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ORIGINAL RESEARCH
Correspondence to M. Mitchell:
e-mail: m.mitchell@salford.ac.uk
Mark Mitchell MSc PhD RN
Senior Lecturer
College of Health and Social Care, University
of Salford, Greater Manchester, UK
Abstract
Aim. To investigate the possible influence of gender and anaesthesia type on anxiety
prior to day surgery.
Background. Elective surgery undertaken on a day, short stay or day of surgery basis
is growing and much emphasis also placed on enhanced recovery for in-patient
surgery. During such brief episodes preoperative apprehension can be considerable but
the opportunity to help reduce anxiety is minimal and formal plans uncommon.
Method. As part of a larger study, a questionnaire was distributed to 1606 patients
undergoing day surgery, with anaesthesia (20052007). Participants were requested
to return the questionnaire by mail 2448 hours following surgery, with 674 returned.
Data were analysed using descriptive statistics and multivariate analysis of variance.
Results. Of the total patients 824% experienced anxiety on the day of surgery with
the wait, anaesthesia and possible pain being common anxiety-provoking aspects. The
majority preferred to receive information between 14 weeks in advance and participants experiencing general anaesthesia required information at a statistically significantly earlier stage. General anaesthesia patients were statistically significantly more
anxious than local anaesthesia patients and desired more information. Female patients
were statistically significantly more anxious, anxiety commenced earlier and they
preferred to wait with a relative/friend or talk with other patients.
Conclusions. Anxiety was experienced by the majority of participants but was more
prevalent amongst general anaesthesia and female patients. For general anaesthesia
patients, a comprehensive level of information may be required a number of weeks
prior to surgery and gender differences associated with the preoperative wait may
require greater consideration.
Keywords: anxiety, day/ambulatory surgery, gender, general and local anaesthesia,
patient information
Introduction
Elective surgery has undergone considerable change over
recent years resulting in the continued reduction of in-patient
surgery and the considerable rise of day, short stay and day
of surgery admissions (Vijay et al. 2008, Martin et al. 2010).
1014
Background
The volume of day surgery being undertaken on a national
and international basis continues to rise. Recent figures
suggest levels in North America of 83% (of all elective
surgery), Canada 83%, Australia 75%, Demark 79%,
Holland 70%, Sweden 66%, England 62%, Germany 60%
and Finland 50% (Mattila & Hynynen 2009, Toftgaard
2009) although in some countries 23-hour stay is classified as
day surgery. Throughout more affluent nations the complexity of day-case procedures is also expanding. Surgery on
suspected malignancy (Marla & Stallard 2009), prostatectomy (Martin et al. 2010), parathyroidectomy (Parameswaran
et al. 2010), neurosurgery (Boulton & Bernstein 2008),
surgery on older people (Lacquiere et al. 2006) and the
development of specialist day surgery units have all helped to
increase the scope. Moreover, many surgical procedures can
increasingly be performed using local anaesthesia (Armellin
et al. 2007) enabling patients to spend less time in hospital.
Much emphasis in day surgery progress has focussed on
advances in medical capability (Hamer et al. 2008), capacity
and costing (Manners et al. 2010) whereas studies investigating nursing knowledge are limited (Pearson et al. 2004a).
The worldwide economic drive for improved medical organization of surgery and minimal stay has ensured a major
proportion of nursing time is focused on efficiency, throughput and initiatives which seek greater clinical streamlining
(Smith et al. 2006). Flanagan (2009) asserts day surgery care
has become fractionalised into its differing areas (preassessment, ward and operating department) and the ambulatory
nursing care role essentially invisible. It is suggested beyond
managerial issues, surgical nursing practice is striving to
define its new role (Williams et al. 2009). Previous nursing
research has focussed on the physical experience of surgery
(Mitchell 2007) but less so on the social and psychological
impact (Mottram 2011). However, much psycho-social care
is needed to enable patients to cope successfully with brief
admission, anaesthesia, surgery and discharge (Demir et al.
2008).
Preoperative patient anxiety has been identified for a
number of years and numerous recommendations made but
many based on in-patient research (Seers et al. 2008) and
2011 Blackwell Publishing Ltd
demanding much nursing time (Saadat et al. 2006). Anxiolytic premedication has been recommended to ease anxiety
(Jakobsson et al. 2008) but premedicated patients can take
additional nursing time and closer attention prior to transfer
to theatre resulting in its limited use (Walker & Smith 2009).
With the increase in the volume of day surgery, time available
to nurses has become restricted and thus new approaches
essential.
