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Parental preparation of children for routine physical examinations
Parental Preparation of Children for Routine Physical Examinations CarolJo Wilson, PhD, RN, CS Preparation of the child and parents/caretakers for health care events is expected to decrease a child's anxiety and uncooperative behaviors. The purpose of this study was to ascertain the methods of preparation (discussion, reading, play, other) and levels of discussion used by parents in readying their preschool and school-age children for six selected events during routine physical examinations. A phone survey was conducted to all parents of children, ages 2 to 12 years, who visited an academic nursing center or public school for a routine physical examination (n = 132). The events are "listen to heart," "look in ears," "take temperature," "feel the stomach," "look at the throat," and "give a shot." The most common method of preparation parents used was discussion that consisted largely of procedural information rather than a reciprocal dialogue with the child. Preschool children were told what the health care provider would do and what they should do during the physical examination more often than school-age children.
Copyright9 1999by W.B. SaundersCompany
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REPARATION OF the child for hospitalization and health care events is recognized as important for several reasons. The positive effects of preparation include preserving the child's psychological integrity (Visintainer & Wolfer, 1975; Wolfer & Visintainer, 1979); decreasing pain (Broome, 1990), anxiety, and fear (Edwinson, 1988; Thompson, 1994); and establishing a positive relationship between the child and health care provider (LaMontagne, 1993). These positive effects are well documented in current literature involving preparation for hospitalization (Meng & Zastowny, 1982) and surgery (Abbott, 1990; Crocker, 1980; Isaacs, 1989). Although guidelines exist to prepare children for hospitalization (Lambert, 1984; Manion, 1990; Petrillo & Sanger, 1980); surgery (Lynch, 1994; Schmidt, 1992); and special procedures (Ott, 1996) such as receiving injections (Broome, 1990), radiographs (Hansen & Evans, 1981), cardiac catheterization (Pederson, 1995), and venipuncture (Ellerton, Ritchie, & Caty, 1994); there has been limited study of preparation for a routine physical examination. Children need special preparation geared toward their developmental and experiential levels to master the challenges presented by a physical examination (Jackson & Saunders, 1993). Current physical assessment textbooks have separate sections or integrate information regarding pediatrics (Barkauskas, Stoltenburg-Allen, Baumann, & Darling-Fisher, 1994; Bates, 1991; Jarvis, 1992). Additional information is presented for techniques for Journalof PediatricNursing,Vol 14, No 5 (October), 1999
the pediatric client, differences seen in terms of variations and abnormalities in the findings, and the differences taken in the approach to the child. The health care professional can and does prepare the child immediately before and during the examination; however, because of time constraints, this is often superficial. The information must also be presented at the child's cognitive developmental level. Although health care professionals have a general idea of each child's current developmental level according to national standards, it is often only the parent/caretaker who truly knows the child's developmental level. In addition, it is usually only the parent who can tie this experience into a similar one the child may have had. Psychological preparation for medical procedures involves giving information (sensory and/or procedural), teaching coping skills, and preparing the parents because they are the best sources for finding out how a child copes and what the child's previous experience may have been (Bossert, 1994; Patterson & Ware, 1988; Ryan-Wenger, 1996). It is essential to have accurate knowledge, presented at the child's developmental level, including both procedural and sensory information about an up-
From Northern Illinois University, Dekalb, IL. This research was partially funded by a grant from Beta Omega chapter, Sigma Theta Tau. Address reprint requests to Carol Jo Wilson, PhD, RN, CS, 607 State Street/Box 250, Maple Park, IL 60151. Copyright 9 1999 by WB. Saunders Company 0882-5963/99/1405-0007510.00/0
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coming event (Lambert, 1984). In addition, identified child behavioral information and parental role information are important factors in developing coping strategies (Melnyk, 1994). In fact, the situation and actions of professionals (including information-giving and preparation) may have more of an impact on stress than characteristics of the individual (Ellerton, Ritchie, & Caty, 1994). Only one study has focused on ascertaining the type of preparation used by parents in readying their child for a routine physical examination. Wilson and Mason (1990) studied 60 children ages 2 to 7 years and found that the majority (95%) of parents prepared their children for one or more of six stressful events using one or more methods (discussion, reading, play). The six events ("look in ears," "look at the throat," "listen to heart," "feel the stomach," "take temperature," "give a shot") were determined experientially as being threatening or frightening to the child (Ferholt & Lott, 1980). The discussion method was the most popular method; however, the level of discussion was not ascertained. Therefore, preparation may have ranged, for example, from merely telling a child the health care provider would check his/her throat to engaging the child in an exchange of information and feelings. Data from this study were further divided into two groups: that from children 3 to 6 years old and from children 6 to 12 years (Wilson, 1991). For all six stressful events, children ages 6 to 12 received less preparation than those ages 3 to 6. The mean percent of preparation (all methods combined) for preschool:school-age children for each event was as follows: heart, 81:77; ear, 94:73; temperature, 78:68; stomach, 83:68; throat, 92:77; and shot, 78:73. The events for which children received the least preparation for both age groups were temperature (73%), shot (75%), stomach (76%), and heart (79%). The events receiving the highest preparation were throat (85%) and ear (84%). There were no statistically significant differences between gender and preparation. The review of literature indicates that preparation of the child for health care encounters is necessary to decrease a child's anxiety, fears, and uncooperative behaviors (Manion, 1990). Preparation is also necessary in establishing a positive relationship between the child and health care professionals, which may benefit the child in any future encounters within the health care system. Preparation for the annual routine physical examination, which has stressful elements, has not been studied in as much depth as other less common
CAROLJO WILSON
health care encounters. This is an area that requires further investigation because the physical examination is a recurring state-mandated event in the lives of school children and, in addition, portions of the physical examination are performed during visits for acute illness episodes.
PURPOSE The purpose of this study was to ascertain the methods (discussion/reading/play/other) and level of discussion used by parents/caretakers in readying their children for routine physical examinations. This descriptive research study addressed the following questions: 1. What methods do parents/caretakers use in preparing their children for the six selected events of the routine physical examination? 2. Does the method of preparation differ depending on the age of the child (preschool versus school-age)? 3. Does the method of preparation differ depending on the gender of the child (male versus female)? 4. What are the levels of discussion used by parents in preparing their children for routine physical examinations?
