Children undergoing surgery face significant psychological stress, with anxiety being a prevalent response, ranging from 42-75%, that can lead to negative perioperative outcomes, including increased pain perception, postoperative delirium, and higher rates of surgical complications and influence future healthcare interactions (Fortier et al., 2010; Getahun et al., 2020; Liu et al., 2022). Furthermore, it may impact the quality of life and increase healthcare costs associated with prolonged postoperative care (Agbayani et al., 2020).
In addition to having different physical, psychological, and emotional needs from adults (Lee et al., 2013), the child's age, cognitive development, and previous medical experiences play integral roles in shaping their anxiety responses (Al-Sagarat et al., 2017).Nurse-led interventions to address preoperative anxiety have been extensively studied and implemented over the years (Capurso & Ragni, 2016; Copanitsanou & Valkeapää, 2014; Dai & Livesley, 2018; Kim et al., 2019) and have shown promise in managing anxiety, providing pain relief, and ensuring a smoother perioperative experience (Rosenbaum et al., 2009).
Interventions vary from pharmacological interventions (i.e., administration of anxiolytic medication preoperatively) and non-pharmacological (Lööf & Lönnqvist, 2022). Psychological preparation, age-appropriate education and familiarisation with the surgical procedure, and distraction techniques have demonstrated efficacy in reducing anxiety levels (Agbayani et al., 2020; Kain et al., 2017), improving cooperation, and enhancing postoperative outcomes (Vaivada et al., 2022). Fortier et al. (2015) found that a comprehensive preoperative intervention (including educational materials, tours of the hospital, and coping strategies) significantly reduced preoperative anxiety and postoperative distress in paediatric patients. Similarly, Blount et al. (2017) showed that multimedia preparation programmes significantly decreased anxiety in children undergoing surgery. Likewise, Kain et al. (2007) delved into the role of parental involvement in preoperative preparation. The researchers found that the active participation of parents in preoperative education sessions led to a decrease in both child and parent anxiety, highlighting the importance of a collaborative approach to preoperative interventions (Buckley & Savage, 2010; Gordon et al., 2011).
Substantial differences regarding the content, delivery mode, timing, and intensity of preoperative preparation exist, as well as the characteristics and preferences of children and their parents (Martins Esteves et al., 2022), which might impact how effective or accepted preoperative preparation is. Lack of time, resources, staff, training, evidence, and guidelines are also common challenges for delivering preoperative preparation.
Consequently, further research is required regarding the cost-effectiveness of such interventions, their impact on healthcare utilisation, and their long-term effects on school-age children and parents' health. School-age children undergoing surgery represent a vulnerable demographic with unique physical, psychological, and emotional needs during the perioperative period. Assessing the cost-effectiveness of these interventions is vital, as it contributes valuable insights into resource allocation and healthcare efficiency. By understanding their economic implications, the project seeks to inform healthcare policies and practices, promoting interventions that not only enhance patient outcomes but also prove economically viable.
Therefore, an economic evaluation emerges as the method for comparing the costs and consequences of different healthcare interventions, programmes, or policies and assessing their value for money (Gomersal et al., 2014).
Anxiety is a multifaceted emotional response, often sparked by the anticipation of a potentially threatening situation, and is especially prevalent among children facing surgery. Research indicates that 42-75% of paediatric patients experience significant preoperative anxiety, which can provoke a range of psychophysiological reactions and negatively affect surgical and postoperative outcomes. Nursing care is pivotal in addressing this challenge: tailored interventions, psychological preparation, clear informational support and non-pharmacological techniques have all been shown to ease anxiety levels effectively. Evaluating the cost–effectiveness of these approaches enables healthcare providers to deploy resources more strategically, enhance patient care and achieve better health outcomes. This project employs a multi-method, multi-phase framework to quantify the health-economic impact of preoperative nursing strategies for managing anxiety in school-aged children, from the perspective of Portugal’s National Health Service.
Specific Objectives:
- Assess the effectiveness of preoperative anxiety management nursing interventions compared to standard care on various perioperative outcomes, including anxiety, pain, compliance during induction of anaesthesia, emergence behaviour, discharge time, sleep and emotional disturbances, quality of life and overall satisfaction in school-age children (Study 1).
- Identify and quantify the preferences of parents, children aged 6-12 and healthcare professionals for key features of preoperative anxiety-reduction interventions (Study 2).
- Evaluate the cost-effectiveness of preoperative nursing interventions for school-age children and the financial implications of implementing them using an economic decision modelling approach and budget impact analysis in the Portuguese setting (Study 3).
- Explore nurse managers' perceptions regarding the challenges or facilitators influencing the implementation of preoperative anxiety management nursing interventions (Study 4).
This research represents a notable advancement through the integration of five complementary methodologies: systematic review and meta-analysis, discrete choice experimentation, economic modeling, and qualitative inquiry. This comprehensive approach facilitates a 360° evaluation of preoperative anxiety-management nursing interventions for school-age children. It consolidates robust evidence on clinical outcomes—anxiety, pain, and recovery—elicits preferences from children, parents, and healthcare professionals, models long-term costs and benefits, and explores real-world barriers and enablers, thereby transcending traditional single-method studies.
The societal impact is substantial. Healthcare professionals will receive evidence-based guidance on effective strategies that enhance recovery and reduce perioperative anxiety, fostering child-centered care. Policymakers will gain valuable cost-effectiveness and budget-impact data to ensure optimal allocation of NHS resources. Families can anticipate reduced procedural distress, shorter hospital stays, and fewer complications, which may lower out-of-pocket costs and emotional trauma. Qualitative insights into organizational dynamics will aid in developing tailored implementation plans that support sustainable adoption. Ultimately, this integrative research identifies effective practices and lays the groundwork for their efficient deployment, improving pediatric surgical experiences and outcomes across the NHS.
Citizen involvement is woven into every stage of this research to ensure that study design, execution and dissemination are genuinely responsive to end-user needs. During the DCE attribute and level development, parents and children will participate in short interviews to validate the relevance, clarity and comprehensiveness of each choice criterion. In preparing our qualitative instruments, patient and caregiver advisors will review and refine interview questions, ensuring that they resonate with lived experiences and priorities. Throughout data analysis, we will convene a lay advisory panel to review emerging themes and contribute to interpretation, thereby grounding our findings in real-world perspectives. Finally, citizens will act as ambassadors in the dissemination phase—co-presenting findings at community events, contributing to lay summaries and advising on accessible communication formats—to foster transparency, accountability and the uptake of recommendations that truly reflect the voices of those whom the NHS serves.
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01/07/2025
26/06/2029
Periop Safe Care – Raciocínio clínico dos enfermeiros e segurança do doente em contexto perioperatório
Care Systems, Organization, Models, and Technology