- Email: [email protected]
Midtrimester abortion patients
roviding nursing care for patients undergoing midtrimester abortion by dilatation and evacuation (D and E) can be a difficult decision for many nurses. Over 50,000 abortions are performed each year by the D and E meth0d.l At the University of California, San Francisco, Medical Center six to ten midtrimester abortions are performed by D and E each week on an outpatient basis. An important aspect in the nursing care of these patients is the attitude of the staff toward abortion and the patient population seeking midtrimester abortions. Practicing perioperative care has been helpful in establishing rapport with these patients. To gain a better understanding of this patient population, we conducted a study to measure their anxiety levels using the Institute for Personality and Ability Testing (IPAT) trait anxiety scale and to measure mood states with the Profile of Mood States (POMS).The purpose of the study was to identify common characteristics among the patients and acquaint the staff with emotional needs of this patient population. Midtrimester abortion by D and E offers women an alternative t o prostaglandin (amnio) procedures. Amnio abortions consist of placement of intracervical laminaria followed by an intraamniotic prostaglandin E injection. Laminaria are thin pieces of desiccated seaweed that cause cervical dilatation as they absorb moisture from the body and expand. The prostaglandin stimulates uterine contractions, which induce labor and fetal expulsion. The D and E method requires insertion of laminaria 12 to 24 hours prior t o surgery in the physician’s office or clinic. After induction of anesthesia, the patient is placed in the lithotomy position. The physician performs a bimanual exam and removes the laminaria. After sterile preparation of the patient, the
P
Midtrimester abortion patients Linda Dickey White, RN Paul F White, MD
756
AORN Jourrial, October 1981, V o l 3 4 . N o 4
surgeon further dilates t h e cervix mechanically and uses ovum forceps and an aspiration cannula to remove the fetus. Kaltreider et a1 compared the experiences of women scheduled for D and E abortions with those having amnio procedures.2 They reported that women who had D and E abortions experienced fewer physical complications (eg, less pain and blood loss) and described the abortion a s “minor surgery.” Conversely, women having amnio abortions were more depressed and angry following the abortion. The procedure itself was associated with pain and often described as “similar t o labor or loss of a child.’’ We have found it helpful to provide perioperative nursing care to midtrimester abortion women to meet their physical and emotional needs. In addition, the staff feels more comfortable with their role as nurses when given an opportunity to meet and talk with the patients preoperatively. A model for patient care of women undergoing midtrimester abortion is summarized in Table 1. A review of psychiatric nursing techniques may be helpful in learning skills to communicate more effectively with these unique patients. Discussions with
Linda Dickey White, RN, BSN, was a clinical nurse IV in the operating rooms at the University of California, San Francisco, when this article was written. She is now educational coordinator for staff development at Stanford (Calif) University Hospital. She received a BSN from the University of California, San Francisco,and a BA in social welfare from the University of California, Berkeley. Paul F White, MD, PhD, is assistant professor of anesthesia at Stanford University Hospital. He received his medical and doctoral degrees from the University of California, San Francisco.
758
family planning counselors may also provide insight into the emotional aspects of abortion and the decision to obtain one. It may also be beneficial to arrange inservice programs with a psychiatric consultant to enable the staff to deal better with their own emotional responses to the patients and the procedure. Since these are outpatient procedures, the nurse first meets the patient in the dressing room immediately before surgery. A preoperative assessment is made to determine the patient’s understanding of the procedure and level of anxiety. This information can be obtained in as little as five to ten minutes by asking the patient to describe, in her own words, what she thinks the procedure involves. Anxiety can be determined by observing physical characteristics such as restlessness, avoidance of eye contact, high-pitched shaking voice, sweating, and wringing of hands. Alternatively, the patient may simply state that she is nervous or upset. For many patients, the experience represents their first exposure to an operating room or to surgical procedures. The nurse tells patients the approximate length of time for the procedure, where their family and friends can wait, where to leave their personal belongings, and similar information. The nurse provides an opportunity for the women to ask questions or express concerns regarding the procedure. The most frequently asked questions deal with pain rather than the procedure itself. Common questions include, “Will it hurt?” “Will I be asleep?” “Will there be needles?” We answer these questions straightforwardly. Other questions, however, are more difficult to answer. Occasionally, patients ask about the disposition of the fetus. We usually tell the patient that the fetus is examined and disposed of in accordance with the policy of the institution. Often
AORN Journal, Ortober 1981. Val 3 4 . No 4
Table 1
A model patient care plan for midtrimester abortion Problem I . Preoperative A. Potential anxiety due to unfamiliar setting and surgical procedures
Expected outcome
Nursing actions
Will know where to leave personal items
Provide orientation for day surgery patients (where to leave clothes, where friends can wait, etc).
