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Preparation of children for surgery and invasive procedures: Milestones on the way to success
INTERNATIONAL PEDIATRIC NURSING Column Editor: Bonnie Holaday, DNS, RN, FAAN
Preparation of Children for Surgery and Invasive Procedures: Milestones on the Way to Success Galit Bar-Mor, RN, MA A
CHILD'S HOSPITALIZATION IS usually an unpleasant and a difficult experience, both for the child and his parents. The hospital as a concept and as a place is perceived as lurking with difficult and unpleasant trials, trials forced on the child and compelling him to experience and to cope with them. When children (aged 3-12) were followed over a period of 1 month after hospitalization and surgery, it was found that the rate of appearance of behavioral and emotional changes and the nature of these changes are quite similar in different countries, different health care systems, and different types of surgery. Fifty-two percent to 78% of the children surveyed displayed changes such as (Friedman & Peled, 1988): 9 Eating disorders 9 Sleeping disorders 9 The appearance of consolatory habits, such as: thumb sucking, nail biting, and masturbation 9 The appearance of frightening imaginations 9 Developmental regression, such as bed wetting and stuttering 9 Change in attitude toward parents, such a s : over-dependence, aggression, indifference, and negativism 9 The appearance of death anxieties These phenomena, which need to be examined individually, might be a sign of the distress that the child is experiencing after his/her hospitalization and surgery. It is important to remember that reactions to surgery may be positive, not only negative. For example: the child learns to know
From the Cardiology Institute, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel. Address reprint requests to Galit Bar-Mor, RN, MA, Cardiac Catheterization Unit, Cardiology Institute, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah-Tiqva, Israel 49202. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-000953.00/0 252
himself, to recognize his spiritual and physical strengths, and to appreciate the love and devotion displayed throughout his hospitalization by his parents and friends, as well as by the staff that cared for him. These insights may leave him with a pleasant impression, despite the discomfort and suffering involved in the illness situation. At any rate, the child's negative or positive responses to hospitalization and surgery are influenced by many factors. These may be divided into four categories (Lambert, 1984):
Factors Depending on the Child 9 The developmental stage the child is in (emotional and cognitive) 9 Previous experience in coping with distress and crisis situations 9 The coping mechanism used by the child (active or passive?) (LaMontagne, 1985) 9 The significance of the disease or state of health, as perceived and interpreted by the child 9 The feelings and sensations evoked by hospitalization, such as: pain, anger, and insult
Factors Depending on the Parents 9 How they perceive the severity of the disease and the threat that it poses, and how they transnfit this perception to the child 9 The degree of support, encouragement, and positive attitude related by the parents to the child 9 Previous experience in coping with stress and crisis situations, and specifically with disease and hospitalization 9 The existence of a support system for the parents 9 Other sources of stress in the family 9 The relationship between the parents and between the parents and the child Journal of PediatricNursing, Vol 12, No 4 (August), 1997
PREPARATION OF CHILDREN
Factors Related to the Disease 9 The nature of hospitalization: urgent versus elective, short versus long, first admission versus readmission 9 The degree of suffering accompanying the disease and the treatment, such as: pain, discomfort, unpleasant procedures, physical and other limitations 9 Frequency, duration, and degree of separation from the child's natural environment
Factors Related to the Hospital 9 The character of the ward in which the child is hospitalized, such as: the intensive care unit versus a pediatric ward (Kupfer, 1991) 9 Suitability of the ward's structure and activities to the child's world 9 The ability of the staff to understand and respond to the child's needs by: ----eliminating the separation of child from parents in all stages of hospitalization, and in particular during the entrance to surgery --minimizing physical pain sensations --reinforcing the child's sense of control over events --building a relationship of affinity and trust between the child and the nursing staff ---offering opportunities for play and expression of positive and negative emotions Many factors influence the child's response to hospitalization and surgery. The nurse's role is to understand them, and to link the present or potential responses of the child to dominant factors that are causing or might cause these reactions. This understanding is the first step in planning the preparation program for hospitalization, surgery, and invasive procedures under anesthesia.
