Running Head: PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 1
Preoperative Anxiety and Postoperative Complications
Courtney Masse & Christine Page
University of New Hampshire

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 2
Preoperative Anxiety and Postoperative Complications
Anxiety, a frequently experienced feeling for most patients preoperatively, is a contributing factor to postoperative complications and pain. Research shows preoperative fear and anxiety affects a patient both physically and mentally. It can change the way a person thinks, feels and acts.
Physiologically, anxiety causes the release of epinephrine into the vascular system, which results in vasoconstriction, increased heart rate, diaphoresis, and an increase in temperature. Due to these physical manifestations, a patient may experience delayed healing and a poorer immune system.
Pain is a postoperative concern for many patients and healthcare workers and evidence correlates increased preoperative anxiety with increased postoperative pain and complications. If anxiety is effectively treated and managed prior to surgery, various postoperative complications related to pain can be avoided. Critiquing and evaluating current literature and studies can help all nurses to utilize evidence based practice to manage preoperative anxiety and therefore decrease the chances of postoperative anxiety and pain.
C linical Practice Question and Clinical Significance
As stated by Lippincott, Williams, and Wilkins (2010), the purpose of a literature review is to acquire knowledge on a topic, evaluate current practices, orient to what the status of evidence base is, and develop evidence-based clinical protocols. Based on evidence found in our preliminary research, many patients experience postoperative pain and postoperative complications. To begin our literature review we wanted to acquire knowledge about the subject and review concepts that could treat our problem statement. The problem statement for our research is that too many patients face postoperative pain and suffer from postoperative complications. The goal of this problem statement is to reduce these postoperative outcomes through clinical practices and interventions. In order to do this we discovered possible causes of postoperative pain and correlated it directly to preoperative anxiety. This has led us to our clinical practice question: does performing interventions

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 3 to treat preoperative anxiety in patients decrease postoperative pain and complications? To address this question we performed a systematic review of literature to discover interventions and important themes that can be implemented into a clinical setting to reduce preoperative anxiety. By doing so, this will enable us to engage in evidence based practice and deliver care to individuals using research-based information for clinical decision making.
Search Strategies
To start the research process, we first explored the University of New Hampshire databases made available on the Diamond Library website. Included on this website are databases such as
CINAHL, which seemed most applicable and useful, Cochrane, Medline, and PubMed. All databases were focused on health care or nursing. After deciding that our problem statement was focused on preoperative anxiety increasing postoperative stress and pain, we decided to search for interventions and processes that may affect preoperative anxiety. Through CINAHL as well as the other databases we first searched terms including "preoperative anxiety" and "postoperative complications." Narrowing our search to view only full text, researched articles, we found researched based articles focused on these two topics first to determine the affects of preoperative anxiety. After learning that it can lead to a complicated recovery and possible pain, we then decided to search terms including "preoperative anxiety" and "nursing interventions." This helped us narrow our search to focus on interventions to prevent postoperative pain and complications related to preoperative anxiety. We only included articles that seemed to have high validity and seemed to be related directly to our topic. We excluded any articles that were not directly related to preoperative anxiety or postoperative complications or the interventions involved with each.
Inclusion Criteri a
Upon researching our topic, there were several guidelines we utilized to identify which articles could be employed in our research and which would not support our study. Among our

