- Email: [email protected]
Pediatric Orientation Programs
SEPTEMBER 1991. VOL 54, NO 3
AORN JOURNAL
Pediatric Orientation Programs HOSPITAL TOURS ALLAY CHILDFEN’S FEARS
Laura Holt, RN; Beverly Maxwell, RN It is your busiest day in the operating room. The surgeon is complaining about slow turnover time, the anesthesiologist is pacing, and your scrub nurse needs you to open the autoclave. You rush to the holding room tofind your patient crying in his mother’s arms. The child’sfather is frustrated. As you reach for the child, he or she begins to kick and scream. You try to console the child, but the child does not hear you. The child’s mother begins to cry, and you have tears in your own eyes. The child’s eyes show fear of the unknown.
W
hat can nurses do to improve this scenario? At Schumpert Medical Center, Shreveport, La, the perioper-
ative nurses have devised a program to familiarize children with surgery. We feel the more they know and understand, the less they have to fear.
Literature Review
A
nticipating a surgical procedure can be stressful, especially to children. Children’s stress is magnified by their parents’ tension and anxiety. Stress elevates anxiety levels and diminishes cognitive thinking abilities, which can decrease children’s coping abilities.’ A 1985 study by Lynda L. LaMontagne, RN, reported that some patients cope with avoidant
Laura Holt
Beverly Maxwell
Laura Holt, RN, BSN, CNOR, is the perioperarive nurse coordinator of surgical services at Schumpert Medical Center, Shreveport, La. She earned her BSN f r o m McNeese State University, Lake Charles, La.
Beverly Maxwell, RN, BSN, is a perioperative patient educator in surgical services at Schumpert Medical Center, Shreveport, La. She earned her BSN from Northwestern State University, Natchitoches, La.
530
AORN JOURNAL
SEPTEMBER I99 I , VOL 54, NO 3
behavior by restricting their awareness of the situation. Other patients engage in active behavior. They cope by seeking more information about their surgery and discussing their impending experiences. A third group, “combination copers,” uses both avoidant and active coping.2 People consciously or unconsciously determine if a situation is harmful, potentially harmful, or challenging. The degree of stress usually is relative to people’s evaluations of situational effects on their well-being. Knowing how children appraise events helps us better understand children’s coping strategies. Effective preoperative teaching programs must be tailored to individual children because children react to the stress associated with surgery differently than adults.
History/Purpose of the Tour Program
A
t Schumpert Medical Center, we are committed to meeting community needs through the implementation of innovative and collaborative programs and services. The need and demand for preoperative education is well documented and has become a standard. Pediatric perioperative education presents a challenge for the nurse’s skill and creativity. We offer children and families introductory OR tours. The tours familiarize children with the hospital environment, assess their readiness for surgery, allay their apprehensions, and enhance their growth and development. Our pediatric orientation program began in 1985 with a general tour of the hospital and a trip to the OR. Our program was offered to schools, pre-schools, and other child-oriented organizations. Many teachers planned their class tours in conjunction with health care or career studies. The surgical team members noticed behavioral differences in patients who had participated in the program. These children demonstrated less anxiety and apprehension throughout their perioperative experience, were more comfortable with the surroundings, sights, and sounds of the OR, and demonstrated less fear and anxi-
ety postoperatively. These positive results encouraged us to develop the pediatric operating room tour (PORT) program.
Marketing
W
hen designing our current program, we contacted our physicians’ offices to determine parental interest. By involving the physician’s office staff, we improved scheduling practices, shortened patient admission times, and improved communication between the office staff and the surgical staff. Only a few families participated in the beginning. We relied on the surgeons and their office personnel to inform parents of the program. Realizing this promotional method alone was ineffective, we conducted a six-month study of 200 participants. The study asked questions about the children’s ages, their surgeries, their surgeons, the day they had the tour, and their tour group size. The study showed that 73% of PORT participants were scheduled for ear, nose, and throat surgery. Eye, genitourinary, and other surgeries comprised the remaining 27%. Our marketing now focuses on patients who are having eye, ear, nose, and throat procedures. The PORT program has a nautical theme. We display colorful posters in the offices of our surgical staff, pediatricians, and family practitioners, and we give the parents an informative brochure when they schedule their childrens’ surgeries. All our promotional materials include a teddy bear and pink flamingos, and during the tour, the children receive a stuffed bear or flamingo as a gift. At the end of the tour, we give the children framed photographs of themselves in their OR attire. These permanent reminders serve as excellent marketing tools when children share them with friends and family. A tour is scheduled for the child when his or her surgery is scheduled. We initially offered the tours once a week, but the program has grown and now we conduct tours every afternoon. This daily schedule makes it more conve531
SEPTEMBER I99 I , VOL 54, NO 3
AORN JOURNAL
begins the preoperative teaching, but also because it occupies the children’s time while they are waiting for the tour group to assemble. The coloring books are fun and informative, and the children can take them home for perusal in more familiar surroundings. The children and their families are greeted by a registered nurse or volunteer assistant who escorts them to the day surgery unit and introduces them to patient room surroundings. The children then begin talking about themselves and their reasons for being on the tour.