THE NEED TO IMPLEMENT PREPARATION PROGRAMS In the 1930s, research and documentation of the psychological implications of disease and hospitalization on the child began (Beverly, 1936). Attention was then directed to the need to minimize the trauma of separation between the child and his parents and the stress and anxiety evoked when encountering a foreign, unfamiliar, and threatening environment. In the 1940s and 1950s, first buds of lengthy and unlimited parent visits began to sprout, and parent involvement in care for the hospitalized child first appeared (levers, Campbell, & Blanche, 1955). The research into the psychological repercussions of disease and hospitalization also affected nursing practice; nurses began to develop indi-
253
vidual and group preparation programs, accompanied by instruction and demonstration aids, such as pamphlets, information sheets, coloring books, illustrated stories, prehospitalization tours, simulation games using hospital equipment, films, puppet theaters, and children's drawings. (Azarnof & Woody, 1981; Durst, 1990; Robinson & Kobayashi, 1991). The prevention or reduction of the child's negative responses to hospitalization and surgery has always been our basic goal in implementing guidance programs; but today, this is not enough. With adequate counseling for the child and his parents throughout all stages of the illness and hospitalization processes, it is often possible to achieve: 9 An atmosphere of affinity and trust between the nurse and the child, and between the nurse and the parents 9 Better compliance of the child to treatment 9 More parent satisfaction from the treatment, the staff, and the service in general 9 Psychological benefit: a recollection of the hospitalization as a difficult but positive experience, cementing an inner strength that could be drawn on when coping with stressful situations in the future. This is all the more valid when dealing with a child who will need continuing treatment and follow-up in the future. Along with a general feeling, supported by research, that preparation programs are desirable and effective, there still remains an important question to be answered: "the eternal question of which treatments, methods and means are suitable to solve which problems, for which people, and under which circumstances" (Kazdin, 1986 in Ronen, 1994).
THE COMPONENTS OF PREOPERATIVE PREPARATION PROGRAMS A preparation program designed for children, whether individual- or group-directed, should aspire to include the following components: establishing relations of trust and affinity, dispensing information, encouraging the expression of emotions, preparation of parents, and teaching coping techniques. The relative weight and specific content of each component changes in accordance with the needs of the recipients and the skills of the deliverer. (Yap, 1988)
Establishing Trust and Affinity Relations of affinity and trust between the child and those caring for him is the basis and the cohesive of all processes and stages in the disease
254
GALIT BAR-MaR
and hospitalization. When the child returns to his home, the pain passes, the examinations and treatments end, and the relations of trust and affinity remain as the central recollection and flavor of his experience. It is accordingly advisable to ensure; that these relations are remembered affectionately. Being in the hospital puts the same kind of pressure on children as their first day in school. Young children may perceive their illness as a punishment for a "sin" they've committed, and in conseq u e n c e - v i e w the members of the nursing staff as unempathetic and the treatments as methods of punishment. Hence, it is of vital necessity to alleviate these fears by building relations of affinity and trust between the child and the nurses. Calming, supportive communication and ultimate consideration for the child's needs and feelings have a moderating effect in stress-illness situations.
them an opportunity to express their feelings. Also a party to the experience of hospitalization and surgery are the child's siblings, especially when dealing with prolonged health problems. Siblings can be a source of strength and support for the child and therefore, it is desirable to involve them in the preparation process. In addition, they, too, need to receive information and to air their feelings concerning their brother/sister's illness.
DispensingInformation
HOW TO SUCCEED IN THE IMPLEMENTATION OF A PREPARATION PROGRAM
Dispensing information about sensations, emotions, and procedures is very important. This information may reduce stress by augmenting the ability to foresee the events and to prepare for them, and thus reinforcing the sense of cognitive control over the situation. The information should be presented clearly, at a level suited to the child's development, and using graphic aids and games.
