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Original Paper

Parental Experiences of the Pediatric Day Surgery Pathway and
the Needs for a Digital Gaming Solution: Qualitative Study
Arja Rantala1*, RN, MHSc; Miia M Jansson2*, RN, PhD; Otto Helve3*, MD, PhD; Pekka Lahdenne4*, MD, PhD;
Minna Pikkarainen5*, PhD; Tarja Pölkki6,7,8*, RN, PhD
1

Research Group of Medical Imaging, Physics and Technology, Research Unit of Nursing Science and Health Management, Faculty of Medicine,
University of Oulu, Oulu, Finland2

Research Group of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland

3

Pediatric Research Center, Department of Pediatrics, Helsinki University Hospital, University of Helsinki, Helsinki, Finland4

Department of Pediatrics, Helsinki University Hospital, Helsinki, Finland5

Research Group of Medical Imaging, Physics and Technology, VTT Technical Research Centre of Finland, University of Oulu, Oulu, Finland

6

Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland

7

Department of Children and Women, Oulu University Hospital, Oulu, Finland

8

Medical Research Center Oulu, Oulu, Finland*

all authors contributed equally

Corresponding Author:
Arja Rantala, RN, MHSc
Research Group of Medical Imaging, Physics and Technology
Research Unit of Nursing Science and Health Management, Faculty of Medicine
University of Oulu
Pentti Kaiteran katu 1
Oulu, FI-90014
FinlandPhone: 358 504340424
Email: arja.rantala@oulu.fi

Abstract
Background: The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative
pain relief, and postoperative guidance. Parents’ experiences help care providers to provide effective, family-centered care that
responds to parents’ needs throughout the day surgery pathway.
Objective: The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs
for a digital gaming solution in order to facilitate the digitalization of these pathways.
Methods: This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to thehospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended
questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheresto the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.
Results: Parental experiences of the children’s day surgery pathway included 3 main categories: (1) needs for parental guidance,(2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparationof child for treatment). The needs for a digital gaming solution were identified as 1 main category—the digital gaming solution
for children and families to support care. This main category included 3 upper categories: (1) preparing children and families forthe day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution.
Conclusions: Parents need guidance and support for their children’s day surgery care pathways. A digital gaming solution may
be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to
digital gaming solutions that provide support and guidance and engage children in the day surgery pathways.
(JMIR Med Inform 2020;8(11):e23626) doi: 10.2196/23626

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KEYWORDS
anxiety; children; day surgery; delivery of health care; digital solution; gamification; nursing; pain; qualitative study; technology

