- Email: [email protected]
Predictors of preoperational anxiety in surgical patients
nursing
kontakt 17 (2015) e201–e205
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/kontakt
Original research article
Predictors of preoperational anxiety in surgical patients Andrea Solgajová a,*, Tomáš Sollár b, Dana Zrubcová a, Gabriela Vörösová a a
Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Department of Nursing, Nitra, Slovak Republic b Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Institute of Applied Psychology, Nitra, Slovak Republic
article info
abstract
Article history:
In clinical practice for the diagnosis of anxiety it is very useful to know the various predictors
Received 16 July 2015
which increase the risk of preoperational anxiety in patients. The aim of this study is to
Accepted 12 October 2015
identify which predictors (gender, age, type of surgery, type of anaesthesia, previous
Available online 24 October 2015
experience with surgery, time before surgery, and medical diagnosis) are significant predictors of preoperational anxiety.
Keywords:
A total of 278 respondents who had a medical diagnosis that required abdominal surgery,
Stress
aged between 18 and 86 (AM = 46.04; SD = 16.5) participated in the study. To assess anxiety in
Adaptation
the patients we used the Anxiety Level-12 scale, which was designed by modifying the
Anxiety
measurement tool ‘‘Anxiety Level from the Nursing Outcomes Classification (NOC)’’ and had
Preoperational period
been validated in the conditions of the Slovak Republic. Anxiety assessment in the patients
Nursing diagnosis
was carried out before their surgeries at various times (AM = 8 h; SD = 5; Mdn = 6.50). The research was approved by the Ethics Committee. The software, SPSS 22.0 multiple linear regression analysis, was used for the statistical data analysis. Gender, type of surgery, type of anaesthesia, and time before the surgery are significant predictors of preoperational anxiety; previous experience with surgery, age, and medical diagnosis are non-significant predictors. Knowing the predictors of preoperational anxiety would help nurses identify at risk patients. They could implement effective intervention strategies ahead of time to reduce preoperational anxiety and ensure a smooth surgery and postoperative period. # 2015 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.
* Corresponding author at: Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Department of Nursing, Tr. A. Hlinku 1, 949 74 Nitra, Slovak Republic. E-mail address: [email protected] (A. Solgajová). http://dx.doi.org/10.1016/j.kontakt.2015.10.005 1212-4117/# 2015 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o. o. All rights reserved.
e202
kontakt 17 (2015) e201–e205
Introduction
Materials and methods
In clinical practice, the condition of anxiety is characterized as an unpleasant feeling of discomfort; it is described as an individual's ability to adapt to stress, it can cause disease or other related factors [1]. Nurses might come into contact with the concept of anxiety in various settings of clinical practice and should have professional competences for its assessment and intervention [2]. In the classification system of nursing diagnoses the NANDA-I, the nursing diagnosis Anxiety (00146), is placed in Domain 9 – Coping/Stress Tolerance, Class 2 – Coping Responses. It is defined as ‘‘a vague, uneasy feeling of discomfort or dread, accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by the anticipation of danger. It is a warning sign that alerts of impending danger and enables the individual to take measures to deal with that threat’’ [3]. According to the NANDA-I, the related factors for the onset of anxiety include: major change in economic status, environment, health status, role status, situational crisis, stressors, threat of death, and unmet needs [3]. According to the authors [4,5], there is also a high incidence of anxiety in surgical patients. Not only the surgery itself, but also changes in the environment related to hospitalization; the presence of other patients who are not always pleasant, or diagnostic tests may increase the risk of anxiety. In the preoperational period, fear of failed surgery, fear of anaesthesia, fear of loss of self-control and fear of death dominate. Pain, loss of physical functions, disturbed body image, and return to daily routine and work life are present in the postoperative period. Preoperational anxiety and postoperative anxiety correlate [4]. Therefore, in clinical practice, if we were able to identify increased anxiety in the preoperational period, and if effective intervention strategies were implemented to reduce it [6], we would prevent postoperative complications (prolonged hospitalization, more intense and longer pain perception) [4,7,8]. Thus the diagnosis of preoperational anxiety is a subject of scientific interest for experts from various fields. According to the latest approaches in the theories of anxiety, besides the threat of a stressful situation, the authors emphasize in particular the influence of personal characteristics [9]. These characteristics, also called psychological characteristics, include coping strategies. Besides key (dispositional) characteristics, anxiety levels are also affected by situational characteristics [10] resulting from situations in which other people occur. Knowing the theories or various predictors of anxiety in the process of diagnosis is very useful; it is recommended that dispositional, situational as well as socio-demographic characteristics should be considered in order to assess the risk of anxiety in patients in both the preoperational and postoperative periods [4]. Multiple research studies have examined the characteristics related to levels of state anxiety in patients before surgery. The significant predictors of preoperational anxiety most frequently include: type of surgery [11,12], medical diagnosis [6,11], gender [4,6,12], time before surgery [13], and age [4,6]. The non-significant predictors include experience with surgery [6,11] and age [11,12].
