Strategies for Decreasing Patient Anxiety in the ... - AORN

Strategies for DecreasingPatient Anxiety in thePerioperative SettingLAILA BAILEY, RN, MSN, CNOR3.0www.aorn.org/CEABSTRACTPerioperative patient anxiety is a pervasive problem that can have far-reachingeffects. Among these effects are increased postoperative pain, increased risk forinfection, and longer healing times. Many factors affect perioperative patient anxiety,including the need for surgery, perceived loss of control, fear of postoperativepain, and alteration of body image. This systematic review of current literature wasundertaken to identify evidence-based interventions for decreasing patient anxiety inperioperative practice. According to the current research literature, perioperativeeducation and music therapy can be used to successfully reduce surgical patients’anxiety. AORN J 92 (October 2010) 445-457. © AORN, Inc, 2010. doi: 10.1016/j.aorn.2010.04.017Key words: preoperative anxiety, surgical patient anxiety, perioperative anxiety,anxiety reduction strategies.Anxiety is a human reaction to any unknownsituation. Although perioperativeanxiety is considered to be a normal partof the surgical experience, it is a pervasive problemwith far-reaching health outcomes. Anxietytriggers the physiologic stress response, whichcan impede healing. 1 Anxiety in surgical patientscan increase the need for anesthesia, whichindicates that continuing education contacthours are available for this activity. Earn the contacthours by reading this article, reviewing thepurpose/goal and objectives, and completing theonline Examination and Learner Evaluation athttp://www.aorn.org/CE. The contact hours forthis article expire October 31, 2013.increases anesthetic risk. 2 Furthermore, anxietyhas been shown to increase postoperative painmedication requirements, which can affect postoperativerecovery, for example, by slowing respirations,which increases pulmonary risks; decreasingactivity, which increases risk of thrombosis;and increasing risk of bowel upset. 2,3 Anxietyalso plays a role in increasing the risk of infectionand decreasing the immune system response. 4Starkweather et al 4 found that patients undergoingspinal surgery experienced high levels ofstress regardless of the scope of the surgery. Elevatedstress and anxiety were associated with decreasedimmune system functioning as measuredby levels of natural killer cell activity andinterleukin-6. 4 Kagan and Bar-Tal 5 found thatpreoperative uncertainty and anxiety affectdoi: 10.1016/j.aorn.2010.04.017© AORN, Inc, 2010 October 2010 Vol 92 No 4 ● AORN Journal 445

October 2010 Vol 92 No 4 BAILEYwell-being and short-term recovery. Both variableswere shown to have a negative effect onpostoperative physical symptoms and recovery aswell as overall mental health.Many factors can contribute to a surgical patient’sanxiety level, and these factors can have acumulative effect. Often, surgery is associated withloss of control, fear of postoperative pain, and alterationin body image. 1 The need for surgery aloneincreases patient stress and anxiety, no matter theextent of the planned surgical procedure. 4,6Preoperative waiting was cited in several studiesas a trigger for anxiety. 1,7,8 In one study, ambulatorysurgery patients felt a sense of abandonmentduring the preoperative period. 7 Long waittimes with little information added to their anxiety.Some patients reported feeling that nurseswere not open to their concerns. In addition, thesepatients felt that they were not treated as individualswhile they were waiting for surgery. 7Jangland et al 6 found that, among those patientswho complained about care and increased anxiety,the most common complaints were insufficientinformation, inadequate respect, and insufficientempathy. These factors increased patient and familymember anxiety and reduced their confidencein the health care system.The environment inside the OR also has aneffect on patient anxiety. Factors such as thesound of alarms on machinery and the noise fromsurgical instruments being unpacked can have asignificant effect on increasing anxiety. 8In today’s health care setting, patients are lesslikely to receive inpatient care. Often, patients aresent home after procedures that would have requiredan overnight stay just a few years ago. 7Helping patients achieve the best outcome is essentialfor their fast recovery and safe returnhome. Perioperative nurses are pushed to be efficientboth during and between procedures, however,which can leave little time to concentrate onthe psychologic needs of the patient. 9Current management of anxiety involves usingmedical interventions, such as administeringmidazolam before surgery, and using effectivecommunication strategies. 2 Perioperative nurseshave expert knowledge not only of surgical proceduresbut also of the surgical environment and theexperiences patients will face during their time inthe perioperative area. This knowledge uniquelypositions perioperative nurses to address patientanxiety with nonmedical interventions. However,given the limited time that most perioperativenurses have to spend with their patients beforesurgery, whatever communication and other nonmedicalinterventions are used must be preciseand effective. This article reviews current researchto identify effective strategies for decreasinganxiety in surgical patients and recommendsevidence-based interventions for perioperativenursing practice.REVIEW OF CURRENT RESEARCHI conducted a literature review by using theCINAHL® and ProQuest nursing databases. Thecombination of the following key words yieldedthe most articles: anxiety, surgery, and intervention.I limited the search to research articles publishedfrom 2003 to 2009. This yielded 10 relevantresearch studies (Table 1).Therapeutic RelationshipErci et al 10 studied the effect of a therapeutic relationshipon preoperative and postoperative anxietyin Turkey. The study sample consisted of 120consecutive patients, 60 assigned to the studygroup and 60 to the control group. Patients wereincluded if they were older than 18 years of age, scheduled for a surgical procedure, and capable of giving voluntary consent.Data were collected by using the Beck AnxietyInventory (BAI). The BAI is designed to assessanxiety in clinical and research settings. It is composedof 21 items rated on a 4-point Likert scale(3 very serious to 0 not serious), with a cumulativescore between zero and 63. The higher thescore, the higher the person’s level of anxiety.446 AORN Journal