Encouraging the Expression of Emotions Expression of emotions helps clarify these feelings to the child himself, to his parents and to those caring for him. It hastens the healing process and generates feelings of relief. Through games, drawing, stories, and movement, it is possible to encourage the child to express his thoughts, fears, and emotions. These feelings may be negative or positive. As members of the nursing team, we must know how to respond to the emotions expressed by the child, even when they are very negative and directed toward the nurses themselves.
Preparing Parents and Siblings The parent is party to the hospitalization experience, bringing into it his own personal characteristics, his past experiences, and his relationship with the child. Parents relate their fears and anxieties to their children verbally or nonverbally. They need assurance that their child is receiving adequate medical treatment, they need information to allow them to understand the child's medical status and the treatment he is receiving. It is important to fortify their feelings of adequacy as parents and their importance to their child, and also to give
TeachingCoping Techniques The object of these techniques is to develop cognitive and behavioral control and to immune against stress. These techniques include: distraction through imagination, positive self-statements, relaxation, deep breathing, and hypnosis. The changes evoked by using these techniques may facilitate coping with intimidating events.
A successful preparation program is based on three components: love for guidance and counseling activities, cooperation, and adaptation of the preparation program for the children's and parents' needs.
Love for Guidance and Counseling Activities Love is the main component and driving force in the preparation program. This is a love for counseling activities, a love for playing with children and listening to parents, accompanied by a feeling of emotional affinity to the "child's world" and an intuitive understanding of this world. These feelings give rise to a desire for counseling in the nurse, and to a willingness to devote time and thought to the subject. The love for counseling turns it into a pleasant and enjoyable experience, to a duty that is also a pleasure; and thus helps to overcome all the obstacles along the way.
Cooperation Cooperation is essential at two levels: intradepartmental and interdepartmental.
Intradepartmental A preparation program, excellent as it may be, is doomed to failure at some point if centered around one person only. Beautiful programs, designed in various teaching formats and implemented on several patients, but not adopted by the nurses in the ward . . . died out and disappeared. It is therefore crucial that the whole nursing team feel committed to implementing the preparation, and participate in the development of the departmental preparation
PREPARATION OF CHILDREN
255
programs, in their evaluation and in their systematic, steady, and continuing application. The cooperation with the medical and paramedical team is also essential9
Interdepartmental During his hospitalization, the child passes through several sites in the hospital (such as: surgery room, anaesthesia ward, intensive care unit, or pediatrics ward). In addition, some of the hospitalized children have had years of treatment at a certain institute or clinic for years (for example, the nephrology institute, the cardiology institute, and so on). It is advisable to design the preparation program in cooperation with the different departments. Such a program will be more effective, encompassing, comprehensive, and consecutive.
Adapting the Preparation Program to the Needs o~Child and Parents According to Yap (1988), the focus on correspondence between the patient and the type of therapy is relatively new in the field of psychological preparation for pediatric surgery, but is nevertheless familiar to those involved in children's treatment and care. Ronen (1994) states that "decisions related to treatment should be based on developmental considerations depending on age, cognitive and emotional level and also on the child's interests, which will allow easier communication with him/her." Therefore, the same factors mentioned as affecting the child's and parents' response to surgery should always be considered. In addition, it is important to understand and take into account the following: 9 The child's style of information seeking: monitoring/blunting (Thompson, 1994) 9 The means of demonstration preferred by the child 9 The usual mode of expression of the child's thoughts and feelings
Stress and anxiety fact as perceived by the child, such as: needle prick, body exposure, anaesthesia, scar, and so on. When dealing with parents, one should take the following into account: 9 The parents' desire to participate in the preparation process 9 The parents' wish that their child participate in the preparation program 9 The parents' preferences relative to the date, the type of preparation (individual or group), and the deliverer of the preparation (the parents themselves, a nurse, a psychologist, a doctor, or another agent). 9 The quantity and type of information the parents wish to receive 9 The quantity and type of information they want their child to receive 9 Stress and anxiety fact as perceived by the parent, such as: anaesthesia, surgeons' and anaesthesiologist's skills, complications of the surgery, implications on the child's future, and so on. 9
SUMMARY The cost of a preparation program is relatively low, but its value for the subject undergoing treatment is very high. Feelings of satisfaction and contentment usually accompany the preparation process, and are mutual. Therefore, it is highly recommended to make the necessary efforts to develop preparation programs and to implement them regularly and systematically. It is probable that a preparation program that allows for the special characteristics of each child and family, that is accompanied by diverse demonstration aids, and that stresses a love for children and counseling, as well as cooperation between all the agents involved 9 should in most cases be a successful one.
