4. Perioperative stress and anxiety in the surgical patient
Melanie Oakley and Rosie Pudner
CHAPTER CONTENTS
Anxiety in the surgical patient46
Methods of relieving anxiety in the surgical patient47
Conclusion49
Introduction
In this chapter the concept of anxiety will be examined, and why the informed view is that nurses should develop strategies to help patients deal with their anxieties. The concept of anxiety in the surgical patient will be explored, and strategies that could be used to alleviate anxiety and stress will be discussed.
Thirty years ago, the perceived wisdom was that theatre and surgical nurses should try and alleviate some of the patient’s anxieties. At that time, seminal work by Hayward, 1975 and Boore, 1978 demonstrated that informing the patient about what was going to happen to them reduced postoperative pain and stress, leading to a quicker postoperative recovery. This research was greeted with enthusiasm, and the concept of preoperative visiting was developed. The idea was that nurses from theatres went to see patients preoperatively and explained what was going to happen to them, e.g. who was going to be in the anaesthetic room, where the intravenous access was going to be sited, etc. It was also explained what would happen to them when they woke up in recovery, e.g. an oxygen mask on their face. Retrospectively, this was the precursor to patients being assessed prior to surgery and nurses taking patients through the surgical pathway (Box 4.1).
Box 4.1 Practice exemplar 1 (from the 1980s)
A lady was admitted on the day before surgery for a total abdominal hysterectomy, and was extremely nervous. The nurse from the recovery unit always went and saw patients prior to their surgery. She would introduce herself and ask the patient what they would prefer to be called. She would always ask them if they would like her to take them through what was going to happen to them on the following day, e.g. transfer from the ward to theatre. Simple things would be discussed, like having oxygen following the operation and why this was; the noises that would be heard; and who would be in the anaesthetic room. The nurse did all of this with this patient but she still appeared nervous. She said that what she had been told was very helpful and had clarified a number of things; however, the thing she was most nervous about was having to clamber onto the trolley, as she was quite small and did not think she would be able to get on the trolley easily and thus would look very undignified doing so. The nurse was then able to reassure her that she would be lifted onto the trolley by the porters; she was very relieved and was immediately more relaxed.
This illustrates how patients can be told all the information we think they want, but it is the really mundane things that they worry about.
As explained in the previous chapter, many patients are undergoing procedures as day cases, and the average length of inpatient stay is decreasing, so inevitably time restrictions are made on the preoperative period. Sadly, it has been identified that the physiological (medical) aspects of care often take precedence over psychological aspects of care (Mitchell, 2003).
When working in an area where elective surgery is carried out five/six days a week, it is extremely easy to treat all patients the same, as they travel along the same integrated care pathway. However, although the care pathway should be tailored for each patient, it is easy to forget that the person following this pathway is an individual person with specific needs, feelings and anxieties (Box 4.2).
Box 4.2 Practice exemplar 2
A 40-year-old lady was admitted for a laparoscopic cholecystectomy. She was extremely nervous and worried about the pain she would experience following the operation. She told the nurses this and they all said it would be alright, and dismissed her concerns. Following surgery she was in severe pain and had to have 40 mg of morphine, a Voltarol® suppository and IV paracetamol. If someone had sat down and discussed her anxieties, would she have been in so much pain and needed so much medication?
Anxiety in the surgical patient
Regardless of the type of operation, whether it is major or minor, under local anaesthetic or general anaesthetic, people are often nervous and anxious at the thought of having surgery. They often fear a loss of control and autonomy, and have feelings of helplessness in the hospital environment (Yung et al, 2002). Patients may also arrive in hospital with preconceived ideas, some knowledge, and a head filled with numerous conversations they have had with ‘friends’ who have had similar operations.
