Preoperative anxiety is a challenging concept in the preoperative care of patients and its incidence varies with different settings. The experience of anxiety state has been linked with the aggravation of pain intensity experienced by surgical patients after their procedures. The study evaluated nursing intervention on the relief of anxiety state and post-operative pain among surgical patients in Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria.
A Quasi-experimental study was conducted among thirty booked adult surgical patients (age=25-80 years) for abdominal surgeries from February 10th and March 15th, 2017. Convenient sampling technique was used to select the surgical patients by “first come first serve” into control and experimental groups, each group having 15 surgical patients. Two standardized assessment tools (State Anxiety Inventory scale and Numeric Rating scale) were adopted in the questionnaire used for the collection of data of anxiety state and pain intensity among patients before and after their procedures respectively. A planned training module was pre-tested and found suitable for the study. The data were processed through statistical package for social science (SPSS), version 20 using descriptive statistics such as mean, standard deviation, and inferential statistics such as Chi-square, to determine the relationship of the variables and test the hypotheses at 0.05 level of significance.
The findings revealed that no standard assessment tool for measurement of anxiety state and pot-operative pain before or after their surgical. The mean baseline anxiety levels of the surgical patients (both experimental (1.74) and control (1.79)) were high before surgery but reduced after their surgeries respectively (1.66 and 1.64 respectively). The surgical patients experienced moderate and severe levels of pain intensity before surgery with mean baseline pain intensity of 3.47 in experimental and 2.95 in the control surgical patients. There was an aggravation of pain intensity experienced by the surgical patients postoperatively with mean values of 4.46 in the experimental and 4.92 in the control groups respectively. There was no significant relationship between nursing intervention for the relief of preoperative anxiety and control of postoperative pain (p=0.514 and 0.413 respectively), even though the preoperative nursing intervention administered on the experimental group brought about reduction of post-operative pain, the rate of reduction was not as marked as compared with the control group without the planned preoperative intervention. There was no significant relationship between gender of surgical patients and their response to nursing intervention for the relief of anxiety (p=0.744) and postoperative pain (p=0.105). Likewise, there was no significant relationship between educational levels of surgical patients and their response to nursing intervention for the relief of anxiety (p=0.163) and postoperative pain (p=0.604) respectively.
The study concluded that the experience of anxiety and pain among surgical patients is a common phenomenon. The study recommended that patient-centered approach should be employed in the assessment and intervention for the relief of anxiety states and post-operative pain.
Keywords: Anxiety state, Preoperative anxiety, Nursing intervention, Post-operative pain
Word Count: 470
TABLE OF CONTENTS
Content Page
Title Page i
Certification ii
Dedication iii
Acknowledgements vi
Abstract v
Table of Contents vi
List of Tables viii
List of Figures ix
Appendices x
Abbreviations xi
CHAPTER ONE: INTRODUCTION
- Background to the Study 1
- Statement of the Problem 4
- Objective of the Study 5
- Research Questions 5
- Hypotheses 6
- Scope of the Study 6
- Significance of the Study 6
- Operational Definition of Terms 6
CHAPTER TWO: REVIEW OF LITERATURE
2.0. Introduction 8
2.1. Concept of Pain 8
2.2. Effects of Pain 10
2.3. Expressions of Pain 11
2.4. Types of Pain 12
2.5. Physiology of Pain 13
2.6. Nociception 13
2.7. Pain after Surgery 15
2.8. Pain Assessment 16
2.8.1. Central Principles of Pain Assessment 17
2.8.2. Roles of Nurses in Pain Assessment 18
2.8.3. Standard Tools for Pain Assessment 19
2.8.4. Patient Self-reporting Pain Scales 21
