Taking care of fearful patients in OR

1
Taking care of fearful patients in OR

• Kirsi Kiviniemi
• RN, PhD, Director in Nursing, Associate
  lecturer
• Hospital District of Southwest Finland, Turku
  University Hospital
• University of Turku, Department of Nursing
  Science

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
2
Content of the presentation

• Conceptual approach to perioperative anxiety
• Anxiety, fear and tension / ahdistus, pelko ja
  jännitys
• Why should we identify and evaluate patients
  perioperative anxiety
• Review of intensity of perioperative anxiety and
  interventions to relieve patients perioperative
  anxiety
• Perioperative anxiety in Finnish parturients who
  underwent planned Caesarean operation
• Challanges for perioperative nursing practice

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
3
Conceptual approach to perioperative anxiety

• Anxiety is
• a vague, uneasy feeling of discomfort or dread
  accompanied by an autonomic response the source
  is often non-specific or unknown to the
  individual (NANDA 1999)
• the degree of perceptions of worry and
  nervousness (Lin Wang 2005)
• Fear is
• anxiety caused by consciously recognized and
  realistic danger. It is a perceived threat, real
  or imagined. Operationally, fear is the presence
  of immediate feeling of apprehension and fright
  source known and specific (NANDA 1999)
• Tension is
• mental, emotional, or nervous strain (NANDA 1999)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
4

• Based on the literature review
• There are various theoretical models considering
  perioperative anxiety
• Drive theory (f.ex. Janis 1959)
• Situational and trait anxiety (f.ex. Spielberger
  1972)
• Perioperative anxiety is measured as intensity
  and incidence of anxiety, fear and tension
• STAI (Spielberger State Trait Anxiety Inventory),
  VAS or VASA (Visual Analogue Scale for Anxiety)
• HADS (Hospital Anxiety and Depression Scale)
• APAIS (The Amsterdam Preoperative Anxiety and
  Information Scale)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
5

• Physiological, cognitive, and behavioural signs
  are joined to increased perioperative anxiety
  level
• Perioperative anxiety provoking fears and
  concerns have been reported
• fears and concerns are extra-, intra- or
  interpersonal
• There are factors relating to increased
  perioperative anxiety level
• patients gender, age, education, marital status,
  financial situation, trait anxiety level,
  surgical history, and mode of present surgery
• some of the relations are conflicting according
  to literature

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
6
High perioperative anxiety relates to

• Female gender
• Moerman et al. 1996, Karanci Dirik 2003
• Age under 40 yrs in adults
• Shafer et al. 1996, Kindler et al. 2000
• Major or emergency surgery
• Leinonen et al. 2001, Karanci Dirik 2003
• Missing or bad prior surgical experiences
• Shafer et al. 1996, Kindler et al. 2000
• Higher trait anxiety level
• Caumo et al. 2001, Talyor-Piliae Molassiotis
  2001, Ng et al. 2004, Carr et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
7
What can You see on the drawing?
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
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2. Why should we identify and evaluate patients
perioperative anxiety

• Documentation of the perioperative nursing
  decision-making process
• Patient Act (785/1992)
• Research has demonstrated that anxiety has both
  psychological and physical effects on the patient
• Guzzetta 1989, Leach et al. 2000, Bally et al.
  2003

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
9
Decision-making in perioperative nursing
following patients, nurses and physicians
assessment INTERPRETATION AND UNDERSTANDING OF
PATIENTS SITUATION
Patients care status
What?
Assessing the need of the care
How?
Nursing interventions
CHOOSING THE RIGHT INTERVENTION
Planning and implementing
Outcomes of the care
Why?
state of health, coping, opinion ANTICIPATING THE
PROGRESS OF THE CARE
Evaluating the outcomes
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
10
Pre-operative anxiety is associated with many
unwanted effects such as

• Increased analgesic requirement
• Davies et al. 1997
• Increased anaesthetic requirement
• Osborn Sandler 2004, Granot Ferber 2005
• Increased postoperative pain
• Granot Ferber 2005, Lin Wang 2005, Pellino et
  al. 2005, Watts McEachan 2005, Carr et al. 2006
• Prolonged recovery and hospital stay
• Kulik et al. 1996, Shuldham 1999 Agarwal et al.
  2005, Hobson et al. 2006
• Misunderstanding of pre-/ postdischarge
  information
• Orr 1986, Kulik et al. 1996, Shuldham 1999
• Missatisfaction with the received care
• Callaghan et al. 1998, Leinonen et al. 2001
  Hobson et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
11
3a) Review of intensity of perioperative anxiety