A lack of adequate patient information has been linked
with increased anxiety and reduced satisfaction (McMurray
et al. 2007). Following a survey of 131 patients Suhonen
et al. (2008) state The major goal of patient management in
day surgery is to promote patient comfort and satisfaction by
reducing the anticipated side-effects of surgery and anaesthesia (p. 170). Ward et al. (2007) concluded that the majority
of patients preferred to be offered simple choices about care
and experienced greater control at the mere prospect of being
asked if they had a preference. In a comparison study by
Oldman et al. (2004), one group received a standard hospital
information leaflet on anaesthesia and a second the same
leaflet plus the drug manufactures patient information leaflet
on Propofol (Diprivan). It has been a legal requirement
(European Directive) since 1999 for manufacturers to supply
patient information leaflets, even those administered solely by
physicians such as anaesthetic drugs. Following admission,
anxiety was measured using a Visual Analogue Scale (VAS)
and State Trait Anxiety Inventory (STAI) (Spielberger et al.
1983) then again 20 minutes after reading the drug information. While manufactures details could be considered anxiety
provoking as they listed possible side effects of Propofol (pain
on injection, decreased arterial pressure, twitching and
shaking, slow or stopping of heart, sexual arousal), no
important differences between the two groups were established. However, 18% felt they had been given too much
information, 65% did not wish to receive such detail and
36% welcomed the information. It was concluded that
patients should be given a choice of anaesthetic information.
In a review by McDonald et al. (2004) patient education
was deemed beneficial in reducing anxiety and Jakobsson
et al. (2008) emphasized the importance of adequate, extensive information to help manage care once home. Gilmartin
and Wright (2008) interviewed 20 patients at home following
day surgery and established information provision and
anxiety to be dominant features. What stands out in the
accounts is the psychological effects resulting from long
periods of preoperative waiting were worsened by increased
nervous tension and boredom (p. 2423). Tsapakis et al.
(2009) surveyed 148-day surgery patients and concluded
patients whose mood was low before surgery continued to
have a low mood after surgery.
1015
M. Mitchell
Khan and Nazir (2007) highlight possible gender differences in anxiety prior to surgery. Rosen et al. (2008) found
women to be statistically significantly more anxious than men
although 57% of all patients rated themselves as not calm
because of the situation. In a dental surgery study by Lai
et al. (2008), the provision of intra-operative music was
statistically significantly related to lower anxiety but women
reported higher levels of anxiety and Haugen et al. (2009)
reported female patients undergoing emergency surgery to be
statistically significantly more anxious than male patients.
Gender differences in anxiety have been established during
in-patient studies (Karanci & Dirik 2003) and in a number of
older day surgery studies (Cowan et al. 2000) but recent
investigations in day surgery are limited.
The rise in the volume of day surgery and minimal surgical
stay is unequivocal and an irreversible national and international development. However, little nursing knowledge has
thus far helped to inform such advances (Pearson et al.
2004b) and limited evidence available about anxiety associated with gender and anaesthesia type. A more formal
approach to anxiety management may now be required as a
result of the continued increase in day, short stay, day of
surgery and enhanced recovery programme admissions
(Department of Health 2010).
Data collection
Data were collected over a 2-year period (20052007). The
principal investigator (MJM) contacted each Day Surgery
Unit (DSU) regularly to supply the questionnaires. The
clinical staff distributed the questionnaires to patients
following admission. Potential participants were invited to
enter the study and an information leaflet about the survey
provided prior to the final decision to take part. Questionnaires were provided to take home for completion and return
after 2448 hours in a freepost self-addressed envelope. The
General Anaesthesia questionnaire had 59 items and the
Local/Regional Anaesthesia version 61 items (additional
items associated with the experience of conscious surgery)
with the vast majority utilizing a Likert-type Scale format.
Anxiety associated with the environment, hospital personnel
and anaesthesia type (local, regional and general) were the
main themes and anxiety measured using a Likert Scale
format with a higher score representing increasing anxiety
(Figure 1). However, only the items from both questionnaires
considering participants preoperative experiences will be
addressed herein (Table 1).
The study
Validity and reliability
To investigate the possible influence of gender and anaesthesia type on anxiety prior to day surgery.
Design
A cross-sectional questionnaire study was undertaken. The
survey was part of a larger study investigating day surgery
patients experience of the environment, hospital personnel
and anaesthesia (local, regional and general). This paper will
only focus on anxiety in relation to gender and anaesthesia
type. Patient experiences of hospital personal, anaesthesia
type and impact of the environment are reported elsewhere
(Mitchell 2008, 2010).
Participants
A convenience sample of patients scheduled for elective
surgery in three public day surgery units was invited to take
part. Potential participants were those who were undergoing
general and local anaesthesia; having non-life-threatening,
intermediate surgery; English-speaking; and aged 18 years or
1016
311
300
Participants
Aims
250
200
150
139
117
100
70
30
50
0
Not
anxious
A Little
anxious
Quite
anxious
Very
Extremely
anxious
anxious
once home can be brief. A pilot study was undertaken for the
first 10% of respondents resulting in slight amendments to
the questionnaires prior to continuation.