METHODS Procedures
During a 3-month period, a phone survey was conducted of each parent/caretaker (n = 132) who accompanied a child ages 2 to 12 years for a routine physical examination at an academic nursing center or one of two elementary schools. The data collection tool, which was designed by the researcher and pilot tested on 10 parents, elicited information on methods (discussion/reading/play/other) of preparation used by parents/caretakers in readying children for six selected events during the physical examination. The events are listening to the heart, looking in the ears, taking the temperature, feeling the stomach, looking at the throat, and giving a shot. The tool, which consisted of both open- and closed-ended questions, also elicited information about the level of discussion used. Parents were phoned between 1 and 3 weeks after the physical examination. Data were cross-tabulated by gender and age group (2 to 5 years 11 months; 6 to 12 years). Descriptive data obtained from the participant's registration form were the parent/caretaker's age, race, gender, socioeconomic level, and educational level. Descriptive data obtained from the child's health history were the child's age, race, gender,
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previous hospitalizations, and previous episodes of chronic illness.
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study and were presenting only for routine physical examinations.
RESULTS
Participants The sample consisted of 132 parents/caretakers who prepared a child between the ages of 2 and 12 for a routine physical examination. Profile of parents/caretakers was 109 mothers, 14 fathers, 6 grandmothers, 2 guardians, and 1 aunt. The children consisted of 72 boys, of which 42 (32%) were under age 6 and 30 (23%) were 6 to 12 years of age, and 60 girls, of which 33 (25%) were under age 6 and 27 (20%) were 6 to 12 years of age. The study sites were a nurse-managed rural community health center or one of two elementary schools. All examinations were performed by one of five female nurse practitioners. Ethnicity of sample could be described as 124 (94%) Caucasian, 7 (5%) Hispanic, and 1 (.8%) Chinese parents. For education level, 37 of 132 (28%) of the parents reported completing grades 10 through 20, with a mean of grade 13. For socioeconomic level, 37 of the 132 (28%) of the parents reported. Of these, 24 were uninsured, 6 had Medicaid, 4 paid cash, and 3 had private insurance. Regarding age, only 24 of 132 (18%) parents reported their ages, ranging from 21 to 43 with a mean of 34 years. In the illness history section of the registration form, parents reported that 35 (27%) of the 132 children had had a previous episode of chronic illness. Chronic illness was defined as one illness lasting more than 3 months or occurring more than three times. Ear infections accounted for the most responses (28), followed by tuberculosis contact (3). Other illnesses mentioned once each were kidney problems, allergic rhinitis, strep throat and high fevers, attention deficit disorder, a hole in the heart (that child "grew out of"), and sclerocornea/ glaucoma. Of the 132 children, 31 (23%) had been hospitalized at least once before with a variety of medical illnesses and operations. Illnesses requiring hospitalization were predominantly respiratory (bronchitis, croup, pneumonia, respiratory syncytial virus). Other illnesses requiring hospitalization included fever, viral infection, spinal meningitis, kidney infection, blocked tear duct, and the flu. Surgical procedures were mostly myringotomy tubes (7), tonsillectomy/adenoidectomy (3), and hernia repairs (2). Additional surgeries for individual children included hypospadias repair, testicular reduction, shoulder surgery for a birth defect, appendectomy, kidney transplant, and multiple eye surgeries for sclerocornea. All of the 132 children were reported as being healthy at the time of this
Results showed that 98% (n = 129) of the parents prepared their children for a routine physical examination, although the preparation consisted mostly of simply telling the child he/she was going to see the physician/nurse. When asked "For this visit, did you discuss parts of the physical exam with the child?", 98% (n = 129) replied affirmatively. The level of discussion ranged from merely telling the child he/she would be visiting the doctor/nurse to the procedural elements of what would happen and what the child should do, to the sensory elements of what the child would feel, to a more involved and reciprocal discussion including questions and answers. Most parents chose a combination of levels of discussion. However, in general, regardless of age or gender, parents mainly provided basic and procedural information versus sensory information and spent very little time in a reciprocal dialogue with the child. Chi square tests were performed to ascertain if there were statistically significant differences between preschool and school-age children or between genders. The statistically significant findings (P < .01) were that preschool-age children were told what the health care provider would do during the examination and what the child should do during the examination (ie, how they would be expected to sit or lie down for different procedures and how to behave) more often than school-age children. Parents who prepared their children for one or more of the events may have supplemented their discussion with reading and/or play. When asked if "For this visit did you and/or your child read a book or books about visiting the doctor/nurse or having a physical?", 28 (21%) parents had, 87 (66%) parents had not, and 17 (13%) parents had in the past. The numbers are further distributed by age and gender (Table 1), although there were no statistically significant differences. In general, the children whose parents had used books to prepare them in the past were in the older age group. There were no significant differences between male and female children, and the younger children were Table !. Mean Percentof ReadingSupplemented Boys3to Boys6to Girts3to Girls6to <6 years 12years <6 years 12 years Total (n=42) {n=30) (n=33) (n=27) (n= 132) Read a book Did not read Read in past
33 67 0
10 57 33
27 67 6
7 74 19
21 66 13
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prepared more frequently with books than the older children. Forty-eight parents (36%) supplemented their discussion with play (toys, games, dolls, medical kits), whereas 52 (39%) parents did not use play. However, an additional 32 (24%) parents reported using play as a preparation technique in the past when their children were younger, thus bringing the number of parents who have supplemented preparation discussion with play to 80 (61%). There were no statistically significant differences by age and gender. Parents were also asked specifically about preparation for the six events. The mean percent of discussion preparation for each event is as follows: ears, 64%; shot, 64%; throat, 61%; heart, 55%; temperature, 45%; and stomach, 39% (Table 2). The mean percent of discussion preparation for each event for preschool:school-age children is as follows: heart, 63%:46%; ears, 72%:54%; temperature, 48%:40%; stomach, 40%:39%; throat, 69%: 51%; and shot, 83%:40%. The mean percent of discussion preparation for each event for boys:gifts is as follows: heart, 57%:53%; ears, 68%:60%; temperature, 43%:47%; stomach, 43%:35%; throat, 65%:57%; and shot, 68%:60% (Table 3). Chi square tests were performed to ascertain if there were statistically significant differences according to age or gender in discussion of events. The only statistically significant finding was that preschool children were prepared for the throat assessment more often than school-age children (P < .05). A variety of reasons were cited by parents for not preparing the child for certain events. Overall, the most common reason (n = 45) given was that the child already knew about that particular event in the examination, having experienced it previously. The second most common reason (n -- 33) overall was that the parent did not think about doing it. Other reasons cited by parents included the uncertainty whether a critical event would be a part of this particular physical (n = 12) or the certainty (especially with injections, n = 6) that it would not be required. Five parents did not know that the required physical examination could be obtained Table 2. Mean Percentof Melhods by Critical Events Event
No Preparation
Discussion
Heart Temperature Throat Ears Stomach Shot
45 55 39 36 61 36
55 45 61 64 39 64
Table 3. Mean Percentof Discussionof Critical Events
Event
Boys3 to <6 years (n = 42)
Boys6 to 12 years (n = 30)
Girls 3 to <6 years (n = 33)
Girls 6 to 12 years (n = 27)
Heart Temp Throat Ear Stomach Shot
62 43 74 71 38 86
50 43 53 63 50 43
64 54 64 73 42 79
41 37 48 44 26 37
during school registration and signed up spontaneously. Only two parents indicated that they did not have the time, and three parents felt they should not frighten the child with preparation information. There were no statistically significant differences between ages or genders in the reasons for no preparation.
