Surgery Buddies: A Music Therapy rogram               for PediatricSurgical Patients

JENNIFER WHIPPLE The Florida State University

Tallahassee Memorial HealthCare

ABSTRACT: Surgical experiences often produce anxiety in pediatric patients and their families that can last throughout hospitalization and sometimes longer. Much of this anxiety develops immediately prior to the surgical procedure when the children and their families are required to wait for extended periods of time before being taken to surgery. Consequently, a music therapy program entitled Surgery Buddies was developed to involve children, their families, and hospital staff in music activities immediately prior to surgery, in order to decrease the opportunities for anxiety to develop. Through program development and implementation, it was discovered that the Surgery Buddies program may not only assist the pediatric patient in coping with hospitalization, but also the patient's family in managing their own anxiety, and hospital staff in carrying out necessary surgical preparation procedures. This program description includes an explanation of the needs of presurgical pediatric patients, logistical challenges of program implementation and possible solutions, and types of activities used within sessions, as well as anecdotal evidence of the program's benefits.

Experiences of hospitalization often produce pain, fear, and anxiety in children, possibly resulting in posttraumatic stress disorder or acute stress disorder lasting as long as one month or more after hospital discharge (Daviss, Mooney & Racusin, 2000; Daviss, Racusin & Fleischer, 2000). In addition, Calvin (2000) found that pediatric surgical patients with higher preoperative anxiety, as ssessed by their parents, required longer stays in the postanesthesia care unit following surgery. Palermo, Drotar, and Lambert (1998) found that children who reported greater use of goal-directed coping strategies for pain with previous surgical experiences reported lower levels of postoperative pain with the surgical experience in question. However, those same children reported higher levels of preoperative stress. Based on these findings, Palermo, Drotar, and Lambert theorized that lack of opportunity for preparation manifested in low levels of preoperative anxiety may result in higher levels of postoperative pain and anxiety, and that moderate levels of preoperative anxiety may actually provide an opportunity for coping skill preparation.

The vision for the Surgery Buddies program developed from research completed by Chetta (1981) and Malone (1996). The effects of live music intervention with pediatric patients under eight years of age receiving intravenous starts and restarts, venipunctures, injections, and heel sticks were examined by Malone (1996). Patients who received an interactive live music distraction technique displayed significantly less behavioral stress than did patients who did not receive music therapy intervention during the procedure. Furthermore, 79 percent of parents reported the addition of music to be beneficial. Chetta (1981) found that pediatric patients who received verbal and musical preparation the evening before surgery, as well as music immediately before, during, and after the initial injection of anesthesia, displayed significantly lower levels of anxiety as evidenced by behavioral and pulse rate responses to pain before, during, and after injection than did patients who received either verbal or verbal and musical preparation and explanation of surgery only on the evening before surgery.

The goal of the Surgery Buddies program is to provide anxiety reduction for pediatric surgical patients and their caregivers. According to a meta-analysis of music in medical treatment completed by Standley (2000), the provision of live music by a trained music therapist is more effective than recorded music, while preferred music is most effective. In addition, children and adolescents display greater responses to music therapy in medical settings than do adults. Also, within the surgical setting, music used during the pre-operative period achieves significantly better results than does music initiated during the procedure or postoperatively. Standley's analysis also provides the following implications for clinical applications of music therapy with hospitalized children:

l         use preferred music and music activities

l         verbally suggest that music will assist in pain relief and anxiety reduction

l         pair music with pleasant verbal associations and guided imagery

l         do not assist medical staff with pain-inducing procedures

l         reinforce signs of relaxation, cooperation, and verbalizations that do not include references to pain or anxiety

l         invite family members to participate in music and encourage them to reinforce positive interactions and allow the child to be independent

l         reinforce independence and cooperation and leave activities with the child that will foster independence and increase positive interactions with others in the environment.

In the previously mentioned study about children's coping during surgical hospitalization, Palermo, Drotar, and Lambert (1998) included a 12 item list of events that had been previously identified by 30 children in a pilot study regarding concerns about surgery and hospitalization. Of that list, the five items in bold are addressed in each Surgery Buddies sessions and all of the others may be incorporated through specific music therapy activities and counseling as needed on an individual basis.

l         spending the night in the hospital

l         wondering if surgery will help his/her condition

l         blood test

l         being away from his/her parents

l         pain after surgery

l         injection

l         uncertainty about the surgical process

l         receiving general anesthesia

l         pain medication

l         missing school having nothing fun to do in the hospital

l         missing friends.