The Nurse’s Challenge
W Fig. I . Children are familiarized with their hospital attire.
nient for patients who must travel a great distance to get here. Thursday is the most popular day for tour participation. The tours are targeted at, but not limited to, three to 10 year-old children. Families are encouraged to accompany the children and become involved with their experiences. This creates an understanding and supportive network for the children. Our study showed that participants ranged in age from eight months to 11 years old, and the average patient was six years old. The average group size was 10 people, including 3.44 patients each with 1.8 guests. Groups have ranged from two to 30 people, and during the first six months of the program, more than 500 people participated.
Getting Acquainted
W
hen the children arrive for the tour, they get a coloring book about a bear’s hospital stay. This waiting area activity is beneficial not only because it 532
’e begin by asking the children what they want to know about their surgeries. This simple question often introduces the most challenging tour situation for perioperative nurses, as we try to answer children’s questions of “Why?’. We discuss physician and nurse roles and evaluate the children’s and their parents’ understanding of the reasons for the surgical procedures. Children need to understand that it is not their fault they need surgery. They have not been bad, and they are not being punished. Helping them understand the need for surgery prevents guilt and shame. The children point to their “fix-up spots” on their bodies, giving them the opportunity to learn more about anatomy as well as their surgery. One child, pointing to his neck, thought he would have a skin incision to remove his tonsils. This is the kind of rnisconception we try to clear up during the tour because misconceptions often increase fear. Another challenge for parents and medical personnel is children who repeatedly cry that they do not want to have surgery. The perioperative nurse understands and points out the benefits of surgery saying, “I wish you didn’t have to have surgery. I know you don’t want to, but it will make you hear better, and you won’t have earaches anymore.” The child whines, “But my ear doesn’t hurt now, and I can hear okay. I don’t want to have surgery !”
SEPTEMBER 1991. VOL 54. NO 3
AORN JOURNAL
The perioperative nurse can respond with, “Do you know what a hero is? Heroes are people who do things that they really don’t want to d o but know they need to do. When your surgery is over and you are well again, you’ll be a surgery hero. Would you like to find out how to be a surgery hero now?’
w
The Tour
’e try to rehearse and visualize the entire surgery day with the children. Initially, the children are asked to remind their parents that they are to have nothing to eat or drink on the morning of surgery. This gives the children a feeling of responsibility. We encourage the children to wear their usual clothes or pajamas when they come to the day surgery unit on the morning of surgery. We show them the identification wristbands and how they will wear them. We position hospital gowns over their clothes, explain that they will be changing clothes, and discuss the gown’s purpose (Fig I). The children also are encouraged to bring a favorite toy. This allows them to continue with their usual rituals and routines and gives them a feeling of control and security. We give each child a stuffed bear or flamingo at this time, and encourage them to bring this gift when they return for surgery. When a child brings the gift to the OR, surgical team members immediately know that the child has been on the tour. The stuffed animal is a friend who accompanies the children through the entire perioperative experience. One parent said, “Tommy named his stuffed animal Cuddles. When he went into the operating room, I noticed that he was clutching Cuddles tightly. Tommy kept Cuddles nearby throughout his recuperation, and now Cuddles is a best friend. It was as if Tommy had a friend along to share the experience.” The stuffed animals, which also are good marketing tools, are clothed in Schumpert Medical Center T-shirts. Part of the tour involves viewing and discussing an animated video film about a dragon having surgery for a throat ailment. This animated video is entertaining and holds the chil534
