ORIGINAL RESEARCH: CLINICAL TRIAL

The effect of an educational pre-operative DVD on parents’ and

children’s outcomes after a same-day surgery: a randomized
controlled trial
Julie Chartrand, Jocelyne Tourigny & Johnna MacCormick

Accepted for publication 6 September 2016

Correspondence to J. Chartrand: C H A R T R A N D J . , T O U R I G N Y J . & M A C C O R M I C K J . ( 2 0 1 7 ) The effect of an

e-mail: julie.chartrand@uottawa.ca
Julie Chartrand PhD RN
Assistant Professor
School of Nursing, University of Ottawa,
Ontario, Canada
Jocelyne Tourigny PhD RN
Full Professor
School of Nursing, University of Ottawa,
Ontario, Canada
Johnna MacCormick MD FRCSC
Associate Professor
Faculty of Medicine, University of Ottawa,
Ontario, Canada
Chief
Division Pediatric Otolaryngology,
Children’s Hospital of Eastern Ontario
(CHEO), Ottawa, Ontario, Canada
educational pre-operative DVD on parents’ and children’s outcomes after a same-
day surgery: a randomized controlled trial. Journal of Advanced Nursing 73(3),
599–611. doi: 10.1111/jan.13161
Abstract
Aims. To examine the effect of a pre-operative DVD on parents’ knowledge,
participation and anxiety and on children’s distress, pain, analgesic requirements
and length of recovery after same-day surgery.
Background. Very few parents are adequately prepared to participate in their
child’s care during a same-day surgery. An educational DVD was developed to
educate parents on how to actively support their child in the recovery room.
Design. Single-blind, post-test randomized controlled trial. Study is registered at
ClinicalTrials.gov NCT02766452.
Methods. Between September 2011–September 2012, 123 parent–child dyads
where the child underwent an ENT or dental same-day surgery were recruited in
a Canadian paediatric hospital. Dyads were randomly assigned to either the
intervention (DVD and standard preparation) or control group (standard
preparation). Parents and children were videotaped in the recovery room where
parental participation and anxiety and children’s distress were measured. Data on
parents’ knowledge, children’s postoperative pain, analgesic requirements and
length of recovery were measured. Independent and paired t-tests, chi square and
repeated measures ANOVA were used to analyse the data.
Results. Parents in the intervention group gained greater knowledge of and used
more positive reinforcement and distraction and relaxation methods than those in
the control group. Children’s postoperative pain in the day-care surgery unit was
significantly lower among the intervention group compared with the control
group.
Conclusion. A pre-operative DVD can increase parents’ participation in the
recovery room and decrease children’s postoperative pain.

Keywords: children, DVD, educational intervention, health education, nursing,

parent participation, parents, programme evaluation, randomized controlled trial,
same-day surgery

