Rajiv Gandhi University of Health Sciences Karnataka



[pic]SYNOPSYS PROFORMA FOR REGISTRATION OF SUBJECT

FOR

DISSERTATION

Mr. JITHIN MATHEW SAJI

FIRST YEAR M.SC (NURSING)

YEAR 2011-2013

INDIAN ACADEMY college of nursing,

bangalore.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SYNOPSYS PROFORMA FOR REGISTRATION OF SUBJECT

FOR

DISSERTATION

| | |JITHIN MATHEW SAJI |

|1. |NAME OF THE CANDIDATE AND ADDRESS |1ST YEAR M.Sc (NURSING) |

| | |INDIAN ACADEMY college of nursing, bangalore. |

| 2. |NAME OF THE INSTITUTION |INDIAN ACADEMY college of nursing, bangalore. |

| | | |

|3. |COURSE OF THE STUDY AND SUBJECT |1ST YEAR M.Sc (NURSING), |

| | |PSYCHIATRY NURSING |

|4. |DATE OF ADMISSION TO THE COURSE |29/10/2011 |

| | |“A Study To Assess The Effectiveness Of Nursing |

|5. |TITLE OF THE STUDY |Intervention And Pre-operative Anxiety On |

| | |Postoperative Recovery In Selected Hospitals In |

| | |Bangalore.” |

6. Introduction

“The one who foresaw your tribulation has armed you to go through it, not without pain but without strain”

-C.S.Lewis

21th century has been aptly termed the age of anxiety. Stress and anxiety have been studied abundantly by nurses for several decades. These topics have been popular in the health related literature for even longer. The concepts of anxiety arouse from psychoanalytic theory and were pivotal to that discipline from the time Freud first wrote about it in 1926. In 1930s the concept was linked to psychosomatic disease when many prominent theorists recognized that anxiety played a pivotal role in disease.2

The primary definition from Webster’s dictionary states that anxiety is: Simon and Schuster (1983) defines as “Concern or solicitude respecting some event, future or uncertain, which disturbs the mind and keep it in a state of painful uneasiness; the state of being anxious”1

According to Miller (1948) “Anxiety is a acquirable or conditioned drive which functions to motivate avoidance responding”.2

James-Lange theory argues that the basis of emotional experiences is based on peripheral and physiological sensation. Anxiety can be an adaptive response when one is confronted with an event that threatens their survival. Overall sensory feedback controls emotional expression. Mild to moderate anxiety serve as an adaptive function, where as highlevels lead to impaired psychological functioning, intellectual errors and distributed and memory.3

It is clear from the above concepts that anxiety is a complex multidimensional phenomenon, and it is the most prevalent response when an individual is confronted with an event that is threatening.5

Lumbar Laminectomy is the surgery performed to reduce the low back pain when all other conservative measures fail. Lumbar Laminectomy is an operation performed on the lower spine to relieve pressure on one or more nerve root. The term is derived from lumbar (lower-spine), Lamina (part of the spinal canals bony roof), and ectomy (removal). Pressure on the nerve root in the lower spine, often called nerve root compression causes pain in the back and leg. Through this operation removal of the source of compression; partly of the herniated disc, a fragment, a tumour or a rough protrusion of bone relieves pressure.19

Since Lumbar Laminectomy is often performed as a last treatment measure, the anxiety with regard to its success in inevitable. A complete psychological programme can be helpful throughout the entire back surgery process, from gathering information according to one’s personal coping styles to get adequate pain control and helping ensure an appropriate level of assertiveness with the medical team. Specific techniques of a psychological preparation programme include:

1. Gathering accurate information about the surgery and recovery.

2. Getting adequate pain control.

3. Learning appropriate cognitive techniques

4. Mastering deep relaxation exercises

5. Paying attention to spiritual issues

6. Developing coping skills and

7. Controlling one’s own environment.

6.1 NEED FOR THE STUDY

The prospect of surgery will elicit fears and concern which are common to many patients, regardless of the specific nature of the operation and of the illness for which it has been recommended. It has been well documented that psychological stress can include numerous physical effects, ranging from increased sympathetic adeno-medulary activity to increased susceptibility to disease. It is therefore possible that psychological stress has a negative effect on physical recovery following surgery.

Many studies have been carried out to explore the relationship between preoperative psychological factor and post operative recovery. Their findings are inconsistent and there has been little harmony across studies with respect to intervention or the measure that have been used to index recovery.

The role of the nurse is currently undergoing change as a movement away from the traditional form of nursing. Nursing should be able to build on its scientific knowledge through the integration of theory with nursing practice and research.

Menzies in 1960 described nurses has distanced themselves from the more stressful aspects of their work, of which the building of a close relationship with the patient in order to relieve their anxieties is one of the examples. With improvement in education and a holistic approach to care, this stress avoidance strategy has largely diminished. A system of task allocation enabled the nurses to provide psychological care only when they had time available. The various strategies adopted by patients to enable them to cope with their anxieties became understood. This resulted in stereotyped labelling of patients as “difficult” or “demanding”.12

Nursing recognizes anxiety as an important concept. The North American nursing diagnosis association (NANDA) recognises anxiety as one of its diagnosis. In fact anxiety has been reported in the literature as one of the most commonly cited nursing diagnosis in acute care settings.