Will verbalize an understanding of explanations
Describe physical layout of operating room. Describe anesthesia preparation (intravenous infusion, electrocardiograph leads, blood pressure cuff).
Will verbalize fears and anxieties regarding surgical procedure
Talk with patient and allow expression of thoughts and feelings by encouraging questions.
A. Potential anxiety due to fear of surgical procedure
Patient exhibits minimal anxiety prior to induction by absence of tachycardia, increased respirations, elevated blood pressures, clying.
Stay with patient prior to induction and provide emotional support appropriate to patient's behavior and needs.
B. Potential neuromuscularl
Patient will have no low back pain, tenderness, or redness from in adequate padding of stirrups.
Check placement of stirrups. Raise and lower both legs together. Stay with patient to prevent leg extension.
Will show no signs of injured fingers (redness, swelling, or lacerations) prior to leaving operating room
Check placement of hands when raising and lowering foot of table. Use armboards or secure arms over chest to avoid strain on muscles and nerves of arm while avoiding restriction of chest movements.
A. Potential postoperative complications of bleeding, respiratory difficulties, and emotional problems due to surgical procedure
Patient will be free of excessive bleeding, respiratory complications, and will not demonstrate emotional problems prior to discharge from recovery room.
Communicate to recovery room nurse any unusual occurrence prior to or during intraoperative care (eg, bleeding, vomiting, difficult intubation, unusual preoperative anxiety, psychologicaliemotional problems).
8. Potential complications
Will state understanding of postoperative care instructions prior to leaving recovery room Will be aware of follow-up appointment with physician
Provide patient teaching according to physician's protocol. Ask if patient has a follow-up appointment with physician.
11. lntraoperative
skeletal injury due to positioning
C. Potential injury to fingers due to raising and lowering foot of table
Ill. Postoperative
due to incomplete information
760
AOKN Journal, October 1981, V o l 3 4 , No 4
he had come alone and stated she did not “need” anyone with her.
S
we are asked about confidentiality, and we reassure the patient that we do not inform families or friends as to the nature of the treatment the patient received. In addition, we do not print their names on our OR schedule, nor do we write the names on our board that lists the current day’s schedule. Nurses also find that preoperative assessments help them to feel more positive about their role as nurses in these procedures. As a result of interviews with operating room nurses, Kaltreider et a1 reported that the nurses felt best about their patients when given an opportunity to meet them pre~peratively.~ As a result of this contact, nurses felt bitter able to provide emotional support preoperatively and postoperatively for midtrimester abortion patients. There are two types of patients whom we encounter most frequently-patients who show signs of distress such as crying and shaking and patients who display signs of denial such as avoiding eye contact or appearing stoic or overly confident. For the distressed patient, a calm approach with sensitivity to the patient’s needs seems to be most suitable. One way to work with these patients is to encourage them to express their feelings. If they are unwilling or unable to do so, a brief conversation about their home or job may help them to relax. With patients who show denial, a straightforward approach appears to be more effective. For example, one patient