© 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 599
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
J. Chartrand et al.
Why is this research needed?
 Parents and healthcare professionals support parental par-
ticipation at the time of a same-day surgery; however, both
groups agree that parents are not adequately prepared.
What are the key findings?
 A short DVD, based on a cognitive-behavioural pedagogi-
cal approach, is effective in increasing parents’ knowledge
about actively supporting their child in the recovery room.
 A pre-operative DVD can increase parents’ use of positive
reinforcement, distraction and relaxation methods and
decrease children’s postoperative pain.
How should the findings be used to influence policy/
practice/research/education?
 In combination with the pre-operative DVD, coaching and
guidance should be provided by nursing staff to parents to
increase the positive outcomes of parents’ participation in
their child’s care in the recovery room.
Introduction
As the philosophy of family-centred care in paediatric nurs-
ing spreads, parents are increasingly more involved in their
child’s care (Chan & Molassiotis 2002, Espezel & Canam
2003, Ygge & Arnetz 2004, Miceli & Clark 2005, Tour-
igny et al. 2005, Shields et al. 2006). Parental involvement
during surgery decreases children’s postoperative pain,
anaesthesia-related side effects, anxiety, duration of recov-
ery, parental anxiety and significantly reduces surgical
departments’ operating costs (Kain et al. 2006, Li et al.
2007, Wright et al. 2010). Currently, parents are permitted
to be present in most operating rooms (OR) during induc-
tion of anaesthesia and in recovery rooms (RR) in the
immediate postanaesthetic period of their child’s surgery
(Paice et al. 2009). Parental presence during induction of
anaesthesia, as a means to reduce children’s pre-operative
anxiety, has been studied extensively (Yip et al. 2010). Yet,
few studies examine the effect of preparing parents to
actively support their child in the RR. This article addresses
parents’ participation in their child’s care in the RR, as a
means of alleviating postoperative anxiety and pain.
Background
Parental participation during a child’s surgery or a hospital-
ization refers to the behaviours parents adopt to provide
600 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
their child with physical, psychological or emotional care.
Parent behaviours related to their child’s physical care
include physical comfort, hygiene, repositioning and feeding
(Caty et al. 1989, Tourigny 1998, Kristensson-Hallstr€ om
2000, Tourigny et al. 2005), whereas positive reinforce-
ment, verbal explanations/feedback, affection, relaxation,
distraction, visualization, positive attitude and defence of
the child’s interests represent behaviours that ensure the
child’s psychological well-being during a hospitalization.
Although parental participation in care, especially emo-
tional support, is often used to reduce children’s periopera-
tive anxiety, very few educational intervention programmes
that support parents’ participation in their child’s care dur-
ing a surgery or a hospitalization have been developed and
evaluated. The format of such programmes includes verbal
(information session, presentation, guided tour) (Kris-
tensson-Hallstr€om et al. 1997) or written information (Kris-
tensson-Hallstr€om et al.1997, Tourigny 1998, Bailey et al.
2015) and videos (Kain et al. 2007, Lardner et al. 2010,
McCarthy et al. 2010a,b).
Parental pre-operative preparations provide parents with
basic information about their child’s postoperative treat-
ment, such as eating, drinking, analgesia and coping
skills. These preparations also educate parents on the
child’s expected reactions to surgery, hospital procedures
related to a same-day surgery (SDS) and how to prepare
their child for surgery and participate in the child’s care
(Kristensson-Hallstr€om et al. 1997, Tourigny 1998, Chan
& Molassiotis 2002, McCarthy et al. 2010a,b, Bailey
et al. 2015). Educational interventions also include images
of parents and their children during an induction of
anaesthesia, showing parents how to participate in the
OR (Kain et al. 2007).
Pre-operative preparations focused on parents’ participa-
tion during their child’s SDS or hospitalization are known
to have an effect on children’s pain, anxiety, the duration
of postoperative recovery and amount of analgesics children
receive. For example, Austrian children who read a story-
book with their parent about a rabbit hospitalized for an
adenoidectomy and tonsillectomy prior to surgery demon-
strated less postoperative pain than children who did not
(Felder-Puig et al. 2003). However, a brief parental pres-
ence preparation delivered electronically did not result in
less postoperative pain, or less anxiety at induction of
anaesthesia for Canadian children (Bailey et al. 2015).
Canadian children whose parents read an educational book-
let pre-operatively showed significantly less postoperative
anxiety than children of parents who did not read the
booklet (Tourigny 1998). Salivary cortisol levels (biological
response to anxiety) were higher in American children of
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes
parents who did not receive an intervention focused on dif-
ferent distraction techniques than those in children of par-
ents who did (McCarthy et al. 2010b). Furthermore, results
showed that children whose parents used more distraction
techniques were less anxious during a medical procedure
(McCarthy et al. 2010b). A multifaceted pre-operative
preparation, called ADVANCE, was developed to prepare
American parents for participation in the OR during their
child’s induction of anaesthesia (Kain et al. 2007). The
preparation programme was critical in significantly reduc-
ing children’s pre-operative anxiety, Fentanyl requirements
and length of stay in the RR (Kain et al. 2007). An Ameri-
can follow-up dismantling study revealed that handling the
anaesthesia mask at home before surgery and parental use
of distraction techniques in the waiting room (both compo-
nents of the ADVANCE programme) are worthy of inclu-
sion in future preparations to relieve children’s pre-
operative anxiety (Fortier et al. 2011).
The effects of pre-operative preparations for parental par-
ticipation have also been examined in relation to parents’
self-efficacy, knowledge acquisition, participation beha-
viours and anxiety. Canadian parents who received written
and narrated information on a tablet about how to help
their child in the OR reported a significant increase in self-
efficacy with respect to their role in the OR (Bailey et al.
2015). A Canadian researcher found that parents who read
an educational booklet acquired greater knowledge than
those who did not, but did not demonstrate a larger num-
ber of participation behaviours in the day care surgery
(DCS) unit (Tourigny 1998). Parents of Chinese children