Over the past 30 years, above 200 research studies, with thousands of patient, investigating psychological preparation for different kinds of surgery have identified several specific benefits. They include:

1. Less anxiety both before and after surgery

2. Fewer complications related to the surgery and recovery.

3. Less pain and less need for post operative pain medication

4. Reduced anaesthesia requirements

5. Quicker return to health

6. Shorter hospitalization period

7. Reduced health care demands due to empowering the patient to take more responsibility.

8. Increase patient satisfaction with treatment

9. Reduced cost per surgery

Theorist Jean Watsons belief of nursing is “nursing is an inter-subjective human process and the places a value on the caring relationship between the nurse and the recipient of care”.11

There have been numerous intervention studies in preoperative anxiety and postoperative recovery in abdominal gynaecological, dental, orthopaedic surgeries etc. Very few are conducted with patients undergoing lumbar laminectomy, through there are various studies documenting the psychological variables as predictors of outcome in the same.

During my hospital experience in hospitals in Kerala, it happened that I was posted to provide care to the patients admitted after Laminectomy. In those patients I found that they had immense amount of anxiety before the surgery. Observing this anxiety I started to provide relaxation techniques to the patient and saw that the anxiety level was reducing. So that is why the researcher thought of selecting this study as my research study.

6.2 REVIEW OF LITERATURE

Review of literature is a systematic search works to gain information about a research topic. It is a compilation that provides the groundwork for further study.

This chapter deals with related, research and non-research literatures that were reviewed to broaden the understanding and to gain insight into the selected area under study. Relevant literatures from various perspectives like psychology, psychiatry, neurosurgery and nursing were taken, to explain the concepts of anxiety, Its relation to surgical outcomes, and the role of a nurse to promote positive outcomes.

The review is organized into the following heading:

1. Literatures pertaining to concept of anxiety.

2. Literatures pertaining to Preoperative anxiety.

3. Literature pertains to effects of preoperative anxiety on postoperative recovery.

4. Literature pertains to effects of nursing intervention on postoperative recovery.

CONCEPT OF ANXIETY

Cannon (2009) demonstrated that psychological stimuli could activate the psychological system of an organism in particular the sympathetic division of the autonomic nervous system, causing the release of adrenalin and non adrenaline by the adrenal medulla.4

Janis (2008) describes 3 major phases of psychological stress thayt typically occur when a person is exposed to situation of objective danger.1) Threat phase, during which the person perceives signs of on coming danger and receives communications of warning which are likely to arouse anticipatory fear. 2) The Danger impact phase, during which a person perceives the physical danger is actually at hand and realizes that his chances of escaping intact depend partly on protective actions executed by himself or by other people who are in a position to help him. 3) The post impact victimization phase, during which the person perceives the losses he has sustained and at, the same time undergoes some severe deprivation which continues for a varying length of time after the acute danger has subsided.17

Bhatia MS (2004) emphasized the role of the adrenal cortex secreting corticoid steroids. He identified theories about the relationship between short term stress reaction and their outcomes- “the disease of adaptation”.5

Spielberger (1996) has made a distinction between state anxiety, which is an increased arousal due to environmental factors, and trait anxiety which is an individual’s characteristics way of reacting to arousal. The level of anxiety displayed by a person is a mutual function of both types of anxiety. Trait anxiety is an aspect of personality and social behaviour and correlates with self-esteem and defensiveness.38

i) Studies conducted to describe anxiety are given below

Weisenberg et al: (2007) in a study “Relevant and irrelevant anxiety in the reaction to pain”, tested the proposition that anxiety can lead to the exacerbation of pain perception when the source of anxiety is related to pain experience. 51 male’s subjects (median age 23.0) participated in the study. A 2 X 3 independent sample design was used. Two anxiety levels (high and low) and 3 foci of anxiety (task, pain, both) were manipulated in a labortary. Verbal, physiological and behavioural differences were obtained showing that focus upon learning alone yielded the lowest pain reaction, but the largest learning errors. While focus upon both pain and learning task yielded the strongest pain reactions, the focus upon pain was in between. Thus the correlation between related anxiety STAI, perception indicates that only approximately 34% of the variance can be explained on the basis of anxiety level alone, other factors are involved.41

Absi and Rokke (2004) hypothesized that anxiety, which is relevant to the source of pain, exacerbates pain, where as anxiety, which is irrelevant to the source of, pain reduces the experience of pain. One hundred female undergraduate psychology students in a 2x2 experiment study were given either high or low anxiety provoking information about a cold presser task. Relevant anxiety or high or low anxiety provoking information about a potential shock (irrelevant anxiety). Subjects demonstrated that subjects who were highly anxious about the cold presser reported experiencing the most pain. And subjects who were highly anxious about the shock reported the least pain and reportedly significantly less pain than subjects who were highly anxious about cold presser. These findings clearly demonstrate that the relationship between anxiety and pain is not always positive or unidirectional.1

