Tonsillectomy and adenoidectomy (T&A) surgery is among the most commonly performed surgical procedures in children across the world (Mitchell et al. 2019). Although routine, this procedure often elicits anxiety – an emotion characterised by fear, apprehension and worry (Siddiqui et al. 2024). Anxiety may stem from anticipated pain, separation from caregivers, and uncertainty about the procedure itself (Aydogdu et al. 2019; Mustafa et al. 2024). Barkmann et al. (2023) noted that preoperative anxiety in children can also be attributed to perceived loss of control, fear and concerns related to body image. Importantly, research has shown that children are capable of vividly recalling stressful experiences, particularly when exposed to unfamiliar procedures, such as invasive surgery (Lee & Shin 2024), and such experiences can affect both immediate recovery and long-term attitudes towards healthcare, potentially resulting in fear and avoidance. Consistent with this, early T&A has been linked to an increased risk of developing stress-related disorders in healthcare contexts later in life (Xiao et al. 2024). Although preoperative anxiety is a common and expected reaction, it requires appropriate management to reduce the risk of adverse postoperative outcomes (Alves et al. 2024). Given that the surgical environment can particularly be intimidating for children – often provoking fear, frustration and helplessness – hospitals must prioritise strategies that enhance their overall surgical experience. These may include child-friendly, non-pharmacological distraction techniques, such as virtual reality, entertainment videos, video games, smartphones, tablets, books, music, clown interventions, reward systems (e.g. stickers), and clear, accessible explanations of procedures – such as guided hospital tours (Mersin, Dizer & Tuna 2025; Mustafa et al. 2024; Nilsson et al. 2014). For example, in an unblinded randomised clinical trial conducted at an Italian paediatric hospital, children scheduled for surgery were shown a short video featuring two clown physicians playfully and humorously – but accurately – introducing the operating room and its equipment (e.g. anaesthesia mask, electrocardiogram electrodes and thermo-blanket), Liguori et al. (2016) demonstrated that children in the video group had significantly lower preoperative anxiety than those in the control group, concluding that this type of video is a low cost, simple and effective method for reducing preoperative anxiety in paediatric surgical patients.

Another promising approach involves the use of visual supports to deliver perioperative information, including picture or text-based schedules, storyboards, communication boards, and individual images, photos or videos (Koekemoer et al. 2025). Research from the United Kingdom has shown that comic-style information leaflets explaining paediatric anaesthesia can effectively reduce preoperative anxiety in children (Kassai et al. 2016). Collectively, these tools can support psychological preparation, reduce anxiety, enhance children’s sense of control and improve communication between the child and the nurse. Their relatively low cost further contributes to their practicality and appeal.

Apart from these psychological preparation techniques, sedative medications are also used. Seyedhejazi et al. (2020) conducted a clinical trial involving children scheduled for adenoidectomy in which they compared two preparation methods: one group received oral midazolam, while the other underwent psychological preparation using an informational booklet along with an explanation from an anaesthesia resident. They concluded that both sedative medication and psychological preparation were effective in reducing preoperative anxiety in children undergoing adenotonsillectomy. Communication is a fundamental human need and a core aspect of human functioning; without it, participation in daily life is significantly limited. Beyond expressing basic needs, emotions and information, communication facilitates social interaction, builds relationships, fosters social closeness, enables individuals to influence others, and allows for exerting control in various contexts (Beukelman & Light 2020). Communication is also a basic human right, explicitly protected for children under the United Nations Convention on the Rights of the Child (Thunberg et al. 2022). These rights encompass both the ability to receive accessible information and to express one’s views. The United Nations Convention on the Rights of Persons with Disabilities further underscores that the right to communicate includes children with disabilities. It also highlights the importance of universal design – ensuring that products, services and environments are accessible and usable by all people, including those with communication disabilities (Thunberg et al. 2022).