DISCUSSION Parents in this study used a variety of methods (discussion/reading/play) in preparing their preschool and school-age children for routine physical examinations. Discussion took many levels ranging from the most frequently identified essential information ("told child he/she would be going to the doctor/nurse"), to procedural information ("told child what doctor/nurse would do" and/or "told child what he/she should do"), to sensory information ("told child how it would feel"), to the least common, a reciprocal dialogue ("asked child if he/she had any questions" and/or "answered questions about the physical examination"). The finding that 93% of parents used some level of discussion in preparing their children is in agreement with an earlier study (Wilson & Mason, 1990) that found that 95% of parents used discussion. There were statistically significant differences between preschool and school-age children in terms of levels of discussion. Preschool children were told what the health care provider would do and what they should do more often than school-age children. In addition, the finding that younger children were more likely to have their discussion supplemented with reading and/or play is in agreement with Wilson's 1991 study. This is also consistent with normal growth and development and experience (Frost & Klein, 1979). Preoperational thinkers learn best through play and questioning (Piaget, 1962). Undoubtedly, the school-age child has had past experiences with the physical examination or parts of it for various acute episodic visits for health care. Parents may have thought that their younger children had less experience with the physical examination and therefore needed more information, direction, and preparation. There were
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no statistically significant differences between ages in reasons for not preparing the child by event. There were no statistically significant differences between boys and girls in method of preparation used, discussion of events, and reasons for not preparing the child. The finding of no gender differences supports previous research findings (Wilson, 1991). Over 50% of parents prepared their children for the stressful events of "ears," "shot," "throat," and "heart." The events associated with the most preparation were the ear (64%) and shot (64%) events. Many children were most likely prepared for the ear event because about a quarter of the children (28, 21%) had previously experienced ear infections and parents could remind the children that they had mastered this part of the physical examination in the past. In general, the child initiated discussion of the shot with 64% of the parents by asking if it would be included in this examination. The only statistically significant difference in terms of event was that preschool children were prepared for the throat examination more often than school-age children, in contrast to no statistically significant differences found in Wilson's 1991 study. The throat finding may be related to the high number of chronic ear infections (n = 28, 21%) in children that were reported by parents. The fact that children were least prepared for "temperature" and "stomach" may be attributable to a number of factors. Parents may have thought "taking a temperature" is a common, nonthreatening event not warranting mention or may not have known that it would be a part of a routine physical because the child was not "sick." In addition, they may have been unsure of the route for taking the temperature (ear, axilla, mouth, rectum), so thought it best not to conjecture. Several parents spoke of a "tympanic temperature," but it is unknown if they related this to the child as a difference or as a similarity between equipment used at home and at the clinic/school. This would warrant future study because discordance between preparation and the perception of the actual experience could have a negative effect on the child (Manion, 1990). The event receiving the least preparation was feeling the stomach. Parents may not have perceived this as particularly threatening to the child even though the child was placed in a vulnerable (recumbent) position for this section of the examination. Another explanation may revolve around the fact that this assessment technique requires no special instruments other than the examiner's hands.
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Therefore, toy medical kits would not contain anything to simulate play in this area. In addition, several parents commented that they did not know that assessment of the abdomen would be included in the physical examination.
RECOMMENDATIONS The findings indicate that the majority of parents are preparing their children for routine physical examinations; however, they could be doing more. Although 93% of the parents prepared a child for one or more of the selected events and with one or more methods, all of the events were not routinely included and the level of discussion was predominantly basic or procedural. The sheer frequency of this event, the physical examination, may lead parents to believe that the child has already experienced it and therefore needs no further preparation. However, children interpret experiences in terms of their cognitive development at the time (Piaget, 1962). Thus, as children grow, they are constantly re-evaluating and reinterpreting experiences such as the physical examination. This study could be replicated with a larger and more representative sample in other areas of the country and in public health departments as well as private clinics and schools. A future study may also limit the population to, for example, parental preparation for a preschooler's physical examination for kindergarten. The toddler population also warrants investigation because this is the most fearful and difficult age of children on which to perform a physical examination (Vessey, 1995). Future studies should elicit more information regarding actual content of the preparation discussion. Future studies might investigate what parents and children actually know about the routine physical examination and its role in health promotion. Can knowledge learned early on help assure a decreased level of stress during regular examinations throughout a lifetime? Do the parents think their chosen methods were effective, or do they plan to use different preparation methods for the next examination? Why or why not? The physical examination consists of many procedures that are potentially threatening to the child's body integrity. In future, possibly longitudinal studies, parents could be assessed regarding the effectiveness of preparation methods that are modified to each child's developmental and experiential level. For example, a child who is comfortable with his/her nurse practitioner or pediatrician may need less preparation than one who is not. The effectiveness of certain methods such as brochures, videos,
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coloring books, or booklets targeted at differing developmental levels needs to be assessed. What are the parents' perceived needs for effectively preparing their children for an examination? Findings suggest that parents may need information on how to prepare the child and what information to include in discussions with the child (Appendix 1). The physical examination should be used to educate about procedures and normal/abnormal findings, offer reassurance, teach health promotion, and validate the family's knowledge and concerns. Attention to preparation may result in increased learning and mutual enjoyment of the physical examination by the child and examiner.