In the research study there were 278 respondents who were hospitalized in the Surgical Clinic, the Teaching Hospital in Nitra. They were aged between 18 and 86 years (AM = 46.04; SD = 16.5). The inclusion criteria in the sampling frame consisted of surgeries (planned or acute), abdominal surgeries with a medical diagnosis according to ICD-10: ruptures in the abdominal cavity – hernias (K40–K46) 44.2%; other diseases of the intestines (K55–K63) 28.8%; disorders of the gallbladder, biliary tract and pancreas (K80–K87) 23%; diseases of the appendix (K35–K38) 4%. Exclusion criteria consisted of the administered premedication, and the presence of an oncologic medical diagnosis that was considered a specific situational characteristic, as anxiety levels in such groups of patients are described as higher [6,10]. There were 27% women; 82% planned surgeries, 18% acute surgeries; 93.5% respondents operated on for the first time; 6.5% respondents re-operated on; 74.5% respondents operated on under general anaesthesia; and 25.5% respondents operated on under spinal anaesthesia. To assess anxiety in patients in preoperational care, we used the Anxiety Level-12 scale, which was designed by modifying the measurement tool: Anxiety Level from the Nursing Outcomes Classification (NOC) [14], which had been validated in the conditions of the Slovak Republic [15]. The scale has good construct and factor validity, and is applicable for the evaluation of psychological variables in the context of nursing diagnosis. It consists of 12 items of behavioural, physiological and psychological character (sleep pattern disturbance, sadness, verbalized anxiety, nervousness, crying, heart pounding, trembling, fear, decreased ability to concentrate, irritability, exaggerated concern about life events, and increased heart rate). A rater (a nurse) rates the levels of these manifestations on a scale from 1 (none) to 5 (severe). The final anxiety level is given by a total score, which ranges between 12 and 60 points. Anxiety assessment was carried out by two nurses who were trained to use the scale. The patients were assessed before their surgery at various times (AM = 8 h; SD = 5; Mdn = 6.50) (min. 1 h before surgery; max. 18.75 h before surgery), and always before premedication administration. The research was approved by the Ethics Committee of the Teaching Hospital in Nitra. The software SPSS 22.0 was used for the statistical data analysis. Multiple linear regression analysis, the stepwise method [16], was used to examine the relationship between state anxiety and its predictors.
Results The results answer the question related to the investigation of the predictors of state anxiety in patients before surgery. We evaluated seven predictors: gender, age, type of surgery (planned or acute), type of anaesthesia, previous experience with surgery, time before surgery, and medical diagnosis. Multiple linear regression analysis (the stepwise method) was used for data evaluation; it statistically eliminates
e203
kontakt 17 (2015) e201–e205
Table 1 – Overall evaluation of models predicting preoperational anxiety.
Model Model Model Model
1 2 3 4
(Gender) (Gender. Type of surgery) (Gender. Type of surgery. Type of anaesthesia) (Gender. Type of surgery. Type of anaesthesia. Time before surgery)
R
Adj R 2
F
p
0.531 0.685 0.763 0.808
0.279 0.465 0.578 0.648
108.17 121.35 127.24 128.32
<0.001 <0.001 <0.001 <0.001
Table 2 – Regression coefficients of predictors in four models of predictors of preoperational anxiety.
Model 1 Model 2 Model 3
Model 4
Gender Gender Type of surgery Gender Type of surgery Type of anaesthesia Gender Type of surgery Type of anaesthesia Time before surgery
B
SE(B)
13.598 11.326 13.081 11.047 14.834 8.911 11.137 10.490 9.746 0.713
1.307 1.150 1.329 1.022 1.198 1.034 0.933 1.240 0.951 0.096
b 0.531 0.442 0.442 0.431 0.501 0.342 0.435 0.354 0.374 0.308
t
p
10.400 9.852 9.846 10.809 12.383 8.621 11.931 8.462 10.254 7.453
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
B – unstandardized regression coefficient, SE(B) – standard error of unstandardized regression coefficient, b – standardized regression coefficient.
non-significant predictors (from the original seven predictors) of the dependent variable (state anxiety). The analysis is conducted in steps. In step 1, the statistically significant and strongest predictor is identified (Model 1). In the next step, the strongest of the remaining predictors is identified and it produces a solution with two variables (Model 2). Analysis continues until none of the remaining variables are statistically significant. In our study, we present four models which predict preoperational anxiety. Table 1 shows the overall evaluation of four models that predict preoperational anxiety. The first model identifies gender as the strongest predictor (out of the seven examined predictors). This model explains 28% of the variability of anxiety (R2 = 0.279). Besides the gender variable, the second model includes the type of surgery variable. This model explains 46.5% of the variability of anxiety (R2 = 0.465); higher levels of anxiety are in women, and if surgery is acute (not planned). Besides the gender and type of surgery variables, the third model includes the type of anaesthesia variable. This model explains 58% of the variability of anxiety (R2 = 0.578); higher levels of anxiety are in women, if surgery is acute and anaesthesia is spinal (not general). The last model includes four variables as significant predictors of preoperational anxiety: gender, type of surgery, type of anaesthesia, and time before surgery. This model
explains 65% of the variability of anxiety (R2 = 0.648); higher levels of anxiety are in women (b = 0.435; p < 0.001), if surgery is acute (b = 0.354; p < 0.001), anaesthesia is spinal (b = 0.374; p < 0.001), and time before surgery is shorter (a negative value of regression coefficient means a shorter time before surgery; b = 0.308; p < 0.001; Table 2). On the basis of the standardized regression coefficient (b) we can evaluate the strength of the relationship between variables (predictors) and the dependent variable. On the basis of the non-standardized regression coefficient (B) we can answer the question of how the dependent variable (anxiety) changes if the value of the independent variable (predictor) changes by one unit (it is expressed in units the variables were measured in). To demonstrate this interpretation we can specify (based on the data in Table 2, Model 4) that on average levels of anxiety are higher in women than in men by 11 points; on average levels of anxiety are higher in acute surgery than in planned surgery by 10 points; on average levels of anxiety are higher for spinal anaesthesia than general anaesthesia by 9 points; and levels of anxiety increase by 1 point every 45 min closer to surgery; changes in points relate to the Anxiety Level12 scale whose theoretical range is 48 points. Table 3 statistically shows the variables that do not significantly contribute to the prediction of anxiety before
Table 3 – Statistically non-significant predictors of preoperational anxiety [17]. Beta in. Model 4
Age Previous experience with surgery Medical diagnosis: K40–K46 Medical diagnosis: K55–K63 Medical diagnosis: K80–K87 Medical diagnosis: K35–K38
0.019 0.058 0.011 0.061 0.058 0.059
t 0.481 1.610 0.294 1.665 1.491 1.556
p 0.631 0.108 0.769 0.097 0.137 0.121
Partial corr. 0.029 0.097 0.018 0.100 0.090 0.094
Beta in. – standardized regression coefficient of increment of the variable for the model; dependent variable: anxiety; independent variables: gender, type of surgery, type of anaesthesia, time before surgery.
