Keywords

Adolescent, anxiety, complementary therapy, perioperative care

 

Authors

  1. Pestana-Santos, Marcia

ABSTRACT

Objective: The objective of this review is to map the range of non-pharmacological interventions used during the perioperative period to prevent anxiety in adolescents.

 

Introduction: Evidence shows that 80% of adolescents report having experienced significant anxiety in the perioperative period. Non-pharmacological interventions implemented in the perioperative period are recommended as a resource to help to control anticipatory, separation and perioperative anxiety and fear related to surgical procedures in adolescents.

 

Inclusion criteria: This review will consider studies that focus on adolescents aged 10 to 19 who have undergone a surgical procedure, regardless of the type of surgery, and participated in non-pharmacological interventions aimed to prevent anxiety in the perioperative period. The intervention may be provided by any healthcare professional. Studies related to non-pharmacological interventions associated with hospitalization in a non-surgical context will be excluded.

 

Methods: The methodology will follow the JBI recommendations for scoping reviews. Any published and unpublished sources of information will be considered. Studies published in English, Spanish and Portuguese will be included, with no geographical or cultural limitations. Duplicates will be removed and two independent reviewers will screen the abstracts and assess the full text of selected studies, based on the inclusion criteria. The results of study selection will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for scoping reviews. Data synthesis will be presented in a narrative summary to provide a description of the existing evidence.

 

Article Content

Introduction

Although adolescence is generally the healthiest period in life,1 7 million adolescents in the United States of America (USA)2,3 and 65,000 adolescents in Canada4 undergo a surgical procedure every year. In Portugal, approximately 17,000 surgical procedures are performed in adolescents every year.5 In the USA, the most common surgeries or conditions requiring surgery in adolescents are sinus pilonidal disease,6 bariatric surgery,7 plastic surgery,2 scoliosis,8pectus excavatum,9 and ear nose and throat surgery. In the current literature, the reported incidence of sinus pilonidal disease in teenagers is between 1.2 and 2 per 10,000 individuals.6 The prevalence of scoliosis in adolescents is between 0.5% and 5.2%, with a female-to-male ratio of 3:1.8 The incidence of pectus excavatum is between 1 and 8 per 1000 individuals, and males are more often affected than females, with a gender distribution of 2:1 to 9:1.9 Nevertheless, there are no country-specific data about the prevalence or incidence of these problems. Although the surgical procedures differ, there are similarities in adolescents' experiences owing to their developmental characteristics.10

 

The World Health Organization defines adolescence as the period between 10 and 19 years of age.1,11 It is recognized as a transitional stage of physiological and psychological development from puberty to the adulthood.12 According to developmental characteristics, adolescence can be divided into three stages, namely: early adolescence (10-14 years), medium adolescence (15-16 years) and late adolescence (17-19 years).13,14 The physical and emotional development of adolescents is a unique state of growth that has many implications for their healthcare. Adolescents may have a physical appearance that more closely resembles an adult while their emotional maturity is still developing.15 It is important to keep this in mind when caring for adolescents throughout the perioperative period.15 Adolescents can experience fear related to surgical procedures including fear of bodily injury, pain, loss of identity and loss of self-control. Adolescents can also be concerned about body image and may worry about the esthetic implications of surgery.16 After the hospital visit, some adolescents also report nightmares and sleeping difficulties, waking up with an intense sense of fear and anxiety for a long time after the recovery period.17 The fear of an unfamiliar environment and loss of control are feelings many adolescents experience.

 

Adolescents are at a unique developmental stage during which they are acquiring mental consciousness and the ability to process information. Therefore, these developmental stages need to be considered when an adolescent begins the perioperative experience.18

 

Adolescents with somatization tendencies and fearful temperaments are prone to high levels of perioperative anxiety.19 According to a pilot study by Fortier et al.,19 adolescents also have a higher tendency toward physical manifestations of anxiety.

 

With no need for prescriptions, non-pharmacological interventions are recommended as a resource for controlling anxiety and fear related to surgery.20 Non-pharmacological interventions implemented during the perioperative period create a peaceful and pleasant state that helps to reduce anticipatory, separation10 and perioperative anxiety.21 This state also increases patients' coherence with pharmacological premedication.21

 

The perioperative period corresponds to three different phases of a surgical procedure, namely preoperative, intraoperative and postoperative.22 The preoperative phase starts with scheduling the surgery and finishes when the adolescent arrives in the anesthesia induction room. It is during this phase that all the preoperative adolescent physical and psychological evaluation occurs and all preventive care measures should take place.23,24

 

During this period, the multidisciplinary team must acquaint themselves with the adolescent, his or her concerns and previous healthcare experiences in order to provide adequate perioperative care23 and minimize complications that may occur, including anxiety symptoms or the increase of associated clinical manifestations, such as pain or maladaptive behaviors.25

 

The intraoperative phase involves the surgery itself. When the surgery is completed, the adolescent is awakened from the anesthesia and is transferred to the post-anesthesia care unit.

