I'm afraid! Children's experiences of being anesthetized

Children experience anesthetization as stressful, and many preoperative measures have been tested for reducing their anxiety. There is, however, little research about children's own experiences and thoughts about being anesthetized.


| INTRODUC TI ON
Being anesthetized is a stressful experience for children. More than 60% of all children undergoing anesthesia report anxiety, and nearly 20% experience a high degree of anxiety. 1 The higher the level of anxiety children experience, the lower their ability to cooperate during the anesthesia induction. 2 Children are provided with nonpharmacological interventions 3 and pharmacological treatments 4 to relieve their anxiety. Although only a few studies have examined why children experience anxiety, high anxiety is known to be associated with younger age, behavioral problems, previous hospital admissions, and anxious parents present at the induction. 5 In addition, children can feel a loss of control when they are in an unknown environment 6  Children have the right to be listened to regarding issues that concern them, including medical procedures. 8 The child's best interests must thus be considered when medical care needs to be provided. A number of studies have investigated children's experiences from a second-person perspective (ie, by interviewing parents or healthcare professionals). 9 There is, however, a gap in the literature where the focus is on the children's own, unique experiences of anesthesia. Filling this gap might facilitate a greater understanding of these experiences, which is thus the goal of this study. Qualitative methodology provides the conditions for discovering how children experience the act of caring in this specific environment. By using a hermeneutic lifeworld approach, the children's own experiences are the main focus. The lifeworld approach has been especially developed for gaining knowledge about meanings in an individual's lifeworld and elucidates lived human experiences. More knowledge is needed about children's feelings, thoughts, and experiences concerning anesthesia. This knowledge may contribute to improving care and help reduce the children's anxiety. This study thus aims to explain and understand the meaning of being anesthetized as experienced by children.

| ME THODS
A qualitative lifeworld hermeneutical approach was used. 10 Data were collected through nonparticipant video observations, field notes, and interviews in 2018.

| Participants and settings
Data were collected from four hospitals in Sweden, two with a child anesthesia specialty and two with both children and adult anesthesia specialties. After approval from the heads of the operating units, the operations coordinator consecutively selected children from the elective operating list. Nurses on the operations or children's wards provided oral and written information to the children and their parents about the study. The first author (LA) provided more oral information the day before the surgery or well in advance on the same day but prior to any premedication. If they agreed to participate, an assent was obtained from the children and written consent was obtained from the parents. The inclusion criteria were as follows: Swedish speaking; 4-13 years old; and planned minor elective surgery/procedures under general anesthesia. All children should belong to ASA class 1-2, a classification of the American Society of Anesthesiologists (https://www.asahq.org/stand ards-and-guide lines /asa-physi cal-statu s-class ifica tion-system). The exclusion criteria were as follows: acute surgery and surgery under local or regional anesthesia. All the children in this study were recruited in 2018, and they varied in terms of ages, gender, diagnosis, and previous experiences of anesthesia (Table 1). All the nurse anesthetists and/or anesthesiologists who participated during the anesthesia gave written informed consent. Other team members in the operating room (OR) were informed orally and could choose to remain in the OR when the child was anesthetized or just wait outside the OR during the video recording.

| Data collection
Data collection was performed through nonparticipant video observations, field notes, and interviews. Forty-five children and their parents were asked to participate in this study, and 28 accepted. All the children were accompanied by one parent in accordance with the hospital's routines and the parents and/or the children were allowed to decide which parent accompanied them into the OR. All the children and the parents met an anesthesiologist preoperatively.
Data collection began with the video session, which started when the participants entered the OR and were completed when the parent(s) left the room (ie, when the anesthesia drugs rendered the children unconscious). The first author sat quietly in a corner and left the OR immediately after the parent. One child did not participate in the video session due to a double booking in the OR. The first author wrote field notes immediately after leaving the OR.
The parents and the children chose the time and place for the interviews, which were performed the same day or up to a maximum of 4 days after the surgery. The initial question to the children was "Could you please tell me about how what it was like to be anesthetized?" Children were encouraged to narrate their experiences as freely and openly as possible. The first author asked follow-up questions such as "What do you mean?" when needed and also presented a storybook to all the children 11 and showed a picture of the OR to encourage them to describe their experiences. This kind of symbolic methodology can generate deeper and richer descriptions.
Each child was asked during the interview to draw a picture of what happened in the OR and then was encouraged to talk about the drawing. Five parents declined the children's follow-up interview,