Anxieties frequently include the amount of pain experienced following surgery, and whether they will suffer nausea and vomiting postoperatively. Many patients are highly anxious about the anaesthetic, and common questions are ‘ Will I be awake during the anaesthetic?’ and ‘ Will I wake up when it is over?’Cobley et al (1991) found the five most distressing occurrences for preoperative patients were: waiting to be collected for theatre; not being allowed to drink; not being able to wear their dentures; going inside theatre; and being taken on a trolley to theatre. Although this study was undertaken several years ago, it is still relevant to clinical practice today. Kindler et al (2000) explored the qualitative aspects of anxiety and found three distinct dimensions: fear of the unknown, fear of feeling ill and fear of one’s life. These fears are normal, and the nurse caring for the surgical patient must develop strategies to reassure patients, and empower them with appropriate knowledge to enable them to cope with the forthcoming anaesthesia and surgery.
The concept of anxiety
Commonly, the terms stress and anxiety are used interchangeably; however, it is important to look at the concepts to understand how these terms are inter-related. Anxiety appears to be a psychological construct which can lead to stress, which in turn is described in terms of physiological changes. Seminal work by Selye, 1976 and Selye, 1985 on stress and anxiety still applies today.
Stress can be defined in three ways:
1. As a stimulus – human beings will have a stressful reaction to any number of stressors in the environment, e.g. meeting new people or hunger (Bond, 1986). Clearly, though, this does not explain stress in its entirety because not everyone will experience a stress response to the same things, and the effects of stress will not consistently be the same in each individual.
2. As a response – this explanation of the stress response is primarily a physiological one and is known as the general adaptation syndrome, identified by Selye (1976). Whatever the stressor, the processes and systems involved are the same. This neuroendocrine response has three distinct phases: alarm, which involves the release of adrenaline (epinephrine) and noradrenaline (norepinephrine) as a reaction to the stressor; adaptation, which is characterized by circulating glucocorticoids due to an increased physiological arousal; and exhaustion, where the individual is no longer able to respond to the stressor. If there is prolonged exposure to the stressor from a physiological perspective, it will become life threatening. However, the general adaptation syndrome theory fails to recognize the psychological component of stress.
3. As a transaction – stress is derived from how we interpret situations and how we cope with the stressor (Lazarus, 1976). Coping involves two processes: primary and secondary appraisal. Primary appraisal looks at the situation, and secondary appraisal is when the decision is taken as to how to deal with the situation. This theory proposes that stress is a necessary function and results in learning and an improved ability to cope.
Benefits of reducing anxiety in the surgical patient
The benefits of reducing anxiety in the surgical patient are not disputed; if a patient is nervous, they may experience more pain following surgery, as increased anxiety leads to increased muscle tension, which in turn leads to increased pain as well as to an increase in blood pressure. This may affect postoperative rehabilitation, and discharge may be delayed. In the modern NHS where the emphasis of care is to reduce the length of hospital stay, the benefits of reducing anxiety are obvious. Preassessment clinics for all elective surgical patients are part of normal practice, and research has shown that reducing anxiety by giving information to patients prior to surgery has potential benefits to the patient (Gilmartin, 2004, Johansson et al., 2005, Kindler et al., 2000 and Mitchell, 2003).
Conversely, Salmon (1993) suggested that anxiety might serve to reduce the physiological stress response to surgery. He cited studies demonstrating that patients who had been prepared psychologically prior to surgery, whilst needing less postoperative analgesics, still had high levels of urinary adrenaline (epinephrine). Salmon (1993) concluded that rather than take a paternalistic approach to preparing patients for anaesthesia and surgery, the approach should be to empower the patient, and suggested:
Rather than countering these (fears) with reassurance the nurse communicates acceptance of these as genuine (as distinct from suggesting that they are realistic).
Methods of relieving anxiety in the surgical patient
Giving information
The concept of assessing the patient prior to forthcoming surgery is not new and is discussed at length in Chapter 1. Preoperative assessment is now not just the domain of day surgery: all elective patients are assessed prior to admission and given the information they need prior to their surgery taking place. Nurses who carry out a preoperative assessment should therefore have undertaken advanced practitioner skills, in order to enhance their role in preoperative assessment.
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