themes emerged, d) revision of themes: the two
interview, nurses were asked to visualize the moment evaluators reviewed the themes to reach an agreement
they first contacted the child and their parents in the and prepare a thematic map, e) definition of themes: the
waiting room. Once the moment was visualized, a boy agreed definitions of each theme were carried out and
or a girl in particular, the first question was introduced: finally, f) elaboration of the report: selection of examples
What do you see in the child that makes you think that of excerpts from the interview and the observations.
they have preoperative anxiety? From this first question, Final analysis of the selected excerpts was carried out
the following ones were asked according to the main according to their relation with the research question
objective. Thus, questions related to anxiety and how and the literature.
each nurse assessed anxiety, used non-pharmacological The observations recorded in the field diary, the
strategies to reduce it, and proposed future strategies for interview transcripts and the notes obtained throughout
its management and assessment were asked (Figure 1). the study were analyzed by peers.

Criteria of rigor and ethical considerations

When do you assess child’s anxiety?, How do you assess child’s
anxiety that makes you think they are nervous? (Child Anxiety
Assessment Process) The Ethics and Clinical Research Committee of

What techniques do you use to reduce preoperative anxiety? On the hospital approved the study (código 15-2018).
what occasions have you had to reduce parental anxiety? (Difficulties All participants were informed about their voluntary
and barriers to reduce anxiety in clinical practice)
participation and signed a consent form.
What do you think should be done to improve the child’s anxiety
management and how do you think it could be done? (Improvements
The recommended reliability criteria were considered
to reduce children’s anxiety) to achieve methodological rigor(25). The participants
Figure 1 - Guide for semi-structured interviews received the transcripts and, later, the results. There were
no changes in this regard. The verbatim reports of the
During the interviews, permission was requested interviews were used to illustrate the results to ensure
for audio recording and field notes were taken, which reliability. The observation of daily practice and the field
were used at the end of the interviews to summarize the notes were analyzed for data triangulation. To ensure a
conversation, clarify some answers and provide additional greater objectivity in data analysis, it was carried out
information. As an additional technique and to increase by peers, with the intervention of the author who did
the quality of the data, participant observation was also not know the participants and the surgical environment,
performed. It was considered necessary to observe together with the main author, an expert perioperative
the nurses during their assessment of anxiety, as it is nurse. A complete description of the context where the
a complex phenomenon to be assessed only through data were collected was carried out to enable their transfer
personal interviews (22)
. A structured observation was to other contexts.
proposed, as it is only possible when the researcher Total anonymity of responses and personal data was
has sufficient information and knowledge about the achieved in accordance with the current legislation on the
phenomenon under study, and it was carried out through protection of personal data.

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4 Rev. Latino-Am. Enfermagem 2023;31:e3738.

Results Theme 1: Communication and persistent

observation of the child and their family or
The average age of the participating nurses was 36.6 assessment of pediatric preoperative anxiety
years (Standard deviation 10.9). All of them were women
Communication and persistent observation of the
with an average length of service of 9.8 years in the unit.
child and their family were identified as key components
Sample characteristics are shown in Table 1.
in the assessment of the child’s anxiety before entering
the operating room. The nurses begin the assessment of
Table 1 - Demographic characteristics of participants.
the children’s anxiety when they first contact them and
Barcelona, Spain, 2019
their parents: While the nurse places the child and his
Age Length of service
Participant parents in the environment, she observes their behaviors
(years) (years)
and actions. This persistent observation continues over
1 40 11
time until the nurse is sure of her assessment: I walk out
2 27 1
and wait two seconds to call the child and I look from the outside
3 25 1 how they are in the waiting room, so if I notice that they are

4 48 21 agitated or something like that, and they are very restless... I

5 50 21 already get worried, of course, because if they are already like this

in the waiting room, in the operating room the situation will be ….