PERIOPERATIVE ANXIETYwww.aornjournal.orgTABLE 1. Summary of Research Articles on Perioperative AnxietyStudySample size andcharacteristicsInterventionInstrumentsusedFindingsErci et al 10 N 120Adults scheduled forsurgery at generalsurgery clinic in Turkey Control group: usual care Study group: interventiondesigned to build atherapeutic relationshipbased on theInterpersonal RelationsModel Beck AnxietyInventory (BAI)Anxiety mean score (P .001): Preintervention: Control group 18.2 Study group 18.5 Postintervention: Control group 9.7 Study group 1.4Researchers concluded thatdecreased patient anxiety wasassociated with the intervention.Spaulding 3 N 10British patients awaitingtotal hip replacementprocedure; and N 7education programpresentersQualitative study withinterviews with presentersof occupational therapistrunpreoperative educationprogram Control group Intervention group Researcherdesigned coding ofthemes fromobservationsIntervention group: Patients stated preoperativeeducation had been helpful Patients suggested that theeducation interventionreduced anxiety in interviewswith researchersNg et al 11 N 196Patients undergoingoral surgery proceduresin Hong KongFour patient educationgroups: Group N: basicpreoperative information Group P: basicinformation with details ofsurgical procedure Group R: basicinformation with details ofexpected recovery Group PR: basicinformation with details ofboth surgical procedureand expected recovery Depression AnxietyStress Scale Self reporting ofanxiety by patients High trait anxiety patients:mean anxiety scores of R andPR groups significantly lowerthan groups N and P(P .653) Low trait anxiety patients: P, PR, and R groups hadlower anxiety than Ngroup (P .753) PR and R groups hadsignificant changes frombaseline anxiety (P .05)Preoperative informationregarding postoperativerecovery and/or surgicalprocedure details led tosignificant reduction of selfreported anxiety.Stirling et al 2 N 40Patients on a thoracicsurgery ward in theUnited KingdomThree groups: Control: routine care Intervention 1: routinecare plus use of neutralessential oils Intervention 2: routinecare plus use of essentialoil blend Strait-Trait AnxietyInventory (STAI)STAI day 21 scores: Control mean 43.13 Neutral oil interventionmean 44.64 Oil blend intervention mean 44.45No statistically significantdifferencesAORN Journal 447

October 2010 Vol 92 No 4 BAILEYTABLE 1. (continued) Summary of Research Articles on Perioperative AnxietyStudySample size andcharacteristicsInterventionInstrumentsusedFindingsRoykulcharoen N 102and Good 12 Patients undergoingabdominal surgery (84women; 18 men) inThailandTwo groups: Control group: usual care Intervention group:systemic relaxation Visual AnalogSensation of Painand Distressscales STAI Control group: Preoperative mean 42.0 End recovery mean 39.7 Intervention group: Preoperative mean 42.5 End recovery mean 38.4No statistically significantdifferenceSeers et al 13 N 118Patients recruited fromgroup admitted fortotal hip or kneereplacement surgery atan orthopaedic hospitalin the United KingdomTwo control groups: one with usual care and one with usual care plusresting quietly for 15minutesTwo intervention groups: one taught jaw relaxationand one taught total bodyrelaxation STAI Visual Analog PainScaleMean changes in STAI scores(preintervention andpostintervention): Usual care group:0.115 (standard deviation[SD] 2.160) Usual care plus restinggroup: 1.179 (SD 2.019) Jaw relaxation group:1.208 (SD 2.502) Total relaxation group:.320 (SD 2.501)There was no statisticallysignificant change in scorebetween groups preinterventionto postintervention.Arsian et al 14 N 64Adult men, ages 18 to65 years, undergoingurogenital surgery inTurkeyTwo groups: Control group: routinecare Intervention group:listening to music for 30minutes withheadphones in thepreoperative area STAISTAI mean scores: Before therapy Control 42.5 Intervention 39.59 After therapy- Control 44.43 Intervention 33.68Control group: increasedanxiety scores (P .003)Intervention group: decreasedanxiety scores (P .000)Cooke et al 15 N 180Adult surgery patients inAustralia admitted anddischarged the sameday as surgery, bothmen and women overthe age of 18 years, ableto use headphones,fluent in English, nopreoperative sedationParticipants randomlyassigned to 1 of 3 groups inthe preoperative area: Control: routine care Placebo: routine careand headphones for 30minutes with no music Intervention: routine careand music of choice viaheadphones for 30minutes STAIPostintervention STAI mean and95% confidence interval (CI): Control: 32.7 (95% CI,31.5-34.0) Placebo: 32.5 (95% CI,31.2-33.8) Intervention: 28.5 (95% CI,27.4-29.6)The music (intervention) grouphad a statistically significantreduction in anxiety comparedwith the control group (P .001).448 AORN Journal