Pike JL at al (2001) studied the effects of chronic life stress upon psychological and physiological responses following challenge with an acute psychological stressor. Male volunteers 12 with and 11 without chronic life stresses were administered a 12 minute laboratory stressor of mental arithmetic Vs, a video control. Compared to video control condition, the effects of the acute psychological stress were – subjective group showed subjective distress, higher peak levels of epinephrine, lower peak levels of beta-endorphin and NK cell lyses and greater redistribution of NK cells in response to the acute psychological challenge. Additionally the acute stressor caused a protracted decline in NK lyses per NK cell in the chronic stress group, but had no effects in the contract. To conclude, an exaggerated psychological and peak reactivity occurs when people who are undergoing chronic life stress are confronted with an acute psychological challenge. This reaction is associated with decrements in individual NK cell function and its protracted beyond termination of the stressor and recovery.30

Masaoka et al (2000) examined the relationship between breathing patterns, personally and ventilator response in emotions caused by mental stress and physical load. 10 normal male (aged 20-25 years) were given STAI and assessed for patterns of breathing both before and after exposure to mental stress and physical load. Results showed unpleasant emotions caused by mental stress altered the breathing pattern. A dominant respiratory rate increase was observed not only in the mental stress but also in physical loading test. In physical loading there was a positive correlation between the state anxiety score and respiratory rate. These results indicate that respiratory patterns are related to personality anxiety.27

PRE-OPERATIVE ANXIETY

Reviews related to preoperative Anxiety are given below:

Janis (2008) in his book “psychological stress” describes that, from a psychological stand point, a major surgical operation constitutes a stress situation. This resembles many other types of catastrophes and disorders in that the victim faces a combination of 3 major forms of serious body damage, and of dying.17

Band (2007) reports that, ultimately surgery represents a threat that one must face alone one must face alone one also engender considerable risk and elements of the unknown.4

Ramsay, (2005) conducted a study to assess the emotional responses of patients to surgery and anaesthesia, and found that 73% of the patients exhibited anxiety.16

EFFECT OF PREOPERATIVE ANXIETY ON POSTOPERATIVE RECOVERY

Janis (2008) developed the emotional drive theory on the basis of 3 quasi-experimental studies of students and surgical patients. He proposed that a curvilinear relationship exist between preoperative anxiety or fear and post-surgical outcome, or specifically that patient showing moderate levels of fear would be alerted to the dangersof the procedure through the “work or worry” and show optimal postoperative adjustment. When compared with either high fear patients who demonstrated neurotically determined fears and low fear patient who show violence or denial of pre-operative threat information, both groups were shown to have adverse surgical outcomes in comparison with moderate fear groups.17

Some empirical evidence now suggest that a positive linear relationship exist between pre-operative fear or anxiety and postoperative fear (Johnoson et al, 1999; Cohen and Lazarus, 1998; Sime, 1996; Johnston,1996; Ray and Fitzgibbons 1994). It’s often assumed that preoperative anxiety also shows a linear relationship with other adverse outcomes including increased consumption of anaesthetic induction agent. During surgery increased post operative complications, delayed recovery time and consumption of analgesics. There is evidence of significant correlation between pre-operative fear and outcomes in several studies, but the results are in consistent.18

Johnson et al, (1999) in a study attempted to examine simultaneously factor which could account for emotional reactions and factor which could account for instrumental reaction during hospitalization. 62 female patients were followed through the experience of having abdominal surgery. It was found that the predisposition variables, i.e chronic anxiety and birth order, as well as situation aroused fear predicted emotional responses. The finding from their study demonstrated that it is not necessary for patients to be frightened and in fact the lower the preoperative fear the more likely there will be low negative emotional reaction post operatively, and also findings suggest emotional reaction do not necessarily interfere with instrumental behaviour.18

Johnston (1996) studied the natural course of anxiety, before and after surgery using state Trait anxiety inventory in 136 surgical patients and found that state anxiety increased throughout the immediate preoperative period and stayed so even after surgery. The highest levels frequently were observed immediately after surgery leading her to conclude that this had great implications for those planning interventions to alleviate associated with surgery.26

Taenzer et al, (1990) using multivariate statistical method assessed the influence of psychological factors on postoperative pain method and analgesics requirements on 40 patients (aged 20-60) undergoing elective gall bladder surgery. Preoperatively psychological state was assessed by STAI, Beck depression inventory, rotter locus of control scale, health locus of control scale and MC Gill pain questionnaire and analgesics intake. The results indicate that approximately half of the variability in the post operative put comes include the patient’s anxiety syndrome and bias toward using medications.35

Vogele and Steptoe (1986) studied physiological and subjective stress responses in 15 surgical patients undergoing major and minor orthopaedic surgery. They were seen daily from 2 days prior to operation till discharge. Mood and coping questionnaires were administered on each session, pain, heart rate, blood pressure, skin conductance level, palmer sweat index and forearm EMG were also recorded. Anxiety was found to be highest immediately after surgery decreasing gradually to less than preoperative levels by 10th postoperative day. Skin conductance and palmer sweating indies fell to low levels on the days immediately following surgery returning to basal values only after several days ratings of fatigue, depression and pain were highest on the immediate post operative days.14

Salmon et al (1985) conducted a study on 71 patients undergoing major abdominal surgery to assess the level of anxiety, type A personality and endocrine response to surgery. Trait anxiety, Type A personality measured preoperatively and cortisol, adrenaline and nor adrenaline were measured pre and post operatively. Anxiety correlated positively with noradrenalin but negatively with cortisol and adrenaline and noradrenalin. Results indicate Type A personalities do not respond to surgery with greater sympathoadrenal activities.33