 

The postoperative phase begins with the admission of the adolescent into the post-anesthesia care unit and ends when the patient is discharged from the surgical procedure.25

 

In the United Kingdom, when a surgical patient is an adolescent, he or she could be included in adult or child groups.26 This depends on the service or hospital where the care is being delivered.26 Even in the same country, the attendance age for pediatric medical care may differ between hospitals. According to studies performed in adolescent groups, the upper range of ages varies significantly from 16 to 21 years.2,19,21,27-32

 

As a result, the perioperative preparation for adolescents undergoing surgical procedures can be challenging for nurses and other healthcare providers due to the heterogeneity of this group, for example, in age and physical, cognitive and psychological maturation.33 Although significant planning is involved in surgery and may seem straightforward to the healthcare providers, it represents one of the most stressful medical procedures that an adolescent can experience.3 This stress generally manifests as anxiety, fear or anger,21 with undesirable consequences for health and well-being.34

 

Anxiety is defined as an unpleasant emotion occurring when a person is in a tense and apprehensive state arising from the anticipation of both internal and external danger.35 In the perioperative period, anxiety is defined as a progressive state characterized by tension, irritability and increased activity of the autonomic nervous system.21 In Fortier et al.'s pilot study19 developed in the USA, it was demonstrated that 80% of adolescents who underwent outpatient surgery reported significant anxiety in the perioperative period.19 However, the signs and symptoms described by some adolescents cannot be limited to the perioperative period, as they may also be present for weeks or months before the surgery,36 reaching high levels at the time of anesthesia induction19 and prolonged for months after the surgery.17,19,37

 

Another important issue is postoperative pain. Previous studies38-40 have demonstrated that anxiety and pain in the perioperative period are correlated. Other studies have shown that the level of adolescent anxiety varies based on factors such as age, maturity, temperament, previous surgical experiences,19 history of pain41 and parental anxiety levels.3,28,30

 

Provided with this knowledge, healthcare professionals must be aware that adolescents require specific non-pharmacological interventions appropriate to the stage of their development (early, middle or late adolescence)42 in order to prevent anxiety and related consequences in the perioperative stage.

 

The types of non-pharmacological interventions are psychological, environmental, social and communication. Psychological interventions are defined as cognitive or behavioral interventions, such as distraction, cognitive tasks, hypnosis, Reiki, massage or virtual reality. Examples of environmental interventions are the use of an induction room, or the adolescent retaining his or her own clothing, especially underwear. Social interventions relate to parental presence or the presence of a support person and healthcare professionals in the induction room. The interventions related to communication with healthcare members include tone of voice and/or neutral or positive language.

 

The available information on adolescent anxiety during the perioperative period (specifically, non-pharmacological interventions, strategies, contexts and groups of adolescents) is mostly combined with data on children,43 which hampers the formulation of precise questions and consequently the process of a systematic review. According to JBI, "scoping reviews undertaken with the objective of providing a 'map' of the available evidence can be undertaken as a preliminary exercise prior to the conduct of a systematic review".44

 

To date, there are no reviews that identify and assess which non-pharmacological interventions are used to prevent anxiety in the adolescent population during the perioperative period. In addition, there is scant information pertaining to which particular non-pharmacological interventions or combinations of interventions are used on adolescents, in what contexts these interventions are implemented, and where perioperative care is delivered, including but not limited, to operating room and/or surgical wards. Moreover, it is necessary to know how surgery-related anxiety or fear affects different adolescent groups and which of these groups, in terms of health status or surgical procedure, most benefit from non-pharmacological interventions to prevent anxiety during the perioperative period.

 

Information is also missing relating to the examination of outcomes and evaluations of those interventions. We are confident that the proposed scoping review will help map available evidence on the non-pharmacological interventions used during the perioperative period to prevent anxiety among adolescents. This will inform the conduct of further research, including primary studies, and help review work that may involve the conduct of a systematic review to determine the effectiveness of non-pharmacological interventions to prevent adolescents' anxiety during the perioperative period.

 

An initial search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, PubMed and Epistemonikos revealed that currently there is no scoping review (published or in progress) on this topic.

 

Review questions

 

i. What non-pharmacological interventions are used during the perioperative period to prevent anxiety in adolescents?

 

ii. What are the characteristics (duration, dose and frequency) of these interventions?

 

iii. What are the contexts in which non-pharmacological interventions are delivered?

 

iv. Which adolescent population has been included in non-pharmacological interventions during a perioperative period with the aim of preventing anxiety?

 

v. What related effects of the anxiety concept (i.e. pain, discomfort and maladaptive behaviors) have been reported by adolescents during the perioperative period?

 

vi. Which healthcare professionals use non-pharmacological interventions to prevent anxiety in adolescents during the perioperative period?

