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Table of Contents
ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 36-41

Effectiveness of instructional video on preoperative anxiety of patients undergoing orthopedic surgery


1 Junior Lecturer (At the time of submission), College of Nursing, CMC, Vellore, India
2 Professor, College of Nursing, CMC, Vellore, India
3 Professor (Rtd), College of Nursing, CMC, Vellore, India
4 Professor, Department of Orthopedics, CMC, Vellore, India

Date of Web Publication23-May-2020

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  Abstract 


Anxiety is very common among patients undergoing orthopedic surgery. Adequate preoperative information reduces anxiety and enhances quick recovery of patients. Structured surgical orientation video has gained more attention as a mode of education facilitating information provision, possibly anxiolytic, and less costly than many other procedures. A quasi experimental study using a pre-test, post-test control group design was conducted to assess the effectiveness of video instruction about perioperative care on preoperative anxiety of patients undergoing orthopedic surgery in selected orthopedic wards of Christian Medical College, Vellore. Cluster randomization of the wards to the experimental and control group was done and 35 subjects in experimental and 35 in control group were selected by total enumeration technique. An instructional video was developed and validated with content validity index of .85. The intervention was carried out on the day before surgery for experimental group. Anxiety was measured using State-Trait Anxiety Inventory on the day before and after surgery. The post intervention anxiety score was significantly reduced in the experimental group (t = 2.07, p = .05) with a mean difference of 2.23 and increased in control group (t = -6.18, p < .001) with a mean difference of 3.94. There was no significant association between the preoperative anxiety levels and the demographic variables such as age, sex, education, and occupation (p = >.05). The preoperative anxiety of patients if intervened, significant reduction is possible. Structured video teaching is found to reduce anxiety in this study and can be recommended for regular preoperative education of patients undergoing orthopedic surgery.

Keywords: anxiety, preoperative teaching, surgical orientation video, perioperative care, orthopedic surgery


How to cite this article:
Paripoorani D, Babu V, Poongodi K, Cherian VM. Effectiveness of instructional video on preoperative anxiety of patients undergoing orthopedic surgery. Indian J Cont Nsg Edn 2015;16:36-41

How to cite this URL:
Paripoorani D, Babu V, Poongodi K, Cherian VM. Effectiveness of instructional video on preoperative anxiety of patients undergoing orthopedic surgery. Indian J Cont Nsg Edn [serial online] 2015 [cited 2022 Aug 16];16:36-41. Available from: https://www.ijcne.org/text.asp?2015/16/2/36/284859






  Introduction Top


Reducing preoperative anxiety is a challenge in the preoperative care of patients as most of them awaiting elective surgery have anxiety. Anxiety is an unpleasant status of uneasiness or tension associated with abnormal hemodynamic state as a result of sympathetic, parasympathetic, and endocrine stimulation (Burgers, 1990). Preoperative anxiety begins when the surgery is planned as it is perceived as the most threatening day of their life. Many factors including age, gender, type and extent of the proposed surgery, previous surgical experience, and personal susceptibility to stressful situations influence the degree of anxiety manifestation. Studies done by Kain, Wang, Mayes,

Caramico, and Hofstadter (1999) suggest that high preoperative anxiety levels can lead to increased postoperative analgesic requirement, prolonged hospital stay, significant contribution to adverse perioperative outcome, poor patient satisfaction, and negative postoperative behavior after hospital discharge. Interventions to reduce preoperative anxiety include pharmacological therapy, provision of information, distraction, and relaxation procedures (Jawaid, Mushtaq, Mukhtar, & Khan, 2007). Nursing aims holistic care considering aspects such as physical, emotional, social, and spiritual care. Clear realistic explanations of proceedings provide a physical and emotional stamina enhancing better patient outcomes. Preoperative education of patients with vital information about their care within restricted time frame has been a challenge. The usual custom of preoperative teaching has been by means of verbal instruction supplemented with written material. However, factors such as degree of attentiveness, emotional aptitude, intellectual level, learning disabilities, and language or cultural barriers can influence the patient’s ability to understand the information thus increasing their anxiety. Technological advancements have enhanced nurses to intensify and strengthen preoperative educational strategies. An attempt to achieve this is the use of structured surgical orientation program that can facilitate patients to overcome their preoperative anxiety (Ong, Miller, Appleby, Allegretto, & Gawlinski, 2009).

