Ms. Chieng Ying Jia Shermin
National University of Singapore & Singapore National University Hospital (NUH) Centre for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute
Contact number: (65) 94304980
Dr. He Hong-Gu
National University of Singapore & Singapore National University Hospital (NUH) Centre for Evidence Based Nursing: A
Collaborating Centre of the Joanna Briggs Institute
Contact number: (65) 65167448
Professor Chan Wai-Chi Sally
Professor and Deputy Head
National University of Singapore & Singapore National University Hospital (NUH) Centre for Evidence Based Nursing: A
Collaborating Centre of the Joanna Briggs Institute
Contact number: (65) 65163117
Expected Completion date
Paediatric surgery has been well-known to be an experience that is rather distressing and overwhelming for children1. Be it a major or a minor surgical procedure, this experience can be a rather frightening one for them2. Today, with the advent of medical equipments and technology, more children are undergoing elective surgical procedures in both the day surgery and inpatient settings. These elective surgical procedures are defined as procedures that are either chosen by the patient, caregiver, or based on recommendations from the medical practitioner3. They are beneficial to the health status of patients but are not considered as urgent, thus can be performed at a time that is convenient for both the patient and surgeon3. Examples of surgical procedures which this review may take into considerations are general surgery such as hernia repair; urological surgery such as circumcision and hypospadias surgery; ear, nose and throat surgery such as tonsillectomy and adenoidectomy; plastic surgery such as cyst removal; or even minor surgical procedures such as endoscopy and colonoscopy4.
Surgical procedures have the potential to induce numerous negative responses in children. Out of all the negative responses, anxiety is observed to be the most prominent response5. According to Spielberger6, anxiety is a subjective experience and it describes a person as being in a state of feeling tense and apprehensive. These feelings of tension and apprehension are believed to be partially contributed by factors such as not being able to be in command of their own emotions and behaviours7 or having a poor understanding of the procedure that they are going to undergo8. As such, these factors pose more stressors in children as compared to that of adults when undergoing surgical procedures.
In literature, several useful and validated instruments were established to assess children's level of perioperative anxiety. During a preliminary search of several databases, some of the commonly used instruments to measure perioperative anxiety in children include - The State-Trait Anxiety Inventory for Children5, 7, 9-15, Modified Yale Preoperative Anxiety Scale15-17 and Children's Emotional Manifestation Scale9,11,18. These instruments are either based on self-reporting from the children themselves or based on behavioural observation by a trained observer.
In addition to the aforementioned factors which can contribute to anxiety in children undergoing elective surgical procedures, pain is frequently reported to be another key factor that can influence or alter a child's level of anxiety19. According to definition provided by Pederson20, pain is defined as an unpleasant sensory and emotional experience that may signal either actual or potential tissue damage to the body. The management of pain in children has been a growing area of concern when it comes to nursing research21. Studies have shown that there is still a phenomenon that children's pain is under-managed and more often than not, children have to tolerate pain which is beyond what they can take22,23. In order to assess children's level of perioperative pain, some of the commonly used self-reporting instruments in the clinical setting are Visual Analogue Scale19,20 and Numeric Rating Scale24,25. In terms of behavioural observation for indication of perioperative pain, the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale26 may be considered.
Perioperative anxiety and pain in children have been associated with suboptimal postoperative outcomes, thus, effective management of these issues is essential and crucial to achieve successful treatment outcomes27. Several studies have reported that anxiety and pain are positively correlated and they have the ability to influence one other8, 19, 21, 27-29. For instance, children who are less anxious preoperatively are generally more cooperative in the postoperative period. Whereas, children who are more anxious preoperatively are often reported to experience more pain in the postoperative period, and often exhibit uncooperative behaviours. This is reinforced by Kain et. al27. Their study demonstrated that children who were more anxious tend to take higher dosages of analgesics and were also presented with more sleep problems and emotional disturbances postoperatively as compared to less anxious children. In addition, Walding30 has highlighted that both pain and anxiety work in a similar mechanism. They activate the sympathetic nervous system, prompting the hypothalamus to release neurotransmitters such as adrenaline and nor-adrenaline30. Thus, when a child is anxious, there is an increase in the sympathetic responses to pain stimuli thus making them more aware of the pain signal31. This increase in awareness to pain will reduce pain thresholds, therefore increasing the pain experienced32. Furthermore, through an initial search from CINAHL and Medline, it is noted that this phenomenon of correlation between perioperative anxiety and perioperative pain are commonly observed and studied in the school-aged going children (ie. 5-12 years old) and adolescents starting from 13 years up to 18 years of age. Therefore, explaining the importance of conducting a systematic review on this phenomenon of interest for this selected age group.
