Effect of Providing “Intra-operative Status Information” on Family Members’ Anxiety

Introduction

The family members in the waiting lounge of the operation theatre, when their loved one is undergoing surgery, face certain levels of anxiety not only about the life and safety of their dear one, but they are also curious and eager to know about what is happening inside the operation theatre. They are obviously in desperate need of the information on these issues and as the time passes, their anxiety increases.

The family members of the patient are anxious during the intra-operative waiting period [1]. This anxiety is of temporary period, hence, called as “State anxiety.” Whereas Trait anxiety is how individual generally feels, his/her tendency/characteristics. Trimm, et al. [2] stated that stress and anxiety during waiting period in the hospital and surgery enhances physical and psychological reaction of the family members. Psychological support to these family members during this period when their loved one is undergoing surgery is fundamental and imperative [3, 4].

The family faces certain levels of anxiety while sitting in the waiting lounge outside the operation theatre. This experience is almost similar irrespective of their nationality, culture, education, socio-economic status, age and gender. When the family has control over the situation, they may be able to manage their anxiety. On the contrary, the family members experiences loss of control over the situation and their emotions due to lack of information from the hospital staffs or when they are unable to acquire information from any other source during this period of temporary separation from their patient. These situations create and aggravate their anxiety. As the time for surgery prolongs, the anxiety levels of family members usually rises. Sometimes they may misinterpret what they don’t see during this period. Hence, they desperately need some help during this period to manage their anxiety and cope up with the situation.

The phenomenon of anxiety is infectious and it can incubate and spread very quickly to others and later on to the patient. Hence, reducing family members’ anxiety is crucial in order to enhance recovery and improve health of their patient. Imparting information is considered as an important and integral part of healthcare. Information about the current situation of their patient may help to eliminate family members’ anxiety. Information should be honest, comprehensive, easy to understand, and should be provided to the relatives without waiting for them to ask for it. This kind of information about the current status of patient’s health should be provided from time to time or at regular intervals to minimize the anxiety levels of family. However, numbers of hospitals in India do not have these additional support services, especially during the intra- operative period. Trained operation theatre nurse, medical professional or authorized and trained person can provide brief information about the patient’s current status to the family members during waiting period.

Methodology

Quasi experimental Pre and post-test design was used for this study. The objective of the study was to compare anxiety of relatives from experimental and control group: in the beginning i.e. after the last eye to eye contact with the patient, and later when the patient was shifted to the recovery room at the end of the surgical procedure.

In this study, what we meant by “intra-operative information” was “the facts told about the patient’s health status during the intra-operative period.” This status report of the patient undergoing cardiac surgery with the permission and approval of the operating surgeon and the anesthetist usually lasted for 3-5 minutes. The intra- operative information included was:

i. Physiological status of the patient ii. Stage of the operation iii. The patient would be transferred to the recovery room after the surgery iv. They could visit the patient after the patient was shifted to the recovery room. The Investigator avoided mentioning specific time frames.

• Sample: Patients who were undergoing open heart surgery, either valve replacement or coronary bypass grafting, were focused and family members of these patients like father, mother, brother, sister, husband, wife, son, daughter were included in this study. Non probability convenience sampling of total 50 relatives (25 in each group - control and experimental respectively) who were above 18 years of age and who could understand and speak Hindi, Marathi or English and gave consent, were included. Investigator assigned first few weeks for relatives from control groups and later weeks for experimental group. This was done in order to avoid contamination of information among relatives during this study.

• Hypothesis:

H0 : There was no significant difference in the state anxiety of the relatives from both the groups.

H1 : At the end of the surgical procedure, there was a significant decrease in the state anxiety of the relatives from the experimental group.

• Tool:

a) Demographic data sheet: This sheet consisted demographic data of the patient’s family members who were in the waiting room during their patient’s surgery.

b) STAI inventory: Anxiety is subjective in nature, hence, self-reporting technique was used to obtain data related to state and trait anxiety of family members. State and trait anxiety inventory (STAI) form-Y1 and form-Y2 developed by Spilberger, were the most suitable one, hence chosen for obtaining data on anxiety of relatives in this study.