6 38 4
even more turbulent. If they are very quiet, that also catches my
7 28 4
attention, so when I take them down the hallway... I also observe
8 24 1
how they behave... And once inside the room, depending on the
9 50 25 questions I ask them and everything else... because sometimes
Note: All participants were women. Length of service refers to the years I have to ask, because some of them don’t know what they’re
the nurse had been working in the Outpatient Surgery Unit and, therefore,
assessing the child’s preoperative anxiety before entering the operating room.
coming for, no, they don’t know they’re coming for surgery, so I

notice them even more nervous. (P: 3)

To illustrate the results, verbatim reports of the

Theme 2: Evaluating what was observed
interviews or excerpts of the field notes have been chosen.
The names of participants have been replaced by the letter While they observe the behaviors, actions and verbal
“P” (participant), followed by a number and the letter “O”, and non-verbal communication of the child and their
which means a field diary entry during the observation. parents with each other or with the health team, the
The interviews lasted an average of 30 minutes. nurse can get an idea of the anxiety, fears and concerns
Four main themes emerged from the analyzed data: regarding the surgical intervention of the children and
assessment, evaluation, management of anxiety and their accompanying persons.
proposals for improving anxiety assessment (Figure 2). Some of the observed behaviors warn the nurses
that the child is very nervous: They grab on to their parents,
they cry, they hide, and based on how they respond when you

ask them, you can notice if they are receptive, if they enjoy when

you offer them to paint. (P:2)

In older, shy or very emotional children, it is

very difficult to assess anxiety, as they can hide their
nervousness, either because they do not show it or
because they are collaborative and participative: It’s the
nervousness that makes them express themselves like that,

very euphoric…they jump, play, they breathe inside the mask

and they participate…so as soon as they come in, they panic.

There are also those who are very withdrawn… it is necessary

to be careful with those too… when it’s their first time or not, if

they know where they are going, and obviously, there are many

factors. (P:5). In these cases, or when there is any doubt

as to whether the child is expressing preoperative anxiety

through their behavior, the nurse asks the parents if they
Figure 2 - Child- and family-centered care during the notice that their child is nervous. Sometimes, the parents’
assessment of pediatric preoperative anxiety assessment of their child’s anxiety is wrong, as they notice

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 Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S. 5

their child as nervous as on other occasions. The nurse they will fall asleep, that we will cure them and when they wake

then doubts about her own criteria, which delays the up they will be cured. And they will soon go back to their mom

nursing assessment of anxiety. Excerpt from a observation and dad when they are awake again, they will go to a room with

note: The nurse asked the parents if they noticed that their child a nurse and then they will go back to mom and dad. As soon as

was nervous. The parents responded that the kid is like that <the I see them, I go look for a mask (…) and I explain to them that

child is like that>. (O of a four-year-old boy) they can come in with their mom or dad (….). I never say operate,

The children’s lack of information about the surgical I say heal. It depends on the child, when I realize that they will

process and the short time to prepare the child are get already scared if I tell them that they will fall asleep, I tell

detected on several occasions as the cause of high them in another way… (P:4)

anxiety during anesthesia induction: All that joy and euphoria During the observation sessions, it was noticed that

turns into a terrifying fear (...) so as soon as they come in (for some parents also lack information about the surgical

anesthesia induction), they panic. (P:5) process. The nurse must, in such cases, provide parents

The children didn’t receive sufficient information about what with information. In such cases, the nurse must take a

they were going to do with them, that is, they were unprepared moment to be alone with the parent who will accompany

from home, in addition, we don’t have too much time either,

their child during the anesthetic induction: The nurse asked
the child if they wanted to go to the restroom. The child went to
however, I can even give them information, but the children also
the restroom accompanied by their father, and the nurse seized
need information given by their parents. (P:6)
the moment with the mother to explain to her alone (without
Theme 3: Managing pediatric preoperative anxiety the child’s presence), in more detail, the moment of entering the

