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Conscious Surgery: Environmental Conscious Surgery: Environmental Influence on Patient AnxietyInfluence on Patient Anxiety
DDr. Mark Mitchellr. Mark MitchellFaculty of Health and Social CareFaculty of Health and Social Care University of SalfordUniversity of SalfordManchesterManchesterEngland.England.m.mitchell@[email protected] (0)161 - 295 - 648044 (0)161 - 295 - 6480
INTRODUCTIONThe scope and quantity of surgery now possible in day and short stay facilities is increasing on a global scale.Toftgaard & Parmentier (2006) Int. Term. in Amb. Surg. & worldwide Pract. In: (Lemos, Jarrett, Philip. Eds) Day Surgery. Development & Practice. Porto: IAAS.
Ojo et al (2008) Safety of day-case surg. in developing countries. Jour One-Day Surgery 18(1) 13.
"In recent years we have seen the biggest changes to surgical practice since its inception as a medical and scientific discipline in the nineteenth century.” Darzi (2007) Saws and scalpels to lazers and robots – Advance in surg. DH: London.
Additionally, anaesthetic advances are progressively enabling a greater proportion of local and regional anaesthesia to be undertaken on a day surgery basis.Raeder (2006) Anaesth. Techniques for ambu. surg. In: (Lemos, Jarrett, Philip. Eds) Day Surgery. Development & Practice. Porto: IAAS. (p. 185)
With this predicted decline in the number of patients undergoing general anaesthesia, the care of the ‘awake’ patient within the operating room will (and has) become a more prominent feature of theatre nursing intervention.Chit Ying et al (2001) Qual. study percept Chinese women during C section & regional anaesth. Midwifery. 17(2) 115.
Once back on the ward, post-operative recovery is increasingly becoming brief with many patients only requiring limited physical nursing intervention.Kingdon & Newman (2006) Determining pt discharge in an OP surg. Setting. AORNJ. 83(4) 898.
Thereby, as the surgical assault on the body diminishes, the need for many once traditional aspects of physical nursing intervention will also inevitably diminish.Suhonen et al (2007) Day-case surgical pts health related quality of life. Int. Jour Nursing Practice. 13(2) 121.
The dominant focus of nursing intervention widely employed and emphasizing many physical aspects of care (Roper, Logan & Tierney 1980) are hence becoming largely redundant in the modern surgical environment.Roper, Logan & Tierney (1980) Elements of Nurs: A model for nursing based on model living. Churchill-Livingston: London.
This transformation in surgical and anaesthetic practice is providing the opportunity for a change in emphasis for peri-operative nursing intervention, that is, more towards enhancement of the nurse/ patient therapeutic relationship.Gilmartin (2007) Contemporary DS: Patient experience of discharge and recovery. Jour Clinical Nursing. 16(6) 1117.Mottram (2009) Therapeutic rels in ds. Jour Clin Nurs. 18(20) 2830.
Such a change may be highly appropriate for patients experiencing local or regional anaesthesia as the possible pain associated with the anaesthetic injection, limited communication and the unknown theatre environment (temperature, darkness, and comfort) are of great concern to many patients.Gnanalingham & Budhoo (1998) Day case hernia under LA vs. GA. Patient prefs. Ambu. Surgery. 6(4) 227.
METHODOLOGYPurpose
The purpose of this aspects of the study was therefore to investigate the psychological impact of the surgical environment on the conscious adult patient undergoing elective, day surgery.
Aims -1) To uncover specific aspects patient’s find
unpleasant or anxiety provoking and possibly dissuade them from opting for local/
regional anaesthesia.2) Aid the construction of more formal
psychological interventions to help manage patient anxiety.
A convenience sample of patients scheduled for elective surgery within three public Day Surgery Units in the United Kingdom were invited to take part in the study. Data were collected over a two year period (2005 - 2007). The study was part of a larger study encompassing an extensive sample of day surgery patients (n=674). The questionnaire contained n=61 items and followed the main themes of the larger study, that is, questions concerning the environment, hospital personnel and patient experience of anaesthesia. However, only the aspects relating to the environment and local or regional anaesthesia will be examined here.
RESULTSParticipants (n=214) underwent a variety of surgical procedures with General Surgery (hernia repair) and Orthopaedic Surgery being the most frequent. It is unknown if choice of type of anaesthesia was offered.
Briefly, some main descriptive statistics -
37% of patients (n=79) desired a detailed level of information provision.
Additionally, the majority of patients 82% (n=173) wanted this information 1 - 4 weeks in advance.
Level of written information required? (n=214) (37%)
26
55
9
38
79
2
0
10
20
30
40
50
60
70
80
90
Preferred to receive written information? (n=214) (82%)
93
48
2012
32
8
0
10
20
30
40
50
60
70
80
90
100
Although only local/ regional anaesthesia was employed, 75% of patients experienced some level of anxiety.
The thought of being awake during surgery was very anxiety provoking or a little anxiety provoking for 51% (n=107) of patients.
Anxiety on the day of surgery (n=210) (75%)
101
39
165
49
0
20
40
60
80
100
120
Thought of being awake during surgery (n=211) (51%)
115
52
81
36
26
0
10
20
30
40
50
60
70
80
90
The thought of seeing the body ‘cut open’ was very anxiety provoking or a little anxiety provoking for 48% (n=101) of patients.
The thought of the numbness ‘wearing off’ too soon was very anxiety provoking or a little anxiety provoking for 53% (n=112) of patients.
Thought of seeing body cut open (n=211) (48%)
4
28
60
78
41
0
10
20
30
40
50
60
70
80
90
Thought of numbness ‘wearing off’ too soon (n=213) (53%)
2 1
16
7682
36
0
10
20
30
40
50
60
70
80
90
All items specifically relating to the intra-operative experience were again entered into a further statistical test named ‘Factor Analysis’.