REFERENCES Azarnoff, P. & Woody, P. (1981). Preparation of children for hospitalization in acute care hospitals in the United States. Pediatrics, 68, 361-368. Beverly, B. (1936). The effect of illness upon emotional development. Journal of Pediatrics, 8, 533-543. Durst, L. (1990). Preoperative teaching videotape: The effect on children's behavior. Aorn, 52,(3), 581-584. Friedman, M., & Peled, N. (1988). Preparation of children for anaesthesia and surgery. HaRefuah Journal of the Israel Medical Association, 114,(9), 432-434. levers, M., Campbell, K., & Blanche, M. (1955). Unrestricted visiting in a children's ward. Lancet, 269, 971-973. Kupfer, A. (1991). Children's (aged 3-6) responses to hospitalization in the intensive care unit. Thesis for master's degree in nursing, Tel Aviv University, Israel. Lambert, S. (1984). Variables the affect the school-age child's
reaction to hospitalization and surgery. Maternal ChiM Nursing Journal, 13.(1), 1-15. LaMontagne, L. (1985). Facilitating children's coping. Aorn, 42,(5), 718-723. Robinson, P. & Kobayashi, K. (1991). Development and evaluation of a presurgical preparation program. Journal of Pediatric Psychology, 16(2), 193-212. Ronen, T. (1994). And Above All--Love, the Art and Skill of Treating Children. Ramot Publishing, Tel Aviv University, Israel. Thompson, M. (1994). Information seeking, coping and anxiety in school-age children anticipating surgery. Children's Health Care, 23(2), 87-89. Yap, J. (1988). A critical review of pediatric preoperative preparation procedures. Journal of Applied Developmental Psychology 9, 359-389.
Preparation of Children for Surgery and Invasive Procedures: Milestones on the Way to Success Galit Bar-Mor, RN, MA A
CHILD'S HOSPITALIZATION IS usually an unpleasant and a difficult experience, both for the child and his parents. The hospital as a concept and as a place is perceived as lurking with difficult and unpleasant trials, trials forced on the child and compelling him to experience and to cope with them. When children (aged 3-12) were followed over a period of 1 month after hospitalization and surgery, it was found that the rate of appearance of behavioral and emotional changes and the nature of these changes are quite similar in different countries, different health care systems, and different types of surgery. Fifty-two percent to 78% of the children surveyed displayed changes such as (Friedman & Peled, 1988): 9 Eating disorders 9 Sleeping disorders 9 The appearance of consolatory habits, such as: thumb sucking, nail biting, and masturbation 9 The appearance of frightening imaginations 9 Developmental regression, such as bed wetting and stuttering 9 Change in attitude toward parents, such a s : over-dependence, aggression, indifference, and negativism 9 The appearance of death anxieties These phenomena, which need to be examined individually, might be a sign of the distress that the child is experiencing after his/her hospitalization and surgery. It is important to remember that reactions to surgery may be positive, not only negative. For example: the child learns to know
From the Cardiology Institute, Schneider Children's Medical Center of Israel, Petah-Tiqva, Israel. Address reprint requests to Galit Bar-Mor, RN, MA, Cardiac Catheterization Unit, Cardiology Institute, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petah-Tiqva, Israel 49202. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-000953.00/0 252
himself, to recognize his spiritual and physical strengths, and to appreciate the love and devotion displayed throughout his hospitalization by his parents and friends, as well as by the staff that cared for him. These insights may leave him with a pleasant impression, despite the discomfort and suffering involved in the illness situation. At any rate, the child's negative or positive responses to hospitalization and surgery are influenced by many factors. These may be divided into four categories (Lambert, 1984):
Factors Depending on the Child 9 The developmental stage the child is in (emotional and cognitive) 9 Previous experience in coping with distress and crisis situations 9 The coping mechanism used by the child (active or passive?) (LaMontagne, 1985) 9 The significance of the disease or state of health, as perceived and interpreted by the child 9 The feelings and sensations evoked by hospitalization, such as: pain, anger, and insult
