Effect of Patient Education on Patient Anxiety Level Using
"Scale of Patient Education Requirements" in Open Heart Surgery

T?lin Y?ld?z1, Arzu Malak1, Sonay Baltac? G?kta?2, Y?cel ?zen3


1 Nam?k Kemal University School of Health, Department of Surgical Nursing, Tekirdag, Turkey

2 Maltepe University School of Nursing, Department of Surgical Nursing, ?stanbul, Turkey

3 Kartal Kosuyolu Education and Research Hospital, Clinic of Cardiovascular Surgery,? ?stanbul, Turkey

ABSTRACT

Introduction: The purpose of this study is to research whether education according to individuals' needs has an effect on the anxiety after surgery using a scale of patient education requirements on the patients who will undergo heart surgery.

Patients and Methods: The research included voluntary patients who would have an open-heart surgery and are already hospitalized in a heart surgery clinic (n= 114). Data were collected using a demographical data form (state-trait anxiety inventory; STAI) and patient education requirements scale forms, which had been developed by the researchers before surgery and three days later than the surgery by individually meeting the patients. During the hospitalization before surgery, STAI was performed. Further, patient requirements scale was applied. According to patient requirements scale results, the patients were informed at the beginning of hospitalization. On the third day of the surgery, STAI was performed one more time. While evaluating the study data, in addition to descriptive statistical methods, such as frequency, percentage, average, standard deviation, the Kolmogorov?Smirnov distribution test was applied to review normal distribution. Furthermore, paired samples t test was used to compare if parameters had normal distribution for 2 groups, and Wilcoxon sign test was used to compare if parameters had abnormal distribution in the groups. Mann-Whitney U test was used for the comparison of parameters in groups. The results were evaluated at a confidence level of 95%, a significance level of p< 0.05, and an advanced significance level of p< 0.01.

Results: The decrease in the state anxiety level after education according to state anxiety level before education was significant (t= 2.003; p= 0.050). Moreover, the decrease in the trait anxiety level after education was also found to be statistically significant (t= 2.984; p= 0.004).

Conclusion: According to the findings obtained in this study, it was revealed that informing the patients using patient education requirements scale according to individuals' needs decreased individuals' anxiety levels.

Key Words: Patient's education; patient learning needs scale; cardiovascular surgery; anxiety

A??k Kalp Cerrahisinde? "Hasta ??renim Gereksinimleri ?l?e?i" Kullan?larak Yap?lan
Hasta E?itiminin Hasta Kayg? D?zeyi ?zerine Etkisi

?ZET

Giri?: Bu ?al??man?n amac? kalp cerrahisi ge?irecek hastalara ameliyat ?ncesi "Hasta ??renim Gereksinimleri ?l?e?i" kullan?larak, bireylerin ihtiya?lar?na g?re yap?lan bilgilendirmenin ameliyat sonras? anksiyete ?zerine herhangi bir etkisinin olup olmad???n? ara?t?rmakt?r.

Hastalar ve Y?ntem: ?al??maya kalp cerrahisi klini?inde a??k kalp ameliyat? planlanan, hastaneye yat??? yap?lan ve ?al??maya kat?lmaya g?n?ll? olan hastalar (n= 114) dahil edildi. Ara?t?rmac?lar taraf?ndan geli?tirilen demografik veri formu, State-Trait Anxiety Inventory (STAI) ve Hasta ??renim Gereksinimleri ?l?e?i formlar? ameliyat ?ncesi ve ameliyat?n 3. g?n? hastalar ile y?z y?ze g?r??me tekni?i kullan?larak dolduruldu. Ameliyat ?ncesi yat??? s?ras?nda ?ncelikle Durumluluk-S?rekli Anksiyete Envanteri, daha sonra Hasta ??renim Gereksinimleri ?l?e?i uyguland?. Hasta ??renim Gereksinimleri ?l?e?i sonu?lar?na g?re hastalar yat???ndan itibaren bilgilendirildi. Ameliyat?n ???nc? g?n? hastalara STAI tekrar uyguland?. ?al??ma verileri tan?mlay?c? istatistiksel metotlar (frekans, y?zde, ortalama, standart sapma) ile ?zetlendi. Normal da??l?m?n incelenmesi i?in Kolmogorov-Smirnov da??l?m testi, normal da??l?m g?steren parametrelerin iki grup i?in kar??la?t?rmalar?nda e?lenik ?rnekler (Paired samples) t testi, normal da??l?m g?stermeyen parametrelerin grup i?i kar??la?t?rmalar?nda ise Wilcoxon i?aret testi kullan?ld?. Parametrelerin gruplar aras? kar??la?t?rmalar?nda Mann-Whitney U test kullan?ld?. Sonu?lar %95 g?ven aral???nda, p< 0.05 anlaml?l?k d?zeyinde ve p< 0.01 ileri anlaml?l?k d?zeyinde de?erlendirildi.

