PREOPERATIVE TEACHING CLINICPREOPERATIVE TEACHING CLINICEFFECTS ONEFFECTS ON

SURGICAL ANXIETY REDUCTION:SURGICAL ANXIETY REDUCTION:

TO ASSESS THE EFFICACY OF A TO ASSESS THE EFFICACY OF A SURGICAL ORIENTATION SURGICAL ORIENTATION

VIDEO IN DECREASING VIDEO IN DECREASING PREOPERATIVE ANXIETYPREOPERATIVE ANXIETY

Richard D. Kuylen, RN, BSNRichard D. Kuylen, RN, BSNLallie Kemp Medical CenterLallie Kemp Medical Center

Independence, LouisianaIndependence, Louisiana

PREOPERATIVE ANXIETYPREOPERATIVE ANXIETY Anxiety and pain – subjective elements of the patient

experience

Can result in an increase in the levels of patients’ experience of pain, which usually requires management through analgesia

Can adversely influence anesthetic induction and patient recovery

Decrease patient satisfaction with the perioperative experience

OPPORTUNITY STATEMENTOPPORTUNITY STATEMENT

Participation in a Preoperative Participation in a Preoperative Teaching Clinic, on a day prior to Teaching Clinic, on a day prior to

scheduled surgery, will significantly scheduled surgery, will significantly decrease preoperative anxiety and decrease preoperative anxiety and

facilitate a smooth transition facilitate a smooth transition through the surgical process for through the surgical process for

patients, family members and patients, family members and operating room staff.operating room staff.

EXCESSIVE EXCESSIVE PREOPERATIVE PREOPERATIVE

ANXIETYANXIETY Can lead to pathopysiological responses:

* tachycardia * hypertension * arrhythmia * higher levels of pain that may persist into the postoperative period

PREOPERATIVE PREOPERATIVE EDUCATIONEDUCATION

The process of informing clients about their condition, surgery and postoperative care

Prepare patients for surgery and help them to manage their care postoperatively

Key to decreased complications and readmission; thus, improving cost effectiveness

GOALS OF GOALS OF PREOPERATIVE PREOPERATIVE

EDUCATIONEDUCATION Provide the means for patients to participate in

treatment decisions with full understanding of factors relevant to their proposed care

Decrease potential complications through patient education and family involvement

Improve postoperative recovery Reduce surgical anxiety Mold attitudes regarding surgery, staff and the facility

Clear up misconceptions and inaccurate information Address questions and concerns Provide emotional support Provide thorough and accurate information to patient

and family Facilitate smooth flow of surgery schedule

METHODS/FORMAT OF METHODS/FORMAT OF PREOPERATIVE EDUCATIONPREOPERATIVE EDUCATION

One to one instruction

Demonstrations

Printed materials

Videotapes

STANDARD PREOPERATIVE STANDARD PREOPERATIVE EDUCATIONEDUCATION

Involves the use of verbal instructions by physicians and nurses

Often delivered during a brief session prior to the day of surgery

Patient memory of instructions often inadequate due to anxiety and feelings of uncertainty

PREOPERATIVE PREOPERATIVE VIDEOTAPED VIDEOTAPED INSTRUCTIONINSTRUCTION

Enhances learning in patients with low literacy skills

Beneficial for elderly patients who have difficulty reading small printed documents

LITERATURE REVIEWLITERATURE REVIEW

Patients scheduled for surgery have increased anxiety and fear of the unknown

Preoperative period is the time when most patients experience significant fear regarding surgery, complications and level of recovery

The more informed and better prepared patients are about what to expect during the surgical experience, the less anxious they tend to be

Efficient organization and utilization of resources available in a preoperative clinic results in cost savings via reduction in operating room delays

LITERATURE REVIEWLITERATURE REVIEW(Cont’d)(Cont’d)

Preoperative teaching clinics improve efficiency in admission and screening of patients

Preoperative teaching programs foster : decreased length of stay * less demand for postoperative analgesic * quicker recovery from surgery * decreased infection rate * decreased anxiety

THEORY-PRACTICE GAPTHEORY-PRACTICE GAP

A Theory-Practice gap identified Preoperative education benefits along with

cost effectiveness to institutions and patients are well documented through years of research

Many facilities have no formal policy or program for providing structured education

Thus, many patients arrive the morning of surgery very anxious and poorly informed

Organizational FrameworkOrganizational Framework

Patient presents to Medicine Clinic or Emergency Room with a complaint/symptom

Patient referred to Surgery Clinic for surgical evaluation if clinically indicated

Surgery scheduled with OR staff based on surgeon’s evaluation/recommendation

Patient provided appointment to Preoperative Teaching Clinic on a day prior to scheduled surgery

Family and friends involved in postoperative care encouraged to attend preoperative education

Aim/Purpose of ProjectAim/Purpose of Project Aim of project: * Promote

awareness of benefits and effectiveness of a Preoperative Teaching Clinic * Encourage development of a Surgical Orientation Video in other LSU Hospitals

Purpose of study: * To evaluate the effectiveness of a preoperative surgical orientation video in decreasing anxiety in patients scheduled for surgery with general anesthesia

Surgical Orientation Video, developed at Lallie Kemp Medical Center, walks a patient through the surgical process from admit through discharge.