e204
kontakt 17 (2015) e201–e205
surgery. They are age, previous experience with surgery, and medical diagnosis. The interpretation of the results is in the discussion below.
Results summary Gender, type of surgery, type of anaesthesia and time before surgery appear as significant predictors of preoperational anxiety, while previous experience with surgery, age and medical diagnosis are not considered as significant predictors. In this type of situation (forthcoming surgery), gender (higher level of anxiety in women) is the most significant predictor, followed by the type of surgery (acute more than planned), type of anaesthesia (spinal more than general), and time before surgery (the shorter the time before surgery, the higher the level of anxiety).
Discussion In the literature, the preoperational period is described as a significant situational factor for the onset of anxiety. In such a situation, the patient experiences stress due to a nonspecific situation that requires a kind of change from the person; the person needs to adapt. The onset of anxiety is described in the context of the person's ability to adapt. People are able to rid themselves of anxiety by their own adaptation mechanisms. If those mechanisms fail, people enter the exhaustion phase, which is characterized by severe anxiety and can cause serious psycho-physiological difficulties in people [18]. In clinical practice, it is important for nurses to be able to identify at risk patients before severe anxiety occurs. Effective intervention strategies for its reduction would lead to the process of effective adaptation with the aim of ensuring an uncomplicated course of surgery and postoperative period [6]. The basis for such a strategy is the correct diagnosis of anxiety [11] in which nurses, in accordance with the recommendations [19], should take research results into account, and thus have prediction, prevention and prognosis of the current status of the patient in mind. Research studies that focus on the diagnosis of preoperational anxiety suggest that multiple dispositional, situational and socio-demographic factors related to levels of state anxiety are important in the process of adaptation to changed conditions (status before surgery) [4,9,10]. In our research, we evaluated which variables (gender, age, type of surgery, type of anaesthesia, previous experience with surgery, time before surgery, and medical diagnosis) are significant predictors of preoperational anxiety. We found that gender is the strongest predictor of preoperational anxiety in patients. Our findings about the incidence of higher levels of anxiety in women support the findings in study [6], in which the authors compared the incidence of anxiety in patients undergoing abdominal surgeries between genders, and found that women were more anxious. Karanci and Dirik [4] also state that there are significant differences in the incidence of anxiety between men and women in the preoperational period, with higher levels of anxiety in women. However, the differences in the postoperative period are not significant. Higher levels of
preoperational anxiety in women are also presented by other authors [6,12,20,21]. It is interesting that gender appears as the most significant predictor of postoperative anxiety too [7]. We assume that the difference between genders relates to the willingness to admit and express emotions or talk about them, which is more natural for women. In general, people who prefer an emotional style of coping are more anxious [6], which is also more typical of women. According to our findings, the type of surgery is the second strongest predictor of preoperational anxiety. We specified the type of surgery according to the possibilities of pre-surgical preparation – acute or planned. Patients who require acute surgery have a short time to adapt to the situation, and anxiety is highly common in them [4]. Multiple authors [4,7,22] state that anaesthesia, and particularly fear of anaesthesia, causes the onset of preoperational anxiety. After anaesthesiologic examination, planned surgery patients are informed about the type of anaesthesia for their surgery. We wanted to find out how information about the type of anaesthesia related to the incidence of preoperational anxiety in patients. We discovered that patients under general anaesthesia were less anxious than patients under spinal anaesthesia. The explanation can be supported by the findings of the study [23] in which they examined preoperational anxiety. Fear of anaesthesia, specifically to be put to sleep ‘‘well’’, and not to feel anything during surgery, was the second strongest of the 10 factors evaluated. Our findings show that the time remaining to surgery is the least statistically significant predictor of anxiety. Our findings support those of the authors [13], who studied the differences in incidence of preoperational anxiety in adolescents in three measurements. They discovered that anxiety increased at each time point. Time remaining to surgery has been described as a significant predictor of preoperational anxiety. Therefore, in the literature [23], they recommend the revaluation of pre-medication in standard time frames, i.e. 1–1.5 h before surgery, particularly in patients who are listed at the end of the surgery programme and wait for their surgeries without pre-medication for up to several hours. We agree with this recommendation in our conditions too. During this period of time, there is also a space for implication of coping-based intervention strategies to prevent critical levels of anxiety. Other examined predictors of preoperational anxiety appear as non-significant, according to our findings. These include previous experience with surgery, age, and medical diagnosis. In accordance with the research results [6,11], previous experience with surgery has no statistically significant effects on the incidence of preoperational anxiety. We also support the results of the authors [11,12] who state that age is not a significant predictor of preoperational anxiety. The last of the examined predictors of preoperational anxiety that has not proved to be statistically significant is medical diagnosis. We studied the differences between the medical diagnoses requiring abdominal surgery; we did not take surgery severity into consideration, as the literature says that patients with a simpler course of surgery experience similar anxiety to patients with a more severe course of surgery [6]. We also did not study the differences related to laparoscopic and laparotomy surgery, as differences in the previous studies
kontakt 17 (2015) e201–e205
were found only in the extent of experienced stress, not anxiety [11]. In the research study we focused on the examination of selected predictors of preoperational anxiety. For further research, it would also be useful to focus on examining the influence of personality traits and coping strategies and their interaction with socio-demographic characteristics, and also to extend the examination of preoperational anxiety for medical diagnoses in other fields of surgery.