Bulgular: Hastalar?n e?itim ?ncesi durumluluk kayg? (state anxiety) d?zeyine g?re e?itim sonras? durumluluk kayg? d?zeyinde meydana gelen d???? (t= 2.003; p= 0.050) ile, e?itim ?ncesi s?rekli kayg? (trait anxiety) d?zeyine g?re e?itim sonras? s?rekli kayg? d?zeyinde meydana gelen d???? istatistiksel olarak anlaml? bulundu (t= 2.984; p= 0.004).

Sonu?: Bu ?al??mada elde edilen bulgular, hastalar?n ameliyat ?ncesi Hasta ??renim Gereksinimleri ?l?e?i kullan?larak bireylerin ihtiya?lar?na g?re yap?lan bilgilendirmenin bireylerin anksiyetesini azaltt???n? g?stermi?tir.

Anahtar Kelimeler: Hasta e?itimi; hasta ??renim gereksinimleri ?l?e?i; kalp cerrahisi; kayg? d?zeyi

INTRODUCTION

Surgical interventions have the potential of causing serious psychosocial and psychiatric problems, and surgical operation can be an anxiety source and affect postoperative morbidity. It has been stated that medical complications increased after surgery for patients having high anxiety levels before surgery, increased the duration of hospitalization, and delayed the recovery time(1,2). Education and preparation of patients before surgery had an effect on the patient care after surgery and at the discharge stage. The priority of the information required by surgical patients varies with type of surgery and needs of individual patients. Heart surgery is perceived by most people as a life-threatening event or crisis(3). The survival rate after open-heart surgery applied by cardiopulmonary bypass definitively increased using innovations of anesthesia management and surgical techniques, advances in cardiopulmonary bypass technology, and development of intensive care treatment principles(4). Despite these developments, anxiety and fear of death persisted in patients.

Symbolic meaning of "heart operation" increases fear of death and the risk of preoperative anxiety(5). The most effective approach toward anxious patients has been to reassure and provide psychological support. Patient education had an important role within suggested methods. Education before surgery is an indispensable part of patient care and one of the most important nursing attempts; education provided during this time continues until discharge from the hospital and has an important role for the patient in terms of gaining information regarding surgical intervention and feeling better physically and psychologically(6). It has been important that patient education requirements are fulfilled before and after surgery. Because fulfilling the education requirements positively affected the quality of patient care results(7,8).

In this study, it was aimed to evaluate the anxiety levels of patients before and after surgery by organizing training and determining patient requirements using the patient education requirement scale.

PATIENTS and METHODS

After receiving approval from the ethical committee and department of surgery, this comparative and descriptive study was conducted between February 1 and May 31. Before surgery, (in the course of the application to the clinic) state-trait anxiety inventory (STAI), patient education requirements scale, and demographic survey were conducted for patients supposed to undergo an open heart surgery and hospitalized (n= 114) in heart surgery clinics. Patient requirements were defined according to the patient learning requirements scale; education started before surgery and continued until the discharge of patients. On the third day after surgery, STAI was re-applied to the patients.

While evaluating the findings in the study, Statistical Package Program was used for statistical analysis. While evaluating the study data, in addition to descriptive statistical methods, such as frequency, percentage, average, standard deviation, Kolmogorov-Smirnov distribution test was used to review normal distribution. Furthermore, paired samples t test was used to compare if parameters had normal distribution for 2 groups and Wilcoxon sign test was used to compare if parame-ters had an abnormal distribution in the groups. Mann-Whitney U test was used for comparing the parameters between the groups. The results were evaluated at a confidence level of 95%, a significance level of p< 0.05, and an advanced significance level of p< 0.01.

RESULTS

In total, 114 patients were involved in the study; 86 (75.4%) patients were male and 68 of them were ≥ 61 years old. Further, 46 (40.5%) patients weighed ≥ 81 kg, 106 (93%) were married, and 110 (96.5%) had at least one child. Eighty patients (70.1%) graduated from primary school. General demographic properties for patients are shown in Table 1.


Table 1

The decrease in the state anxiety level after education according to the state anxiety level before education was statistically significant (t= 2.003; p= 0.050 < 0.05). The decrease in trait anxiety levels after education was also statistically significant (t= 2.984; p= 0.004 < 0.05) (Table 2). It was determined that the average trait anxiety level of patients was affected by variables, such as gender, smoking, exercising before and after education.


Table 2

The difference between before and after education trait anxiety levels according to gender was evaluated. The difference between the group average before education (Mann-Whitney U test= 193.50; p= 0.046 < 0.05) and the group average after education (Mann-Whitney U test= 193.00; p= 0.045 < 0.05) was found to be statistically significant (Table 3). The trait anxiety level of females before and after education (n= 49.74, n= 45.23, respectively) was higher than those of males before and after education (n= 43.38, n= 39.95, respectively).