The surgical schedule is finalized one day prior to surgery at which point a music therapist (MT) is assigned to each surgery scheduled for pediatric patients aged 18 months through 12 years. As a standing referral exists for music therapy for all pediatric pre-surgical patients, the MT is assigned by the music therapy department coordinator based on MT and department scheduling needs. The majority of pediatric surgery occurs in the morning because patients are restricted from eating and drinking until the conclusion of procedures. Most pediatric surgical patients are admitted to the hospital on the morning of the scheduled procedure and, while some patients are discharged to home on the same day as the surgical procedure, some are admitted to the hospital following surgery. Procedures range from eye surgery to exploratory to hernia repair. The MT reports to the nurses' station on the unit of admission approximately one hour before the scheduled surgery time and then proceeds to the patient's room where the MT invites the child, family members, and hospital staff to interact in music activities. Throughout the session, the MT avoids interfering in the surgical preparation process. In most cases, the music activity can continue during nursing intervention. For example, if a nurse needs to fasten an identification bracelet around the patient's wrist, the MT can shift his or her body position if necessary to provide the nurse access to the patient without a break in music. At other times, it may be necessary for a music game or activity to end, such as Music Therapy Perspectives (2003), Vol. 21 when hospital staff arrive to transport the patient to the surgical suite. However, even while music materials are removed and the MT steps away from the patient's bed, music singing, listening, and discussion, and limited instrument playing can continue. If a hospital staff member needs to discuss something with the patient, music can still be played quietly in the background, and, when staff and parent discussion occurs, the involvement of the child in music is often highly beneficial.

Session planning requires flexibility, the ability to assess and immediately respond to the child's needs, and a large repertoire of age-appropriate music and activities. Robb (2000) evaluated the effects of a contextual support model of music therapy on the behaviors of hospitalized children. In music therapy sessions based on this model, the natural structure of the music, session formats incorporating opportunities for self expression and decision making regarding activities (e.g., music instrument selection, song writing, etc.), and the support of the therapist promote a sense of control and opportunities for coping skill development in hospitalized children. Engaging behaviors were considered to be active physical responses, focused attention, choice making, following directions, and positive affect. Pediatric patients involved exhibited greater engagement with their environment during the music activities than during reading or normal hospital activities. In fact, a higher score was achieved for each of the engaging behaviors during the music condition and decreased in all categories except choice making during the reading condition, as it provided a choice of two recorded storybooks to be shared with the therapist. While reading is an appropriate activity and potentially beneficial coping strategy, analysis of the engaging behaviors examined indicated that music involvement may provide more opportunities for active coping strategy development.

Much like the model described by Robb (2000), Surgery Buddies sessions include singing, music instrument selection and playing, music games, song writing, reading of children's literature, and discussion of coping strategies related to feelings about hospitalization and the impending procedure. The provision of opportunities for distraction, even when not developing into a discussion about concerns about hospitalization, can be a coping strategy as described by Palermo et al. (1998). In order to elevate the patient's sense of control, every decision made and initiative taken by the child is validated, including decisions related to the structure of activities as well as the possible request to stop the music therapy session at any time. When preparing for sessions, the MT knows only the child's name, age, type and time of scheduled surgery, and sometimes gender. Rarely does the MT know prior to entering the patient's room the child's previous surgical and hospitalization history, any additional diagnoses, issues affecting development and abilities, music preferences, interests, or what the child's emotional state will be. Child history is not usually known by hospital staff until the medical chart is started upon admission, approximately 30 minutes before the MT arrives to provide intervention. The MT has access to the child's medical chart once arriving on the unit, but if the chart is being Surgery Buddies sed by another hospital staff member, the MT may choose not to wait an indefinite period of time to read it, which would cause the beginning of an already potentially short MT session to be delayed. Nursing staff members, depending on availability and the amount of time already spent with the patient or in reviewing the medical chart, are sometimes a resource for such information. Additionally, a Surgery Buddies session, while designed to last approximately one hour, lasts for an indeterminable length of time, anywhere from five minutes to two hours or more, depending on the progression of the day's surgery schedule. Because of these challenges to session planning, the MT takes to the patient's room a variety of activities and moves from one to the next as directed by the patient's interactions and eventual transport to surgery. Robb, Nichols, Rutan, Bishop, and Parker (1995) examined the effects of music assisted relaxation including preferred, recorded music listening in the patient's room, during transport to the surgical suite, during induction of anesthesia, and again in the recovery room, deep diaphragmatic breathing, progressive muscle relaxation, and imagery with preoperative pediatric patients. Training in music assisted relaxation was provided on the evening before surgery and then implemented beginning on the morning of surgery. The group of children receiving treatment showed a significant reduction in anxiety scores based on the State-Trait Anxiety Index for Children, while children not receiving intervention did not show change. During transport, the MT was available for emotional support and then served as a transitional figure once the child was separated from his or her parents. This transition from the patient's room all the way into the operating room was reported to be easier for patients in the treatment group. Staff members stated that the rapport between the MT and the patient, as well as the soothing and distracting nature of the music helped to provide a smoother transition into the operating room, especially during the moment of separation from the parents, which was beneficial to the patient, staff, and parents. Consequently, within the Surgery Buddies program, the MT offers to accompany the patient and family when the child is transported to the surgical holding area. If the offer is accepted, music activities are continued in the holding area until the patient is moved into the operating room. Intravenous starts generally occur in the operating room once the pediatric patient is unconscious following the initial induction of anesthesia via an anesthesia mask. While studies by Chetta (1981) and Malone (1996), which were the impetus for this program, focused on the reduction of pediatric patient stress during needle sticks, such pain management distraction techniques are not usually required during a Surgery Buddies session. However, if the patient does experience a needle stick of any sort during the Surgery Buddies session, the MT provides music that is familiar to the child as well as an interactive song composed by Malone (Batson, 1994) for this purpose. At the conclusion of the session, music instruments and materials are disinfected and then returned to the music therapy storage area.

