Effectiveness of preoperative tour to a simulated anaesthesia induction at operating theatre in reducing preoperative anxiety in children and their parents: a pragmatic, single-blinded, randomised controlled trial/ King Fahad Medical City

Abstract

Objective

To evaluate the effectiveness of a preoperative tour to a simulated anaesthesia induction at operating theatre on reducing children’s and parents’ preoperative anxiety.

Design

A pragmatic, single-centre, assessor-blinded, randomised controlled trial.

Setting

In preoperative anaesthesia clinic and the operating room at a tertiary care centre in Saudi Arabia.

Participants

One hundred and sixteen children–parents dyads (pairs) (n=57) intervention group (IG); (n=59) control group (CG) with children aged 4–14 years who were planned for day case procedures under general anaesthesia.

Interventions

Participants’ dyads were randomly allocated through a computer to receive either a preoperative tour to a real operating theatre and simulate anaesthesia induction or standard of care.

Main outcome measure

The primary study outcome was children’s anxiety levels as measured by the modified-Yale Preoperative Anxiety Scale (m-YPAS), and the parent’s anxiety level as assessed by the Beck Anxiety Inventory Scale. The children’s anxiety levels were measured at two time points, the preoperative holding area (T0) and before the anaesthesia induction (T1), and the parents’ anxiety level was measured after the anaesthesia induction. The secondary outcomes were the prevalence of preoperative anxiety and children’s somatic signs of anxiety including heart rate and systolic blood pressure.

Results

The Mann-Whitney U test of m-YPAS scores showed significant differences in the children’s anxiety levels between the CG and IG at T0 (Z −5.009); p<0.01) and T1 (Z −6.599); p<0.01). BIAS analysis revealed a significant difference in the parents’ anxiety level between the CG and IG (Z −4.353); p<0.01). The prevalence of children’s anxiety was reported by 55 (93.2%) in the CG compared with 25 (43.9%) in the IG, with a statistically significant difference (p<0.001).

Conclusion

The preoperative simulated anaesthesia induction was effective in reducing preoperative anxiety in children and their parents.

What is already known on this subject.

• Anxiety is a common feeling experienced by children and parents in the preoperative period. Clinicians have attempted sedative drugs that reducing preoperative anxiety prevalence and impact. However, sedative drugs have their limitations due to undesirable adverse effects.

What this study adds.

• Preoperative simulated anaesthesia induction at operating theatre can reduce children’s and parents’ anxiety, and can halve the prevalence of preoperative anxiety.

Introduction

Children represent a significant percentage of the worldwide volume of surgery.¹ More than 65% of those children are experiencing significant anxiety during the preoperative period, and 70% suffering a high level of anxiety and stress during the induction of anaesthesia.² Children’s preoperative anxiety (POA) is one of the most commonly reported emotions that could be manifested as complications in the perioperative period.³

POA during the anaesthetic induction is associated with a prolonged period of anaesthesia induction, poor outcomes of surgical procedures, postoperative pain, emergence delirium and postoperative mal-adaptive behavioural changes.^{2 4–6} Furthermore, enuresis, general anxiety disorder, separation anxiety disorder, temper tantrums, coping disturbances, suppressing wound healing process and postoperative immunosuppression are well-documented adverse effects.^{7 8}

Several factors may play a significant role in increasing POA, including; fear of the unknown, previous negative experience with medical care, type of hospitalisation, fear of postoperative pain and presence of anxious or unprepared parents during anaesthesia induction.^{5 9–11}

Several clinical pharmacological and non-pharmacological strategies have been described and implemented to reduce POA including sedatives and preoperative preparation programmes. The pharmacological interventions are associated with undesirable side effects, such as ‘nausea, vomiting, respiratory depression and prolongation time of recovery’.^{12 13} Moreover, several studies evaluated various psychological interventions to relive fears associated with the POA. Distraction techniques during anaesthesia induction such as (storytelling pictures, smartphones, handheld videogames and clown’s doctors) had different levels of anxiety relief,^14–17 ignore the parent’s anxiety and were found to be interruptive from the perception of operating room staff.¹⁶

Preoperative education programmes using storybooks, web-based programmes and audiovisual presentations were helpful to decrease anxiety in both children and parents.^18–21 Family-centred preoperative preparation workshops and parents’ education on how to actively participate in caring for their child during day-case surgery had shown positive impacts as well.^22–24 Other studies examined the impact of educational preparation for the children and parents about the anaesthesia equipment with a description of the mask induction revealed a significant decrease in their anxiety level.^{10 25–27} However, we hypothesise that the use of self-learning or theoretical material can only evoke but not replicate reality, hence, children and their parents’ benefits from it requires further attention.