Conclusion The analysis of the results shows that the incidence of preoperational anxiety is particularly affected by gender (higher anxiety in women), type of surgery (acute more than planned), type of anaesthesia (spinal more than general), and time before surgery (anxiety level increases with a shorter time before surgery). In the process of the diagnosis of anxiety in patients during the preoperational period, and decisionmaking about interventions, it is necessary for nurses to take the predictors of anxiety into account, as well as to implement an individual approach in care.
Conflict of interest The authors have no conflict of interest to disclose.
Acknowledgements The paper was supported by the Grant Agency APVV (Grant No. APVV-0532-10 ‘‘Psychometric analysis and synthesis of existing anxiety and coping assessment methods in nursing’’) and by the grant UGA CPU in Nitra (UGA-IX/8/2015 ‘‘Validation of nursing diagnosis Anxiety’’).
references
[1] Gurková E, Čáp J. Úzkosť. In: Gurková E, Čáp J, Žiaková K, editors. Vybrané ošetrovateľské diagnózy v klinickej praxi. Martin: Osveta; 2009. p. 152–62. [2] Oliveira N, Chianca T, Rassool GH. A validation study of the nursing diagnosis anxiety in Brazil. Int J Nurs Terminol Classif 2008;19:102–10. [3] Herdman TH, Kamitsuru S. NANDA International Nursing Diagnoses: definitions & classification, 2015–2017. 10th ed. Oxford: Wiley-Blackwell; 2014.
e205
[4] Karanci AN, Dirik G. Predictors of pre- and postoperative anxiety in emergency surgery patients. J Psychosom Res 2003;55:363–9. [5] Johnson M, Bulechek G, Butcher H, Dochterman J, Maas M, Moorhead S, et al. Nursing diagnoses, outcomes & interventions: NANDA, NIC, and NOC linkages. 2nd ed. St. Louis: Mosby Inc.; 2006. [6] Domar AD, Everett LL, Keller MG. Preoperative anxiety: is it a predictable entity? Anesth Analg 1989;69:763–7. [7] Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, Adamatti LC, et al. Risk factors for postoperative anxiety in adults. Anaesthesia 2001;56:720–8. [8] Viars J. Anxiety and open heart surgery. Medsurg Nurs 2009;18:283–91. [9] McDowell I. Measuring health: a guide to rating scales. 3rd ed. New York: Oxford University Press; 2006. [10] Haugen AS, Eide GE, Olsen MV, Haukeland B, Remme ÅR, Wahl AK. Anxiety in the operating theatre: a study of frequency and environmental impact in patients having local, plexus or regional anaesthesia. J Clin Nurs 2009;18:2301–10. [11] Dos Santos BM, Martins JC, Oliveira LM. Anxiety, depression and stress in the preoperative surgical patient. Rev Enferm Ref 2014;IV:7–15. [12] Yilmaz M, Sezer H, Gürler H, Bekar M. Predictors of preoperative anxiety in surgical inpatients. J Clin Nurs 2012;21:956–64. [13] Fortier MA, Martin SR, MacLaren Chorney J, Mayes LC, Kain ZN. Preoperative anxiety in adolescents undergoing surgery: a pilot study. Paediatr Anaesth 2011;21:969–73. [14] Moorhead S, Johnson M, Maas LM, Swanson E. Nursing Outcomes Classification (NOC). 4th ed. MO, USA: Mosby Inc.; 2008. [15] Solgajová A, Sollár T, Vörösová G. Level of Anxiety Scale 12: validation study. In: Sollár T, editor. Anxiety and coping in hospitalized patients measurement tools and findings. Krakow: Scientia, Arts, Education; 2014. p. 7–30. [16] Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Pearson Education Inc.; 2007. [17] Cohen J, Cohen P, West SG, Aiken LS. Applied multiple regression/correlation analysis for the behavioral sciences. 3rd ed. New Jersey: Lawrence Erlbaum Associates Inc.; 2003. [18] Pasquali EA, Arnold HM, De Basio N. Mental health nursing: a holistic approach. St. Louis: Mosby Inc.; 1989. [19] Gurková E, Žiaková K. Ošetrovateľská diagnostika v kontexte praxe založenej na dôkazoch. Kontakt 2009;11: 32–7. [20] Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996;82:445–51. [21] Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D. The visual analogue scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns. Anaesth Analg 2000;90:706–12. [22] Pritchard MJ. Identifying and assessing anxiety in preoperative patients. Nurs Stand 2009;23:35–40. [23] McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthesia 1990;45:153–5.
kontakt 17 (2015) e201–e205
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/kontakt
Original research article
Predictors of preoperational anxiety in surgical patients Andrea Solgajová a,*, Tomáš Sollár b, Dana Zrubcová a, Gabriela Vörösová a a
Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Department of Nursing, Nitra, Slovak Republic b Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Institute of Applied Psychology, Nitra, Slovak Republic
article info
abstract
Article history:
In clinical practice for the diagnosis of anxiety it is very useful to know the various predictors
Received 16 July 2015
which increase the risk of preoperational anxiety in patients. The aim of this study is to
Accepted 12 October 2015
identify which predictors (gender, age, type of surgery, type of anaesthesia, previous
Available online 24 October 2015
experience with surgery, time before surgery, and medical diagnosis) are significant predictors of preoperational anxiety.
