How to help patients with pre-operative anxiety
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How to help patients with pre-operative anxiety

Nick Evans Health journalist

Communication and planning are vital – as is understanding how much information the patient wants to know

When faced with undergoing anaesthetic, and thoughts of risk factors, surgical instruments and a possible long recovery, it is understandable for patients to feel nervous ahead of surgery.

Nursing Standard. 36, 12, 73-75. doi: 10.7748/ns.36.12.73.s25

Published: 01 December 2021

But for some it can become a real issue, triggering physical and emotional responses – and could affect surgery outcomes.

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How COVID-19 has affected patient anxiety

About one in four patients become what can be classed as very anxious before surgery, according to a review of 34 studies involving 3,750 patients, published in the journal Anaesthesia.

Those admitted as inpatients are more likely than day patients to struggle with pre-operative anxiety, the research suggested, and anxiety is more common in women than men.

‘You should not underestimate what a big thing having surgery is for people,’ says RCN perioperative forum chair Beck Diedo. ‘And COVID-19, of course, has made things more difficult.’

She says worries over catching the virus while in a hospital setting and the use of personal protective equipment can heighten feelings of anxiety – and then there are the restrictions on visitors.

‘Not having people to accompany you and sit with you in the waiting room has for some made it more difficult. Anxiety ahead of surgery needs to be taken seriously.’

Why some patients are more anxious before surgery

There are numerous reasons why someone may develop pre-operative anxiety.

A survey of 500 patients published in the European Journal of Medical Research found the most common factors were fear of waking up during surgery and pain. Other factors included worrying about dying during surgery, the surgery not working, becoming disabled as a result of surgery, injections and needles, and post-operative vomiting and nausea.

Healthcare education and training consultant Bob Price says much of it is related to the loss of control. ‘Surgery is clearly outside everyday experience so it becomes a powerful stressor,’ he says.

He says too much – or too little – knowledge can exacerbate feelings of anxiety ahead of surgery. ‘Too little accessible information and we become anxious, and too much information can produce the same effect if we are imaginative,’ he adds. ‘Some individuals are hyper-imaginative, and can imagine mishaps.

‘Our ability to process threat is strongly associated with life experience. Some patients may be predisposed to anxiety because of difficult life experiences.’

He advises trying to ascertain a patient’s predisposition to anxiety ahead of any hospital admission and surgery.

‘There is no reason why a nurse cannot ask “how do you manage new experiences, such as surgery?”’

The different ways anxiety presents in patients

Anxiety can manifest itself in different ways, both physically and psychologically.

In some people it may be noticeable changes in behaviour, for example they become aggressive, tense or visibly nervous. This can affect the patient’s interaction with staff, and they may become argumentative or find it difficult to follow instructions.

Those with low-level anxiety may react the opposite way and appear almost calm or relaxed.

Other physical signs may include heightened senses, nervous diarrhoea, fever and symptoms that could affect surgery outcomes, such as hypertension and raised heart rate, which could cause bleeding.

In addition, studies show a high level of pre-operative anxiety is associated with an increased need for postoperative pain-relief.

Family support and familiar faces in theatre: improving cardiac care

Heart surgery is among the most daunting operations a person can undergo.

The Liverpool Heart and Chest NHS Foundation Trust made changes to the way it organises surgery in late 2017 to try to reduce the anxiety felt by some patients.

Patients are typically admitted 24 hours before their operation, so the trust introduced a system where patients receive a visit from the theatre team after they arrive, who explain what they can expect.

Rotas are planned so at least one member of the team the patient meets will be working the following day, to ensure there is a familiar face when they go to theatre.

Friends and relatives can accompany patients

On the day of surgery, the patient can have friends and relatives accompany them to the area where they wait before being given an anaesthetic, although this has to be paused during the pandemic.

Families are also called directly after the surgery has been completed or, in longer operations, during surgery, to give progress updates.

Changes were also made to the way surgery is organised for people with learning disabilities. These patients are offered a home visit by a safeguarding nurse and an individual plan is put in place, including timing their operation after all other patients have been sent for surgery, to ensure the environment is calmer and quieter.

How can nurses help their patients ahead of surgery?

Preparation is key – and this is where a good pre-operative assessment comes in.

Kingston and St George’s University London senior lecturer in clinical skills and simulation Emily Marron says it is important that people are given clear information about what to expect about the experience, from pre-assessment to post-surgery.

Many hospitals use videos and printed guides for patients to view and read at home, as well as explaining the information to them verbally. Research suggests that patient information leaflets can increase patient knowledge and satisfaction.

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About one in four patients can be classed as very anxious before surgery

Ms Marron says it is a good idea to establish with the patient how much they would like to know. ‘Use your active listening skills, being attentive to what the person is saying to understand their feelings, views and perceptions,’ she says.

She advises that information should be delivered in a clear format. A ‘chunk and pause’ technique, where you break down key sentences or phrases before pausing, can be useful.