Pick et al, (1982) investigated the influence of psychological component on post-operative fatigue by conducting a study on 74 patients undergoing coronary artery bypass graft surgery. Circulating catecholamine levels measured at intervals peri-operatively and questionnaires were used to measure fatigue, depression and anxiety up to 30 days post operatively. The authors tested whether the fatigue was related to the catecholamine or to the emotional response to surgery, fatigue at 30 days was greatest in patients whose noradrenalin levels were greatest preoperatively. Independently of this relationship fatigue at 30 days correlated with concurrent levels of depression and anxiety. Post operative fatigue has both psychological and physiological correlates.30

Kiel colt – Glaser et al, (1980) conducted a quasi-experimental study on 26 women (ages between 47-80) of which 13 women were caregivers of demented relatives and other 13 were controls (non – caregivers) matched for age and family income. The aim was to assess the rate of wound healing in relation to psychological stress. In this study all subjects underwent a 3.5mm punch biopsy. Wound – healing was assessed by photography of the response to hydrogen peroxide. Wound healing took significantly longer in caregivers than controls.22

i) Postoperative recovery in Lumbar Laminectomy

Studies pertaining to effect of preoperative anxiety on postoperative recovery in patients undergoing spinal surgery are given below.

Oostdam et al, (2009) conducted a study on 162 patients undergoing surgical treatment for low back pain with of aim of predicting the outcome of surgical intervention from psychological and other biographic data. These patients were investigated preoperatively using a number of psychological and other biographical data. These patients were investigated preoperatively using a number of psychological tests. The effect of surgical intervention was determined after 6 months. The judgement of the neurosurgeon and of the patients themselves were used to assign patients to three outcome categories: satisfactory, moderate and unsatisfactory. Differences in several psychological and biological factors were found between the 3 categories. On the basis of preoperative variables it is possible to predict the outcome of surgery in 80% of patients.29

Thorvaldsen and Sorensen (2008) carried out a prospective surgery of the outcome following lumbar spine surgery during a period of 6 months. 130 cases were postoperatively evaluated during the 6 month follow up. A test of psychological vulnerability was significantly associated with poor outcome irrespective of age, sex, pre-operative somatic health and persisting pain attribute to psychological vulnerability was 1:8. The findings support the contention that psychogenic factors independently and significantly contribute to the multiple interactions that short-term outcome.39

Graver et al, (2005) in a prospective study 122 patients with herniated lumbar disc were assessed preoperatively using psychological questionnaires. Surgical outcome was evaluated 12 months post operatively mainly by a composite clinical overall score, and by its separate element. Anxiety and psychosomatic symptoms (MSPQ) had predictive value: fewer symptoms favoured a satisfactory overall outcome and vice versa. The HAD- A scale had a predictive power of poor and satisfactory outcome of 28% and 81% respectively.14

EFFECTS OF NURSING INTERVENTION ON POSTOPERATIVE RECOVERY

The previous section confirms the intuitive view that surgery is associated with anxiety and the possibility of patients with patients with high anxiety having delayed postoperative recovery than those with low anxiety. The nurse plays an important role in averting this situation. The importance of intervention methods designed to reduce anxiety is seen in this section. This section will be further subdivided into the studies related to;

a) Effects of information b) Effects of relaxation

A) Effects of information:

Fortin and Kirouac, (2009) conducted a randomized controlled trail on men and women undergoing abdominal surgery under general anaesthesia, for the purpose of evaluating the efficiency of a nursing intervention in management of selected and representative elective surgical patients. Efficacy was assessed by studying the effect of the new structured preoperative patient education programme on physical functional capacity, on the comfort and on the satisfaction of patients. Efficiency was evaluated by determining the impact of the programme on length of hospitalization, and on length of delay before patients was formed, within pairs, random no tables were used to form the experiment and control group. Results show that the physical functional capacity of the experiment group was significant better when compared to the control group. With regard to use of analgesics postoperatively there were no differences between the group in the first 24 hours. However over the next 72 hours, there was statistically significant reduction in the use of analgesics in the experimental group and experimental group, experienced a greater comfort and satisfaction. There were no differences in length of hospitalization or readmission among the group.11

Hart field and Cason, (2009) to assess the effects of information on emotion response conducted a quasi-experimental study during barium enema. 24 patients were assigned to one of three information conditions: sensation, procedure, or no information. Prior to barium enema all subjects took the Trait portion of STAI, to measure relatively individual differences in anxiety proneness. Two groups heard a taped measure of sensation or procedural information; the 3rd group heard no information. After the barium enema, all subjects took the state portion of STAI, to measure their emotional response during the barium enema. Subjects who received sensation information reported less anxiety than subjects who received no information did or procedural information did.15

In an experiment study conducted by Zeimer (2005) to examine the effects of providing patients with selected types of information prior to surgery and the reported frequency of use of coping behaviours following surgery and relationship between the reported frequency of coping and outcome of surgery. A total number of 111 patients undergoing surgery were randomly assigned to 3 groups, one received procedural information, second, procedural and sensation information; and a 3rd group; procedure and sensation and information on selected coping strategies. Results showed no evidence that the type of information provided for patients prior to surgery increased the reported frequency of coping behaviours or that reported frequency of coping behaviours was related to improve outcomes as evaluated by pain intensity, distress or selected physical complaints.43