Fig. 2. Children are dressed in OR attire for active role play. dren’s attention. Children are comfortable watching television, and their interest in the video helps them relax and offers discussion material. After the film, the children get empty medication cups so they can practice taking the oral preoperative medication. At our hospital, the preoperative medication is a liquid mixture rather than an intramuscular injection. Children are relieved when they learn they will not receive an injection, as they previously anticipated, and are overwhelmingly cooperative in this activity. Next, we show the children the medical team’s attire. The children slip scrub shirts, caps, shoe covers, masks, and gloves over their clothes to enter the OR (Fig 2). Wearing surgical team member attire is a form of role reversal. The children actively play the roles of the individuals who will be caring for them. This not only reduces the children’s apprehension, but also assists them in understanding professional roles. This activity makes the children feel important. We introduce the children to other hospital personnel and tell them that many of these people have children or grandchildren and will take good care of them until they see their parents again. The tour group goes down the service eleva-
AORN JOURNAL
that the separation is only about as long as a nap or a movie. Using terms children can relate to helps them better understand how long they will be away from their parents. Schumpert Medical Center is a trauma center. Sometimes the OR tours are limited because of emergency cases, but we like the children to sit or lie on the operating room bed, try on the safety belt, and look up at the big lights when possible. The children view machinery, equipment, and instrument setups (Fig 3). We show the children the anesthesia mask and tell them how they will get the special “hospital sleep air” (Fig 4). Each child is encouraged to practice closing his or her eyes, taking deep breaths with the mask in place, and pretending to feel sleepy. 536
SEPTEMBER 1991. VOL 54, NO 3
Fig 4. The children practice taking deep breaths with the mask on.
The group then visits the postanesthesia care unit (PACU) where the children look at the monitors, pulse oximeter, electrocardiogram (ECG) sticky pads, and try on the blood pressure cuffs. The children see the IV set-up, and we tell them about fluid replacement and administering medications. We show the children where the IV will be inserted and let them handle the tubing and catheter. Children tolerate the appearance of IV fluids better when they are introduced to them in a nonthreatening environment. We remind the children that after the blood
SEPTEMBER 1991, VOL 54. NO 3
AORN JOURNAL
and s h o e c o v e r s , surgical mask, g l o v e s , medicine cup, ECG buttons, adhesive bandages). Additionally, e a c h c h i l d gets a Schumpert Medical Center PORT “Certificate of Achievement” recognizing his or her attendance and encouraging a spirit of cooperation, courage, and heroism (Fig 5). We encourage them to “show and tell” what they have learned with their friends and family. Sharing the experience with others reinforces the children’s learning and gives parents a chance to clarify any misconceptions and ask questions.
Evaluation
M Fig 5. Each child receives a certificate of achievement.
drawing “sticks” or “pokes,” there will be no more “hurts” before they “go to sleep.” Without placing undue emphasis on anticipated postoperative pain and discomfort, we must explain how the children can expect to feel following their surgery. We present the information about pain honestly to establish and maintain trust. Upon returning to the patient room, the children get refreshments similar to those they are allowed following surgery. During this social time, the children can continue playing with the anesthesia masks, IV equipment, and other items. We give the parents directions for postsurgical home care and answer any other questions at this time. T h e children leave with a “Schumpert Medical Center Day Surgery” bag full of collected paraphernalia (eg, coloring book, hair 538
any children who wanted to be astronauts and ballet dancers at the beginning of t h e tour want to become physicians and nurses by the end of the tour. In addition to helping the children, we are helping ourselves by recruiting a future generation of health care providers. On several occasions, we have had families return for tours before subsequent surgeries. Children on their second tour display more confidence and understanding of the upcoming events, and participate much more openly and actively in the tour. We call the families postoperatively to monitor the children’s progress, reinforce postoperative instructions, answer questions, and listen to any problems parents wish to discuss. The postoperative phone call is a good opportunity for the perioperative nurse to assess patient satisfaction levels a n d ask f o r suggestions to improve the program. As of this writing, we have had 100%positive responses to the tours. Some parents who were not immediately receptive when originally contacted commented that they were glad they took the time to participate and felt the tour made a difference.
