1. Rieker, Michael DNP, CRNA

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A basic tenet of nursing is to provide holistic care, addressing not only the physical needs of our patients but also their emotional needs. Parental presence during induction of anesthesia (PPIA) aims to reduce the stress of separation of young surgical patients from their parents. The brief separation is only one aspect of the surgical experience that causes anxiety, however. Allowing PPIA assumes that this limited additional parental incursion into the surgical process will alleviate anxiety in our clients. In my opinion, the challenges associated with safely and effectively managing PPIA outweigh the limited and inconsistent benefit it provides.


Few people are familiar with the process of anesthetic induction in children, including the involuntary movements that often occur in patients and the firm manual restraint that is sometimes necessary to provide safety for the patient to prevent the natural tendency to resist induction. For the uninitiated, the vision of a child struggling involuntarily (and unconsciously) may be very disturbing. In a study supporting PPIA, 25% of parents present at induction found the experience to be "upsetting or scary" (Blesch, 1996). I am reminded of a case in which the anxious parents insisted on being present for the induction of their child. Their anxiety further upset the child, who became inconsolable at the sight of her mother crying. After the induction, the parents stood sobbing in an embrace. No one in that room felt very good about what was technically a problem-free, routine pediatric induction. Although PPIA may be intended to reduce anxiety in the child and/or the parents, outcome studies have failed to consistently demonstrate reductions in indicators of stress or anxiety among participants in PPIA. Parental satisfaction with the surgical experience is not exclusively limited to PPIA, and a high level of client satisfaction can be obtained instead by thoughtful teaching and preparation before the procedure (Palermo, Tripi, & Burgess, 2000).


One of the greatest challenges in implementing PPIA is selecting appropriate candidates. Whereas parents with low trait anxiety may beneficially calm their children during anesthesia induction, parents with high levels of anxiety may actually worsen the child's anxiety by their presence (Kain, Caldwell-Andrews, Maranets, Nelson, & Mayes, 2006). Unfortunately, measuring anxiety in parents and then disqualifying certain parents from PPIA while allowing others poses daunting challenges for nurses. Other logistical challenges include the time required for screening and preparation of parents and moving these lay people into and out of a sterile environment during a time (anesthetic induction) when staff responsibilities are high. With concern for patient privacy, there are other significant implications of leading lay people through a surgery department, where they may likely observe patients in rather immodest situations. Also in the face of fast-paced anesthetic interventions, the untrained observer may misinterpret actions as being irregular or indicative of professional negligence. This leads some anesthesia providers to become very anxious about their performance when they feel that one of the intentions of parent "observers" may be to monitor for signs of staff incompetence. Although this concern may not be appropriate, I have heard it voiced by numerous professionals, and therefore I must consider whether their anxiety could actually lead them to alter their normally safe, vigilant routine in a nonbeneficial way.


Although PPIA sounds like a wonderful way to allay the emotional stress of pediatric surgery, its effectiveness is inconsistent, and it demands much additional staff time and resources. Departments that frequently care for children are often adept at minimizing parental separation, and their staff are cognizant of the need for attentive concern for family dynamics. Therefore, I argue that such a level of resources and nursing care makes PPIA superfluous, because the challenges of appropriately implementing it outweigh its limited potential benefit (Palermo et al., 2000).




Blesch, P. (1996). The impact of parental presence on parental anxiety and satisfaction. AORN Journal, 63, 761-768. [Context Link]


Kain, Z., Caldwell-Andrews, A., Maranets, I., Nelson, W., & Mayes, L. (2006). Predicting which child-parent pair will benefit from parental presence during induction of anesthesia: A decision-making approach. Anesthesia and Analgesia, 102, 81-84. [Context Link]


Palermo, T., Tripi, P., & Burgess, E. (2000). Parental presence during anaesthesia induction for outpatient surgery of the infant. Paediatric Anaesthesia, 10, 487-491. [Context Link]