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 4 criterion, we included reliability, validity, over all research methodology, limitations involved, clinical significance, and generalizability.
Reliability, as stated by Fain (2009), is the consistency with which an instrument or test measures a particular concept. To critique the reliability of a study it is important to look at the reliability coefficient, which is calculated by looking at stability, equivalence, and homogeneity of the study. The closer the coefficient is to 1.00, the more reliable the study is. To assess reliability, the researcher can use test-retest, internal consistency, and interrater strategies. In terms of our research we included articles involving experiments that we felt had an acceptable reliability coefficient and used at least one of the reliability assessment strategies.
Fain (2009) also defines validity in his text, which, similar to reliability, is the value that refers to the accuracy with which an instrument or test measures what it is supposed to measure. To assess this, researchers conducting an experiment must take content, criterion, and construct into consideration. It is important to ask the question, “Is the test valid for what and for whom?” After reading through several articles, we included those that were in our opinion valid, and therefore very reliable.
Research methodology, or research design, was also looked at when we critiqued and appraised our research articles. According to Fain (2009), a research design is a set of guidelines by which a researcher obtains answers to questions. The researcher should ask, “What is the best way to answer my research question in order to provide the most accurate and interpretable data?”
Depending on the research question, the design can be planned on a broad or narrow spectrum.
Narrow spectrum designs may give more definitive results, but may not be as easily generalizable to entire populations. When conducting our research, we looked at the research designs of each of the studies. If the design seemed to be adequate for testing the research question for that particular study then, using our judgment, we used it in our literature review.

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 5
The limitations that were involved with each study were also a significant indicator of whether or not the research article was practical for our literature review. Some of the articles we found had the limitations listed, but not all, which made this portion of the research fairly difficult.
Because the limitations weren’t listed on some of the article we had to make use of our own judgment in deciding what limitations may have been applicable. Limitations, as defined by Fain
(2009), are aspects within the study that are potentially confounding to the primary study variables.
If we felt a study possessed too many of these confounding aspects we decided to exclude it from our literature review.
Generalizability, an essential feature of results of a study according to Fain (2009), is the extent to which the findings of a research project can be generalized beyond the specific research situation to other situations and groups. “In conducting a study, the researcher needs to consider whether the sample size is too small, to allow generalization of findings” (Fain 2009, p. 236). As researchers we looked at each sample size from the given population for the study. If the sample size seemed significantly small related to the type of research being done, we excluded it from our sources and considered it not representative of an entire population, which in this case is all patients undergoing an operation. However, if the research article could be projected onto a broader spectrum, and generalized to most, if not all, patients experiencing preoperative anxiety or postoperative complications and pain then we considered them for our review of literature.
Clinical significance was the most important aspect guiding our research. By definition clinical significance is findings that have meaning for patient care in the absence or presence of statistical significance. To assess clinical significance researchers should ask, “Why is this test important in terms of clinical practice?” and, “Will it further our knowledge and affect nursing practice?” The results of all research studies that we evaluated were looked at and if determined to be clinically significant, then we included them in our literature review.

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 6
Evidence for Clinical Decision Making and Analysis of Literature Review
According to our literature review, anxiety preoperatively is positively correlated to increased postoperative pain and complications. Several of our articles prove the relation between anxiety and pain, while other articles discuss interventions to decrease anxiety preoperatively. In the article, Does Preoperative Anxiety Level Predict Postoperative Pain?, a meta-analysis study was conducted to review previous literature to determine if preoperative anxiety levels could predict postoperative pain levels. One of the studies reviewed in this article used a statistical analysis to determine if there was a cause and effect relationship between a patient’s anxiety and postoperative pain. Researchers concluded that implementing anxiety-reducing strategies along with analgesics can reduce a patient’s level of pain, and suggested that pre and postoperative anxiety reducing strategies should be implemented along with pain relievers. Another study reviewed in this article determined if anti-anxiety medications preoperatively could control postoperative pain. Placebos were given to one of the two groups, and the other group received anti-anxiety medication. Results showed that the group who received that anti-anxiety medication experienced reduced anxiety and a shorter recovery period. The final study in this article correlated preoperative anxiety and postoperative pain and reported that pain perception increases with anxiety because a patient is more attentive to his or her pain. This study discussed how anxiety produces similar physiological responses as pain such as increased heart rate and restlessness. Researchers found that pain intensity and total analgesic consumption were directly related to preoperative anxiety and depression, and suggest that psychological interventions be implemented before surgery to reduce fear and anxiety.
After reviewing all of the literature throughout the entire article, it can be concluded that anxiety and postoperative pain were significantly related and that nurses should plan to decrease preoperative anxiety for optimal postoperative pain control (Vaughn, 2007).