Introduction
Background
The Global Observatory for eHealth has defined mobile health(mHealth) solutions as “medical and public health practicesupported by mobile devices, such as mobile phones,
patient-monitoring devices, personal digital assistants (PDAs),
and other wireless devices” [1]. These digital or connected
health services or solutions are changing medical and publichealth practices [2]. However, assessment frameworks should
respect the needs and capacity of each medical system or country[3]. Gaming and gamification are areas of mHealth, which can
expand users’ acquiescence with health interventions andimprove users’ capability to self-administer and adherence totreatment [4]. Among health care professionals, developing
games should be evidence-based and targeted to those who needthem [5]. Gamification includes game design elements in a
nongame context [6]. Game elements include competition underrules, a narrative context, a feedback and communication system,and time pressure. In addition, gamification engages users with
unparalleled intensity and as per a duration system [6,7]. Serious
health games (SHGs) can include educational and physiologicalelements as well as additional knowledge on how to influence
the goal achieved through the game, such as alleviating pain oranxiety among children or parents [5,8].
For children, day surgery procedures are more common thaninpatient procedures [9]. Every year, approximately 3%-10%
of children (age <17 years) experience hospital stays indeveloped economies, such as the United States and Europe[9-11]. Day surgery patients are admitted, operated on, anddischarged on the same calendar day [12,13]. A day surgicalpathway should be based on a well-planned protocol, defining
all the steps from planned treatment, to hospital admission, andto hospital discharge within the same day. A day surgicalpathway is cost-effective and includes a nurse‐delivered
preanesthetic assessment consisting of preoperative education
and appropriate postoperative care guidance. Such carefulpatient guidance reduces hospital readmissions. [14]. Surgicalconditions constitute a significant proportion of the global
burden of diseases [15]. However, careful patient selection,refinements in surgical and anesthetic techniques and devices,and successful patient outcomes have contributed to the optimal
utilization of surgical processes along with early discharge [14].
Outpatient care also includes patients who are sedated formagnetic resonance imaging (MRI) and are discharged after
treatment [16]. Guidelines from the Association of Anaesthetists
and the British Association of Day Surgery underline theimportance of instructions concerning day surgery and its flow[14]. An ideal day surgery pathway includes minimized waitingtimes, information on day surgery procedures, routine
preoperative checks on the day of admission, analgesia andother postoperative information at discharge, and eventually,
instructions for telephone follow-up [13]. The information
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families), and age-appropriate (for children) [14,17]. Patientsshould be admitted to the day surgery units as close as possible
to the time of their surgery.
This paper focuses on parental experiences from the pediatricday surgery pathway. Our study is part of the Icory (Intelligent
Customer-driven Solution for Orthopaedic and PaediatricSurgery Care) project in which the ecosystem of hospitals,
researchers, and technology providers, together with children
and families, are codeveloping a digital gaming solution for the
day surgery path.
According to the previous meta-analysis, digital gaming
solutions can reduce children’s preoperative anxiety and increase
parental satisfaction [18]. In addition, digital gaming solutions
can be considered as nonpharmacological distraction tools forchildren. Parents’ experiences may help care providers to deliver
more effective, family-centered care that responds to parents’needs throughout the day surgery pathway [18]. Family-centeredcare considers the individual needs of parents and children [19]and emphasizes the role of written information intended toreduce parental anxiety and stress regarding day surgeries[20,21]. In the child-centered care, a child is a person with theirown voice and joint participation and partnership in a careenvironment and is considered competent [19].
In day surgery processes, appropriate preoperative preparationis crucial [22,23]. Usually, the day surgical treatment is a uniqueexperience for both the child and family. The incidence of
preoperative anxiety in children varies between 40% and 75%[24,25]. In order to avoid unexpected stress, the whole familyneeds to be prepared for upcoming surgery [26]. Untreatedanxiety is associated with increased intensity of pain afterwards[26-28]. In addition, parental anxiety has an enormous effecton children’s preoperative anxiety, which correlates withincreased postoperative pain in children [28]. Correspondingly,
the factor of postoperative pain is associated with parental
satisfaction in pediatric day surgery [29].
The parents of hospitalized children perceive high levels ofstress and anxiety [30,31]. In addition, they are dissatisfied withwaiting times [32,33], fasting [32], discharge criteria [13,34],
and postoperative pain relief [29]. Parental satisfaction withtreatment and the care itself, however, is good [29].
Our study focuses on the gap between the information provided
to parents and their needs. In addition, the expectations from a
digital gaming solution were addressed to support thedigitalization of pediatric day surgery pathways. The researchquestions were as follows:1.
2.

What are the experiences of parents of care in the pediatricday surgery pathway?
What are the needs of parents for a digital gaming solution
in the pediatric day surgery pathway?

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This was a descriptive qualitative study based on the experiencesof parents of hospitalized children [35,36].

specialized health care in pediatrics, including pediatric surgery,child neurology, and child psychiatry. In addition, the hospitalhas been assigned the national treatment responsibilities in
specific pediatric conditions, for example, cardiac surgery andorgan transplant. In 2019, a total of 6883 surgical operations
were performed of which 3300 were day surgery procedures.

Participants and Settings

Data Collection

Participants were asked to volunteer and participate in the study
using convenience sampling [35]. The inclusion criteria wereas follows: parent or custodian of a child who was receiving a
day surgical treatment at the selected hospital, ability tounderstand and write in Finnish, and access to a laptop or amobile app for answering the questionnaire. The selectedparticipants were acquainted with the research topic [37] becauseof the experience of their child’s day surgery pathway in thehospital.