2.9. Methods of Pain Management 24
2.9.1. Non-Drug Techniques to Manage Pain 24
2.9.2. Pharmacological Methods of Pain Management 29
2.10. Anxiety 31
2.11. Types of Anxiety 32
Content Page
2.12. Causes of Anxiety 32
2.13. Effects of Anxiety 33
2.14. Prevalence of Anxiety 34
2.15. Levels of Anxiety 35
2.16. Assessment of Anxiety in Surgical Patients 36
2.17. Management of Anxiety in Surgical Patients 38
2.18. Empirical Reviews of Surgical Patients’ Anxiety 42
2.19. Theoretical Model and Framework 45
2.19.1. Theory of Health as Expanding Consciousness 45
2.19.2. Application of the Theory to the Study 46
CHAPTER THREE: METHODOLOGY
3.0. Introduction 48
3.1. Research Design 52
3.2. Population 52
3.3. Sample size and sampling Technique 52
3.4. Instrumentation 53
3.5. Validity and Reliability of Instrument 54
3.6. Method of Data Collection 55
3.7. Method of Data Analysis 55
3.8. Ethical Consideration 56
CHAPTER FOUR: DATA ANALYSIS, RESULTS
AND DISCUSSION OF FINDINGS
4.0. Introduction 58
4.1. Data Analysis and Result Presentations 58
4.8. Discussion of Findings 67
CHAPTER FIVE: SUMMARY, CONCLUSION, AND
RECOMMENDATIONS
5.0. Introduction 73
5.1. Summary 73
5.2. Conclusion 73
5.3. Recommendations 74
5.4. Limitation of the Study 75
5.5. Suggestion for Further Studies 75
REFERENCES 76
APPENDICES 108
LIST OF TABLES
Table Page
4.1. Socio-Demographic Data of Study Participants 53
4.2. Assessment of Anxiety States and Pain Intensity using a
Tool/ instrument by nurses 55
4.3. Distribution of Study Participants and their Perception
of their Anxiety in the Pre-Operative Periods (a & b) 56
4.4. Distribution of Study Participants and their Perception
of their Anxiety in the Post-Operative Periods (a & b) 58
4.5. Baseline and Post-Operative Anxiety and Pain intensity
among surgical patients 60
4.6. Relationship between nursing intervention for the relief of
Pre-Operative anxiety and control of post-operative pain 62
4.7. Relief of anxiety state levels in response to nursing
intervention on the basis of gender and educational levels 64
4.8. Relief of post-operative pain intensity in response to nursing
intervention on the basis of gender and educational levels 65
4.9. Hypothesis testing of the relationship between nursing intervention
for the relief of anxiety levels and post-operative pain 66
4.10. Hypothesis testing of relationship of the relief of Anxiety levels
in response to nursing intervention on the basis of Gender and Educational
levels 66
4.11. Hypothesis testing of relationship of the relief of Post-Operative pain in
response to nursing intervention on the basis of Gender and
Educational levels 67
LIST OF FIGURES
Figure Page
- Visual Analogue Scale 21
- Numeric Pain Scale 22
- Verbal Rating Scale 23
- Verbal Analogue Scale 23
- Analgesic Ladder 29
- Conceptual Framework of Margaret Newman 47
APPENDICES
Appendix Page
Informed Consent 108
Questionnaire 110
Planned Preoperative Teaching Module 113
Ethical Approval 115
ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome
ANOVA Analysis of Variance
CNS Central Nervous System
DSM IV-TR Diagnostic and Statistical Manual of Mental Disorders (4th edition,Text Revision)
HEC Health as Expanded Consciousness
HIV Human Immuno-deficiency Virus
HND Higher National Diploma
IASP International Association for the Study of Pain
IBM International Business Machines
JCAHO Joint Commission on Accreditation of Healthcare Organizations
NRS Numeric Rating Scale
NSAIDs Non-Steroidal Anti-Inflammatory Drugs
OND Ordinary National Diploma
PCA Patient-Controlled Analgesia
STAI State-Trait Anxiety Inventory
VAS Visual Analogue Scale
VDS Verbal Descriptor Scale
WHO World Health Organization
CHAPTER ONE
INTRODUCTION
- Background to the Study
Health has been described as the nonexistence of disease and impairment, as well as a condition of complete wellness in the mental, physical, and social realms. The persistence of the internal environment of any human system is dependent on their physiological, sociological and psychological equilibrium. Nursing care has the primary objective to render service for maintenance of health through the preservation of a stable internal environment, and assisting to ensure the restoration of equilibrium in the condition of illness (Birol, 2005; Şanli, 1991).