ACKNOWLEDGMENT The author gratefully acknowledges the assistance of Kristina L. Foster, RN, BSN, MS, graduate assistant, for the data collection and preparation of this manuscript.
APPENDIX 1. General Guidelines for Preparation 1. Tell child about the physical examination visit the night before (4- to 7-year-olds) or up to 1 week in advance (7- to 12-yearolds). 2. For each of the six stressful events, tell the child what the doctor/nurse will do, what the child should do (including telling the health care professional if anything is uncomfortable or hurts), and how it feels. For example: "The doctor/nurse will listen to your heart
with a stethoscope that may feel cold. You need to sit (or lie) very quietly so they can hear your heartbeat." "The doctor/nurse will check your temperature by placing a thermometer in your ear (mouth, under the arm, etc). It doesn't hurt, and you need to sit quietly." "The doctor/nurse will look in your mouth with a special flashlight. You will need to sit and open your mouth as wide as you can so they can get a good look." "The doctor/nurse will look in your ears with a special flashlight. Only a light goes inside, nothing else. You'll need to sit and bend your head so they can get a good view inside." "The doctor/nurse will feel your stomach with his/her hands. You'll need to lie on your back with your hands to your sides. This will help to relax your stomach so it is easier to feel." "The doctor/nurse will be giving you a shot to keep you well today. There's always a good reason for a shot. They are not punishment. The doctor/nurse does not like that the shot hurts. It's OK to be brave, to cry, to yell, to say "I don't like shots"; you only have to sit still. Sometimes it's hard to hold still and someone might hold you to help." . Ask if the child has any questions about the examination and answer truthfully. If you do not know the information, try to find out for the child.
REFERENCES Abbott, K. (1990). Therapeutic use of play in the psychological preparation of preschool children undergoing cardiac surgery. Issues in Comprehensive Pediatric Nursing, 13, 265-277. Bates, B. (1991). A guide to physical examination (5th ed.). Philadelphia: Lippincott. Barkauskas, V. H., Stoltenberg-Allen, K., Baumann, L. C., & Darling-Fisher, C. (1994). Health and physical assessment. St. Louis: Mosby. B ossert, E. (1994). Factors influencing the coping of hospitalized schoolage children. Journal of Pediatric Nursing, 9, 299-306. Broome, M. E. (1990). Preparation of children for painful procedures. Pediatric Nursing, 16(6), 537-541. Crocker, E. (1980). Preparation for elective surgery: Does it make a difference? Journal of the Association for the Care of Children's Health, 9(1), 3-11. Edwinson, M., Arnbjornsson, E., & Ekman, R. (1988). Psychologic preparation program for children undergoing acute appendectomy. Pediatrics, 82(1), 30-36. Ellerton, M. L., Ritchie, J. A., & Caty, S. (1994). Factors influencing young children's coping behaviors during stressful
healthcare encounters. Maternal ChiM Nursing Journal, 22(3), 74-82. Ferholt, J., & Lott, D. (1980). Clinical assessment of children: A comprehensive approach to primary pediatric care. Philadelphia: Lippincott. Frost, J. L., & Klein, B. L. (1979). Children's play and playgrounds. Boston: Allyn & Bacon. Hansen, B. D., & Evans, M. L. (1981). Preparing a child for procedures. American Journal of Maternal Child Nursing, 6(6), 392-397. Isaacs, E J. (1989). Crisis prevention in an outpatient surgery center. Maternal-Child Nursing, 14, 352-354. Jackson, D. B., & Saunders, R. B. (1993). Child health nursing. Philadelphia: Lippincott. Jarvis, C. (1992). Physical examination and health assessment. Philadelphia: Lippincott. Lambert, S. A. (1984). Variables that affect the school-age child's reaction to hospitalization and surgery: A review of the literature. Maternal-Child Nursing Journal, 13, 1-18. LaMontagne, L. L. (1993). Bolstering personal control in child patients through coping interventions. Pediatric Nursing, 19(3), 235-237.
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Lynch, M. (1994). Preparing children for day surgery. Children's Health Care, 23(2), 75-85. Manion, J. (1990). Preparing children for hospitalization, procedures, or surgery. In M. Craft & J. Denehy (Eds.), Nursing interventions for infants and children. Philadelphia: Saunders. Melnyk, B. (1994). Coping with unplanned childhood hospitalizations: Effects of informational interventions on mothers and children. Nursing Research, 45, 50-55. Meng, A., & Zastowny, T. (1982). Preparation for hospitalization: A stress inoculation training program for parents and children. Maternal-Child Nursing Journal, 11(2), 87-94. Ott, M. J. (1996). Imagine the possibilities! Guided imagery with toddlers and preschoolers. Pediatric Nursing, 22(1 ), 34-38. Patterson, K. L., & Ware, L. L. (1988). Coping skills for children undergoing painful medical procedures. Issues in Comprehensive Pediatric Nursing, 11, 113-143. Pederson, C. (1995). Effect of imagery on children's pain and anxiety during cardiac catheterization. Journal of Pediatric Nursing, 10(6), 365-374. Petrillo, M., & Sanger, S. (1980). Emotional care of hospitalized children: An environmental approach (2rid ed.), Philadelphia: Lippincott. Piaget, J. (1962). Play, dreams and imitation in childhood. New York: Norton.
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Ryan-Wenger, N. A. (1996). Children coping and the stress of illness: A synthesis of the research. Journal of the Society of Pediatric Nurses, 1(3), 126-138. Schmidt, C. (1992). Pre-operative preparation: Effects on immediate pre-operative behavior, post-operative behavior and recovery of children having same-day surgery. Maternal-Child Nursing Journal, 19, 321-330. Thompson, M. L. (1994). Information-seeking, coping, and anxiety in school age children. Children's Health Care, 23(2), 87-97. Vessey, J. A. (1995 ). Developmental approaches to examining young children, 21(1), 53-56. Visintainer, M. A., & Wolfer, J. A. (1975). Psychological preparation for surgical pediatric patients and the effects on children's and parents' stress response and adjustment. Pediatrics, 56, 187-202. Wilson, C. J. (1991). Parental methods of preparation for the routine physical exam. Unpublished manuscript. Wilson, C. J., & Mason, M. (1990). Preparation for routine physical examination. Children's Health Care, 19(3), 178-182. Wolfer, J. A., & Visintainer, M. A. (1979). Pediatric surgical patients' and parents' stress responses and adjustments. Pediatrics, 64(5), 646-655.