The data were collected using an unstructured questionnaire.
The questionnaire was planned and designed via remotemeetings in 2018 by a panel of 7 specialists from the Universityof Oulu, VTT Technical Research Centre of Finland, Helsinki
University Hospital, and Oulu University Hospital. The panel
included pediatricians, nurses, and researchers. The
questionnaire was designed to gather information on current
pathways of children’s day surgeries in order to develop a moredigitized pathway; it was based on the findings from an earlier
study [2]. The questionnaire was designed to address theresearch questions using 3 demographic and 6 open-ended
questions (Textbox 1). The questionnaire was tested in March
2019 by a PhD student and a professor in the selected hospitalwith parents who were waiting for treatment for their children.
The parents were invited to respond to Questback Essentials’
web-based unstructured questionnaire via a quick response (QR)
code using their own mobile phones. A total of 5 parents
responded, and thus the questionnaire was considered usable.

Methods
DesignThe respondents consisted of parents (N=31) whose children
were admitted to otolaryngologic surgery (n=7), plastic surgery(n=3), oral/dental surgery (n=1), ophthalmic surgery (n=1),
orthopedic surgery (n=7), soft tissue surgery (n=3),
gastroenterological surgery (n=5), vascular surgery (n=1), andMRI (n=3). Out of the 31 parents, 23 (74%) were females aged
30-39 years, and 8 (26%) were males.
The study was conducted at the university hospital in Finland,a 140-bed tertiary care pediatric hospital. The hospital provides
Textbox 1. Unstructured questionnaire for parents.
1.

Respondents’ demographics

2.

Respondents’ demographics

3.

Has your child been in a day surgery unit? Yes/No

4.

What kind of treatment has your child had?

5.

What kind of information did you receive from the hospital staff about what is going to happen during your child’s day surgery treatment?

6.

Could you describe what kind of support you received during your child’s treatment?

7.

Can you tell us how your child was involved in the care path provided by the hospital staff?

8.

Did you have an access to any treatment-related games during your child’s care that you would have played with your children?

9.

Demo of the Icory solution: What do you think of this solution? What kind of solution should be available?

Data collection was conducted from October 2019 to December
2019. The research nurse recruited voluntary respondents fromthe hospital’s recovery room while children were in the
postanesthesia care unit. The parents answered the anonymousquestionnaire via their own smartphones or laptops. If the
respondent did not have a smartphone or a laptop, one wasprovided to them by the research nurse. The researchers were
not able to identify individual respondents.

Data Analysis
The qualitative data were analyzed by conducting an inductive
content analysis, which included 3 main phases: preparation,organization, and reporting [35,36]. Inductive content analysis
is used when knowledge is fragmented or when there is little
knowledge of the phenomenon [38]. Content analysis is amethod of analyzing written, verbal, or visual communicationthat distills words into content-related categories for providing
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new knowledge of the phenomenon [38,39]. The data wereanalyzed using NVivo 12 (QRS International), a qualitative
research software. Demographic data were reported using
frequencies and percentages.
First, the data were evaluated for quality by 3 researchers (AR,
MMJ, and TP). The data were transferred to NVivo 12. In theanalysis, initial impressions were written down as notes. Second,the data were abstracted into open codes and transferred into
tables. Similarly, open codes were grouped into categories [38].
Third, those categories were named using a word that wascharacteristic of the content and were formed into subcategories.
Similar subcategories were grouped together and called upper
categories. The process produced 294 open codes, 21
subcategories, 9 upper categories, and 4 main categories. The
data analysis was conducted by 2 researchers (AR and MMJ),
discussed and agreed upon by 3 researchers (AR, MMJ, andJMIR Med Inform 2020 | vol. 8 | iss. 11 | e23626 | p. 3
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TP), and commented on by the researchers who developed thequestionnaire (OH, MP, and PL).

Rigor
Rigor was ensured using the criteria of credibility, dependability,
confirmability, transferability, and authenticity [35,40,41].
Credibility and dependability in this study were ensured bydesigning the questionnaire based on early studies [2,25,42]
and based on the actual needs of the selected hospital.
Confirmability was established in the analysis process throughresearcher triangulation (AR, MMJ, and TP). The preparation
phase included defining participant inclusion criteria, planningthe data collection in questionnaire format to reach data
saturation, and selecting the unit of analysis.
Saturation was achieved when the written answers began torepeat themselves in the collected data. Transferability wasestablished in this study by describing the hospital environment
in which the study was conducted in order to enable theinterpretation and transfer of the results in other contexts.
Authenticity was ensured through quotations to indicate therichness of data [41]. The reporting was performed
systematically according to the COREQ (Consolidated Criteria
for Reporting Qualitative Research) criteria (Multimedia
Appendix 1) [43].

