Article Type: Special Interest Article

Title: A Primer on Parental and Child Satisfaction in the Perioperative Setting

Running Title: Parent and Child Satisfaction in the Perioperative Settings

Authors: Beverly A. Mendoza, BS1,2; Michelle Fortier, PhD1,3; Lily N. Trinh, BS1; Lauren N.

Schmid, BA4; Zeev N. Kain, MD, MBA1,2,5,6

1
Center on Stress & Health, University of California School of Medicine, Irvine, USA

2
Department of Anesthesiology and Perioperative Care, University of California, Irvine, USA

3
Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA

4
Hahn School of Nursing and Health Science, University of California, San Diego, CA, USA

5
Yale Child Study Center, Yale University, New Haven, CT, USA

6
Health Policy Research Institution (HPRI), University of California, Irvine, USA

Corresponding Author:

Zeev N. Kain, MD

UCI Center on Stress and Health

505 S. Main St. Suite 940

Orange, CA 92868 USA

zkain@uci.edu
1
T: 1-714-456-2833

F:1-714-465-7553

Acknowledgements:

Conflicts of interest: Zeev N. Kain serves as a speaker or coach to Studer Group, Edwards

Lifesciences, Medtronics, and Medacta. His research is supported by the National Institutes of

Health (NICHD).

Abstract: The renewed focus on patient and family-centered care and the implementation of the

Hospital Value-Based Purchasing Program in the US has prompted an increased emphasis on

patient satisfaction scores in pediatric perioperative settings. This report summarizes predictors

of parental and child satisfaction, as well as interventions that have been implemented to

improve satisfaction. Studies were examined for both modifiable and non-modifiable predictors

such as provider communication skills and quality of clinical care and intervention studies were

analyzed separately according to perioperative setting. We found that patient-provider

communication, staff attitudes, and tailored perioperative information were associated with

increased satisfaction of parents and children. Interventions such as preparation programs

integrating role-play and hospital tours and patient discharge programs were rated highly in

satisfaction. Healthcare providers and institutions should consider implementing such

interventions to improve patient experience and satisfaction ratings.

Keywords: Child satisfaction, parental satisfaction, patient experience, pediatric surgery

Background

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Family-centered care in healthcare is defined as the collaborative partnership between healthcare

providers, patients, and their families. The four core concepts of patient- and family-centered

care include: (1) dignity and respect, (2) information sharing, (3) power and control, and (4)

collaboration, which all aim to improve health outcomes, staff satisfaction, patient and family

satisfaction.1–3 Within pediatric perioperative care, establishing patient- and family-centered care

is essential in guiding and collaborating with families throughout their child’s surgery. By

integrating families as stakeholders in the perioperative care team, families can become well-

equipped with preparation material, management strategies to utilize on the day of surgery, and a

postoperative pain management plan, all tailored to the patient and family’s anxiety, coping

level, surgery, and preferred delivery mechanism.4 Family-centered care respects the family’s

values and with open communication from the family and the healthcare team, leads to better

health outcomes and increased patient experience.1

In 2006, the US Agency for Healthcare Research and Quality established the Hospital

Consumer Assessment of Healthcare Providers and Systems (HCAHPS). This hospital-specific

survey allows hospitals to gain insight into how patients perceive communication with healthcare

providers, communication between providers, quality of clinical care, pain management

information, hospital environment, communication about medications, quality of the information

provided to the patient at discharge, and overall hospital rating.5 As patients report their hospital

experience, hospitals can assess how they perform in different domains across their institutions

to provide a better quality of care.

Ever since the US Centers for Medicare and Medicaid Services implemented the Hospital

Value-Based Purchasing (VBP) Program, patient satisfaction has been a topic of growing

popularity.6 The VBP program instituted a method for reimbursing hospital practices based on

3
their overall performance in delivering quality care.6 Cost efficiency, safety, clinical care, and

patient experience are currently the four domains that equally determine each hospital’s VBP

performance score. If healthcare providers implemented patient- and family-centered care in

their practice, they may improve their patient satisfaction scores and thus, reimbursements.