A structured surgical orientation video is an effective and efficient mode of providing vital perioperative care information that can enhance patients’ ability to remember the important aspects of their preoperative instruction. As a consequence, patients gain confidence and control over their clinically relevant postoperative activities. Apart from enhancing information provision, videotapes are possibly anxiolytic, which are less costly than many other procedures. A study done by Jlalal, French, Foxall, Hardman, and Bedforth (2010) reports that preoperative information provided in the form of video teaching alleviates patients’ anxiety. Hence this study was done to assess the effectiveness of instructional video on preoperative anxiety of patients undergoing orthopedic surgery.

The objectives of the study were to

  • assess the level of preoperative anxiety of patients posted for orthopedic surgery
  • develop and validate video instruction on perioperative care
  • compare pre interventional and post interventional levels of anxiety between the experimental and the control groups
  • associate the level of anxiety with selected demographic variables such as age, sex, education, and occupation.



  Methods Top


A pre-test, post-test quasi experimental design with an experimental and control group was employed to assess the effectiveness of video instruction about perioperative care on preoperative anxiety of patients undergoing orthopedic surgery in selected orthopedic wards of Christian Medical College, Vellore. The population consisted of male and female patients undergoing elective orthopedic surgery. Sample size was calculated using the formula n = 4pq/d2 where p denotes the prevalence of subjects fulfilling the inclusion criteria decided after the pilot study as 70. Cluster randomization of the wards to the experimental and control group was done using lottery method. Total enumeration technique was used to select 35 subjects in each group.

Patients undergoing surgery for the first time for fractures of the upper/lower limbs, both male and female patients above the age of 18 years who could read and understand English, Tamil, Hindi, or Bengali were included in the study. Patients refusing to participate in the study and those having altered GCS, visual, and hearing loss were excluded.

Anxiety was measured using the State-Trait Anxiety Inventory (STAI) developed by Spielberger, Gorsuch, and Lushene (1970) which is a self report scale appropriate for those who have at least a sixth grade reading level. The instrument has twenty questions. Patients were asked to rate their feeling on a four point likert scale.

The STAI is a standardized tool for the assessment of anxiety levels with an internal consistency coefficients ranging from .86 to .95; test-retest reliability coefficients from .65 to .75. Considerable evidence attests to the construct and concurrent validity of the scale (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The total score was calculated for each subject, converted into percentages and interpreted as follows (Spielberger et al., 1970):

  • Very high anxiety - > 90%
  • Elevated anxiety -> 70% - 90%
  • Average anxiety - > 30% - 70%
  • Low anxiety - 1% -30 %


The intervention used in the study is the surgical orientation video which was made to individually orient the patients undergoing orthopedic surgery in Christian Medical College, Vellore. This 15 minutes video prepared in four languages (English, Tamil, Hindi and Bengali) contains general information regarding the care before, during and after the surgery including the preparations, theater setup, anesthesia, surgery, recovery room, postoperative care, the diet, exercise, and discharge plan. The voice recording was done in simple understandable terms in all the four languages for better comprehension. The video is a role play showing the activities to be performed by the patients undergoing orthopedic surgery. The content validity of the intervention was done by five nursing and medical clinical experts in the field of orthopedics and the content validity index was found to be .85. Ethical clearance was obtained from College of Nursing research committee and the Institutional Review Board.

On the preoperative day between 3 and 8pm, the investigator met the patients in their respective wards, explained the study, its purpose and obtained oral and written consent. The socio-demographic data including age, sex, education, and occupation was collected.

Both the experimental and control groups received the questionnaire to rate their anxiety level on the day before surgery. Then the experimental group alone received the structured surgical orientation video. The video was played to each patient separately in individual basis using laptop in their preferred language. Any queries were clarified by the investigator. The control group had the regular teaching. On the day of surgery (7am to 10am), anxiety was assessed in both the groups before any pre-medication was administered.