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Ethical Considerations
The study was reviewed by the local ethical committee (decision#3181-2018) and was granted a research permit (decision#284-2019). The aim of this study was verbally explained to
the respondents by the research nurse, and they were informedthat responding to the questionnaire was entirely voluntary. The
questionnaire was designed so that it would be impossible toidentify the respondents. The study followed the Helsinki
Declaration [44]. All participants were informed about thevoluntary nature of the research [21,45].

Results
Analysis of the data for the first research question revealed 3
main categories related to the parents’ experiences of theirchildren’s day surgery pathways: (1) needs for parental guidance(which included 2 upper categories—content of informationand patient flow during the day surgery pathway), (2) needs forsupport in the children’s day surgery pathway (which included
the upper categories—physiological support for children andpsychological support for children and families), and (3) childinvolvement in their own pathway (which included upper
categories—consideration of an individual child and preparing
a child for treatment) (Table 1).

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Table 1. Parental experiences of the care in the children’s day surgery pathway.
Categories

Experiences

Main category 1: Needs for parental guidanceUpper category 1: Content of information
Subcategory 1: Transparency of the pathway

•
•
•
•
•
•
•

Lack of knowledge regarding operating theater activities
Unexpected follow-up overnightUnexpected changes in day surgery pathway
Lack of knowledge regarding day surgery pathway
Lack of instruction regarding surgical wound
Instructions could be sent by email
Instructions in the information letter should be updated

Subcategory 2: Analgesia and amnesia•••

Lack of knowledge regarding pain management
Need for pain management guidance
Need for information about anesthesia

Subcategory 1: Physical environment•••

Lack of information regarding free parking
Guidance signs are needed
Timely permission for entering the waiting room

Subcategory 2: Waiting time

•
•
•
•
•

The overall waiting time was too long
Waiting is challenging with hungry children
The waiting time for the operation was too long
Progress regarding the waiting time should be shared by nurse
Unsustainable schedules

Subcategory 3: Roles and responsibilities

•
•
•
•

Doctor did not call following operation
Discrepancies in responsibilities
Superficiality of information
Nurses are better at sharing information

Subcategory 1: Eating after operation•••

Meal requirements
Unsuitable food after operation
Conflicting information regarding available meals

Subcategory 2: Environment safety•

Hearing protectors for sound-sensitivity

Subcategory 1: Rewards and trophies•

Rewards are pleasing

Subcategory 2: Psychological needs••

Parents’ psychological needs should be enquired about
Parental well-being should be considered

Subcategory 3: Timing of guidance••

Correct timing for nursing guidance
Parental role and timing in sudden situation

Subcategory 1: Individual needs••

Needs of sound-sensitive children
Own devices for sound-sensitive child

Subcategory 2: Giving more time to children••

More time should be given to children by the nurse
Calming should be ensured before operation•

Familiarization with treatment should be ensured

Upper category 2: Patient flow during the day surgery pathway

Main category 2: Needs for support
Upper category 1: Physiological support for children

Upper category 2: Psychological support for children and family

Main category 3: Child’s involvement in his or her own pathway
Upper category 1: Consideration of individual children

Upper category 2: Preparation for treatment
Subcategory 1: Preparation for treatment

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Categories

Experiences••

Subcategory 2: Preparation with games and pictures

Analysis of the data for the second research question revealed
1 main category, a digital gaming solution for children andfamilies to support care. This category included 3 upper

Pictures to help preparation
Games to help preparation

categories: preparing children and families for the day surgery
via the solution, gamification in the solution, and connecting
people through the solution (Table 2).

Table 2. Parental needs for a gamification solution in the day surgery pathway.
Digital gaming solution for children and families to support care

Experiences

Upper category 1: Preparing children and families for the day surgery via the solution
Subcategory 1: Preparing via digital gaming solution••

General information about surgery
Instructions available beforehand in solution

Subcategory 2: Virtual familiarization with the care environment•••

Virtual tour
Familiarization with operation room beforehand
Visibility of real environment

Subcategory 3: Waiting time in solution••

Information on waiting timeDistraction from waiting

Subcategory 1: Gamification to overcome hospital anxiety and fear

•
•
•
•

Games with music
Videos in solution
Fun in order to relieve fear
Games for reducing fear

Subcategory 2: Gamification in support of care•••Games for preparation
Games for rehabilitation
Age-appropriate material for children

Upper category 2: Gamification in the solution

Upper category 3: Connecting people through the solution
Subcategory 1: Interaction between the medical staff, families, and children ••Interaction between nurses and patient
Support and guidance from staff (apart from game••

Children telling stories about treatment via solution
Ability to share feelings

Subcategory 2: Peer support

Needs for Parental Guidance
The parents described their experiences and ideas regarding theinformation that could help both families and children address
the challenges they experienced in the day surgery pathway.
Identified categories were related to the content of informationand patient flow during the day surgery pathway.