PERIOPERATIVE ANXIETYwww.aornjournal.orgTABLE 1. (continued) Summary of Research Articles on Perioperative AnxietyStudySample size andcharacteristicsInterventionInstrumentsusedFindingsKain et al 16 N 408Healthy pediatricpatients, ages 2through 10 yearsundergoing generalanesthesia for electiveoutpatient surgery andtheir parents at Yale-New Haven Children’sHospitalFour groups: Control: usual care Group 2: parentalpresence at induction ofanesthesia Group 3: midazolam 30minutes before inductionof anesthesia Group 4: integratedbehavioral preparationprogram includingparental presence atinduction of anesthesia Parents: STAI Child: ModifiedYale PreoperativeAnxiety Scale(mYPAS) Emergencebehavior:observation Analgesicrequirements:codeine-unit scaleSignificant differences betweengroups:F 4.2; P .0006Group 4 had significantdecrease in anxiety(P .001)MacLaren N 112and Kain 17 Pediatric patients aged2 through 7 yearsundergoing surgery andtheir parentsTwo groups: Control: routine care Intervention: educationprovided to childrenundergoing generalanesthesia about maskinduction and expectedbehaviors in the OR;parental instruction alsoprovided mYPAS InductionComplianceChecklist Anxiety: Change in mYPASseparation to inductioncomparing groups – F (1,101) 6.32, P .02 Induction compliance vsnoncompliance (intervention vscontrol) – 2 (1, N 99) 6.14, P .01The intervention group wassignificantly more compliant atanesthesia induction than thecontrol group.On the patient’s first day of enrollment in thestudy, the patient completed a baseline BAIin the general surgery clinic. Immediately afterthis, the study group was given an interventionbased on Peplau’s Interpersonal RelationshipModel, which was designed to build a therapeuticrelationship between patient and caregiver, whichin this study was specifically the researcher. TheInterpersonal Relationship Model has four phases(ie, orienting, identification, exploitation, resolution).This researcher used activities of caringwithin each of the model’s four phases as the interventionsof the study. The second BAI wascompleted by the patient the day before surgery,the third was completed the day after surgery,and the fourth and final BAI was completed theday the patient was discharged home. There wasno statistical demographic difference between thetwo groups, and preintervention anxiety scoresshowed no statistical difference. There was a significantdecrease in mean scores for patient anxietyin the study group compared with the controlgroup. This change was most pronounced betweenthe third and fourth measurements. 10Preoperative InformationTwo studies examined the effect of preoperativeinformation on relieving anxiety. 3,11 In Britain,Spaulding 3 looked at the effects of a preoperativeeducation program run by occupational therapistsfor patients awaiting total hip replacement. In thisqualitative, observational study, researchers collecteddata from written patient evaluations, inpersoninterviews with patients, interviews withAORN Journal 449