• Validity of tools: Demographic data sheet for relatives was subjected to “construct, content validity” along with its adequacy and relevance to the study. Validity was done by total 11 experts from surgery, nursing, psychiatry and psychology fields. STAI tool was translated into Hindi and Marathi languages. The validity of this tool was established by language experts followed by its retranslation into English language.

• Reliability of tools: Cronbach’s alpha for the STAI ranges from 0.92 to 0.94, hence, this tool was statistically reliable.

• Pilot study: A Pilot test was conducted on 5 family members from control and experimental group each after their consent. This Pilot study results were comparable with respect to the age, gender, educational status and operation done. The analysis showed that anxiety levels of relatives increased significantly towards the end of the operation, whereas it decreased in the experimental group. This Pilot study also confirmed that both the tools were reliable for this study.

• Ethical consideration: Informed verbal consent was obtained by relatives from the pilot study as well as the main study. Written permission was obtained by the hospital authorities and the ethical committee. Data was coded, and privacy and security of data was maintained throughout the study.

Results

Study sample consisted of 29 male and 21 female family members with a mean age of 39 years, ranging from 18 to more than 57 years of age; 9 were adult children of the patient, and the remaining family members were spouses (n = 16), siblings (n = 11), parents (n = 14). Of the participants; 6 were illiterate, 1 had completed primary education, 38 had completed secondary education and 5 were graduated. Table 3 shows that the majority of family members i.e. 72 percent from the control and 64 percent from the experimental group had previous experience of hospitalization either as a patient, as a care-giver or both.

(Scores are in percentages) Table 3: Previous experience of hospitalization of family members.

52 percent of family members from the control group had previous experience of surgery and 48 percent did not have any experience of surgery as reported in Table 4. In contrast, Table 4 also demonstrates that only 28 percent of family members from the experimental group had previous experience of surgery and 72 percent did not have any experience of surgery, so, it was their “first time waiting” for the loved one’s surgery.

(Scores are in percentages) Table 4: Previous experience of surgery of family members.

Table 5 confirms no significant difference was found between the groups’ state and trait anxiety scores during pre-test. In contrast significant difference (t value = 8.76 and p value= <0.01) was found in the post-test state anxiety scores of the family members from both the groups. One relative refused to fill the form at the time of posttest hence n=24 for posttest.

df= Degrees of Freedom NS= No Significant Difference SD= Significant Difference Table 5: Comparison of anxiety scores of family members from both the groups.

Table 6 and Table 7 illustrate that there was no significant difference between trait anxiety scores of relatives who had and who did not have previous experience of hospitalization. Post-test State anxiety scores of relatives from both the groups who did have (t value=6.43 and p value=<0.01) and who did not have previous experience of hospitalization (t value=5.55 and p value=<0.01) showed significant difference at the end of the surgery.

df= Degrees of Freedom NS= No Significant Difference SD= Significant Difference Table 6: Comparison of anxiety scores of family members who had previous experience of hospitalization.

df= Degrees of Freedom NS= No Significant Difference SD= Significant Difference Table 7: Comparison of anxiety scores of family members who did not have previous experience of hospitalization.

Table 8 and Table 9 illustrate that there was no significant difference between trait anxiety scores of relatives who had and who did not have previous experience of surgery. Post- test State anxiety scores of relatives from both the groups who did have (t value=5.2 and p value=<0.01) and who did not have previous experience of surgery (t value = 6.43 and p value=<0.01) showed significant difference at the end of the surgery (Table 8 and Table 9).

df= Degrees of Freedom NS= No Significant Difference SD= Significant Difference Table 8: Comparison of anxiety scores of family members who had previous experience of surgery.

df= Degrees of Freedom NS= No Significant Difference SD= Significant Difference Table 9: Comparison of anxiety scores of relatives who did not have previous experience of surgery.

