Because more surgery is carried out as day cases, nurses have less time to allay patient anxiety about surgery and anaesthesia, so a different approach is needed
An increase in minimal-stay surgery has reduced opportunities for nurses to discuss patients’ anxieties about anaesthesia and the procedures that they will undergo.To allay patient anxieties and therefore promote a good recovery from surgery, nurses need to put in place a planned programme of information provision for patients. They are in a good position to promote patients’ feelings of control and ability to cope, and help them to think positively.
Citation: Mitchell M (2012) Anxiety management in minimal stay surgery. Nursing Times; 108: 48, 14-16.
Author: Mark Mitchell is senior lecturer at College of Health and Social Care, University of Salford.
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Adult elective surgery has changed over the last decade, with a reduction in inpatient surgery and a rise in day surgery. This is because of increased use of laparoscopic surgical techniques, improved anaesthetic practice, need for cost savings and patient preference. The range of day-case procedures has increased (British Association of Day Surgery Council, 2011) and patient turnover in day surgery is far greater than in previous years.
However, this modern approach to healthcare can constrain nurses’ ability to provide the professional care deemed appropriate for patients having day surgery (Fraczyk et al, 2010). The opportunity for nurses to interact with patients, allay possible anxiety and provide information on the day of surgery can be greatly reduced (Jlala et al, 2010). A planned, coherent approach to pre-operative psychological care is therefore essential.
Psychological care delivery
Essential psychological care needs to be explicit in integrated care pathways to ensure implementation, especially where time for nurse-patient interaction is minimal. Essential elements are listed in Box 1.
Providing information about pre-admission, surgery, anaesthesia and home recovery is a challenge, especially with the increasing complexity of day surgery procedures (Blandford et al, 2011). Many patients require detailed information (Mitchell, 2010); however, too much information can increase anxiety in some patients (Oldman et al, 2004).
Formal delivery of information about anaesthesia before the day of surgery, emphasising the notion of “controlled unconsciousness” and dispelling common misconceptions, can be of great benefit in limiting anxiety (Lack et al, 2003).
The most anxiety-provoking aspects for patients having general anaesthesia are listed in Box 2. Such worries can be quickly dispelled once nurses are aware of them. The emphasis on information in specialist areas such as neurosurgery may differ a little and more surgery/recovery information may be needed (Perks et al, 2009) (due to the idea of surgery on the brain and the uncertainty of outcome).
Patients experiencing surgery under local or regional anaesthesia are less anxious than those undergoing general anaesthesia (Mitchell, 2012) and have different concerns (Box 3).
Patients see minimal stay as an opportunity to retain control over events (Nilsson et al, 2009). Although not always possible, minor interventions can collectively give an impression of perceived control (Ward et al, 2007). For example, asking if patients wish to remain dressed if they are later
on the operating list, allowing their partner to remain with them, keeping them informed of events or introducing staggered admission times may all provide an impression of control. These simple measures can foster feelings of maintaining some choice.
“Self-efficacy” - the perceived ability to cope - may be reduced in some patients when undergoing general anaesthesia, surgery and discharge all in one day.
Minimal-stay surgery environments are unfamiliar places, with complicated technical language and complex medical events that most patients will see as having an element of inherent risk.
However, patients who experience a high degree of self-efficacy may recover more quickly from surgery (Schwarzer et al, 2005). Promoting individual choice, and an all-round positive experience (with effective communication, privacy and dignity, kindness and consideration) can provide an excellent platform for recovery (Thirlway et al, 2012).
Box 1 Essential elements of psychological care
- Information provision
- Self-control enhancement
- Self-efficacy enhancement
- Therapeutic use of self
- Environmental considerations
Source: Mitchell (2011)
Box 2 Causes of Anxiety over surgery
- Thought of dying during anaesthesia
- Fear of not waking (staying in a coma)
- Fear of waking during surgery
- Trusting strangers
- Losing control
- Having a mask over the face
- Experiencing injections
Source: Mitchell (2010)
Box 3 Anxiety regarding local or regional surgery
- The procedure being painful
- Seeing the body cut open
- Numbness wearing off too quickly
- Feeling what the surgeon is doing
Source: Mitchell (2008)
Therapeutic use of self
Supportive interventions, involving the physical and emotional presence of a nurse, doctor or relative in close proximity, can provide a therapeutic element to care.
It is not merely the physical presence of health professionals that is important, but also their interaction with patients and the statements of assurance that they make. Therapeutic use of self can be considered in terms of social support, optimistic outlook and cognitive coping strategies.
Many patients would like a friend or relative to remain with them where possible to help reduce anxiety.
Doctors and nurses are viewed as experts and being physically close may enhance patients’ perception of safety, in a similar way to the presence of a mother for a young child.
Women can be much more anxious than men before general anaesthesia, and may have a preference for greater social interaction and a desire for the presence of a relative or friend (Mitchell, 2012). Conversely, men may prefer to read information about their surgery, listen to music or read a book (Mitchell, 2012). However, these are generalisations, and should not be assumed.
Having negative views and constant catastrophising thoughts about the proposed anaesthesia and/or surgery can lead to a slower recovery (Mitchell, 2011; Broadbent et al, 2003). To help minimise such views and thoughts, nurses can place emphasis on controlled, monitored anaesthesia aiding painless surgery using safe medication and say: “Many patients have this procedure and are safe and well.”
Cognitive coping strategies
Purposeful emotional attempts by patients to promote fewer negative, intrusive thoughts can beneficial (Crockett et al, 2007). The use of phrases to engender a realistic impression of safety are therefore vital, such as “you will be monitored continually while asleep”, and “the medications used are very safe and effective”. Collectively, these may give patients the “tools” to promote fewer negative thoughts (Chan et al, 2012).
Long periods of waiting can increase anxiety and lead to boredom, while a clean, efficient environment can engender feelings of professionalism and safety (Mottram, 2012).
For patients experiencing conscious surgery, additional fears may add to anxiety, such as the possibility of the procedure being painful, requiring more local anaesthetic injections, seeing the body “cut open”, numbness “wearing off” too soon and hearing proceedings (Mitchell, 2008).
Talking to patients immediately before anaesthesia, offering the option of some physical contact throughout surgery, limiting the impact of the environment (sights, smell, and noise) and enabling someone to accompany the patient during or immediately after surgery may all be beneficial (Mauleon et al, 2007).
Minimal stay adult elective surgery is increasing in all areas, with developments such as increased day surgery, more frequent day-of-surgery admission and the “enhanced recovery” programme (Department of Health, 2010).
The nature of nurse-patient interaction in this new era has restricted the opportunity for the expression of nursing knowledge. To accommodate the shift in care, the profession must adapt to these changes from attending to physical needs to providing information and advice (Table 1). A planned and consistent approach to psychological care is a major first step.
- Pre-operative anxiety before general anaesthesia is common
- A planned programme of information provision before minimal-stay surgery is vital
- Offering choices (real or perceived) and positive encouragement will benefit patients
- Therapeutic use of the self by nurses in brief exchanges with patients can help to promote a therapeutic environment
- Minimising the impact of the environment can dispel anxiety
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