October 2010 Vol 92 No 4 BAILEYpresenters of the educational programs, and observation.Educational presenters were interviewedtwice, as were patients. The study sample consistedof 10 patients and 7 presenters. Patient participantswere selected from the list of patients onthe total hip replacement waiting list and wereinvited by mail to attend the preoperative patientprogram. According to the researchers, these subjectivefindings suggest that preoperative educationreduces anxiety because it gives the patient asense of what to expect. 3Ng et al 11 studied the effect of preoperativeinformation on the anxiety of patients undergoingoral surgery in Hong Kong. Patients of six dentalpractitioners were recruited for the study by usingnotices placed in the dental offices. The 196 patientswho entered the study were separated intofour groups: N—received basic information, P—received basic information plus detailsabout the surgical procedure, R—received basic information plus details ofthe expected recovery, PR—–received basic information plus detailsof both the surgical procedure and expectedrecovery.The Depression Anxiety Stress Scale was used tomeasure study participants’ level of trait anxietybefore, during, and after surgery. The DepressionAnxiety Stress Scale is composed of three separatescales (ie, anxiety, depression, stress). Eachscale has 14 items and is answered by the participanton a 4-point Likert scale (0 not applicableto 3 always applicable). The scale was completedbefore the patients received any preoperativeinformation. Groups were further dividedbased on measurements of high or low trait anxiety.The patients’ self-reported anxiety before,during, and after surgery by rating their subjectiveanxiety on a scale of zero to 100 (0 none to100 most intense). The PR and R groups hadstatistically significant decrease in anxiety comparedwith the baseline measure. The researchersdetermined that preoperative education that includedinformation about recovery or informationabout recovery and the intraoperative and postoperativeperiods helped decrease the anxiety ofstudy participants. However, receiving only basicinformation about the procedure (ie, the N group)only decreased anxiety in those participants whohad a lower level of anxiety before the surgicalexperience. 11Essential OilsThe effect of essential oils in reducing perioperativepatient anxiety was studied by Stirling et al. 2This was a double-blind randomized study to determinethe feasibility for a larger study to examinethe effects of essential oils on the anxiety ofpatients awaiting surgery in a thoracic ward. Participantswere randomly assigned to either thecontrol or study group. Although the goal was tohave 30 participants in each group and 71 patientsconsented to participate, only 40 completed thestudy.Participants were given essential oils to selfapplyand to take home to continue use for 21days after discharge. Participants were instructedto use the oil continuously from postoperative day1 through day 21. Participants completed theState-Trait Anxiety Inventory (STAI), which consistsof 20 statements rated using 4-point Likertscale, to indicate how they felt at a particulartime. Higher scores indicate higher anxiety. Datawere collected before the intervention and at day3 and day 21 of the study. Results were reportedas differences in STAI measurements on day 3and day 21 for each participant.Low patient participation made it difficult forthe researchers to draw specific conclusions fromthe results. In addition, the study had less powerto detect differences in anxiety because the patientpopulation did not have uniform preinterventionanxiety. This study did not demonstratea statistically significant relationship between theuse of essential oils and anxiety reduction. It is450 AORN Journal

PERIOPERATIVE ANXIETYwww.aornjournal.orgdifficult to draw specific conclusions about theintervention because of the study’s limitations. 2Relaxation TechniquesTwo studies examined the use of relaxation techniquesin surgical patients. 12,13 Roykulcharoenand Good 12 examined the effect of systematicrelaxation on pain and anxiety during recoveryafter abdominal surgery. Their work was based onOrem’s Self-Care Theory and the theoretical assumptionthat nurses assist patients in meeting theneed to care for themselves. This study was undertakenat a large hospital in Thailand. Patientsundergoing surgery were eligible to participate ifthey were 20 to 65 years of age, were expecting to remain in the hospital twoto three days after surgery, and would receive opioid pain medication asneeded.Participants were randomly assigned to the experimentalor control group. Participants in theexperimental group were taught systematic relaxationbefore surgery. The Visual Analog Sensationof Pain and Distress scale was used to measurepain in the area of the patient’s incision. TheVisual Analog Sensation of Pain and Distressscale is a dual scale; the pain scale is a 100-mmhorizontal line, with ends marked zero (ie, nosense of pain) and 100 (ie, the worst imaginablepain), and the distress scale is a 100-mm horizontalline with ends marked zero (ie, no distress)and 100 (ie, most distress imaginable). Pain wasmeasured immediately after patients returned tobed after ambulation and then 15 minutes afterrelaxation techniques were used. The distressscale was used to indicate the amount of emotionalupset associated with the pain. Participants’opioid use was also measured. The researchersreported that patients in the experimental grouphad significantly less distress and decreased sensationsof pain than patients in the control group;however, the intervention did not affect postoperativeanxiety or opioid intake. 12In a separate study, Seers et al 13 studied postoperativepain and anxiety, and the effects of relaxation.They examined jaw relaxation techniquesas well as total body relaxation techniqueswith patients admitted for total hip or knee replacementin an orthopaedic hospital in theUnited Kingdom. The goal was to enlist 236 patients,but only 200 were recruited, and only 118completed the study. There were two relaxationintervention groups and two control groups. Thefirst experimental group was taught total bodyrelaxation, and the second experimental groupwas taught jaw relaxation. The first control groupreceived the usual care, and the second controlgroup received the usual care and also rested quietlyon their own for 15 to 20 minutes. Pain andanxiety scores were measured before surgery andafter the intervention by using the STAI. Althoughthere were changes in pain scores, no significantdifference was found in anxiety scoresbetween any of the groups. In addition, the researchersreport that the effect of total body relaxationwas not long-lasting. 13Music TherapyTwo articles described the effects of music onstress and anxiety in surgical patients. 14,15 Arsianet al 14 investigated the effect of music on preoperativeanxiety. The sample was composed ofmen who were to undergo urogenital surgery inTurkey. Patients were recruited from an inpatient urology clinic, between the ages of 18 and 65 years, and fluent in Turkish.After enrolling in the study, 32 participants wereassigned to the control group and 32 participantswere assigned to the experimental group. On theday of surgery, participants in both the controland experimental groups completed the STAI.The participants in the experimental group werethen asked to pick their favorite selection from avariety of music. They were given a portable cassetteplayer with their choice of music and headphones,and they listened to the music for 30AORN Journal 451