operating room: what will happen, where the child will be sitting,
This category is about those strategies that nurses
how they should act in the operating room and what behaviors
put into action through communication and observation
she will observe in the child when they are unconscious. (O of a
of the child and their parents to reduce anxiety in both.
6-year-old boy)
When the nurse detects that the child has anxiety, she
Sometimes the strategies used by the nurses to
immediately acts to minimize it: providing information
reduce anxiety do not have the expected result, so it is
about the procedure appropriate to the child’s age and
necessary to inform the anesthesiologist. This outcome
cognitive level, offering distracting activities (stories,
is sometimes frustrating for the nurse, since the efforts
drawings to color, games, etc.) or relying on other
she made and the actions she used to reduce the
professionals (clowns and volunteers). Considering that
child’s anxiety were ineffective and the last choice to
when entering the operating room, the child will find out
get a cooperative child during anesthetic induction is to
that they have to breathe inside the mask, the nurse, in
give preoperative sedation. This alternative solution to
addition to providing information, insists that they practice
manage preoperative anxiety, when non-pharmacological
with her how to do it in order to become familiar with
alternatives have failed, causes concern among nurses,
it. It was observed that sometimes the face mask was since the anesthesiologist does not arrive in time so that
impregnated with strawberry essence to avoid the child the sedation has the desired effect on the child before
to reject it: The nurse has asked for a face mask from the entering the operating room, and it is not desirable to
operating room (the one that the girl will wear later). She explains receive sedation to avoid side effects of the drug: Yes,
how to put it on her face after the girl’s refusal to put the mask you’ve done everything, but something tells you that when they
on herself. The nurse teaches the process to her using the doll go into the operating room, they will be even more nervous…. So,
that the girl had in her hands. When the mask was close to the I wait for the anesthesiologist and I tell him that the child needs
doll, the girl realized that the mask had a known odor and not premedication, that they are very nervous, with anxiety. (P:5).
the odor that she supposed. The eight-year-old girl relaxed and There are some anesthesiologists who do not want the children
began to practice how to breathe inside the mask while the nurse to receive preoperative sedation because they say there is no
was telling her that when she is with her mom in the operating enough time, or whatever the reason. New anesthesiologists are
room, the doctor would place a tube, and that she would have to more receptive. (P:1)
breathe into it to fall asleep while her mom would be with her. The observation confirmed that the first child in the
(O of a six-year-old girl) surgical program is the most difficult to assess, estimate
In addition, nurses use words appropriate for the and develop an effective management of anxiety, as the
child’s cognitive age, avoiding others that can cause more surgical intervention begins when the anesthesiologist
stress, anxiety or fear. Nurses involve parents in this arrives, so if the child is very nervous and the strategies
process, instructing and explaining about the anesthetic are non-pharmacological, they do not have the wanted
induction process to them. (….) information, that they will effect. In addition, the problem is heightened by the
have to breathe inside a mask like the one on airplanes, that fact that the first children in the session are usually the

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6 Rev. Latino-Am. Enfermagem 2023;31:e3738.

youngest ones and least receptive to non-pharmacological actions. Other studies have also reported that the operating
interventions: A nurse says that the work pace in the afternoon room staff are the ones in charge to assess and interpret
shift is faster, the children are scheduled with a short space of the child’s behavior through clinical judgment(26-28). However,
time between them and sometimes, we do not have enough time such assessment is prone to an important subjective error,
to explain the process or teach them how to put the mask. (P:3) as it depends on the skill of the observer to interpret the
behaviors and the time available to observe(16).
Theme 4: Improving the assessment of pediatric
Our study suggests that nurses interpret the child’s
preoperative anxiety or future proposals for the
behaviors to assess anxiety and that, if there are doubts
management of pediatric preoperative anxiety
about their interpretation, parents are asked. However, the

This category includes those proposals that nurses assessment of preoperative anxiety in children by trained

have observed in their daily practice, which could improve personnel has been shown to be more accurate than that

the assessment and management of pediatric preoperative reported by parents(28), although it is not sufficient to

anxiety. The nurses proposed that parents should also help detect all children with preoperative anxiety(16).