Copyright9 1999by W.B. SaundersCompany
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REPARATION OF the child for hospitalization and health care events is recognized as important for several reasons. The positive effects of preparation include preserving the child's psychological integrity (Visintainer & Wolfer, 1975; Wolfer & Visintainer, 1979); decreasing pain (Broome, 1990), anxiety, and fear (Edwinson, 1988; Thompson, 1994); and establishing a positive relationship between the child and health care provider (LaMontagne, 1993). These positive effects are well documented in current literature involving preparation for hospitalization (Meng & Zastowny, 1982) and surgery (Abbott, 1990; Crocker, 1980; Isaacs, 1989). Although guidelines exist to prepare children for hospitalization (Lambert, 1984; Manion, 1990; Petrillo & Sanger, 1980); surgery (Lynch, 1994; Schmidt, 1992); and special procedures (Ott, 1996) such as receiving injections (Broome, 1990), radiographs (Hansen & Evans, 1981), cardiac catheterization (Pederson, 1995), and venipuncture (Ellerton, Ritchie, & Caty, 1994); there has been limited study of preparation for a routine physical examination. Children need special preparation geared toward their developmental and experiential levels to master the challenges presented by a physical examination (Jackson & Saunders, 1993). Current physical assessment textbooks have separate sections or integrate information regarding pediatrics (Barkauskas, Stoltenburg-Allen, Baumann, & Darling-Fisher, 1994; Bates, 1991; Jarvis, 1992). Additional information is presented for techniques for Journalof PediatricNursing,Vol 14, No 5 (October), 1999
the pediatric client, differences seen in terms of variations and abnormalities in the findings, and the differences taken in the approach to the child. The health care professional can and does prepare the child immediately before and during the examination; however, because of time constraints, this is often superficial. The information must also be presented at the child's cognitive developmental level. Although health care professionals have a general idea of each child's current developmental level according to national standards, it is often only the parent/caretaker who truly knows the child's developmental level. In addition, it is usually only the parent who can tie this experience into a similar one the child may have had. Psychological preparation for medical procedures involves giving information (sensory and/or procedural), teaching coping skills, and preparing the parents because they are the best sources for finding out how a child copes and what the child's previous experience may have been (Bossert, 1994; Patterson & Ware, 1988; Ryan-Wenger, 1996). It is essential to have accurate knowledge, presented at the child's developmental level, including both procedural and sensory information about an up-
From Northern Illinois University, Dekalb, IL. This research was partially funded by a grant from Beta Omega chapter, Sigma Theta Tau. Address reprint requests to Carol Jo Wilson, PhD, RN, CS, 607 State Street/Box 250, Maple Park, IL 60151. Copyright 9 1999 by WB. Saunders Company 0882-5963/99/1405-0007510.00/0
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coming event (Lambert, 1984). In addition, identified child behavioral information and parental role information are important factors in developing coping strategies (Melnyk, 1994). In fact, the situation and actions of professionals (including information-giving and preparation) may have more of an impact on stress than characteristics of the individual (Ellerton, Ritchie, & Caty, 1994). Only one study has focused on ascertaining the type of preparation used by parents in readying their child for a routine physical examination. Wilson and Mason (1990) studied 60 children ages 2 to 7 years and found that the majority (95%) of parents prepared their children for one or more of six stressful events using one or more methods (discussion, reading, play). The six events ("look in ears," "look at the throat," "listen to heart," "feel the stomach," "take temperature," "give a shot") were determined experientially as being threatening or frightening to the child (Ferholt & Lott, 1980). The discussion method was the most popular method; however, the level of discussion was not ascertained. Therefore, preparation may have ranged, for example, from merely telling a child the health care provider would check his/her throat to engaging the child in an exchange of information and feelings. Data from this study were further divided into two groups: that from children 3 to 6 years old and from children 6 to 12 years (Wilson, 1991). For all six stressful events, children ages 6 to 12 received less preparation than those ages 3 to 6. The mean percent of preparation (all methods combined) for preschool:school-age children for each event was as follows: heart, 81:77; ear, 94:73; temperature, 78:68; stomach, 83:68; throat, 92:77; and shot, 78:73. The events for which children received the least preparation for both age groups were temperature (73%), shot (75%), stomach (76%), and heart (79%). The events receiving the highest preparation were throat (85%) and ear (84%). There were no statistically significant differences between gender and preparation. The review of literature indicates that preparation of the child for health care encounters is necessary to decrease a child's anxiety, fears, and uncooperative behaviors (Manion, 1990). Preparation is also necessary in establishing a positive relationship between the child and health care professionals, which may benefit the child in any future encounters within the health care system. Preparation for the annual routine physical examination, which has stressful elements, has not been studied in as much depth as other less common
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health care encounters. This is an area that requires further investigation because the physical examination is a recurring state-mandated event in the lives of school children and, in addition, portions of the physical examination are performed during visits for acute illness episodes.
PURPOSE The purpose of this study was to ascertain the methods (discussion/reading/play/other) and level of discussion used by parents/caretakers in readying their children for routine physical examinations. This descriptive research study addressed the following questions: 1. What methods do parents/caretakers use in preparing their children for the six selected events of the routine physical examination? 2. Does the method of preparation differ depending on the age of the child (preschool versus school-age)? 3. Does the method of preparation differ depending on the gender of the child (male versus female)? 4. What are the levels of discussion used by parents in preparing their children for routine physical examinations?
