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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 200-206

Effectiveness of structured pre operative education on anxiety level of patients undergoing elective orthopaedic surgery


1 Professor, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
2 Deputy Nursing Superintendent, Scudder Memorial Hospital, Ranipet, Tamil Nadu, India
3 Medical Superintenednt, Scudder Memorial Hospital, Ranipet, Tamil Nadu, India
4 Research Officer, Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission19-Oct-2020
Date of Decision25-Nov-2021
Date of Acceptance26-Nov-2021
Date of Web Publication31-Jan-2022

Correspondence Address:
Dr. T Jeni Christal Vimala
College of Nursing, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_110_20

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  Abstract 


The prevention of anxiety is of prime importance for patients undergoing surgeries. This experimental study was designed to find out the effectiveness of preoperative education on anxiety of patients undergoing orthopaedic surgeries. In this study, 46 patients who fulfilled the inclusion criteria were recruited and randomly allocated to experimental and control groups. On the previous day of surgery, the demographic and clinical data were collected with a specially designed pro forma, the pre- and post-operative anxiety level was assessed by using the state-trait anxiety inventory form Y-1 questionnaire and factors influencing anxiety were assessed by a self-developed questionnaire. The mean change in the level of anxiety from pre-operative to the post-operative period in the control group was 8.10 (standard deviation [SD] = 11.12). Whereas in the experimental group this was 9.08 (SD = 15.28). The difference in change of anxiety level from control to experimental group is −0.98 (95% confidence interval:-8.94, 6.98), which is not statistically significant (P = 0.805). There is no significant association between the level of anxiety and demographic variables. The fear about post-operative pain was the factor experienced by most of the patients (78.3%) both in the control and experimental group to cause anxiety. The study concluded that almost all the patients had one or more reasons for anxiety in the pre-operative period. Both control and experimental groups had reduction in anxiety level from pre-intervention to post-intervention. However, the difference in mean anxiety scores was not significant between control and experimental group. Most of the patients in both groups gave positive feedback on teaching, which made them feel at ease and was helpful in overcoming anxiety. The structured education did not produce any unique impact on the post-operative anxiety in patients undergoing orthopaedic surgery. Other factors related to perioperative anxiety warrants exploration.

Keywords: Anxiety, elective orthopaedic surgery, structured pre-operative education


How to cite this article:
Christal Vimala T J, Martin R, Rao AS, Joy M. Effectiveness of structured pre operative education on anxiety level of patients undergoing elective orthopaedic surgery. Indian J Cont Nsg Edn 2021;22:200-6

How to cite this URL:
Christal Vimala T J, Martin R, Rao AS, Joy M. Effectiveness of structured pre operative education on anxiety level of patients undergoing elective orthopaedic surgery. Indian J Cont Nsg Edn [serial online] 2021 [cited 2022 May 28];22:200-6. Available from: https://www.ijcne.org/text.asp?2021/22/2/200/336892




  Introduction Top


Perioperative anxiety is a pervasive problem present in patients waiting for any surgical intervention. Anxiety is inevitable when patients are waiting for investigations and procedures. It is a normal experience of any patient posted for surgery and it can cause extensive or significant effects.

Clients undergo surgery for various reasons. Surgery is an invasive method of treatment that may be planned or unplanned, major or minor and that may involve any body part or system. Elective surgery leads to fear and anxiety for clients who associate surgery with pain, possible disfigurement, dependence and perhaps even loss of life.[1]

Anxiety is body's natural response to stress and is a common reaction to an unknown situation in human. It is a normal human emotion and is experienced in varying degrees as a state of emotional or physical uneasiness. Excessive anxiety occurs in response to an actual or anticipated situation.[2] It is a common reaction to any stressful situation, a state of mental uneasiness and can be experienced at the conscious, subconscious, or unconscious level.[3]

If a patient is anxious and fearful about surgery, it can affect the surgical outcomes and lead to surgical complications. In some instances, surgery may be postponed until anxiety is reduced. Thus, patients requiring surgery need to be assessed for the presence of anxiety and if they are found to have a high level of anxiety, they should be scheduled for an additional counselling or an educational session by a nurse or an anaesthetist or a surgeon.