Previous research on patient experience has primarily focused on adult satisfaction,

whereas little data exist on patient and parent satisfaction within pediatric subspecialties. 5

Previously, our center reported that the themes of modifiable and non-modifiable factors for

adult patients include satisfaction from clinician communication skills, information provision to

patients, organization aspects of the unit, and demographic and health status predictors.7 This

special interest article focuses on the emerging topic of parental and child perioperative

satisfaction within the context of surgical settings and family centered care.

Measuring Pediatric Perioperative Patient Satisfaction

For adult patients, the topic of measurement of patient satisfaction is well-developed since the

introduction of the CAHPS surveys in 2006. 8,9 In contrast, measuring both child satisfaction and

parent satisfaction is notably less established, and there are very few validated government-

recommended measures that are utilized in these settings.10 The lack of standardized government

developed measures of parental satisfaction instruments may reflect the relative infrequency of

hospitalization in children as only 3.6% of children under 18 years require hospitalization in a

year compared with 16.2% of adults older than 65 years. 11 However, in 2009, the Children’s

Health Insurance Program Reauthorization Act (CHIRPA) was passed by the US Congress to

measure and improve child health quality.12 As a result, CMS and AHRQ sought to address the

lack of a standardized measure for parents of pediatric patients to assess their most recent

hospitalization and funded the development of a Child HCAHPS.12 Toomey and collegues

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conducted reliability and validity tests on the Child HCAHPS and implemented this measure

across 69 hospitals nationwide.13,14 Significant variation in patient experience was identified

across hospitals, with the lowest reported item regarding patient safety. 14 Nevertheless, the

feedback obtained through Child HCAHPS provides an opportunity to improve patient-centered

care and patient satisfaction.15

In surveying children, there exists the issue of developmental stage and the ability to

answer questions related to the complex construct of satisfaction and experience. However,

studies have found that children as young as four years old can express their opinion on their

hospital care as long as the questionnaires are at an appropriate level for their age. 16–18 Separating

children into age groups of 4-6, 7-11, and 12-20 years, demonstrated variability in responses

from each age group.19 Children ages 4-6 provided short, straightforward answers regarding how

hospitalization affected their everyday activities. Middle-aged children provided responses that

recognized their providers in helping them feel better while also giving feedback on how

hospitalization could be improved. Lastly, the eldest group responded with the most detailed

suggestions on factors that could be improved and aspects of their experiences they liked and

disliked. Although children of different age groups have different cognitive abilities in

responding to their hospital experiences, their perspectives help tailor their care and should be

sought out.

Outcomes of Patient Satisfaction

Whether or not patient satisfaction leads to better clinical outcomes has been debated, as

it is not feasible to conduct a randomized controlled trial on this topic directly. 20–23
Adult patients

who received care at hospitals with high satisfaction scores had lower rates of postoperative

mortality, minor complications, and death as a result of a complication. 20 Overall, prior studies

5
have demonstrated a correlation between adult patient experience and positive clinical outcomes,

such as safety and effectiveness. 23 However, some studies have demonstrated a negative

association or no association between adult patient experience and clinical outcomes.21 For

example, Fenton and colleagues reported that high satisfaction scores were linked with higher

mortality rates in a sample of adults, after adjusting for factors such as access to care, chronic

illnesses, and sociodemographics.21,22 Likewise, pediatric parent satisfaction has also

demonstrated varied outcomes in the patient experience of the parent and child. For example,

high satisfaction scores were found among pediatric patients who were given premedication and

allowed parental presence prior to surgery, as compared to patients with no parental presence. 24