Simulation is a strategy that imitates or reproduces substantial aspects of the real world in an entirely interactive way. As an educational method in healthcare settings, simulation education and training have been found to provide the learners with the knowledge, skills and attitudes in a safe, educationally orientated and efficient approach. Besides, it can improve patients’ safety and decrease healthcare expenses.²⁸ One type of preoperative preparation intervention proved effective in reducing POA is to provide information to children on what they will experience in the operating room.²⁹ A guided simulated tour into the operating room is an effective intervention for providing children the information needed to reduce their fear of the unknown and to augment their sense of control.^{30 31} However, the current researchers could not identify any published article demonstrate the impact of taking children and their parents on a tour to the operating theatre and letting them simulate the procedures on reducing their POA and fears.

A simulated anaesthesia induction at a real operating theatre was introduced in the preoperative anaesthesia clinic at King Fahad Medical City (KFMC), Saudi Arabia, as one of the non-pharmacological preoperative strategies which may contribute effectively in decreasing the POA in children scheduled for surgeries under general anaesthesia and their parents. The purpose of this randomised control trial was to evaluate the impact of the preoperative tour to a simulated anaesthesia induction at the operating theatre in reducing the POA among children, and their parents, who were scheduled for day-case surgeries under general anaesthesia.

Methods

Study design

We conducted a pragmatic (focus on the correlation between intervention and outcomes), assessor-blinded, randomised control trial from January to October 2019 at a tertiary medical centre, Saudi Arabia. The guardian’s written informed consent and child assent form (children aged >7 years) were obtained before enrolment.

Participants

The study population included children aged 4–14, and their parents, who were scheduled for elective day-case procedures under general anaesthesia at KFMC, class 1 or 2 according to the American Society of Anesthesiology physical status. We excluded children if they were diagnosed as having mental or psychological disorders. Prescribing sedatives were optional based on the clinical judgement of the anaesthesiologist; however, patients who had given sedatives in the preoperative period were dropped out of the samples.

Randomisation and blinding

Dyads who have appointments at the preanaesthesia clinic were randomly assigned (1:1 ratio) to the intervention group (IG) or the control group (CG) using an electronic randomiser list. Dyads were informed to maintain their group allocation covert. The assessors of the study outcomes were successfully maintained unaware of the groups’ assignment.

Interventions and procedures

Dyads allocated to the IG were taken into a tour to a real operating theatre accompanied by an expert anaesthesia technologist 2 weeks before the day of surgery. This operating theatre is equipped with a surgical trolley, ceiling surgical lights, anaesthesia machine, vital signs monitor, stethoscope, surgical trays, surgical sink and gas supply pendent. It was prepared with popular cartoon characters, child manikin and face masks connected to the anaesthesia circuit and rebreathing bag. After being assessed by anaesthesia clinic doctors, children and their parents in the IG were given a chance to visit the operating theatre, to receive orientation, education and demonstration orientation about what they are going to experience in the operating room. Children were encouraged to apply vital signs monitoring, and to simulate providing mask anaesthesia induction to a child manikin. The researcher developed the acronym of (I SEE KFMC) as a brief guide for the instructors during the tour, where each letter stands for one step as, ‘I; Introduce yourself, S; Show the plan, E; Educate and clarify, E; Encourage child to simulate, K; Keep smiling, F; Funny interactive technique, M; Mutual Respect, C; Continuous support’ and each tour took around 15–20 min. Dyads assigned to the CG were provided only the standard practice on their day admission to the hospital, which includes clinical assessment for the patients, and giving the opportunity for the child and parents to ask questions and discuss options (figure 1 illustrates the participants’ flow).

Figure 1.

Participants’ flow. BAIS, Beck Anxiety Inventory Scale; BP, blood pressure; HR, heart rate; m-YPAS, modified-Yale Preoperative Anxiety Scale.

Outcome measures

The primary outcome was the children’s anxiety level and was measured using the modified-Yale Preoperative Anxiety Scale (m-YPAS). The m-YPAS is an observational anxiety scale used to assess anxiety levels in the preoperative period and during the induction of anaesthesia.³² The m-YPAS consists of 22 items in five categories of children’s behaviour, including activity, vocalisations, emotional expressivity, state of apparent arousal and use of parents. Each category has four items, except the vocalisation has six items. The total score of the scale ranged from 23 to 100, the reference point to define high anxiety cases in the preoperative period is 30.