Anxiety and fear affect the patient's ability to learn, cope and co-operate with teaching and operative procedures. It may influence the amount and type of anaesthesia needed and may slow down the recovery.[4] Thus, teaching patients about their surgical procedure and expectations before and after surgery is best done during the pre-operative period. Patients are more alert and free of pain at this time.

One of the top priority nursing interventions for patients awaiting surgery is 'relieving anxiety'. Thus, pre-operative education becomes a major concern for nurses in surgical setting. Pre-operative education is any educational intervention delivered before surgery that aims to improve knowledge, health behaviours and health outcomes.[5] Perioperative education decreases anxiety and fear, increases confidence and control over pain.[6] When patients are educated on perioperative nursing care, it enhances reduction in length of hospital stay, anxiety and post-operative complication, promote quick healing and improve the outcome of surgery.[7]

Patient education is very important because it increases patient's autonomy, and decreases any knowledge deficits. Having a structured pre-operative education programme enables nurses to approach patients confidently. If nurses can determine the level of anxiety, and identify the factors influencing anxiety, they can play a major role in reducing their anxiety.

Surgery, no matter how minor it is, causes stress and poses risk and complications. The age of the patient, procedures performed, co-existing medical conditions, the family support, experience of previous surgery, etc., influence the anxiety of patients.

Surgery may be seen as a threat to life, body image, self-esteem, self-concept or life style. An observational study on patients who underwent surgical treatment for endometrial cancer revealed that pre-operative education resulted in a reduction in the levels of anxiety from mild to minimum.[8]

While taking care of patients who undergo various surgical procedures, pre- and post-operatively, we can identify anxiety in these patients. The education provided preoperatively to patients can have an effect on post-operative anxiety level.[9] The nurse being an integral part of peri-operative team, should be confident in giving pre-operative teaching, which can reduce the anxiety level of patients.

If a nurse identifies the factors which influence anxiety for a patient, she will be able to help the patient to prevent that factor and reduce their anxiety. Hence, this study was designed to assess the level of anxiety, identify the various factors which influence the anxiety of patients during their pre-operative period and to find out the effect of pre-operative education on anxiety.

Objectives

  1. To assess the pre- and post-operative level of anxiety among patients posted for elective orthopaedic surgery in the experiment and control group patients
  2. To evaluate the effect of structured pre-operative education on the level of anxiety among patients posted for elective orthopaedic surgery
  3. To determine the association of anxiety among both groups with selected demographic variables.



  Methodology Top


A true experimental design was adopted in this study. The population consisted of patients undergoing elective orthopaedic surgery in the orthopaedic wards of a 250 bedded secondary care facility in South India.

The samples comprised of all those patients who are posted for elective orthopaedic surgery who fulfilled the inclusion criteria such as male and female patients above 18 years of age, with or without a history of previous surgical procedures. Patients with cognitive impairment and mental retardation diagnosed to have anxiety disorder or any other psychiatric illness, who are consuming anxiolytic medications and with difficulty in speech and hearing resulting in impaired communication were excluded from the study.

The sample size for the study was calculated based on the study done by Koshy (2007) which had the standard deviation (SD) of anxiety score 8.22 in both the control and experimental groups, and the mean difference of anxiety score between both the groups was 10. Keeping 90% power, 1% alpha error and 2-sided, the sample size was 20 in each group. Further considering 10% dropout rate we have studied 23 samples in each group.[10]

Data collection instrument

Data were collected using the tool which had two parts.

Part I

Demographic data and factors influencing anxiety were collected by using a clinical pro forma which was prepared by the investigator. Validity was obtained from the experts and the feasibility was tested with a pilot study.

