General Anaesthesia and Day-case
Patient Anxiety
Dr. Mark Mitchell
Faculty of Health and Social Care
University of Salford
Manchester
England.
m.mitchell@salford.ac.uk
(+44) (0)161 - 295 - 6480
INTRODUCTION
In the later part of the 20th Century patients remained
in a hospital bed during their post-operative recovery
period for many days. Patients could also remain in
hospital for a number of weeks.
Watson
(1979) Medical-Surgical Nursing and Related Physiology
Saunders, London.
As a result of the ensuing patient incapacity, the
organisation and delivery of physical aspects of
nursing care dominated.
Aspects such as wound dressings, pain
management, comfort, hygiene, general and
specific pre and post-operative care consumed
much nursing time and intervention.
Pearce (1975) A General Textbook of Nursing: A Compendium of
Nursing Knowledge. Faber and Faber, London.
The model of nursing by Roper, Logan & Tierney
(1980) with a central focus on the Activities of
Daily Living was thereby widely used and highly
appropriate.
Roper, Logan & Tierney (1980) Elements of Nurs: A model for
nursing based on model living. Churchill-Livingston: London.
However, as the surgical assault on the body has
diminished, the need for many such traditional
aspects of physical nursing intervention has also
diminished.
Suhonen et al (2007) Day-case surgical pts health related quality
of life. Int. Jour Nursing Practice. 13(2) 121.
Cutting people open is no longer the focus of modern
day surgery.
Planned and emergency surgery must be separated.
An increase in day surgery is crucial not only for saving
money but also patients recovery quicker.
"In recent years we have seen the biggest changes to
surgical practice since its inception as a medical and
scientific discipline in the nineteenth century.”
Darzi (2007) Saws & Scalpels to Lasers & Robots - Advances in Surg.
London: DoH (p. 6).
We are therefore witnessing the greatest changes to
elective surgical practice in 200 years.
Once back on the ward, post-operative recovery for
the modern surgical patient is now quick and many
patients only require limited physical nursing
intervention.
Kingdon & Newman (2006) Determining pt discharge in an OP surg.
Setting. AORNJ. 83(4) 898.
Such a transformation in surgical practice is
providing the opportunity for a much-needed change
in emphasis for peri-operative nursing intervention
in modern surgery.
Gilmartin (2007) Contemporary DS: Patient experience of discharge
and recovery. Jour Clinical Nursing. 16(6) 1117.
A number of studies, spanning many years, have
consistently reported much patient anxiety prior to
elective day surgery.
Mitchell (2007) Nurs. research into DS: A Lit. Review. Amb. Surgery.
13(4) 1.
Mottram (2009) Therapeutic rels in ds. Jour Clin Nurs. 18(20) 2830.
Many patients have been reported to require an
increased level of peri-operative psychological
support.
Stomberg et al (2008) Clinical pract. & routines for DS in Sweden:
improved nurs. interven. Jour PeriAnesth. Practice. 23(5) 311.
With the demise of many physical aspects of
nursing care, the opportunity in which to provide
more formalised care of this nature may be
emerging.
Tse & So (2008) Nurs. perception peri-op teaching amb. Surg. pts.
Jour Adv Nurs. 63(6) 619.
METHODOLOGY
Purpose To investigate adult patient anxiety prior to
elective day surgery and general anaesthesia.
Aims 1)
Establish the degree of anxiety arising from
elective day surgery and general anaesthesia.
2)
Uncover specific aspects patients find anxiety
provoking.
3)
Gain evidence to help establish more formal
psychological interventions.
A convenience sample of patients scheduled for
elective surgery within three public Day Surgery
Units in the United Kingdom were invited to take part
in the study.
Data were collected over a two year period (2005 2007). The study was part of a larger study (n=674)
gaining the views of day surgery patients.
The questionnaire contained n=59 items and
followed the main themes of the whole study, that is,
questions concerning the environment, hospital
personnel and patient experience of anaesthesia.
However, only the aspects relating to the
environment and general anaesthesia will be
examined here.
RESULTS
Participants (n=460) underwent a variety of surgical
procedures with Gynaecological surgery, General
Surgery and Orthopaedic Surgery being the most
frequent.
Briefly, some of the main descriptive pre-operative
findings –
50% of patients (n=229) desired a detailed level of
information provision.
Additionally, the majority of patients 87% (n=403)
desired this information 1 - 4 weeks in advance.
Level of written information required?
250
(n=460) (50%)
229
200
150
100
78
66
57
50
24
4
0
D
ed
l
i
eta
m
u
i
d
e
M
n
a
t
S
rd
a
d
m
u
i
d
e
/m
l
l
Fu
An
y
ne
o
N
Preferred to receive written information? (n=460) (87%)
200
180
160
140
174
121
108
120
100
80
60
40
31
16
20
0
ks
ks
e
e
e
e
w
w
3
>4
2
1
ek
e
w
w
Fe
ys
a
d
h
w
Fe
rs
u
o
6
ne
o
N
85% of patients experienced some anxiety prior to
surgery and general anaesthesia.