with their child’s surgery preparation, and this would also In care services with high levels of pressure, such

help them to lessen their own anxiety, and consequently, as those in the surgical field, there is a limited time to

lessen that of their children: Before the child comes in the prepare patients. However, the time necessary to provide

operating room, you can give as much information as possible to

children and their parents with important preoperative

the parents, to the children, so that they are in agreement at home,

information about postoperative pain, anesthesia, meal

right? It´s important that the parents explain to them what the
initiation, and discharge requirements should already be

process will be like, what they will have to do. (P:8). In addition,
considered within this short preoperative time(29). Parents

they suggest that parents should be instructed during the need information and health literacy has been shown to

process not only providing them with information, but also reduce anxiety so that they can feel as an active part in
the surgical process of their children(30).
so that with this information they can help their children
All the actions that the nurse takes to reduce
face the day of surgical intervention: Sometimes children have
preoperative anxiety, such as providing age-appropriate
anxiety because their parents have anxiety. There are children who
information and avoiding words that may cause more
come without knowing why they come and that also influences them.
stress, anxiety or fear, aim at achieving a more cooperative
In addition, sometimes the parents have not told them the truth
child during anesthesia induction. The implementation
because they are the ones who are nervous. (P:2)
of non-pharmacological strategies, such as information
When the child is very young, or when it is not
about the procedure, playing with the face mask and
possible to understand them due to their age or pathology,
other distractions, is effective in reducing the child’s
nurses claim the need for a protocol that unifies the
preoperative anxiety, however, sometimes these strategies
decisions and that preoperative sedation medication is
are insufficient to help the child cope with the situation(31).
prescribed in advance in consultations: A boy with behavioral
In these cases, it is necessary to notify the anesthesiologist
problems was admitted during the observation period, his mother
to administer sedation to the child. However, as in other
stated that the boy had already undergone surgery on other
studies(32), this work shows that decisions regarding the
occasions and that he became very nervous and that on some
administration of preoperative sedation are based on
occasion he had been given medication to calm him down (O a
personal criteria that lead to non-unified practices.
4-year-old boy). The interviewed nurses suggested that the
The results show that there is no protocol or
preoperative sedation guidance should be standardized
preparation program for parents and children who will
from the anesthesiologist’s consultation: Evaluate anxiety,
undergo outpatient surgery in the hospital studied. These
we already do that, it’s fine, but as for the medication, we should
preparation programs, suggested by the nurses studied,
have something standardized from anesthesia, or something
have already been pointed out in the literature as one of the
like that, or a paper that gives us authorization to pre-medicate
aspects that would reduce the levels of anxiety in parents
(…) to perform everything more or less in the same way… (P:5)
and children on the day of the surgical intervention(33) and

Discussion would save time in the surgical process(34).

Training the use of the face mask at home and
The objective of this study was to know how teaching distraction techniques to parents are two
perioperative nurses interpret the child’s behavior and components of the preoperative preparation program
how they act accordingly in their daily practice. observed as the most effective in keeping the child’s
In this study, the assessment of child’s anxiety before anxiety stable throughout all phases of the preoperative
entering the operating room was carried out by the nurses period on the day of the surgical intervention(35). In
in charge of preoperative care by observing behaviors and addition, the child who is aware of the process is a

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 Jerez-Molina C, Lahuerta-Valls L, Fernandez-Villegas V, Santos-Ruiz S. 7

facilitator and it is beneficial for the health professional, distraction, clarification on the surgical process and age-
as the child can actively participate if they are informed .
(36)
appropriate communication.
Likewise, when the parents are informed about what is Lack of time is the main barrier for strategies such
going to happen and about what is expected of them as active listening, therapeutic play and age-appropriate
as parents, they feel involved in the care of their child information to reduce children’s anxiety before surgical
and not as bystanders, as for example, during anesthetic intervention. It would be up to the facilitator to guide and
induction . Preoperative preparation of children and their
(37)
train parents before their children’s surgical intervention
parents could reduce the levels of anxiety, improve coping, so that they can be an active part of the process, as
and promote postoperative recovery(38). The nurses in this well as provide children with age-appropriate information
study have stated that children and parents should be through the implementation of preoperative preparation
prepared before going to the operating room(39). programs and parent training throughout the surgical
Although we currently have non-pharmacological process so that they can be an active part in this process.
strategies to reduce pediatric preoperative anxiety, we Although there is still a need to assess preoperative
still have limitations(14). As the surgical time to prepare anxiety through the use of validated instruments that aim
children and parents is very short on the day of the to unify the care and strategies based on the objective
surgical intervention, other strategies not related to assessment of preoperative anxiety, nurses consider that
therapeutic play could be proposed, since these have perioperative care should focus on the child and their
already proven to be effective(40). Thus, these strategies family, and therefore, the assessment of anxiety should
would be supplemented with other ones, such as be performed considering the child-parents and child-
information on the process by team trained in emotional nurse relationships.
care(41) and reinforced by means of written information(42). Based on the results found, future studies are
One of the limitations of this study is that the recommended to assess whether the preoperative
assessment was performed only in a pediatric outpatient information provided by a team trained in pediatric
surgery unit of a specific hospital. However, the emotional care reduces the child’s anxiety on the
triangulation of techniques such as systematic observation day of the surgical intervention, as well as to study
and interviews with both novice and expert nurses means whether the variation and difficulty in the assessment
that, although the results cannot be generalized, they of preoperative anxiety in daily practice is homogenized
can be considered in similar contexts to improve the by using preoperative anxiety assessment protocols that
assessment of pediatric surgical anxiety in daily practice. were unified by all health professionals involved in the
This study contributes to the knowledge on the perioperative process.
importance of perioperative nurses in the management
of pediatric preoperative anxiety. Nursing care for child Acknowledgments
makes all the strategies used aim at a single objective: to
minimize the child’s preoperative anxiety, as high levels of We thank all the nurses of the Outpatient Surgery