PERIOPERATIVE ANXIETYwww.aornjournal.orgParental anxiety was measured by using theSTAI; child anxiety was measured on the modifiedYale Preoperative Anxiety Scale (mYPAS).The mYPAS consists of 27 items in five categories,and data are gathered via observation to assessthe anxiety behavior of children in the perioperativesetting. Emergence behavior was ratedon a 3-point scale by trained observers, analgesiarequirements were measured from the patient’smedical record and converted to a codeine-unitscale, and time the patient arrived in the postanesthesiacare unit was used for the dischargetime. There were 408 participants in the study,and all of the four groups were similar in demographiccharacteristics. Using two-way ANOVA,researchers determined that there was significantlylower anxiety in the children in the ADVANCEgroup compared with children in the other threegroups (P .001). In addition, children in theADVANCE group were less likely to exhibit emergence delirium, received only half as much fentanyl comparedwith the parental-presence group and onlyone-third as much fentanyl as the other twogroups, and were discharged significantly earlier than childrenin the other three groups. 16MacLaren and Kain 17 examined an educationalprogram for pediatric patients concerning anesthesiainduction and what to expect of the anestheticexperience. The researchers randomly assigned112 children, ranging from two to seven years ofage, to either the control or the interventiongroup. Measures were made with the mYPAS, theSTAI, and the Induction Compliance Checklist.The Induction Compliance Checklist is an 11-itemscale used to analyze a child’s behavior duringinduction of anesthesia. Each item represents abehavior that interferes with mask induction (eg,turning the head away from the mask) and israted zero (ie, present) or 1 (ie, absent). The InductionCompliance Checklist was used in thisstudy to measure the behavior of the participantsat the time of anesthesia induction as rated by theresearch observer.After patients and their family members hadarrived in the preoperative holding area, the parentswere given the STAI, while the childrenwere observed by trained research assistants whofilled out the mYPAS. After this baseline observation,children were randomly assigned to one ofthe two groups. Children in the intervention groupwere then exposed to the shaping intervention,which included being introduced to the anesthesiamask and to the desired behaviors expected whenthey enter the OR. Examples of desired behaviorincluded the child playing with an anesthesia facemask, the child putting the mask over his or hermouth, the child allowing the parents to hold themask on the child’s face, and the child climbingonto the examination table.Parents of children in the intervention groupalso were given instructions about the inductionof anesthesia. The children in both groups wererated on the mYPAS when called to the OR andat induction of anesthesia. Multivariate analysiswas used to evaluate the findings. This analysisfound that there were significant differences betweengroups (P .02). In addition, there was arelationship between group and time. Anxiety increasedsignificantly from the baseline measurementto when the measurement was taken at thepoint of separation from the parents for the interventiongroup compared with the control group.However, there was a significant increase in anxietyfor the control group from separation fromparents to induction of anesthesia, whereas theintervention group had a statistically significantdecrease in this score. In addition, children in theintervention group were significantly more likelyto be compliant at induction than children in thecontrol group (P .01). Parents’ anxiety wasmeasured in the preoperative holding area andagain at separation from their child. Parents’ anxietyincreased regardless of group assignment. Theresearchers concluded that children in the interventiongroup were significantly more compliantAORN Journal 453

October 2010 Vol 92 No 4 BAILEYat induction of anesthesia and had smaller increasesof anxiety from baseline than did childrenin the control group, but the intervention did notaffect the anxiety scores of the parents. 17IMPLICATIONS FOR PRACTICEAs this literature review demonstrates, many strategiesfor reducing patient anxiety have been tried,but only a few have proven successful. The mosteffective interventions from the current literatureare perioperative patient education and musictherapy. A care plan that identifies nursing actionsto manage the perioperative anxiety of any patientundergoing a surgical procedure is presented inTable 2.Preoperative EducationIn today’s health care system, it is rare for patientsundergoing scheduled surgery to be admittedbefore the morning of their procedure. Thisadmission routine limits the time that nurses haveto implement a preoperative education plan. Inaddition, nurses in the preoperative and intraoperativeareas are pushed to move patients throughquickly. These factors can limit the amount oftime that can be dedicated to a preoperative educationprogram.From the review of current evidence, it is clearthat some form of basic education should be implementedfor patients on the day of surgery. Becausesome individuals do not want as much informationas others, a framework of generalinformation can be put in place for all patients.Opportunities should be provided for patients toask questions if more information is sought. Thisbasic educational material should include an overviewof the surgical process. I suggest the informationshould include what to expect in the preoperativearea, emphasizingthat wait times can vary,who to ask for information should a questionarise,who they will meet during this time, andthe general process of getting ready forsurgery.Patients also should be given general intraoperativeinformation, including that they will move to another bed after arriving inthe OR, there will be unusual equipment around, people may be coming and going, and that it can be cold, but warm blankets are alwaysavailable.Postoperative InformationPostoperative information that patients need includesreassurance that pain needs will be met, anexplanation of how the pain scale will work tohelp them communicate their needs, and whatto expect on discharge. Although not all healthcare providers will be able to give the postoperativeinformation specific to each surgery andsurgeon, a general overview of the postoperativeand discharge process should be includedin any teaching plan. For families with pediatricpatients, research results show that educationbefore the day of surgery is helpful. 17 Ifthat is not possible, then basic informationabout induction of anesthesia should be includedwith other basic preoperative teaching tohelp decrease fears and increase understandingby patients and their parents. 16Music TherapyMusic therapy is an intervention that has alsoshown effectiveness in reducing preoperativeanxiety. However, giving each patient his orher own music player for use on the day of surgerymay not be feasible in all settings, especiallygiven current constraints on health careorganization budgets. Other, more cost-effectiveways of providing calming music in the preoperativeand intraoperative environments shouldbe evaluated by facilities as a way of reducinganxiety for patients.454 AORN Journal