Augmentative and alternative communication (AAC) strategies – such as gestures, manual signs, real objects, photographs, pictures and speech-generating devices (usually applications today) – play a crucial role in supporting both expressive and receptive communication in healthcare settings. Expressive AAC methods facilitate communication for individuals who are permanently or temporarily non-verbal, as discussed earlier, while input strategies enhance comprehension – an especially important function in paediatric care. The use of AAC as an input strategy does not imply that the child lacks adequate language skills; rather, it recognises that children can benefit from visual supports in the form of pictorial schedules to help clarify the complexity of medical procedures, particularly during the preoperative phase (Koekemoer et al. 2025). By supporting comprehension, challenging behaviour can be reduced (Kaitsalmi et al. 2024), creating opportunities for more effective nurse−patient communication.

A pictorial schedule generally consists of a sequence of pictures that illustrate and represent the steps of an activity or procedure, most often presented in a cell or square, with a word or phrase included above or under the picture (Beukelman & Light 2020). Pictures or photographs are particularly valuable because they are not dependent on language competency, are more universally interpretable, and reflect the concrete reality they represent. Spoken language or text, which is otherwise typically used, is abstract, arbitrary, and dependent on learning and competency (Thunberg et al. 2022). By visually mapping out events and expectations, pictorial schedules help children not only understand but also anticipate upcoming events – ultimately reducing anxiety and improving cooperation in clinical settings. Pictorial schedules, therefore, offer several advantages in paediatric healthcare contexts. They are commonly used to augment comprehension, reduce anxiety and challenging behaviours, support task completion, and facilitate smoother transitions between activities, while requiring fewer adult prompts (Thunberg, Törnhage & Nilsson 2016). In the context of complex medical procedures – such as the sequence of steps involved before T&A, pictorial schedules can help children gain a sense of control and independence by clearly informing them of what will happen and when (Bray, Appleton & Sharpe 2019; Koekemoer et al. 2025; Thunberg et al. 2016). As previously noted, visual supports such as pictorial schedules can reduce anxiety by providing children with clear, predictable information, thereby helping them cope with the unfamiliar and often intimidating hospital environment (Koekemoer et al. 2025). This is especially relevant in the context of T&A, where children frequently experience anxiety not only because of fear of the procedure itself but also because of limited access to developmentally appropriate explanations (Alves et al. 2024; Atefeh 2025). Paper-based pictorial schedules appeal to healthcare practitioners because they are affordable, accessible and easy to implement (Woodring & Harmon 2023). Moreover, they can enhance children’s understanding of the surgical process. Research shows that even babies as young as 3 months old can recognise photos of their mothers (Barrera & Maurer 1981), and by 5 months, they are capable of identifying two-dimensional representations such as drawings that depict familiar objects (Slater, Rose & Morison 1984). Furthermore, children, from about 30 months of age, may use pictures on a symbolic level as resources for information about the world (DeLoache & Burns 1994), and during the following years, also for more abstract concepts (Astle-Rahim & Kamawar 2020). Therefore, children undergoing T&A are likely to possess the cognition required to understand and follow a visual schedule outlining procedural steps, making this a practical and developmentally appropriate tool in perioperative care. The hospitalisation of a child scheduled for T&A surgery starts with the perioperative phase – a phase that starts from the moment the decision to perform surgery is made and ends with their transfer to the operating theatre. During this phase, nurse–patient communication improves the emotional well-being of the patient, especially paediatric patients undergoing T&A surgery, if they prepare children and their family for surgery, both physically and emotionally, by mitigating fears of pain, death, bodily image, family separation, and so forth, while gathering and recording medical information (Hassan et al. 2024). In doing so, nurses protect, promote and optimise patients’ health while advocating for the care of the patients and their families. Nurses should be able to measure the effectiveness of communication strategies as well as the child’s emotional state in order to achieve quality patient care (Nilsson, Buchholz & Thunberg 2012). The two most important strategies for identifying anxiety in children are validated tools for self-reporting and observational measurement. Self-reporting is considered the gold standard for assessing anxiety intensity (Thurillet et al. 2022), as it provides meaningful information about both the level and duration of unpleasantness (McGrath 1987). However, this method can be challenging, particularly for younger children who may lack the cognitive or communicative ability to reflect upon and fully express their emotional state (McGrath 1987; Mesko et al. 2011). Nevertheless, research has shown that even children aged 4 years – 6 years are capable of defining and acknowledging feelings of anxiety, albeit with only a basic awareness (Valentine, Buchanan & Knibb 2010). Importantly, children’s ability to articulate distress evolves as they develop, making it necessary to complement self-reports with observational or objective measurements to enhance the reliability and depth of data collected (McGrath 1987). This approach is further justified by findings from Nilsson et al. (2013), who highlighted a discrepancy between objective and self-report measures of anxiety, showing that behavioural changes do not always align with changes in the child’s experienced distress. Objective measures of childhood anxiety often involve the use of behavioural checklists or rating scales completed by trained observers. One such validated observational tool is the Faces, Legs, Activity, Cry and Consolability (FLACC) scale, developed by Merkel et al. (1997), which has been shown to reliably identify both pain-related unpleasantness and anxiety (Nilsson, Finnström & Kokinsky 2008). A key strength of the FLACC scale lies in its ease of use: it can be administered by both nurses and parents, and its outcomes are not significantly influenced by variables such as the timing of the assessment, or the child’s age or gender (McGrath 1987; Nilsson et al. 2008).

