Conscious Surgery: Environmental Influence on Patient Anxiety

1. Conscious Surgery: Environmental Influence on Patient Anxiety Dr. Mark Mitchell Faculty of Health and Social Care University of Salford Manchester England. m.mitchell@salford.ac.uk 44 (0)161 - 295 - 6480

2. INTRODUCTION The scope and quantity of surgery now possible in day and short stay facilities is increasing on a global scale. Toftgaard & Parmentier (2006) Int. Term. in Amb. Surg. & worldwide Pract. In: (Lemos, Jarrett, Philip. Eds) Day Surgery. Development & Practice. Porto: IAAS. Ojo et al (2008) Safety of day-case surg. in developing countries. Jour One-Day Surgery 18(1) 13. "In recent years we have seen the biggest changes to surgical practice since its inception as a medical and scientific discipline in the nineteenth century.” Darzi (2007) Saws and scalpels to lazers and robots – Advance in surg. DH: London.

3. Additionally, anaesthetic advances are progressively enabling a greater proportion of local and regional anaesthesia to be undertaken on a day surgery basis. Raeder (2006) Anaesth. Techniques for ambu. surg. In: (Lemos, Jarrett, Philip. Eds) Day Surgery. Development & Practice. Porto: IAAS. (p. 185) With this predicted decline in the number of patients undergoing general anaesthesia, the care of the ‘awake’ patient within the operating room will (and has) become a more prominent feature of theatre nursing intervention. Chit Ying et al (2001) Qual. study percept Chinese women during C section & regional anaesth. Midwifery. 17(2) 115.

4. Once back on the ward, post-operative recovery is increasingly becoming brief with many patients only requiring limited physical nursing intervention. Kingdon & Newman (2006) Determining pt discharge in an OP surg. Setting. AORNJ. 83(4) 898. Thereby, as the surgical assault on the body diminishes, the need for many once traditional aspects of physical nursing intervention will also inevitably diminish. Suhonen et al (2007) Day-case surgical pts health related quality of life. Int. Jour Nursing Practice. 13(2) 121.

5. The dominant focus of nursing intervention widely employed and emphasizing many physical aspects of care (Roper, Logan & Tierney 1980) are hence becoming largely redundant in the modern surgical environment. Roper, Logan & Tierney (1980) Elements of Nurs: A model for nursing based on model living. Churchill-Livingston: London. This transformation in surgical and anaesthetic practice is providing the opportunity for a change in emphasis for peri-operative nursing intervention, that is, more towards enhancement of the nurse/ patient therapeutic relationship. Gilmartin (2007) Contemporary DS: Patient experience of discharge and recovery. Jour Clinical Nursing. 16(6) 1117. Mottram (2009) Therapeutic rels in ds. Jour Clin Nurs. 18(20) 2830.

6. Such a change may be highly appropriate for patients experiencing local or regional anaesthesiaas the possible pain associated with the anaesthetic injection, limited communication and the unknown theatre environment (temperature, darkness, and comfort) are of great concern to many patients. Gnanalingham & Budhoo (1998) Day case hernia under LA vs. GA. Patient prefs. Ambu. Surgery. 6(4) 227.

7. METHODOLOGY Purpose The purpose of this aspects of the study was therefore to investigate the psychological impact of the surgical environment on the conscious adult patient undergoing elective, day surgery. Aims - 1) To uncover specific aspects patient’s find unpleasant or anxiety provoking and possibly dissuade them from opting for local/ regional anaesthesia. 2) Aid the construction of more formal psychological interventions to help manage patient anxiety.

8. A convenience sample of patients scheduled for elective surgery within three public Day Surgery Units in the United Kingdom were invited to take part in the study. Data were collected over a two year period (2005 - 2007). The study was part of a larger study encompassing an extensive sample of day surgery patients (n=674). The questionnaire contained n=61 items and followed the main themes of the larger study, that is, questions concerning the environment, hospital personnel and patient experience of anaesthesia. However, only the aspects relating to the environment and local or regional anaesthesia will be examined here.

9. RESULTS Participants (n=214) underwent a variety of surgical procedures with General Surgery (hernia repair) and Orthopaedic Surgery being the most frequent. It is unknown if choice of type of anaesthesia was offered. Briefly, some main descriptive statistics -

10. 37% of patients (n=79) desired a detailed level of information provision. Additionally, the majority of patients 82% (n=173) wanted this information 1 - 4 weeks in advance.

