Kids voices: Exploring children’s perspective of tonsillectomy surgery

Feedback around the hospital experience is often sought from caregivers; however, consultation with children offers a unique perspective that can also be valuable for quality improvement purposes. There are limited studies collecting direct feedback from children on their surgical and hospital experience, one study highlighting the need for individualised care in a perioperative setting, which can only be discerned through direct and meaningful conversations with children.1 Tonsillectomies are one of the most common childhood surgical procedures.2 This procedure may be a source of great stress to children, amplified by a painful prolonged recovery process, which can last for up to two weeks, as well as other complications such as nausea, vomiting, difficulty swallowing and the fear of bleeding.2, 3 We aimed to assess children's subjective opinion of their hospital stay and recovery post-tonsillectomy through semi-structured phone interviews. Data was prospectively collected as part of an approved institutional audit (Approval No: GEKO 39785).

Feedback around the hospital experience is often sought from caregivers; however, consultation with children offers a unique perspective that can also be valuable for quality improvement purposes. There are limited studies collecting direct feedback from children on their surgical and hospital experience; one study highlighting the need for individualized care in a perioperative setting, which can only be discerned through direct and meaningful conversations with children. 1 Tonsillectomies are one of the most common childhood surgical procedures. 2 This procedure may be a source of great stress to children, amplified by a painful prolonged recovery process, which can last for up to two weeks, as well as other complications such as nausea, vomiting, difficulty swallowing, and the fear of bleeding. 2,3 We aimed to assess children's subjective opinion of their hospital stay and recovery post-tonsillectomy through semi-structured phone interviews. Data were prospectively collected as part of an approved institutional audit (Approval No: GEKO 39785).
Fifty children (Female n = 25 and Male n = 25) with English as a first language, aged 3-13 years (4-6 years n = 23, 7-10 years n = 18, and 11-13 years n = 9), who had recently undergone tonsillectomy procedures were interviewed. Children were randomly selected from surgical lists. Interviewers firstly contacted parents by phone at least two weeks after their child's procedure and verbal consent was granted by parents prior to speaking to each child. Data collection was performed through short semi-structured phone interviews. Questions were structured as a guide for children to share their honest opinions and ideas. Interviews were transcribed verbatim and lasted approximately 10 min. Data were coded into themes and analyzed using a frequency table.
Participant results are presented in Table 1. Most children commented on experiencing pain after their surgery (82%). 52% of the children interviewed felt sick after their surgery. The majority of children felt that they were given enough information before their surgery (63%). For the 37% of children who said that they did not have enough information, children wanted more information about the surgical process (17%) and pain/sickness (13%). For 33% of children, the worst part was the anesthetic process, specifically gas/ induction mask or the "needle" in the hand. A further 29% of children said the worst part was the pain/sickness after.
Encouragingly, children often remember fun and enjoyable aspects of the hospital experience, with 15 children specifically mentioning the ice cream as the best part of their experience. Children also enjoyed the novelty of being in hospital and away from home, describing how they got to watch TV and play games. An important finding of this audit was that children distinctly remembered enjoyable aspects too, such as the ice cream after their surgery and getting stickers. This highlights the importance TA B L E 1 Themes identified around the hospital experience, as described by participants (n = 50)

Theme
Participants n (%) Key quotes

Pain
Felt pain after surgery , particularly at home 41 (82) "Yes, it was very sore. When I got home it was the most sore"-P 38 Pain rated as severe 17 (47) "Yes it was sore. It was most sore when I got home. It was sometimes really really sore"-P 50 Sickness Felt sick after surgery 24 (48) "Yes [I felt sick] for a week because I did not eat"-P 13 If sick, the sickness persisted for a few days 10 (42)

Information Level
Given enough information before their surgery 27 (63) "Yes, [they] sent a letter and then the nurses explained again when I got there"-Participant 13 "Yes, I knew enough. When I found out, I feel like I understood it"-P 49 Not given enough information 16 (37) "Didn't really know what was going to happen"-P 3 Wanted more information on surgical process 5 (17) "… someone to tell me about what happens when you're asleep"-P 1 "… they didn't say they would take my tonsils"-P 10 Wanted more information pain and sickness 4 (13) "...they didn't say that it would hurt when I woke up. I would have liked to be told that"-P 6 Information Delivery Delivery system was good as it is 15 (52) "Happy not knowing too much"-P 37 Information best coming from doctors or nurses 6 (21) "Mum explained what was going to happen but the doctors didn't"-P 7 Information best coming from parents 3 (10) "Would prefer pre-operative information to come from parents"-P 39 Information best delivered through visual stimulus 5 (17) "…movie would be helpful"-P 22 "… picture would have been useful"-P 18 Hospital Experience Best part was the food and drink 21 (40) "You get to eat ice-cream for five weeks!"-P 1 Best part was the hospital environment 21 (40) "… the nurses were nice and my brother was not there, which was nice"-Participant 50 "Stickers were the best part… " Participant 3 Worst part was the perioperative process 15 (33) "…didn't like getting tonsils out"-P 18 "…Scared of the operation"-P 43 Worst part was the pain/sickness after surgery 13 (29) "... feeling sick so I didn't want to eat my favourite treats was the worst part"-P 3 "…when it hurt a couple of days after"-P 16 Specific complaint about the gas/induction mask or "needle" in the hand 6 (13) "… when they put the mask on my face"-P 7 "… needle was sore in hand"-P 37 "… didn't like the thing in the hand, couldn't move thumb"-P 36 Suggestions for the Future Children who provided various suggestions 11 "…tell kids to bring something to calm them down"-P 30 "tell [children] about where the tonsils are and why getting them out will make you feel better"-P 9 "Maybe next time make it more fun by being fun"-P 48 "Maybe make it nicer. The nurses were really nice, keep them the same"-P 50 of nonsurgery-related factors to improve the overall hospital ex- By making these memories as positive as possible, we can potentially attenuate children's avoidance behaviors and procedural anxiety in the future.

ACK N OWLED G M ENTS
We would like to thank the amazing children and their families for being involved in this project.

CO N FLI C T O F I NTE R E S T
BS vUS is a section editor for Pediatric Anesthesia.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing will be considered on an individual basis within the institutional ethical guidelines.