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 7
Another article we reviewed that shows a relation between preoperative anxiety and postoperative pain and complications is the article, Preoperative Anxiety, Postoperative Pain, and
Behavioral Recovery in Young Children Undergoing Surgery. This study was conducted to determine if increased preoperative anxiety in children predicted a slower and more painful postoperative recovery. It involved 241 children aged 5 to 12 years scheduled to undergo elective outpatient tonsillectomy and adenoidectomy. The children’s pain was measured by parental assessment using a 15-item Postoperative Pain Measure for Parents (PPMP), the child’s report of pain using the Bieri Faces Scale, by measuring analgesic consumption, observing separation and general anxiety after surgery, examining eating difficulties/ improvement, and monitoring sleep patterns. This article found that increased anxiety preoperatively in children was associated with an increase in pain, analgesic consumption, general anxiety, sleeping problems, and decreased postoperative eating improvement. This article concludes that decreasing preoperative anxiety will result in improved postoperative recovery (Kain, 2006).
An article we reviewed regarding interventions to decrease anxiety is titled, Reducing
Anxiety by Pre-Operative Education: Make the Future Familiar. The purpose of this research was to gain an understanding of how the preoperative education process is beneficial in reducing anxiety for patients awaiting a total hip replacement. Data was collected from observations, interviews with patients, and documentation. The participants for this study were health care professionals who attended the pre-operative education programs during the nine-month data collection period, and a sample of patients who attended the programs. This article found that preoperative education reduces anxiety because it allows the patient to know what to expect. Many patients anxiety stems from the fear of the unknown, and if the unknown is decreased or eliminated through education and awareness, the patient is likely to feel less anxious during their stay in the hospital. The patient can experience anxiety from the unfamiliar experiences (surgery), staff, and environment. This article

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 8 concluded that health care providers should educate patients on what to expect during the surgery, familiarize them with the staff so the patient feels comfortable, and familiarize the patient to the new hospital environment (Spalding, 2003).
In the article, Abdominal Surgery, Pain and Anxiety: Preoperative Nursing Intervention, a randomized control study was performed to examine the effects of preoperative nursing interventions for anxiety preoperatively and postoperatively and how these interventions effected pain after surgery in patients undergoing abdominal surgery. This study consisted of two groups, the control group and experimental group. Both groups received routine care preoperatively such as physical preparation and education about the procedure. The experimental group also received preoperative interventions for pain while the control group did not. These interventions included explaining the causes of pain and feelings likely to occur after the operation, explaining the influences of postoperative pain and the importance of pain management, teaching how to decrease pain with non-medicinal pain-relief methods, encouraging requests for analgesics after surgery if pain is felt, and encouraging expression of feelings and answering questions. A structured questionnaire including an anxiety scale, pain attitude scale, and Brief Pain Inventory was then used after surgery to assess the results. The study’s results showed that patients who received preoperative pain interventions had a significant decrease in preoperative anxiety and postoperative pain. This study concluded that preoperative nursing interventions for anxiety and pain has positive effects for patients undergoing surrey and the interventions in this study should be used in the future by other nurses to improve patient care (Lin, 2005).
Another article we reviewed is titled, The Effect of Music on Preoperative Anxiety in Day
Surgery . This study used a randomized control trial to determine if patients who listen to music during their preoperative wait will have lower levels of anxiety than patients who receive routine care. In the article it states, “The theoretical basis for music as an intervention for anxiety lies in its

