Title: Taking care of fearful patients in OR
1Taking care of fearful patients in OR
- Kirsi Kiviniemi
- RN, PhD, Director in Nursing, Associate
lecturer - Hospital District of Southwest Finland, Turku
University Hospital - University of Turku, Department of Nursing
Science
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
2Content of the presentation
- Conceptual approach to perioperative anxiety
- Anxiety, fear and tension / ahdistus, pelko ja
jännitys - Why should we identify and evaluate patients
perioperative anxiety - Review of intensity of perioperative anxiety and
interventions to relieve patients perioperative
anxiety - Perioperative anxiety in Finnish parturients who
underwent planned Caesarean operation - Challanges for perioperative nursing practice
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
3Conceptual approach to perioperative anxiety
- Anxiety is
- a vague, uneasy feeling of discomfort or dread
accompanied by an autonomic response the source
is often non-specific or unknown to the
individual (NANDA 1999) - the degree of perceptions of worry and
nervousness (Lin Wang 2005) - Fear is
- anxiety caused by consciously recognized and
realistic danger. It is a perceived threat, real
or imagined. Operationally, fear is the presence
of immediate feeling of apprehension and fright
source known and specific (NANDA 1999) - Tension is
- mental, emotional, or nervous strain (NANDA 1999)
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
4- Based on the literature review
- There are various theoretical models considering
perioperative anxiety - Drive theory (f.ex. Janis 1959)
- Situational and trait anxiety (f.ex. Spielberger
1972) - Perioperative anxiety is measured as intensity
and incidence of anxiety, fear and tension - STAI (Spielberger State Trait Anxiety Inventory),
VAS or VASA (Visual Analogue Scale for Anxiety) - HADS (Hospital Anxiety and Depression Scale)
- APAIS (The Amsterdam Preoperative Anxiety and
Information Scale)
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
5- Physiological, cognitive, and behavioural signs
are joined to increased perioperative anxiety
level - Perioperative anxiety provoking fears and
concerns have been reported - fears and concerns are extra-, intra- or
interpersonal - There are factors relating to increased
perioperative anxiety level - patients gender, age, education, marital status,
financial situation, trait anxiety level,
surgical history, and mode of present surgery - some of the relations are conflicting according
to literature
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
6High perioperative anxiety relates to
- Female gender
- Moerman et al. 1996, Karanci Dirik 2003
- Age under 40 yrs in adults
- Shafer et al. 1996, Kindler et al. 2000
- Major or emergency surgery
- Leinonen et al. 2001, Karanci Dirik 2003
- Missing or bad prior surgical experiences
- Shafer et al. 1996, Kindler et al. 2000
- Higher trait anxiety level
- Caumo et al. 2001, Talyor-Piliae Molassiotis
2001, Ng et al. 2004, Carr et al. 2006
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
7What can You see on the drawing?
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
82. Why should we identify and evaluate patients
perioperative anxiety
- Documentation of the perioperative nursing
decision-making process - Patient Act (785/1992)
- Research has demonstrated that anxiety has both
psychological and physical effects on the patient - Guzzetta 1989, Leach et al. 2000, Bally et al.
2003
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
9Decision-making in perioperative nursing
following patients, nurses and physicians
assessment INTERPRETATION AND UNDERSTANDING OF
PATIENTS SITUATION
Patients care status
What?
Assessing the need of the care
How?
Nursing interventions
CHOOSING THE RIGHT INTERVENTION
Planning and implementing
Outcomes of the care
Why?
state of health, coping, opinion ANTICIPATING THE
PROGRESS OF THE CARE
Evaluating the outcomes
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
10Pre-operative anxiety is associated with many
unwanted effects such as
- Increased analgesic requirement
- Davies et al. 1997
- Increased anaesthetic requirement
- Osborn Sandler 2004, Granot Ferber 2005
- Increased postoperative pain
- Granot Ferber 2005, Lin Wang 2005, Pellino et
al. 2005, Watts McEachan 2005, Carr et al. 2006 - Prolonged recovery and hospital stay
- Kulik et al. 1996, Shuldham 1999 Agarwal et al.