Case Examples

The stories below of "Andy," "Billy," "Colby," "Daisy," and "Emma" are typical of Surgery Buddies patients and sessions. All five patients were admitted to and discharged from the hospital on the days of their scheduled procedures, and all received general anesthesia once inside the operating room with the addition of local anesthesia as needed at the incision site. Consequently, music therapy intervention was not required during a needle stick procedure for any of the following patients.

Case Example 1

Andy, a six-year-old boy, and his fourteen-year-old brother were assigned to the same room, as both patients were awaiting the same colonoscopy to the cecum procedure to rule out lower gastrointestinal lesions. Andy has a strong familial history of colon cancer and two of his siblings had already had juvenile polyps removed. When the music therapy session began, both boys appeared to be relaxed, as evidenced by their postures, behaviors, and comments. When asked to identify their emotions about the impending procedures, they used words such as "excited" and made statements such as, "I'm glad it's finally going to be over." Their mother, however, was fidgeting and repeatedly used the word "scared" to describe the boys' emotional states. While music therapy intervention focused on Andy, his brother was supportive and participated in activities that interested him. After approximately 30 minutes of music therapy, their mother appeared to relax, discontinued use of the word "scared", and ceased fidgeting. She

began asking questions about the instruments and involving herself in the session's activities. In addition, she was able to attend to the nurses' questions while the boys attended to the music. Due to a delay in the surgical schedule, the music therapy session continued for one hour and fifteen minutes at which point Andy was transported to surgery and his brother appeared to fall asleep. Andy tolerated the procedure well and no large polypoid lesions were found. Approximately one hour later, the patients' mother saw the MT in the elevator where she expressed her appreciation, stating that she had enjoyed the music activities, had learned a lot about her children's musical abilities, and that she was considering purchasing some instruments like those used in the session because the boys had taken such interest in them. This session appeared to provide positive experiences for the two patients and anxiety reduction for their mother as well as facilitate focused discussion between the nurse and mother.

Case Example 2

Billy was eight years old when admitted for excision of a sebacious cyst at the lower rim of the umbilicus and for exploration to rule out underlying congenital abnormalities. He immediately involved himself in the music therapy intervention, playing various rhythm instruments, requesting to play the MT's guitar, and strumming the guitar as the MT fingered chords. He appeared to be completely distracted from the surgical preparation activities occurring in his room. Family members also became involved in the music interventions, clapping along with the songs, laughing, smiling, joking with Billy, and encouraging him to participate in the music activities. At one point a nurse commented, "I thought we were here for surgery. I didn't know we could have so much fun in the hospital." Billy was so engaged in the music therapy session that he failed to notice when additional hospital staff arrived to transport him to surgery. There were no surgical complications, Billy tolerated the procedure well, and the inflammatory cyst was determined to be benign. Billy had not displayed any signs of anxiety prior to the introduction of music therapy and did not display any throughout the session. It is possible that his distraction from hospitalization through engagement in music therapy may have prevented the development of anxiety. In addition, this session allowed for the patient, his family, and hospital staff to have fun together.

