Reduction and Management of Perioperative Anxiety: Facing Responsibilities

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“Reduction and Management of Perioperative Anxiety: Facing Responsibilities”

Laura Stirling MSc RGN RNT LLSA MIFPA

Lecturer, School of Acute and Continuing Care Nursing, NapierUniversity, Edinburgh

Principal Tutor / registered practitioner with International Federation of Professional Aromatherapists (IFPA)

Current Post: Lecturer in adult nursing BN and BSc programmes at Napier University with specific interest and teaching input into matters relating to acute patient care within the cardiothoracic surgery field; cardiopulmonary resuscitation ; intensive care and death and dying.

Correspondence:

Laura Stirling

School of Acute and Continuing Care Nursing

NapierUniversity

74 Canaan Lane

EDINBURGH

EH9 2TB

E-mail:

ABSTRACT

Patient anxiety is a normal part of the surgical patient’s ‘career’ and would be anticipated by nurses in a number of settings. Anxiety causes a number of undesirable effects which may place the patient at greater perioperative risk. Factors that mitigate against the nurse being able to devote adequate time to this important aspect of patient care will not disappear overnight and arguably, without quality psychological care, patients are being placed at greater risk.

This article considers the issue of perioperative anxiety with the aim to revise the concept and highlight the serious implications of giving it a lesser priority within patient care. Alternative strategiesshould be sought that might also help the patient take back some control over their own challenging situation. Practitioners must acknowledge that there is a need to investigate their current practice and that they have a responsibility to address patient anxiety effectively.

Reduction and Management of Perioperative Anxiety

Patients who face surgery or those who await the results of investigative surgery are highly anxious (Shearer and Davidhizar 1998; Shuldham et al 1995). Hollaus et al (2003) reflect that pre-operative anxiety is ubiquitous in surgical patients, irrespective of diagnosis. According to Salmon (1993), it has become normal to consider anxiety as an undesirable patient problem despite the recognition that it is a necessary human behaviour which prepares the body both psychologically to face a threat or challenge, as well as physically to deal with that threat if required. In his view, an element of anxiety is essential in helping a person to prepare to face a threat and should therefore, not be so far reduced that a patient loses his ability to cope with that stressor. However, there is plenty evidence to suggest that anxiety in the perioperative patient puts them at greater anaesthetic or surgical risk (Kanto, 1996; McCleane and Cooper, 1990) and influences their anaesthetic requirement (Lindgren et al 1980; Kindler et al, 2000). Maranets and Kain (1997) found that although state anxiety had nothing to do with the need for increased anaesthetic, trait anxiety was indeed a predictor of intra-operative requirements. Delayed postoperative recovery, as a result of perioperative anxiety is also a real risk and may manifest in a number of ways (Boeke et al, 1991; Kindler et al 2000). Amongst others, the need of increased post operative analgesia (de Groot et al, 1997; Linn et al 1988; Munafo and Stevenson 2001), incidence of post-operative complications (Mathews and Ridgeway 1981; Stengrevics et al, 1996), influences on patient mood (Munafo and Stevenson, 2001), delayed wound healing (Kiecolt-Glaser et al, 1995); delayed recovery and increased stay in hospital (Boeke et al, 1992; Linn et al, 1988), and decreased ability to resist infection (Fyfe 1999) have all been reported as outcomes of pre-operative anxiety. From the evidence, it appears that there is considerable rationale for trying to relieve anxiety in the surgical patient. This should happen as a matter of course, but nurses, whilst trained observers and skilled communicators, often have little time to pick up upon the anxiety states of their patients, let alone devote quality time to employ useful anxiety-relieving approaches with them. Historically, according to Franklin (1974), nurses rarely saw anxiety as a significant problem and in Mitchell’s (2000) opinion, emphasis on physical assessment both pre and post-operatively has dominated over psychological care.

Advances in surgical technology and practices have meant that more patients are suitable for day case or short term surgery. Cahill (1999) suggests that an increased patient turnover and the need to deal with physical demands has dictated that little time remains to concentrate on the psychological needs of the surgical patient. This is mirrored by Mitchell (2003 p.813), who states,

“Current anxiety management appears to be dominated more by the desire for clinical efficiency than by effective individual requirements”.