Waiting in turn to go to theatre gave rise to much
anxiety for 59% (n=270) of patients.
Overall anxiety on the day of surgery (n=460) (85%)
250
210
200
150
100
100
68
54
50
25
0
N
A
ot
iou
x
n
s
L
A
e
l
itt
s
u
io
x
n
A
e
t
i
Qu
s
u
o
i
nx
r
Ve
n
A
y
us
o
i
x
t
x
E
ly
e
re m
s
u
xio
n
A
What aspects were anxiety provoking? (n=460) (59%)
300
270
250
190
200
150
149
140
143
129
101
100
50
0
on
i
t
er a
p
O
U
on
c
n
A
es
a
n
s
in
n
s
a
w
e
P
no
cc
k
u
S
Un
it
a
W
The thought of dying during anaesthesia was
anxiety provoking for 48% (n=220) of patients.
Additionally, the thought of not waking up from the
anaesthetic was anxiety provoking for 48% (n=220)
of patients.
Thought of dying during anaesthesia (n=460) (48%)
250
201
200
150
106
116
100
30
50
4
2
0
Th
r
ve
e
N
gh
u
o
t
ry
e
V
lm
a
C
tle
t
i
L
s
s
ce
u
u
n
o
o
xi
re
xi
e
n
n
f
A
A
if
y
D
e
l
r
t
No
Ve
Lit
lm
a
C
Thought of not waking up afterward surgery (n=460) (48%)
250
200
200
150
102
118
100
31
50
4
3
0
Th
r
ve
e
N
gh
u
o
t
ry
e
V
lm
a
C
tle
t
i
L
s
s
ce
u
u
n
o
o
xi
re
xi
e
n
n
f
A
A
if
y
D
e
l
r
t
No
Ve
Lit
lm
a
C
The anaesthetist explaining events prior to surgery
was calming for 78% (n=357) of patients.
Physical contact with the nurse immediately prior to
anaesthesia was desired by 48% (n=220) of patients
although significantly more females preferred this
than males.
Anaesthetist explaining prior to surgery
250
(n=460) (78%)
219
200
150
138
100
73
50
23
6
0
ry
e
V
lm
a
C
tle
t
i
L
lm
a
C
N
oD
ce
n
re
e
f
if
L
A
e
l
itt
u
o
i
nx
s
ry
e
V
A
us
o
i
nx
Holding the hand of a nurse immediately prior to
anaesthesia (n=460) (48%)
250
211
200
157
150
100
63
50
23
1
0
ry
e
V
lm
a
C
tle
t
i
L
lm
a
C
N
oD
ce
n
re
e
f
if
L
A
e
l
itt
u
o
i
nx
s
ry
e
V
A
us
o
i
nx
All items specifically relating to pre-operative anxiety
were also entered into a further statistical test named
‘Factor Analysis’.
This test examines associations between variables,
based on the correlations between them to uncover any
emerging patterns.
…..EXAMPLE - Online clothes/ book stores frequently
state “people who bought this also bought this”. This is
just how factors analysis works.
The items and subsequent themes developed were -
Nurse explaining events
Anaesthetist visiting
Anaesthetist explaining events
Told the length of anaesthesia
Told when can eat and drink again
Told what will happen next
Pre-operative Anaesthetic Information
Thought of anaesthetic mask over face
Thought of losing all control
Though of waking up during surgery
Thought of having to trust strangers
Thought of dying while sleeping
Though of not waking up afterwards
Anaesthetic Catastrophising
Waiting to go to theatre
Thought of removing false items
Thought of arriving at theatre door
Imminence of Surgery
The issues associated here with 1) Pre-operative Anaesthetic Information
(anaesthetists’ visit, anaesthetist & nurse explaining)
2) Anaesthetic Catastrophising
(waking during surgery, not waking afterwards)
3) Imminence of Surgery
(waiting, arriving at theatre door)
could explain 30% of the variance in ratings of anxiety
on the day of surgery.
In more simple terms -
If this Pie chart were
to represent the total
amount of patient
anxiety on the day of
surgery
30% of anxiety can
be explained by
the issues
associated here
with Pre-operative
Anaesthetic
Information
ANXIETY
Anaesthetic
Catastrophising
Imminence of
Surgery
The issues concerning -
Pre-operative Anaesthetic Information
Anaesthetic Catastrophising
Imminence of Surgery
are thereby reasonable predictors of
Increased levels of anxiety on
the day of surgery
SUMMARY
Much patient anxiety was generated under these newly
formed headings of 1) Anaesthetic Information Provision:
Need for information/ uncertainty of information.
Elements
concerning
induction
of
general
anaesthesia such as mask over the face, length of
anaesthesia and trusting strangers.