Keywords:
A total of 278 respondents who had a medical diagnosis that required abdominal surgery,
Stress
aged between 18 and 86 (AM = 46.04; SD = 16.5) participated in the study. To assess anxiety in
Adaptation
the patients we used the Anxiety Level-12 scale, which was designed by modifying the
Anxiety
measurement tool ‘‘Anxiety Level from the Nursing Outcomes Classification (NOC)’’ and had
Preoperational period
been validated in the conditions of the Slovak Republic. Anxiety assessment in the patients
Nursing diagnosis
was carried out before their surgeries at various times (AM = 8 h; SD = 5; Mdn = 6.50). The research was approved by the Ethics Committee. The software, SPSS 22.0 multiple linear regression analysis, was used for the statistical data analysis. Gender, type of surgery, type of anaesthesia, and time before the surgery are significant predictors of preoperational anxiety; previous experience with surgery, age, and medical diagnosis are non-significant predictors. Knowing the predictors of preoperational anxiety would help nurses identify at risk patients. They could implement effective intervention strategies ahead of time to reduce preoperational anxiety and ensure a smooth surgery and postoperative period. # 2015 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.
* Corresponding author at: Constantine the Philosopher University in Nitra, Faculty of Social Sciences and Health Care, Department of Nursing, Tr. A. Hlinku 1, 949 74 Nitra, Slovak Republic. E-mail address: [email protected] (A. Solgajová). http://dx.doi.org/10.1016/j.kontakt.2015.10.005 1212-4117/# 2015 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o. o. All rights reserved.
e202
kontakt 17 (2015) e201–e205
Introduction
Materials and methods
In clinical practice, the condition of anxiety is characterized as an unpleasant feeling of discomfort; it is described as an individual's ability to adapt to stress, it can cause disease or other related factors [1]. Nurses might come into contact with the concept of anxiety in various settings of clinical practice and should have professional competences for its assessment and intervention [2]. In the classification system of nursing diagnoses the NANDA-I, the nursing diagnosis Anxiety (00146), is placed in Domain 9 – Coping/Stress Tolerance, Class 2 – Coping Responses. It is defined as ‘‘a vague, uneasy feeling of discomfort or dread, accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by the anticipation of danger. It is a warning sign that alerts of impending danger and enables the individual to take measures to deal with that threat’’ [3]. According to the NANDA-I, the related factors for the onset of anxiety include: major change in economic status, environment, health status, role status, situational crisis, stressors, threat of death, and unmet needs [3]. According to the authors [4,5], there is also a high incidence of anxiety in surgical patients. Not only the surgery itself, but also changes in the environment related to hospitalization; the presence of other patients who are not always pleasant, or diagnostic tests may increase the risk of anxiety. In the preoperational period, fear of failed surgery, fear of anaesthesia, fear of loss of self-control and fear of death dominate. Pain, loss of physical functions, disturbed body image, and return to daily routine and work life are present in the postoperative period. Preoperational anxiety and postoperative anxiety correlate [4]. Therefore, in clinical practice, if we were able to identify increased anxiety in the preoperational period, and if effective intervention strategies were implemented to reduce it [6], we would prevent postoperative complications (prolonged hospitalization, more intense and longer pain perception) [4,7,8]. Thus the diagnosis of preoperational anxiety is a subject of scientific interest for experts from various fields. According to the latest approaches in the theories of anxiety, besides the threat of a stressful situation, the authors emphasize in particular the influence of personal characteristics [9]. These characteristics, also called psychological characteristics, include coping strategies. Besides key (dispositional) characteristics, anxiety levels are also affected by situational characteristics [10] resulting from situations in which other people occur. Knowing the theories or various predictors of anxiety in the process of diagnosis is very useful; it is recommended that dispositional, situational as well as socio-demographic characteristics should be considered in order to assess the risk of anxiety in patients in both the preoperational and postoperative periods [4]. Multiple research studies have examined the characteristics related to levels of state anxiety in patients before surgery. The significant predictors of preoperational anxiety most frequently include: type of surgery [11,12], medical diagnosis [6,11], gender [4,6,12], time before surgery [13], and age [4,6]. The non-significant predictors include experience with surgery [6,11] and age [11,12].