reported significantly lower postoperative anxiety after
receiving written and verbal information about the impor-
tance of their role in the OR (Chan & Molassiotis 2002).
However, a children’s storybook had no significant effect
on Austrian parents’ level of postoperative anxiety (Felder-
Puig et al. 2003). Furthermore, a brief video application
providing sensory and procedural information did not result
in a reduction of pre-operative anxiety for Canadian par-
ents (Bailey et al. 2015). The extensive ADVANCE pro-
gramme, which showed American parents how to teach
their child to use an anaesthesia mask and how to commu-
nicate effectively with their child, had, however, a statisti-
cally significant effect on decreasing parents’ pre-operative
anxiety (Kain et al. 2007).
Given that extensive pre-operative preparations require
significant resources to develop, assess and sustain, a brief
educational intervention focusing on parental use of distrac-
tion and other participation behaviours could be an excel-
lent vehicle for increasing parental participation and
reducing children’s anxiety and pain during a SDS. Since an
© 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
educational booklet describing how to support their child
postoperatively was not effective in changing parents’ beha-
viours (Tourigny 1998), a pre-operative DVD was devel-
oped, based on the learnt capabilities and conditions of
learning model (Gagne 1985), to show parents how to sup-
port their child in the RR (Chartrand 2014). This study is
the first to explore the effects of a pre-operative educational
DVD on parent participation and its impact on parents’
and children’s outcomes during a SDS.
The study
Aims
A randomized controlled trial was conducted to determine
the effectiveness of an educational pre-operative DVD on
parent and child outcomes. The following hypotheses were
considered:
Primary outcome
Hypothesis 1 Parents in the experimental group will
demonstrate significantly greater participation behaviours in
the RR compared with parents in the control group.
Secondary outcomes
Hypothesis 2 Parents in the experimental group will
demonstrate significantly greater knowledge acquisition (of
notions and behaviours related to participation in care in
the RR) than parents in the control group.
Hypothesis 3 Parents in the experimental group will
report significantly less anxiety before, during and after par-
ticipating in their child’s care in the RR compared with par-
ents in the control group.
Hypothesis 4 Children in the experimental group will
show significantly less postanaesthetic distress than children
in the control group.
Hypothesis 5 Children in the experimental group will
show significantly less postoperative pain compared with
children in the control group.
Hypothesis 6 Children in the experimental group will
require significantly fewer doses of analgesics during the
postoperative period than children in the control group.
Hypothesis 7 Children in the experimental group will
have a significantly shorter period of recovery compared
with children in the control group.
Design
This study was a single-blind, clustered randomized con-
trolled trial with a control group.
601
J. Chartrand et al.
Participants
Between September 2011–September 2012, parent–child
dyads with a child between the ages of 3 and 10 years
who was scheduled for an elective outpatient ENT or den-
tal surgery, were recruited in the pre-assessment clinic
(PAC). Parents were excluded if they could not speak or
read English or French. Also excluded were children who
had a surgical or postanaesthetic complication (e.g. car-
diorespiratory distress, bleeding, severe emotional distress,
etc.), because they were admitted to the paediatric inten-
sive care unit following surgery, making data collection no
longer possible.
Randomization
Dyads were randomly assigned to the intervention (DVD)
group or the control group according to clusters represent-
ing their (PAC) appointment day, to limit the risk of con-
tamination between groups at the time of the pre-operative
preparation held in the hospital’s family library. To achieve
balanced recruitment between groups, block randomization
with random variable block lengths of 4 and 6 was used. A
computer-generated list of random numbers was used by a
third party to generate the allocation. The random numbers
were concealed in security envelopes, which were opened
only at the time research assistants enrolled the first dyad
of the day to determine the nature of pre-operative prepara-
tion.
Sample size
The primary outcome of this study was parents’ participa-
tion behaviours as measured by the Inventaire des con-
duites parentales (ICP) (Parental Behaviours Inventory)
(Tourigny et al. 2005). The sample size was calculated
using power analysis for independent samples t-test. To
detect an average difference of three participation beha-
viours between groups, with a type I error of 0
05, a
power of 80% and a standard deviation of 5
31, a sample
size of 50 parent–child dyads per group was necessary.
Accounting for some intra-cluster correlation due to the
study’s sampling plan led to a sample size of 52 dyads
per group. An attrition rate of 20% was anticipated from
similar studies (Tourigny et al. 2005, 2011, Tourigny &
Chartrand 2009), therefore a total of 125 dyads were to
be recruited.
Blinding
Bedside nurses, research assistants responsible for coding
the video segments and researchers were blinded to study
group allocation.
602 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
Interventions
Pre-operative preparation. After their PAC appointment,
parents in both the intervention and control groups took
the hospital’s 20-minute surgical virtual tour (see
Appendix 1) in the hospital’s family library.
Intervention. Parents in the intervention group also
watched the 12-minute DVD entitled ‘You and Your Child
in the RR’ in the hospital’s family library after their PAC
appointment (see Appendix 2). This pre-operative educa-
tional tool was developed and tested in a pilot study (Char-
trand 2014). It was designed to provide parents with
knowledge about the equipment and procedures in the RR
and about the roles of nurses and parents in supporting
their child. The DVD also focused on potential reactions of
children waking up after a general anaesthesia and strate-
gies parents could use to support their child in the RR. The
DVD included images of RR equipment and positive nurse–
family and parent–child interactions.
Data collection
Demographics and concomitant variables
Socio-demographic variables included parent characteristics
(e.g. age, education level and relationship with child) and
child characteristics (e.g. age). Concomitant data were
related to parents (e.g. previous experience with a paedi-
atric surgery and a RR stay) and to children (e.g. previous
experience with surgery and type of surgery). Socio-demo-
graphic and concomitant data were collected using two