Part II

State-trait anxiety inventory (STAI) form Y1 questionnaire was used to assess the anxiety level and to assess the anxiety among both the groups. This tool developed by Spielberger et al. STAI (Y1) is a standardised, valid instrument to measure anxiety in adult patients. Permission was obtained from the concerned author for using the scale in this study. The STAI form Y-1 consists of 20 statements that evaluate how respondents feel at that moment and marked in 4-point scale and scored. The scores range from 20 to 80 with higher scores correlating with greater anxiety. The internal consistency coefficients for the scale ranged from 0.86 to 0.95; test-retest reliability coefficients have ranged from 0.65 to 0.75.[11]

Data collection and analysis

After getting approval from the institutional research ethics committee, the study was conducted for 2 months. A written informed consent was obtained from the patients after informing the purpose of the study. All the patients who fulfilled the inclusion criteria were selected for the study. To assess the anxiety level of patients for both the groups, data collection was done by providing a questionnaire preoperatively before intervention and the next day of surgery postoperatively.

Participants were randomly assigned to the experimental and control group using identical opaque envelopes with serial number of the sample written outside the envelope. These envelopes were kept confidential. Every day the patients were identified with the inclusion and exclusion criteria, the envelope was opened by the investigator and noted which patient fell under which category either experimental and control group. The envelopes were opened according to the serial number written outside. Only one patient was selected and intervened at a time. Immediately after randomisation, demographic data were collected. Then their pre-operative anxiety level was assessed for both the groups by using STAI (Y1) questionnaire.

Structured pre-operative education for the experimental group included the following aspects: Pre-operative routines of hospital care on the previous day of surgery, on the day of surgery, (pre-, intra-, post-operative care and recovery) and post-operative exercises. For the experimental group, apart from the routine education by the nursing staff or doctors in the ward, individual teaching was given in a structured manner with interactive session by the investigator and it was possible to resolve their doubts regarding peri-operative nursing care. The session took about 10–15 min for each patient. The control group received the regular routine care given by health care team. Both experimental and control group patients were allowed to receive routine information by the doctors and nurses.

On the second post-operative day, the anxiety level of patients was assessed for both the groups using STAI (Y1) questionnaire. Factors influencing anxiety were assessed by the self-developed questionnaire.

Statistical analysis

Demographic data were analysed using frequency and percentage. The level of anxiety was expressed as mean and SD. Change in the level of anxiety from pre-operative period to post-operative period for experimental and control groups were calculated separately. Comparison of anxiety levels between experimental and control groups was calculated using independent two-sample t-test. A paired t-test was used to compare the difference in anxiety between pre- and post-operative period of measurement. Analysis of variance/t-test was used to identify the association of anxiety with demographic variable. A P < 0.05 was considered statistically significant. Randomisation was done using SAS software version 9.4. All the statistical analysis was performed using IBM SPSS Statistical Software for Windows, Version 21.0 (Armonk, NY, USA: IBM Corp).


  Results Top


This study was intended to assess the effect of structured pre-operative education on the level of anxiety among adult patients posted for elective orthopaedic surgery. Most of them belonged to the age group of above 57 years (43. 50%), majority of them (56.5% in experimental and 78.3% in control group) had family income of less than Rs. 10,000/month, 20 patients (87.0%) in experimental and 21 patients (91.3%) in the control group were posted for major surgery, and among the 46 patients, 14 (60.9%) in experimental and 15 (65.2%) in control group had previous history of surgery [Table 1].
Table 1: Distribution of participants based on demographic variables

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[Table 2] reveals that the fear about post-operative pain was the factor experienced by most of the patients (78.3%) both in experimental and control groups to cause anxiety. This was followed by fear about surgery (69.6%) in experimental group. Only 13% in both the groups have expressed lack of pre-operative instruction as the cause for anxiety. Almost all participants had one or more reasons for anxiety in the pre-operative period. Few other factors which caused anxiety were fear about anaesthesia (58.7%), fear about outcome of surgery (58.7%), fear of dependency (52.2%), fear of postponement of surgery (52.2%) and fear of economic issues (58.7%) in both the groups.
Table 2: Factors associated with anxiety of patients undergoing elective orthopedic surgery