Ethical considerations
All surgeons, anaesthetists and nursing staff in the three
public Day Surgery Units involved gave their agreement for
the study prior to Ethical Committee approval. All participants were given information concerning the study and it was
emphasised that a decision to withdraw at any time, or a
decision not to take part, would not affect their care.
Statistical analysis
Analysis was undertaken using Statistical Package for Social
Science (SPSS Inc., Chicago, IL, USA) v16 and statistical
significance set at P 005. Data were preliminarily examined using descriptive statistics. Following this a Multivariate
analysis of variance (MANOVA ) test for all between group
2011 Blackwell Publishing Ltd
Results
Overall, 1606 questionnaires were distributed and 674
returned (response rate 419%). Participants ages ranged
from 18 years to 75 years, with the average age being
43 years (385 female patients and 287 male patients).
Participants underwent a variety of procedures with general
surgery (hernia repair, cholecystectomy) and orthopaedic
surgery being most frequent (Table 2). The number of
participants undergoing general anaesthesia was 460
(628%) with 214 (318%) undergoing local anaesthesia.
A total of 824% of patients were anxious on the day of
surgery (Figure 1) with anxiety for the majority commencing
1017
M. Mitchell
350
Procedure
Cases, n (%)
300
General surgery
Orthopaedic surgery
Gynaecological surgery
Urological surgery
ENT surgery
Uncertain
Dental surgery
Medical investigations
Missing (patient did not complete)
181
166
114
72
71
33
6
2
29
(28)
(26)
(18)
(11)
(11)
(5)
(09)
(03)
(4)
Participants
308
250
200
133
150
95
92
100
33
50
0
300
250
Participants
206
150
109
100
50
81
46
200
156
100
28
0
<2
weeks
before
Few
days
before
Few
Few
Not
hours minutes anxious
before before
153
150
50
0
>2
weeks
before
267
250
Participants
191
200
Any
Full
Medium Standard Mixture
None
information
account account account
51
14
None
28
Few
hours
before
Few
days
before
1
week
before
23
weeks
before
>4
weeks
before
Cases, n (%)
Waiting
Pain
Anaesthesia
Unknown
Operation
Operation successful
Unconsciousness
Nausea and vomiting (PONV)
Family
Work
Past experience
384
238
221
211
205
187
107
81
78
52
41
(57)
(35)
(32)
(31)
(30)
(28)
(16)
(12)
(12)
(8)
(6)
Sum of
Mean
squares d.f. square F
Anxiety on day
of surgery
Anxiety start
Preferred
information level
Preferred to receive
information
11592
29787
20826
1
1
13691
Alpha
Partial
g2
Item
Anxiety on day
of surgery
Anxiety start
Preferred information
level
Prefer to receive
information
Type of
anaesthesia
Mean
SD
GA
LA
GA
LA
GA
LA
GA
LA
24678
21791
22639
18010
48248
44378
37317
34179
105439
095800
135941
128849
145385
152557
111209
123874
451
201
451
201
451
201
451
201
Discussion
Study limitations
Limitations of the study were associated with gender numbers and response rate. First, more female patients than
malepatients were surveyed (385 female patients and 287
male patients) possibly reflecting the level of gynaecological
surgery undertaken (Table 3). However, the statistical test
employed was sufficiently robust to compensate for this. The
response rate could be deemed low but such a response rate is
common in postal surveys, especially with a surgical population who once home, quickly resume their normal lifestyle
(Pandit & Davies 2005).
Sum of
squares
d.f.
Mean square
Alpha
Partial g2
34525
39890
10713
1
1
1
34525
39890
10713
34296
22209
7756
0000*
0000*
0006*
0051
0033
0012
2864
6193
5082
10102
1
1
1
1
2864
6193
5082
10102
4248
8276
6241
10914
0040*
0004*
0013*
0001*
0007
0013
0010
0017
2214
2214
3721
0054*
0006
5742
5742
6590
0010*
0010
1019
M. Mitchell
Gender
Mean
SD
Female
Male
Female
Male
Female
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
25718
21047
23360
18339
33035
20623
19278
22087
20108
24309
26101
29675
27148
20786
19603
19322
21227
103518
095925
131084
137835
119556
082020
082215
087993
084478
090663
089664
098578
092953
075671
079071
091679
095520
369
277
369
277
369
369
277
369
277
369
277
369
277
369
277
369
277
Anxiety start
Anaesthetic not working rare
Modern looking ward
Modern looking equipment
Talking to other patients
Reading information about
operation
Listening to music/reading
a book
Partner or friend being
with you
M. Mitchell
Conclusion
The majority of patients undergoing elective surgery will
increasingly experience day, short stay or day of surgery
1022
Funding
Partial funding for the study came from a Fellowship Award
by the British Association of Day Surgery. This funding was
gratefully received and contributed to the successful completion of the study.
Conflict of interest
No conflict of interest has been declared by the author.
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