short questionnaires filled out by parents of both groups,
the first one at the PAC and the second in the DCS unit.
Primary outcome measure
Parents’ participation behaviours. Parents’ participation
behaviours were defined as the physical and psychological
care parents provided to their child in the RR. Each par-
ent–child dyad was digitally video-recorded in the RR every
three minutes for 15 second segments. Up to six segments
were randomly selected, such that the maximum length of
recordings per parent was 1½ minutes. Parents’ participa-
tion behaviours were measured using an observational
checklist, the Inventaire des conduites parentales (ICP) (Par-
ental Behaviours Inventory), which includes behaviours par-
ents demonstrate during a child’s SDS (Tourigny et al.
2005). The ICP includes 13 items divided into three cate-
gories: verbal information (e.g. providing information to
the child and answering the child’s questions); cognitive
strategies (e.g. applying positive reinforcement and
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes
implementing coping strategies); and attitudes (e.g. showing
affection and being close to the child). Each demonstrated
parental behaviour is worth one point, with a maximum
score of 13 for each video segment. A parental behaviour
was checked off only once during a segment. The average
score of parental behaviours demonstrated during all six
segments was used as the parents’ participation behaviours
score in the RR. The ICP established a significant difference
between fathers and mothers regarding the frequency of
demonstrated behaviours in a DCS unit (t = 2
895,
P = 0
004) (Tourigny 2004, Tourigny et al. 2004). In a
subsequent study, where parents’ behaviours were evaluated
in a DCS unit, the ICP’s correlation total-category ranged
from 0
56 to 0
84, P = 0
01 (Tourigny et al. 2005).
Secondary outcome measures
Parents’ knowledge acquisition. Parents’ knowledge repre-
sented their familiarity with the RR equipment and environ-
ment. It also represented parents’ understanding of child
development, expected reactions of children emerging from
anaesthesia and behaviours used to assist their child in the
RR. A multiple-choice questionnaire was designed and vali-
dated for this study, then used to measure parents’ knowl-
edge. Parents’ answers were tabulated to get a total score
for each parent and for each test (test 1: Pre-intervention
and test 2: Postintervention). The maximum score for each
test was 10. Parents’ knowledge acquisition was measured
by calculating the difference between parents’ scores on test
1 and test 2.
Parents’ anxiety was defined by parents’ self-reporting of
their anxiety at three time points: 1) immediately before
entering the RR; 2) 5 minutes after entering the RR; and 3)
5 minutes after leaving the RR with their child. Parents’ anxi-
ety was measured using the Visual Analogue Scale for Anxi-
ety (VAS-A) (Vogelsang 1988), which is a 10 centimetre
horizontal line, from 0 cm = ‘Not at all anxious’ to 10 cm =
‘As anxious as I could be’. There is a moderate–high signifi-
cant correlation (r = 0
84 and P = 0
01) between the VAS-A
and the state scale of the State-Trait Anxiety Inventory
(STAI) (Vogelsang 1988). In this study, parents drew a verti-
cal line on the VAS-A to report their anxiety. The intersection
of the vertical and the horizontal lines of the scale repre-
sented the parents’ self-reported anxiety score.
Children’s distress in the RR was defined as facial, ver-
bal and affective manifestations and motor indicators of
emotional distress related to anxiety, anger, fear and pain.
Parent–child dyads were digitally video-recorded in the
RR. The video segments randomly selected to measure
parents’ participation behaviours in the RR were also used
to measure children’s distress behaviours. Children’s
© 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
distress behaviours were measured with the Echelle 
descriptive du comportement de l’enfant opere (EDCEO)
(Observation scale to assess the behaviour of children
undergoing surgery) (Tourigny 2000). The EDCEO
includes six items: facial expression, verbal exchange,
activity-interaction, affect, participation and activity-com-
fort. Each item has a scale from 0 to 3. For example, for
the item ‘facial expression’, 0 = relaxed and 3 = tearful.
The maximum score of the EDCEO is 18. A higher score
indicates greater distress. The average of children’s distress
scores obtained for all items during all six segments was
considered to be the children’s distress level in the RR.
The EDCEO earned an internal consistency of 0
83 and
item-total correlation coefficients of 0
59-0
90, with a
P < 0
01 (Tourigny 2000).
Children’s pain. Children’s postoperative pain was
assessed in the RR and the DCS unit and documented by
nurses using the Modified Children’s Hospital of Eastern
Ontario Pain Score (mCHEOPS) (Splinter et al. 1994). This
observation scale has five items: cry, facial, verbal, torso
and legs. Each item has a score ranging from 0-2. For
example, scores for the item ‘facial’ include 0 = smiling,
1 = composed and 2 = grimace. The maximum score of the
mCHEOPS is 10; a higher score indicates greater pain.
Children’s analgesic requirements. Postoperative analgesics
required by children in the RR and in the DCS unit included
opioid analgesics (e.g. Fentanyl and Morphine) and non-
opioids (e.g. Acetaminophen). These analgesics were admin-
istered and documented in the children’s medical record by
nurses. A chart review was conducted to determine children’s
analgesic requirements in terms of doses (e.g. two doses).
Children’s length of recovery. Children’s length of recov-
ery was the elapsed time (in minutes) between arrival in the
RR and departure from the DCS unit. The time at which
children were discharged from the DCS unit was based on
specific criteria regarding level of activity and conscious-
ness, vital signs, blood perfusion, pain and wound assess-
ment and feeding. The hospital’s protocol requires this
information to be documented in the nurses’ notes. A chart
review was conducted to determine children’s postoperative
recovery time.
Ethical considerations
This trial was reviewed and approved by the Research
Ethics Board of one university and one university-affiliated
paediatric hospital in Canada. Parents and children were
603
J. Chartrand et al.
assured that refusal to participate or withdrawal from the
study would not affect the quality of care received. Written
consent was obtained from all parents and older children
and verbal assent was obtained from all younger children.
Data analysis
Data were analysed using the Statistical Package for the
Social Sciences (SPSS) software (Version 21 for Windows).
Descriptive analysis was generated from the socio-demo-
graphic and concomitant variables to describe the sample.
The Student’s t-test on independent samples was used to
analyse parents’ participation behaviours and children’s post-