Prior to the commencement of this systematic review, the Joanna Briggs Institute Library of Systematic Reviews and Protocol, Cochrane library and CINAHL database were searched and no previous systematic reviews on this specific topic were identified as being published or being underway. Hence, by conducting this systematic review it would give us an in-depth understanding of the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures. This will inform the direction for future studies on interventions to tackle anxiety so as to better assist children to go through the peri-operative process and deal with their postoperative pain experiences.
This systematic review is to critically appraise, synthesize and present the best available evidence related to the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures.
More specifically, the review questions to be addressed are:
- What is the evidence that there is a correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures?
- How do children's demographic characteristics (age, gender, types of surgical procedures et cetera) affect their perioperative anxiety and perioperative pain related to their elective surgical procedures?
All studies to be included in this systematic review should meet all inclusion criteria in terms of types of study designs, participants, interventions/ phenomenon of interest and outcome measures.
Types of study designs
This review will consider studies that draw on the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures. This review will consider studies that focus on quantitative data including, but not limited to, designs such as randomised-controlled trials (RCT), quasi-RCT, before and after studies, case control studies, descriptive studies and case series. In the absence of such research studies, other text such as opinion papers and reports will be considered in a narrative summary.
Types of participants
The review will consider studies that involved participants of all ethnic groups, aged between 5 to 18 years old and had undergone an elective surgical procedure in the hospital setting. Contexts that will be taken into consideration will include the pediatric day surgery and pediatric surgical wards in acute hospital settings in all countries.
This review will exclude studies that involved participants who are less than 5 years old and more than 18 years old, having cognitive and mental disabilities as well as those who underwent emergency surgical procedures.
Types of interventions/ phenomena of interest
No specific intervention is of interest. However, this review will consider studies that examine the correlation between perioperative anxiety and perioperative pain in children undergoing elective surgical procedures.
The search strategy aims to find published and unpublished studies and papers. The search will be limited to English language reports and those that were published before year 2010. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe article. These key words may include: “anxiety”, “pain”, “surgery”, “child” and “adolescent”. A second extensive search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. A hand search of relevant key journals not indexed in the databases will not be conducted due to time and resources constraints.
Electronic databases to be searched include:
- CINAHL Plus with Full Text
- PubMed (MEDLINE)
- PsycINFO (Ovid SP)
- Mednar: Deep Web Medical Search
- Trip Database
- ProQuest Dissertations and Theses
- Scirus ETD (Electronic Theses and Dissertations) Search
- Web of Science (Conference proceedings Search)
A list of initial keywords used in the search strategy can be found in Appendix I.
All studies identified during the database search will be assessed for relevance to the review based on the information provided in the title and abstract. A full copy of the article will be retrieved for all studies that meet the inclusion criteria. Studies identified by study title, from reference list searches will be assessed for relevance based on their abstracts and if suitable, the full article will be retrieved.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II).
Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix III). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Quantitative data will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
Where statistical pooling is not possible, the findings concerning correlation of perioperative anxiety and perioperative pain will be synthesised and presented in narrative form.
I would like to express my heartfelt appreciation to NUS librarians for their support in searching of articles for this review.
Potential conflict of interest
There is no potential conflict of interest.
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2. Fennell ME. Parents in the OR? You bet!… parent-present induction program. RN. 1999;62(12):38-40.
3. Slee VN, Slee DA, Schmidt HJ. Slee's healthcare terms. 4, illustrated ed. Sudbury, MA: Jones & Barlett Learning; 2001.
4. Thompson C, MacLaren JE, Harris A, Kain Z. Brief report: prediction of children's preoperative anxiety by mothers and fathers. Journal of Pediatric Psychology. 2009;34(7):716-21.
5. Li HCW, Lopez V. Psychometric evaluation of the Chinese version of the State Anxiety Scale for Children. Research in Nursing & Health. 2004;27(3):198-207.
6. Spielberger CD. State-Trait Anxiety Inventory (STAI). Mind Garden, 855 Oak Grove Avenue, Suite 215, Menlo Park, CA 94025; (650)322-6300; (650)322-6398, FAX; 1983.
7. Li HCW, Lopez V. The reliability and validity of the Chinese version of the Trait Anxiety Scale for Children. Research in Nursing & Health. 2004;27(6):426-34.
8. Vaughn F, Wichowski H, Bosworth G. Does preoperative anxiety level predict postoperative pain? AORN Journal. 2007;85(3):589.
9. Li HCW, Lam HYA. Paediatric day surgery: impact on Hong Kong Chinese children and their parents. Journal of Clinical Nursing. 2003;12(6):882-7.