Factors Depending on the Parents 9 How they perceive the severity of the disease and the threat that it poses, and how they transnfit this perception to the child 9 The degree of support, encouragement, and positive attitude related by the parents to the child 9 Previous experience in coping with stress and crisis situations, and specifically with disease and hospitalization 9 The existence of a support system for the parents 9 Other sources of stress in the family 9 The relationship between the parents and between the parents and the child Journal of PediatricNursing, Vol 12, No 4 (August), 1997
PREPARATION OF CHILDREN
Factors Related to the Disease 9 The nature of hospitalization: urgent versus elective, short versus long, first admission versus readmission 9 The degree of suffering accompanying the disease and the treatment, such as: pain, discomfort, unpleasant procedures, physical and other limitations 9 Frequency, duration, and degree of separation from the child's natural environment
Factors Related to the Hospital 9 The character of the ward in which the child is hospitalized, such as: the intensive care unit versus a pediatric ward (Kupfer, 1991) 9 Suitability of the ward's structure and activities to the child's world 9 The ability of the staff to understand and respond to the child's needs by: ----eliminating the separation of child from parents in all stages of hospitalization, and in particular during the entrance to surgery --minimizing physical pain sensations --reinforcing the child's sense of control over events --building a relationship of affinity and trust between the child and the nursing staff ---offering opportunities for play and expression of positive and negative emotions Many factors influence the child's response to hospitalization and surgery. The nurse's role is to understand them, and to link the present or potential responses of the child to dominant factors that are causing or might cause these reactions. This understanding is the first step in planning the preparation program for hospitalization, surgery, and invasive procedures under anesthesia.
THE NEED TO IMPLEMENT PREPARATION PROGRAMS In the 1930s, research and documentation of the psychological implications of disease and hospitalization on the child began (Beverly, 1936). Attention was then directed to the need to minimize the trauma of separation between the child and his parents and the stress and anxiety evoked when encountering a foreign, unfamiliar, and threatening environment. In the 1940s and 1950s, first buds of lengthy and unlimited parent visits began to sprout, and parent involvement in care for the hospitalized child first appeared (levers, Campbell, & Blanche, 1955). The research into the psychological repercussions of disease and hospitalization also affected nursing practice; nurses began to develop indi-
253
vidual and group preparation programs, accompanied by instruction and demonstration aids, such as pamphlets, information sheets, coloring books, illustrated stories, prehospitalization tours, simulation games using hospital equipment, films, puppet theaters, and children's drawings. (Azarnof & Woody, 1981; Durst, 1990; Robinson & Kobayashi, 1991). The prevention or reduction of the child's negative responses to hospitalization and surgery has always been our basic goal in implementing guidance programs; but today, this is not enough. With adequate counseling for the child and his parents throughout all stages of the illness and hospitalization processes, it is often possible to achieve: 9 An atmosphere of affinity and trust between the nurse and the child, and between the nurse and the parents 9 Better compliance of the child to treatment 9 More parent satisfaction from the treatment, the staff, and the service in general 9 Psychological benefit: a recollection of the hospitalization as a difficult but positive experience, cementing an inner strength that could be drawn on when coping with stressful situations in the future. This is all the more valid when dealing with a child who will need continuing treatment and follow-up in the future. Along with a general feeling, supported by research, that preparation programs are desirable and effective, there still remains an important question to be answered: "the eternal question of which treatments, methods and means are suitable to solve which problems, for which people, and under which circumstances" (Kazdin, 1986 in Ronen, 1994).