operative distress, pain and recovery time (Tabachnick &
Fidell 2007). A general linear mixed (GLM) model analysis
was chosen over an ANOVA to account for a possible effect of
randomization by cluster on each dependent variable
(Eldridge & Kerry 2012). The day of randomization (cluster)
corresponded to the random variable, whereas the fixed vari-
able corresponded to the group. The Student’s t-test on
paired samples was used to compare groups (experimental
and control) regarding parents’ knowledge acquisition, while
a repeated measures ANOVA was conducted on the parental
anxiety variable (Tabachnick & Fidell 2007). A GLM model
was used to examine differences between groups regarding
parents’ knowledge acquisition and anxiety. Chi-square anal-
ysis was conducted to examine the difference between groups
based on children’s postoperative analgesic requirements
(Tabachnick & Fidell 2007). All tests conducted were two-
tailed and P values < 0
05 were considered statistically signif-
icant. To avoid withdrawal bias, statistical analysis of partic-
ipant data was performed according to the group where
parents were distributed, regardless of the pre-operative
preparation they completed (intention-to-treat).
Validity and reliability
The study had strong internal validity. The protocol was
methodically designed and the process was meticulously
documented to ensure that the study could be reproduced.
The research team and paediatric nursing experts developed
the questionnaires used to collect socio-demographic and
concomitant data in accordance with tools used in similar
studies. These were piloted among 21 parents of children
ranging from 3–10 years old who were scheduled for a
PAC appointment for a SDS at the children’s hospital.
No validated tool existed to assess parents’ knowledge
specific to the hospital’s pre-operative preparation. There-
fore, the research team built a questionnaire based on the
children’s hospital PAC appointment, surgical virtual tour
604 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
and the DVD content (Chartrand 2014). Ten multiple-
choice questions, each with four possible answers, were
developed by the team. The questionnaire was submitted to
a group of experts (paediatric nurses, physicians, child life
specialists and statisticians) for review and consensus. The
questionnaire was clear and concise. A test-retest was done
in a two-week interval by 21 parents of children (3–
10 years old) who were undergoing a SDS at the children’s
hospital. The intra-cluster correlation coefficient was 0
88.
A tool for assessing parents’ participation behaviours in
the RR already existed. Therefore, two research assistants,
both advanced practice nurses in paediatric care, were
trained to use the ICP (Tourigny et al. 2005). From the
video segments that were not selected during the random-
ization of six segments per parent, those of 11 parents
(10% of the expected sample size n = 104) were randomly
selected and coded. During training, the research assistants
reached an inter-rater reliability rate of 91
6% and an
intra-rater reliability rate of 93
9%. Halfway through the
data collection process (n = 50), respective rates were
90
1% and 93
1%.
The research assistants were also trained in the use of the
EDCEO (Tourigny 2000) to measure children’s distress in
the RR. They watched and coded the video segments of 11
children. The inter-rater reliability rates were 90
2% during
training and 92
3% when the study was well underway
(n = 50). Intra-rater reliability was also tested; rates were
91
3% during training and 93
9% halfway through the
study.
Results
Participant enrolment and withdrawals
Of the 323 parent–child dyads eligible to participate, 200
dyads declined (Figure 1). Of the 123 dyads who agreed to
participate in the study, 18 were excluded. The final sample
of 105 parent–child dyads were randomly distributed
between the experimental group (n = 49) and the control
group (n = 56).
Parents’ and children’s baseline characteristics
Dyads in the experimental group and in the control group
were similar in their baseline characteristics (Table 1).
Parents’ participation behaviours
Independent samples t-test was conducted to examine the
difference between groups with regard to parents’
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes
Assessed for eligibility (n = 4322)
Randomized (n = 123)
Allocated to DVD and standard
preparation (n = 59)
Received allocated intervention (n = 47)
Did not complete allocated intervention
(n = 12)
• Did not complete intervention,
interrupted at the pre-assessment
clinic
Analyzed (n = 49)
Excluded from analysis (n = 10)
• Parent withdrew after intervention
(n = 5)
• Parent could not complete
questionnaires (n = 1)
• Surgery was cancelled (n = 3)
• Parent was not in recovery room
(n = 1)
Figure 1 CONSORT participant flow diagram.
participation behaviours in the RR. Results revealed no sig-
nificant difference between the two groups (P = 0
30)
(Table 2). However, when each category of parents’ partici-
pation behaviours was analysed separately, parents in the
experimental group made greater use of cognitive strategies
(e.g. positive reinforcement, distraction and relaxation) with
their child in the RR than did parents in the control group
(Table 3). There was no statistically significant difference
between groups with regard to the remaining categories of
parents’ participation behaviours (e.g. verbal information,
attitudes-cognitive and attitudes-behavioural).
Parents’ knowledge acquisition
The knowledge questionnaire was completed by 104 par-
ents at time 1 (1–21 days before the child’s surgery) and by
© 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
Excluded
• Did not meet inclusion criteria
(n = 3999)
• Declined to participate (n = 200)
Allocated to standard preparation
(n = 64)
Received allocated intervention (n = 54)
Did not complete allocated intervention
(n = 10)
• Did not complete intervention,
interrupted at the pre-assessment
clinic
Analyzed (n = 56)
Excluded from analysis (n = 8)
• Parent withdrew after intervention
(n = 2)
• Parent could not complete
questionnaires (n = 2)
• Surgery was cancelled (n = 3)
• Parent was not in recovery room
(n = 1)
105 parents at time 2 (1–2 hours before surgery). Accord-
ing to the results of a paired samples t-test, all parents
acquired significant knowledge from time 1 to time 2
(P < 0
001) (Table 4). However, parents who watched the
DVD acquired greater knowledge than those who did not
(P = 0
03) (Table 2).
Parents’ anxiety
The results of a repeated measures ANOVA showed no statis-
tically significant difference between groups in parents’ anx-
iety before, during or after their stay in the RR (Table 2).
Thus, there was no significant difference between groups in
parents’ anxiety across time (P = 0
75) (Table 5). However,
time did have a significant effect on parents’ anxiety
(P = 0
00) (Table 5). Regardless of their allocation, parents
605
J. Chartrand et al.