was extremely hostile toward the staff and reluctant to answer questions. She had come alone and stated she did not “need” to have anyone with her. Her anger was upsetting to the staff, although as a result of our preoperative assessment we felt we were better able to understand the basis of her denial. After the procedure, she began to cry and accepted the efforts of the nursing staff to comfort her. Her attitude toward the abortion and the staff had changed, and we were able to perceive her changing needs and respond. In the intraoperative phase, the nurse prepares the patient for surgery, while assisting the anesthesiologist and surgeon. The nurse is also available t o provide emotional support to the patient immediately prior to induction of anesthesia. One often encounters a variety of behaviors ranging from denial to sadness and loneliness and must be prepared to handle these reactions effectively. Often a gentle touch and reassurance that someone will remain with her throughout the procedure may ease her feeling of loneliness and despair. An expression that indicates an understanding of her emotional needs, such as “I understand that you feel sad,” may help the patient deal with her feelings and decrease her anxiety. The postoperative phase begins when the patient enters the recovery room and ends when she has fully recovered from the effects of the anesthetic agents
AORN Journal, October 1981, Vol34, No 4
763
Table 2
Preoperative and postoperative responses to level of anxiety “Not at all” “Just a little” “Quitea bit” “Very much”
Preoperative
Postoperative
10% 46% 17% 27%
41O/o 29‘/o
16% 8Yo
24 to 48 hours after surgery. Before the patient leaves the recovery room, the nurse and patient can evaluate the overall experience. The patient has an opportunity to talk about her feelings regarding the procedure and to receive supportive counseling from the nurse. Although many patients are still somewhat sedated from the anesthesia prior to discharge, they often comment on the care they received and express appreciation to the staff. This brief interaction also provides the nurse with an opportunity to evaluate the nursing care plan. To maintain confidentiality, we do not make postoperative phone calls to our patients. To gain a better understanding of midtrimester abortion patients, we examined personality characteristics of 50 randomly selected unpremedicated women (age 18 and over; mean age 24) scheduled for D and E abortions. Informed consent was obtained by the attending anesthesiologist, and an IPAT trait anxiety scale was administered immediately prior t o surgery. The IPAT is a simple self-analysis form consisting of 40 statements to which patients respond “yes,” “in between,” or “no.” Overall trait anxiety measured by the IPAT scale included covert or less obvious anxiety traits as well as overt traits that related directly to anxiety and its
764
symptoms. Analysis of the responses to the IPAT demonstrated that the anxiety shown by our sample was only slightly higher than a nonsurgical population matched for sex, age, and educational background. Our results indicated that the overall personality profile of the D and E patients is not unique. They did not display the expected high levels of anxiety during the immediate preoperative period. This may indicate that the preoperative assessments by the nurse, surgeon, and anesthesiologist contributed to decreasing the patient’s anxiety. This warrants further investigation to determine the effect of a preoperative nursing assessment. Prior to discharge from the recovery room to home (one to two hours after awakening from anesthesia), patients were given a Profile of Mood States (POMS)questionnaire. The POMS is designed to identify and assess different mood or affective states. The six components measure tension-anxiety, depression-dejection, anger-hostility, vigoractivity, fatigue-inertia, and confusionbewilderment. Subsequently, 24 to 48 hours after recovering from the surgery and anesthesia, each patient completed a repeat POMS questionnaire and a short open-ended sentence completion form that were returned to us by mail. Our results demonstrated that the scores of the D and E sample population fall within the normal range for each of the six mood characteristics. As expected, our patients were less vigorous and more fatigued and confused during the immediate postoperative period. This probably represented mood changes secondary to residual levels of anesthetic agents present during the early recovery period in addition to the effects of the surgical procedure itself. In the 24-hour follow-up evaluation, our patients felt significantly more vigorous and active and experienced less fatigue and inertia
AORN Journal, October 1981, Val 34, No 4
S
taff members often ask why women wait until the second trimester.