Kain et al (2000) maintain that interventions within the hospital setting for the reduction of patient anxiety are diminishing for mainly financial reasons. Whatever the truth of this matter, the nurse should, as a matter of course, recognise the anxious patient and realise the responsibility of holistic care. Because anxiety is expected in pre-operative patients as a normal human response to the relatively unknown or worry about operative well-being, have nurses become blasé about the importance of trying to lessen it? Are they unaware of the evidence that highlights the benefit of so doing? Mitchell (2000) feels that not only is reduction of anxiety advised from a medical perspective, but it remains a desire of most nurses to promote well-being and help a patient to help themselves regain control over their own situation. (Fig.1) According to Shearer and Davidhizar (1998), a nurse must be able to identify when a patient is fearful and appreciate that there is a real need to respond and manage this effectively. Physical signs of anxiety such as sweaty, shaky hands and blotchy skin (O’Rourke 1993); elevated heart rate (Scheinin et al, 1990 ); neck and back pain, change in gastro-intestinal routine, angina and headaches (Keegan 2000) are all recognisable with adequate observation or verbal interaction with the patient. Psychological signs of anxiety, which include emotional unpredictability, expression of illogical thoughts (Keegan 2000; O’Rourke 1993), depression and forgetfulness (Keegan 2000), could all be detected through the admission interview (if the line of questioning allowed) and subsequent verbal and non-verbal feedback through interaction with the patient. Given the level of perioperative risk that anxiety can create, measures to reduce it are warranted.

Sources of Patient Anxiety

Insight into what might source the patient’s general or specific anxieties would allow for a more efficient assessment and earlier and meaningful therapeutic intervention strategy to be employed. Kindler et al (2000) suggest that perioperative anxiety can be categorised into 3 areas; fear of the unknown; fear of feeling ill and fear for one’s life. To expand, a perceived loss of the sense of security and control over life, derived from a change in surroundings and routines (Fyfe 1999) or removal from the family unit (Kanto 1996; Kiecolt-Glaser 1998); concern about what lies ahead and the expectations to be made of them (O’Rourke 1993), may all lead to feelings of being unable to cope with the experience (Mitchell 2000). Fear of the anaesthetic or drugs to be used in surgery (Zvara et al 1994), fear of dying (Kiecolt-Glaser et al 1998) and post-operative pain (Brunner and Suddarth 1993) have been found to be very real sources of anxiety to many surgical patients.

Managing Patient Anxiety

Scott (2004) supports the comments of Wilson-Barnett (1976) in that she believes that it is not possible for a health professional to remove all perceived foci of the individual’s anxiety and as such, perhaps the role of the professional is to more realistically help the person manage the presenting stressful situation. So what are the skills and strategies that nurses should use in the everyday care of anxious patients? With the use of simple counselling and communication skills, the nurse should be able to provide the patient with an invitation to disclose and discuss any worries and feelings pre-operatively. According to Shearer and Davidhizar (1998), as well as encouraging reflection on fears, distraction from negative outcomes should have a place in the care of anxious patients. Although honest preparation of the patient is good practicepsychologically, it is possible that the patient’s imagination of what lies ahead is exaggerated beyond what is a logical and likely outcome. The aim should be to find a balance between truthful, sensible preparation and false hope. Information about the nature of what the surgical patient faces should be provided in both verbal and non-verbal form (such as leaflets/information sheets specific to the work of a unit or ward). It should not be assumed that the patient will remember all that is said, as anxiety interferes with comprehension and memory (Fyfe 1999). Quality rather than quantity of any information given has been found to be more important in relief of anxiety (Hollaus et al, 2003) and the social interaction between nurse and patient can provide time to build trust and offer reassurance (Litt et al 1995). McCleane and Cooper (1990) found that a pre-operative visit to offer encouragement in this way reduced anxiety, lessened the need for post-operative opiate analgesia and shortened the stay in hospital. If relatives can be privy to the information as it is being given, they effectively share the process of gathering information about what is to happen and can then act as an additional source of that detail for the patient later (Mitchell 1997, 2000). Not many alternative strategies for the management of reduction of pre-operative patient anxiety are documented within nursing texts, however, use of premedication which includes anxiolytic drugs is commonplace practice. Research into the effects of music (as a distraction) played both before and/or during an operation, such as those by Miluk-Kolasa et al (1996) and Cooke et al (2005), have been conducted over the years, but few studies have proved significant benefits in terms of anxiety reduction. Watching the television or using relaxation tapes as other distractions have been studied, again with limited reliable evidence of worth. Without shifting the responsibility for managing anxiety completely from the health professional team, is there room for the patient to be guided into taking other measures to reduce their risk of perioperative complications? (Fig 2)