Devine and Cook (2005) conducted a meta- analytic analysis of 49 studies of the relationship between brief psycho educational interventions and length of post surgical hospitalization. Results show that interventions reduce hospital stay by about 11/4 days and that reduction does not depend on whether the discharge physician was aware of the patient’s experimental conditions or whether the studies were lacking internal validity. This study supports the belief psycho educational interventions may be cost effective with surgical patients of many kinds because the length of hospital stay is reduced.10

Wong and Wong (2002) conducted a randomized controlled study to evaluate the effects of new education strategy to preoperative teaching on patient’s compliance. Sample included, 98 subjects, who were randomly assigned to experimental group (51 patients) and control group (47 patients). Tools used were compliance behaviour index, the patient satisfaction index. A significant difference was found between the experimental and controls patients in the regularity, willingness and accuracy with which they performed the prescribed postoperative exercises (compliance). The experimental patients were significantly more satisfied with this approach to preoperative teaching than the control.42

Through a descriptive survey, Walts and Brooks (2002) examined the preoperative information which patients need about the events they may experience in intensive care, when they are admitted there following elective surgery. Questionnaires were posted to a convenience sample of 57 people who had been admitted post – operatively to one ICU in the past year 43 of questionnaires were returned and were analysed with the 5 returned in the pilot study. The results suggested that pre-operative information about ICU was perceived helpful by all respondents, particularly with management of pain and nausea, the likely site of pain, moth care, the high nurse patient ratio and having a urinary catheter. Information rated helpful less frequently, included noise levels, visiting times and men and women being nursed in the same room. The most popular method of receiving the information was via a preoperative visit from a nurse working in ICU.40

Rui G (2001) conducted a quasi-experimental two group design study to identify the effect of informational support on psychological well being of post mastectomy patients. 30 patients were purposively selected according to the inclusion criteria. The 1st 15 subjects; the control group, received the routine information provided by the nurse, and the second 15 subjects the experimental group, received the informational support provided by the researcher. Data was collected post operatively on the third day as a pre test and on the tenth day as a post test. The tools used were demographic data, psychologiacal well being questionnaire and the informational support guideline developed by the researchers. There was a statistical significant difference between pre-test and post-test score in the control group at the level (0.01, 0.2). In the experiment group at the level (0.05, 0.3). There was a statistical significant difference on psychological well being between control and experimental group at the level of .01.32

Xiuyue (1999) conducted a one group qusi-experimental pre-test and post-test design to investigate the effects of instruction on postoperative anxiety among abdominal surgical patients. The instruments used were SATI (y1 form) and demographic data record form. They also received the instruction manual developed by the researcher. The results of the study revealed that there was statistical significant decreasing of preoperative anxiety after receiving instruction among the subjects at the level of .001. The finding if this study provided guideline for nursing practice to decrease anxiety of surgical clients including implications for nursing education and further nursing research.36

B) Effects of Relaxation:

Aikken (2010) conducted a study to assess the effectiveness of systematic relaxation in reducing preoperative stress; she used deep muscle relaxation on 15 male open heart surgery patients and compared with no treatment group of 15 male open heart surgery patients. A tape of the relaxation exercise recorded by the nurses was given to each patient of the experiment group with instructions for daily practice session. Both age and education levels varied widely in this patient population with the resultant findings that the education was the best predictor of successful outcome. The more highly educated patient was found to be more likely to practice and seemed better able to perceive stress had an influence in surgical recovery. Incidence of postoperative reaction was 8% in the treatment group as compared to 40% in the control group.31

Flaherty and Jyoce (2008) conducted a preliminary experiment study to determine the effectiveness of a relaxation technique to increase the comfort level in the patients in their first postoperative attempt at getting out of bed was tested on 42 patients (age 18-65) who were hospitalized for elective surgery. Study group patients were taught the relaxation technique. Blood pressure, pulse and respiratory rates of subjects in both groups were compared prior to surgery and after the postoperative attempt to get out of the bed. Subjects reports of the incision pain and body distress were measured via a pain and distress scale after their attempt at getting out of bed. Amounts os analgesics used in the first 24 hours following surgery were examined. Mean differences, in report of incision pain and body distress, analgesics consumption and respiratory rate change were statistically significant, supporting the hypotheses that use of a relaxation technique to reduce muscular tension will lead to an increased comfort level of postoperative patients.26

A replication of the study was, undertaken by Corah, Gali and Illing (1995) with further objective of examining gender differences in response to treatment. Another difference in this study is that anxiety scale was used as a dependent variable in addition to an independent one. A main effect of treatment was found with respect to change in anxiety ratings with relaxation group reporting a greater decrease in anxiety. There was a significant Gender x treatment x session interaction for self ratings of discomfort, with women in the relaxation group having significant lower self rating of discomfort from session 1 to session 2. There were no effects on EDR. As in the previous study, dentist rating showed that the relaxation group exhibited a greater decrease in discomfort from the first to the second session where as the control group did not overall. These results are consistent with the earlier study by Corach et al showing a beneficial effect of relaxation.28

