ABSTRACT
Preoperative anxiety is a challenging concept in the
preoperative care of patients and its incidence varies with different settings.
The experience of anxiety state has been linked with the aggravation of pain
intensity experienced by surgical patients after their procedures. The study evaluated
nursing intervention on the relief of anxiety state and post-operative pain
among surgical patients in Obafemi Awolowo University Teaching Hospitals
Complex, Ile-Ife, Osun State, Nigeria.
A Quasi-experimental study was conducted among
thirty booked adult surgical patients (age=25-80 years) for abdominal surgeries
from February 10th and March 15th, 2017. Convenient sampling
technique was used to select the surgical patients by “first come first serve”
into control and experimental groups, each group having 15 surgical patients.
Two standardized assessment tools (State Anxiety Inventory scale and Numeric
Rating scale) were adopted in the questionnaire used for the collection of data
of anxiety state and pain intensity among patients before and after their
procedures respectively. A planned training module was pre-tested and found
suitable for the study. The data were processed through statistical package for
social science (SPSS), version 20 using descriptive statistics such as mean,
standard deviation, and inferential statistics such as Chi-square, to determine
the relationship of the variables and test the hypotheses at 0.05 level of
significance.
The findings revealed that no standard assessment
tool for measurement of anxiety state and pot-operative pain before or after
their surgical. The mean baseline anxiety levels of the surgical patients (both
experimental (1.74) and control (1.79)) were high before surgery but reduced
after their surgeries respectively (1.66 and 1.64 respectively). The surgical
patients experienced moderate and severe levels of pain intensity before
surgery with mean baseline pain intensity of 3.47 in experimental and 2.95 in
the control surgical patients. There was an aggravation of pain intensity
experienced by the surgical patients postoperatively with mean values of 4.46
in the experimental and 4.92 in the control groups respectively.There was no
significant relationship between nursing intervention for the relief of preoperative
anxiety and control of postoperative pain (p=0.514 and 0.413 respectively),
even though the preoperative nursing intervention administered on the
experimental group brought about reduction of post-operative pain, the rate of
reduction was not as marked as compared with the control group without the
planned preoperative intervention. There was no significant relationship
between gender of surgical patients and their response to nursing intervention
for the relief of anxiety (p=0.744) and postoperative pain (p=0.105). Likewise,
there was no significant relationship between educational levels of surgical
patients and their response to nursing intervention for the relief of anxiety
(p=0.163) and postoperative pain (p=0.604) respectively.
The
study concluded that the experience of anxiety and pain among surgical patients
is a common phenomenon. The study recommended that patient-centered approach
should be employed in the assessment and intervention for the relief of anxiety
states and post-operative pain.
CHAPTER
ONE
INTRODUCTION
1.1.Background
to the Study
Health has been
described as the nonexistence of disease and impairment, as well as a condition
of complete wellness in the mental, physical, and social realms. The
persistence of the internal environment of any human system is dependent on
their physiological, sociological and psychological equilibrium. Nursing care
has the primary objective to render service for maintenance of health through
the preservation of a stable internal environment, and assisting to ensure the
restoration of equilibrium in the condition of illness (Birol, 2005; Şanli, 1991) .
There are three phases
in the nursing care a surgical patient passes through in the health care
services called perioperative nursing. These phases include: pre-operative,
intra-operative and post-operative. The pre-operative phase involves the
administration of nursing care to the clients who are planned to undergo
surgical procedures (Phillips, 2013; Spry, 2005). The primary responsibility of
the health care providers as reported in literatures is to assess and educate
the patient during this phase, to minimize the dangers during the surgery and have
better outcomes of the patients. The main rationale for preoperative phase of
care is linked to reduction of defects operative morbidities and decrease stay
of patients at hospital (Association of Anesthetists of Great Britain, and
Ireland (AABI) safety guidelines, 2010).