and less confusion and bewilderment after recovering from the procedure and anesthesia. Tension-anxiety, depression-dejection, and anger-hostility scores were not significantly changed after complete recovery. It is not clear, however, whether these data represent mood changes secondary to the surgical procedure or represent the effects of anesthesia. The open-ended sentence form was completed 24 to 48 hours after awakening from anesthesia and served as an evaluation tool for the perioperative experience. When questioned about how they felt immediately before arriving in the operating room, 65% of our patients described feeling scared and nervous, while only 20% denied nervousness. Upon entering the operating room, 56% stated that the first things they noticed were operating room personnel and equipment, 16%noticed just people, and 14% noticed only the equipment in the room. Feelings prior t o induction ranged from fear (20%)to no feelings at all (16%). When asked what feelings helped alleviate their anxiety, 30% mentioned confidence in the staff, 23% answered “nothing,” and 30% described having comforting thoughts that often included family and friends. As an overall evaluation, 80%felt they had received a thorough explanation of the procedure. Their feelings postoperatively ranged from “great” (40%) to “pretty good” (30%)and %o-so” (20%).A
766
comparison of the level of anxiety felt preoperatively and postoperatively is in Table 2. Staff members often ask why women wait until the second trimester of pregnancy t o seek an abortion. Karenyi indicated that these women often demonstrated an inability to grasp their situation and deal with it reali~tically.~ Also, a lack of basic sex education and a tendency to procrastinate may result in the lack of a reliable method of birth control. Fielding found that denial, ambivalence, fear, and menstrual irregularity accounted for the greatest number of women seeking late abort i o n ~This . ~ study found that fear was the most common reason for delay among the younger women, whereas denial was more evident in older patients. Bracken and Kasl cite obstacles such as lack of accessibility to physicians who perform abortions, delays in raising money to pay for services, missed or late diagnosis of pregnancy, fear of parental disapproval, or abortions forced by parents. These problems may be compounded by feelings of ambivalence and poor communication with the woman’s partner.6 Several of our patients have had more than one abortion. Steinhoff cites three reasons why women have repeat abortions: (1)failure of contraceptives due to imperfections in technique, (2) social and personal factors make the chosen method impractical, (3) an underlying
AORN Journal, October 1981, V o l 3 4 , No 4
desire to become pregnant.’ At our institution, staff members agree that participating in abortion is stressful. Kane reported feelings of anxiety and depression among staff who frequently experienced difficulty resolving their ambivalence over their decision to participate.* Many staff members felt a need to find a medical reason for the abortion, such as the age of the mother, general health of the mother, or possibility of congenital defects in the fetus. Sharing one’s feelings with other staff members is the most helpful way to deal with these reactions. Physicians and nurses can work together to create a n environment that encourages the discussion of these thoughts and feelings. This can be done in a formal setting with an organized discussion or on a n informal basis. Voluntary participation in D and E procedures is essential, and team members must work together to ensure open communication. This will benefit not only the patients but also the staff by allowing them to work in a positive and supportive atmosphere. This environment is important if we are t o maintain quality standards of patient care in the 0 operating room. Notes 1. W Cates, Jr, D N Grimes, “Death from second trimester abortion by D and E: Causes, prevention and future,” American Journal of Obstetrics and Gynecology (in press). 2. N Kaltreider et al, “Impact of midtrimester abortion techniques on patients and staff,” American Journalof Obstetrics and Gynecology 135 (Sept 15, 1979) 235-238. 3. Ibid. 4. T D Kerenyi et al, “Reasons for delayed abortion: results of 400 interviews,” American Journal of Obstetrics and Gynecology 117 (Oct 1, 1973) 299311. 5. W L Fielding et al, “Comparison of women seeking early and late abortion,” Obstetrics and Gynecology 52 (July 1978) 56-58. 6. M B Bracken, S V Kasl, “Delay in seeking induced abortion: A review and theoretical analysis,”
768
American Journal of Obstetrics and Gynecology 121 (April 1, 1975) 1008-1019. 7. P G Steinhoff et al, “Women who obtain repeat abortions,” Family Planning Perspectives 1 1 (January-February 1979) 30-38. 8. F J Kane, Jr, et al, “Emotional reactions of abortion services personnel,” Archives of General Psychiatry 28 (March 1973) 409-411.