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 9 ability to promote relaxation through the autonomic nervous system. It is believed that the auditory stimulation of music occupies a number of neurotransmitters, thereby diverting feelings of anxiety, fear and pain and resulting in a more positive experience” (Cook, 2005, p. 48). The researchers of this study examined previous studies on the effects of music and preoperative anxiety and determined that further research needed to be conducted in order to be able to generalize the findings. The participants consisted of 60 patients, over the age of 18, on a surgical unit. Patients were unable to participate if they had preoperative sedatives, did not like music, were hearing impaired or had difficulty wearing headphones, could not read and write English, or had anticipated preoperative waiting time of less than 45 minutes. Pre and post-test measures of anxiety were carried out using the State-Trait Anxiety Inventory. Results of this study showed that music significantly reduces anxiety levels. The study concluded that nurses should spend time with patients before surgery to reduce anxiety since results have correlated preoperative anxiety with postoperative pain. Since music is an easy and convenient way to reduce anxiety, nurses should incorporate music therapy into their interventions (Cook, 2005).
The final article we reviewed regarding interventions to decrease anxiety is titled, The
Impact of Therapeutic Relationship on Preoperative and Postoperative Patient Anxiety.
This study used a randomized clinical trial design consisting of 120 patients who attending the surgery clinical at Ataturk University Hospital in Erzurum, Turkey to determine if the Peplau’s Interpersonal
Relations Model was effective in decreasing preoperative and postoperative anxiety. The central element of Peplau’s model is to develop a therapeutic relationship between patient and caregiver
(Erci, 2008). There are four phases of Peplau’s model in the nurse- patient relationship: orientation, identification, exploitation, and resolution. In the orientation phase, the patient has a felt need and looks for professional assistance. In the identification phase, the patient begins to respond to those who offer the help needed. In the exploitation phase, the relationship is at its fullest and the greatest

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 10 amount of benefit is achieved. In the resolution phase, the patient is able to strengthen his or her ability to stand alone and no longer feels psychologically dependent on others. Researches in this study divided the subjects into a study group and a control group. The researchers worked with patients in the study group throughout each phase of Peplau’s model and developed therapeutic relationships with each patient. The researchers helped patients talk through their anxiety and identify areas of fear and concern, and helped the patients get over these concerns. Results showed that the anxiety level of patients in the study group decreased considerably before surgery. There was also a significant difference between the study group and the control group in terms of the mean anxiety score postoperatively and before discharge from the hospital. This study concluded that nurses should use Peplau’s model as an intervention to decrease anxiety preoperatively and postoperatively (Erci, 2008).
Recommendations for Nursing Practice
Based on our research, we found that preoperative anxiety and postoperative pain and complications are significantly related, therefore nurses should implement interventions in order to decrease this anxiety. Several of our articles discussed effective interventions to decrease anxiety such as patient education, music therapy, and therapeutic relationships. Nurses should preoperatively plan for patients with high levels of anxiety in order to predict postoperative pain levels, which can lead to further complications and delayed healing time. As nurses, it is our job to do everything we can to make our patients time at the hospital as agreeable as possible under the given circumstances, and since research proves that decreasing anxiety can promote healing and decrease pain postoperatively, we should employ these interventions into practice. Nurses should implement pharmacologic methods to decrease anxiety as well as be open to non-pharmacologic methods such as therapeutic touch, patient education, music therapy, and deep breathing exercises.

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 11
There are several limitations in our research. Although anxiety can be measured objectively, it is a subjective feeling as well. All of our articles used different methods of measurement, and therefore may be inconstant compared to one another. Another limitation is that the article
Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing
Surgery is limited to children and is not aimed to examine pain across age groups. The study assumes that the results found is not age dependent and can be applied to various populations, which may not be accurate. In the study Abdominal Surgery, Pain and Anxiety: Preoperative
Nursing Intervention , the participants were only undergoing abdominal surgery, which could limit the reliability of the results to different kinds of surgery. The studies also all suggest that further research be conducted to prove that the correlation between preoperative anxiety and postoperative pain is clinically significant. Future nursing research should involve different and most effective ways to reduce patient anxiety as well as determine the clinical significance between preoperative anxiety and postoperative complications.
Conclusion
After evaluating the results from each of the studies we reviewed, we can conclude that interventions used to decrease anxiety preoperatively will decrease pain and other complications postoperatively. Anxiety is a major concern before surgery for most patients, and since research shows that there are effective ways to decrease this anxiety as well as the negative effects it can cause postoperatively, nurses should integrate anxiety-reducing methods into their care plans. According to our research, therapeutic relationships, patient education, and interventions such as music therapy can significantly reduce anxiety. Pain postoperatively can lead to further problems after surgery such as respiratory complications from failure to perform deep breathing exercises due to the discomfort, as well as the development of negative attitudes due to the inability to see a full recovery in the near future. These postoperative complications will in turn lead to an increased

