2. PREOPERATIVE TEACHING CLINIC EFFECTS ON SURGICAL ANXIETY REDUCTION: TO ASSESS THE EFFICACY OF A SURGICAL ORIENTATION VIDEO IN DECREASING PREOPERATIVE ANXIETY Richard D. Kuylen, RN, BSN Lallie Kemp Medical Center Independence, Louisiana

3. PREOPERATIVE ANXIETY Anxiety and pain – subjective elements of the patient experience Can result in an increase in the levels of patients’ experience of pain, which usually requires management through analgesia Can adversely influence anesthetic induction and patient recovery Decrease patient satisfaction with the perioperative experience

4. OPPORTUNITY STATEMENT Participation in a Preoperative Teaching Clinic, on a day prior to scheduled surgery, will significantly decrease preoperative anxiety and facilitate a smooth transition through the surgical process for patients, family members and operating room staff.

5. EXCESSIVE PREOPERATIVE ANXIETY Can lead to pathopysiological responses: * tachycardia * hypertension * arrhythmia * higher levels of pain that may persist into the postoperative period

6. PREOPERATIVE EDUCATION T he process of informing clients about their condition, surgery and postoperative care Prepare patients for surgery and help them to manage their care postoperatively Key to decreased complications and readmission; thus, improving cost effectiveness

7. GOALS OF PREOPERATIVE EDUCATION Provide the means for patients to participate in treatment decisions with full understanding of factors relevant to their proposed care Decrease potential complications through patient education and family involvement Improve postoperative recovery Reduce surgical anxiety Mold attitudes regarding surgery, staff and the facility Clear up misconceptions and inaccurate information Address questions and concerns Provide emotional support Provide thorough and accurate information to patient and family Facilitate smooth flow of surgery schedule

8. METHODS/FORMAT OF PREOPERATIVE EDUCATION One to one instruction Demonstrations Printed materials Videotapes

9. STANDARD PREOPERATIVE EDUCATION Involves the use of verbal instructions by physicians and nurses Often delivered during a brief session prior to the day of surgery Patient memory of instructions often inadequate due to anxiety and feelings of uncertainty

10. PREOPERATIVE VIDEOTAPED INSTRUCTION Enhances learning in patients with low literacy skills Beneficial for elderly patients who have difficulty reading small printed documents

11. LITERATURE REVIEW Patients scheduled for surgery have increased anxiety and fear of the unknown Preoperative period is the time when most patients experience significant fear regarding surgery, complications and level of recovery The more informed and better prepared patients are about what to expect during the surgical experience, the less anxious they tend to be Efficient organization and utilization of resources available in a preoperative clinic results in cost savings via reduction in operating room delays

12. LITERATURE REVIEW (Cont’d) Preoperative teaching clinics improve efficiency in admission and screening of patients Preoperative teaching programs foster : decreased length of stay * less demand for postoperative analgesic * quicker recovery from surgery * decreased infection rate * decreased anxiety

13. THEORY-PRACTICE GAP A Theory-Practice gap identified Preoperative education benefits along with cost effectiveness to institutions and patients are well documented through years of research Many facilities have no formal policy or program for providing structured education Thus, many patients arrive the morning of surgery very anxious and poorly informed

14. Organizational Framework Patient presents to Medicine Clinic or Emergency Room with a complaint/symptom Patient referred to Surgery Clinic for surgical evaluation if clinically indicated Surgery scheduled with OR staff based on surgeon’s evaluation/recommendation Patient provided appointment to Preoperative Teaching Clinic on a day prior to scheduled surgery Family and friends involved in postoperative care encouraged to attend preoperative education

15. Aim/Purpose of Project Aim of project: * Promote awareness of benefits and effectiveness of a Preoperative Teaching Clinic * Encourage development of a Surgical Orientation Video in other LSU Hospitals Purpose of study: * To evaluate the effectiveness of a preoperative surgical orientation video in decreasing anxiety in patients scheduled for surgery with general anesthesia Surgical Orientation Video, developed at Lallie Kemp Medical Center, walks a patient through the surgical process from admit through discharge. By viewing video, patient sees many nurses and anesthesia personnel that will provide care morning of surgery, along with some monitoring equipment used

16. PREOPERATIVE TEACHING CLINIC VISIT Intervention group (n=13) – views a preoperative surgical orientation video and receives surgery-specific preoperative education Control group (n=17)– receives standard preoperative education without viewing the orientation video Surgery and anesthesia-related anxiety evaluated by using a quantitative scale of preoperative anxiety before and after implementing preoperative education and viewing the preoperative video

17. RESEARCH DESIGN T wo - group, pretest / posttest research design Determine significant difference in anxiety levels between: * group that received standard preoperative education (control group) * group that received standard preoperative education, along with viewing the surgical orientation video (intervention group) Sample size : 30 patients (n=30) * randomly assigned to either * intervention or control group

18. HYPOTHESIS The intervention group that also views the video will have less preoperative anxiety than the control group that does not view the video The intervention group will have decreased anxiety after preoperative teaching is implemented The control group will also have decreased anxiety after preoperative teaching is implemented There will be no difference in anxiety between the two groups prior to preoperative teaching

19. METHODOLOGY Principal Investigator (PI) obtained approval to conduct study from the following authorities: * Institution Compliance liaison and privacy officer * LSU HCSD Office of Research and Development * Institution Medical Executive Committee Institutional Review Board of Southeastern Louisiana University (SLU) also granted permission Population consisted of patients seen in the surgery clinic at a LSU HSC Lallie Kemp Medical Center

20. METHODOLOGY (Cont’d) Patients evaluated in the surgery clinic and scheduled for surgery Patients scheduled for preoperative teaching clinic visit for surgery and anesthesia education, on a day prior to surgery Family members involved in postoperative care encouraged to attend preoperative education