This test examines associations between variables, based on the correlations between them to uncover any emerging patterns.
…..EXAMPLE - Online clothes/ book stores frequently state “people who bought this also bought this”. This is just how factors analysis works.
The items and subsequent themes developed were -
Thought of needing more than 1 injection
Thought of needing intravenous infusion
Thought of being awake during operation
Thought of hearing during operation
Thought of feeling surgeon during operation
Thought of seeing body cut open
Thought of RA/ LA being more painful
Nurse explaining anaesthetic
Intra-operative Apprehension
Anaesthetist explaining the anaesthetic
Nurse explaining the anaesthetic
Informed how long anaesthetic will last
Informed how long numbness will last
Anaesthetic Information Provision
The issues associated with -
1) Intra-operative apprehension
(being awake, seeing, hearing)
2) Anaesthetic information provision
(providing explanations)
could explain 37% of the variance in ratings of anxiety on the day of surgery.
In more simple terms -
Pie chart represents the total amount of patient anxiety on the day of surgery
ANXIETYANXIETY
37% of anxiety can 37% of anxiety can be explained by be explained by the issues the issues associated here associated here with -with -
Intra-operative Intra-operative Apprehension.Apprehension.
Anaesthetic Anaesthetic Information Information Provision.Provision.
The issues concerning -
Intra-operative Apprehension Intra-operative Apprehension
Anaesthetic Information ProvisionAnaesthetic Information Provision
are thereby accurate predictors of
Increased levels of anxiety on the dayIncreased levels of anxiety on the day
of surgery for many patients of surgery for many patients
SUMMARY1) Anaesthetic Information ProvisionAnxiety was generated regarding gaining insight into -
Length of anaesthesiaDuration of numbnessEvents being explained
2) Intra-operative ApprehensionAnxiety was also generated just by the thought of being in theatre -
Possibility of increased level of painNeed for more local anaesthetic injectionsSeeing the body ‘cut open’Numbness ‘wearing off’ too soonHearing proceedings
CLINICAL RECOMMENDATIONS1) Pre-operative Information Provision
Alluding to the possible unhelpful thoughts relating to the unfamiliar intra-operative experience (being awake, seeing, hearing, experiencing increased pain) could greatly help limit anxiety prior to, and during, surgery under local/ regional anaesthesia.
Clear, unambiguous information provision explaining intra-operative events and local/ regional anaesthesia (time span, numbness, injections) could also help the formal management of patient anxiety. However, such information provision will be necessary in advance of the day of surgery to aid effective anxiety management.
2) Intra-operative Information Provision
Continuing to explain intra-operative experiences (possibly by a named person in theatre) and thereby alleviating many misconceptions (being awake, seeing, hearing, experiencing increased pain) could also help contribute to the more formal management of anxiety.
Integrated Care Pathways have been described as ‘structured, patient-centred maps of care” and inclusion of such aspects of care in this documentation may be of great benefit to future patient management in day surgery.
Suggested Intervention Plan
Intervention
Anaesthetic Information
Provision
Intra-operative Apprehension
Suggested Intervention Plan
Intervention
Anaesthetic InformationProvision
Prior to the day of surgery provided with information to help dispel misconceptions and limit unwarranted thoughts.
Additional opportunity on the day of surgery to discuss such possible misconceptions.
Emphasis upon body not being seen ‘cut open’.
Suggested Intervention Plan
Intervention
Anaesthetic InformationProvision
Prior to the day of surgery provided with information to help dispel misconceptions and limit unwarranted thoughts.
Additional opportunity on the day of surgery to discuss such possible misconceptions.
Emphasis upon body not being seen ‘cut open’.
Emphasize anaesthesia will not ‘wear off’ too soon although immediate action will be taken in this unlikely event.
Where possible, dedicated nurse to interact throughout surgery regarding comfort, temperature, environment, for example, explaining theatre noise.
Planned approach formally documented.
Suggested Intervention Plan
Intervention
Intra-operative Apprehension
Emphasis upon safe and effective anaesthesia - drugs, methods and professional skills.
Reassuring interaction with patient immediately prior to anaesthesia.
Prompting regarding, comfort, temperature, anxiety, catastrophising thoughts, experience of pain or feeling surgeon.
Suggested Intervention Plan
Intervention
Intra-operative Apprehension
Emphasis upon safe and effective anaesthesia - drugs, methods and professional skills.
Assuring interaction with patient immediately prior to anaesthesia.
Prompting regarding, comfort, temperature, anxiety, catastrophising thoughts, experience of pain or feeling surgeon.
Some physical contact with the patient where possible and if desired.
Simple methods of distraction (if desired) such as music via headphones or conversing.
If deemed appropriate, emphasize any additional aspects to the patient which demonstrate safe and controlled practices.
CONCLUDENursing contact with the modern surgical patient is now very brief. Also, the physical aspects of care for the patient experiencing local/ regional anaesthesia have become minimal in comparison to previous decades.
Although the majority of patients prefer day surgery such minimal contact has the potential to limit effective nurse/ patient communication and thereby hinder adequate anxiety management.
It has been suggested that care in modern surgery is progressing in a somewhat ‘mechanistic’ manner (rules, procedures) and actual nursing intervention (highly valued by patients) can become somewhat ‘hidden’. Nursing-based knowledge must thereby strive to maintain its position in the future of modern surgery.
Formal anxiety management strategies based upon nursing knowledge could become a more central feature of surgical nursing practice and a stronger element in future nurse education programmes of study to help demonstrate how nursing knowledge can indeed successfully contribute to this new surgical era.
Mitchell (2008) Conscious surgery. Jour. Advanced Nursing. Vol.64 No.3 p. 261 - 271.