THE COMPONENTS OF PREOPERATIVE PREPARATION PROGRAMS A preparation program designed for children, whether individual- or group-directed, should aspire to include the following components: establishing relations of trust and affinity, dispensing information, encouraging the expression of emotions, preparation of parents, and teaching coping techniques. The relative weight and specific content of each component changes in accordance with the needs of the recipients and the skills of the deliverer. (Yap, 1988)
Establishing Trust and Affinity Relations of affinity and trust between the child and those caring for him is the basis and the cohesive of all processes and stages in the disease
254
GALIT BAR-MaR
and hospitalization. When the child returns to his home, the pain passes, the examinations and treatments end, and the relations of trust and affinity remain as the central recollection and flavor of his experience. It is accordingly advisable to ensure; that these relations are remembered affectionately. Being in the hospital puts the same kind of pressure on children as their first day in school. Young children may perceive their illness as a punishment for a "sin" they've committed, and in conseq u e n c e - v i e w the members of the nursing staff as unempathetic and the treatments as methods of punishment. Hence, it is of vital necessity to alleviate these fears by building relations of affinity and trust between the child and the nurses. Calming, supportive communication and ultimate consideration for the child's needs and feelings have a moderating effect in stress-illness situations.
them an opportunity to express their feelings. Also a party to the experience of hospitalization and surgery are the child's siblings, especially when dealing with prolonged health problems. Siblings can be a source of strength and support for the child and therefore, it is desirable to involve them in the preparation process. In addition, they, too, need to receive information and to air their feelings concerning their brother/sister's illness.
DispensingInformation
HOW TO SUCCEED IN THE IMPLEMENTATION OF A PREPARATION PROGRAM
Dispensing information about sensations, emotions, and procedures is very important. This information may reduce stress by augmenting the ability to foresee the events and to prepare for them, and thus reinforcing the sense of cognitive control over the situation. The information should be presented clearly, at a level suited to the child's development, and using graphic aids and games.
Encouraging the Expression of Emotions Expression of emotions helps clarify these feelings to the child himself, to his parents and to those caring for him. It hastens the healing process and generates feelings of relief. Through games, drawing, stories, and movement, it is possible to encourage the child to express his thoughts, fears, and emotions. These feelings may be negative or positive. As members of the nursing team, we must know how to respond to the emotions expressed by the child, even when they are very negative and directed toward the nurses themselves.
Preparing Parents and Siblings The parent is party to the hospitalization experience, bringing into it his own personal characteristics, his past experiences, and his relationship with the child. Parents relate their fears and anxieties to their children verbally or nonverbally. They need assurance that their child is receiving adequate medical treatment, they need information to allow them to understand the child's medical status and the treatment he is receiving. It is important to fortify their feelings of adequacy as parents and their importance to their child, and also to give
TeachingCoping Techniques The object of these techniques is to develop cognitive and behavioral control and to immune against stress. These techniques include: distraction through imagination, positive self-statements, relaxation, deep breathing, and hypnosis. The changes evoked by using these techniques may facilitate coping with intimidating events.
A successful preparation program is based on three components: love for guidance and counseling activities, cooperation, and adaptation of the preparation program for the children's and parents' needs.
Love for Guidance and Counseling Activities Love is the main component and driving force in the preparation program. This is a love for counseling activities, a love for playing with children and listening to parents, accompanied by a feeling of emotional affinity to the "child's world" and an intuitive understanding of this world. These feelings give rise to a desire for counseling in the nurse, and to a willingness to devote time and thought to the subject. The love for counseling turns it into a pleasant and enjoyable experience, to a duty that is also a pleasure; and thus helps to overcome all the obstacles along the way.
Cooperation Cooperation is essential at two levels: intradepartmental and interdepartmental.
Intradepartmental A preparation program, excellent as it may be, is doomed to failure at some point if centered around one person only. Beautiful programs, designed in various teaching formats and implemented on several patients, but not adopted by the nurses in the ward . . . died out and disappeared. It is therefore crucial that the whole nursing team feel committed to implementing the preparation, and participate in the development of the departmental preparation
PREPARATION OF CHILDREN
255
programs, in their evaluation and in their systematic, steady, and continuing application. The cooperation with the medical and paramedical team is also essential9
Interdepartmental During his hospitalization, the child passes through several sites in the hospital (such as: surgery room, anaesthesia ward, intensive care unit, or pediatrics ward). In addition, some of the hospitalized children have had years of treatment at a certain institute or clinic for years (for example, the nephrology institute, the cardiology institute, and so on). It is advisable to design the preparation program in cooperation with the different departments. Such a program will be more effective, encompassing, comprehensive, and consecutive.