In the research study there were 278 respondents who were hospitalized in the Surgical Clinic, the Teaching Hospital in Nitra. They were aged between 18 and 86 years (AM = 46.04; SD = 16.5). The inclusion criteria in the sampling frame consisted of surgeries (planned or acute), abdominal surgeries with a medical diagnosis according to ICD-10: ruptures in the abdominal cavity – hernias (K40–K46) 44.2%; other diseases of the intestines (K55–K63) 28.8%; disorders of the gallbladder, biliary tract and pancreas (K80–K87) 23%; diseases of the appendix (K35–K38) 4%. Exclusion criteria consisted of the administered premedication, and the presence of an oncologic medical diagnosis that was considered a specific situational characteristic, as anxiety levels in such groups of patients are described as higher [6,10]. There were 27% women; 82% planned surgeries, 18% acute surgeries; 93.5% respondents operated on for the first time; 6.5% respondents re-operated on; 74.5% respondents operated on under general anaesthesia; and 25.5% respondents operated on under spinal anaesthesia. To assess anxiety in patients in preoperational care, we used the Anxiety Level-12 scale, which was designed by modifying the measurement tool: Anxiety Level from the Nursing Outcomes Classification (NOC) [14], which had been validated in the conditions of the Slovak Republic [15]. The scale has good construct and factor validity, and is applicable for the evaluation of psychological variables in the context of nursing diagnosis. It consists of 12 items of behavioural, physiological and psychological character (sleep pattern disturbance, sadness, verbalized anxiety, nervousness, crying, heart pounding, trembling, fear, decreased ability to concentrate, irritability, exaggerated concern about life events, and increased heart rate). A rater (a nurse) rates the levels of these manifestations on a scale from 1 (none) to 5 (severe). The final anxiety level is given by a total score, which ranges between 12 and 60 points. Anxiety assessment was carried out by two nurses who were trained to use the scale. The patients were assessed before their surgery at various times (AM = 8 h; SD = 5; Mdn = 6.50) (min. 1 h before surgery; max. 18.75 h before surgery), and always before premedication administration. The research was approved by the Ethics Committee of the Teaching Hospital in Nitra. The software SPSS 22.0 was used for the statistical data analysis. Multiple linear regression analysis, the stepwise method [16], was used to examine the relationship between state anxiety and its predictors.
Results The results answer the question related to the investigation of the predictors of state anxiety in patients before surgery. We evaluated seven predictors: gender, age, type of surgery (planned or acute), type of anaesthesia, previous experience with surgery, time before surgery, and medical diagnosis. Multiple linear regression analysis (the stepwise method) was used for data evaluation; it statistically eliminates
e203
kontakt 17 (2015) e201–e205
Table 1 – Overall evaluation of models predicting preoperational anxiety.
Model Model Model Model
1 2 3 4
(Gender) (Gender. Type of surgery) (Gender. Type of surgery. Type of anaesthesia) (Gender. Type of surgery. Type of anaesthesia. Time before surgery)
R
Adj R 2
F
p
0.531 0.685 0.763 0.808
0.279 0.465 0.578 0.648
108.17 121.35 127.24 128.32
<0.001 <0.001 <0.001 <0.001
Table 2 – Regression coefficients of predictors in four models of predictors of preoperational anxiety.
Model 1 Model 2 Model 3
Model 4
Gender Gender Type of surgery Gender Type of surgery Type of anaesthesia Gender Type of surgery Type of anaesthesia Time before surgery
B
SE(B)
13.598 11.326 13.081 11.047 14.834 8.911 11.137 10.490 9.746 0.713
1.307 1.150 1.329 1.022 1.198 1.034 0.933 1.240 0.951 0.096
b 0.531 0.442 0.442 0.431 0.501 0.342 0.435 0.354 0.374 0.308
t
p
10.400 9.852 9.846 10.809 12.383 8.621 11.931 8.462 10.254 7.453
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
B – unstandardized regression coefficient, SE(B) – standard error of unstandardized regression coefficient, b – standardized regression coefficient.
non-significant predictors (from the original seven predictors) of the dependent variable (state anxiety). The analysis is conducted in steps. In step 1, the statistically significant and strongest predictor is identified (Model 1). In the next step, the strongest of the remaining predictors is identified and it produces a solution with two variables (Model 2). Analysis continues until none of the remaining variables are statistically significant. In our study, we present four models which predict preoperational anxiety. Table 1 shows the overall evaluation of four models that predict preoperational anxiety. The first model identifies gender as the strongest predictor (out of the seven examined predictors). This model explains 28% of the variability of anxiety (R2 = 0.279). Besides the gender variable, the second model includes the type of surgery variable. This model explains 46.5% of the variability of anxiety (R2 = 0.465); higher levels of anxiety are in women, and if surgery is acute (not planned). Besides the gender and type of surgery variables, the third model includes the type of anaesthesia variable. This model explains 58% of the variability of anxiety (R2 = 0.578); higher levels of anxiety are in women, if surgery is acute and anaesthesia is spinal (not general). The last model includes four variables as significant predictors of preoperational anxiety: gender, type of surgery, type of anaesthesia, and time before surgery. This model
explains 65% of the variability of anxiety (R2 = 0.648); higher levels of anxiety are in women (b = 0.435; p < 0.001), if surgery is acute (b = 0.354; p < 0.001), anaesthesia is spinal (b = 0.374; p < 0.001), and time before surgery is shorter (a negative value of regression coefficient means a shorter time before surgery; b = 0.308; p < 0.001; Table 2). On the basis of the standardized regression coefficient (b) we can evaluate the strength of the relationship between variables (predictors) and the dependent variable. On the basis of the non-standardized regression coefficient (B) we can answer the question of how the dependent variable (anxiety) changes if the value of the independent variable (predictor) changes by one unit (it is expressed in units the variables were measured in). To demonstrate this interpretation we can specify (based on the data in Table 2, Model 4) that on average levels of anxiety are higher in women than in men by 11 points; on average levels of anxiety are higher in acute surgery than in planned surgery by 10 points; on average levels of anxiety are higher for spinal anaesthesia than general anaesthesia by 9 points; and levels of anxiety increase by 1 point every 45 min closer to surgery; changes in points relate to the Anxiety Level12 scale whose theoretical range is 48 points. Table 3 statistically shows the variables that do not significantly contribute to the prediction of anxiety before
Table 3 – Statistically non-significant predictors of preoperational anxiety [17]. Beta in. Model 4
Age Previous experience with surgery Medical diagnosis: K40–K46 Medical diagnosis: K55–K63 Medical diagnosis: K80–K87 Medical diagnosis: K35–K38
0.019 0.058 0.011 0.061 0.058 0.059
t 0.481 1.610 0.294 1.665 1.491 1.556
p 0.631 0.108 0.769 0.097 0.137 0.121
Partial corr. 0.029 0.097 0.018 0.100 0.090 0.094
Beta in. – standardized regression coefficient of increment of the variable for the model; dependent variable: anxiety; independent variables: gender, type of surgery, type of anaesthesia, time before surgery.