21. CRITERIA FOR INCLUSION IN STUDY English - speaking patient Between the ages of 21 and 65 Basic Literacy (able to read and understand) First 30 that met criteria were randomly assigned to: ** intervention group -13 ** ** control group - 17 **

22. SETTING Preoperative Teaching Clinic at Lallie Kemp Medical Center in Independence, Louisiana Patients provided scheduled appointment to see the preoperative teaching nurse when discharged from the surgery clinic Focus on anxiety reduction through surgery - specific preoperative education Preoperative Surgical Orientation Video viewed after preoperative education implemented Krames color illustrated surgical literature used to facilitate preoperative education

23. INSTRUMENTATION Amsterdam Preoperative Anxiety and Information Scale (APAIS) Anxiety Scale * consists of 4 questions (1, 2, 4, 5) * each question scores from 1 to 5 * score is the sum of the four questions, ranging from 4 to 20 Subscales * anesthesia-related anxiety (Sum A=1+2) * surgery- related anxiety (Sum S=4+5) * combined anxiety component Sum C=Sum A +Sum S=1+2+4+5 Scale also includes an information desire component (3+6)

24. AMSTERDAM PREOPERATIVE ANXIETY & INFORMATION SCALE CRONBACH’S CALCULATED ALPHA ESTIMATES FOR ANXIETY COMPONENTS For Anesthesia - Related Anxiety (Alpha.779) For Surgery - Related Anxiety (Alpha.848) For Combined -Anesthesia Component (Alpha.810) For Information - Desire Component (Alpha.730) * Findings confirm the internal consistency and reliability of the measurements * Results also confirm the scales validity for use in preoperative anxiety assessment

25. DATA ANALYSIS & CALCULATIONS SPSS PROGRAM DATA ANALYSIS & CALCULATIONS SPSS PROGRAM  Demographic data * Gender * Age * Educational level * Frequencies and percentages of responses  T- test for differences between control and intervention groups on anxiety * Independent t-test - compares across group means * Paired t-test – compares pre- and posttest scores across each group

26. RESULT EXPERIMENTAL 2-GROUP PRETEST- /POSTTEST DESIGN PURPOSE – to determine if significant anxiety exists between the control and intervention groups SAMPLE – 30 patients (n=30) scheduled for elective surgery with general anesthesia > Randomly assigned to either : * control group (n=17) * intervention group (n=13) > Gender Frequency * Males (n=11) 36.7% * Females (n=19) 63.3% * Age range: 21 – 62 years (m=44.4years) > Educational level * Less than high school – 23 % (n=7) * High school graduate - 70 % (n=21) * Post high school - 7 % (n=2)

27. HYPOTHESIS I Intervention group will have less preoperative anxiety than the control group after preoperative teaching is implemented * Independent sample t- test – conducted to evaluate hypothesis * Post t- test – all p- values greater than.05 Not enough evidence to say that the means are different at the 95% confidence level However, pre-test means in the Intervention group were higher in all categories than pre-test means in Control group Hypothesis I is not supported

28. HYPOTHESIS II Intervention group will have decreased anxiety after preoperative teaching is implemented Paired t- test analysis results (p-value) * anesthesia related anxiety - 0.006 * surgery related anxiety - 0.002 * information desire component - 0.001 * combined anxiety component - 0.003 P- values less than 0.05 – There is enough evidence to say that the means are different at 95% confidence Hypothesis II is supported

29. HYPOTHESIS III The control group will have decreased anxiety after implementation of preoperative teaching Control group t- test results (p- value) * anesthesia related anxiety - 0.227 ( >.05) * surgery related anxiety - 0.039 ( <.05) * information desire component - 0.005 ( <.05) * combined anxiety component - 0.037 ( <.05) Not enough evidence to say that means are different at 95% confidence for anesthesia related anxiety With 95% confidence, there is not enough evidence to say that the means are equal in all other anxiety components Hypothesis III is partially supported

30. HYPOTHESIS IV There will be no difference in anxiety between the two groups prior to preoperative teaching Independent sample t-test results (p-value) * anesthesia-related anxiety - 0.014 (.05) T-test at pre-measure significantly higher in one out of three measures Pre-test means higher in all components in the intervention group than in the control group Hypothesis IV is not supported

31. DISCUSSION/CONCLUSION Participation in a Preoperative Teaching Clinic prior to surgery can significantly decrease preoperative anxiety as evident in this small pilot study Intervention group: significant decrease in mean anxiety between pre and post test analysis for : * anesthesia-related anxiety (p= 0.006) * surgery-related anxiety (p= 0.002) * information desire component (p= 0.001) * combined anxiety component (p= 0.003)

32. DISCUSSION (Cont’d) Control group: significant decrease with preoperative education for : * surgery-related anxiety (p= 0.039) * information desire component (p= 0.005) * combined anxiety component (p= 0.037) No significant reduction in mean anesthesia-related anxiety (p=0.227) shown in the control group compared to intervention group (p=0.006) with preoperative education. Video includes section where Anesthesiologist speaks with patient prior to surgery Perhaps this decreased anxiety in this group! Pilot study showed no significant difference in preoperative education with addition of surgical orientation video as evidenced by independent samples t-test for post test between groups (Table 2).

33. Systems Impacted The LSU HCSD system could benefit from results of this pilot study by improving preoperative education or developing preoperative teaching clinics Preoperative Surgical Orientation Videos specific to each hospital could also facilitate preoperative education

34. Since this was a small pilot study conducted in a rural hospital that caters to a mostly indigent population, future research is indicated to assess the Preoperative Surgical Orientation Video’s effects on anxiety reduction. Larger studies in multiple, non-profit and private hospitals would increase the validity of the findings.