METHODS Procedures
During a 3-month period, a phone survey was conducted of each parent/caretaker (n = 132) who accompanied a child ages 2 to 12 years for a routine physical examination at an academic nursing center or one of two elementary schools. The data collection tool, which was designed by the researcher and pilot tested on 10 parents, elicited information on methods (discussion/reading/play/other) of preparation used by parents/caretakers in readying children for six selected events during the physical examination. The events are listening to the heart, looking in the ears, taking the temperature, feeling the stomach, looking at the throat, and giving a shot. The tool, which consisted of both open- and closed-ended questions, also elicited information about the level of discussion used. Parents were phoned between 1 and 3 weeks after the physical examination. Data were cross-tabulated by gender and age group (2 to 5 years 11 months; 6 to 12 years). Descriptive data obtained from the participant's registration form were the parent/caretaker's age, race, gender, socioeconomic level, and educational level. Descriptive data obtained from the child's health history were the child's age, race, gender,
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previous hospitalizations, and previous episodes of chronic illness.
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study and were presenting only for routine physical examinations.
RESULTS
Participants The sample consisted of 132 parents/caretakers who prepared a child between the ages of 2 and 12 for a routine physical examination. Profile of parents/caretakers was 109 mothers, 14 fathers, 6 grandmothers, 2 guardians, and 1 aunt. The children consisted of 72 boys, of which 42 (32%) were under age 6 and 30 (23%) were 6 to 12 years of age, and 60 girls, of which 33 (25%) were under age 6 and 27 (20%) were 6 to 12 years of age. The study sites were a nurse-managed rural community health center or one of two elementary schools. All examinations were performed by one of five female nurse practitioners. Ethnicity of sample could be described as 124 (94%) Caucasian, 7 (5%) Hispanic, and 1 (.8%) Chinese parents. For education level, 37 of 132 (28%) of the parents reported completing grades 10 through 20, with a mean of grade 13. For socioeconomic level, 37 of the 132 (28%) of the parents reported. Of these, 24 were uninsured, 6 had Medicaid, 4 paid cash, and 3 had private insurance. Regarding age, only 24 of 132 (18%) parents reported their ages, ranging from 21 to 43 with a mean of 34 years. In the illness history section of the registration form, parents reported that 35 (27%) of the 132 children had had a previous episode of chronic illness. Chronic illness was defined as one illness lasting more than 3 months or occurring more than three times. Ear infections accounted for the most responses (28), followed by tuberculosis contact (3). Other illnesses mentioned once each were kidney problems, allergic rhinitis, strep throat and high fevers, attention deficit disorder, a hole in the heart (that child "grew out of"), and sclerocornea/ glaucoma. Of the 132 children, 31 (23%) had been hospitalized at least once before with a variety of medical illnesses and operations. Illnesses requiring hospitalization were predominantly respiratory (bronchitis, croup, pneumonia, respiratory syncytial virus). Other illnesses requiring hospitalization included fever, viral infection, spinal meningitis, kidney infection, blocked tear duct, and the flu. Surgical procedures were mostly myringotomy tubes (7), tonsillectomy/adenoidectomy (3), and hernia repairs (2). Additional surgeries for individual children included hypospadias repair, testicular reduction, shoulder surgery for a birth defect, appendectomy, kidney transplant, and multiple eye surgeries for sclerocornea. All of the 132 children were reported as being healthy at the time of this
Results showed that 98% (n = 129) of the parents prepared their children for a routine physical examination, although the preparation consisted mostly of simply telling the child he/she was going to see the physician/nurse. When asked "For this visit, did you discuss parts of the physical exam with the child?", 98% (n = 129) replied affirmatively. The level of discussion ranged from merely telling the child he/she would be visiting the doctor/nurse to the procedural elements of what would happen and what the child should do, to the sensory elements of what the child would feel, to a more involved and reciprocal discussion including questions and answers. Most parents chose a combination of levels of discussion. However, in general, regardless of age or gender, parents mainly provided basic and procedural information versus sensory information and spent very little time in a reciprocal dialogue with the child. Chi square tests were performed to ascertain if there were statistically significant differences between preschool and school-age children or between genders. The statistically significant findings (P < .01) were that preschool-age children were told what the health care provider would do during the examination and what the child should do during the examination (ie, how they would be expected to sit or lie down for different procedures and how to behave) more often than school-age children. Parents who prepared their children for one or more of the events may have supplemented their discussion with reading and/or play. When asked if "For this visit did you and/or your child read a book or books about visiting the doctor/nurse or having a physical?", 28 (21%) parents had, 87 (66%) parents had not, and 17 (13%) parents had in the past. The numbers are further distributed by age and gender (Table 1), although there were no statistically significant differences. In general, the children whose parents had used books to prepare them in the past were in the older age group. There were no significant differences between male and female children, and the younger children were Table !. Mean Percentof ReadingSupplemented Boys3to Boys6to Girts3to Girls6to <6 years 12years <6 years 12 years Total (n=42) {n=30) (n=33) (n=27) (n= 132) Read a book Did not read Read in past
33 67 0
10 57 33
27 67 6
7 74 19
21 66 13
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prepared more frequently with books than the older children. Forty-eight parents (36%) supplemented their discussion with play (toys, games, dolls, medical kits), whereas 52 (39%) parents did not use play. However, an additional 32 (24%) parents reported using play as a preparation technique in the past when their children were younger, thus bringing the number of parents who have supplemented preparation discussion with play to 80 (61%). There were no statistically significant differences by age and gender. Parents were also asked specifically about preparation for the six events. The mean percent of discussion preparation for each event is as follows: ears, 64%; shot, 64%; throat, 61%; heart, 55%; temperature, 45%; and stomach, 39% (Table 2). The mean percent of discussion preparation for each event for preschool:school-age children is as follows: heart, 63%:46%; ears, 72%:54%; temperature, 48%:40%; stomach, 40%:39%; throat, 69%: 51%; and shot, 83%:40%. The mean percent of discussion preparation for each event for boys:gifts is as follows: heart, 57%:53%; ears, 68%:60%; temperature, 43%:47%; stomach, 43%:35%; throat, 65%:57%; and shot, 68%:60% (Table 3). Chi square tests were performed to ascertain if there were statistically significant differences according to age or gender in discussion of events. The only statistically significant finding was that preschool children were prepared for the throat assessment more often than school-age children (P < .05). A variety of reasons were cited by parents for not preparing the child for certain events. Overall, the most common reason (n = 45) given was that the child already knew about that particular event in the examination, having experienced it previously. The second most common reason (n -- 33) overall was that the parent did not think about doing it. Other reasons cited by parents included the uncertainty whether a critical event would be a part of this particular physical (n = 12) or the certainty (especially with injections, n = 6) that it would not be required. Five parents did not know that the required physical examination could be obtained Table 2. Mean Percentof Melhods by Critical Events Event
No Preparation
Discussion
Heart Temperature Throat Ears Stomach Shot
45 55 39 36 61 36
55 45 61 64 39 64
Table 3. Mean Percentof Discussionof Critical Events
Event
Boys3 to <6 years (n = 42)
Boys6 to 12 years (n = 30)
Girls 3 to <6 years (n = 33)
Girls 6 to 12 years (n = 27)
Heart Temp Throat Ear Stomach Shot
62 43 74 71 38 86
50 43 53 63 50 43
64 54 64 73 42 79
41 37 48 44 26 37
during school registration and signed up spontaneously. Only two parents indicated that they did not have the time, and three parents felt they should not frighten the child with preparation information. There were no statistically significant differences between ages or genders in the reasons for no preparation.