The English version of the m-YPAS was used. English is the formal language used at the study site as the site includes more than 32 nationalities. The data collectors received training by a psychiatric nurse specialist on how to approach the participants and standardising the way of assessment. Individual rehearsal for the study coordinator was conducted and assessed during the pilot study before conducting our main study.

The m-YPAS was conducted at two time points, first at the holding area (T0) and second inside the operating theatre before anaesthesia induction (T1). In addition, somatic signs of anxiety, including children’s heart rate (HR) and systolic blood pressure (SBP) were recorded at T0 and T1.

Parent’s attendance to the induction of anaesthesia was optional in both groups. Parents’ anxiety was assessed during the procedure using Arabic validated version of the Beck Anxiety Inventory Scale (BAIS).³³ BAIS is a self-administered questionnaire with 21 items rated on a 4-point Likert scale and range from 0 (not at all) to 3 (severely). The total scale score range from 0 to 63, where a score of 0–9 indicates no anxiety, 10–18 mild anxiety, 19–29 moderate anxiety and 30–63 severe anxiety.

Sociodemographic variables included children’s age and gender, history of previous anaesthesia, parents’ presence during anaesthesia induction and parent relationship status (child living with). A trained assessor (anaesthesia technician) blinded to group assignment performed dyads anxiety assessments and children’s somatic signs at designated intervals.

Sample size calculation

A pilot was done to determine the characteristics of the tools in this context, the m-YPAS was measured at the time of anaesthesia induction for all dyads, and a subsequent sample size calculation at 0.8 power, 0.05 alpha and an effect size of 0.5 by Cohen,³¹ resulted in a projected minimal sample size of 120 for the primary study. The sample of the pilot trial had not been included in the study sample.

Data analysis plan

Scalar data were described as average mean score (±SD) and median, whereas the nominal data were described as frequency (%). Student’s independent t-test was applied for measuring the difference in means across the CG and IG. Similarly, the difference in proportions across the CG and IG for all the non-metric variables was measured by the χ² test. A significance level of 0.05 was used. Intragroup variance at holding area and inside operating room in the CG and IG for m-YPAS was measured by the Mann-Whitney U test. Besides, the bivariate correlations were measured by Karl Pearson’s method for metric variables; otherwise, Kendall’s τ b method was applied for the nominal and ordinal level of measurement variables. All the inferences were drawn at 95% CI. The statistical program SPSS (V.25.0, IBM) was used for data analysis.

Results

A total of 120 dyads were consented and randomised equally to the IG and CG. Three participants from the IG and one from the CG were excluded as they were given sedative drugs in the preoperative period. A total of 116 dyads were taken up in the study and distributed in CG (n=59) with a mean age of 6.9 (SD 2.6) years and IG (n=57) with a mean age of 7.9 (SD 2.7) years p=0.037. There was no significant difference in the other sociodemographic characteristics of the dyads in the two study groups (table 1).

Table 1.

Sociodemographic characteristics of control and intervention groups

		Control	Intervention	P value
Child’s age	Mean±SD	6.92±2.61	7.96±2.76	0.037
	Median (min - max)	6 (4–14)	8 (4–13)
Child’s gender	Female	33 (55.9%)	23 (40.4%)	0.093
	Male	26 (44.1%)	34 (59.6%)
Parental status (child living with)	Father	2 (3.4%)	3 (5.3%)	0.673
	Mother	15 (25.4%)	11 (19.3%)
	Parents	42 (71.2%)	43 (75.4%)
History of previous general anaesthesia	No	38 (64.4%)	31 (54.4%)	0.272
	Yes	21 (35.6%)	26 (45.6%)
Parents presence (during general anaesthesia induction)	No	10 (16.9%)	17 (29.8%)	0.352
	Yes	49 (83.1%)	40 (70.2%)

The results of the Mann-Whitney U test showed that m-YPAS scores are significantly higher in the CG compared with the IG at T0 (Z −5.009); p<0.01), and T1 (Z −6.599); p<0.01). While the difference between the two times (T1–T0) revealed no significant difference (Z −0.512); p=0.609). The parents’ BAIS scores were found to be significantly higher in the CGs than the IG (Z −4.353); p<0.01) (table 2).

Table 2.