Self-report measures are particularly effective for capturing the multidimensional nature of anxiety. Commonly used self-report scales for children include the Coloured Analogue Scale (CAS) and the Facial Affective Scale (FAS) (McGrath et al. 1996), which both use numerical rating scales to enable accurate measurement of changes in anxiety levels. Given that nurses in the preoperative phase are ideally positioned to observe behavioural cues and facilitate children’s self-reporting of anxiety, their role is central to accurately assessing and managing distress. This study focuses on the perioperative nurse who provides care to patients and their families throughout their hospital stay, specifically during the procedural steps before T&A surgery. Nurses are valuable role players during the preoperative phase, as they possess the knowledge and skills to reduce anxiety preceding surgery. Evidence-based practice has shown that effective nurse–patient communication can foster familiarity with difficult procedures, thereby alleviating anxiety (Jiang et al. 2023). To achieve this, child-friendly communication strategies, such as using pictorial schedules to prepare for and understand difficult procedures, are essential. Although nurse–patient communication is widely recognised as a crucial component of healthcare management, several barriers hinder its effectiveness. A systematic review reported that while establishing and maintaining preoperative relationships with patients is essential, nurses often face time constraints and heavy workloads that negatively impact communication (Kaitsalmi et al. 2024). Despite these challenges, nurses acknowledge the importance of communication – including talking, listening and using text- or picture-supported methods – and advocate for the implementation of various AAC strategies to enhance patient care and reduce anxiety (Pampoulou et al. 2025; Simmons et al. 2021; Zaylskie et al. 2023). The main aim of this study was to investigate potential changes in self-reported and observed anxiety among children aged 4 years to 9 years when provided with a pictorial schedule prior to undergoing T&A in a hospital setting.

This exploratory study used a quasi-experimental time series design with a delayed comparison group (Leedy & Ormrod 2019) as it enabled the measurement of anxiety during the specific procedural steps depicted in the pictorial schedule, using self-report and observational measurements. This design is advantageous as it can accurately explore potential tendencies of stability and change during specific measurement intervals (Leedy & Ormrod 2019). To ensure that the changes in anxiety across the procedural steps were resulting from the intervention strategy (i.e. the pictorial schedule, described later), a delayed comparison group was used, in which participants had no knowledge of the intervention strategy. Participants were allocated to the intervention or comparison groups using an alternating assignment method. The delayed comparison group did not receive a pictorial schedule preceding T&A, but they received it post-surgery, explaining that it could be used at home to tell friends and family about the surgery.