Weighing up the obvious benefits of anxiety reduction for the patient against the real lack of time to undertake meaningful techniques in the clinical areas (or update knowledge) other than social interaction or administering prescribed medication, there is a need to think more holistically about other therapeutic measures that could be used to help people gain back some perspective over their worries and perceive themselves to be more emotionally ready to face their surgical fears. This need not necessarily mean additional competition for the nurses’ time. There is room to consider simple interventions that the patient could employ themselves, with nurse guidance, which in so doing, might provide a chance for them to regain control over an aspect of their well being and share with the professionals, their preparation for surgery. Without research, however, nothing can be considered for patient use. Requests for randomised controlled trials within the nursing domain have been made (Biley and Freshwater, 1999; Ribeaux and Spence 2001)

Research Need

There is a need to develop research within the complementary health arena, with specific focus on the potential there is for complementary and orthodox interventions to be used together toward the aim of improving the patient experience. In specific reference to the increasingly popular complementary approach of aromatherapy, Balacs (1997) claims that there is still a lack of reliable research conducted by health professionals and as yet, few studies have shown efficacy of essential oils in humans.

The author commenced a CSO funded research project in February 2004, which will run for one year. The aim of the project is to test the efficacy of an essential oil blend in reducing anxiety in perioperative thoracic patients who await the results of investigative surgery. Unlike many health-related complementary therapy studies, the current project does not involve massage as the vehicle by which essential oils are administered to the participants. Many small studies in health care areas have considered essential oil use with massage for a variety of patient benefits (Buckle 1993; Corner et al 1995; Hadfield 2001 etc). The double-blinded randomised controlled trial method is being used in the author’s study and anxiety is being measured by the use of the State-Trait Anxiety Inventory (STAI) and Hospital Anxiety and Depression Score (HADS). Consenting patients receive either a vegetable oil with essential oils; a plain vegetable oil, or no intervention (which is the norm). Patientswho are allocated oils apply them to their skin as and when it is suitable to them, so have control over the intervention (and keep a diary of oil use). It is the author’s hope that data will suggest a significant reduction in anxiety within the essential oil group. Such a finding may pave the way for a simple intervention like this to be incorporated into patient anxiety management in future nurse practice, at relatively low cost. Many people are familiar these days with the potential benefits of essential oils and to date, uptake of patients to this study has been encouraging. The project aim, if achieved, may see the potential for orthodox and complementary approaches to be used together towards one mutual goal - the improvement of the patient experience.

Conclusion

Anxiety management is not a new care concept, yet it does not always receive the dedicated time and attention that it should. This may be because nurses have lost touch with the importance that it has in the overall perioperative experience and have relatively little time to devote to exploring psychological issues with their patients in a surgical settling. It could also be explained by a lack of knowledge of the research in this area. Regular searching for recent study findings and publications with this focus would serve to remind and reinforce the need for anxiety to be adequately managed. If quality time to improve the psychological preparation for surgery is not always readily available, then use of a patient -controlled intervention, for use at home or in hospital, would not only give the patient an active part in their own care, but would provide a chance for the nurse to enter a partnership with the patient towards a shared goal.

Word Count: 2084

Key Points

• Reduction of anxiety in surgical patients is an accepted nursing aim but

time to effectively address patient anxiety in clinical practice is often

limited

• Failure to reduce perioperative anxiety can lead to physical and psychological problems
• Reflection upon the current state of anxiety management within the field of individual nurse’s practice is required
• The time has come to develop other anxiety management options and scientifically rigorous research, both in the field of nursing and aromatherapy, is required to improve the patient experience.

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