Case Example 3

Colby was a ten-year-old boy admitted for eye surgery, including Sceral Buckle, Trans Pars Plana Vitrectomy (TPPV), membrane peel, Endolaeser, silicone oil placement, and indirect laser procedures. His left eye had been hit accidentally by his younger brother, resulting in decreased central vision. He was sitting slumped in a chair with his head down on the arm of the chair when the MT entered his assigned room. When asked if he wanted to participate in music activities, he responded by asking if the MT was the person who would "give [him] the shot." Upon further explanation of what the music therapy session would entail and a mention of some music instruments, Colby immediately sat up straight in his chair and asked to see the instruments. He then participated in all music activities presented, selecting rhythm instruments to play, frequently requesting to "keep on going" because he wanted "to do another one," and independently arranging the Boomwhackers?(plastic tubes ranging in length from 12 to 24 inches, tuned to different pitches that can be hit against the body or an object one at a time or simultaneously, combining tones to create chords, with different surfaces creating different timbres) on the floor and playing them to accompany numerous songs. Colby appeared to be completely distracted from what was happening around him in the room, which allowed the nursing staff to attach an identification band around his wrist and to talk with his parents about the impending procedure. Colby did not appear to realize when staff arrived to transport him to surgery, but then assisted the MT in packing up the instruments before leaving for surgery.

When Colby returned 32 days later for repetition of the TPPV, membrane peel, and silicone oil placement procedures, his father was standing in the hall outside the room as the MT arrived. As soon as he recognized the MT from the previous surgical visit, he said, "Hi. I remember you. Are you here to see [Colby] again?" When assured that the MT was there to see his son, he said, "Great, great, come on in," seemingly very pleased and excited about the involvement of music therapy in his son's care. In fact, Colby's father mentioned that he had just asked a nurse if music therapy would be available. Music Therapy Perspectives (2003), Vol. 21 Colby, who was sitting quietly on his bed when the MT entered the room, immediately recognized the MT and smiled. Colby quickly began participating in the music intervention, playing various rhythm instruments and singing. He became so involved in the session that he created new rules for the rhythm instrument sequencing activity in which he and the MT were participating and suggested that they incorporate additional sources of rhythm (e.g., clapping, tapping the bedside table and the bed, etc.). There were no complications, but surgery revealed a serious retinal detachment, possibly from Coat's disease. Prior to surgery it had been determined that the procedures might not improve Colby's vision, but would prevent pain and shrinkage. Should additional surgeries be warranted, music therapy services would be offered again. In both sessions, music therapy seemed to elevate Colby's mood and reduce his level of anxiety. In addition, Colby's engagement in music therapy allowed free discussion between his parents and nursing staff.

Daisy, a three-year-old girl admitted for repair of an umbilical hernia, appeared withdrawn at the beginning of the session, displaying a flat affect as she sat on her mother's lap and leaned to one side. However, she sat up and smiled when music instruments were introduced. Daisy participated in song selection, instrument playing, and some singing. Her family provided a supportive and positive environment throughout the session. Daisy smiled when a nurse attached an identification bracelet around her wrist, but her smile faded after transport staff arrived and discussion of moving her to the surgical holding area began. She smiled again when the nurse and MT suggested that music therapy continue in the holding area. Once in the holding area, smooth transitions were achieved between music and nursing interventions. The holding room nurse even danced into the room to the music created by Daisy and the MT in order to check Daisy's identification band and was able to interact with the family while Daisy continued playing instruments. Daisy did not display any additional anxiety until the same nurse picked her up to carry her into the operating room at which point she began to cry. Music stopped as Daisy was taken from the room, but neither musical nor verbal session closure was provided. Daisy tolerated the surgical procedure well. Through both its successes and missing elements at the end, this session demonstrated the importance of continuing music therapy throughout the preoperative experience if desired by the child and family. This continuity can include the transition from the patient's

room to the surgical suite holding area, as well as into the operating room, as described in Robb, et al. (1995).