Wilson et al (1995) induced muscle relaxation as one of three conditioned investigating for preparing patients to undergo gastrointestinal endoscopy. The 14 patients in the relaxation group listened to an audiotape of instructions for systematic muscular relaxation. All of the patients used the tape at least once on the evening prior to the endoscopy. Patients in the control group received the standards explanation about the procedure from their attending physician. Measures of adjustment during endoscopy consisted of pre-procedural and post procedural self-report rating of fear (e.g afraid, worried and uneasy) and mood (e.g Helpless, cheerful), observer ratings of distress (e.g gagging, moaning, and arm movements). During the procedure, changes in heart rate and the amount of Valium administered during the procedure were assessed. Patients prior to receiving the treatment intervention also completed a coping lifestyle questionnaire. It was found that patients in the relaxation group had lower heart rate increase, and distress during tube insertion than controls. Relaxation patients reported significantly greater increase in mood following the endoscopy. Overall results suggest the relaxation had a positive effect on the adjustment of the patients.20

Mogan et al (1993) conducted a randomized control trial, parallel group study on 72 patients posted for elective abdominal surgery (22-70yrs) to assess the effects of relaxation on pain distress, amount of analgesics use and hospital stay in surgical patients. The patients were randomly assigned to 2 groups 1) Relaxation training including pleasant memory Jaw relaxation and breathing techniques(n=40). 2) Standard pre-surgical instruction with deep breathing and coughing (n=32). The treatment were taught pre operatively and assessments were done upto 4 postoperative days, the measure included pain sensation and pain distress, analgesic consumption and total time in hospital. Positive results were obtained in favour of relaxation group for pain distress only and nil significant results for other measures.12

Levin et al (1992) conducted a study with the purpose of assessing the effectiveness of different relaxation techniques in the management of postoperative pain. The sample consisted of 40 women between the ages of 21 and 65 years who were undergoing elective cholecystectomy. Using an experimental design, participants were randomly assigned to 4 groups. The 3 experimental group received a taped recording of a rhythmic breathing exercise (RB), tape recording of Bensons relaxation technique (BRT), amd an attention – distraction group (CA) who received a taped recording of a history of the hospital. The standard control (CB) group received only the routine peri-operative care which all groups received. Data was collected on postoperative session and distress at 5 line points during the first 32 postoperative hours, number of doses of post operative hospital days. Data were analyzed using multivariate and univariate analyses of variance. The BRT group was significantly different from the CA group in a combined sensation and distress factor (p=0.011). No significant differences were found among groups for doses of analgesics (p=0.68) or post operative days (p=0.56).24

Good (1990) conducted a review to assess the effectiveness of relaxation and music on postoperative pain. Relaxation and music were effective in reducing effective and observed pain in the majority of studies, but they were less often effective in reducing sensory pain or opiod intake. However, the study differences in surgical procedures, experimental techniques, activities during testing, measurement of pain and amount of practice make comparison difficult.13

Ma, Y.L. et al, (1990) studied the effects of relaxation training upon surgical stress response, on 51 abdominal surgery patients, randomly assigned to 2 groups. The experimental group (n=25) received preoperative instruction and training in relaxation, control group received preoperative instruction alone. State anxiety and physical symptoms of anxiety, blood pressure, heart rate, and heart rate, blood serum level of cortisone and post operative pain of the 2 groups were evaluated and compared on the 3rd preoperative day, operation day, and on the 1st and fourth postoperative days. Results showed 1) significant differences between the 2 groups regarding state anxiety scores on each day. Physical anxiety symptoms and pain severity on the 1st and 4th postoperative days 2)compared with the control group, systolic and diastolic blood pressure and heart rate decreased in the experiment group 3) compared to control the experiment group has significantly decreased blood serum cortisone level. In conclusion, these results demonstrate that relaxation training exerts positive effects upon stress response to surgery, particularly in reducing psychological response to surgery.25

This chapter has dealt with the review of the literature related to concepts, preoperative anxiety, effects of post operative anxiety on recovery and effects of nursing intervention, particularly information and relaxation on postoperative recovery. However an effort was made to identify Indian studies and studies directly related to the topic and the study sample, the researcher could not obtain them and hence the other related studies were compiled here. The review has helped the researcher to gain insight into the problem. The review has further helped the researcher to select the tool and the intervention programme.

6.3a STATEMENT OF THE PROBLEM

“A Study To Assess The Effectiveness Of Nursing Intervention And Pre-operative Anxiety On Postoperative Recovery In Selected Hospitals In Bangalore”

6.3b OBJECTIVE OF THE STUDY

For the purpose of the study, the following objectives were outlined.

1. To assess the level of anxiety in patient posted for Lumbar Laminectomy

2. To find out the association between the preoperative anxiety and post operative recovery with certain demographic and clinical variables.

3. To find out the effect of nursing intervention on postoperative recovery.

4. To assess the level of pre operative anxiety.

5. To assess the relationship between preoperative and postoperative anxiety.

6.3c OPERATIONAL DEFINITIONS

Nursing Intervention – Assisting patients to reduce anxiety by providing information and relaxation exercise information and relaxation exercises, prior to surgery to affect optimum postoperative recovery.

Preoperative Anxiety – A vague uneasy feeling, experienced by the patients, one to two days prior to the Lumbar laminectomy.

Postoperative recovery – Is the outcome of lumbar laminectomy as determined by pain, ambulation, co-operation, feeling of wellness and nutrition and emotions on the first four post operative days.