Content of Information
This upper category included 2 subcategories: transparency ofthe pathway and analgesia and amnesia. Generally, the content
of the provided information (eg, admission instructions, dining,
fasting, overnight stay, pain management, parking, patient
flow—including preoperative preparation, time, and place) was
considered sufficient. For instance, one parent wrote:
I think we got proper information throughout thewhole treatment process. They told us where to go
and how to prepare for the treatment.

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However, some respondents faced challenges regarding thetransparency of the pathway and analgesia and amnesia, which
are subcategories of this upper category.
Transparency of the pathway included the needs for knowledgeof information concerning the children’s day surgical pathway.
Parents faced challenges in receiving information on the stages,
milestones, and procedures of day surgeries. According toparents, there was a lack of knowledge about the discharge
criteria. Moreover, sudden changes brought further challenges
in obtaining information. For instance, one respondent wrote:“It was supposed to be a day surgery treatment, but our childneeded to be monitored overnight.” Correspondingly,
respondents made suggestions related to the information on
postsurgery care: “I would like to have better instructions onwhat to be aware of and what not to do with a surgical wound.”According to parents, a digital solution with different kinds offeatures (eg, email) could be utilized in order to enhance
information transfer, as one of the respondents remarked, “Yeah,
an email could have been a working solution” for providing
information about the day surgery. The implementation of
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information transfer (eg, individual counseling delivered via
face-to-face contact and telephone; written counseling delivered
via letter, email, and SMS reminders) was considered sufficient.
One of the parents expressed the following view: “The flow of
the care pathway was well communicated by the medical staff
on the day, before the treatment, and before and after thetreatment in the recovery room.”Analgesia and amnesia included needs for information
concerning pain management. According to respondents, there
was a lack of information on the management of postoperative
pain and treatment-related pain. One of the respondents
maintained, “We don’t know anything about that (painmanagement at home) yet, I have asked about possible pain
but...” In addition, there is a lack of knowledge related toamnesia/sedation. For instance, one respondent wrote:
The one thing we were worried about was how
amnesia would go and we asked about it. However,that was confirmed in the operation room.

Patient Flow During the Day Surgery Pathway
The parents described their experiences and ideas regarding thepatient flow in the day surgery pathway. Identified categories
were related to the physical environment, waiting time, androles and responsibilities, which are 3 subcategories of thisupper category.
Physical environment was related to the lack of information
regarding free parking and guidance signs. The respondents
faced challenges in accessing parking and parents’ waiting areas.
According to the respondents, more information about the free
car parking and waiting places needed to be added to theinformation letter. One of the respondents described thefollowing challenge:
We haven't been to the place (hospital) before. I
verified the location of the car park from the website.
The respondent also added: “The only thing was that the request
for entry to the parents’ living room was made too late.”
Waiting time was related to the main challenges and needs. The
arrival time, for instance, was considered to be the same as
surgery time. One of the respondents expressed this view bystating, “We had time for the treatment but still we had to waitwith other parents for 2-3 hours.” Overall, the waiting time wasconsidered too long, and more information regarding theremaining waiting time was warranted. The following excerpt
from one of the respondents expresses such a view: “There
should have been some kind of information about how long ourwaiting time (for the treatment) would be.” The timing of patient
counseling was also considered nonoptimal in certain
circumstances.
Roles and responsibilities were related to the challenges facedby children and parents in their interactions with the hospital
staff. It was unclear how and who would announce what. Despite
certain promises, surgeons did not share information about thesurgery before and after surgery, or they shared information
about surgery superficially and briefly. For instance, one
respondent wrote, “There was information on the screen in the

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waiting room that the doctor would call after the treatment, but
this never happened.”
In addition, the answers received were somewhat
indicative/suggestive. However, the respondents made somesuggestions regarding the digital gaming solutions and childinvolvement in their own care pathways.