Case Example 5

Emma, a nine-year-old girl, appeared to be experiencing anxiety prior to surgery, determined by parent and nursing reports to music therapy staff as well as her flat affect and reluctance to speak with music therapy staff and participate in music activities. However, she did agree for the MT to readSurgery Buddies aloud a story, the focus of which was dreaming. With prompting, Emma did select instruments and movements to represent the story's characters and assigned the various parts to herself and her family members present. Although reserved throughout the session, Emma did appear to become more comfortable during the story activity, as evidenced by freer body movements and increasing frequency of eye contact with the MT. At the conclusion of the story, Emma discussed with the MT that she would be receiving anesthesia, which would cause her to sleep, and imagined aloud about the pleasant things she might dream about. When asked, Emma told the MT that she did not want to participate in any additional music activities then laid down, appearing more relaxed than prior to the session, and, smiling, said goodbye to the MT. This session provided an enjoyable activity in which the patient became engaged, allowing distraction and reduction in anxiety. Though her desired dreams were not discussed in detail, this is an example of counseling with a patient in which the activity included short discussion to prepare for the impending surgical process. As previously discussed, according to Palermo, et al. (1998), such acknowledgment of the surgical procedure and potential anxiety allows for coping skill development beneficial to the pediatric patient.

Further Considerations

The hospital where the Surgery Buddies program was developed is fortunate to host both an Arts In Medicine (AIM) volunteer program and a music therapy clinical services program. Surgery Buddies began as a project of the Arts In Medicine (AIM) volunteer program, the purpose of which is to enhance the hospital environment for patients, visitors, and staff through experiences in music, dance, theater, visual art, and computer discovery, in the form of exhibits, performances, permanent art installations, and hands-on experiences. Regardless of specific Surgery Buddies training, volunteers frequently expressed feeling uncomfortable in implementing the program, yet volunteers who were enrolled in a university music therapy academic program did not seem to report the same intensity of anxiety as other volunteers. Periodically, music therapy staff led Surgery Buddies sessions when volunteers were unavailable. Based on those experiences and volunteer reports, it became apparent that volunteer uneasiness may have resulted from essentially being asked to conduct music therapy sessions in which counseling issues often arose. Consequently, it was decided that, while AIM volunteers excel in and are a vital part of many areas of service at the hospital, the Surgery Buddies program requires trained clinicians prepared to handle such situations appropriately and therapeutical ly.

Another consideration may be the presence of other patients rin the same room, which can occur on the unit of admission or in the surgical holding area. A patient not receiving music therapy could be irritated by music from his or her roommate's session or could have different emotional or developmental needs. However, inclusion of multiple patients in one session can provide a beneficial support group atmosphere. Music and activity selection may need to be varied in order to meet the developmental and chronological age abilities, personal preferences, and emotional needs of each patient. Clinical implementation of this has occurred at times within the Surgery Buddies program. "Frank," age three, "Grace," age four, and their family members were unexpectedly all in the ame pediatric holding area in the day surgery unit of the hospital when the MT arrived. A group was spontaneously formed of all present. As one patient left for the operating room, the nurse anesthetist who had observed the positive social and music interactions of the children and their families asked to take some instruments into the anesthesia room to assist in the transition process. This case description illustrates the ease in implementation and potential benefit of a group session, however unexpected.

Program Evaluation

Until this point, program success has been determined based on patient behavioral changes informally observed by the MT and on staff and parent comments. However, more formal a) surveys of patient, family, and staff perceptions, b) behavioral observations of patients, and c) patient physiologic measures are certainly feasible methods of measurement of program benefits for future exploration.

The Surgery Buddies program seems to provide a positive experience for the patient and his or her family as well as for hospital and music therapy staff. Unit staff members appear appreciative for and supportive of music therapy services for pediatric surgical patients, as the provision appears to benefit their interactions with the children and allows them to complete the necessary surgical preparations relatively quickly with few complications. Parents and guardians also tend to be appreciative for the distraction of music therapy for their children, which can allow families time to discuss questions and concerns with staff prior to the child's actual transport to surgery. Active family involvement in the music-making process can also provide a way to alleviate or at least distract parents and guardians from their fears and anxieties about their child's impending surgical procedure. Unit staff members appear appreciative for and supportive of music therapy services for pediatric surgical patients, as the provision appears to benefit their interactions with the children and allows them to complete the necessary surgical preparations relatively quickly with few complications.