Future Plans
W
e are developing a postcard invitation that w e will mail when w e receive notification of a child’s impending surgery. We are cooperating with
SEPTEMBER 1991, VOL 54, NO 3
AORN JOURNAL
office personnel for advance notification. We feel we can reach everyone by sending postal invitations. We also are developing a customized coloring book using our PORT theme. The coloring book will tell of an adventure aboard the S S Schumpert and will explain events and feelings the children are likely to experience. We plan to produce our own videotape including all the sights, scenes, sounds, and protocol of our institution. We will show the film in the designated play area in our preadmission testing center. The videotape will be especially helpful to families and children who are unable to attend the PORT tour. Our experience with videotapes from other institutions is that, though they are informative, they do not hold the children’s interest. The videotape must appeal to children of all ages. The animated video we currently use lacks realism. It portrays a make-believe, playful situation. We want to present serious information in our videotape, with a touch of humor to maintain interest and help put families at ease. Some parents would like to be involved in anesthesia induction and postanesthesia care, and we plan to incorporate these things in future programs. We also would like to develop more objective methods of measuring our results and productivity. Many of our innovative ideas are difficult to measure. Past surveys indicate that the program is effective; however, goodwill is difficult to measure.
Conclusion
T
he main purpose of the tours is to allay stress and apprehension, but PORT has many other positive results. Children pretend to be nurses and doctors, and they see what life is like on the other side of surgery. The tours also foster a supportive environment where families can discuss concerns and feelings with other people in similar situations. They offer an opportunity for children to learn more about health, the physical body, growth and development, the health care profession, 540
and the health care setting. The PORT program offers creative challenges for perioperative nurses as well as children and families. Nurses have the opportunity to practice the nursing process and the principles they have learned. Meeting pediatric patients’ special needs is a great challenge, but PORT offers a fun, informative way for nurses to meet those needs. 1 I Notes 1. A Nyamathi, A Kashiwabara, “Preoperative anxiety: Its affect on cognitive thinking,” AORN Journal 47 (January 1988) 164-170. 2. L LaMontagne, “Facilitating children’s coping: Preoperative assessment interviews,” AORN Journal 42 (November 1985) 718-723. Suggested reading Durst, L M “Preoperative teaching videotape: The effect on children’s behavior.” AORN Journal 52 (September 1990) 576-584. Hathaway, D. “Effect of preoperative instruction on postoperative outcomes: A meta analysis.” Nursing Research 35 (September/October 1986) 269-275. Lazarus, R S. Psychological Stress and the Coping Process. New York City: McCraw Hill Book Co, 1966. Lazarus, R S; Folkman, S. Stress, Appraisal, and Coping. New York City: Springer Publishing Co, 1984.
AORN JOURNAL
Pediatric Orientation Programs HOSPITAL TOURS ALLAY CHILDFEN’S FEARS
Laura Holt, RN; Beverly Maxwell, RN It is your busiest day in the operating room. The surgeon is complaining about slow turnover time, the anesthesiologist is pacing, and your scrub nurse needs you to open the autoclave. You rush to the holding room tofind your patient crying in his mother’s arms. The child’sfather is frustrated. As you reach for the child, he or she begins to kick and scream. You try to console the child, but the child does not hear you. The child’s mother begins to cry, and you have tears in your own eyes. The child’s eyes show fear of the unknown.
W
hat can nurses do to improve this scenario? At Schumpert Medical Center, Shreveport, La, the perioper-
ative nurses have devised a program to familiarize children with surgery. We feel the more they know and understand, the less they have to fear.
Literature Review
A
nticipating a surgical procedure can be stressful, especially to children. Children’s stress is magnified by their parents’ tension and anxiety. Stress elevates anxiety levels and diminishes cognitive thinking abilities, which can decrease children’s coping abilities.’ A 1985 study by Lynda L. LaMontagne, RN, reported that some patients cope with avoidant
Laura Holt
Beverly Maxwell
Laura Holt, RN, BSN, CNOR, is the perioperarive nurse coordinator of surgical services at Schumpert Medical Center, Shreveport, La. She earned her BSN f r o m McNeese State University, Lake Charles, La.
Beverly Maxwell, RN, BSN, is a perioperative patient educator in surgical services at Schumpert Medical Center, Shreveport, La. She earned her BSN from Northwestern State University, Natchitoches, La.
530
AORN JOURNAL
SEPTEMBER I99 I , VOL 54, NO 3
behavior by restricting their awareness of the situation. Other patients engage in active behavior. They cope by seeking more information about their surgery and discussing their impending experiences. A third group, “combination copers,” uses both avoidant and active coping.2 People consciously or unconsciously determine if a situation is harmful, potentially harmful, or challenging. The degree of stress usually is relative to people’s evaluations of situational effects on their well-being. Knowing how children appraise events helps us better understand children’s coping strategies. Effective preoperative teaching programs must be tailored to individual children because children react to the stress associated with surgery differently than adults.