Profits OK for chapter educational offerings The National Committee on Education has learned that some chapters believe they are not supposed to make a profit on their educational offerings. This is not true. Obviously, the AORN Approval Board does not expect chapters to suffer a loss from an educational offering. Certainly it is desirable not only to meet all expenses but also to realize a nice profit as a reward for the chapter‘s efforts. The Approval Board does discourage chapters from charging excessive registration fees, however, if this will produce a profit of $2,000 to $3,000. Keep in mind that chapters have an obligation to meet the educational needs of a// their members. That should be the first priority of an offering, not fund raising. If chapters set their fees too high in order to raise money to send delegates to Congress, then only a few members are benefiting. Excessive fees will discourage attendance. It would be more appropriate to set the fee at a figure that would attract more members and still make a profit. A reasonable fee that most chapters charge is $10 to $25 per day, not counting lunch. Each chapter is unique. Each should use good judgment and set its fees accordingly. In summary, present quality offerings,set fees that will encourage the highest attendance, and by all means, make a prof it.
Ginny Green, RN Chairman-elect National Committee on Education
AORN Journal, October 1981, Val 34, N o 4
P
Midtrimester abortion patients Linda Dickey White, RN Paul F White, MD
756
AORN Jourrial, October 1981, V o l 3 4 . N o 4
surgeon further dilates t h e cervix mechanically and uses ovum forceps and an aspiration cannula to remove the fetus. Kaltreider et a1 compared the experiences of women scheduled for D and E abortions with those having amnio procedures.2 They reported that women who had D and E abortions experienced fewer physical complications (eg, less pain and blood loss) and described the abortion a s “minor surgery.” Conversely, women having amnio abortions were more depressed and angry following the abortion. The procedure itself was associated with pain and often described as “similar t o labor or loss of a child.’’ We have found it helpful to provide perioperative nursing care to midtrimester abortion women to meet their physical and emotional needs. In addition, the staff feels more comfortable with their role as nurses when given an opportunity to meet and talk with the patients preoperatively. A model for patient care of women undergoing midtrimester abortion is summarized in Table 1. A review of psychiatric nursing techniques may be helpful in learning skills to communicate more effectively with these unique patients. Discussions with
Linda Dickey White, RN, BSN, was a clinical nurse IV in the operating rooms at the University of California, San Francisco, when this article was written. She is now educational coordinator for staff development at Stanford (Calif) University Hospital. She received a BSN from the University of California, San Francisco,and a BA in social welfare from the University of California, Berkeley. Paul F White, MD, PhD, is assistant professor of anesthesia at Stanford University Hospital. He received his medical and doctoral degrees from the University of California, San Francisco.
758
family planning counselors may also provide insight into the emotional aspects of abortion and the decision to obtain one. It may also be beneficial to arrange inservice programs with a psychiatric consultant to enable the staff to deal better with their own emotional responses to the patients and the procedure. Since these are outpatient procedures, the nurse first meets the patient in the dressing room immediately before surgery. A preoperative assessment is made to determine the patient’s understanding of the procedure and level of anxiety. This information can be obtained in as little as five to ten minutes by asking the patient to describe, in her own words, what she thinks the procedure involves. Anxiety can be determined by observing physical characteristics such as restlessness, avoidance of eye contact, high-pitched shaking voice, sweating, and wringing of hands. Alternatively, the patient may simply state that she is nervous or upset. For many patients, the experience represents their first exposure to an operating room or to surgical procedures. The nurse tells patients the approximate length of time for the procedure, where their family and friends can wait, where to leave their personal belongings, and similar information. The nurse provides an opportunity for the women to ask questions or express concerns regarding the procedure. The most frequently asked questions deal with pain rather than the procedure itself. Common questions include, “Will it hurt?” “Will I be asleep?” “Will there be needles?” We answer these questions straightforwardly. Other questions, however, are more difficult to answer. Occasionally, patients ask about the disposition of the fetus. We usually tell the patient that the fetus is examined and disposed of in accordance with the policy of the institution. Often
AORN Journal, Ortober 1981. Val 3 4 . No 4
Table 1
A model patient care plan for midtrimester abortion Problem I . Preoperative A. Potential anxiety due to unfamiliar setting and surgical procedures
Expected outcome
Nursing actions
Will know where to leave personal items
Provide orientation for day surgery patients (where to leave clothes, where friends can wait, etc).
Will verbalize an understanding of explanations
Describe physical layout of operating room. Describe anesthesia preparation (intravenous infusion, electrocardiograph leads, blood pressure cuff).