DISCUSSION Parents in this study used a variety of methods (discussion/reading/play) in preparing their preschool and school-age children for routine physical examinations. Discussion took many levels ranging from the most frequently identified essential information ("told child he/she would be going to the doctor/nurse"), to procedural information ("told child what doctor/nurse would do" and/or "told child what he/she should do"), to sensory information ("told child how it would feel"), to the least common, a reciprocal dialogue ("asked child if he/she had any questions" and/or "answered questions about the physical examination"). The finding that 93% of parents used some level of discussion in preparing their children is in agreement with an earlier study (Wilson & Mason, 1990) that found that 95% of parents used discussion. There were statistically significant differences between preschool and school-age children in terms of levels of discussion. Preschool children were told what the health care provider would do and what they should do more often than school-age children. In addition, the finding that younger children were more likely to have their discussion supplemented with reading and/or play is in agreement with Wilson's 1991 study. This is also consistent with normal growth and development and experience (Frost & Klein, 1979). Preoperational thinkers learn best through play and questioning (Piaget, 1962). Undoubtedly, the school-age child has had past experiences with the physical examination or parts of it for various acute episodic visits for health care. Parents may have thought that their younger children had less experience with the physical examination and therefore needed more information, direction, and preparation. There were
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no statistically significant differences between ages in reasons for not preparing the child by event. There were no statistically significant differences between boys and girls in method of preparation used, discussion of events, and reasons for not preparing the child. The finding of no gender differences supports previous research findings (Wilson, 1991). Over 50% of parents prepared their children for the stressful events of "ears," "shot," "throat," and "heart." The events associated with the most preparation were the ear (64%) and shot (64%) events. Many children were most likely prepared for the ear event because about a quarter of the children (28, 21%) had previously experienced ear infections and parents could remind the children that they had mastered this part of the physical examination in the past. In general, the child initiated discussion of the shot with 64% of the parents by asking if it would be included in this examination. The only statistically significant difference in terms of event was that preschool children were prepared for the throat examination more often than school-age children, in contrast to no statistically significant differences found in Wilson's 1991 study. The throat finding may be related to the high number of chronic ear infections (n = 28, 21%) in children that were reported by parents. The fact that children were least prepared for "temperature" and "stomach" may be attributable to a number of factors. Parents may have thought "taking a temperature" is a common, nonthreatening event not warranting mention or may not have known that it would be a part of a routine physical because the child was not "sick." In addition, they may have been unsure of the route for taking the temperature (ear, axilla, mouth, rectum), so thought it best not to conjecture. Several parents spoke of a "tympanic temperature," but it is unknown if they related this to the child as a difference or as a similarity between equipment used at home and at the clinic/school. This would warrant future study because discordance between preparation and the perception of the actual experience could have a negative effect on the child (Manion, 1990). The event receiving the least preparation was feeling the stomach. Parents may not have perceived this as particularly threatening to the child even though the child was placed in a vulnerable (recumbent) position for this section of the examination. Another explanation may revolve around the fact that this assessment technique requires no special instruments other than the examiner's hands.
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Therefore, toy medical kits would not contain anything to simulate play in this area. In addition, several parents commented that they did not know that assessment of the abdomen would be included in the physical examination.
RECOMMENDATIONS The findings indicate that the majority of parents are preparing their children for routine physical examinations; however, they could be doing more. Although 93% of the parents prepared a child for one or more of the selected events and with one or more methods, all of the events were not routinely included and the level of discussion was predominantly basic or procedural. The sheer frequency of this event, the physical examination, may lead parents to believe that the child has already experienced it and therefore needs no further preparation. However, children interpret experiences in terms of their cognitive development at the time (Piaget, 1962). Thus, as children grow, they are constantly re-evaluating and reinterpreting experiences such as the physical examination. This study could be replicated with a larger and more representative sample in other areas of the country and in public health departments as well as private clinics and schools. A future study may also limit the population to, for example, parental preparation for a preschooler's physical examination for kindergarten. The toddler population also warrants investigation because this is the most fearful and difficult age of children on which to perform a physical examination (Vessey, 1995). Future studies should elicit more information regarding actual content of the preparation discussion. Future studies might investigate what parents and children actually know about the routine physical examination and its role in health promotion. Can knowledge learned early on help assure a decreased level of stress during regular examinations throughout a lifetime? Do the parents think their chosen methods were effective, or do they plan to use different preparation methods for the next examination? Why or why not? The physical examination consists of many procedures that are potentially threatening to the child's body integrity. In future, possibly longitudinal studies, parents could be assessed regarding the effectiveness of preparation methods that are modified to each child's developmental and experiential level. For example, a child who is comfortable with his/her nurse practitioner or pediatrician may need less preparation than one who is not. The effectiveness of certain methods such as brochures, videos,
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coloring books, or booklets targeted at differing developmental levels needs to be assessed. What are the parents' perceived needs for effectively preparing their children for an examination? Findings suggest that parents may need information on how to prepare the child and what information to include in discussions with the child (Appendix 1). The physical examination should be used to educate about procedures and normal/abnormal findings, offer reassurance, teach health promotion, and validate the family's knowledge and concerns. Attention to preparation may result in increased learning and mutual enjoyment of the physical examination by the child and examiner.
ACKNOWLEDGMENT The author gratefully acknowledges the assistance of Kristina L. Foster, RN, BSN, MS, graduate assistant, for the data collection and preparation of this manuscript.