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 12 recovery period and longer stay at the hospital, which is not in the best interest of the patient or the hospital. Nurses should strive to do everything they can to make a patients time in the hospital as complication free as possible, and anxiety reducing methods should be a top priority for patients undergoing any kind of surgery.

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 13
Citation
Authors, Year
(List full citation under references)
Lin, L., & Wang, R.
(2005). Abdominal surgery, pain and anxiety: preoperative nursing intervention.
Journal of
Advanced Nursing,
51(3), 252-260.
Retrieved from
CINAHL Plus with
Full Text database.
Cooke, M.,
Chaboyer, W.,
Schluter, P., &
Hiratos, M. (2005).
The effect of music on preoperative anxiety in day surgery. Journal of
Advanced Nursing,
52(1), 47-55.
Purpose of the study
Examine the effects of preoperative nursing intervention for pain on abdominal surgery patient’s preoperative anxiety, and pain attitude, and postoperative pain.
Examine the effects of music on preoperative anxiety in patients involved in day surgery.
Erci, B., Sezgin, S.,
& Kacmaz, Z.
(2008). The impact of therapeutic relationship on preoperative and postoperative patient anxiety.
Australian Journal of Advanced
Nursing, 26(1), 59-
66. Retrieved from
CINAHL Plus with
Full Text database.
Sample
(number, characteristics, setting)
Patients about to have surgery of the stomach, bowel, liver or spleen in a medical centre in southern Taiwan between the ages of
20 and 70.
Design type
Variables: dependent / independent
Design type : experimental, randomized control study.
Dependent : Effect of interventions on preoperative and postoperative anxiety.
Independent:
Preoperative intervention.
Data source or instrument
A structured questionnaire was administered in preoperative and postoperative period in order to evaluate the effects of intervention.
Limitations
Patient’s perceptions of pain and anxiety may differ, the type of abdominal surgery performed and the success of the surgery may differ among patients, which would affect the amount of post-operative pain and anxiety.
Findings & Implications
Preoperative nursing intervention significantly decreased patients overall preoperative pain and anxiety, preoperative pain attitude, and pain perception of patients having abdominal surgery. These positive effects of the nursing intervention implicate that nurses should implement preoperative interventions into practice.
Determine the effectiveness of Peplau’s
Interpersonal
Relations
Model on preoperative and postoperative patient anxiety.
A group of 60 patients, over the age of 18, on a surgical unit undergoing procedures such as orthopedic surgery, cystoscopy, and biopsy. Patients un able to participate were those who had preoperative sedatives, did not like music, were hearing impaired or had difficulty wearing headphones, could not read and write
English, or had anticipated preoperative waiting time of less than 45 minutes.
120 patients who attended the surgery clinic at Ataturk
University Hospital in Erzurum, Turkey between June 1 and
October 30, 2004.
Design Type : experimental, randomized control study.
Dependent : effect of music therapy on preoperative anxiety.
Independent : music therapy
Design Type :
Randomized
Controlled trial
Dependent :
Anxiety levels preoperatively and postoperatively.
Independent :
Implementation of
Peplau’s
Interpersonal
Relations Model.
A questionnaire with a Likerttype scale was given as pretest and posttest.
The range of age may affect the results, how the patient may view or handle stressful situations may differ, the number of previous hospital visits and surgery by each patient may differ, the type of surgery each patient is receiving may differ.
All of these may affect the patient’s anxiety and stress level in experimental, placebo, and control groups.
Data was collected using the Beck
Anxiety
Inventory, a
Likert scale survey, and a questionnaire related to demographic information about each patient.
The study sample only reflects one group of patients in Turkey and therefore cannot be generalized to all patients in Turkey or other countries. The study also used the BAI scale, which may be perceived differently by each patient.
These findings support the use of music as an independent nursing intervention for patients experiencing preoperative anxiety before day surgery.
II
The study concluded that the implementation of
Peplau’s Interpersonal
Relations Model significantly decreased patient’s anxiety.
Therefore nurses could use this model to intervene when necessary to decrease patient anxiety preoperatively and postoperatively.
II
Rating* of level of evidence level
II