What is already known
• Many children experience being anesthetized as stressful and anxiety inducing.
• Different preoperative measures have been tested to reduce these children's anxiety.

What this article adds
• As many children experience being anesthetized as being powerless and vulnerable, they use different strategies to gain control.
• The children need their parent(s) to be physically nearby.
• It is important to listen to the unique child's wishes and provide individualized information in a positive and calm environment with as few unknown people as possible present.
which they were allowed to do without giving any reason. All interviews were audio-taped, and both the audiotapes and videotapes were transcribed verbatim.

| Data analysis
The analysis process started with the authors viewing the video observations, and reading the field notes and interviews several times to acquire a general sense of the entirety of the data and a preliminary understanding of it. The interpretation phase began by searching for and identifying the meanings of the data. Meaning units were then sorted and grouped for similarities and differences into themes representing the different meanings of the phenomenon. The analysis continued by searching for underlying meanings (ie, searching for meanings "between the lines" to create the tentative interpretation).
The analysis was complemented by a questioning and critical approach during this phase, which continued until all data related to the aim were included. Data were then grouped into preliminary interpretations. A validation procedure was implemented prior to the next phase. 10,12 The authors first ensured that the interpretations were derived from the data and did not reflect the researchers' biases or assumptions. Secondly, the authors ensured that there could be no other meaningful explanations of the data. Thirdly, the authors ensured that there were no contradictions in the data and that the interpretation could be considered valid.
A movement between the whole (ie, all the data from the audio-video observations, transcriptions of the audio-video, field notes, interviews) and the parts (ie, the interpretations of the children's stories) was performed to capture the meaning of the text and the preliminary interpretations throughout the analysis process.
This back-and-forth movement between the whole and the parts was carried out to ensure that the interpretations were related to the phenomenon under study: being anesthetized as experienced by children. Some tentative interpretations were excluded during this phase because they did not fulfill the validity criteria. This resulted in four tentative interpretations that were related to the aim: Being powerless, Striving for control, Experiencing ambiguous comprehensibility, and Seeking security.  Time in the operating room until the child was asleep.

TA B L E 1 (Continued)
level of abstraction and a more developed understanding of the phenomenon, and the comprehensive understanding is more profound than the tentative interpretation conducted at the beginning of the analysis. Validity was tested in the last stage of this phase, where two more criteria: to ensure the comprehensive understanding did not leave out any relevant data and to ensure the tentative interpretations (ie, the parts) related to the main interpretations (ie, the whole) confirmed each other. 10,12

| Ethical considerations
The study was approved by the Regional Ethical Review Board (Dnr 2017/532-31). The participants were informed that their participation was voluntary and that they could withdraw at any time without giving any reason.

| RE SULTS
Anxiety concerns the children's worries and fears and is a core emotion that emerged in all of the themes. The interpretive themes should be understood on this basis.

| Being powerless
Being powerless can manifest itself with reactions such as stomach aches, body tremors, and difficulty sleeping days before the anesthesia and usually increases as the day of anesthesia induction approaches. Anxiety can be expressed through verbal and bodily protests in the OR; for example, one child hid under a blanket and another kicked or pulled his/her head to one side (9 and 12 years old, respectively). Sometimes feelings of powerlessness were expressed through silence in an attempt to regain their power. This sense of powerlessness appears to be related to a feeling of not being able to affect the care process. Anxiety about complications may occur, such as pain and insufficient anesthesia, and thus, a risk of waking up during the surgery may also involve thoughts about the risk of dying: "The anxiety will always be there when you're being anesthetized.
Even if you're an adult, I think that you'll be anxious as there is a chance that you'll die" (13 years old).