Figure 3a illustrates that both the FAS and ChAS scores for the intervention group clustered at the lower end of the scale, with three children scoring 1 and one child scoring 2. In contrast, the comparison group displayed a wider distribution of scores, with individual scores of 1, 5, 6 and 10. Although we observed a marked difference between the two groups, suggesting that the use of the pictorial schedule may be associated with reduced anxiety levels, it is important to interpret these findings cautiously, as factors such as prior hospitalisation, age, and the small sample size may have influenced the results. Further studies controlling for these variables are needed to confirm this potential effect. A similar pattern was observed with the FLACC scores (Figure 3b), where all four children in the intervention group scored 0. In the comparison group, two children scored 0, while the remaining two scored 2 and 3, respectively. These observations may indicate a potential effect of the pictorial schedule on reducing observable distress, but as noted above, small sample size and possible confounding factors limit the strength of this conclusion.

Figure 4a shows that all four children in the intervention group scored 1 on both the FAS and ChAS, indicating no anxiety. In contrast, scores in the comparison group were more varied. On the FAS, two children scored 1, while the remaining two scored 3 and 4, respectively. Similarly, on the ChAS, two children scored 1, with the others scoring 4 and 5. Figure 4b presents the FLACC scores, where the intervention group again showed unanimous low scores, with all children scoring 0. In comparison, two children in the comparison group scored 0, while the others scored 2 and 3. The FLACC results correspond closely with the self-reported FAS and ChAS scores, reinforcing the finding that the intervention group exhibited no signs of anxiety. In contrast, the comparison group’s responses ranged from no anxiety to moderate anxiety. Taken together, the FAS, ChAS, and FLACC scores suggest that the children in the intervention group did not experience anxiety, whereas the comparison group demonstrated a broader spectrum of anxiety levels.

Figure 5a shows that within the intervention group, two children scored 1 on the FAS, one child scored 2, and the other scored 9. In the comparison group, two children scored 1, while the remaining two scored 3 and 7, respectively. A similar pattern was seen on the ChAS: three children in the intervention group scored 1, while one child scored 10 – a notably high score that was not reflected in the corresponding FLACC results. In the comparison group, two children scored 2 on the ChAS, with the remaining two scoring 1 and 5. Figure 5b presents the FLACC scores. In the intervention group, three children scored 0, indicating no observable signs of distress, while one child scored 3. In the comparison group, two children scored 0, one scored 2, and one child scored 6. During this particular procedural step, both the intervention and comparison groups displayed a broader range of responses than in earlier steps. On the FAS and ChAS, most children in the intervention group reported low anxiety, although one child reported extreme anxiety – this outlier was not reflected in the corresponding FLACC score. In contrast, the comparison group showed more consistent responses across the subjective measures (FAS and ChAS), with most children appearing mildly anxious. The FLACC scores supported these trends: while most children in the intervention group showed no observable distress, one child showed mild signs (score of 3). In comparison, the FLACC identified one child in the comparison group as moderately anxious (score of 6), further indicating higher anxiety levels in this group. This stands in contrast to earlier steps such as ‘I get a bed’ (Figure 3b) and ‘The nurse is coming’ (Figure 4b), where all intervention group children received FLACC scores of 0, indicating no anxiety.

Figure 6a shows that FAS scores were identical across both the intervention and comparison groups: in each group, two children scored 1, while one child scored 2 and the other scored 3. On the ChAS, all children in the intervention group scored 1, suggesting no anxiety. In the comparison group, two children scored 2, while two children did not provide responses. Figure 6b presents the FLACC scores. All four children in the intervention group scored 0, indicating no observable signs of anxiety. In contrast, the comparison group showed higher levels of observable anxiety: two children scored 0, while the other two scored 3 and 4, respectively. The two missing ChAS responses in the comparison group may reflect mild anxiety, as suggested by their corresponding FLACC scores. When comparing the FLACC results across groups, it is evident that participants in the comparison group exhibited mild anxiety, while those in the intervention group did not. Notably, in the intervention group, the consistency between the subjective (ChAS) and observational (FLACC) measures supports the conclusion that these participants experienced no anxiety during this procedural step.