10. Li HCW, Lopez V. Do trait anxiety and age predict state anxiety of school-age children? Journal of Clinical Nursing. 2005;14(9):1083-9.
11. Li HCW, Lopez V. Assessing children's emotional responses to surgery: a multidimensional approach. Journal of Advanced Nursing. 2006;53(5):543-50.
12. Li HCW, Lopez V. Development and validation of a short form of the Chinese version of the State Anxiety Scale for Children. International Journal of Nursing Studies. 2007;44(4):566-73.
13. Li HCW, Wong MLE, Lopez V. Factorial structure of the Chinese version of the State Anxiety Scale for Children (short form). Journal of Clinical Nursing. 2008;17(13):1762-70.
14. Pardo GD, García IM, Gómez-Cía T. Psychological effects observed in child burn patients during the acute phase of hospitalization and comparison with pediatric patients awaiting surgery. Journal of Burn Care & Research. 2010;31(4):569-78.
15. Vagnoli L, Caprilli S, Robiglio A, Messeri A. Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study. Pediatrics. 2005;116(4):e563-7.
16. Aron JH, Schwartz G, Fernandez-Silva J, Mahajan A, Kasperowicz K, Smallman B. Novel distraction technique for pediatric pre-operative anxiety prevention. Internet Journal of Anesthesiology. 2007;14(1):5p.
17. Jasinski DM. Use of play therapy in same day pediatric surgery: impact on patient and parent anxiety and level of parent satisfaction: Catholic University of America; 2000.
18. Li HCW, Lopez V. Children's Emotional Manifestation Scale: development and testing. Journal of Clinical Nursing. 2005;14(2):223-9.
19. LaMontagne LL, Hepworth JT, Salisbury MH. Anxiety and postoperative pain in children who undergo major orthopedic surgery. Applied Nursing Research. 2001;14(3):119-24.
20. Pederson C. Effect of imagery on children's pain and anxiety during cardiac catheterization. Journal of Pediatric Nursing. 1995;10(6):365-74.
21. Gillies ML. Post-operative pain in children: a review of the literature. Journal of Clinical Nursing. 1993;2(1):5-10.
22. He HG, Pölkki T, Pietilä A, Vehviläinen-Julkunen K. A survey of Chinese nurses' guidance to parents in children's postoperative pain relief. Journal of Clinical Nursing. 2005;14(9):1075-82.
23. He HG, Pölkki T, Pietilä A, Vehviläinen-Julkunen K. Chinese parent's use of nonpharmacological methods in children's postoperative pain relief. Scandinavian Journal of Caring Sciences. 2006;20(1):2-9.
24. Sutters KA, Miaskowski C, Holdridge-Zeuner D, Waite S, Paul SM, Savedra MC, et al. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy. Clinical Journal of Pain. 2010;26(2):95-103.
25. Choo EK, Magruder W, Montgomery CJ, Lim J, Brant R, Ansermino JM. Skin Conductance Fluctuations Correlate Poorly with Postoperative Self-report Pain Measures in School-aged Children. Anesthesiology. 2010;113(1):175-82.
26. Willis MHW, Merkel SI, Voepel-Lewis T, Malviya S. FLACC Behavioral Pain Assessment Scale: a comparison with the child's self-report. Pediatric Nursing. 2003;29(3):195-8.
27. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;118(2):651-8.
28. Klassen JA, Liang Y, Tjosvold L, Klassen TP, Hartling L. Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials. Ambulatory Pediatrics. 2008;8(2):117-28.
29. Jeffs DA. A pilot study of distraction for adolescents during allergy testing. Journal for Specialists in Pediatric Nursing. 2007;12(3):170-85.
30. Walding MF. Pain, anxiety and powerlessness. Journal of Advanced Nursing. 1991;16(4):388-97.
31. Arntz A, Dreesen L, Jong DP. The influence of anxiety on pain: attentional and attributional mediators. Pain. 1994;56(3):307-14.
32. Linton SJ, Linton S. Understanding pain for better clinical practice: a psychological perspective. St. Louis: Elsevier Health Sciences; 2005.
APPENDIX I - Initial keywords or terms used in search strategy
APPENDIX II: Critical appraisal tools for MASTARI
JBI Critical Appraisal Checklist for Randomised and pseudo- randomised studies
JBI Critical Appraisal Checklist for Cohort/Case Control appraisal
JBI Critical Appraisal Checklist for Descriptive/Case series studies
JBI Critical Appraisal Checklist for Text/Opinion
APPENDIX III: Data extraction tools from MASTARI