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 14
Kain, Z., Mayes, L.,
Caldwell-Andrews,
A., Karas, D., &
McClain, B. (2006).
Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics ,
118 (2), 651-658.
Retrieved from
CINAHL Plus with
Full Text database.
This study was conducted to determine if increased preoperative anxiety in children predicted a slower and more painful postoperative recovery.
Spalding, N. (2003).
Reducing anxiety by pre-operative education: make the future familiar.
Occupational
Therapy
International, 10(4),
278-293. Retrieved from CINAHL Plus with Full Text database.
The purpose of this research was to gain understanding of how the preoperative education process is beneficial in reducing anxiety for patients awaiting a total hip replacement
Vaughn, F.,
Wichowski, H., &
Bosworth, G.
(2007). Does preoperative anxiety level predict postoperative pain?.
AORN Journal ,
85 (3), 589.
Retrieved from
CINAHL Plus with
Full Text database.
The purpose of this study was to determine of preoperative anxiety levels could predict postoperative pain levels
This study involved
241 children aged 5 to 12 years scheduled to undergo elective outpatient tonsillectomy and adenoidectomy at
Yale-New Haven
Children's Hospital between July 1998 and January 2004
This is a longitudinal, controlled cohort study that followed the children 5 days before the surgery until 14 days postoperatively. It was a quantitative, non-experimental study that divided the children into two groups: high anxiety ( n =44) and low anxiety ( n =
197). The dependent variable was postoperative pain and complications and the independent variable was preoperative anxiety level.
The participants in this study were a convenient sample of voluntary health care professionals who presented information on preoperative education during a nine-month data collection period, and a sample of patients who attended the program
This study involved a review of previous literature to evaluate the presence and significance of any correlation between preoperative anxiety and postoperative pain. The studies reviewed the significance of anxiety and postoperative pain in the healing process as well as if there was a correlation between anxiety and pain.
This was a qualitative study that evaluated whether patient education decreased preoperative anxiety. It was a non-experimental study with no manipulation of certain groups.
Only surveys, interviews, and patient’s experiences regarding patient education before surgery were looked at. The dependent variable was patient’s anxiety level and the independent variable was patient education before surgery.
This study is a meta-analysis systematic review of previous literature regarding the relationship between preoperative anxiety and postoperative pain.
Data that was used included parental assessment of children’s postoperative pain using a
15- item
Postoperative
Pain Measure for Parents
(PPMP), child report of pain using the Bieri
Faces Scale, measuring analgesic consumption, observing separation and general anxiety after surgery, eating difficulties/ improvement, and monitoring sleep patterns.
Data was collected from observing five pre-operative education programs, 26 written patient evaluations,
16 interviews with seven presenters of the education, observation of three team meetings, 20 interviews with
10 patients, and documentation pertaining to the program
This article was the first pediatric study in this area that carefully controlled all possible confounding variables such as surgical procedure, surgical technique, patient population, anesthetic management, and postoperative pain management. The study was also not aimed to examine pain differences across age groups. This study assumed that the association between preoperative anxiety and postoperative pain and behavioral changes are not age dependent.
Limitations of the study were not being able to control for researcher bias and not providing a standardized instrument to collect data. It was recommended that further research be carried out to understand the dynamics between patient education and the reduction of anxiety among patients undergoing hip replacements.
This studied showed that increased anxiety before surgery in children is associated with increased postoperative pain, analgesic consumption, general anxiety, and sleeping problems and decreased postoperative eating improvement.
Decreasing anxiety of children preoperatively will result in improved postoperative recovery
Patient education reduces anxiety by making the unknown more familiar.
Nurses should explain the experiences the patient may experience during and after surgery, give the patient a chance to meet the staff to familiarize them with the staff, and experience the new environment to comfort patients about their future stay.
IV
VI
The date source for this study is the previous literature reviews. The researchers used medical databases to find relevant literature. The results were related to anxiety and pain and then the researchers investigated for studies correlating the two.
Studies reviewed were inconsistent in regard to methodology and control variables. Only two articles reviewed looked at preoperative pain levels. The studies differed in patient populations, surgical procedures performed, postoperative measures used, and statistical analyses performed.
The literature showed a correlation between preoperative anxiety and postoperative pain. This article showed that identifying high levels of preoperative anxiety could allow health care practitioners to anticipate increased postoperative pain. Nurses should treat preoperative anxiety through medications, relaxation techniques, and education to improve pain control postoperatively.
Preoperative planning for patients with increased anxiety should be implemented for optimal postoperative pain control
V

