The four P's of preparing children for procedures

James is a 7-year-old boy scheduled for a tonsillectomy and adenoidectomy (T’s & A’s) at a regional day surgery unit. He has never been in hospital before and is anxious about “doctors and needles.” His mother is equally nervous.

The admitting nurse recognises this as an opportunity to apply the 4 P’s framework – Prepare, Play, Parent, Praise – to reduce anxiety and improve cooperation.

1. Prepare 

On arrival, James clutches his mother’s hand tightly and looks worried, he is not engaging with the staff and doesn’t want to answer questions. 

The nurse kneels to his level and explains what is going to happen step-by-step using his toy dinosaur to demonstrate the steps:

“First, we put some cream on Dino’s hand to make it numb. Then later we use a tiny straw to help Dino get sleepy medicine. When Dino wakes up, you and your Mum will be right there.”

The nurse avoids jargon, uses concrete language (“tiny straw”), and is honest about discomfort while providing reassurance. James is offered the chance to ask questions and apply the cream to Dino also. Numbing cream is then applied promptly to James' hand after the demonstration to allow time for effect.

Top Tip: Honest, age-appropriate explanations reduce pre-operative anxiety and help children feel respected and in control (Jaaniste, Hayes, & von Baeyer, 2007; SPANZA, 2019).

2. Play 

While waiting, James is given further opportunities to engage in medical play. He places a pulse oximeter on his toy dinosaur and uses a syringe filled with coloured water. Later, at anaesthetic induction, James chooses to listen to his favourite song through headphones while the nurse counts with him until he drifts off.

These playful strategies transform frightening equipment into familiar objects and give James a sense of mastery.

Top Tip: Medical play and distraction (e.g., iPads, music, bubbles) significantly lower distress and improve procedural cooperation (Fortier et al., 2015).

3. Parent 

Throughout the process, James’s mother is treated as an active partner. She is invited to stay during induction, reassured about her role, and taught how to support James with calm breathing games and holding his comfort item.

After surgery, she is brought into recovery as soon as possible. Her presence reduces James’s agitation and helps him re-orient quickly.

Top Tip: Family-centred care – including caregiver presence and involvement – improves perioperative outcomes and reduces anxiety for both child and parent (Kain et al., 2007; Coyne, Holmström, & Söderbäck, 2018).

4. Praise 

In recovery, the nurse high fives James:
“You did such a great job keeping your arm still. That really helped us.”

He receives a sticker and a certificate and his toy Dino is there in the bed with him when he wakes up as promised. His mother is also commended for her support, helping her feel valued as part of the care team.

Top Tip: Positive reinforcement builds resilience, reduces negative recall, and strengthens trust for future healthcare encounters (SPANZA, 2019).

Outcome

James tolerated his procedure with minimal distress. His mother felt supported, informed, and confident about caring for him at home. The staff noted his cooperation during IV insertion was great despite his initial anxiety on arrival.

Lessons for Practice

The 4 P’s – Prepare, Play, Parent, Praise – offer a simple, memorable framework for health professionals to guide children and families through day procedures. Using this approach ensures care is:

• Developmentally appropriate

• Family-centred

• Evidence-based

• Trauma-informed

Professional Guidelines & Evidence-Based Resources

What is covered in this blog is just the basics, if you wish to learn more, here are some good resources to begin with

• SPANZA (Society for Paediatric Anaesthesia in New Zealand and Australia) – Perioperative care of the paediatric patient: Guideline for health professionals (2019). Practical, evidence-based standards for paediatric perioperative care. SPANZA Guidelines
  
  

• Royal Children’s Hospital Melbourne – Kids Health Info & Clinical Guidelines: Resources on pre-procedure preparation, procedural pain, and family-centred communication.
  
  

• Association of Child Life Professionals (ACLP, USA) – resources and training modules on play therapy, preparation, and family-centred care.

References

• Coyne, I., Holmström, I., & Söderbäck, M. (2018). Centeredness in healthcare: A concept synthesis of family‐centered care, person‐centered care and child‐centered care. Journal of Pediatric Nursing, 42, 45–56. https://doi.org/10.1016/j.pedn.2018.07.001
  
  

• Fortier, M. A., Bunzli, E., Walthall, J., Olshansky, E., Saadat, H., Santistevan, R., & Kain, Z. N. (2015). Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): Formative evaluation and randomized controlled trial. Anesthesia & Analgesia, 120(4), 915–922. https://doi.org/10.1213/ANE.0000000000000610
  
  

• Jaaniste, T., Hayes, B., & von Baeyer, C. L. (2007). Providing children with information about forthcoming medical procedures: A review and synthesis. Clinical Psychology: Science and Practice, 14(2), 124–143. https://doi.org/10.1111/j.1468-2850.2007.00071.x
  
  

• Kain, Z. N., Caldwell‐Andrews, A. A., Mayes, L. C., Weinberg, M. E., Wang, S. M., MacLaren, J. E., & Blount, R. L. (2007). Family‐centered preparation for surgery improves perioperative outcomes in children: A randomized controlled trial. Anesthesiology, 106(1), 65–74. https://doi.org/10.1097/00000542-200701000-00013
  
  

• Society for Paediatric Anaesthesia in New Zealand and Australia (SPANZA). (2019). Perioperative care of the paediatric patient: Guideline for health professionals. Retrieved from https://www.spanza.org.au

Learn more here: Lunch and Learn - Perioperative care of the neurodivergent child