2005, Hobson et al. 2006 - Misunderstanding of pre-/ postdischarge
information - Orr 1986, Kulik et al. 1996, Shuldham 1999
- Missatisfaction with the received care
- Callaghan et al. 1998, Leinonen et al. 2001
Hobson et al. 2006
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
113a) Review of intensity of perioperative anxiety
- Surgical patients are more anxious prior the
operation than after the operation - While waiting surgery at home (Koivula 2002,
Cooke et al. 2005) - On arrival at the hospital (Bellan et al. 2002)
- Immediately prior to surgery (Jones et al. 2004)
- Patients anxiety level tends to remain high and
constant from the afternoon before to surgery to
the morning of surgery Doering et al. 2000 - There is a linear and positive correlation
between patients anxiety level prior and after
the operation - Kain et al. 2000, Gejervalla et al. 2005, Carr
et al. 2006
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
12Intensity of perioperative anxiety
- Perioperative anxiety measured by STAI (ranging
from 20 to 80) - Mild anxiety 20 39, moderate anxiety 40 59,
strong anxiety 60 - 80 - Anxiety level on arrival at hospital
- 28.0 43.9 (Parent Fortin 2000, Jones et al.
2004) - Anxiety level immediately prior the operation
- 33.9 59.0 (Lin et al. 1997, Marucci et al.
2003) - Anxiety level postoperatively at hospital
- 27.6 43.0 (Karanci Dirik 2003, Gejervall et
al. 2005) - Anxiety level at home, one to six months after
operation - 28.4 37.3 (Heikkilä et al. 1999)
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
133b) Review of interventions which relieve
patients perioperative anxiety
- Studies have assessed the effect of the provision
of information on preoperative anxiety - Beddows 1997, Shuldham 1999, Hodgkinson et al.
2000, Sjöling et al. 2003, McDonald et al. 2004,
van Vliet et al. 2004 - Routine preoperative information/education and in
addition - A tour of the operating department (Deyirmenjian
et al. 2006) - A kit of nonpharmacologic strategies for anxiety
and pain (Pellino et al. 2005) - A computer website intervention. The website
instruction module content was a replication of
the standardized verbal instruction module
enhanced with digital photos (Hering et al.
2005) - A preoperative nursing intervention for pain (Lin
Wang 2005)
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
14- Preoperative information mostly relieves
patients perioperative anxiety - Patients need information about illness, surgical
processes, possible risk factors, anticipated
sensations/discomforts - Patients expect written and verbal information
- Walker 2002, Johansson et al. 2003
- Preoprative information is preferred to receive 1
to 3 weeks prior to surgery - Mitchell 2000
- Preoperative teaching should be individually
tailored - Guruge Sidani 2002
- Incorporating preoperative psycho-educational
interventions is recommended - Calvin Lane 1999
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
15Music and perioperative anxiety
- The theoretical basis for music as an
intervention for anxiety lies in its ability to
promote relaxation through the autonomic nervous
system - Thaut 1990
- Music promotes feelings of physical and mental
relaxation by refocusing attention on to
pleasurable emotional states - Bailey 1986,Bonny 1986, Brown et al. 1989,
McCaffery 1990, Magill-Levreault 1993 - Patients awareness of time passing becomes hazy
as they focus on the music thus promoting a
relaxation response - Guzzetta 1995
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
16Examples of music interventions and results
- Receiving 20 minutes of music vs. having 20
minutes of rest in bed after cardiac surgery - Sendelbach et al. 2006
- Receiving 30 minutes of music therapy vs. only
routine care - Chang Chen 2005
- Listening to music of patient choice during the
preoperative wait (30 min) vs. wearing the
headphones but receiving no music for 30 minutes
vs. control group receiving routine care only - Cooke et al. 2005
- Music decreased preoperative anxiety in patients
having outpatient and day surgery - Wang et al. 2002, Lee et al. 2004
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
17Other interventions and perioperative anxiety
- Guided imagery
- Tusek et al. 1997. Walker 2002, Mitchell 2003
- Relaxation, hypnosis, reflexology
- Goldman et al. 1988, Ernst Koder 1997
- A systematic method of relaxing the body on the
sensory relaxation did not result in
significantly less anxiety. However, group
differences in state anxiety were in the expected
direction - Roykulcharoen Good 2004
- Guided imagery and relaxation decrease
perioperative state anxiety
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