  Results Top


In the experimental group, 25% were in the age group of 25 to 35 years. 71.4% were males, 48.6 % were graduates and 65.7 % were employed. Whereas in the control group 5.7% of them were in the age group of 36 to 45 years.

About 68.6% were males, 37.1% were subjects with secondary education, and 80% employed (see [Table 1]).
Table 1: Socio-demographic Data of the Study Subjects

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[Table 2] compares the anxiety scores in both the groups before and after the intervention. This study reveals that in the control group, 5.7% had elevated anxiety which rose to 17.1% on the day of surgery (post-intervention), whereas in the experimental group 8.6% had elevated anxiety level which reduced to none (0%) after the intervention.
Table 2: Distribution of Level of Anxiety Before and After the Intervention

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In the experimental group the mean anxiety score has reduced from 37.74 to 35.51 with a mean difference of 2.23 after the intervention and in the control group it has increased from 40.40 to 44.34 with a mean difference of 3.94 (see [Figure 1]).
Figure 1: Distribution of mean anxiety before and after intervention in both groups

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The paired sample t test (see [Table 3]) shows that on the day of surgery, post intervention anxiety score was significantly reduced in the experimental group (t = 2.074, p = .046) and increased in control group (t = -6.183, p = .001) signifying that the experimental group had low mean anxiety score compared to the control group. The independent t test shows the experimental group has significant low anxiety compared to the control group (p = 0.001) explaining the difference between the mean anxiety scores of the experimental group and control group after the intervention.
Table 3: Difference in Anxiety scores following the Intervention

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There was no significant association between the preoperative anxiety levels and the demographic variables such as age, sex, education, and occupation.


  Discussion Top


Many studies that have been done to assess the preoperative anxiety have revealed that the anxiety among the patients ranges from low to average levels. In this study, majority of the subjects experienced average anxiety levels (88.6% in experimental and 86% in control group) with a few experiencing elevated anxiety levels (8% in experimental and 5.7% in control group). Similar results of having low to average level of preoperative anxiety was seen in a study conducted by Koivula, Tarkka, Tarkka, Laippala, and Pounonen-Ilamonen (2002) in Finland among patients undergoing coronary artery bypass graft (CABG) surgery. Kalkhoran and Karimollahi (2007) in their study observed that about 66.7% of subjects had moderate level of preoperative anxiety. Another similar observation was seen from the study done by Alves et al. (2007) which showed that the preoperative anxiety level of 45.3% of patients was moderate. The above mentioned studies had used the STAI scale for measuring the anxiety levels.

This study showed that viewing the surgical orientation video helped to reduce the preoperative anxiety of patients undergoing orthopedic surgery. Sorlie, Busund, Sexton, Sexton, and Sorlie (2007) also have explained the positive impact of video information in combination with individualized session. 109 patients were selected, 55 in experimental group and 54 in control group. A similar finding is reported among patients who underwent coronary artery bypass graft. It was reported that information given in the form of video instruction enhances patient’s sense of decision making as well as influences their diet and exercise after CABG. Video information stimulates patient’s curiosity. Patients who had video education were emotionally strong and less anxious at the time of discharge. There was a higher capacity to handle different challenges to cope which was observed as a long term effect of video education (Sorlie et al., 2007).

There was no significant association found between the demographic variables and the anxiety levels. A study done by Alves et al. (2007) and Kiyohara et al. (2004) showed a similar finding. Whereas a few study findings (Romanik, Kanski, Soluch, & Szymanska, 2009; Wen, Leslie, &

Rajendra, 2009) reveal that women have more level of anxiety than men. Some studies (Krannich et al., 2007) also report that younger patients have more anxiety (p = .03). Koivula et al. (2002) has found that educated patients had more anxiety. But such significant correlation is not found in this study. But the study done by and Kiyohara et al. (2004) showed a similar result with education having no influence on anxiety levels.