Table 1 Parents’ and children’s baseline characteristics. experimental group was significantly lower than that of
children in the control group (P = 0
02).
Control group Experimental Sample
(n = 56) group (n = 49) (n = 105)
Variables n (%) n (%) n (%)
Children’s analgesic requirements
Parents
Table 2 reveals that all children received more postoperative
Mothers 47 (84) 38 (78) 85 (81)
Age (years); 37
3 (5
4) 37
9 (5
8) 37
6 (5
6) analgesics in the RR compared with the DCS unit. Chi-square
mean (SD) test’s results revealed that there was no significant difference
English speaking 43 (77) 36 (74) 79 (75) between groups in the children’s analgesic requirements,
Diploma or 48 (86) 41 (84) 89 (85) either in the RR (P = 0
21) or in the DCS unit (P = 0
94).
Degree prepared
1st SDS experience 31 (55) 26 (47) 57 (54)
1st time in RR 33 (59) 30 (61) 63 (60) Children’s length of recovery
With other children 48 (86) 43 (88) 91 (87)
Children The children’s length of recovery according to group and
Boys 37 (66) 27 (55) 64 (61) postoperative period (RR and DCS unit) are included in
Age (yrs); 5
5 (1
8) 5
1 (1
8) 5
3 (1
8)
Table 2. According to the results of an independent samples
mean (SD)
t-test, there was no significant difference between the length
English speaking 43 (77) 36 (74) 79 (75)
1st SDS experience 36 (64) 32 (65) 68 (65) of recovery in the RR of children in the experimental group
ENT surgery 37 (66) 28 (57) 65 (62) or the control group (P = 0
35). Similarly, no significant
difference was established between the length of recovery in
Yrs, years; SD, standard deviation; SDS, same-day surgery; RR,
recovery room; ENT, ear nose and throat.
the DCS unit of children in the experimental group or the
control group (P = 0
45).
were most anxious before entering the RR and gradually
became less anxious during their child’s postoperative
Discussion
recovery.
This study has many strengths, including the use of a rigor-
ous research design (RCT), an educational theoretical
Children’s distress
framework and a direct observation of parents’ behaviours
Independent samples t-test was used to compare children’s in RR. It also focuses on preparing parents specifically for
postanaesthetic distress between groups. Results showed their participation in care in the RR. A strength of this
no significant difference between groups regarding chil- study is the use of a randomized controlled trial to deter-
dren’s distress (P = 0
51) (Table 2). All children, regardless mine whether our intervention could yield positive parent
of the group to which their parents were assigned, demon- and child outcomes during a SDS. Other researchers have
strated low levels of distress (25
46 out of 108). Due to also used an experimentation study design to examine the
the effects of general anaesthesia and narcotics adminis- effect of pre-operative preparations (Kain et al. 2007, Lard-
tered in the OR and RR, more than 70% of all children ner et al. 2010, Bailey et al. 2015). An experimental design
were sleeping in at least one video segment taken in the provides a high level of scientific evidence, as it decreases
RR. All children slept on average for more than 40% of the risk of bias (Oxford Centre for Evidence-Based Medi-
the video segments taken in the RR and therefore showed cine 2011). Thus, when a significant difference is estab-
little distress. lished, it can be largely attributed to the intervention. In
this study, significant differences between groups are mostly
due to our educational pre-operative DVD.
Children’s pain
Unlike the majority of published pre-operative interven-
Children’s postoperative pain was greater in the RR than in tions, our intervention, including its content and format,
the DCS unit, regardless of the group to which they were was developed based on an educational theoretical frame-
assigned. As indicated in Table 2, there was no significant work. Based on Gagne’s learnt capabilities (1985), the
difference between groups in the level of pain children DVD increased parents’ use of cognitive strategies (one type
exhibited in the RR according to the results of an indepen- of learnt capability) as participation behaviours in the RR.
dent samples t-test (P = 0
27). Nevertheless, the pain It also contributed to a significant decrease in children’s
demonstrated in the DCS unit by children in the postoperative pain in the DCS unit. A pre-operative booklet