Adapting the Preparation Program to the Needs o~Child and Parents According to Yap (1988), the focus on correspondence between the patient and the type of therapy is relatively new in the field of psychological preparation for pediatric surgery, but is nevertheless familiar to those involved in children's treatment and care. Ronen (1994) states that "decisions related to treatment should be based on developmental considerations depending on age, cognitive and emotional level and also on the child's interests, which will allow easier communication with him/her." Therefore, the same factors mentioned as affecting the child's and parents' response to surgery should always be considered. In addition, it is important to understand and take into account the following: 9 The child's style of information seeking: monitoring/blunting (Thompson, 1994) 9 The means of demonstration preferred by the child 9 The usual mode of expression of the child's thoughts and feelings
Stress and anxiety fact as perceived by the child, such as: needle prick, body exposure, anaesthesia, scar, and so on. When dealing with parents, one should take the following into account: 9 The parents' desire to participate in the preparation process 9 The parents' wish that their child participate in the preparation program 9 The parents' preferences relative to the date, the type of preparation (individual or group), and the deliverer of the preparation (the parents themselves, a nurse, a psychologist, a doctor, or another agent). 9 The quantity and type of information the parents wish to receive 9 The quantity and type of information they want their child to receive 9 Stress and anxiety fact as perceived by the parent, such as: anaesthesia, surgeons' and anaesthesiologist's skills, complications of the surgery, implications on the child's future, and so on. 9
SUMMARY The cost of a preparation program is relatively low, but its value for the subject undergoing treatment is very high. Feelings of satisfaction and contentment usually accompany the preparation process, and are mutual. Therefore, it is highly recommended to make the necessary efforts to develop preparation programs and to implement them regularly and systematically. It is probable that a preparation program that allows for the special characteristics of each child and family, that is accompanied by diverse demonstration aids, and that stresses a love for children and counseling, as well as cooperation between all the agents involved 9 should in most cases be a successful one.
REFERENCES Azarnoff, P. & Woody, P. (1981). Preparation of children for hospitalization in acute care hospitals in the United States. Pediatrics, 68, 361-368. Beverly, B. (1936). The effect of illness upon emotional development. Journal of Pediatrics, 8, 533-543. Durst, L. (1990). Preoperative teaching videotape: The effect on children's behavior. Aorn, 52,(3), 581-584. Friedman, M., & Peled, N. (1988). Preparation of children for anaesthesia and surgery. HaRefuah Journal of the Israel Medical Association, 114,(9), 432-434. levers, M., Campbell, K., & Blanche, M. (1955). Unrestricted visiting in a children's ward. Lancet, 269, 971-973. Kupfer, A. (1991). Children's (aged 3-6) responses to hospitalization in the intensive care unit. Thesis for master's degree in nursing, Tel Aviv University, Israel. Lambert, S. (1984). Variables the affect the school-age child's
reaction to hospitalization and surgery. Maternal ChiM Nursing Journal, 13.(1), 1-15. LaMontagne, L. (1985). Facilitating children's coping. Aorn, 42,(5), 718-723. Robinson, P. & Kobayashi, K. (1991). Development and evaluation of a presurgical preparation program. Journal of Pediatric Psychology, 16(2), 193-212. Ronen, T. (1994). And Above All--Love, the Art and Skill of Treating Children. Ramot Publishing, Tel Aviv University, Israel. Thompson, M. (1994). Information seeking, coping and anxiety in school-age children anticipating surgery. Children's Health Care, 23(2), 87-89. Yap, J. (1988). A critical review of pediatric preoperative preparation procedures. Journal of Applied Developmental Psychology 9, 359-389.