In addition, an association was found between high quality, family-centered access to care to

decreased future non-urgent emergency department utilization.25 Nonetheless, there is also

evidence that parental presence during induction and in the post anesthesia care unit does not

impact pediatric satisfaction scores.26

As mentioned previously, the adult VBP program provides reimbursement to hospitals

for high HCAHPS scores.6 It has been shown that hospitals that perform higher on adult

HCAHPS scores than lower-quality institutions cost less for Medicare. 6 When adult patients

visited hospitals with high HCAHPS scores, for the first 30 days, Medicare spent about $2,700

less than an adult patient visiting a low-quality hospital. 27 However, because a standardized tool

to measure the performance of the pediatric perioperative experience is lacking, there are

currently no data for pediatric patients.

Factors Affecting Parental Perioperative Satisfaction

We have chosen to report our findings in the format of modifiable vs. non-modifiable factors that

impact parent satisfaction in perioperative settings (Figure 1). We have adopted this approach

6
based on the different action steps that anesthesiologists, surgeons, nurses, and organizations can

take in an effort to improve the satisfaction of our patients and their families. A summary of the

included articles is shown in Table 1.

PARENT MODIFIABLE FACTORS

Organizational aspects of the surgical unit

According to self-reported questionnaires, parent satisfaction is correlated with accessibility to

care and comfort of the environment. 28,29 Parents also reported positive experiences with services

provided at the preoperative clinic and the surgical ward, the discharge process, and having time

to discuss the surgery and outcomes. 30,31 Parents were more likely to recommend a particular

practice when influenced by the ease of scheduling a child examination and parents who were

dissatisfied with a practice were affected by the difficulty of obtaining their desired appointment

time and phone call promptness.28,32,33 Although some parents were satisfied with the conditions

and wait times in the waiting and exam room, 31,34 others reported negative experiences with long

wait times, waiting room conditions (e.g. cleanliness, comfortability), and amenity

availability.28,35–40 Additionally, parents expressed concerns over the limitations of allowing only

one parent to accompany their child in the operating room. 41 Inadequate space, lack of privacy,

the teaching setting, and feeling rushed out of the hospital all negatively impacted parents’

satisfaction scores.42–44 The surgery start time, length of surgery, and postoperative length of stay

demonstrated no significant association with parental satisfaction.45

Communication

When parents had a positive perception of the quality of perioperative communication by

anesthesiologists, parents were more likely to recommend friends and family to a hospital and

7
were more satisfied with their child’s care. 45 Satisfaction was also associated with nurses’

explanations, the provided respect, and responses to questions.35 While the quality of

communication was also associated with parental satisfaction, observational data demonstrated

most of the communication healthcare providers have with families results in medical talk. 37,42,46

Families interactions with the healthcare team impacted their experiences of feeling listened to,

feeling confident, feeling involved in decision making and being seen as a resource in pediatric

day surgery.47 Dissatisfaction was influenced by inadequate staff communication in the waiting

area and short-lasting physician encounters.28,38

Information Provision

Parental satisfaction is associated with educational information provided for their child’s

surgery.48–50 Parents who had greater knowledge due to previous experiences or provider

education had more positive attitudes and higher satisfaction with care. 51 Parents were satisfied

with receiving fasting and admission information through a preoperative call.31,52 Parents were

also satisfied with providing material written in plain language for parents with all literacy levels

and preferred to receive information in a brochure. 49,53 Although parents reported high

satisfaction with information received, parents continued to seek out information from outside

sources, such as friends and family members.49,52 Dissatisfaction was associated with inadequate

information on postoperative home care, directing questions, hospital routines, and identifying

members of the healthcare team.54,55 Parents expressed wanting more information on

premedication, waiting times, anesthesia induction, operating room equipment, side effects, and

postoperative pain relief.41,48,54,56 Overall, the data indicate that more specific information offered

to parents can improve their satisfaction level.