| Striving for control
Striving for control occurs when different strategies are used and when the children try to endure and distance themselves in order to manage their feelings: "I was a little anxious, but I am not the type who is sensitive, I can hold out" (11 years old). Some children wanted to keep from crying: "My body said stop, try not to do it. It just said so. I don't know why" (6 years old). These children often expressed doubts about being able to live up to expectations (eg, not being brave).
Children want to understand the process of anesthesia and the equipment they will be exposed to, but they also want the opportunity to be involved and make decisions about the process. For example, they could hold the breathing mask or sit on the operating effect of the premedication contributed to a desire for control for some children: "I was so tired that I couldn't ask for anything" (12 years old). A loss of control can also be due to the child succumbing as there is no return from the situation. This situation is explained by the fact that the child's anxiety cannot be reduced, so they do not ask questions and choose to be anesthetized quickly. There is, however, an ambivalence about how much information the child desires. It becomes a question of balancing between comprehensibility and incomprehensibility. There also seems to be a need for the children to distance themselves from the information that is available. The ambiguity that arises in the quest for comprehensibility also includes the time in the OR: "It went so fast, I wanted them to talk more about what they would do, they could have done one thing at a time, it went so fast, it became too much" (12 years old).

| Seeking security
Seeking security is connected to the fact that the children see their parents as being responsible for stability and the latter thus become an obvious part of anesthesia process; that is, children see their parents as protection against danger: " Seeking security can be understood as a desire to bring the parent, who is responsible for basic security, into the OR. It may apply to the parent who is generous with physical proximity and who is usually the one who is available the most to provide comfort and support in everyday life: "It's just that my body says mom" (9 years old). However, most of the children also request participation from both parents. This can be explained as constituting a strengthened protection against danger since parents can complement each other and thus further reduce anxiety ( Figure 2).
The staff on the unit also represent security, but it seems that they do not generate the same sense of security for the children as the parents can do because they are unfamiliar to the child and establishing relations with the staff is difficult. The children's memories of the staff from the anesthetic unit in the OR are vague: "The only thing I remember was mom" (10 years old). These staff need to initiate communication because children might find it difficult to have a conversation with a stranger: "The best was the guy who talked, those who talk, and that they talk to me because I'm the one to be operated on" (10 years old). Some children can also be made to do and what to say. That's all that's needed" (13 years old). These conversations can also involve using toys or a tablet such as an iPad.
Other objects brought from home such as cuddly toys or computer games can also strengthen feelings of safety, increasing the child's sense of security ( Figure 3).

| Main interpretation
Being anesthetized can be understood as a threat to life and where anxiety is more or less constantly present. Children fear both being anesthetized and the overall procedure. It is a struggle to keep the body intact from the external threat that may occur in the OR. The goal is to achieve health and well-being, but the way to get there is perceived as difficult. There is a desire to gain comprehensibility in order to be able to cope with anxiety, but knowledge can also increase anxiety. It seems as though anxiety can be reduced

F I G U R E 2
The drawing illustrates the importance of parental involvement for the child and shows the child's wishes. "I said both [parents]! But then it was just my mom" (6 y old)

F I G U R E 3
The drawing illustrates how a child wishes the procedure to be carried out: "A happy mouth [on the child in this figure] and my mom holding me and a nurse sitting next to me and giving the injection. The nurse came into the room and talked and so. Without any machines nearby" (9 y old) by implementing measures that enable control and security. The more protective factors there are, the stronger the shield against the threat located in the OR. Protective factors include allowing parents to be present and applying a caring approach with the individual child in focus.