History/Purpose of the Tour Program
A
t Schumpert Medical Center, we are committed to meeting community needs through the implementation of innovative and collaborative programs and services. The need and demand for preoperative education is well documented and has become a standard. Pediatric perioperative education presents a challenge for the nurse’s skill and creativity. We offer children and families introductory OR tours. The tours familiarize children with the hospital environment, assess their readiness for surgery, allay their apprehensions, and enhance their growth and development. Our pediatric orientation program began in 1985 with a general tour of the hospital and a trip to the OR. Our program was offered to schools, pre-schools, and other child-oriented organizations. Many teachers planned their class tours in conjunction with health care or career studies. The surgical team members noticed behavioral differences in patients who had participated in the program. These children demonstrated less anxiety and apprehension throughout their perioperative experience, were more comfortable with the surroundings, sights, and sounds of the OR, and demonstrated less fear and anxi-
ety postoperatively. These positive results encouraged us to develop the pediatric operating room tour (PORT) program.
Marketing
W
hen designing our current program, we contacted our physicians’ offices to determine parental interest. By involving the physician’s office staff, we improved scheduling practices, shortened patient admission times, and improved communication between the office staff and the surgical staff. Only a few families participated in the beginning. We relied on the surgeons and their office personnel to inform parents of the program. Realizing this promotional method alone was ineffective, we conducted a six-month study of 200 participants. The study asked questions about the children’s ages, their surgeries, their surgeons, the day they had the tour, and their tour group size. The study showed that 73% of PORT participants were scheduled for ear, nose, and throat surgery. Eye, genitourinary, and other surgeries comprised the remaining 27%. Our marketing now focuses on patients who are having eye, ear, nose, and throat procedures. The PORT program has a nautical theme. We display colorful posters in the offices of our surgical staff, pediatricians, and family practitioners, and we give the parents an informative brochure when they schedule their childrens’ surgeries. All our promotional materials include a teddy bear and pink flamingos, and during the tour, the children receive a stuffed bear or flamingo as a gift. At the end of the tour, we give the children framed photographs of themselves in their OR attire. These permanent reminders serve as excellent marketing tools when children share them with friends and family. A tour is scheduled for the child when his or her surgery is scheduled. We initially offered the tours once a week, but the program has grown and now we conduct tours every afternoon. This daily schedule makes it more conve531
SEPTEMBER I99 I , VOL 54, NO 3
AORN JOURNAL
begins the preoperative teaching, but also because it occupies the children’s time while they are waiting for the tour group to assemble. The coloring books are fun and informative, and the children can take them home for perusal in more familiar surroundings. The children and their families are greeted by a registered nurse or volunteer assistant who escorts them to the day surgery unit and introduces them to patient room surroundings. The children then begin talking about themselves and their reasons for being on the tour.
The Nurse’s Challenge
W Fig. I . Children are familiarized with their hospital attire.
nient for patients who must travel a great distance to get here. Thursday is the most popular day for tour participation. The tours are targeted at, but not limited to, three to 10 year-old children. Families are encouraged to accompany the children and become involved with their experiences. This creates an understanding and supportive network for the children. Our study showed that participants ranged in age from eight months to 11 years old, and the average patient was six years old. The average group size was 10 people, including 3.44 patients each with 1.8 guests. Groups have ranged from two to 30 people, and during the first six months of the program, more than 500 people participated.
Getting Acquainted
W
hen the children arrive for the tour, they get a coloring book about a bear’s hospital stay. This waiting area activity is beneficial not only because it 532
’e begin by asking the children what they want to know about their surgeries. This simple question often introduces the most challenging tour situation for perioperative nurses, as we try to answer children’s questions of “Why?’. We discuss physician and nurse roles and evaluate the children’s and their parents’ understanding of the reasons for the surgical procedures. Children need to understand that it is not their fault they need surgery. They have not been bad, and they are not being punished. Helping them understand the need for surgery prevents guilt and shame. The children point to their “fix-up spots” on their bodies, giving them the opportunity to learn more about anatomy as well as their surgery. One child, pointing to his neck, thought he would have a skin incision to remove his tonsils. This is the kind of rnisconception we try to clear up during the tour because misconceptions often increase fear. Another challenge for parents and medical personnel is children who repeatedly cry that they do not want to have surgery. The perioperative nurse understands and points out the benefits of surgery saying, “I wish you didn’t have to have surgery. I know you don’t want to, but it will make you hear better, and you won’t have earaches anymore.” The child whines, “But my ear doesn’t hurt now, and I can hear okay. I don’t want to have surgery !”