Will verbalize fears and anxieties regarding surgical procedure
Talk with patient and allow expression of thoughts and feelings by encouraging questions.
A. Potential anxiety due to fear of surgical procedure
Patient exhibits minimal anxiety prior to induction by absence of tachycardia, increased respirations, elevated blood pressures, clying.
Stay with patient prior to induction and provide emotional support appropriate to patient's behavior and needs.
B. Potential neuromuscularl
Patient will have no low back pain, tenderness, or redness from in adequate padding of stirrups.
Check placement of stirrups. Raise and lower both legs together. Stay with patient to prevent leg extension.
Will show no signs of injured fingers (redness, swelling, or lacerations) prior to leaving operating room
Check placement of hands when raising and lowering foot of table. Use armboards or secure arms over chest to avoid strain on muscles and nerves of arm while avoiding restriction of chest movements.
A. Potential postoperative complications of bleeding, respiratory difficulties, and emotional problems due to surgical procedure
Patient will be free of excessive bleeding, respiratory complications, and will not demonstrate emotional problems prior to discharge from recovery room.
Communicate to recovery room nurse any unusual occurrence prior to or during intraoperative care (eg, bleeding, vomiting, difficult intubation, unusual preoperative anxiety, psychologicaliemotional problems).
8. Potential complications
Will state understanding of postoperative care instructions prior to leaving recovery room Will be aware of follow-up appointment with physician
Provide patient teaching according to physician's protocol. Ask if patient has a follow-up appointment with physician.
11. lntraoperative
skeletal injury due to positioning
C. Potential injury to fingers due to raising and lowering foot of table
Ill. Postoperative
due to incomplete information
760
AOKN Journal, October 1981, V o l 3 4 , No 4
he had come alone and stated she did not “need” anyone with her.
S
we are asked about confidentiality, and we reassure the patient that we do not inform families or friends as to the nature of the treatment the patient received. In addition, we do not print their names on our OR schedule, nor do we write the names on our board that lists the current day’s schedule. Nurses also find that preoperative assessments help them to feel more positive about their role as nurses in these procedures. As a result of interviews with operating room nurses, Kaltreider et a1 reported that the nurses felt best about their patients when given an opportunity to meet them pre~peratively.~ As a result of this contact, nurses felt bitter able to provide emotional support preoperatively and postoperatively for midtrimester abortion patients. There are two types of patients whom we encounter most frequently-patients who show signs of distress such as crying and shaking and patients who display signs of denial such as avoiding eye contact or appearing stoic or overly confident. For the distressed patient, a calm approach with sensitivity to the patient’s needs seems to be most suitable. One way to work with these patients is to encourage them to express their feelings. If they are unwilling or unable to do so, a brief conversation about their home or job may help them to relax. With patients who show denial, a straightforward approach appears to be more effective. For example, one patient
was extremely hostile toward the staff and reluctant to answer questions. She had come alone and stated she did not “need” to have anyone with her. Her anger was upsetting to the staff, although as a result of our preoperative assessment we felt we were better able to understand the basis of her denial. After the procedure, she began to cry and accepted the efforts of the nursing staff to comfort her. Her attitude toward the abortion and the staff had changed, and we were able to perceive her changing needs and respond. In the intraoperative phase, the nurse prepares the patient for surgery, while assisting the anesthesiologist and surgeon. The nurse is also available t o provide emotional support to the patient immediately prior to induction of anesthesia. One often encounters a variety of behaviors ranging from denial to sadness and loneliness and must be prepared to handle these reactions effectively. Often a gentle touch and reassurance that someone will remain with her throughout the procedure may ease her feeling of loneliness and despair. An expression that indicates an understanding of her emotional needs, such as “I understand that you feel sad,” may help the patient deal with her feelings and decrease her anxiety. The postoperative phase begins when the patient enters the recovery room and ends when she has fully recovered from the effects of the anesthetic agents
AORN Journal, October 1981, Vol34, No 4