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 15
Scale for levels of evidence used for Evidence Based Nursing
Level I:
Level II:
Level III:
Level IV:
Level V:
Level VI:
Level VII:
Evidence from a systematic review or meta-analysis of all relevant RCTs or evidence-based clinical practice guidelines based on systematic reviews of RCTs
Evidence obtained from at least one well-designed RCT
Evidence obtained from well-designed controlled trials without randomization
Evidence from well-designed case-control or cohort studies
Evidence from a single descriptive or qualitative study
Evidence from systematic reviews of descriptive and qualitative studies
Evidence from the opinion of authorities and/or reports of expert committees
*Chart above taken from: Melnyk BM, Fineout-Overholt E. "Making the case for evidence-based practice." In:
Evidence-based practice in nursing & healthcare - a guide to best practice. Philadelphia: Lippincott Williams &
Wilkins; 2005. p. 3-24 [PUT IN APA]

PREOPERATIVE ANXIETY AND POSTOPERATIVE COMPLICATIONS 16
Works Cited
Cooke, M., Chaboyer, W., Schluter, P., & Hiratos, M. (2005). The effect of music on preoperative anxiety in day surgery. Journal of Advanced Nursing, 52(1), 47-55.
Erci, B., Sezgin, S., & Kacmaz, Z. (2008). The impact of therapeutic relationship on preoperative and postoperative patient anxiety. Australian Journal of Advanced Nursing, 26(1), 59-66.
Retrieved from CINAHL Plus with Full Text database.
Fain, J.A. (2009). Reading, understanding, and applying nursing research . Third Edition.
Philadelphia: F.A. Davis Company.
Kain, Z., Mayes, L., Caldwell-Andrews, A., Karas, D., & McClain, B. (2006). Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery.
Pediatrics , 118 (2), 651-658. Retrieved from CINAHL Plus with Full Text database.
Lin, L., & Wang, R. (2005). Abdominal surgery, pain and anxiety: preoperative nursing intervention. Journal of Advanced Nursing, 51(3), 252-260. Retrieved from CINAHL Plus with Full Text database.
Lippincott, Williams, & Wilkins. (2010). Finding and reviewing research evidence. (PowerPoint
Slides).
Spalding, N. (2003). Reducing anxiety by pre-operative education: make the future familiar.
Occupational Therapy International, 10(4), 278-293. Retrieved from CINAHL Plus with
Full Text database.
Vaughn, F., Wichowski, H., & Bosworth, G. (2007). Does preoperative anxiety level predict postoperative pain?. AORN Journal , 85 (3), 589. Retrieved from CINAHL Plus with Full
Text database.