SEPTEMBER 1991. VOL 54. NO 3
AORN JOURNAL
The perioperative nurse can respond with, “Do you know what a hero is? Heroes are people who do things that they really don’t want to d o but know they need to do. When your surgery is over and you are well again, you’ll be a surgery hero. Would you like to find out how to be a surgery hero now?’
w
The Tour
’e try to rehearse and visualize the entire surgery day with the children. Initially, the children are asked to remind their parents that they are to have nothing to eat or drink on the morning of surgery. This gives the children a feeling of responsibility. We encourage the children to wear their usual clothes or pajamas when they come to the day surgery unit on the morning of surgery. We show them the identification wristbands and how they will wear them. We position hospital gowns over their clothes, explain that they will be changing clothes, and discuss the gown’s purpose (Fig I). The children also are encouraged to bring a favorite toy. This allows them to continue with their usual rituals and routines and gives them a feeling of control and security. We give each child a stuffed bear or flamingo at this time, and encourage them to bring this gift when they return for surgery. When a child brings the gift to the OR, surgical team members immediately know that the child has been on the tour. The stuffed animal is a friend who accompanies the children through the entire perioperative experience. One parent said, “Tommy named his stuffed animal Cuddles. When he went into the operating room, I noticed that he was clutching Cuddles tightly. Tommy kept Cuddles nearby throughout his recuperation, and now Cuddles is a best friend. It was as if Tommy had a friend along to share the experience.” The stuffed animals, which also are good marketing tools, are clothed in Schumpert Medical Center T-shirts. Part of the tour involves viewing and discussing an animated video film about a dragon having surgery for a throat ailment. This animated video is entertaining and holds the chil534
Fig. 2. Children are dressed in OR attire for active role play. dren’s attention. Children are comfortable watching television, and their interest in the video helps them relax and offers discussion material. After the film, the children get empty medication cups so they can practice taking the oral preoperative medication. At our hospital, the preoperative medication is a liquid mixture rather than an intramuscular injection. Children are relieved when they learn they will not receive an injection, as they previously anticipated, and are overwhelmingly cooperative in this activity. Next, we show the children the medical team’s attire. The children slip scrub shirts, caps, shoe covers, masks, and gloves over their clothes to enter the OR (Fig 2). Wearing surgical team member attire is a form of role reversal. The children actively play the roles of the individuals who will be caring for them. This not only reduces the children’s apprehension, but also assists them in understanding professional roles. This activity makes the children feel important. We introduce the children to other hospital personnel and tell them that many of these people have children or grandchildren and will take good care of them until they see their parents again. The tour group goes down the service eleva-
AORN JOURNAL
that the separation is only about as long as a nap or a movie. Using terms children can relate to helps them better understand how long they will be away from their parents. Schumpert Medical Center is a trauma center. Sometimes the OR tours are limited because of emergency cases, but we like the children to sit or lie on the operating room bed, try on the safety belt, and look up at the big lights when possible. The children view machinery, equipment, and instrument setups (Fig 3). We show the children the anesthesia mask and tell them how they will get the special “hospital sleep air” (Fig 4). Each child is encouraged to practice closing his or her eyes, taking deep breaths with the mask in place, and pretending to feel sleepy. 536
SEPTEMBER 1991. VOL 54, NO 3
Fig 4. The children practice taking deep breaths with the mask on.
The group then visits the postanesthesia care unit (PACU) where the children look at the monitors, pulse oximeter, electrocardiogram (ECG) sticky pads, and try on the blood pressure cuffs. The children see the IV set-up, and we tell them about fluid replacement and administering medications. We show the children where the IV will be inserted and let them handle the tubing and catheter. Children tolerate the appearance of IV fluids better when they are introduced to them in a nonthreatening environment. We remind the children that after the blood
SEPTEMBER 1991, VOL 54. NO 3
AORN JOURNAL
and s h o e c o v e r s , surgical mask, g l o v e s , medicine cup, ECG buttons, adhesive bandages). Additionally, e a c h c h i l d gets a Schumpert Medical Center PORT “Certificate of Achievement” recognizing his or her attendance and encouraging a spirit of cooperation, courage, and heroism (Fig 5). We encourage them to “show and tell” what they have learned with their friends and family. Sharing the experience with others reinforces the children’s learning and gives parents a chance to clarify any misconceptions and ask questions.