• Surgical patients are more anxious prior the
  operation than after the operation
• While waiting surgery at home (Koivula 2002,
  Cooke et al. 2005)
• On arrival at the hospital (Bellan et al. 2002)
• Immediately prior to surgery (Jones et al. 2004)
• Patients anxiety level tends to remain high and
  constant from the afternoon before to surgery to
  the morning of surgery Doering et al. 2000
• There is a linear and positive correlation
  between patients anxiety level prior and after
  the operation
• Kain et al. 2000, Gejervalla et al. 2005, Carr
  et al. 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
12
Intensity of perioperative anxiety

• Perioperative anxiety measured by STAI (ranging
  from 20 to 80)
• Mild anxiety 20 39, moderate anxiety 40 59,
  strong anxiety 60 - 80
• Anxiety level on arrival at hospital
• 28.0 43.9 (Parent Fortin 2000, Jones et al.
  2004)
• Anxiety level immediately prior the operation
• 33.9 59.0 (Lin et al. 1997, Marucci et al.
  2003)
• Anxiety level postoperatively at hospital
• 27.6 43.0 (Karanci Dirik 2003, Gejervall et
  al. 2005)
• Anxiety level at home, one to six months after
  operation
• 28.4 37.3 (Heikkilä et al. 1999)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
13
3b) Review of interventions which relieve
patients perioperative anxiety

• Studies have assessed the effect of the provision
  of information on preoperative anxiety
• Beddows 1997, Shuldham 1999, Hodgkinson et al.
  2000, Sjöling et al. 2003, McDonald et al. 2004,
  van Vliet et al. 2004
• Routine preoperative information/education and in
  addition
• A tour of the operating department (Deyirmenjian
  et al. 2006)
• A kit of nonpharmacologic strategies for anxiety
  and pain (Pellino et al. 2005)
• A computer website intervention. The website
  instruction module content was a replication of
  the standardized verbal instruction module
  enhanced with digital photos (Hering et al.
  2005)
• A preoperative nursing intervention for pain (Lin
  Wang 2005)

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
14

• Preoperative information mostly relieves
  patients perioperative anxiety
• Patients need information about illness, surgical
  processes, possible risk factors, anticipated
  sensations/discomforts
• Patients expect written and verbal information
• Walker 2002, Johansson et al. 2003
• Preoprative information is preferred to receive 1
  to 3 weeks prior to surgery
• Mitchell 2000
• Preoperative teaching should be individually
  tailored
• Guruge Sidani 2002
• Incorporating preoperative psycho-educational
  interventions is recommended
• Calvin Lane 1999

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
15
Music and perioperative anxiety

• The theoretical basis for music as an
  intervention for anxiety lies in its ability to
  promote relaxation through the autonomic nervous
  system
• Thaut 1990
• Music promotes feelings of physical and mental
  relaxation by refocusing attention on to
  pleasurable emotional states
• Bailey 1986,Bonny 1986, Brown et al. 1989,
  McCaffery 1990, Magill-Levreault 1993
• Patients awareness of time passing becomes hazy
  as they focus on the music thus promoting a
  relaxation response
• Guzzetta 1995

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
16
Examples of music interventions and results

• Receiving 20 minutes of music vs. having 20
  minutes of rest in bed after cardiac surgery
• Sendelbach et al. 2006
• Receiving 30 minutes of music therapy vs. only
  routine care
• Chang Chen 2005
• Listening to music of patient choice during the
  preoperative wait (30 min) vs. wearing the
  headphones but receiving no music for 30 minutes
  vs. control group receiving routine care only
• Cooke et al. 2005
• Music decreased preoperative anxiety in patients
  having outpatient and day surgery
• Wang et al. 2002, Lee et al. 2004

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
17
Other interventions and perioperative anxiety