pre-operative anxiety in a child can have post-operative Unit for their time during the interviews. Likewise, we

consequences that go beyond their stay in the hospital. also thank the people who selflessly helped to improve

Supervisors in these units should consider the need to the manuscript.

focus preoperative nursing care on the child and their

family, either by training parents to be facilitators in the
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Authors’ contribution
for parents”. J Clin Nurs. 2017;26(23-24):4246-54. https://
doi.org/10.1111/jocn.13747
Study concept and design: Carmen Jerez Molina, Laura
34. Zainal Abidin H, Che Omar S, Zulfakar Mazlan M,
Lahuerta Valls, Victoria Fernandez Villegas. Obtaining
Hasyizan Hassan M, Isa R, Ali S, et al. Postoperative
data: Carmen Jerez Molina, Victoria Fernandez Villegas.
Maladaptive Behavior, Preoperative Anxiety and Emergence
Data analysis and interpretation: Carmen Jerez Molina,
Delirium in Children Undergone General Anesthesia: A
Laura Lahuerta Valls, Victoria Fernandez Villegas, Susana
Narrative Review. Glob Pediatr Heal. 2021;8:1-9. https://
Santos Ruiz. Statistical analysis: Laura Lahuerta Valls,
doi.org/10.1177/2333794X211007975
Susana Santos Ruiz. Obtaining financing: Carmen Jerez
35. Fortier MA, Blount RL, Wang SM, Mayes L, Kain Z.
Molina. Drafting the manuscript: Carmen Jerez Molina,
Analysing a family-centred preoperative intervention
Laura Lahuerta Valls, Victoria Fernandez Villegas, Susana
programme: a dismantling approach. Br J Anaesth.
Santos Ruiz. Critical review of the manuscript as to
2011;106(5):713-8. https://doi.org/10.1093/bja/aer010
its relevant intellectual content: Carmen Jerez Molina,
36. Quaye AA, Coyne I, Söderbäck M, Hallström IK.
Susana Santos Ruiz.
Children’s active participation in decision-making processes
All authors approved the final version of the text.
during hospitalisation: An observational study. J Clin Nurs.
2019;28(23-24):4525-37. https://doi.org/10.1111/ Conflict of interest: the authors have declared that

jocn.15042 there is no conflict of interest.

37. Chang ME, Baker SJ, Marques ICS, Liwo AN, Chung
SK, Richman JS, et al. Health Literacy in Surgery.
Health Lit Res Pract. 2020;4(1):e46-65. https://doi.
org/10.3928/24748307-20191121-01
38. Al-sagarat AY. Preparing the Family and Children for Received: May 21st 2022
Accepted: Jul 15th 2022
Surgery. Crit Care Nurs Q. 2017;40(2):99-107. https://
doi.org/10.1097/CNQ.0000000000000146 Associate Editor:
Lorena Chaparro-Diaz

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