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Conscious Surgery: Environmental Influence on Patient Anxiety D r. Mark Mitchell Faculty of Health and Social Care University of Salford Manchester England. firstname.lastname@example.org 44 (0)161 - 295 - 6480 INTRODUCTION
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Dr. Mark Mitchell
Faculty of Health and Social Care University of Salford
44 (0)161 - 295 - 6480
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.
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.
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.
Roper, Logan & Tierney (1980) Elements of Nurs: A model for nursing based on model living. Churchill-Livingston: London.
This transformation in surgical and anaesthetic practice is providing the opportunity for a change in emphasis for peri-operative nursing intervention, that is, more towards enhancement of the nurse/ patient therapeutic relationship.
Gilmartin (2007) Contemporary DS: Patient experience of discharge and recovery. Jour Clinical Nursing. 16(6) 1117.
Mottram (2009) Therapeutic rels in ds. Jour Clin Nurs. 18(20) 2830.
Such a change may be highly appropriate for patients experiencing local or regional 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.
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.
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.
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.
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 -
Additionally, the majority of patients 82% (n=173) wanted this information 1 - 4 weeks in advance.
The thought of being awake during surgery was very anxiety provoking or a little anxiety provoking for 51% (n=107) 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.
This test examines associations between variables, based on the correlations between them to uncover any emerging patterns.
…..EXAMPLE - Online clothes/ book stores frequently state “people who bought this also bought this”. This is just how factors analysis works.
The items and subsequent themes developed were -
Thought of needing 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
Nurse explaining the anaesthetic
Informed how long anaesthetic will last
Informed how long numbness will last
Anaesthetic Information Provision
1) Intra-operative apprehension
(being awake, seeing, hearing)
2) Anaesthetic information provision
could explain 37% of the variance in ratings of anxiety on the day of surgery.
In more simple terms -
Pie chart represents the total amount of patient anxiety on the day of surgery
37% of anxiety can be explained by the issues associated here with -
Anaesthetic Information Provision.
Anaesthetic Information Provision
are thereby accurate predictors of
Increased levels of anxiety on the day
of surgery for many patients
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
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.
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.
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.
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.