Mann-Whitney U test for m-YPAS and BAIS

Descriptive statistics
Group		N	Mean	SD	Minimum	Maximum	Percentiles
							25th	50th (Median)	75th
Control	BAIS_SCORE	59	12.84	12.75	0	50	2	8	22
	m-YPAS_SCORE_DIFF	59	13.32	16.48	0	68	0	8	20
	m-YPAS_SCORE_T0	59	39	14.79	23	82	23	37	50
	m-YPAS_SCORE_T1	59	59.23	20.67	23	100	47	55	73
Intervention	BAIS_SCORE	57	4.24	7.67	0	42	0	1	6
	m-YPAS_SCORE_DIFF	57	13.8	14.37	0	55	0	10	21
	m-YPAS_SCORE_T0	57	27.47	10.38	23	73	23	23	27.5
	m-YPAS_SCORE_T1	57	34.5	17.42	23	95	23	27	42
Test statistics*
		BAIS_SCORE		m-YPAS _SCORE_DIFF		m-YPAS _SCORE_T0		m-YPAS _SCORE_T1
Mann-Whitney U		905.5		1590.5		836.5		498.5
Wilcoxon W		2558.5		3360.5		2489.5		2151.5
Z		−4.353		−0.512		−5.009		−6.599
Asymp. Sig. (two tailed)		0.000		0.609		0.000		0.000

*Grouping variable: group.

BAIS, Beck Anxiety Inventory Scale; m-YPAS, modified-Yale Pre-Operative Anxiety Scale.

Furthermore, a significant difference (p=0.001) was found in the percentage of change in SBP readings from T0 to T1 between the two groups with a mean of 8.09% (SD 9.11) for CG and 3.74% (SD 3.88) for IG. The percentage of change in children’s HR from T0 to T1 was significantly higher in the CG compared to the IG with means of 13.32% (SD 11.05) and 5.18% (SD 5.55), respectively, p<0.001 (table 3).

Table 3.

Proportions of anxious versus not anxious children and their somatic signs

		Control	Intervention	P value
m-YPAS T0	<30 (no anxiety)	20 (33.9%)	47 (82.5%)	<0.001
	≥30 (anxious)	39 (66.1%)	10 (17.5%)
m-YPAS T1	<30 (no anxiety)	4 (6.8%)	32 (56.1%)	<0.001
	≥30 (anxious)	55 (93.2%)	25 (43.9%)
SBP T0	Mean±SD Median (min - max)	97.58±11.69 96 (80–136)	103.6±12.67 101 (71–136)	0.009
SBP T1	Mean±SD Median (min - max)	104.66±13.4 104 (80–140)	105.81±12.41 105 (70–135)	0.634
Percentage change in SBP	Mean±SD	8.09%±9.11%	3.74%±3.88%	0.001
HR T0	Mean±SD Median (min - max)	98.36±13.05 98 (73–140)	100.39±14.46 100 (74–156)	0.429
HR T1	Mean±SD Median (min - max)	110.76±15.47 107 (78–158)	104.26±14.87 103 (77–159)	0.023
Percentage change in HR	Mean±SD	13.32%±11.05%	5.18%±5.55%	0.000

HR, heart rate; m-YPAS, modified-Yale Pre-Operative Anxiety Scale; SBP, systolic blood pressure.

A significant difference in the parents’ anxiety level between the IG and CG was observed. Moreover, the stratification of fathers and mothers showed same results between groups, and stratification within the same group showed that fathers were significantly less anxious than mothers in both groups (table 4).

Table 4.

Parents’ anxiety levels among and between groups

Ranks			N	Mean rank	Sum of ranks
Control group	BAIS_SCORE	Father	27	25.11	678.00
		Mother	32	34.13	1092.00
		Total	59
Intervention group	BAIS_SCORE	Father	21	23.40	491.50
		Mother	36	32.26	1161.50
		Total	57
Test statistics
Control group		BAIS_SCORE	Intervention group		BAIS_SCORE
	Mann-Whitney U	300.000		Mann-Whitney U	260.500
	Wilcoxon W	678.000		Wilcoxon W	491.500
	Z	−2.013		Z	−2.057
	Asymp. Sig. (2-tailed)	0.044		Asymp. Sig. (2-tailed)	0.040
Ranks			N	Mean rank	Sum of ranks
Father	BAIS_SCORE	Control group	27	29.7	802
		Intervention group	21	17.81	374
		Total	48
Mother	BAIS_SCORE	Control group	32	43.44	1390
		Intervention group	36	26.56	956
		Total	68
Test statistics
Father		BAIS_SCORE	Mother		BAIS_SCORE
	Mann-Whitney U	143.000		Mann-Whitney U	290.000
	Wilcoxon W	374.000		Wilcoxon W	956.000
	Z	−3.017		Z	−3.544
	Asymp. Sig. (two tailed)	0.003		Asymp. Sig. (2-tailed)	0.000

BAIS, Beck Anxiety Inventory Scale.