763
Table 2
Preoperative and postoperative responses to level of anxiety “Not at all” “Just a little” “Quitea bit” “Very much”
Preoperative
Postoperative
10% 46% 17% 27%
41O/o 29‘/o
16% 8Yo
24 to 48 hours after surgery. Before the patient leaves the recovery room, the nurse and patient can evaluate the overall experience. The patient has an opportunity to talk about her feelings regarding the procedure and to receive supportive counseling from the nurse. Although many patients are still somewhat sedated from the anesthesia prior to discharge, they often comment on the care they received and express appreciation to the staff. This brief interaction also provides the nurse with an opportunity to evaluate the nursing care plan. To maintain confidentiality, we do not make postoperative phone calls to our patients. To gain a better understanding of midtrimester abortion patients, we examined personality characteristics of 50 randomly selected unpremedicated women (age 18 and over; mean age 24) scheduled for D and E abortions. Informed consent was obtained by the attending anesthesiologist, and an IPAT trait anxiety scale was administered immediately prior t o surgery. The IPAT is a simple self-analysis form consisting of 40 statements to which patients respond “yes,” “in between,” or “no.” Overall trait anxiety measured by the IPAT scale included covert or less obvious anxiety traits as well as overt traits that related directly to anxiety and its
764
symptoms. Analysis of the responses to the IPAT demonstrated that the anxiety shown by our sample was only slightly higher than a nonsurgical population matched for sex, age, and educational background. Our results indicated that the overall personality profile of the D and E patients is not unique. They did not display the expected high levels of anxiety during the immediate preoperative period. This may indicate that the preoperative assessments by the nurse, surgeon, and anesthesiologist contributed to decreasing the patient’s anxiety. This warrants further investigation to determine the effect of a preoperative nursing assessment. Prior to discharge from the recovery room to home (one to two hours after awakening from anesthesia), patients were given a Profile of Mood States (POMS)questionnaire. The POMS is designed to identify and assess different mood or affective states. The six components measure tension-anxiety, depression-dejection, anger-hostility, vigoractivity, fatigue-inertia, and confusionbewilderment. Subsequently, 24 to 48 hours after recovering from the surgery and anesthesia, each patient completed a repeat POMS questionnaire and a short open-ended sentence completion form that were returned to us by mail. Our results demonstrated that the scores of the D and E sample population fall within the normal range for each of the six mood characteristics. As expected, our patients were less vigorous and more fatigued and confused during the immediate postoperative period. This probably represented mood changes secondary to residual levels of anesthetic agents present during the early recovery period in addition to the effects of the surgical procedure itself. In the 24-hour follow-up evaluation, our patients felt significantly more vigorous and active and experienced less fatigue and inertia
AORN Journal, October 1981, Val 34, No 4
S
taff members often ask why women wait until the second trimester.
and less confusion and bewilderment after recovering from the procedure and anesthesia. Tension-anxiety, depression-dejection, and anger-hostility scores were not significantly changed after complete recovery. It is not clear, however, whether these data represent mood changes secondary to the surgical procedure or represent the effects of anesthesia. The open-ended sentence form was completed 24 to 48 hours after awakening from anesthesia and served as an evaluation tool for the perioperative experience. When questioned about how they felt immediately before arriving in the operating room, 65% of our patients described feeling scared and nervous, while only 20% denied nervousness. Upon entering the operating room, 56% stated that the first things they noticed were operating room personnel and equipment, 16%noticed just people, and 14% noticed only the equipment in the room. Feelings prior t o induction ranged from fear (20%)to no feelings at all (16%). When asked what feelings helped alleviate their anxiety, 30% mentioned confidence in the staff, 23% answered “nothing,” and 30% described having comforting thoughts that often included family and friends. As an overall evaluation, 80%felt they had received a thorough explanation of the procedure. Their feelings postoperatively ranged from “great” (40%) to “pretty good” (30%)and %o-so” (20%).A
766