PERIOPERATIVE ANXIETYwww.aornjournal.orgTABLE 2. Care Plan for Managing Perioperative Patient AnxietyDiagnosisNursing interventionsInterim outcomestatementOutcomestatementAnxietyor ineffectivecoping Identifies psychosocial status.Evaluates psychosocial status relative to age andstage of development.Identifies patient home profile (eg, householdcomposition, ages, gender, roles, occupations; familycoping skills, limitations). Identifies patient’s resources (eg, insurance, homeenvironment, extended family, community). Assesses coping mechanisms. Reviews patient’s coping pattern and itseffectiveness. Identifies patient’s religious practices. Identifies philosophical, cultural, and spiritual beliefsand related practices. Asks the patient to describe current methods ofdealing with stress. Observes for behavior that may indicate ineffectivecoping (eg, verbalization of anger, depression,ineffective coping, alterations in diet, disruption ofsleep pattern; restlessness; absence of eye contact;absence of or reduced participation in plan of care;withdrawal from family or staff members; hostilitytoward family or staff members). Determines when these behaviors became firstapparent. Encourages patient to express feelings. Determines the most effective methods ofcommunication and support. Evaluates availability and effectiveness of supportsystem. Identifies patient and designated support person’seducational needs. Determines knowledge level. Elicits perceptions of surgery. Identifies barriers to communication. Determines the patient’s ability to understand theinformation offered. Includes the patient or designated support person inperioperative teaching. Explains expected sequence of events. Provides status reports to the designated support person. Implements measures to provide psychologic support. Assesses for signs and symptoms of anxiety or fear(eg, fears and concerns, preoperative insomnia,muscle tenseness, tremors, irritability, change inappetite, restlessness, diaphoresis, tachypnea,tachycardia, elevated blood pressure, facial pallor orflushing, withdrawn behavior). The patientverbalizes thesequence of eventsto expect before andimmediately aftersurgery. The patient statesrealistic expectationsregarding recoveryfrom the procedure. The patient andfamily describe theprescribedpostoperativeregimen accurately. The patient ordesignated supportperson demonstratesknowledge of theexpected responsesto the operative orinvasive procedure.AORN Journal 455

October 2010 Vol 92 No 4 BAILEYTABLE 2. (continued) Care Plan for Managing Perioperative Patient AnxietyDiagnosisNursing interventionsInterim outcomestatementOutcomestatement Orients patient to environment and care routines andpractices. Introduces staff members. Assures the patient that a member of the staff isnearby. Provides information and answers questions honestly. Maintains a calm, supportive, confident manner. Provides an atmosphere of care and concern (eg,privacy, nonjudgmental approach, empathy, respect). Offers alternative methods to minimize anxiety (eg,music, humor). Reinforces physician’s explanations and clarifiesmisconceptions. Explains the purpose of preoperative preparationsbefore implementation. Encourages patient participation in decision makingand planning for postoperative care. Evaluates psychosocial response to the plan of care.FURTHER RESEARCHThe evidence presented here supports implementationof perioperative education and music therapyto decrease patient anxiety. Managing theenvironment also could help decrease the effect ofthe perioperative environment on patients’ anxiety.When a patient enters the OR, care should betaken to silence machinery, so that unnecessaryalarms do not startle or frighten the patient. Inaddition, unpacking and moving instruments andequipment should be minimized. Implementing asystem to keep patients and their family membersupdated while they are waiting for their procedurescould help decrease anxiety and reassure patientsthat all is well. Reliable, replicable programs inthese areas should be developed and tested to determinethe optimal interventions to reduce perioperativeanxiety for patients and families.Although articles about anxiety and surgeryare available in the current literature, more studiesneed to be performed to develop and testinterventions to determine their effectiveness inreducing anxiety in the fast-paced perioperativearea. Because of the paucity of research beingperformed on this topic in the United States,many of the studies reviewed here for evidencehave come from other cultures and disciplines.Although it can be difficult to extrapolate andapply data from research done in diverse cultures,these studies can point the way for furtherresearch opportunities. Anxiety can have farreachingeffects on surgical outcomes. Developingeffective anxiety-reducing strategies based on evidenceis essential to optimize patient care.Editor’s note: CINAHL, Cumulative Index toNursing and Allied Health Literature, is a registeredtrademark of EBSCO Industries, Birmingham,AL.References1. Grieve RJ. Day surgery preoperative anxiety reductionand coping strategies. Br J Nurs. 2002;11(10):670-678.2. Stirling L, Raab G, Alder EM, Robertson F. Randomizedtrial of essential oils to reduce perioperative patientanxiety: feasibility study. J Adv Nurs. 2007;60(5):494-501.456 AORN Journal