There are three phases in the nursing care a surgical patient passes through in the health care services called perioperative nursing. These phases include: pre-operative, intra-operative and post-operative. The pre-operative phase involves the administration of nursing care to the clients who are planned to undergo surgical procedures (Phillips, 2013; Spry, 2005). The primary responsibility of the health care providers as reported in literatures is to assess and educate the patient during this phase, to minimize the dangers during the surgery and have better outcomes of the patients. The main rationale for preoperative phase of care is linked to reduction of defects operative morbidities and decrease stay of patients at hospital (Association of Anesthetists of Great Britain, and Ireland (AABI) safety guidelines, 2010).
Surgery is one of the major life changes that cause anxiety. Hospitalization provokes anxiety in the patient admitted for surgery, even in the absence of disease. Stress resulting from protracted anxiety may eventually endanger the client if not discovered early and slow-down recovery(Goebel, Kaup, & Mehdorn, 2011; Jafar & Khan, 2009; Swindale, 2004; Yilmaz, Sezer, Gurler, & Beker, 2011). Surgery can trigger a panic attack in a patient who is prone to anxiety. The preparative care of surgical patients becomes very challenging with the increasing existence of anxiety before surgery.
Anxiety experience is common to most patients awaiting elective surgery and generally seen as normal response(Jawaid, Mushtaq, Mukhtar, & Khan, 2007). Surgical patients perceived the day of surgery as highly terrifying in their lives. Patients manifest anxiety with varying degrees in relation to what is expected in future and these are associated with many factors which may be type and extent of the proposed surgery, gender, age, previous surgical experiences, and personal tendency for unpleasant events(Ping, Linda, & Antony, 2012). The intervention for employed by the healthcare providers has been found to promote, comfort, and favorable surgical outcomes. Nurses and other healthcare givers needs to know patients who are prone to anxiety in the population in order to reduce the occurrence of anxiety resulting from surgery.
The Babylonian clay tablets revealed the evidence of thephenomenon of pain as referenced in achieves. The Greek philosopher, Aristotle, in the 4th century B.C., identified pain as an emotion, and a reciprocal of pleasure. Although emotions certainly play an important role in pain perception, there is much more to the experience than the feelings involved. In the Middle Ages, pain had religious interpretations, in which pain was seen as God’s punishment for sins or as evidence that an individual was possessed by demons. This meaning of pain is embraced by some clients with the mindset that the suffering is their “cross to bear.” The relief of pain may not be the goal for individuals who believe in this definition of pain. Spiritual counseling may need to be implemented before this person is willing to work toward relief. The most widely accepted definition of pain is one developed by the International Association for the Study of Pain (IASP). This organization defines pain as an offensive sensation and mind-blowing experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 2008).
Postoperative pain is very common and develops naturally as a warning(Apfelbaum, Chen, & Mehta, 2003). The development of postoperative pain can be predicted, should be prevented and treated (Power, 2005). Besides the disagreeable aspects and physiological repercussions of postoperative pain, it delays ambulation and hospital discharge. Some authors believe that, despite the drugs and anesthetic techniques available, the prevalence of postoperative pain is still high(Apfelbaum, Chen, & Mehta, 2003; Omote, 2007; Power, 2005). The most unwelcomed outcome of surgery is postoperative pain. This pain can result to prolonged hospital stay and hinder rapid recovery if poorly managed(Schug & Chong, 2009).