11. Level of written information required?(n=214) (37%)

12. Preferred to receive written information? (n=214) (82%)

13. Although only local/ regional anaesthesia was employed, 75% of patients experienced some level of anxiety. The thought of being awake during surgery was very anxiety provoking or a little anxiety provoking for 51% (n=107) of patients.

14. Anxiety on the day of surgery (n=210) (75%)

15. Thought of being awake during surgery (n=211) (51%)

16. The thought of seeing the body ‘cut open’ was very anxiety provoking or a little anxiety provoking for 48% (n=101) of patients. The thought of the numbness ‘wearing off’ too soon was very anxiety provoking or a little anxiety provoking for 53% (n=112) of patients.

17. Thought of seeing body cut open (n=211) (48%)

18. Thought of numbness ‘wearing off’ too soon (n=213) (53%)

19. All items specifically relating to the intra-operative experience were again entered into a further statistical test named ‘Factor Analysis’. This test examines associations between variables, based on the correlations between them to uncover any emerging patterns. …..EXAMPLE - Online clothes/ book stores frequently state “people who bought this also bought this”. This is just how factors analysis works. The items and subsequent themes developed were -

20. Thought of needing more than 1 injection Thought of needing intravenous infusion Thought of being awake during operation Thought of hearing during operation Thought of feeling surgeon during operation Thought of seeing body cut open Thought of RA/ LA being more painful Nurse explaining anaesthetic Intra-operative Apprehension

21. Anaesthetist explaining the anaesthetic Nurse explaining the anaesthetic Informed how long anaesthetic will last Informed how long numbness will last Anaesthetic Information Provision

22. The issues associated with - 1) Intra-operative apprehension (being awake, seeing, hearing) 2) Anaesthetic information provision (providing explanations) could explain 37% of the variance in ratings of anxiety on the day of surgery. In more simple terms -

23. Pie chart represents the total amount of patient anxiety on the day of surgery 37% of anxiety can be explained by the issues associated here with - Intra-operative Apprehension. Anaesthetic Information Provision. ANXIETY

24. The issues concerning - Intra-operative Apprehension Anaesthetic Information Provision are thereby accurate predictors of Increased levels of anxiety on the day of surgery for many patients

25. SUMMARY 1) Anaesthetic Information Provision Anxiety was generated regarding gaining insight into - Length of anaesthesia Duration of numbness Events being explained 2) Intra-operative Apprehension Anxiety was also generated just by the thought of being in theatre - Possibility of increased level of pain Need for more local anaesthetic injections Seeing the body ‘cut open’ Numbness ‘wearing off’ too soon Hearing proceedings

26. CLINICAL RECOMMENDATIONS 1) Pre-operative Information Provision Alluding to the possible unhelpful thoughts relating to the unfamiliar intra-operative experience (being awake, seeing, hearing, experiencing increased pain) could greatly help limit anxiety prior to, and during, surgery under local/ regional anaesthesia. Clear, unambiguous information provision explaining intra-operative events and local/ regional anaesthesia (time span, numbness, injections) could also help the formal management of patient anxiety. However, such information provision will be necessary in advance of the day of surgery to aid effective anxiety management.

27. 2) Intra-operative Information Provision Continuing to explain intra-operative experiences (possibly by a named person in theatre) and thereby alleviating many misconceptions (being awake, seeing, hearing, experiencing increased pain) could also help contribute to the more formal management of anxiety. Integrated Care Pathways have been described as ‘structured, patient-centred maps of care” and inclusion of such aspects of care in this documentation may be of great benefit to future patient management in day surgery.

28. Suggested Intervention Plan

29. Suggested Intervention Plan

30. Suggested Intervention Plan

31. Suggested Intervention Plan

32. Suggested Intervention Plan

33. CONCLUDE Nursing contact with the modern surgical patient is now very brief. Also, the physical aspects of care for the patient experiencing local/ regional anaesthesia have become minimal in comparison to previous decades. Although the majority of patients prefer day surgery such minimal contact has the potential to limit effective nurse/ patient communication and thereby hinder adequate anxiety management.

34. It has been suggested that care in modern surgery is progressing in a somewhat ‘mechanistic’ manner (rules, procedures) and actual nursing intervention (highly valued by patients) can become somewhat ‘hidden’. Nursing-based knowledge must thereby strive to maintain its position in the future of modern surgery. Formal anxiety management strategies based upon nursing knowledge could become a more central feature of surgical nursing practice and a stronger element in future nurse education programmes of study to help demonstrate how nursing knowledge can indeed successfully contribute to this new surgical era. Mitchell (2008) Conscious surgery. Jour. Advanced Nursing. Vol.64 No.3 p. 261 - 271.