PERIOPERATIVE ANXIETYwww.aornjournal.org3. Spaulding NJ. Reducing anxiety by pre-operative education:make the future familiar. Occup Ther Int. 2003;10(4):278-293.4. Starkweather AR, Witek-Janusek L, Nockels RP, PetersonJ, Mathews HL. Immune function, pain, and psychologicalstress in patients undergoing spinal surgery.Spine. 2006;31(18):E641-E647.5. Kagan I, Bar-Tal Y. The effects of preoperative uncertaintyand anxiety on short-term recovery after electivearthroplasty. J Clin Nurs.2008;17(5):576-583.6. Jangland E, Gunningberg L, Carsson M. Patients’ andrelatives’ complaints about encounters and communicationin health care: evidence for quality improvement.Patient Educ Couns. 2009;75(2):199-204.7. Gilmartin J, Wright K. Day surgery: patients’ felt abandonedduring the preoperative wait. J Clin Nurs. 2008;17(18):2418-2425.8. Haugen AS, Eide GE, Olsen MV, Haukeland B,Remme AR, Wahl AK. Anxiety in the operating theatre:a study of frequency and environmental impact inpatients having local, plexus or regional anesthesia.J Clin Nurs. 2009;18(16):2301-2310.9. Stirling L. Reduction and management of perioperativeanxiety. Br J Nurs.2006;15(7):359-361.10. Erci B, Sezgin S, Kacmaz Z. The impact of therapeuticrelationship on preoperative and postoperative patientanxiety. Aust J Adv Nurs. 2008;26(1):59-66.11. Ng SKS, Chau AWL, Leung WK. The effect of preoperativeinformation in relieving anxiety in oral surgerypatients. Community Dent Oral Epidemiol. 2004;32(3):227-235.12. Roykulcharoen V, Good M. Systematic relaxation to relievepostoperative pain. J Adv Nurs. 2004;48(2):140-148.13. Seers K, Crichton N, Tutton L, Smith L, Saunders T.Effectiveness of relaxation for postoperative pain andanxiety: randomized controlled trial. J Adv Nurs. 2008;62(6):681-688.14. Arsian S, Ozer N, Ozyurt F. Effect of music on preoperativeanxiety in men undergoing urogenital surgery.Aust J Adv Nurs. 2008;26(2):46-54.15. Cooke M, Chaboyer W, Schluter P, Hiratos M. Theeffect of music on preoperative anxiety in day surgery.J Adv Nurs. 2005;52(1):47-55.16. Kain ZN, Caldwell-Andrews AA, Mayes LC, et al.Family-centered preparation for surgery improves perioperativeoutcomes in children: a randomized controlledstudy. Anesthesiology. 2007;106(1):65-74.17. MacLaren JE, Kain ZN. Development of a brief behavioralintervention for children’s anxiety at anesthesiainduction. Child Health Care. 2008;37(3):196-209.Laila Bailey, RN, MSN, CNOR, is a staffnurse and urology/cystoscopy specialist atInova Fairfax Hospital Ambulatory SurgeryCenter, Fairfax, VA. Ms Bailey has no declaredaffiliation that could be perceived asposing a potential conflict of interest in thepublication of this article.AORN Journal 457

EXAMINATIONCONTINUING EDUCATION PROGRAMStrategies for Decreasing PatientAnxiety in the Perioperative Setting3.0www.aorn.org/CEPURPOSE/GOALTo educate perioperative nurses about methods to decrease patient anxiety in theperioperative setting.OBJECTIVES1. Describe the physiologic stress response triggered by anxiety.2. Identify factors that can contribute to a surgical patient’s anxiety level.3. Discuss methods to decrease surgical patients’ anxiety that perioperative nursescan implement.4. Discuss anxiety as it relates to pediatric patients and their parents.The Examination and Learner Evaluation are printed here for your convenience.To receive continuing education credit, you must complete the Examinationand Learner Evaluation online at http://www.aorn.org/CE.QUESTIONS1. Anxiety triggers the physiologic stress response,which can1. impede healing.2. increase the need for anesthesia.3. increase postoperative pain medicationrequirements.4. affect postoperative recovery.5. increase the risk of infection.a. 1 and 2 b. 3, 4, and 5c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 52. Factors that contribute to a surgical patient’s anxietylevel include1. alteration in body image.2. fear of postoperative pain.3. loss of control.4. the need for surgery.5. lack of information about upcomingprocedures.a. 2 and 5 b. 1, 3, and 4c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 53. In a study by Jangland et al, among patients whocomplained about care, the most common factorsthat patients said increased their anxiety were1. dissatisfaction with the need to arrive early atthe facility.2. poor quality of postoperative snacks.3. insufficient empathy.4. insufficient information.5. inadequate respect.a. 1 and 3 b. 2 and 4c. 3, 4, and 5 d. 1, 2, 3, and 44. Factors such as the sound of alarms on machineryand the noise from surgical instruments being458 AORN Journal ● October 2010 Vol 92 No 4 © AORN, Inc, 2010