Effectiveness – It refers to the extent to which nursing interventions has achieved the desired outcome.

6.3d RESEARCH HYPOTHESIS

H1: The postoperative recovery of patients receiving the nursing intervention will be significantly better than that of patients who do not receive the nursing intervention.

H2: There will be a significant relationship between the preoperative anxiety and postoperative recovery in the control group.

6.3e ASSUMPTION

The post operative recovery in the experimental group will be better than the control group, after nursing intervention and there will be subsidiary reduction in the preoperative anxiety among experimental group.

6.3f DELIMITATION

1. Patients who are posted for Lumbar Laminectomy.

2. Patients posted for Lumbar Laminectomy between ages the age of 20-60 years.

3. Patients who are consenting for the study.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected from three to four selected tertiary hospitals in Bangalore (Karnataka).

7.2 METHODS OF DATA COLLECTION

i) RESEARCH DESIGN: Quasi experimental control group non equivalent pre-test post-test

ii) RESEARCH APPROACH: The experimental approach with two-group, one group control and one group experimental is selected for the study

iii) RESEARCH VARIABLES:

a. Independent variables

a) Nursing intervention - information and relaxation exercises

b) Preoperative anxiety - STAI-Y1 and Y2, HADS2.

b. Dependent variable

a) Post operative recovery – Pain intensity, Feeling of wellness, Coperation with ward staff nurse, Ambulation, Nutrition, STAI Y1, HADS

c. Demographic variable

This deals with the information regarding age, sex, marital status, education, total monthly income, amount spent for treatment, debts, type of family, size of the family, occupation and history of illness in the family.

IV) SETTINGS: The research is to be conducted in three to four tertiary care hospitals where the procedure Lumbar Laminectomy is performed.

V) POPULATION AND SAMPLE

Target population comprised of the patients posted for Lumbar Laminectomy. All the patients fulfilling the inclusion / exclusion criteria are to be selected (60 samples).

VI) CRITERIA FOR SAMPLE SELECTION

a. Inclusion criteria

1. Patients posted for elective lumbar laminectomy.

2. Patients in the range of 20-60 years, both male and female.

3. Patients who were consenting to participate.

b. Exclusion criteria

1. Patients who are in altered sensorium.

2. Patients who have co-morbid psychiatric conditions or any major medical illness.

3. Patients who have disorder in which anxiety is a presenting symptom.

VII) SAMPLING TECNIQUE

All the patients fulfilling the above criteria will be selected and will be sequentially allotted to the experiment and control groups using the systematic sampling technique. The possibility of contamination of the control group is also taken into consideration while sampling the subjects to the respective groups.

VIII) TOOL FOR DATA COLLECTION

Socio-demographic Performa:

The investigator to collect regarding the socio-demographic and clinical characteristic of the patients will construct a semi-structured Performa. This tool is divided into 2 sections.

Section A: Demographic variables: This deals with information regarding age, sex, marital status, total monthly income, amount spent for treatment, debts, type of family, size of family, occupation and history of illness in the family.

Section B: Clinical variables: This section of the tool deals with disease variables like signs and symptoms, etiology, onset of disease, course and duration of illness, treatment history, nature of disability, co morbid medical conditions, patients and relatives knowledge regarding diagnosis and treatment procedures, presence of ongoing stressors and concerns regarding surgery.

1. State and triate anxiety inventory (STAI):

STAI consist of 2 forms (y1 and y2) each comprising of 20 items. Clients responding to this scale circle the number on the data sheet to the right of each item that best describes the intensity of their feelings using the 4-point scale.12

Form y1 assesses state of anxiety, defined as a transitory emotional state that varies in intensity, fluctuates over time and is characterized by feeling of tension and apprehension and by heightened activity of the autonomic nervous system. It evaluates how the respondents feel “right now” at this movement.

Form y2 evaluates Trait anxiety, which is defined as a relative stable individual predisposition to respond to situations perceived as threatening. It assesses how the respondents feel most of the time.

The score for each of the form range from 20-80, with high score indicating presence of high levels of anxiety. Each item has weighed score of 1-4

A- State scale: (1) Not at all, (2) somewhat (3) moderately so, or (4) very much so.

A- Trait scale: (1) almost never, (2) sometimes (3) often (4) almost always.

Some of the statements are scored as 4,3,2 and 1 for almost never, sometimes, often and almost alwats, respectively; where as some are scored in the reversed fashion, i.e 1,2,3 and 4 for the same response. For e.g some of the STAI items (e.g I am tense) are worded in such a manner that a rating of ‘4’ indicates a high level of anxiety while other items (e.g I feel pleasant) are worded so that a high ratings indicate low anxiety. The reversed items on STAI sub-scale are:

A-State Scale: 1,2,5,8,10,11,15,16,19 and 20

A-Trait Scale: 1,3,6,7,10,13,14,16, and 19

The overall median alpha co-efficient is .92 and the tool has adequate concurrent convergent, divergent and construct validity. The normative data reported for a sample of clients with general medical and surgical conditions; witout psychiatric complication is:

A-State Scale: 42.68+13.6

A-Trait Scale: 41.33+12.55

The kannada and tamil versions of STAI – y1 and y2 form were used. Sargunaraj et al, (1991 b) reported that the vernacular translations are reliable measures of anxiety. This tool has been extensively used in the Indian context and found to be useful.