When surveyed by Kristensson-Hallstrom (2000), parents of pediatric surgical patients reported feelings of guilt, anxiety, loss of control, and uncertainty over their children's health and the unfamiliar hospital environment. However, parents who were actively involved in their children's care perceived that their children experienced lower levels of pain than reported by parents who chose to be less involved in the caregiving process. Similarly, parental distress seemed to increase parent perceptions of pediatric patient distress and was greater in parents whose children had experienced prior traumatic events (Daviss, Racusin, & Fleischer, 2000). It is, therefore, understandable that Andy's mother seemed to be experiencing greater anxiety about her children undergoing surgery than they were, yet appeared to become less anxious herself as she became engaged in the Surgery Buddies session. Chetta (1981) and Malone (1996) employed the use of parent report in assessing the efficacy of music therapy intervention, focusing on parent perceptions of the patient's pain and anxiety. In the day surgery unit of the same hospital as the Surgery Buddies program, Oggenfuss (2001) investigated the effect of live music therapy sessions with pediatric patients on the anxiety of their parents and guardians. Ninety-five percent of parents and guardians who observed their children participating in a music therapy session prior to surgery reported decreased anxiety, although pre- and post-session Likert scale completion results did not reach significance. Additionally, 100 percent of those parents and guardians stated that the music therapy intervention was beneficial to their children's well being and expressed that they would welcome music therapy as part of their children's care again.

Consequently, the Surgery Buddies program has been expanded to the day surgery unit where larger numbers of pediatric surgeries, most in the form of tonsilectomy, adenoidectomy, and ear tube insertion and removal procedures, are performed daily, ending with patients being discharged to home. Unlike in the surgical experiences scheduled for the hospital's main operating room described in the above case examples, the pediatric area of the day surgery unit environment was designed for children. The holding room used for pediatric patients to age 10, often several at a time, has animal scenes painted on the walls, a television and VCR with children's video tapes, and a play mat area for infants and toddlers. The pediatric atmosphere is further enhanced through explanation of the entire surgical process in terms that are non-threatening and easily understood by children. The day surgery patients are even given a choice of anesthesia flavor (grape, strawberry, chocolate, or bubblegum) and the privilege of pressing the "magic button" on the wall to open the door leading to the operating room. This already age-appropriate environment is only further enhanced by the addition of music therapy services.

Based on the anecdotal information presented in the above case examples and research by Oggenfuss (2001), it seems advantageous to investigate further the parental benefits of the Surgery Buddies program, likely related to the distraction of parents from their own anxiety as well as the comfort derived from their children's reduction in anxiety. This could be accomplished through simple pre- and post-intervention survey, as previously suggested, or more formal behavioral observation and pre- and post-intervention State-Trait Anxiety Inven- Music Therapy Perspectives (2003), Vol. 21 tory of parents. These advancements may not only refine knowledge of interventions helpful in assisting pediatric patients and their families, but may also further justify the need for music therapy services for pediatric surgical patients, as benefits seem to extend beyond the one patient on whom a session may focus. Potential also exists for intervention with parents while they are waiting for their child to emerge from surgery.

To strengthen the Surgery Buddies program, a transitional song to be used specifically when children are transported to the holding area and into the operating room could be composed. Adaptation of such a song within sessions would allow for individualization as well as the integration of patient composition as appropriate. Transitional song addition, along with staff education in its purpose and use, might assist in smoother transitions from the room of admission to the holding area and from the holding area to the operating room, so that sessions do not end as Daisy's did. It is possible that such a song signaling the close of the music therapy session could trigger tears from a patient; however, such expression of sadness and fear is already often apparent during the room transition process. This addition could facilitate a smoother transition, especially if the song were the same, but with different verses for the various stages of transport. Hospital procedures are changing so that pediatric surgical patients scheduled for the main operating room are no longer admitted to the general outpatient surgery unit, but are first admitted to the pediatric floor, equipped with pediatric nurses, creatively decorated hallways and rooms, music listening opportunities, toys, and books. Still, these young patients are subsequently transported to the main operating room holding area and then the main operating room, transitions in which use of a specific song could assist in maintaining a therapeutic environment and shaping a more child-friendly atmosphere.

The anecdotal evidence presented supports the clinical implementation of research completed by Chetta (1981), Malone (1996), Robb (1995, 2000), and Oggenfuss (2001) regarding pediatric hospitalization and surgery. The possibilities mentioned, as well as many others, for future program evaluation and development may facilitate making such programming comprehensive for the patient, family, and hospital staff.

                                                                REFERENCES

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Calvin, R. L. (2000). Pediatric day surgery outcomes management: The role of preoperative anxiety and home pain management protocol. Association of Operating Room Nurses Journal, 77(3), 695.

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