Table 3

The trait anxiety levels were significantly different with respect to the working status of patients (Mann-Whitney U test= 113.00; p= 0.014 < 0.05). Trait anxiety level of unemployed patients (n= 46.41) was higher than those of employed patients before education (n= 40.02) (Table 4).


Table 4

The difference in anxiety levels respect to exercising was significant before education (Mann-Whitney U test= 135.00; p= 0.004 < 0.05) and after education (Mann-Whitney U test= 167.00; p= 0.026 < 0.05) (Table 3). State anxiety levels of patients who were not exercising before and after education (n= 40.49, n= 37.09, respectively) was higher than the? patients who were exercising (n= 31.52, n= 30.48, respectively) (Table 5).


Table 5

It was observed that 26 (22.8%) patients were regularly smoking and 28 (24.9%) were exercising (Table 6). The difference between trait anxiety levels according to the smoking status was not significant before education (Mann-Whitney U test= 221.500; p= 0.395 > 0.05) was not statistically significant. However, the difference was significant after education (Mann-Whitney U test= 155.50; p= 0.030 < 0.05) (Table 6). State anxiety levels of patients (n= 40.31) who were smoking after education was higher than those of patients (n= 34.06) who quit smoking after education.


Table 6

DISCUSSION

It is crucial that nurses determine education requirements considering the education requirements of patients and their families(9,10). In the present study, we showed that informing the patients using patient education requirements scale according to individuals' needs decreased individuals' anxiety levels of patients undergoing open-heart surgery.

Demographic characteristics of our study population was similar to those of previous studies on patients undergoing an open-heart surgery(11,12,13,14).

One of the important targets of the care before surgery is to eliminate the anxiety of patients. The common reasons of anxiety before surgery is pain, fear of disorder, change in body image, being addicted to others, loss of job, and damage of physical integrity. Education before surgery considerably decreases anxiety levels of patient, and the response of patients to treatment become easier(7). In addition, it has been stated that the most effective method to handle preoperative anxiety was educating patients regarding the disease and surgery(9).

Guo et al(15) have stated that education before coronary artery bypass surgery had a positive effect in decreasing the anxiety and stress of patients; they emphasized that education should be routinely provided to all patients. In the study, it was declared that education had no effect on pain. 'In our study pain was not evaluated but the other findings that Guo and his friends(15) obtained were parallel with our findings. In both studies, it has been concluded that education provided before surgery decreased anxiety levels, and recovery became faster. In another study, the efficiency of preoperative education has been studied and it has been observed that programmed preoperative education decreased anxiety levels(16).

Gallagher and McKidney(17) declared that female and old patients who would have coronary artery bypass surgery had more stress and anxiety in the study conducted in 2007. Furthermore, it was concluded that patients were stressed while they were waiting before surgery, and stressors were the awaiting surgery, thinking of pain, being away from home, thinking of dying from disease or surgery, changing lifestyle, requiring help, and knowing of undergoing surgery. In our study, stressors were not defined. Moreover, it was consistent with the state obtained in the study that trait anxiety levels of female patients before and after education (n= 49.745, n= 45.233, respectively) were higher than those of male patients before and after education (n= 43.378, n= 39.946, respectively).

In the study by Asilioglu and Celik(16), 100 patients (50 experiment, 50 control) were examined. In the study, postoperative state and trait anxiety points were found slightly higher than patients in the experimental group. It was concluded that there was no statistical difference between the points of state and trait anxiety levels in groups. In studies conducted by Sidar et al(11), statistical significance was not found between total point average gained by state anxiety scale of patients and trait anxiety scale in postoperative period (t= 0.6, p > 0.05; t= −1.0, p > 0.05). Our study results were consistent with those of the study conducted by Asilio?lu and ?elik(16) and supported the hypothesis that education decreased or eliminates anxiety levels.

Deyirmenjian et al. evaluated the effect of preoperative patient education on anxiety level with Beck anxiety scale in 2006(3). Before surgery, education to the experimental group was provided but the control group had no education. According to the study, significant differences were not found between postoperative anxiety, intubation time, duration of hospitalization, and systolic blood pressure values of two groups. However, statistical difference was found for number of patients who required sedatives in the 2 groups. While in our study, state and trait anxiety points were defined only before and after education; it was inconsistent with the study by Deyirmenjian et al(3), likely because of the different comparison and evaluation criteria.

CONCLUSION

Therefore, it is believed that the education provided to patients of open-heart surgery considering learning requirements for individuals decreases anxiety levels of patients and improves their quality of life by making them feel safe.