Surgery is one of the major
life changes that cause anxiety. Hospitalization provokes anxiety in the patient
admitted for surgery, even in the absence of disease. Stress resulting from
protracted anxiety may eventually endanger the client if not discovered early
and slow-down recovery(Goebel, Kaup, & Mehdorn, 2011; Jafar & Khan, 2009;
Swindale, 2004; Yilmaz, Sezer, Gurler, & Beker, 2011). Surgery
can trigger a panic attack in a patient who is prone to anxiety. The
preparative care of surgical patients becomes very challenging with the
increasing existence of anxiety before surgery.
Anxiety experience is
common to most patients awaiting elective surgery and generally seen as normal
response(Jawaid, Mushtaq, Mukhtar, & Khan, 2007) .
Surgical patients perceived the day of surgery as highly terrifying in their
lives. Patients manifest anxiety with varying degrees in relation to what is
expected in future and these are associated with many factors which may be type
and extent of the proposed surgery, gender, age, previous surgical experiences, and personal
tendency for unpleasant events(Ping, Linda, & Antony, 2012) .
The intervention for employed by the healthcare providers has been found to
promote, comfort, and favorable surgical outcomes. Nurses and other healthcare
givers needs to know patients who are prone to anxiety in the population in
order to reduce the occurrence of anxiety resulting from surgery.
The Babylonian clay
tablets revealed the evidence of thephenomenon of pain as referenced in
achieves. The Greek philosopher, Aristotle, in the 4th century B.C., identified
pain as an emotion, and a reciprocal of pleasure. Although emotions certainly
play an important role in pain perception, there is much more to the experience
than the feelings involved. In the Middle Ages, pain had religious
interpretations, in which pain was seen as God’s punishment for sins or as
evidence that an individual was possessed by demons. This meaning of pain is
embraced by some clients with the mindset that the suffering is their “cross to
bear.” The relief of pain may not be the goal for individuals who believe in
this definition of pain. Spiritual counseling may need to be implemented before
this person is willing to work toward relief. The most widely accepted
definition of pain is one developed by the International Association for the
Study of Pain (IASP). This organization defines pain as an offensive sensation
and mind-blowing experience associated with actual or potential tissue damage
or described in terms of such damage (IASP, 2008).
Postoperative pain is
very common and develops naturally as a warning(Apfelbaum, Chen, & Mehta, 2003) .
The development of postoperative pain
can be predicted, should be prevented and treated (Power, 2005) .
Besides the disagreeable aspects and physiological repercussions of
postoperative pain, it delays ambulation and hospital discharge. Some authors
believe that, despite the drugs and anesthetic techniques available, the
prevalence of postoperative pain is still high(Apfelbaum, Chen, & Mehta, 2003; Omote, 2007;
Power, 2005) .
The most unwelcomed outcome of surgery is postoperative pain. This pain can
result to prolonged hospital stay and hinder rapid recovery if poorly managed(Schug & Chong, 2009) .
Research studies have
repeatedly reported that about 20 to 80% of patients having surgical procedures
experiencepains which are poorly managed (Lorentzen, Hermansen, &Botti,
2011; Marks &Sachar, 1973). Pain is grouped among grievous public health
challenges both in the modernized (Stephens, Laskin, Pashos, Pena, & Wong, 2003)
and in developing countries(Klopper, Andersson, Minkkinen, Ohlsson,
&Sjostrom, 2006; Lin, 2000; Shen, Sherwood, McNeill, & Li, 2008). Pain
continues to be poorly controlled and pose a substantial obstacle to the care
of surgical patients with the protracted existence of postoperative pain as a
serious public health problem, and the increased knowledge and resources for
treating pain(Botti, Bucknall, & Manias, 2004; Dihle, Helseth, Kongsgaard,
& Paul, 2006; Helfand& Freeman, 2009; Manias, Bucknall, &Botti,
2005).