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[Table 3] shows that the mean level of anxiety among the control group in the pre-operative period was 44.13 (SD = 15.26), whereas, in the post-operative period, it was reduced to 36.03 (SD = 11.70), which was statistically significant (P < 0.05). Similarly, in the experimental group, it was 44.51 (SD = 13.03) in the pre-operative period and was reduced to 35.43 (SD = 11.44). This difference also is statistically significant (P < 0.05).
Table 3: Comparison of mean pre- and post-operative scores in control and experimental groups

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Further, it reveals that the mean difference in the level of anxiety from pre-operative to the post-operative period in the control group is 8.10 (SD = 11.12). Whereas in the experimental group it was 9.08 (SD = 15.28). The difference in the level of anxiety from control to experimental group was −0.98 (95% confidence interval:-8.94, 6.98). This finding is not statistically significant (P = 0.805) [Table 4].
Table 4: Comparison of mean difference in post-operative scores between control and experimental group (n=46)

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[Table 5] reveals that there is no significant association between the level of anxiety and the demographic variables.
Table 5: Association of demographic variables and level of anxiety (n=46)

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  Discussion Top


The present study aimed at assessing the effect of structured pre-operative education on the level of anxiety among the patients undergoing elective orthopaedic surgery. The findings of the study revealed that there is statistically significant reduction in anxiety level in both control and experimental group. The difference in the level of anxiety in the post test at 24 h after surgery between the control to experimental group was not statistically significant showing that both regular instructions and structured teaching were effective and the structured teaching did not have a unique effect on anxiety. Similar results of having no difference in the level of anxiety related to surgery with patient education handouts was seen in a study conducted by Ortiz et al.[12] in the USA among patients going through anaesthesia and surgery. In contrast to this study, the effectiveness of instructional video on pre-operative anxiety of patients undergoing orthopaedic surgery was done by Paripoorani et al.[6] concluded that structured video teaching reduced anxiety of patients undergoing orthopaedic surgery and Tou et al.[13] identified from their study on the effect of pre-operative two-dimensional animation information on perioperative anxiety that there was no significant difference in baseline anxiety score between two groups but significant reduction in anxiety score in the video group at discharge compared to non-video group.

McDonald et al.[5] also concluded through their Cochrane database systematic review on pre-operative education for patients undergoing Hip or Knee replacement surgery that there was no significant effect on postoperative anxiety was detected either on the day following surgery or at discharge. The reason for this may be due to various factors such as previous pleasant experiences of hospitalisation during surgical procedure, explanations given by the health care team during outpatient visit, confidence and satisfaction of care by the attending health care personnel in the hospital and so on. However, education that included visual and auditory teaching aids appear to be more effective in reducing the level of anxiety.[6],[13]

A randomised controlled clinical trial was done in London, the UK[14] on the impact of pre-operative education on recovery following coronary artery bypass surgery. The findings demonstrated that there was no benefit to be gained from their form of pre-operative education and that there was an associated increase in length of hospital stay. As per the review of randomised controlled trials study among cardiac surgery patients on effects of pre-operative education interventions to reduce anxiety conducted by Guo[15] concluded that some trials have demonstrated no evidence that patient's anxiety is reduced after pre-operative education.

A quasi-experimental study conducted on the effect of pre-operative educational intervention on pre-operative anxiety and postoperative outcomes in patients undergoing open cholecystectomy at Menoufia University, Egypt[7] and from the study on effect of pre-operative education on anxiety of open cardiac surgery patients[16] reported that no statistically significant differences in pre-operative anxiety existed between both study and control group. In another study done in Lebanese, patients to assess the impact of pre-operative education on anxiety of patients undergoing Open-heart surgery by Deyirmenjian[17] a borderline statistical significance was noted for the experimental group in terms of pre-operative and postoperative anxiety and the study failed to support the benefits of pre-operative patient education. The above studies show similar results like the present study and they are in concordance with the present study findings.