Needs for Support
Support for Children and Family
The second main category included 2 upper categories thatparents described as needs for the day surgical pathway:physiological support for children and psychological support
for children and families. The received support (eg, explanations,parents’ involvement, support from nearby, and friendliness ofstaff) was considered sufficient. In addition, most of the
respondents felt that the service provided by the hospital wasfriendly, attentive, and informative.

Physiological Support
This upper category was related to the challenges of eating afteran operation and environmental safety. Conflicting information
was observed related to postsurgery meals. The postoperation
meal requirements were referenced in many responses, as was
the need for hearing protectors for sound-sensitive children.

Psychological Support for Children and Families
This upper category addressed the need for rewarding children
after operation, timing of guidance from nurses in sudden
situations, parental role and timing in sudden situations, andlack of psychological support for parents. Parental involvement
was also related to the challenges in their roles. One respondent
stated, “It was hard in the operating room (before anesthesia),
when you should be focused on your child’s excitement and at
the same time matters relating to anaesthesia.”
One of the respondents felt that their psychological needs wereignored in the hospital and mentioned, “Psychological needs
were not taken into account and they (hospital staff) could haveasked us about it.”Child Involvement in His or Her Own Care Pathway
Consideration and Preparation
The parents described their experiences and ideas regarding
their children’s involvement in their own care pathways. The
identified categories were related to the consideration of anindividual child and preparation for treatment, reflecting 2 upper
categories in this main category.
Children’s involvement in their own care pathway (eg,answering the child’s questions, talking to the child, turning
attention elsewhere, considering the child’s fear, encouraging
and praising the child, giving time to situations faced bychildren, listening to the child, involving the child in the carepath, and taking the individual into account) was consideredsufficient. For instance, one respondent stated, “My child was
also allowed to ask questions that bothered him, and they wereanswered really well.”

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However, some respondents had faced challenges regarding
consideration of an individual child and preparing a child fortreatment, which were subcategories for this main category.

Consideration of an Individual Child
This category was related to the needs of children with special
needs and allowing time for children to calm down. The
individual needs of sound-sensitive children should be taken
into account.

Preparation for Treatment
This category included the challenges related to children’s needs
for parents in the operation room before anesthesia, needs tofamiliarize themselves with the hospital environment in advance,and needs of requiring more time to deal with frightening
situations. Respondents collectively described these needs as
giving time to children before their operations. One respondent
explained this need as follows:
Going to the operating room caused a little extra
stress, as the speed was faster there than the speed
in the restroom. It would have been good to calm thechild down a bit before starting the operation.

A Digital Gaming Solution for Children and Families
to Support Care
Preparation, Gamification and Connection
Respondents described their needs for a digital gaming solutionthat could help children and families in children’s day surgery
care. This included 3 upper categories: preparing children andfamilies for the day surgery, gamification in solutions, andconnecting people through the solution (Table 2).
Games are not implemented in the hospital’s current pathwaysof pediatric day surgeries. However, parents reported positive
attitudes toward a digital gaming solution for pediatric day
surgery. For instance, one respondent noted, “Today’s kids areborn at this time of technology, so I think games could work
well for kids of a certain age.”
In addition, attitudes toward rehabilitation through playing andgaming were positive. The identified requirements for digital
gaming solutions were divided into 7 subcategories.

Preparing Children and Families for the Day Surgery
via the Solution
The proposed needs for a digital gaming solution were related
to 3 different items: preparing via a digital gaming solution,
virtual familiarization with the care environment, and managing
the waiting time with a solution. These are the subcategories ofthis upper category.
Preparing via a Digital Gaming Solution
This subcategory included aspects that could enable children
to prepare for their treatment. The solution should include
general information about surgery, whereas instructions
concerning treatment were supposed to be already available.
Information storage in the game would decrease the need for
information retrieval. According to respondents, the developed
digital gaming solution should be easy to use. An informative
gaming solution would reduce the need for Googling, as a
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respondent added, “That kind of solution would reduce needfor Google.”
Virtual Familiarization With the Care Environment
Virtual familiarization with the care environment included
parental needs for a virtual tour for children and families,
information about the operating room via virtual visits, and theability to see the hospital via the solution. In addition, a digital
gaming solution could include genuine pictures of various
hospital spaces.
Managing the Waiting Time With a Solution
This subcategory, managing the waiting time with a solution,
was seen as an important requirement for the solution. The
solution would need to provide parents with information about
the waiting times following the treatments. In addition, thesolution could be applied in other circumstances to relieve
waiting.