By viewing video, patient sees many nurses and anesthesia personnel that will provide care morning of surgery, along with some monitoring equipment used

PREOPERATIVE PREOPERATIVE TEACHING CLINIC VISITTEACHING CLINIC VISIT

Intervention group (n=13) – views a preoperative surgical orientation video and receives surgery-specific preoperative education

Control group (n=17)– receives standard preoperative education without viewing the orientation video

Surgery and anesthesia-related anxiety evaluated by using a quantitative scale of preoperative anxiety before and after implementing preoperative education and viewing the preoperative video

RESEARCH DESIGNRESEARCH DESIGN Two - group, pretest / posttest research

design Determine significant difference in anxiety

levels between: * group that received standard preoperative education (control group) * group that received standard preoperative education, along with viewing the surgical orientation video (intervention group)

Sample size : 30 patients (n=30) * randomly assigned to either * intervention or control group

HYPOTHESISHYPOTHESIS The intervention group that also views the video

will have less preoperative anxiety than the control group that does not view the video

The intervention group will have decreased anxiety after preoperative teaching is implemented

The control group will also have decreased anxiety after preoperative teaching is implemented

There will be no difference in anxiety between the two groups prior to preoperative teaching

METHODOLOGYMETHODOLOGY

Principal Investigator (PI) obtained approval to conduct study from the following authorities: * Institution Compliance liaison and privacy officer * LSU HCSD Office of Research and Development * Institution Medical Executive Committee

Institutional Review Board of Southeastern Louisiana University (SLU) also granted permission

Population consisted of patients seen in the surgery clinic at a LSU HSC Lallie Kemp Medical Center

METHODOLOGYMETHODOLOGY(Cont’d)(Cont’d)

Patients evaluated in the surgery clinic and scheduled for surgery

Patients scheduled for preoperative teaching clinic visit for surgery and anesthesia education, on a day prior to surgery

Family members involved in postoperative care encouraged to attend preoperative education

CRITERIA FOR CRITERIA FOR INCLUSION IN STUDYINCLUSION IN STUDY

English - speaking patientEnglish - speaking patientBetween the ages of 21 and 65Between the ages of 21 and 65

Basic Literacy (able to read and understand)Basic Literacy (able to read and understand)

First 30 that met criteria were randomly First 30 that met criteria were randomly assigned to:assigned to:

** intervention group -13 **** intervention group -13 ** ** control group - 17 ** ** control group - 17 **

SETTINGSETTING

Preoperative Teaching Clinic at Lallie Kemp Medical Center in Independence, Louisiana

Patients provided scheduled appointment to see the preoperative teaching nurse when discharged from the surgery clinic

Focus on anxiety reduction through surgery - specific preoperative education

Preoperative Surgical Orientation Video viewed after preoperative education implemented

Krames color illustrated surgical literature used to facilitate preoperative education

INSTRUMENTATIONINSTRUMENTATION

Amsterdam Preoperative Anxiety and Information Scale (APAIS)

Anxiety Scale * consists of 4 questions (1, 2, 4, 5) * each question scores from 1 to 5 * score is the sum of the four questions, ranging from 4 to 20

Subscales * anesthesia-related anxiety (Sum A=1+2) * surgery-related anxiety (Sum S=4+5) * combined anxiety component Sum C=Sum A +Sum S=1+2+4+5

Scale also includes an information desire component (3+6)

AMSTERDAM PREOPERATIVE ANXIETY AMSTERDAM PREOPERATIVE ANXIETY & INFORMATION SCALE& INFORMATION SCALE

CRONBACH’S CALCULATED ALPHA CRONBACH’S CALCULATED ALPHA ESTIMATES FOR ANXIETY COMPONENTSESTIMATES FOR ANXIETY COMPONENTS

For Anesthesia - Related Anxiety (Alpha.779) For Surgery - Related Anxiety (Alpha .848) For Combined -Anesthesia Component (Alpha .810) For Information - Desire Component (Alpha .730)

* Findings confirm the internal consistency and reliability of the measurements

* Results also confirm the scales validity for use in preoperative anxiety assessment