Figure 7a presents the FAS scores, showing that two children in the intervention group scored 2, one child scored 1, and the other scored 4. In the comparison group, half of the participants scored 5, while the remaining two scored 1 and 6, respectively, indicating generally higher levels of self-reported anxiety. On the ChAS, three children in the intervention group scored 1, and one child scored 2, reflecting low levels of anxiety. The comparison group’s scores were more varied, with one child each scoring 1, 3, 5 and 6. The FAS and ChAS results suggest that most children in the intervention group experienced little to no anxiety, with only one child reporting mild anxiety. In contrast, the comparison group reported mild to moderate anxiety across both self-report measures. Figure 7b shows the FLACC scores. All children in the intervention group scored 0, indicating no observable signs of anxiety. In the comparison group, scores were equally distributed, with two children scoring 2 and the other two scoring 3, reflecting mild to moderate anxiety. The FLACC findings align with the self-reported measures. The intervention group displayed no observable signs of anxiety, consistent with their FAS and ChAS scores. In contrast, the comparison group exhibited both mild and moderate anxiety across all three measurement instruments.

Figure 8a shows that the FAS responses in the intervention group were widely distributed, with one child each scoring 1, 5 and 9, and one child not providing a score for this step. In the comparison group, two children scored 1, while the remaining two scored 3 and 6, respectively. On the ChAS, only two children in the intervention group provided responses – one scored 1 and the other 10, indicating a stark contrast in perceived anxiety. The remaining two children did not record responses. In the comparison group, ChAS scores were more moderate, with two children scoring 2 and one each scoring 1 and 6. The intervention group’s self-report responses (FAS and ChAS) were highly variable, with two non-responses, suggesting that this procedural step may have been more anxiety-inducing for them. In contrast, the comparison group reported more consistent and moderate anxiety levels, with no extreme scores recorded. Figure 8b displays the FLACC scores. In the intervention group, two children scored 4, and the others scored 1 and 2, respectively. Notably, none of the children scored 0, indicating elevated observable signs of anxiety compared to previous steps. In the comparison group, two children scored 3, and the others scored 0 and 2, reflecting mild to moderate anxiety. The FLACC results confirm that the intervention group experienced higher levels of anxiety during this step compared to earlier procedures, and also in comparison to the control group. While one child in the intervention group reported a score of 10 on the ChAS, this level of severity was not reflected in their FLACC score. This discrepancy highlights the importance of incorporating both self-report and observational measures, as anxiety may not always manifest in observable behaviours.

Figure 9a shows that FAS scores in the intervention group were equally distributed, with one child each scoring 1, 5 and 9, and one child not providing a response. Similarly, on the ChAS, two children scored 10 – indicating extreme anxiety – while one child scored 1, and one did not respond. In the comparison group, FAS scores were more moderate, with one child each scoring 1, 3, 6 and 7. Children’s Anxiety Scale scores in this group followed a similar pattern, with scores of 1, 3, 5 and 6. These results suggest an increase in anxiety within the intervention group during this perioperative waiting period, with one child reporting moderate anxiety and another reporting extreme anxiety. The comparison group, by contrast, demonstrated a range of responses from no anxiety to moderate anxiety across both self-report tools. Figure 9b presents the FLACC scores. In the intervention group, two children scored 2, while the others scored 1 and 5, respectively. The comparison group’s scores were evenly distributed, with one child each scoring 0, 3, 4 and 5. These FLACC results indicate that children in both groups displayed mild to moderate observable signs of anxiety during this phase. In the comparison group, the observational (FLACC) scores were consistent with the self-reported FAS and ChAS scores. However, in the intervention group, the FLACC did not reflect the extreme anxiety reported by one child on the ChAS. This discrepancy again highlights the value of using both self-report and observational measures to capture the full range of children’s perioperative anxiety.