Clinical care

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Parents’ and children’s perception of staff as well as the staff’s skills, competencies, attitudes,

teamwork, and ability to listen and connect with families affected satisfaction of their surgical

experience.33,50,55–57 In addition, the quality of care, support, and trust of nurses and physicians

positively influenced satisfaction.28,32–34,36,38,40,41 Satisfaction was also associated with the overall

treatment, pain management plan, and having the child under anesthesia for less than 15

minutes.58–60 Similar parental satisfaction levels were reported for outpatient surgeries at an

ambulatory practice as compared to a hospital-based facility. 61

NON-MODIFIABLE FACTORS ON PARENTAL SATISFACTION:

Demographic and Health Status Predictors

Although parents of young children reported significantly lower overall satisfaction, generally,

demographic information such as child’s age and gender were not significantly associated with

overall perioperative satisfaction.50,62,63 Families with higher maternal education were less

satisfied with their child’s surgical care, while the level of satisfaction was not correlated with

paternal education. 50,60

Specifically, for the maternal education level of 12 years and less, the

degree of satisfaction for the surgeon, nursing staff, and general information and treatment

satisfaction was higher compared to families with a higher maternal education level. 50,60

Additionally, the number of parents who care for the child is associated with satisfaction, and

single parenthood families showed higher satisfaction than two-parent families. 50,60 Regarding

their child’s conditions, parents who perceive their child to be of poor health or had more

anxious children were less likely to be satisfied with care. 45,62,64 Dissatisfaction was also

correlated with caregivers feeling overwhelmed with their other children to properly care for the

child that had surgery.43 In a study across six pediatric outpatient surgical centers, satisfaction

9
scores did not differ by socioeconomic status or minority status.37 The surgical specialty, type of

sedation, type of insurance, and child’s amount of perioperative bleeding were also not

associated with parental satisfaction.42,60,63

Factors Affecting Child Perioperative Satisfaction

CHILD MODIFIABLE FACTORS

To provide a patient- and family-centered experience, the child’s perspective is also an important

component of care.65 Healthcare providers should be attentive to the child’s desires, experiences,

and actions throughout the perioperative experience as these may contribute to adverse

outcomes, such as child anxiety, pain, and fear.66

Organizational aspects of the surgical unit

Children ages 8 to 11 years who perceived the hospital environment as lacking in child-friendly

items, such as toys, reported lower patient experience and increased, tension and fear in these

settings.47 Children were more satisfied with distraction and child-friendly rooms.47,56 Children

also reported lower satisfaction scores when they experienced longer waiting times.67

Information Provision

In general, children lacked perioperative information and did not feel prepared for

surgery.47,63,68,69 Children older than seven years of age wanted more perioperative information

regarding their surgery, such as information about pain and anesthesia, complications, and the

surgical enviornment.70 Furthermore, providing information to more anxious children is vital to

easing their uncertainty around surgery.71 Notably, age did not impact the child’s type of desire

for information. For example, pre-adolescent children (7-11 years old) desired more information

10
surrounding the appearance of the operating and recovery room.70 When children ages 6-9 years

old were interviewed, responses reflected the desire for information about parental presence

throughout the day of surgery and the discomfort after surgery. 68 Children over the age of 10

years who had undergone outpatient surgeries were least satisfied with the information provided

for surgery and discharge.72

Communication

As children are present throughout their perioperative care, children have expressed the desire to

participate in surgery discussions.47 Results from qualitative interviews with children between

the ages of 8-11 demonstrated that children had a more positive experience when participating in

their care and interacting with their providers. 47 Children actively participate in discussions when

their provider listens, builds trust, and includes them in the decision-making process. 47 By

addressing the child’s desire to be directly spoken and listened to, focusing on communication

can greatly improve the patient-and family-centered care experience.