The limitations of the study include that the effect of potential sources of anxiety such as anesthesia, surgical techniques, success of the operation, fear of any anticipated complications, or amount of information provided to patients was not assessed. Also, the study is not empowered to show the effect of previous surgical experience on anxiety and the sample size is limited.


  Conclusion Top


The major finding of this study is that most patients undergoing surgery, experience anxiety that requires an intervention. Surgical orientation video helps to alleviate anxiety significantly than the usual preoperative teaching. Hence it can be recommended that video teaching can be included as a regular routine of preoperative preparation of patients for surgery and in surgical wards and OPDs for more realistic understanding to reduce the fear of unknown and better psychological preparation of patients. Instructional videos can be made available to patients so that they can view it when they are comfortable and prepare themselves for the surgery. Also, protocols can be made to ensure that all aspects of patient preparation (including psychological aspect) are done. Furthermore, interventions can be identified and checked for its effect in handling preoperative anxiety. The same study can be done in multiple settings with a larger sample size to identify the association of socio-demographic data and clinical data with anxiety levels.

Conflicts of Interest: The authors have declared no conflicts of interest.



 
  References Top

1.
Alves, M. L., Pimentel, A. J., Guaratini, A. A., Marcolino, J. A., Gozzani, J. L., & Mathias, L. A. (2007). Preoperative anxiety in surgeries of breast; a comparative study between patients with suspected breast cancer and undergoing cosmetic surgery. Reevista Brasiliera de anestesiologica, 57(2), 147-156.  Back to cited text no. 1
    
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Burgers, A. W. (1990). Psychiatric Nursing in the hospital and community (5th ed.). Norwalk: Appleton and Lange.  Back to cited text no. 2
    
3.
Jawaid, M., Mushtaq, A., Mukhtar, S., & Khan, Z. (2007). Preoperative anxiety before elective surgery. Neurosciences, 12(2), 145-148.  Back to cited text no. 3
    
4.
Jlalal, H. A., French, J. L., Foxall, G. L., Hardman, J. G., & Bedforth, N. M. (2010). Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. British Journal of Anaesthesia, 1, 1-6.  Back to cited text no. 4
    
5.
Kain, Z. V.,Wang, S. M., Mayes, L. C., Caramico, L. A., & Hofstadter, M. B. (1999). Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesthesia and Analgesia, 88, 1042-1047.  Back to cited text no. 5
    
6.
Kalkhoran, M. A., & Karimollahi, M. (2007). Religiousness and preoperative anxiety: A correlational study. Annals of General Psychiatry, 6(17). doi:10.1186/1744-859X- 6-17  Back to cited text no. 6
    
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Kiyohara, L. Y., Kayano, L. K., Oliveira, L. M., Yamamoto, M. U., Inagaki, M. M., Ogawa, N. Y., … & Vieira, J. E. (2004). Surgery information reduces anxiety in the preoperative period. Revista do Hospital das Clinicas; Faculdade de Medicina da Universidade de Sao Paulo (Sao Paulo), 59(2), 51-56. Retrieved from http ://www. scielo .br/pdf/rhc/v5 9n2/a01 v59n.  Back to cited text no. 7
    
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Koivula, M., Tarkka, M. T., Tarkka, M., Laippala, P., & Paunonen-Ilmonen, M. (2002). Fear and anxiety in patients at different time-points in the coronary artery bypass process. International Journal of Nursing Studies, 39(8), 811-22.  Back to cited text no. 8
    
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Krannich, J. A., Weyers, P., Lueger, S., Herzog, M., Bohrer, T., & Elert, O. (2007). Presence of depression and anxiety before and after coronary artery bypass graft surgery and their relationship to age. BioMed Central, 7(47). doi: 10.1186/1471-244X-7-47  Back to cited text no. 9
    
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Sorlie, T., Busund, R., Sexton, J., Sexton, H. & Sorlie, D. (2007). Video information combined with individualized information sessions: Effects upon emotional well-being following coronary artery bypass surgery-A randomized trial. Patient Education and Counselling, 65(2), 180-8.  Back to cited text no. 12
    
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