e204
kontakt 17 (2015) e201–e205
surgery. They are age, previous experience with surgery, and medical diagnosis. The interpretation of the results is in the discussion below.
Results summary Gender, type of surgery, type of anaesthesia and time before surgery appear as significant predictors of preoperational anxiety, while previous experience with surgery, age and medical diagnosis are not considered as significant predictors. In this type of situation (forthcoming surgery), gender (higher level of anxiety in women) is the most significant predictor, followed by the type of surgery (acute more than planned), type of anaesthesia (spinal more than general), and time before surgery (the shorter the time before surgery, the higher the level of anxiety).
Discussion In the literature, the preoperational period is described as a significant situational factor for the onset of anxiety. In such a situation, the patient experiences stress due to a nonspecific situation that requires a kind of change from the person; the person needs to adapt. The onset of anxiety is described in the context of the person's ability to adapt. People are able to rid themselves of anxiety by their own adaptation mechanisms. If those mechanisms fail, people enter the exhaustion phase, which is characterized by severe anxiety and can cause serious psycho-physiological difficulties in people [18]. In clinical practice, it is important for nurses to be able to identify at risk patients before severe anxiety occurs. Effective intervention strategies for its reduction would lead to the process of effective adaptation with the aim of ensuring an uncomplicated course of surgery and postoperative period [6]. The basis for such a strategy is the correct diagnosis of anxiety [11] in which nurses, in accordance with the recommendations [19], should take research results into account, and thus have prediction, prevention and prognosis of the current status of the patient in mind. Research studies that focus on the diagnosis of preoperational anxiety suggest that multiple dispositional, situational and socio-demographic factors related to levels of state anxiety are important in the process of adaptation to changed conditions (status before surgery) [4,9,10]. In our research, we evaluated which variables (gender, age, type of surgery, type of anaesthesia, previous experience with surgery, time before surgery, and medical diagnosis) are significant predictors of preoperational anxiety. We found that gender is the strongest predictor of preoperational anxiety in patients. Our findings about the incidence of higher levels of anxiety in women support the findings in study [6], in which the authors compared the incidence of anxiety in patients undergoing abdominal surgeries between genders, and found that women were more anxious. Karanci and Dirik [4] also state that there are significant differences in the incidence of anxiety between men and women in the preoperational period, with higher levels of anxiety in women. However, the differences in the postoperative period are not significant. Higher levels of
preoperational anxiety in women are also presented by other authors [6,12,20,21]. It is interesting that gender appears as the most significant predictor of postoperative anxiety too [7]. We assume that the difference between genders relates to the willingness to admit and express emotions or talk about them, which is more natural for women. In general, people who prefer an emotional style of coping are more anxious [6], which is also more typical of women. According to our findings, the type of surgery is the second strongest predictor of preoperational anxiety. We specified the type of surgery according to the possibilities of pre-surgical preparation – acute or planned. Patients who require acute surgery have a short time to adapt to the situation, and anxiety is highly common in them [4]. Multiple authors [4,7,22] state that anaesthesia, and particularly fear of anaesthesia, causes the onset of preoperational anxiety. After anaesthesiologic examination, planned surgery patients are informed about the type of anaesthesia for their surgery. We wanted to find out how information about the type of anaesthesia related to the incidence of preoperational anxiety in patients. We discovered that patients under general anaesthesia were less anxious than patients under spinal anaesthesia. The explanation can be supported by the findings of the study [23] in which they examined preoperational anxiety. Fear of anaesthesia, specifically to be put to sleep ‘‘well’’, and not to feel anything during surgery, was the second strongest of the 10 factors evaluated. Our findings show that the time remaining to surgery is the least statistically significant predictor of anxiety. Our findings support those of the authors [13], who studied the differences in incidence of preoperational anxiety in adolescents in three measurements. They discovered that anxiety increased at each time point. Time remaining to surgery has been described as a significant predictor of preoperational anxiety. Therefore, in the literature [23], they recommend the revaluation of pre-medication in standard time frames, i.e. 1–1.5 h before surgery, particularly in patients who are listed at the end of the surgery programme and wait for their surgeries without pre-medication for up to several hours. We agree with this recommendation in our conditions too. During this period of time, there is also a space for implication of coping-based intervention strategies to prevent critical levels of anxiety. Other examined predictors of preoperational anxiety appear as non-significant, according to our findings. These include previous experience with surgery, age, and medical diagnosis. In accordance with the research results [6,11], previous experience with surgery has no statistically significant effects on the incidence of preoperational anxiety. We also support the results of the authors [11,12] who state that age is not a significant predictor of preoperational anxiety. The last of the examined predictors of preoperational anxiety that has not proved to be statistically significant is medical diagnosis. We studied the differences between the medical diagnoses requiring abdominal surgery; we did not take surgery severity into consideration, as the literature says that patients with a simpler course of surgery experience similar anxiety to patients with a more severe course of surgery [6]. We also did not study the differences related to laparoscopic and laparotomy surgery, as differences in the previous studies
kontakt 17 (2015) e201–e205
were found only in the extent of experienced stress, not anxiety [11]. In the research study we focused on the examination of selected predictors of preoperational anxiety. For further research, it would also be useful to focus on examining the influence of personality traits and coping strategies and their interaction with socio-demographic characteristics, and also to extend the examination of preoperational anxiety for medical diagnoses in other fields of surgery.