In Africa, pain associated
with HIV/AIDS and cancer has been greatly explored (Dekker, Amon, & Le
Roux, 2012; Powell, Radbruch, Mwangi-Powell, Cleary, &Cherny, 2013; Selman,
Simms, Penfold, Powell, &Mwangi-Powell, 2013), although greater burden is
associated with pain from surgical procedures. Studies in the past have
revealed that underdeveloped countries endure lack of analgesia and little
priority is given to pain control in these countries.
In Nigeria, 95% of
surgical patients were reported by Kolawole and Fawole (2003) to have
experienced postoperative pain of various degrees. Another study carried out in
Nigeria reported that inadequate pain relief after surgery is suffered among a
high percentage of patients in Nigeria (Size, Soyannwo, & Justins, 2007) .
A Human Rights Watch’s report (Human Rights Watch, 2011)
revealed that only 10% of this group of patients is able to receive the best of
pain control. Powell, Radbruch, Mwangi-Powell,
Cleary, and Cherny (2013), and Vijayan (2011) reported that shortage of
clinicians, rigorous law enforcement on morphine access, and insufficient
knowledge left millions of people to suffer because of poor pain control, even
though various workshops and African Union summits adopted pain relief as basic
human right.
Inadequate clinical
practice in the post-operative assessment and management of pain has been
reported by several studies (Dihle, Helseth, Kongsgaard, & Paul, 2006;
Manias, Bucknall, &Botti, 2005; Schafheutle, Cantrill, &Noyce, 2001;
Schoenwald& Clark, 2006). It is the duty of nurses to know how to assess
pain by appropriate planning and implementing the adequate treatments in pain
management. The nurse requires to monitor the adverse effects and advocate for
the patient during the assessment of the effectiveness of those interventions.
This helps the healthcare giver to know when the interventions are ineffective
in relieving pain (Lippincott, 2013).
1.2.Statement
of the Problem
The observation of the researcher in the past 10
years of clinical practice at the perioperative environment was the apparent
uneasiness, confusion and anxious appearance demonstrated by the surgical
patients coming for procedures in the operating suites. A number of these
patients’ responses to their surgical procedures were undesirable. Many
surgical patients nowadays looked for information on their conditions on the
internet as a helpful tool, they often become puzzled and troubled.
The setting of surgery determines the incidence of
preoperative anxiety, and it is connected with increased anaesthetic
requirement, difficulty with venous access establishment, and autonomic
fluctuations. A number of researches have also correlated preoperative anxiety
with pain aggravation, nausea and vomiting after surgical operations, increased
incidence of infections and delayed recovery (Bailey, 2010; Fauza&Shazia,
2007; Foggitt, 2001; Pittman &Kridli, 2011; Pokharel, Bhattarai, Tripathi,
&Subedi, 2011). Preoperative anxiety was reported as one of the factors
causing delayed discharge following a day surgery (Vadivelu, Mitra, & Narayan, 2010) .
Anxieties of patients in general have been reported
to be linked with poor information (Miner, 1990). Anxiety, fear, challenges of
communication have been found to intensify the experience of pain by the
patients (Williams, 2005). Evaluation of pain and observation for possible
complications are the roles of the nurse (Hawthorn, & Redmond,1999).
Many surgical patients continue to suffer from
unrelieved pain, although there exists a great body of knowledge on the
processess of pain, care of pain and better strategies for controlling pain.
Pain becomes a public health issue due to its increasing prevalence and impact
on the health of people (Blyth, March, Brnabic, & Cousins, 2004; Fox,
Parminder, &Jadad, 1999). The relief of pain has been widely declared as a
fundamental right of man by the World Health Organization and it becomes a
malpractice and breach of human rights not to effectively manage a client’s
pain (Brennan,
Carr, & Cousins, 2007) .
Therefore, the effectiveness of preoperative nursing
intervention on the relief of anxiety state and post-operative pain among
surgical patients needs to be studied by evaluating it’s impact on patient’s
care in the context of the Nigerian health facilities and many cultural diversities.