Changes or reduction in the level of anxiety is not only because of pre-operative education but also may be due to other factors such as familiarity or previous experiences of surgical procedure, the site and type of surgery, the explanation given by the surgeon during hospital visit, the faith and confidence they had with the surgeon, feeling of satisfaction of care by the hospital, the cultural background, family and social support or spiritual relationship with God, etc., The evidence from literature and also from this study clarifies that education does not directly contribute to reduction in anxiety. The anxiety of patients may reduce automatically by the perception that they have come through the surgery successfully especially when it is assessed on the second post-operative day as done in this study. The above assumptions related to the reduction of anxiety in both the groups can be explored by doing a qualitative study on anxiety related to surgical procedures.

There was no significant association between the level of anxiety and the demographic variables of the participants. A similar finding is reported from a study on pre-operative anxiety in Indian surgical patients' experience of a single unit. It was reported that there was no significant anxiety related with age, level of education and previous anaesthetic exposure.[18]

As per the present study, the fear of post-operative pain is identified as the factor influencing anxiety by most of the patients (78.3%). Similar findings were made by Mulugeta et al.[19] They have concluded from their study on pre-operative anxiety and associated factors among adult surgical patients, at North West Ethiopia that the most common reported factor responsible for pre-operative anxiety was fear of complication (52.4%).

A study on stressors and anxiety in patients undergoing Coronary Artery Bypass surgery[20] revealed that being female and having more concerns about waiting for surgery, being in pain/discomfort and resuming lifestyle were predictors of increased anxiety before surgery.

Even though there is no statistically significant difference in reduction of anxiety level between both groups, at the end of teaching session, most of the patients in the intervention group were satisfied, as their doubts were clarified. Some patients gave positive feedback on teaching which made them to feel at ease and was helpful in overcoming anxiety. Information regarding expected pain, effect of anaesthesia, assurance about pain control measures during post-operative period may help in reducing their anxiety.

The limitation of the study is the small sample size of 46, and therefore, the chance of generalisation is minimised. The STA scale although is widely used may not provide specific information about surgery-related anxiety.


  Conclusion Top


Anxiety is considered a major issue in most of the people when facing unusual situations. Furthermore, many studies have proved that the anxiety of the patients undergoing various operative procedures experience varied level of anxiety for which the pre-operative teachings may or may not help to reduce their anxiety. However, this study has added to the evidence that reduction in anxiety is seen in all patients irrespective of the type of education. This does not underestimate the structured pre-operative education but suggests that other factors related to anxiety need to be taken into consideration when measuring anxiety. It is important for the nursing personnel to identify the factors influencing anxiety and ensure that patients are at ease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev 2014;5:CD00352.  Back to cited text no. 5
    
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Tou S, Tou W, Mah D, Karatassas A, Hewett P. Effect of preoperative two-dimensional animation information on perioperative anxiety and knowledge retention in patients undergoing bowel surgery: A randomized pilot study. Colorectal Dis 2013;15:e256-65.  Back to cited text no. 13
    
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Shuldham CM, Fleming S, Goodman H. The impact of pre-operative education on recovery following coronary artery bypass surgery. A randomized controlled clinical trial. Eur Heart J 2002;23:666-74.  Back to cited text no. 14
    
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Guo P. Preoperative education interventions to reduce anxiety and improve recovery among cardiac surgery patients: A review of randomised controlled trials. J Clin Nurs 2015;24:34-46.  Back to cited text no. 15
    
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Asilioglu K, Celik SS. The effect of preoperative education on anxiety of open cardiac surgery patients. Patient Educ Couns 2004;53:65-70.  Back to cited text no. 16
    
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Deyirmenjian M, Karam N, Salameh P. Preoperative patient education for open-heart patients: A source of anxiety? Patient Educ Couns 2006;62:111-7.  Back to cited text no. 17
    
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Mulugeta H, Ayana M, Sintayehu M, Dessie G, Zewdu T. Preoperative anxiety and associated factors among adult surgical patients in Debre Markos and Felege Hiwot referral hospitals, Northwest Ethiopia. BMC Anesthesiol 2018;18:155.  Back to cited text no. 19
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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