CE EXAMINATIONwww.aornjournal.orgunpacked can have a significant effect onincreasing anxiety.a. true b. false5. According to a study by Ng et al, providing onlybasic information about the procedure only decreasedanxiety in those participants who had ahigher level of anxiety before the surgicalexperience.a. true b. false6. In a study by Roykulcharoen and Good, use ofsystematic relaxation techniques1. decreased sensations of pain.2. decreased postoperative anxiety.3. resulted in less distress.4. decreased opioid intake.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 47. According to a study by Cooke et al, listening tomusic for 30 minutes before surgery on the dayof surgery was associated with a significant decreasein preoperative anxiety.a. true b. false8. In a study on children and families by Kain et al,the researchers determined that compared withthe other groups, children in the ADVANCE (ie,Anxiety-reduction, Distraction, Video modelingand education, Adding parents, No excessivereassurance, Coaching, and Exposure/shaping)group1. had statistically significant lower anxiety.2. received less fentanyl.3. were discharged significantly earlier.4. were less likely to exhibit emergence delirium.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 49. In a study of pediatric patients by MacLaren andKain, the researchers concluded that1. children in the intervention group had smallerincreases of anxiety from baseline.2. children in the intervention group were significantlymore compliant at induction ofanesthesia.3. the intervention did not affect the anxietyscores of the parents.4. the intervention decreased the anxiety scoresof the parents.a. 1 and 3 b. 2 and 4c. 1, 2, and 3 d. 1, 2, and 410. As found in this review of current literature, themost effective interventions for decreasing patientanxiety in the perioperative setting are1. essential oils.2. music therapy.3. perioperative education.4. relaxation techniques.a. 1 and 4 b. 2 and 3c. 1, 3, and 4 d. 1, 2, 3, and 4The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor,with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewellhave no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.AORN Journal 459

LEARNER EVALUATIONCONTINUING EDUCATION PROGRAMStrategies for Decreasing PatientAnxiety in the Perioperative Setting3.0www.aorn.org/CEThis evaluation is used to determine the extent towhich this continuing education program metyour learning needs. Rate the items asdescribed below.OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Describe the physiologic stress response triggeredby anxiety. Low 1. 2. 3. 4. 5. High2. Identify factors that can contribute to a surgicalpatient’s anxiety level. Low 1. 2. 3. 4. 5. High3. Discuss methods to decrease surgical patients’anxiety that perioperative nurses can implement.Low 1. 2. 3. 4. 5. High4. Discuss anxiety as it relates to pediatric patientsand their parents. Low 1. 2. 3. 4. 5. HighCONTENT5. To what extent did this article increase yourknowledge of the subject matter?Low 1. 2. 3. 4. 5. High6. To what extent were your individual objectivesmet? Low 1. 2. 3. 4. 5. High7. Will you be able to use the information fromthis article in your work setting? 1. Yes 2. No8. Will you change your practice as a result ofreading this article? (If yes, answer question#8A. If no, answer question #8B.)8A. How will you change your practice? (Select allthat apply)1. I will provide education to my team regardingwhy change is needed.2. I will work with management to change/implement a policy and procedure.3. I will plan an informational meeting withphysicians to seek their input and acceptanceof the need for change.4. I will implement change and evaluate theeffect of the change at regular intervals untilthe change is incorporated as best practice.5. Other:8B. If you will not change your practice as a resultof reading this article, why? (Select allthat apply)1. The content of the article is not relevant tomy practice.2. I do not have enough time to teach othersabout the purpose of the needed change.3. I do not have management support to make achange.4. Other:9. Our accrediting body requires that we verifythe time you needed to complete the 3.0 continuingeducation contact hour (180-minute)program: ___________This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Centerapproves or endorses products mentioned in the activity.AORN is provider approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of thisactivity for relicensure.Event: #10271; Session: #4026 Fee: Members $15, Nonmembers $30The deadline for this program is October 31, 2013.A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.460 AORN Journal ● October 2010 Vol 92 No 4 © AORN, Inc, 2010