Communication strategies, such as pictorial schedules, are recommended in hospital settings to create a sense of familiarity with procedural steps, thereby enhancing orientation and a sense of control in an otherwise unfamiliar and overwhelming hospital situation (Kaitsalmi et al. 2024; Koekemoer et al. 2025). A study similar to the current one employed pictorial supports grounded in universal design principles to uphold the communication rights of paediatric patients undergoing T&A. These supports enabled children to express their thoughts and feelings, thereby promoting a more person-centred approach to care (Thunberg et al. 2022). In addition, this approach fostered collaboration among children, parents and healthcare professionals, helping all parties feel more prepared for the procedure. Tonsillectomy and adenoidectomy surgery is common, but evokes anxiety and fear (Liang et al. 2021; Xiao et al. 2024). Anxiety is multifaceted, and it is difficult for children to communicate how they feel. It is therefore suggested that self-reporting of anxiety and pain is an effective assessment tool (Barkmann et al. 2023; Levy et al. 2025). The self-report measures used in this study, namely the FAS and ChAS, confirmed that the children were able to indicate their levels of anxiety effectively. According to Nilsson et al. (2013), validated self-report measurements are more difficult to administer, but this is the most effective way to determine anxiety in children. The ChAS and FAS are both validated self-report measurements for children aged 4 years and above (McGrath et al. 1996; Nilsson et al. 2013). During the study, both scales proved to be effective tools for measuring anxiety. However, the FAS appeared to be more sensitive to change than the ChAS, as it yielded a wider range of responses, suggesting it could detect more nuanced shifts in anxiety levels. The FAS responses from both the intervention and comparison groups indicated that children’s level of anxiety was wide ranging, particularly during the final two procedures before surgery. The results also indicate that self-report measures, such as the FAS and ChAS, are both effective and important. These tools are easy to score, and anxiety levels were not always accurately reflected in the observational measure (i.e. the FLACC). The FLACC was an efficient objective measurement tool, especially when the participants failed to reflect on the self-report measurement tools (Sutters et al. 2012). The objective measure correlated with the self-report measurements, indicating the effect of a pictorial schedule on anxiety in children from the intervention and delayed comparison groups preceding surgery. It is important to note that factors such as prior hospitalisations and age may have contributed to variability in anxiety levels and responses. Because our study employed a group design rather than a single-subject design, we cannot determine how these factors influenced individual outcomes. Future studies with larger samples and designs allowing for individual-level analysis would help clarify the impact of these variables on intervention effectiveness. Although the FLACC is validated and can reflect the level of anxiety, it was clear that it was not as sensitive towards change, especially further on in the procedural steps, closer to surgery. However, it is effective to use more than one measurement tool to establish an overall impression of a child’s level of anxiety (Nilsson et al. 2013). Also, in order to manage anxiety and reduce further harm, it is important for nursing staff to identify the level of anxiety (Thunberg et al. 2016).

The results also indicated that the intervention group became more anxious towards the end of the procedural steps, and their level of anxiety was higher than the comparison group at the procedural step closest to the surgery, as described in Figure 7a and Figure 7b. This could indicate that the pictorial schedule can reduce anxiety for initial steps of the process, but that it also indicates when surgery will take place, which might then increase anxiety. Because T&A are invasive surgery, it is normal to be anxious (Alves et al. 2024). These findings align with those of a study conducted in China involving children aged 2 years–7 years, which reported an 84.0% increase in anxiety from the point at which children exited the operating room elevator to their arrival in the preoperative waiting area (Liang et al. 2021). This rise in anxiety was attributed to separation from their caregivers, who were not permitted to accompany them beyond this point – a pattern also reflected in the results presented in Figure 7a and Figure 7b of the current study. Furthermore, the results point towards the individual perception of the level of anxiety, as ratings were seen to be more varied when closer to surgery for both groups. This pinpoints the need for a tailored and person-centred approach to care, focusing on each child–parent perception (Thunberg et al. 2022).

This exploratory study indicates that pictorial schedules may reduce anxiety in children between 4 years and 9 years of age before undergoing T&A surgery. Furthermore, the results indicate that validated self-report measurements as well as objective measurements may be used to determine anxiety in young children before T&A surgery.