• Guided imagery
• Tusek et al. 1997. Walker 2002, Mitchell 2003
• Relaxation, hypnosis, reflexology
• Goldman et al. 1988, Ernst Koder 1997
• A systematic method of relaxing the body on the
  sensory relaxation did not result in
  significantly less anxiety. However, group
  differences in state anxiety were in the expected
  direction
• Roykulcharoen Good 2004
• Guided imagery and relaxation decrease
  perioperative state anxiety

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
18

• Hand massage and hand holding as nursing
  interventions on the anxiety
• Richards et al. 2000, Moon Cho 2001, Oh Park
  2004
• Humour
• Gaberson 1995, Åstedt-Kurki et al. 2001
• Aromatherapy
• Jellinek 1999
• Psychosocial support
• Mitchell 2003, Krenzischek et al. 2004
• Nurse Case Manager (NCM) Model to care the
  patients
• Palese et al. 2005
• Massage, hand holding, humour, aromatherapy,
  psychosocial support, and NCM model have been
  reported to decrease perioperative anxiety. The
  decrease is not always significant but the
  patients feel better and they are satisfied

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
19
4. Perioperative anxiety in Finnish parturients
who underwent planned Caesarean operation

• ARE YOU ANXIOUS, AFRAID OR TENSE
• Perioperative anxiety and empowering nursing
  prior, during and after planned caesarean
  delivery
• By
• Kirsi Kiviniemi
• Annales Universitatis Turkuensis Ser. D Tom. 704
• Medica Odontologica
• University of Turku 2006

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
20
Summary of the theoretical starting points of the
study
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The research questions were

• What kind of perioperative anxiety do women
  express prior, during and after planned Caesarean
  delivery?
• What kind of expectations and experienced do
  women express regarding empowering perioperative
  nursing prior and after planned Caesarean
  delivery?
• What kind of association there is between
  perioperative anxiety and empowering
  perioperative nursing prior and after planned
  Caesarean delivery?

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
22
Perioperative measurement time points, variables,
instruments, and sample
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
23
Intensity of state anxiety across the
perioperative period
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
24
The relation between high state anxiety and
background factors
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
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Empowering perioperative nursing

• Empowerment is a process of helping or preparing
  people to assert control over their health
  problems and the consequences
• Gibson 1991, Rodwelle 1996, Kuokkanen
  Leino-Kilpi 2000
• Six dimensions of empowering perioperative
  nursing
• Bio-physiological empowerment
• Cognitive empowerment
• Experiential empowerment
• Functional empowerment
• Ethical empowerment
• Social empowerment
• Modified from Leinonen et al. 1996, Leino-Kilpi
  et al. 1998, 1999

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
26
Parturients expectations of the empowering
perioperative nursing

• Feeling safe
• Smooth collaboration between the staff
• Ongoing information of the newborn child
• Peaceful atmosphere
• Trust-creating non-verbal communication
• Sincere interest from the staff
• Being taken seriously
• Understandable verbal information
• Possibility to participate in their treatment
  planning
• Pleasant position on the OR table
• Technical competent staff

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
27
Parturients perceptions of empowering
perioperative nursing

• Technical competent staff
• Nurses and physicians were kind and cheerful
• Non-verbal communication was trust-creating
• Smooth collaboration between staff members
• Peaceful atmosphere
• Being taken seriously
• Feeling safe
• Their privacy was protected
• Staff was able to act in sudden situation
• Staff demonstrated sincere interest

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
28
Expected and received empowering perioperative
nursing care
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
29
5. Challanges for perioperative nursing practice

• Perioperative anxiety should be evaluated and
  documented systematically
• Simple visual analogue scale for anxiety is a
  useful instrument
• Spielberger state trait anxiety inventory is
  another noteable instrument
• Electronic patient documentation systems should
  involve an instrument to evaluate patients
  perioperative anxiety level
• A check-list of usual factors which strengthen
  perioperative anxiety should be employed when
  patients perioperative needs are evaluated
• Its important to evaluate pain and anxiety
  simultaneously

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
30
Challenges for perioperative nursing
administration

• Developing practice to evaluate patients
  perioperative anxiety
• Developing anxiety-related perioperative nursing
  interventions
• Defining patients dependency and in allocating
  perioperative nursing staff resources accurate

Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
31
Thank you for your attention
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science