606 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes

Table 2 Parents’ and children’s outcomes.

Statistics
Experimental group (n = 49) Control group (n = 56)
Outcomes M (SD) M (SD) Test value P

Parents
Participation behaviours 16
49 (4
15) 15
71 (4
65) t = 1
06 0
30†
Knowledge acquisition 1
82 (1
18) 1
33 (0
82) t = 2
23 0
03‡*
Anxiety in RR
 Before 3
32 (2
50) 3
51 (2
43) t = 0
68 0
66§,¶
 During 2
76 (2
60) 2
73 (2
44) t = 0
68 0
66§,¶
 After 0
98 (1
71) 1
31 (2
01) t = 0
68 0
66§,¶
Children
Distress score in RR 26
73 (19
19) 24
34 (17
51) t= 0
55 0
59†
Pain score (mCHEOPS)
 RR 1
51 (1
89) 2
06 (2
36) t = 1
13 0
27†
 DCS 0
49 (0
84) 1
16 (1
59) t = 2
39 0
02†*
Analgesic requirements (in doses)
 RR 1
18 (1
07) 0
93 (1
02) v2 = 1
54 0
21§
 DCS 0
49 (0
74) 0
50 (0
76) v2 = 0
07 0
94§
Recovery time (in minutes)
 RR 62
94 (24
67) 58
61 (22
8) t = 0
94 0
35†
 DCS 98
91 (45
93) 106
27 (46
83) t = 0
77 0
45†

Bold data indicate a significant difference between the two groups.

*P < 0
05.
†
Independent samples t-test.
‡
Paired samples t-test.
§
Chi-square.
¶
Repeated measures ANOVA- Parents’ anxiety.
M, mean; SD, standard deviation; RR, recovery room; mCHEOPS, Modified Children’s Hospital of Eastern Ontario Pain Score; DCS, day
care surgery.

Table 3 Parents’ participation behaviours by category and group. Table 4 Comparison of parents’ knowledge scores by paired sam-
ples t-tests (n = 103).
Categories of Statistics
parents’ Experimental Control Time 1 Time 2
participation group (n = 49) group (n = 56) Group (mins) (mins) t P
behaviours M (SD) M (SD) F P
Experimental (n = 54) 7
51 (1
14) 9
33 (0
85) 76
70 <0
001*
Verbal 1
53 (1
43) 1
82 (2
10) 0
66 0
42 Mean (SD)
information Control (n = 49) 7
64 (1
04) 8
96 (0
90) 73
71 <0
001*
Cognitive 2
04 (1
53) 1
41 (1
30) 4
96 0
03* Mean (SD)
strategies
Attitudes: 0
49 (0
79) 0
54 (0
93) 0
99 0
35 *P < 0
05.
cognitive type mins, minutes; SD, standard deviation.
Attitudes: 12
42 (3
27) 11
95 (2
84) 0
23 0
64
behavioural type
The use of direct observation to measure parental partici-
Independent samples t-test was used for the data analysis summa- pation behaviours in the RR is another strength of this
rized in this table.
study. This method was chosen over parents’ self-reporting
*P < 0
05.
to ensure greater validity of the results and allowed for rig-
M, mean; SD, standard deviation.
orous and systematic evaluation of parents’ participation.
based on the same educational theoretical framework Many studies examined interventions that prepared par-
(Gagne 1985) and intended to educate patients and families ents for their child’s surgery (Chan & Molassiotis 2002,
on a SDS, also significantly increased parents’ knowledge Felder-Puig et al. 2003, Kain et al. 2007, Fortier et al.
acquisition and use of positive reinforcement, distraction or 2011, Bailey et al. 2015). However, studies examining the
relaxation methods (Tourigny 1998). effect of interventions that prepare parents specifically for