Evaluation
M Fig 5. Each child receives a certificate of achievement.
drawing “sticks” or “pokes,” there will be no more “hurts” before they “go to sleep.” Without placing undue emphasis on anticipated postoperative pain and discomfort, we must explain how the children can expect to feel following their surgery. We present the information about pain honestly to establish and maintain trust. Upon returning to the patient room, the children get refreshments similar to those they are allowed following surgery. During this social time, the children can continue playing with the anesthesia masks, IV equipment, and other items. We give the parents directions for postsurgical home care and answer any other questions at this time. T h e children leave with a “Schumpert Medical Center Day Surgery” bag full of collected paraphernalia (eg, coloring book, hair 538
any children who wanted to be astronauts and ballet dancers at the beginning of t h e tour want to become physicians and nurses by the end of the tour. In addition to helping the children, we are helping ourselves by recruiting a future generation of health care providers. On several occasions, we have had families return for tours before subsequent surgeries. Children on their second tour display more confidence and understanding of the upcoming events, and participate much more openly and actively in the tour. We call the families postoperatively to monitor the children’s progress, reinforce postoperative instructions, answer questions, and listen to any problems parents wish to discuss. The postoperative phone call is a good opportunity for the perioperative nurse to assess patient satisfaction levels a n d ask f o r suggestions to improve the program. As of this writing, we have had 100%positive responses to the tours. Some parents who were not immediately receptive when originally contacted commented that they were glad they took the time to participate and felt the tour made a difference.
Future Plans
W
e are developing a postcard invitation that w e will mail when w e receive notification of a child’s impending surgery. We are cooperating with
SEPTEMBER 1991, VOL 54, NO 3
AORN JOURNAL
office personnel for advance notification. We feel we can reach everyone by sending postal invitations. We also are developing a customized coloring book using our PORT theme. The coloring book will tell of an adventure aboard the S S Schumpert and will explain events and feelings the children are likely to experience. We plan to produce our own videotape including all the sights, scenes, sounds, and protocol of our institution. We will show the film in the designated play area in our preadmission testing center. The videotape will be especially helpful to families and children who are unable to attend the PORT tour. Our experience with videotapes from other institutions is that, though they are informative, they do not hold the children’s interest. The videotape must appeal to children of all ages. The animated video we currently use lacks realism. It portrays a make-believe, playful situation. We want to present serious information in our videotape, with a touch of humor to maintain interest and help put families at ease. Some parents would like to be involved in anesthesia induction and postanesthesia care, and we plan to incorporate these things in future programs. We also would like to develop more objective methods of measuring our results and productivity. Many of our innovative ideas are difficult to measure. Past surveys indicate that the program is effective; however, goodwill is difficult to measure.
Conclusion
T
he main purpose of the tours is to allay stress and apprehension, but PORT has many other positive results. Children pretend to be nurses and doctors, and they see what life is like on the other side of surgery. The tours also foster a supportive environment where families can discuss concerns and feelings with other people in similar situations. They offer an opportunity for children to learn more about health, the physical body, growth and development, the health care profession, 540
and the health care setting. The PORT program offers creative challenges for perioperative nurses as well as children and families. Nurses have the opportunity to practice the nursing process and the principles they have learned. Meeting pediatric patients’ special needs is a great challenge, but PORT offers a fun, informative way for nurses to meet those needs. 1 I Notes 1. A Nyamathi, A Kashiwabara, “Preoperative anxiety: Its affect on cognitive thinking,” AORN Journal 47 (January 1988) 164-170. 2. L LaMontagne, “Facilitating children’s coping: Preoperative assessment interviews,” AORN Journal 42 (November 1985) 718-723. Suggested reading Durst, L M “Preoperative teaching videotape: The effect on children’s behavior.” AORN Journal 52 (September 1990) 576-584. Hathaway, D. “Effect of preoperative instruction on postoperative outcomes: A meta analysis.” Nursing Research 35 (September/October 1986) 269-275. Lazarus, R S. Psychological Stress and the Coping Process. New York City: McCraw Hill Book Co, 1966. Lazarus, R S; Folkman, S. Stress, Appraisal, and Coping. New York City: Springer Publishing Co, 1984.