Gamification in the Solution
The upper category of gamification in the solution included thefollowing 2 subcategories: gamification to overcome hospitalanxiety and fear and gamification in support of care. This upper
category also considers parents’ expectations from gamificationin the solution.
Gamification to Overcome Hospital Anxiety and Fear
This category included parental needs for solutions for children.
According to parents, a digital gaming solution could include
all sorts of fun and interactive features (eg, videos, games, andmusic) to reduce fear. The following excerpt expresses thisview:
After all, children can’t help but like everythinginteractive and cool. Even if the device offers nothing
but fun for the child, it will certainly be helpful torelieve fear.
Gamification in Support of Care
According to respondents, the gamification could include
age-appropriate information regarding the most common typesof surgeries. According to parents, certain games could be
utilized for the preparation for surgery as well as postoperative
recovery (eg, rehabilitation). For instance, one respondent stated,“It would be good to prepare themselves for treatment via asolution.”

Connecting People Through a Solution
This upper category included 2 subcategories—interactions
between medical staff, families, and children and peer support.
The parents stated that the digital gaming solution could enableinteraction between the hospital and families and enable thepeer support: “I like the thought that with the help of the solution
parents could connect with nurses.”
According to parents, a digital gaming solution could include
children’s own positive stories regarding their day surgery
pathways. In addition, a digital gaming solution could enable
the sharing of feelings with others in order to reduce fear. Oneof the respondents expressed, “Being able to share their feelings

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with others going through similar measures could be a good
way to address their fears.”

Discussion
Principal Results
To the best of our knowledge, this is the first qualitative study
that explores parental experiences throughout the entire pathwayof pediatric day surgeries in order to support the digitalizationof that pathway in the selected hospital. Our findings revealed
that although the current content and information transfer wereconsidered sufficient, parents expected (1) better guidance
related to the content of information, (2) more psychologicalsupport, and (3) involvement of children in their own carepathway. Additionally, it was found that there was a need fora digital gaming solution that would provide the required
information and help families to be better prepared for their
oncoming treatments.

Strengths and Limitations
The results present the experiences of the needs of parents intheir children’s day surgery pathways. Almost all (28/31, 90%)
children had been in a day surgery, whereas 10% (3/31)
respondents had undergone an MRI. The number of respondents
was reasonably small—only 31—and the text material they
produced (that was analyzed in this study) was brief, as it usuallyis when responding via the internet. However, the respondents
had a fresh perspective on the care the hospital provided to theirchildren, which strengthens our results.
The data could have had a greater breadth if there had been an
opportunity to conduct individual or focus group interviews.
Then the interviewees could have provided richer material tobe analyzed, or different perspectives could have been clarified.
However, the saturation was achieved, and the respondents
produced texts that included rich material for our inductive
content analysis. For future studies, the perspectives of children
should be included for broadening and strengthening the results.
It was not possible to get feedback on the results at an organized
event at the hospital because the respondents were anonymized,
and they did not ask the research nurse any further questions
while responding to the anonymous questionnaire. The results
are transferable to similar contexts where a hospital has
developed its own digital environment, but the generalizabilityof the results would require further quantitative research witha larger sample size.