 

Inclusion criteria

Participants

This scoping review will consider studies that focus on adolescents aged 10 to 19 years who have undergone a surgical procedure, regardless of the type of surgery, and participated in non-pharmacological interventions during the perioperative period to prevent anxiety, provided by any healthcare professional.

 

Concepts

The concept being considered in this review is non-pharmacological interventions provided to prevent anxiety during the perioperative period. These non-pharmacological interventions may include psychological therapy, psychological intervention, alternative therapy, cognitive behavioral intervention, complementary therapy or variations of specific non-pharmacological interventions, such as guided imagery, distraction, music, virtual reality, hypnosis, Reiki, massage or communication. Other interventions might be included if the outcome is related to the prevention of anxiety namely pain, discomfort or maladaptive behaviors.

 

All studies that refer to the prevention of perioperative anxiety in adolescents will also be considered, regardless of whether non-pharmacological interventions are used alone or combined with pharmacological interventions.

 

The non-pharmacological interventions may be delivered on an individual basis, face-to-face or via technological devices. Interventions delivered in a group session with adolescents or with adolescent and parents together will be also eligible for inclusion.

 

Any of these non-pharmacological interventions can be led by any member of the healthcare team such as registered nurses, anesthesiologists, physiotherapists, psychologists and child specialists or other healthcare professionals.

 

Only evidence relating non-pharmacological interventions for the prevention of anxiety or relative outcomes during the perioperative period will be included.

 

Studies related to non-pharmacological interventions provided to prevent anxiety associated to the hospitalization in a non-surgical context will be excluded.

 

Context

This scoping review will consider all non-pharmacological interventions implemented and evaluated with the aim of preventing anxiety in adolescents during the perioperative period. The context includes hospital departments where perioperative care is delivered, including, but not limited to, the operating room and/or surgical wards. Studies performed in any country will be included.

 

Types of sources

The purpose of this scoping review is to map any non-pharmacological intervention used in adolescents in the perioperative period existing in the literature. For this purpose, the authors will consider any source of information, including experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports and descriptive cross-sectional studies, for inclusion.

 

Qualitative studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description and action research will also be considered. In addition systematic reviews that meet the inclusion criteria will also be considered. Text and opinion papers will also be considered for inclusion.

 

Methods

Search strategy

The search strategy aims to find published and unpublished studies. A three-step search strategy will be used in this review.44,45 Initial limited searches of MEDLINE and CINAHL were undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for the PubMed database. This full strategy is listed in detail in Appendix I. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of each selected study will be screened for additional studies.

 

Studies published in English, Spanish and Portuguese will be considered for inclusion in this review. The authors will ensure rigor in the translation process and their reporting. Where there is any doubt relating to translation, advice will be sought from a native person.

 

There is no time, geographical or cultural limitation for the studies included. This should add an understanding of how non-pharmacological interventions used during the perioperative period to prevent anxiety in adolescents has been researched and understood over time.

 

Information sources

The databases to be searched will include CINAHL Plus with Full Text, PubMed, Cochrane Central Register of Controlled Trials, LILACS, Scopus, Library, Information Science & Technology Abstracts, PsycINFO, JBI Connect+, and the Cochrane Database of Systematic Reviews.

 

The search for unpublished studies will include TDX - Tesis Doctorals en Xarxa (Spain), RCAAP - Repositorio Cientifico de Acesso Aberto de Portugal, OpenGrey, andMedNar.

 

Study selection

Following the search, all identified citations will be collated and uploaded into the citation management software: EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment according to the inclusion criteria for the review. Potentially relevant studies will be retrieved in full. Two independent reviewers will assess the full text of selected articles and documents in detail against the inclusion and exclusion criteria. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the final scoping review. The results of the study selection process will also be reported in full in the final scoping review and presented in a PRISMA flow diagram.45,46 Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer.

 

Data extraction

Quantitative and qualitative data will be extracted from articles included in the review by two independent reviewers using a data extraction tool developed by the reviewers as indicated by methodology for scoping reviews proposed by JBI.45

 

The data extracted will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. A draft charting table is provided in Appendix II. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

 

Data presentation

The results will be presented in a tabular form according to the study design, for example randomized controlled trial, cohort study, phenomenology or other. A draft results table has been developed to address each question, as presented in Appendix III. A diagrammatic map of the evidence will also be produced to emphasize the level and quantity of evidence for each non-pharmacological intervention linked with the outcome. A narrative summary will synthetize the findings to provide a description of the existing evidence related to the review objective and questions.

 

Acknowledgments

The authors would like to thank the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC), for their support.

 

Appendix I: Search strategy for PubMed

Search conducted on 27 June 2018

Appendix II: Draft charting table

Appendix III: Tabular summary for results presentation

Studies included:

Characteristics of included studies (review questions 1 and 2)

Contexts of interventions (review question 3)

Population and age groups (review question 4)

Non-pharmacological interventions and related concepts (review question 5)

Healthcare professionals who led the interventions (review question 6)

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