LIMITATIONS

The results of the study were limited with the university hospital where the study was conducted. It could not be generalized with other patients who had open-heart surgery.

CONFLICT of INTEREST

The authors declare that there were no conflict of interests in the stage of drafting and publishing this article.

FINANCIAL SUPPORT

The authors declare that they did not take any financial support in the process of researching and writing this article.

AUTORSHIP CONTRIBUTIONS

Concept/Design: TY

Analysis/Interpretation: SG, AM, Y?

Data acquisition: TY, AM

Writing: TY, AM, SG

Critical revision: TY, AM, Y?

Final approval: All of authors

REFERENCES

  1. Milano MR, Kornfield DS. Psychiatry and surgery. In: Grinspan L (ed). Review of psychiatry. 3. cilt, Washington DC: American Psychiatric Press Inc 1984:256-77.
  2. Bekaro?lu M, Uluutku N, Alp K, L?leci N. Ameliyat ?ncesi kayg? ve depresyon durumunun ameliyat komplikasyonlar?na ve yat?? s?resine etkisi ?zerine bir ?al??ma. T?rk Psikiyatri Dergisi 1991;2:285-8.
  3. Deyirmenjian MN, Karam N, Salameh P. Preoperative patient education for open-heart patients: A source of anxiety? Patient Educ Couns 2006;62:111-7.
  4. Rothenhausler HB, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study. Gen Hosp Psychiatry 2005;27:18-28.
  5. Pasnau RO, Fawzy FI, Skotzko CE. Surgery and surgical subspecialties. In: Rundell JR, Wise MG (eds). The American Psychiatric Press textbook of consultation-liaison psychiatry. Washington DC: American Psychiatric Press Inc, 1996:608-39.
  6. Yavuz M. Ameliyat ?ncesi bak?m. In: Karadakovan A, Eti AF (eds). Dahili ve cerrahi hastal?klarda bak?m. 2. bask?. Adana: Nobel Kitapevi, 2010:293-307.
  7. Catal E. Hasta ??renim gereksinimleri ?l?e?i'nin T?rkiye'de ge?erlilik ve g?venirlik ?al??mas?. Dokuz Eyl?l ?niversitesi Sa?l?k Bilimleri Enstit?s? Cerrahi Hastal?klar? Hem?ireli?i Anabilim Dal?, Y?ksek Lisans Tezi, ?zmir, 2007.
  8. Walker JA. What is the effect of preoperative ?nformation on patient satisfaction? Br J Nurs 2007;16:27-32.
  9. Cimilli C. Cerrahide anksiyete. Klinik Psikiyatri 2001;4:182-6.
  10. G?rlek O, Yavuz M. Cerrrahi kliniklerde ?al??an hem?irelerin ameliyat ?ncesi hasta e?itimi uygulama durumlar?. Anadolu Hem?irelik ve Sa?l?k Bilimleri Dergisi 2013;16:8-15.
  11. Sidar A, Dedeli ?, ??kesen A?. A??k kalp cerrahisi ?ncesi ve sonras? hastalar?n kayg? ve a?r? distresi: A?r? d?zeyi ile ili?kisinin incelenmesi. Yo?un Bak?m Dergisi 2013;4:1-8.
  12. ?zer N, K??kar ?, Yurtta? A. Kalp damar cerrahisi klini?inde yatan hastalar?n hem?irelik hizmetlerinden memnuniyeti. Atat?rk ?niversitesi Hem?irelik Y?ksekokulu Dergisi 2009;12:12-9.
  13. Ayd?n ?F. Koroner arter bypass greft ameliyat? ge?iren hastalar?n taburculuk sonras? iki ayl?k d?nemde ya?ad?klar? g??l?kler (Tez). Ankara: Hacettepe ?niv Sa?l?k Bilimleri Enstit?s?; 2000.
  14. ?zcan H. A??k kalp ameliyat? sonras? hem?ireler taraf?ndan verilen taburculuk e?itiminin hastalar taraf?ndan kullan?lma oranlar? (Tez). Edirne: Trakya ?niversitesi Sa?l?k Bilimleri Enstit?s?; 2008.
  15. Guo P, East L, Arthur A. The preoperative education intervention to reduce anxiety and improve recovery among Chinese cardiac patients: a randomized controlled trial. Int J Nurs Stud 2012;49:129-37.
  16. Asilioglu K, Celik SS. The effect of preoperative education on anxiety of open cardiac surgery patients. Patient Educ Couns 2004;53:65-70.
  17. Gallagher R, McKinley S. Stressors and anxiety in patients undergoing coronary artery bypass surgery. Am J Cri Care 2007;16:248-57.

Yaz??ma Adresi

T?lin Y?ld?z

E-posta: tyildiz70@hotmail.com

Geli? Tarihi: 10.10.2014 Kabul Tarihi: 12.01.2015