Table 5 shows a significant difference and lower anxiety levels among children and parents in the IG than children and parents in the CG in both situations, wherever the parents were present or absent during anaesthesia induction (T1).

Table 5.

Subgroup analysis of m-YPAS T1 and BAIS

Ranks
Parent presence		Group	N	Mean rank	Sum of ranks
No	BAIS_SCORE	Control	10	19.30	193.00
		Intervention	17	10.88	185.00
		Total	27
No	m-YPAS_T1	Control	10	20.70	207.00
		Intervention	17	10.06	171.00
		Total	27
Yes	BAIS_SCORE	Control	49	52.55	2575.00
		Intervention	40	35.75	1430.00
		Total	89
Yes	m-YPAS_T1	Control	49	58.19	2851.50
		Intervention	40	28.84	1153.50
		Total	89
Test statistics
Parent presence (no)	BAIS_SCORE	m-YPAS_T1	Parent presence (yes)	BAIS_SCORE	m-YPAS_T1
Mann-Whitney U	32.000	18.000	Mann-Whitney U	610.000	333.500
Wilcoxon W	185.000	171.000	Wilcoxon W	1430.000	1153.500
Z	−2.869	−3.571	Z	−3.077	−5.362
Asymp. sig. (two tailed)	0.004	0.000	Asymp. sig. (two tailed)	0.002	0.000
Exact sig. (2* (one-tailed sig.))	0.007	0.000

*Statistically significant at p-value <0.05

BAIS, Beck Anxiety Inventory Scale; m-YPAS, modified-Yale Pre-Operative Anxiety Scale.

Table 6 shows a significant positive and weak correlation between children HR in the CG and their anxiety scores at T1 (r=0.238, p=0.001). Similarly, a significant positive and weak correlation between children HR in the IG and their anxiety score at T1 (r=0.253, p=0.012). Moreover, the results showed as well a positive and weak correlation between parents’ anxiety score in the IG and their child anxiety scores at T0 (r=0.305, p=0.021) and T1 (r=0.331, p=0.012).

Table 6.

Correlation between children and parents’ characteristics and anxiety levels

Characteristic	Control group			Intervention group
	m-YPAS score T0	m-YPAS score T1	m-YPAS score diff (TI-T0)	m-YPAS score T0	m-YPAS score T1	m-YPAS score diff (TI-T0)
	R (p)	R (p)	R (p)	R (p)	R (p)	R (p)
Age	−0.180 (0.162)	−0.180 (0.184)	−0.050 (0.702)	−0.160 (0.221)	−0.170 (0.216)	−0.11 (0.401)
Gender	−0.150 (0.183)	−0.200 (0.068)	−0.12 (0.26)	0.080 (0.508)	0 (0.986)	−0.050 (0.675)
Parental status	−0.100 (0.372)	0 (0.973)	0.120 (0.271)	0.050 (0.677)	0.050 (0.652)	0.110 (0.357)
History of anaesthesia	−0.030 (0.773)	−0.130 (0.246)	−0.12 (0.28)	0.200 (0.118)	0.150 (0.222)	0.080 (0.513)
Percentage change in SBP	0.205 (0.032)	0.197 (0.063)	0.110 (0.255)	−0.017 (0.871)	−0.004 (0.970)	0.045 (0.644)
Percentage change in HR	0.011 (0.905)	0.238** (0.01)	0.162 (0.068)	0.134 (0.206)	0.253** (0.012)	−0.055 (0.568)
BAIS SCORE	−0.160 (0.234)	−0.140 (0.289)	−0.030 (0.808)	0.305* (0.021)	0.331* (0.012)	0.260 (0.051)

Boldface are Karl Pearson method driven, otherwise; Kendall’s τ b correlation method driven correlations are reported in the table.

*Correlation is significant at the 0.05 level (two tailed), **correlation is significant at the 0.01 level (two tailed).

BAIS, Beck Anxiety Inventory Scale; HR, heart rate; m-YPAS, modified-Yale Pre-Operative Anxiety Scale; SBP, systolic blood pressure.

No significant correlations were detected between the POA level of the children and their age, gender, parental status and previous history of anaesthesia.