CHILD NON-MODIFIABLE FACTORS: EMOTIONAL STATES

Children experience many emotional stressors throughout their surgical experience. During the

preoperative stage, children are mainly concerned with enduring an unknown, unpredictable, and

distressful situation.73 Children report feeling scared not knowing anyone that has undergone

surgery in which they could turn to their experiences. 71 Intraoperatively, children feel distressed

and a lack of control as they do not know what to anticipate. 73 Postoperatively, they feel relieved

and a sense of accomplishment. 73 As children navigate the surgery experience, they are exposed

to face many unfamiliar emotional states that affect their experience and thus, satisfaction.

Interventions

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Preoperative

Numerous interventions have attempted to improve parents and children’s satisfaction with

surgical care.74–87 In the preoperative stages, researchers have implemented various preparation

programs, including role-play, videos, information leaflets, hospital tours, and distraction with

toys. These tools have generally been well rated by parents. However, the effects on parental

satisfaction and parent and child anxiety levels are varied. When families were provided with a

preparation program including multiple components such as video or pictures of the

perioperative stages, role play, and hospital tour, compared to the routine information provided,

there was no significant difference in parent’s satisfaction between the two groups. However,

this preparation significantly reduced parents’ state anxiety.74,75,80,81 Anxiety scores of children

and mothers were lower than the control group, and parental satisfaction was higher when

children were given toys or therapeutic play during a preoperative visit. 82,83
The introduction of

an information leaflet about anesthesia increased parent’s satisfaction with information

provision, and most parents found it helpful to receive it at their clinic appointment. 84,85 Most

parents that were provided with informational videos did not statistically differ in

satisfaction.76,86,87 Families assessed with language-concordant care reported better

communication with providers and higher satisfaction.77,78 No difference in satisfaction was

observed between families assessed by an anesthesiologist versus families assessed by a nurse

practitioner.79

Day Surgery

In general, parents have been satisfied with their day surgery experience, especially with the

components of provisioned information, convenience, easy scheduling, care, and rapid

12
recovery.88–92 Surgeons did suggest better staff coordination with the aim of having the same

surgeon examine and operate on the child. 89

Perioperative

Within the surgical setting, parental presence during induction has been shown to have no impact

on child behavioral distress during induction. Although parents prefer to be present for induction,

those who were present had similar satisfaction scores, parental and child anxiety levels, and

child compliance during induction as compared to parents who were absent during induction.
24,26,93,94
Parents who attended their child’s induction reported higher satisfaction when given clear

explanations, staff demonstrated care and concern, and when interacting positively with

anesthesia care providers.95 Lastly, high satisfaction was reported for telehealth sessions with the

ease of facilitating access to services such as preoperative examinations and follow-up care.96

Postoperative

Interventions targeting the postoperative period have aimed to improve instructions for at-home

care. Satisfaction with a patient education program at discharge has been rated highly by nurses

and parents.97 No difference was found for the incidence of pain or parental satisfaction in

parents that were given pain management advice and take-home analgesics at discharge as

compared to parents that were only provided with pain management advice. Furthermore, parents

poorly retained pain management advice, with only less than half of parents recalling analgesic

instructions.98 However, a telephone call one week after surgery provided parents with positive

support and instructions lacking at discharge.99

Conclusion

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Understanding the different modifiable and non-modifiable factors that influence pediatric

satisfaction is essential to providing high quality perioperative care. In this article, we identified

multiple factors throughout the perioperative experience associated with satisfaction. Figure 1

lists those factors that contribute to high satisfaction such as staff attitudes, ease of scheduling,

quality of communication, and tailored information to families. Non-modifiable factors

associated with satisfaction included maternal education, number of parents, and patient’s age.

Furthermore, we discussed interventions that have targeted a component of the perioperative

experience and demonstrated improved patient or child satisfaction. Considering the

multidimensional nature of patient satisfaction, a multi-disciplinary team should be assembled

when implementing interventions to improve satisfaction. We suggest that readers initiate

discussions with institutional leaders regarding how practices measure satisfaction and how they

can be modified and improved.

Financial Disclosures: None

14
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