2. Hospital anxiety and depression scale-HADS:

Indian version of this tool adapted by Chaturdevi et al (1994) was used in this study to screen subjects for anxiety and depression.

HADS is a brief, self-administered rating scale desingned for patients with medical illness. It consist of 14 items. Item No: 3,5,7,9,11 and 13 measures anxiety and item No: 2,4,6,8,10,12 and 14 measure depression.

This tool is based on 4 point liker format. Each item in the tool is scored on an ordinal scale from 0-3. This cut-off score of 7 on anxiety and a cut off score of 8 on depression subscales are suggestive of anxiety and depression. The HADS has already established adequate psychometric properties, high internal consistency and reliable factor structure by testing in 70 Indian cancer patients.

The cut off scor of ‘7’ on the anxiety subscale gives the sensitivity and specificity and values of 87% and 79% respectively. Whereas a cut off score of ‘8’ on the depression subscale gives the sensitivity and specificity values of 75% and 76% respectively and these seems to be the best for Indian population.

3. Visual analogue scale (VAS)

VAS was originally devised by Aitken (1955) to assess the depressed mood, latter it was found to be useful in assessing subjective distress of patients in any other condition.

The scale consists of a straight-line 100mm in length with ‘no phenomenon’ at the left-hand side and “maximum of phenomenon” on the right extreme. The respondent is required to mark on the line, grading the severity of the phenomenon felt at the moment, between these two extremes. The mark gives the reading in mm which is used as a ratio scale.

4. Physical indices of postoperative recovery

a) Ambulation

Ambulation will be assessed during the immediate postoperative period. The time taken from the completion of the operation to the time taken for the patient to first move in bed, stand with support walk with support and walk without support, will be calculated in hours and recorded.

b) Nutrition

Similarly, the time duration from the completion of surgery to the time taken for the patient to tolerate fluids and solid will be calculated and recorded.

INTERVENTION

The nursing interventions included in the study was:

1) Information

2) Relaxation exercises

1. Information:

The information to be provided to patients during the preoperative period includes:

a) Nature of the disease condition

b) Surgical procedure (Laminectomy)

c) Recover from Lumbar Laminectomy

d) Instructions regarding post operative care (immediate and after discharge)

e) Routines and procedures in the OT, recovery/post operative wards and surgical wards.

2. Relaxation exercises:

Varying types of relaxation techniques will be successfully employed to treat a wide range of medical condition. In this study, a) Structured deep breathing exercise and b) Jacobsons Progressive muscular relaxation was adopted.

a) Structured deep breathing exercise

This relaxation technique consists of deep breathing in a structured form. Each patient is asked to breathe deeply from the abdomen, for 30 times, the patients are asked to close their eyes and concentrate only on the breathing. Of the 30 deep breathing, in the 10 deep breaths the patients concentrates on the stomach, second 10, on the chest and last 10 on the nostril (air passage). Patients are instructed to this, 4 times a day till surgery and follow it even during the postoperative period.

b) Jacobsons progressive muscular relaxation

This technique was originally developed by Jacobson (1938) and modified by Mishra (1974). The modified form of the JPMR was used in this study.

JPMR helps the individual to break the pain – muscle tension- pain cycle and decreased muscle contraction. It involves successive tensing and relaxing of separate muscle groups on an orderly and progressive manner until all the main muscle groups of the body are relaxed. The difference between feeling of muscle contraction and relaxation helps the individual to develop understanding and awareness of deep relaxation. The relaxation response is a set of physiological changes opposite to those of the stress response.

The researcher will undergo training to administer the relaxation technique, under the guidance and supervision of the co-guide. Once the co-guide approves the competence of the researcher in administering JPMR, the researcher will administer it on the study group.

A calm and quite set up is to be selected; the patient should be given adequate instruction prior to administration of the technique. Once the patient closes his eyes, the instructions will be given in calm and soothing voice. Each muscle group will tense for about 10 seconds and relaxes for about 30 seconds. The total time taken for each session will be about 30-45 minutes. Each patient will receive only one session of JPMR prior to surgery (one day before surgery)

PROCEDURE

A formal permission to conduct the study will obtained from the Head of the department. All the consultants and the senior residents of the department will be informed about the study.

X) PLAN FOR DATA ANALYSIS

Descriptive Statistics: Percentage, frequency distribution, mean range, and standard deviation are to be used to assess the socio demographic and other study variables.

Inferential Statistics: T test, partial correlation and ANOVA are to be used for data and testing the hypotheses.

XI) PROJECTED OUTCOME

The post operative recovery in the experimental group will be better than the control group, after nursing intervention and there will be subsidiary reduction in the preoperative anxiety among experimental group.

7.3 Does the study require any investigation or intervention to the patient or others human beings/animals?

Yes

7.4 Has ethical clearance been obtained from the concerned authority to conduct the study?

Yes.

BIBLIOGRAPHY

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9. Signature of the candidate :

10. Remarks of the guide :

11. Name and designation of :

11.1 Guide :

11.2 Signature :

11.3 Co-guide :

11.4 Signature :

11.5 Head of the department :

11.6 Signature :

12. Remarks of the Principal :

12.1 Signature :

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