DATA ANALYSIS & DATA ANALYSIS & CALCULATIONSCALCULATIONSSPSS PROGRAMSPSS PROGRAM

Demographic data * Gender * Age * Educational level * Frequencies and percentages of responses

T- test for differences between control and intervention groups on anxiety * Independent t-test - compares across group means * Paired t-test – compares pre- and posttest scores across each group

RESULTRESULTEXPERIMENTAL 2-GROUP EXPERIMENTAL 2-GROUP

PRETEST-/POSTTEST DESIGNPRETEST-/POSTTEST DESIGN

PURPOSE – to determine if significant anxiety exists between the control and intervention groups

SAMPLE – 30 patients (n=30) scheduled for elective surgery with general anesthesia > Randomly assigned to either : * control group (n=17) * intervention group (n=13) > Gender Frequency * Males (n=11) 36.7% * Females (n=19) 63.3% * Age range: 21 – 62 years (m=44.4years) > Educational level * Less than high school – 23 % (n=7) * High school graduate - 70 % (n=21) * Post high school - 7 % (n=2)

HYPOTHESIS IHYPOTHESIS I Intervention group will have less preoperative anxiety than

the control group after preoperative teaching is implemented * Independent sample t- test – conducted to evaluate hypothesis * Post t- test – all p- values greater than .05

Not enough evidence to say that the means are different at the 95% confidence level

However, pre-test means in the Intervention group were higher in all categories than pre-test means in Control group

Hypothesis I is not supported

HYPOTHESIS IIHYPOTHESIS II Intervention group will have decreased anxiety after

preoperative teaching is implemented

Paired t- test analysis results (p-value) * anesthesia related anxiety - 0.006 * surgery related anxiety - 0.002 * information desire component - 0.001 * combined anxiety component - 0.003

P- values less than 0.05 – There is enough evidence to say that the means are different at 95% confidence

Hypothesis II is supported

HYPOTHESIS IIIHYPOTHESIS III The control group will have decreased anxiety after

implementation of preoperative teaching

Control group t- test results (p- value) * anesthesia related anxiety - 0.227 ( > .05) * surgery related anxiety - 0.039 ( < .05) * information desire component - 0.005 ( < .05) * combined anxiety component - 0.037 ( < .05)

Not enough evidence to say that means are different at 95% confidence for anesthesia related anxiety

With 95% confidence, there is not enough evidence to say that the means are equal in all other anxiety components

Hypothesis III is partially supported

HYPOTHESIS IVHYPOTHESIS IV There will be no difference in anxiety between the two groups prior to preoperative

teaching

Independent sample t-test results (p-value) * anesthesia-related anxiety - 0.014 ( < .05 ) *

combined anxiety component - 0.024 ( < .05 ) * surgery-related anxiety - 0.320 ( > .05)

T-test at pre-measure significantly higher in one out of three measures

Pre-test means higher in all components in the intervention group than in the control group

Hypothesis IV is not supported

DISCUSSION/CONCLUSIONDISCUSSION/CONCLUSION

Participation in a Preoperative Teaching Clinic prior to surgery can significantly decrease preoperative anxiety as evident in this small pilot study

Intervention group: significant decrease in mean anxiety between pre and post test analysis for : * anesthesia-related anxiety (p= 0.006) * surgery-related anxiety (p= 0.002) * information desire component (p= 0.001) * combined anxiety component (p= 0.003)

DISCUSSIONDISCUSSION(Cont’d)(Cont’d)

Control group: significant decrease with preoperative education for :

* surgery-related anxiety (p= 0.039) * information desire component (p= 0.005) * combined anxiety component (p= 0.037)

No significant reduction in mean anesthesia-related anxiety (p=0.227) shown in the control group compared to intervention group (p=0.006) with preoperative education. Video includes section where Anesthesiologist speaks with patient prior to surgery

Perhaps this decreased anxiety in this group! Pilot study showed no significant difference in

preoperative education with addition of surgical orientation video as evidenced by independent samples t-test for post test between groups (Table 2).

Systems ImpactedSystems Impacted

The LSU HCSD system could benefit from results of this pilot study by improving preoperative education or developing preoperative teaching clinics

Preoperative Surgical Orientation Videos specific to each hospital could also facilitate preoperative education

Since this was a small pilot Since this was a small pilot study conducted in a rural study conducted in a rural

hospital that caters to a mostly hospital that caters to a mostly indigent population, future indigent population, future

research is indicated to assess research is indicated to assess the Preoperative Surgical the Preoperative Surgical

Orientation Video’s effects on Orientation Video’s effects on anxiety reduction. Larger anxiety reduction. Larger

studies in multiple, non-profit studies in multiple, non-profit and private hospitals would and private hospitals would increase the validity of the increase the validity of the

findings.findings.