Research studies have repeatedly reported that about 20 to 80% of patients having surgical procedures experiencepains which are poorly managed (Lorentzen, Hermansen, &Botti, 2011; Marks &Sachar, 1973). Pain is grouped among grievous public health challenges both in the modernized (Stephens, Laskin, Pashos, Pena, & Wong, 2003) and in developing countries (Klopper, Andersson, Minkkinen, Ohlsson, & Sjostrom, 2006; Lin, 2000; Shen, Sherwood, McNeill, & Li, 2008). Pain continues to be poorly controlled and pose a substantial obstacle to the care of surgical patients with the protracted existence of postoperative pain as a serious public health problem, and the increased knowledge and resources for treating pain (Botti, Bucknall, & Manias, 2004; Dihle, Helseth, Kongsgaard, & Paul, 2006; Helfand & Freeman, 2009; Manias, Bucknall, & Botti, 2005).
In Africa, pain associated with HIV/AIDS and cancer has been greatly explored (Dekker, Amon, & Le Roux, 2012; Powell, Radbruch, Mwangi-Powell, Cleary, & Cherny, 2013; Selman, Simms, Penfold, Powell, &Mwangi-Powell, 2013), although greater burden is associated with pain from surgical procedures. Studies in the past have revealed that underdeveloped countries endure lack of analgesia and little priority is given to pain control in these countries.
In Nigeria, 95% of surgical patients were reported by Kolawole and Fawole (2003) to have experienced postoperative pain of various degrees. Another study carried out in Nigeria reported that inadequate pain relief after surgery is suffered among a high percentage of patients in Nigeria (Size, Soyannwo, & Justins, 2007). A Human Rights Watch’s report (Human Rights Watch, 2011) revealed that only 10% of this group of patients is able to receive the best of pain control. Powell, Radbruch, Mwangi-Powell, Cleary, and Cherny (2013), and Vijayan (2011) reported that shortage of clinicians, rigorous law enforcement on morphine access, and insufficient knowledge left millions of people to suffer because of poor pain control, even though various workshops and African Union summits adopted pain relief as basic human right.
Inadequate clinical practice in the post-operative assessment and management of pain has been reported by several studies (Dihle, Helseth, Kongsgaard, & Paul, 2006; Manias, Bucknall, & Botti, 2005; Schafheutle, Cantrill, &Noyce, 2001; Schoenwald& Clark, 2006). It is the duty of nurses to know how to assess pain by appropriate planning and implementing the adequate treatments in pain management. The nurse requires to monitor the adverse effects and advocate for the patient during the assessment of the effectiveness of those interventions. This helps the healthcare giver to know when the interventions are ineffective in relieving pain (Lippincott, 2013).
- Statement of the Problem
The observation of the researcher in the past 10 years of clinical practice at the perioperative environment was the apparent uneasiness, confusion and anxious appearance demonstrated by the surgical patients coming for procedures in the operating suites. A number of these patients’ responses to their surgical procedures were undesirable. Many surgical patients nowadays looked for information on their conditions on the internet as a helpful tool, they often become puzzled and troubled.
The setting of surgery determines the incidence of preoperative anxiety, and it is connected with increased anaesthetic requirement, difficulty with venous access establishment, and autonomic fluctuations. A number of researches have also correlated preoperative anxiety with pain aggravation, nausea and vomiting after surgical operations, increased incidence of infections and delayed recovery (Bailey, 2010; Fauza & Shazia, 2007; Foggitt, 2001; Pittman & Kridli, 2011; Pokharel, Bhattarai, Tripathi, & Subedi, 2011). Preoperative anxiety was reported as one of the factors causing delayed discharge following a day surgery (Vadivelu, Mitra, & Narayan, 2010).
Anxieties of patients in general have been reported to be linked with poor information (Miner, 1990). Anxiety, fear, challenges of communication have been found to intensify the experience of pain by the patients (Williams, 2005). Evaluation of pain and observation for possible complications are the roles of the nurse (Hawthorn, & Redmond,1999).
Many surgical patients continue to suffer from unrelieved pain, although there exists a great body of knowledge on the processess of pain, care of pain and better strategies for controlling pain. Pain becomes a public health issue due to its increasing prevalence and impact on the health of people (Blyth, March, Brnabic, & Cousins, 2004; Fox, Parminder, &Jadad, 1999). The relief of pain has been widely declared as a fundamental right of man by the World Health Organization and it becomes a malpractice and breach of human rights not to effectively manage a client’s pain (Brennan, Carr, & Cousins, 2007).