APPENDIX 1. General Guidelines for Preparation 1. Tell child about the physical examination visit the night before (4- to 7-year-olds) or up to 1 week in advance (7- to 12-yearolds). 2. For each of the six stressful events, tell the child what the doctor/nurse will do, what the child should do (including telling the health care professional if anything is uncomfortable or hurts), and how it feels. For example: "The doctor/nurse will listen to your heart
with a stethoscope that may feel cold. You need to sit (or lie) very quietly so they can hear your heartbeat." "The doctor/nurse will check your temperature by placing a thermometer in your ear (mouth, under the arm, etc). It doesn't hurt, and you need to sit quietly." "The doctor/nurse will look in your mouth with a special flashlight. You will need to sit and open your mouth as wide as you can so they can get a good look." "The doctor/nurse will look in your ears with a special flashlight. Only a light goes inside, nothing else. You'll need to sit and bend your head so they can get a good view inside." "The doctor/nurse will feel your stomach with his/her hands. You'll need to lie on your back with your hands to your sides. This will help to relax your stomach so it is easier to feel." "The doctor/nurse will be giving you a shot to keep you well today. There's always a good reason for a shot. They are not punishment. The doctor/nurse does not like that the shot hurts. It's OK to be brave, to cry, to yell, to say "I don't like shots"; you only have to sit still. Sometimes it's hard to hold still and someone might hold you to help." . Ask if the child has any questions about the examination and answer truthfully. If you do not know the information, try to find out for the child.
REFERENCES Abbott, K. (1990). Therapeutic use of play in the psychological preparation of preschool children undergoing cardiac surgery. Issues in Comprehensive Pediatric Nursing, 13, 265-277. Bates, B. (1991). A guide to physical examination (5th ed.). Philadelphia: Lippincott. Barkauskas, V. H., Stoltenberg-Allen, K., Baumann, L. C., & Darling-Fisher, C. (1994). Health and physical assessment. St. Louis: Mosby. B ossert, E. (1994). Factors influencing the coping of hospitalized schoolage children. Journal of Pediatric Nursing, 9, 299-306. Broome, M. E. (1990). Preparation of children for painful procedures. Pediatric Nursing, 16(6), 537-541. Crocker, E. (1980). Preparation for elective surgery: Does it make a difference? Journal of the Association for the Care of Children's Health, 9(1), 3-11. Edwinson, M., Arnbjornsson, E., & Ekman, R. (1988). Psychologic preparation program for children undergoing acute appendectomy. Pediatrics, 82(1), 30-36. Ellerton, M. L., Ritchie, J. A., & Caty, S. (1994). Factors influencing young children's coping behaviors during stressful
healthcare encounters. Maternal ChiM Nursing Journal, 22(3), 74-82. Ferholt, J., & Lott, D. (1980). Clinical assessment of children: A comprehensive approach to primary pediatric care. Philadelphia: Lippincott. Frost, J. L., & Klein, B. L. (1979). Children's play and playgrounds. Boston: Allyn & Bacon. Hansen, B. D., & Evans, M. L. (1981). Preparing a child for procedures. American Journal of Maternal Child Nursing, 6(6), 392-397. Isaacs, E J. (1989). Crisis prevention in an outpatient surgery center. Maternal-Child Nursing, 14, 352-354. Jackson, D. B., & Saunders, R. B. (1993). Child health nursing. Philadelphia: Lippincott. Jarvis, C. (1992). Physical examination and health assessment. Philadelphia: Lippincott. Lambert, S. A. (1984). Variables that affect the school-age child's reaction to hospitalization and surgery: A review of the literature. Maternal-Child Nursing Journal, 13, 1-18. LaMontagne, L. L. (1993). Bolstering personal control in child patients through coping interventions. Pediatric Nursing, 19(3), 235-237.
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Lynch, M. (1994). Preparing children for day surgery. Children's Health Care, 23(2), 75-85. Manion, J. (1990). Preparing children for hospitalization, procedures, or surgery. In M. Craft & J. Denehy (Eds.), Nursing interventions for infants and children. Philadelphia: Saunders. Melnyk, B. (1994). Coping with unplanned childhood hospitalizations: Effects of informational interventions on mothers and children. Nursing Research, 45, 50-55. Meng, A., & Zastowny, T. (1982). Preparation for hospitalization: A stress inoculation training program for parents and children. Maternal-Child Nursing Journal, 11(2), 87-94. Ott, M. J. (1996). Imagine the possibilities! Guided imagery with toddlers and preschoolers. Pediatric Nursing, 22(1 ), 34-38. Patterson, K. L., & Ware, L. L. (1988). Coping skills for children undergoing painful medical procedures. Issues in Comprehensive Pediatric Nursing, 11, 113-143. Pederson, C. (1995). Effect of imagery on children's pain and anxiety during cardiac catheterization. Journal of Pediatric Nursing, 10(6), 365-374. Petrillo, M., & Sanger, S. (1980). Emotional care of hospitalized children: An environmental approach (2rid ed.), Philadelphia: Lippincott. Piaget, J. (1962). Play, dreams and imitation in childhood. New York: Norton.
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Ryan-Wenger, N. A. (1996). Children coping and the stress of illness: A synthesis of the research. Journal of the Society of Pediatric Nurses, 1(3), 126-138. Schmidt, C. (1992). Pre-operative preparation: Effects on immediate pre-operative behavior, post-operative behavior and recovery of children having same-day surgery. Maternal-Child Nursing Journal, 19, 321-330. Thompson, M. L. (1994). Information-seeking, coping, and anxiety in school age children. Children's Health Care, 23(2), 87-97. Vessey, J. A. (1995 ). Developmental approaches to examining young children, 21(1), 53-56. Visintainer, M. A., & Wolfer, J. A. (1975). Psychological preparation for surgical pediatric patients and the effects on children's and parents' stress response and adjustment. Pediatrics, 56, 187-202. Wilson, C. J. (1991). Parental methods of preparation for the routine physical exam. Unpublished manuscript. Wilson, C. J., & Mason, M. (1990). Preparation for routine physical examination. Children's Health Care, 19(3), 178-182. Wolfer, J. A., & Visintainer, M. A. (1979). Pediatric surgical patients' and parents' stress responses and adjustments. Pediatrics, 64(5), 646-655.