© 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd. 607
J. Chartrand et al.
Table 5 Repeated measures ANOVA for parents’ anxiety (n = 102).
Effects d.f. F P
Group 1 0
20 0
66
Time 2 54
86 <0
001*
Group-time 2 0
28 0
75
*P < 0
05.
their child’s emergence from anaesthesia are scarce. This
study focused on the effect of an intervention that prepares
parents specifically for their participation in care in the RR.
Limitations
This study has some limitations. For example, most chil-
dren in our study were sleeping during their RR stay, which
may explain why parents in the experimental group did not
demonstrate greater participation behaviours or less anxiety
in the RR than those in the control group. It is possible that
parents did not feel the need to participate in care because
their child was obviously not in distress. The effect of gen-
eral anaesthesia and analgesics in the RR may explain the
lack of significant difference in children’s distress and pain
between groups in this study. Future studies would benefit
from measuring parents’ and children’s outcomes up to and
beyond the RR.
The fact that our pre-operative preparation in this study
included only one component may have affected the results.
Our intervention was a brief, user-friendly and relatively
inexpensive way to prepare parents for their stay in the RR
and did not yield significant differences in parent anxiety
between groups. Similarly, a brief electronically delivered
preparation for parental presence during induction of
anaesthesia did not decrease parents’ anxiety (Bailey et al.
2015). These interventions did not include pamphlets, role-
play and parent support, as does the ADVANCE prepara-
tion which significantly decreased parents’ anxiety in the
OR (Kain et al. 2007). This comprehensive preparation had
multiple components, such as video modelling, verbal infor-
mation, coaching, pamphlets, distraction and exposure. Our
intervention could not provide parents with coaching, feed-
back or reinforcement at the time of their participation in
the RR. Parents from both groups received very little feed-
back from nurses or research assistants on their participa-
tion behaviours in the RR. Real-time parent support may
be necessary for parents, because it may be difficult for
them to recall information during a stressful situation (Oei
et al. 2006). Further research is needed to evaluate a multi-
component intervention, which would include physical and
emotional support for parents by nurses and a pre-operative
608 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
educational tool on parents’ participation in the context of
a SDS.
Another limitation of this study is that parents’ participa-
tion behaviours and children’s distress were not measured
up to and beyond the RR. Although it can be challenging
to videotape parents and children in the DCS unit, future
research should measure parent and child outcomes
throughout the entire SDS experience to determine the
effect of pre-operative preparations beyond the RR.
Finally, the participants represented a convenience sam-
ple of parents accompanying their 3–10-year-old child
undergoing an elective dental or ENT SDS in a single ter-
tiary care hospital. This sampling method may affect the
generalizability of results. Future research could duplicate
this study with larger samples of children undergoing other
types of surgery and in several tertiary care hospitals across
different countries to enhance the generalizability of our
findings.
Conclusion
These findings suggest that viewing a pre-operative DVD,
inspired by an educational theory and focused on strategies
that parents can use in the RR, allows parents to gain
knowledge and behaviours to actively support their child in
the RR. The DVD can thereby assist parents in reducing
their child’s pain for up to two hours immediately after sur-
gery. However, a DVD might not be sufficient to decrease
parents’ anxiety in the RR. The lack of reported negative
effects implies that a DVD is a simple and safe way to edu-
cate parents who intend to participate in their child’s care
at the time of a SDS and that it could be part of a larger
pre-operative educational preparation.
Acknowledgements
The authors thank the participating families who made this
study possible. They also thank Dr. Nick Barrowman and
Mary Aglipay for their advice on conducting the statistical
analyses.
Funding
This study was supported by the Children’s Hospital of
Eastern Ontario Research Institute Surgery Associates
Research and Development Fund. Julie Chartrand was sup-
ported by a Canadian Institutes for Health Research
(CIHR) Frederick Banting and Charles Best Canada Gradu-
ate Scholarship and by an Ontario Graduate Scholarship
Award (Ministry of Training, Colleges and Universities,
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes
Ontario, Canada). Julie Chartrand also received financial
support from the Canadian Health Services and Research
Foundation (CHSRF) as well as the Consortium national
pour la formation en sante (CNFS).
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
• substantial contributions to conception and design,
acquisition of data or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
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Script Outline
anaesthesia in children. Cochrane Database Systematic Review
2010(11), 1–61.
Scene 1
• Welcoming remarks

Appendix 1 • Narratives and images of the nurse’s role in the RR

Hospital surgical virtual tour navigation map

Scenes 2 & 3
Headings
• Narratives and images of the RR (setting and equip-
Welcome ment)

Pre-Assessment Clinic (PAC)

Scenes 4, 5 & 6
• Waiting room
• Narratives and images of the RR’s practices and proce-
• Pre-assessment clinic
dures

610 © 2016 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Effects of a pre-operative DVD on parents’ and children’s peri-operative outcomes

Scenes 7, 8, 9, 10 & 11 Scene 12

• Situation scenarios related to strategies parents can use • Additional advice
to support their child in the RR • Closing remarks

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