| D ISCUSS I ON
The main finding in this qualitative study is that being anesthetized is multifaceted and can be understood as feelings of powerlessness.
Being anesthetized also involves anxiety about enduring painful procedures and being in a technologically advanced environment with unknown people. Although children have extremely limited choices and therefore reduced participation in ORs, they strive for control.
When the children seek comprehensibility in anesthesia, it concerns gaining knowledge about how anesthesia can be implemented.
However, when the search for comprehension becomes ambiguous, children can feel ambivalent about how much information they want and need. When anxiety is present, children seek security, especially by leaning toward their parents. The anesthetic staff can provide some protection, but it seems they are not as significant for the children's security as the parents are.
Earlier studies have also found that children are anxious during anesthesia induction. 1 Our study found that children expressed their feelings in different ways in an attempt to restore a sense of power, of being in control. One study showed that only 3% expressed significant vocal and/or physical resistance during induction. 13 This response can be explained by the fact that children can use different strategies such as being quiet or hiding when they feel threatened. Children develop coping strategies (ie, their own ability to deal with a threat) based on their own internal conditions and previous experiences. 14 Children attempt to regain control or participate in decision-making in spite of their limited choices. Their control can to some extent increase if they are able to make some decisions themselves. This is in line with the findings from other studies; for example, children want to express their opinions, ask questions about care and procedures, 15 and make decisions about small matters such as holding the breathing mask. 6 Staff and parents should demonstrate that they want to hear what the children have to say and about how they are feeling as well as encouraging them to be involved in decision-making and sharing of responsibility in order to access and understand the children's perspectives. 16 Staff are more likely to talk with an older child to provide information and to include them in decision-making, 17 but it is necessary to involve all children in decision-making irrespective of age. These seemingly small interventions can improve outcomes. This does not mean that the children should be pressed into being involved in decision-making; that is, listening to children is not the same as giving them sole responsibility for making decisions. 18 Children need to be given space regarding time, support, and active engagement to ensure participation. 19 One study 20 also indicated that children are uncertain about which method of information and timing would be the best. In an earlier study, younger children asked for more information about the operating environment and it has been shown that children who exhibit a higher degree of anxiety demand more information. The information requested by children mainly concerns the operation, anesthesia, and any pain associated with a procedure. 21 Reducing children's anxiety is still a challenging issue, and various methods have been studied and can be used. The role of parents in the OR has been discussed for decades, and some studies have shown that parental presence in the OR might not reduce preoperative anxiety. The children in our study thought that their parents' presence in the OR reduced their anxiety and often portrayed their parents as defenders, a response that resembles the way Bowlby's 22 attachment theory is linked to anxiety. This type of anxiety is related to unfamiliar people and places, sudden changes in the environment, and being alone without parents. Attachment theory highlights the importance of a lasting relationship with parents, which includes a strong tendency to seek security when experiencing anxiety. The parent-child relationship is one of our strongest emotional relationships. The older a child is, the less significant is the attachment; nonetheless, an older child might experience anxiety if there is a threat and/or loss of someone close.
Our results support the practice of allowing both parents to be present during anesthesia induction. One parent is usually allowed to be present in Sweden. Parents have a strong desire to be present and they also want to be with the other parent. 23 The parents in our study appeared to manage their own emotions very well, at least until the children were anesthetized, a time when support is needed.
There is a correlation between parents' level of anxiety and their children's level of anxiety. 24 Reducing children's anxiety is partly the result of reducing parental anxiety. Parents should thus be offered behavioral or other interventions to help them manage their own anxiety.

| CON CLUS ION
Being anesthetized makes children feel powerless, and unable to protect their bodies. Being anesthetized induces anxiety as the children are in a technologically advanced environment with members of staff that are unknown to them while enduring possibly painful procedures. To facilitate their experiences, staff from the anesthetic unit should highlight the children's own feelings, listen to their unique wishes, provide individualized information in a positive and calm environment with few people around, and let parents be physically close.

CO N FLI C T O F I NTE R E S T
Nothing to declare.

AUTH O R CO NTR I B UTI O N
LA was involved in all phases. KK, PJ, and SA-Ö prepared the study design, analyzed the data, and participated in writing the article. All authors agreed to be accountable for all aspects of the work.