2) Anaesthetic Catastrophising:
Anxiety regarding intra-operative management
such as waking up during surgery, dying while
anaesthetised or not waking up afterwards.
3) Imminence of Surgery:
Waiting their turn for theatre.
Arriving in the theatre, seeing medical equipment.
CLINICAL RECOMENDATIONS
1) Pre-operative Anaesthetic Information
50% of patients desired a detailed level of information
provision.
This desired level of surgical and anaesthetic
information is required 1 - 4 weeks in advance of the
day of surgery. Initial provision of such information on
the day of surgery was too late for the majority of
patients.
Integrated Care Pathways have been described as
‘structured, patient-centred maps of care” and
inclusion of such aspects of care in this documentation
may be of great benefit to future patient management.
Fisher & McMillan (2004) Integrated care path. for Day Surgery Patients.
Colman: Norwich UK (www.daysurgeryuk.org)
Timmins & McCabe (2009) Day Surgery: Contemp. Approach Nurs. Care
Wiley-Blackwell: UK.
2) Anaesthetic Catastrophising
Misconceptions regarding anaesthesia together with
other aspects of information must again be provided 1 - 4
weeks in advance of surgery.
Catastrophising thoughts such as waking up during
surgery, not waking afterwards or dying under
anaesthesia should be explored in advance as they may
be common amongst patients awaiting anaesthesia (Payne
et al. 2003).
RCoA (UK) have stated patient-centred anaesthetic
information provision for the effective management of
anxiety cannot be underestimated (Lack et al 2003).
Lack et al (2003) Raising the Standard: Info. for patients. RCoA and AAGBI,
London.
Payne et al. (2003) Anaesthesia for day case surg: A survey UK adult
practice. European Journal of Anaesthesiology. 20(4), 311.
3) Imminence of Surgery
The interpersonal skills of the anaesthetist and nurse
can be of great value in limiting anxiety (van der Zee et al.
2002).
van der Zee et al (2002) Influence of premed consult and prep. info on
anxiety patients for cardiac surg. Anxiety, Stress & Coping. 15(2), 123.
Aspects also determined to be of benefit to patients are
close physical support, words of encouragement
(Kaldenberg & Becker 1999) and methods of distraction
(Pearson et al. 2004).
Kaldenberg & Becker (1999) Eval. care by amb. surg patients. Health Care
Man. Review 24(3), 73.
Pearson et al (2004) Best pract DS: Review of evid. Amb. Surg 11(1 - 2), 49.
Suggested Intervention Plan
Intervention
Pre-operative
Information
Anaesthetic
Catastrophising
Imminence of
Surgery
Suggested Intervention Plan
Intervention
Pre-operative
Information
Anaesthetic
Catastrophising
Imminence of
Surgery
Information 1 - 4 weeks in advance for majority.
Detailed level of information for majority.
Both surgical and anaesthetic information.
Planned approach formally documented.
Suggested Intervention Plan
Intervention
Pre-operative
Information
Information 1 - 4 weeks in advance for majority.
Detailed level of information for majority.
Both surgical and anaesthetic information.
Planned approach formally documented.
Erroneous and unhelpful thoughts regarding
anaesthesia explored in advance.
Anaesthetic
Emphasis upon “carefully controlled and
Catastrophising supervised unconsciousness” RCoA (UK).
Emphasize close physical presence of the
anaesthetist and nurse during surgery.
Imminence of
Surgery
Suggested Intervention Plan
Intervention
Pre-operative
Information
Information 1 - 4 weeks in advance for majority.
Detailed level of information for majority.
Both surgical and anaesthetic information.
Planned approach formally documented.
Erroneous and unhelpful thoughts regarding
anaesthesia explored in advance.
Anaesthetic
Emphasis upon “carefully controlled and
Catastrophising supervised unconsciousness” RCoA (UK).
Emphasize close physical presence of the
anaesthetist and nurse during surgery.
Imminence of
Surgery
Close physical support, hand-holding (if
desired) and words of encouragement.
Simple methods of distraction.
Close support from a relative or friend where
possible.
CONCLUSION
The Nursing Profession must naturally always be
guided by medical innovation. However, Nursing is also
professionally obligated to enhance such innovation
and not to be merely instructed by it.
The nursing-based knowledge outlined here has the
potential to be an effective addition to ongoing surgical
and anaesthetic innovation in modern elective surgery.
As the use of Integrated Care Pathways continues to
grow, nursing knowledge regarding formal anxiety
management could be an inclusive aspect.
Finally, it is impossible to completely eradicate all
patient anxiety during the brief episodes of
hospitalisation and limited contact with unfamiliar staff.
However, more taught, planned and deliberate attempts
to manage anxiety more effectively must become a
central feature of modern surgical nursing and occupy
the ground vacated by the now largely redundant
physical intervention approach to surgical nursing care.
M. Mitchell (2009) General anaesth. & patient anxiety.
Nursing. Vol.66 No.5 p. 1059 – 1071.
Jour. Advanced