Figure 1 shows interesting findings regarding state anxiety levels of family members from both the groups at the beginning and at the end of the surgery. Figure 1 shows that family members from the control group experienced 16 percent mild and 64 percent moderate state anxiety score which decreased to 4 percent and 48 percent respectively during post-test period. In contrast, percentages of severe state anxiety score of relatives from the control group was doubled during post-test - i.e. from 20 percent, it rose to 48 percent. In figure 1, we also see an entirely different picture of the family members from the experimental group. There were 8 percent of relatives, who experienced mild state anxiety. This percentage increased to 60 percent during post-test. The number of relatives with moderate anxiety levels reduced from 56 percent in the pre-test to 36 percent in the post-test. Severe anxiety levels as experienced by the family members from the experimental group as noticed in the pre-test was observed to be alleviated during post-test period, that is to say, no relatives from experimental group experienced severe state anxiety levels during post-test.

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Figure 2 shows percentages of trait anxiety scores of family members from both the groups. Trait reveals overall nature of anxiety of that individual. It was important to compare trait anxiety with state anxiety, because trait affects how individual experiences situational anxiety i.e. state anxiety. Intra-operative period enhances situational anxiety among family members. Figure 2 reveals mild (32, 28), moderate (64,52) and severe (4,20) trait anxiety percentages of family members from the control group and the experimental groups respectively.

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Discussion

The family members are anxious during intra-operative period in spite of variation in length and type of surgery [5] and this is irrespective of their nationality, cast and creed, age, gender, educational and socioeconomic status. Family is separated from the loved one for temporary period, but their need for the patient’s health-status information is greatly increased during this period. Number of studies confirmed this statement. For example, Carmody, et al. [6] revealed that family members expressed the need for this information as the highest priority during peri-operative period. Likewise Sayin, et al. [7] studied around 200 family members who expressed need for more intra-operative information.

Intra-operative waiting period is challenging for the family members. Trimm, et al. [2] reported balancing emotional equilibrium during waiting period was the main concern of the family members. Hence reducing anxiety is the need of the family members during intra-operative period. If these needs are not met with, their anxiety may be transferred to other family members during waiting period [8] as well as later to their patients. Family members are unable to provide required support to their patients after the surgery; because they are psychologically entangled in their own apprehension, anxiety, feeling of helplessness and desperation about patient’s health along with the outcome of surgery. They are struggling, fighting and seeking support from the hospital service providers to face such a situation.

This study confirms that providing intra-operative information helps the family members manage their anxiety during waiting period. Number of researchers support the findings of this study. For example, Eldridge, Ruth [4] reported that patients’ relatives were benefitted with intra- operative progress report during cardiac surgery. Likewise, Leske JS [1] conducted four group quasi-experimental post- test during intra-operative period. Results revealed that the group, who received “in-person progress report” about the patient’s health status, reported lower anxiety scores as compared to other three groups. Mi and Vasuki [9] stated that surgical progress reports via Short Message Service (SMS) reduced the anxiety of the family members during intra-operative period. Muldoon, et al. [8] issued “family care card” to 47 family members who were waiting during the surgical procedure on their loved ones. This card consisted information regarding the surgical procedure and estimated time, instructions for relatives during waiting period, instructions related to interactions with volunteers, and phone numbers for the contact. Muldoon, et al. [8] reported that majority (55percent) of the family members expressed that family care card helped them to reduce their anxiety during waiting period.

Trecartin, et al. [10] studied 151 family members waiting during invasive cardiac procedures on their loved ones. This was a study conducted on three groups, i.e. Group 1 (50 family members who received standard of care), Group 2 (50 family members who received standard of care and informational report), Group 3 (51 family members who received standard of care and informational report and were allowed post procedure visit). State anxiety was lowest in the Group 3. State anxiety was lesser in the Group 2 (who received informational report) as compared to the Group 1 (who received only standard of care).

Conclusion

The findings of our study are in line with other researchers who examined the anxiety levels of families during intra-operative period. Our study suggests that situational support given to the family members helps to reduce their anxiety levels during intra-operative period. Such practices of giving intra-operative information to family members should be inculcated as a routine practice in any hospital around the world.

Acknowledgment

Authors express gratitude to all patients’ family members and the hospital for permission to conduct this research study.

Declaration of Conflict of Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.