comparison of the level of anxiety felt preoperatively and postoperatively is in Table 2. Staff members often ask why women wait until the second trimester of pregnancy t o seek an abortion. Karenyi indicated that these women often demonstrated an inability to grasp their situation and deal with it reali~tically.~ Also, a lack of basic sex education and a tendency to procrastinate may result in the lack of a reliable method of birth control. Fielding found that denial, ambivalence, fear, and menstrual irregularity accounted for the greatest number of women seeking late abort i o n ~This . ~ study found that fear was the most common reason for delay among the younger women, whereas denial was more evident in older patients. Bracken and Kasl cite obstacles such as lack of accessibility to physicians who perform abortions, delays in raising money to pay for services, missed or late diagnosis of pregnancy, fear of parental disapproval, or abortions forced by parents. These problems may be compounded by feelings of ambivalence and poor communication with the woman’s partner.6 Several of our patients have had more than one abortion. Steinhoff cites three reasons why women have repeat abortions: (1)failure of contraceptives due to imperfections in technique, (2) social and personal factors make the chosen method impractical, (3) an underlying
AORN Journal, October 1981, V o l 3 4 , No 4
desire to become pregnant.’ At our institution, staff members agree that participating in abortion is stressful. Kane reported feelings of anxiety and depression among staff who frequently experienced difficulty resolving their ambivalence over their decision to participate.* Many staff members felt a need to find a medical reason for the abortion, such as the age of the mother, general health of the mother, or possibility of congenital defects in the fetus. Sharing one’s feelings with other staff members is the most helpful way to deal with these reactions. Physicians and nurses can work together to create a n environment that encourages the discussion of these thoughts and feelings. This can be done in a formal setting with an organized discussion or on a n informal basis. Voluntary participation in D and E procedures is essential, and team members must work together to ensure open communication. This will benefit not only the patients but also the staff by allowing them to work in a positive and supportive atmosphere. This environment is important if we are t o maintain quality standards of patient care in the 0 operating room. Notes 1. W Cates, Jr, D N Grimes, “Death from second trimester abortion by D and E: Causes, prevention and future,” American Journal of Obstetrics and Gynecology (in press). 2. N Kaltreider et al, “Impact of midtrimester abortion techniques on patients and staff,” American Journalof Obstetrics and Gynecology 135 (Sept 15, 1979) 235-238. 3. Ibid. 4. T D Kerenyi et al, “Reasons for delayed abortion: results of 400 interviews,” American Journal of Obstetrics and Gynecology 117 (Oct 1, 1973) 299311. 5. W L Fielding et al, “Comparison of women seeking early and late abortion,” Obstetrics and Gynecology 52 (July 1978) 56-58. 6. M B Bracken, S V Kasl, “Delay in seeking induced abortion: A review and theoretical analysis,”
768
American Journal of Obstetrics and Gynecology 121 (April 1, 1975) 1008-1019. 7. P G Steinhoff et al, “Women who obtain repeat abortions,” Family Planning Perspectives 1 1 (January-February 1979) 30-38. 8. F J Kane, Jr, et al, “Emotional reactions of abortion services personnel,” Archives of General Psychiatry 28 (March 1973) 409-411.
Profits OK for chapter educational offerings The National Committee on Education has learned that some chapters believe they are not supposed to make a profit on their educational offerings. This is not true. Obviously, the AORN Approval Board does not expect chapters to suffer a loss from an educational offering. Certainly it is desirable not only to meet all expenses but also to realize a nice profit as a reward for the chapter‘s efforts. The Approval Board does discourage chapters from charging excessive registration fees, however, if this will produce a profit of $2,000 to $3,000. Keep in mind that chapters have an obligation to meet the educational needs of a// their members. That should be the first priority of an offering, not fund raising. If chapters set their fees too high in order to raise money to send delegates to Congress, then only a few members are benefiting. Excessive fees will discourage attendance. It would be more appropriate to set the fee at a figure that would attract more members and still make a profit. A reasonable fee that most chapters charge is $10 to $25 per day, not counting lunch. Each chapter is unique. Each should use good judgment and set its fees accordingly. In summary, present quality offerings,set fees that will encourage the highest attendance, and by all means, make a prof it.
Ginny Green, RN Chairman-elect National Committee on Education
AORN Journal, October 1981, Val 34, N o 4