‘By chunking and pausing you allow time for the information to be assimilated and questions to be formed and asked by the person,’ she says.

‘Unfortunately, anxiety can be a barrier to effective listening and it is possible that someone who is anxious may adopt a different listening style, such as selective listening – listening out for words or an idea that may validate fears and emotions – or critical thinking, where someone tries to evaluate everything the other person is saying, which can be positive but also can be negatively critical.’

Therefore, it is important to check regularly if they are comfortable with the pace of information.

And, she says, don’t forget that just having a chat about something else can provide a distraction from the person’s anxiety. ‘Ask about holidays or kids – anything that can take a patient’s mind off the surgery and help them relax.’

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‘Too little accessible information and we become anxious, and too much information can produce the same effect if we are imaginative’

Bob Price, pictured, healthcare education and training consultant

Communicating and planning for the patient’s needs

Simple steps to make the waiting rooms for pre-operative appointments more relaxing can make a difference. Having music playing or even a few pot plants can help reduce anxiety, research suggests.

Theatre teams should also discuss and make plans for anxious patients in their daily huddles.

The RCN’s Ms Diedo says it is vital that particularly anxious patients are identified in advance at the pre-operative assessment so that the theatre team can be informed and plan for this.

‘It is all about being prepared and empowering the patient. Anxiety is made worse when people are taken by surprise. If they know exactly what will happen that can make a huge difference.’

She says there are steps theatre teams can take if they know in advance that a person is likely to be anxious, such as numbing skin before a needle is inserted or getting a nurse to act as a chaperone. However, giving medication or sedatives for anxiety is a last resort.

‘I’ve acted as a chaperone,’ says Ms Diedo. ‘It can really make a difference. You are there to provide emotional support, make sure the patient is safe, to reassure and communicate to the patient, and to advocate on their behalf to the rest of the theatre team.

‘For an anxious patient having a general anaesthetic, you can accompany the patient into the anaesthetic room, offer reassurance, hold their hands and stay with them until they are asleep.

‘For patients undergoing surgery under a local or regional anaesthetic, you would stay with them throughout the procedure, ensuring they remain comfortable, explain the procedure and what they may hear and see. If they like, you can even play some music for them.’

Extra support and reassurance for children and parents

There are certain patient groups where extra steps may be needed, the most obvious of which is children.

Dedicated paediatric surgical units adapt the environment to make it more child-friendly, with books, games and decorations.

Waiting is often kept to a minimum and parents may be allowed to accompany their children into theatre until the anaesthetic takes effect and they are unconscious.

Bespoke pre-surgery plans for people with learning disabilities

For people who have learning disabilities, bespoke plans need to be put in place in advance.

These include creating social stories to help the individual understand the situation and allowing them to bring in certain items that may help keep them calm.

Making changes to the environment, such as turning the lights down and having quieter areas for both pre and postoperative stays, can make a difference.

Independent learning disability consultant nurse Gwen Moulster says pre-admission visits to allow individuals to meet staff and look around at the hospital are also important.

How an app is reducing pre-operative anxiety in children

The Little Journey App was launched at Norfolk and Norwich University Hospitals NHS Foundation Trust in 2019. It provides young patients with a virtual tour before they have surgery, taking in the day ward, anaesthetics room and recovery room.

Animated characters, including a virtual reality doctor, nurse and anaesthetist, explain what happens when patients require a general anaesthetic and introduce the equipment that is used. The app can also be used in 3D using a virtual reality headset, and has videos tailored to children in age groups ranging from 3-12.

‘Tangible benefits’ for the NHS and society

Funded by Norfolk and Norwich Hospitals Charity and designed by a student at University College London, the app was first introduced at the trust’s Jenny Lind Children’s Hospital. It is now being used by a number of NHS hospitals and its impact has been assessed by the Eastern Academic Health Science Network.

The network looked at its use across five different sites and found that for every £1 invested in the app there was a ‘tangible benefit’ of £3.50 to the NHS and £6 to society.

For the health system, the saving comes through a decrease in last-minute surgery cancellations, better use of staff time and a drop in pre-medication rates for anxious children. For society, Little Journey brings savings through a reduction in the number of school and work days missed by children and their parents related to the children’s surgery.

Little Journey tinyurl.com/little-journey-app

‘There is much that can be done to reduce anxiety. If there is not a learning disability liaison nurse, seek out support from a community learning disability nurse to help.’

She says it may also be appropriate to coordinate planning so other interventions and treatment can be carried out at the same time, such as dental treatment, phlebotomy, scans or even immunisations.

‘Enabling a range of interventions reduces the need for multiple operations under general anaesthetic and helps minimise anxiety.’

Find out more

European Journal of Medical Research article: Evaluation of preoperative anxiety and fear of anesthesia using APAIS score tinyurl.com/APAIS-anxiety

Anxious and agitated: how to help a nervous patient rcni.com/nervous-patients

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