1.3.Objectives
of the Study
The main objective of the study was
to evaluate the effect of preoperative nursing information (teaching) on
anxiety state and post-operative pain of surgical patients at Obafemi Awolowo
University Teaching Hospital Complex, Ile-Ife and the specific objectives are
to:
1. Identify
the existing tools used by nurses for assessing preoperative anxiety and
post-operative pains among surgical patients;
2. Determine
baseline levels of preoperative anxiety and pain among surgical patients;
3.
Determine the levels of post-operative
anxiety and pain among surgical patients;
4. Evaluate
the relationship between nursing intervention for the relief of preoperative
anxiety and the control of post-operative pain, and
5. Determine
the relief of anxiety and post-operative pain in response to nursing
interventions on the basis of gender and educational levels of surgical
patients.
The
study was guided by the following research questions:
1.
What is/ are the specific tools used by nurses
for assessing preoperative anxiety and post-operative pains among surgical
patients of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC),
Ile-Ife?
2.
What are the levels of preoperative
anxiety and preoperative pain experienced among surgical patients of
ObafemiAwolowo University Teaching Hospitals Complex, Ile-Ife?
3.
What are the levels of postoperative
anxiety and pain among surgical patients of OAUTHC, Ile-Ife?
4.
What is the relationship between the
nursing interventions administered for relieving preoperative anxiety
associated with effective post-operative pain control?
5.
What are the relationships between
educational levels and gender of surgical patients on the response to nursing
interventions towards relief of preoperative anxiety and control of
post-operative pain?
1.5.Hypotheses
HO1.There is no
significant relationship between nursing interventions for relieving
HO2. Educational levels
and gender of patients have no significant influence on their
response to nursing interventions
for relief of preoperative anxiety and control of post-
operative pain.
1.6.Scope of the Study
The
scope of the study focused on adult surgical in-patients booked for elective
surgeries in the ObafemiAwolowo University Teaching Hospitals Complex, Ile-Ife
in the first quarter of year 2017 only. The anxiety
state and surgical pain of the patients were studied in the context of nursing
intervention.
1.7.Significance of the Study
The
results of this study may provide adequate information about the occurrence and
prevalence of preoperative anxiety and post-operative pain among surgical
patients to the health care givers. The reports may assist the nurses to
provide suitable and appropriate nursing intervention to their surgical
patients.
The
reports in this study may assist the nurses in the development of appropriate
guidelines for the prevention of preoperative anxiety and reduce the incidence
of post-operative pain.
Furthermore, this study
may generate empirical data for further research studies in other parts of the
country and the world at large, which may help in making policies and establish
workshops for capacity building to improve the skills of nurses required to
allay the anxiety of clients before surgery and the remaining period of care.
1.8.Operational
Definition of Terms
The following terms are
defined operationally for the purpose of this study as follows:
1. Anxiety State:
It is the current unpleasant state of uneasiness or tension that the surgical
patient experienced.
2. Preoperative phase:
This is the period from the time of admission of the client into the ward for
surgical procedure until the patient is made insensitive to pain.
3. Preoperative anxiety:
It is an unpleasant state of uneasiness or tension that the surgical patient
experienced before the actual surgical procedure.
4. Post-operative pain:
It is stinging, pinching, gripping burning sensation that may be localized or
widespread, resulting from the surgical procedure carried out in the operating
theatres of ObafemiAwolowo University Hospitals Complex, Ile-Ife.
5. Preoperative Nursing intervention:
The planned health teaching given to the surgical clients a day before an actual
surgical procedure. It involves information provision, skill training,
psychological support and, demonstration as well as use of teaching aids in
relation to the surgical condition and procedure.
6. Surgical patient:
A patient booked for elective abdominal surgery and was admitted in the ward of
the hospital.
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