Comparison With Prior WorkThe need for support is in line with previous studies [21,23,29],
which explained a situation in which parents were unfamiliar
with how to conduct postoperative pain management for theirchildren. However, in our study, the parents were ready to viewa digital gaming solution as a relevant tool for supporting carein different situations concerning the children’s day surgery
pathways. In recent studies, parents also needed more guidance
regarding fasting [23,32], equipment used in the operating andrecovery rooms [21], discharge criteria [13,34], andpostoperative complications [23,29]. In our study, parents
wanted to increase gamification, as it was considered as an
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Rantala et alimportant aspect of the required guidance. The need forpsychological support is in line with previous literature, in thatparticipants were most frequently dissatisfied with waiting times[21,32,33,46]. Thus, interventions aimed at reducing waitingtimes and raising patient satisfaction are warranted. In our study,
parents were ready for a digital gaming solution, which could
be used in different kinds of situations, such as waiting fortreatment, reducing children’s anxiety, and patient guidance.
For future studies or for developing SHGs for parents andchildren in the day surgery pathway, our study has addressed
the first stage of developing a gaming solution. We haveidentified a target audience and expected outcomes [5].
According to respondents, the digital gaming solution could be
used to help families be better prepared for the coming
treatments. This could include a virtual tour of a hospital tofamiliarize children with the environment beforehand. In the
study by Carlsson and Henningsson [47], the researchers realizedthat visiting the operation room might not reduce parents’ orchildren’s anxiety in surgery care situations. This finding iscontradicted by the study of Rantala et al [18], who argued basedon a recent meta-analysis that web-based interventions (eg,educational web-based programs or age-appropriate streamed
videos) could be used to reduce children’s anxieties [18]. In
another study by Rantala et al [23], health specialists observedthat a digital gaming solution (developed for a hospitalenvironment, including virtual visits to the hospital for different
surgeries) would help families and children to be better oriented
to an upcoming treatment. In our study, parents considered achild’s personal involvement in his or her care to be very
important. A gaming digital solution developed throughout thecare path can solve this challenge. In addition, the World HealthOrganization [1] raises an important aspect that mHealth could
be used to increase patient commitment to their own care andto develop a more personalized path for patient care. In aprevious systematic review, gamification was mostly used inchronic diseases and for improving physical activity among
patients; there were no designed SHGs for children’s day surgery
pathway [4]. Thus, our study produces new knowledge for the
rapid day surgery pathway and helps developers consider theparental perspective. In addition, peer support has been used inmHealth app solutions for children with chronic diseases [4,48].
In our study, parents were open to peer support via a gaming
digital solution. For future studies, it would be important toexamine whether this could be used as an alternative methodof patient counseling that could reduce hospital readmissions
in children’s day surgeries [14,34].
Overall, the results of the study agree with the existing literature
on patients’ expectations and needs related to hip and knee
arthroplasty [49]. In this study, the patients suggested that theyneeded a digital solution that allows for better real-timecommunication methods (eg, information transfer, discussion
forums) and patient counseling (eg, resources, content andimplementation). In addition, our results support the previous
literature on treatment pathways for surgical patients [49-52].
To the best of our knowledge, prior studies have not focusedon the pathways of pediatric day surgeries. In this respect, ourstudy produces new research.

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Conclusion
The parents of children in day surgeries need reliable
information about the pathways of those surgeries. Children
must be involved in the care paths of their day surgeries. These
parents were open to digital gaming solutions. They expressed
their thoughts on what kinds of solutions would be relevant to

Rantala et al
the clinical practice and could positively affect the care provisionin hospitals. The digital gaming solution should be developed
for the needs of children and provide important information
about day surgeries to families. The findings of this study canbe applied for integrating digital solutions into hospitalenvironments.

Acknowledgments
The authors wish to thank all the parents and participants who shared their experiences by responding to our questionnaire. The
research was conducted as part of the project entitled Icory (Intelligent Customer-driven Solution for Orthopaedic and PaediatricSurgery Care), which was funded by Business Finland, a Finnish Funding agency, during 2018-2020. The funder has not influenced
the design, conduct, analysis, or reporting of the study.

Conflicts of Interest
None declared.

Multimedia Appendix 1
COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist for qualitative research.
[PDF File (Adobe PDF File), 193 KB-Multimedia Appendix 1]

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Abbreviations
COREQ: Consolidated Criteria for Reporting Qualitative ResearchmHealth: mobile health
MRI: magnetic resonance imaging
PDA: personal digital assistants
QR: quick response
SHG: serious health game

Edited by C Lovis; submitted 21.08.20; peer-reviewed by X Garcia-Eroles, M Lall; comments to author 06.10.20; revised version
received 17.10.20; accepted 18.10.20; published 13.11.20
Please cite as:
Rantala A, Jansson MM, Helve O, Lahdenne P, Pikkarainen M, Pölkki T
Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative StudyJMIR Med Inform 2020;8(11):e23626
URL: http://medinform.jmir.org/2020/11/e23626/
doi: 10.2196/23626
PMID: 33185556
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