Conclusion The analysis of the results shows that the incidence of preoperational anxiety is particularly affected by gender (higher anxiety in women), type of surgery (acute more than planned), type of anaesthesia (spinal more than general), and time before surgery (anxiety level increases with a shorter time before surgery). In the process of the diagnosis of anxiety in patients during the preoperational period, and decisionmaking about interventions, it is necessary for nurses to take the predictors of anxiety into account, as well as to implement an individual approach in care.
Conflict of interest The authors have no conflict of interest to disclose.
Acknowledgements The paper was supported by the Grant Agency APVV (Grant No. APVV-0532-10 ‘‘Psychometric analysis and synthesis of existing anxiety and coping assessment methods in nursing’’) and by the grant UGA CPU in Nitra (UGA-IX/8/2015 ‘‘Validation of nursing diagnosis Anxiety’’).
references
[1] Gurková E, Čáp J. Úzkosť. In: Gurková E, Čáp J, Žiaková K, editors. Vybrané ošetrovateľské diagnózy v klinickej praxi. Martin: Osveta; 2009. p. 152–62. [2] Oliveira N, Chianca T, Rassool GH. A validation study of the nursing diagnosis anxiety in Brazil. Int J Nurs Terminol Classif 2008;19:102–10. [3] Herdman TH, Kamitsuru S. NANDA International Nursing Diagnoses: definitions & classification, 2015–2017. 10th ed. Oxford: Wiley-Blackwell; 2014.
e205
[4] Karanci AN, Dirik G. Predictors of pre- and postoperative anxiety in emergency surgery patients. J Psychosom Res 2003;55:363–9. [5] Johnson M, Bulechek G, Butcher H, Dochterman J, Maas M, Moorhead S, et al. Nursing diagnoses, outcomes & interventions: NANDA, NIC, and NOC linkages. 2nd ed. St. Louis: Mosby Inc.; 2006. [6] Domar AD, Everett LL, Keller MG. Preoperative anxiety: is it a predictable entity? Anesth Analg 1989;69:763–7. [7] Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, Adamatti LC, et al. Risk factors for postoperative anxiety in adults. Anaesthesia 2001;56:720–8. [8] Viars J. Anxiety and open heart surgery. Medsurg Nurs 2009;18:283–91. [9] McDowell I. Measuring health: a guide to rating scales. 3rd ed. New York: Oxford University Press; 2006. [10] Haugen AS, Eide GE, Olsen MV, Haukeland B, Remme ÅR, Wahl AK. Anxiety in the operating theatre: a study of frequency and environmental impact in patients having local, plexus or regional anaesthesia. J Clin Nurs 2009;18:2301–10. [11] Dos Santos BM, Martins JC, Oliveira LM. Anxiety, depression and stress in the preoperative surgical patient. Rev Enferm Ref 2014;IV:7–15. [12] Yilmaz M, Sezer H, Gürler H, Bekar M. Predictors of preoperative anxiety in surgical inpatients. J Clin Nurs 2012;21:956–64. [13] Fortier MA, Martin SR, MacLaren Chorney J, Mayes LC, Kain ZN. Preoperative anxiety in adolescents undergoing surgery: a pilot study. Paediatr Anaesth 2011;21:969–73. [14] Moorhead S, Johnson M, Maas LM, Swanson E. Nursing Outcomes Classification (NOC). 4th ed. MO, USA: Mosby Inc.; 2008. [15] Solgajová A, Sollár T, Vörösová G. Level of Anxiety Scale 12: validation study. In: Sollár T, editor. Anxiety and coping in hospitalized patients measurement tools and findings. Krakow: Scientia, Arts, Education; 2014. p. 7–30. [16] Tabachnick BG, Fidell LS. Using multivariate statistics. 5th ed. Pearson Education Inc.; 2007. [17] Cohen J, Cohen P, West SG, Aiken LS. Applied multiple regression/correlation analysis for the behavioral sciences. 3rd ed. New Jersey: Lawrence Erlbaum Associates Inc.; 2003. [18] Pasquali EA, Arnold HM, De Basio N. Mental health nursing: a holistic approach. St. Louis: Mosby Inc.; 1989. [19] Gurková E, Žiaková K. Ošetrovateľská diagnostika v kontexte praxe založenej na dôkazoch. Kontakt 2009;11: 32–7. [20] Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996;82:445–51. [21] Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D. The visual analogue scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns. Anaesth Analg 2000;90:706–12. [22] Pritchard MJ. Identifying and assessing anxiety in preoperative patients. Nurs Stand 2009;23:35–40. [23] McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthesia 1990;45:153–5.