Discussion

In this clinical trial, we aimed to assess the effectiveness of a preoperative tour to a simulated anaesthesia induction at operating theatre guided by an expert anaesthesia technologist on reducing the POA levels for children who were scheduled for elective day case procedures under general anaesthesia and their parents’ anxiety levels.

This study revealed that children who received the intervention had significantly lower POA levels than controlled children. The study showed as well significantly lower anxiety levels among parents who received the intervention than controlled parents.

The results of our study align with other studies using non-pharmacological interventions in reducing the POA in children.10 11 14–27 29–31 Such non-pharmacological interventions are superior over the use of sedative drugs that can cause adverse effects.^{12 13}

It is estimated that nearly 65% of the children undergoing surgery experience POA,² and could reach up to 70% during anaesthesia induction.⁷ However, the findings in this study were in accordance with that estimation at the preoperative period (64.4%), but it had exceeded it during anaesthesia induction reaching up to 93.2% among the CG, whereas the prevalence among the IG was 43.9%. This significant difference indicates the effectiveness of our intervention in reducing POA levels (table 3).

Several studies have reported that parents’ presence in preoperative preparation interventions has a considerably positive effect on anxiety levels of children.^34–36 However, other studies have revealed that parents’ presence does not have a better impact on children’s anxiety levels.^37–39 The results of our study showed parents’ presence or absence did not reflect any change in the results on their anxiety levels and on their child anxiety levels between groups. This means that parents’ presence alone failed to show some additional effect in reducing their child’s anxiety in both groups. This might explain the positive effect of a preoperative simulated anaesthesia induction alone on the reduction of children’s anxiety in the interventional group. These results warrant conducting further randomised clinical trials of preoperative simulated anaesthesia induction with parents’ presence and absence during anaesthesia induction, and with lager and equal groups’ size to confirm or reject our findings.

Our results were not inconsistent with previous study conducted by Kain et al,³⁷ which concluded that prenatal presence does not increase or decrease their anxiety.³⁷

Children’s age was not associated with their anxiety levels (m-YPAS) at T0 and T1, which is dissimilar to findings reported by Caprilli et al.³⁵ The direct positive correlation, though weak, between the parents and their children anxiety which is similar to Thompson et al’s results.⁵ Previous pieces of literature have demonstrated that parent anxiety predicts and exacerbate child anxiety during the preoperative period.³⁴ Therefore, it is significant to minimise parents’ anxiety when caring for children scheduled for an invasive medical procedure in a family-centred care approach,⁴⁰ and by using other feasible proved preoperative interventions.^22–24 In this study, the correlation test failed to demonstrate a significant association between children’s anxiety and their parents’ anxiety in the CG, which indicates the stressful experience at T0 and T1 despite parental anxiety level.

The principal use for simulated anaesthesia induction is to help the children and their parents are more accustomed to the perioperative environment, which would contribute to a better experience with less anxiety through identifying deliberately the drivers of their fears. Medical simulation is a powerful learning technique that helps healthcare professionals, as learners, achieves higher levels of competence and safer care.²⁸ Simulation-based medical education can be broadened to accommodate ‘patient’s centred simulation’ approach to enhance the acquisition of predefined benchmarks and skill sets, with potential impact on patient safety

Limitations

Our study results should be interpreted in light of some limitations. For example, the children were not matched by age, gender or procedure type, and the parents' level of education was neglected. The sample limitation to day-case procedures may preclude the effect of surgery’s severity on the anxiety. Moreover, we did not measure dyads' perception and experience in the IG about the simulated anaesthesia induction tour, and the effect of operating room staff’s attitude on POA was other study limitations.

Conclusion and implications for practice

Our clinical trial introduces the preoperative tour to a simulated anaesthesia induction as an effective intervention in reducing children’s and parents’ anxiety. In addition, our results showed critical levels of POA among the CG. Preoperative tour to simulated anaesthesia induction, as a child-friendly manoeuvre, is feasible and could be considered for children and their parents scheduled for day-case procedures under general anaesthesia. Further studies are recommended to assess the possible effectiveness of preoperative simulated anaesthesia induction compared with other pharmacological and non-pharmacological interventions. Also, more studies are needed to evaluate the effectiveness of preoperative simulated anaesthesia induction on postoperative recovery, reducing postoperative pain and healthcare costs.

Data availability statement

Data are available on reasonable request. Deidentified participant data.

Ethics statements

Patient consent for publication

Not required.

Ethics approval

The study site institutional review board approved the study (IRB No. 18–534).