Therefore, the effectiveness of preoperative nursing intervention on the relief of anxiety state and post-operative pain among surgical patients needs to be studied by evaluating it’s impact on patient’s care in the context of the Nigerian health facilities and many cultural diversities.
- Objectives of the Study
The main objective of the study was to evaluate the effect of preoperative nursing information (teaching) on anxiety state and post-operative pain of surgical patients at ObafemiAwolowo University Teaching Hospital Complex, Ile-Ife and the specific objectives are to:
- Identify the existing tools used by nurses for assessing preoperative anxiety and post-operative pains among surgical patients;
- Determine baseline levels of preoperative anxiety and pain among surgical patients;
- Determine the levels of post-operative anxiety and pain among surgical patients;
- Evaluate the relationship between nursing intervention for the relief of preoperative anxiety and the control of post-operative pain, and
- Determine the relief of anxiety and post-operative pain in response to nursing interventions on the basis of gender and educational levels of surgical patients.
The study was guided by the following research questions:
- What is/ are the specific tools used by nurses for assessing preoperative anxiety and post-operative pains among surgical patients of ObafemiAwolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife?
- What are the levels of preoperative anxiety and preoperative pain experienced among surgical patients of ObafemiAwolowo University Teaching Hospitals Complex, Ile-Ife?
- What are the levels of postoperative anxiety and pain among surgical patients of OAUTHC, Ile-Ife?
- What is the relationship between the nursing interventions administered for relieving preoperative anxiety associated with effective post-operative pain control?
- What are the relationships between educational levels and gender of surgical patients on the response to nursing interventions towards relief of preoperative anxiety and control of post-operative pain?
- Hypotheses
The hypotheses of this study were tested at 0.05 level of significance.
HO1.There is no significant relationship between nursing interventions for relieving
preoperativeanxiety and the post-operative pain control.
HO2. Educational levels and gender of patients have no significant influence on their
response to nursing interventions for relief of preoperative anxiety and control of post-
operative pain.
The scope of the study focused on adult surgical in-patients booked for elective surgeries in the ObafemiAwolowo University Teaching Hospitals Complex, Ile-Ife in the first quarter of year 2017 only. The anxiety state and surgical pain of the patients were studied in the context of nursing intervention.
- Significance of the Study
The results of this study may provide adequate information about the occurrence and prevalence of preoperative anxiety and post-operative pain among surgical patients to the health care givers. The reports may assist the nurses to provide suitable and appropriate nursing intervention to their surgical patients.
The reports in this study may assist the nurses in the development of appropriate guidelines for the prevention of preoperative anxiety and reduce the incidence of post-operative pain.
Furthermore, this study may generate empirical data for further research studies in other parts of the country and the world at large, which may help in making policies and establish workshops for capacity building to improve the skills of nurses required to allay the anxiety of clients before surgery and the remaining period of care.
- Operational Definition of Terms
The following terms are defined operationally for the purpose of this study as follows:
- Anxiety State: It is the current unpleasant state of uneasiness or tension that the surgical patient experienced.
- Preoperative phase: This is the period from the time of admission of the client into the ward for surgical procedure until the patient is made insensitive to pain.
- Preoperative anxiety: It is an unpleasant state of uneasiness or tension that the surgical patient experienced before the actual surgical procedure.
- Post-operative pain: It is stinging, pinching, gripping burning sensation that may be localized or widespread, resulting from the surgical procedure carried out in the operating theatres of ObafemiAwolowo University Hospitals Complex, Ile-Ife.
- Preoperative Nursing intervention: The planned health teaching given to the surgical clients a day before an actual surgical procedure. It involves information provision, skill training, psychological support and, demonstration as well as use of teaching aids in relation to the surgical condition and procedure.
- Surgical patient: A patient booked for elective abdominal surgery and was admitted in the ward of the hospital.
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