18- Hand massage and hand holding as nursing
interventions on the anxiety - Richards et al. 2000, Moon Cho 2001, Oh Park
2004 - Humour
- Gaberson 1995, Ã…stedt-Kurki et al. 2001
- Aromatherapy
- Jellinek 1999
- Psychosocial support
- Mitchell 2003, Krenzischek et al. 2004
- Nurse Case Manager (NCM) Model to care the
patients - Palese et al. 2005
- Massage, hand holding, humour, aromatherapy,
psychosocial support, and NCM model have been
reported to decrease perioperative anxiety. The
decrease is not always significant but the
patients feel better and they are satisfied
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
194. Perioperative anxiety in Finnish parturients
who underwent planned Caesarean operation
- ARE YOU ANXIOUS, AFRAID OR TENSE
- Perioperative anxiety and empowering nursing
prior, during and after planned caesarean
delivery - By
- Kirsi Kiviniemi
- Annales Universitatis Turkuensis Ser. D Tom. 704
- Medica Odontologica
- University of Turku 2006
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
20Summary of the theoretical starting points of the
study
21The research questions were
- What kind of perioperative anxiety do women
express prior, during and after planned Caesarean
delivery? - What kind of expectations and experienced do
women express regarding empowering perioperative
nursing prior and after planned Caesarean
delivery? - What kind of association there is between
perioperative anxiety and empowering
perioperative nursing prior and after planned
Caesarean delivery?
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
22Perioperative measurement time points, variables,
instruments, and sample
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
23Intensity of state anxiety across the
perioperative period
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
24The relation between high state anxiety and
background factors
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
25Empowering perioperative nursing
- Empowerment is a process of helping or preparing
people to assert control over their health
problems and the consequences - Gibson 1991, Rodwelle 1996, Kuokkanen
Leino-Kilpi 2000 - Six dimensions of empowering perioperative
nursing - Bio-physiological empowerment
- Cognitive empowerment
- Experiential empowerment
- Functional empowerment
- Ethical empowerment
- Social empowerment
- Modified from Leinonen et al. 1996, Leino-Kilpi
et al. 1998, 1999
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
26Parturients expectations of the empowering
perioperative nursing
- Feeling safe
- Smooth collaboration between the staff
- Ongoing information of the newborn child
- Peaceful atmosphere
- Trust-creating non-verbal communication
- Sincere interest from the staff
- Being taken seriously
- Understandable verbal information
- Possibility to participate in their treatment
planning - Pleasant position on the OR table
- Technical competent staff
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
27Parturients perceptions of empowering
perioperative nursing
- Technical competent staff
- Nurses and physicians were kind and cheerful
- Non-verbal communication was trust-creating
- Smooth collaboration between staff members
- Peaceful atmosphere
- Being taken seriously
- Feeling safe
- Their privacy was protected
- Staff was able to act in sudden situation
- Staff demonstrated sincere interest
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
28Expected and received empowering perioperative
nursing care
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
295. Challanges for perioperative nursing practice
- Perioperative anxiety should be evaluated and
documented systematically - Simple visual analogue scale for anxiety is a
useful instrument - Spielberger state trait anxiety inventory is
another noteable instrument - Electronic patient documentation systems should
involve an instrument to evaluate patients
perioperative anxiety level - A check-list of usual factors which strengthen
perioperative anxiety should be employed when
patients perioperative needs are evaluated - Its important to evaluate pain and anxiety
simultaneously
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
30Challenges for perioperative nursing
administration
- Developing practice to evaluate patients
perioperative anxiety - Developing anxiety-related perioperative nursing
interventions - Defining patients dependency and in allocating
perioperative nursing staff resources accurate
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science
31Thank you for your attention
Hospital District of Southwest Finland, Turku
University Hospital University of Turku,
Department of Nursing Science