Clinical nursing practice for the reduction of anxiety in patients in the cardiac preoperative period: an intervention research

Luana Maria Bráz Benevides1, Leticia Moura Fernandes2, Lucia de Fátima da Silva2, Maria Sinara Farias2, Ana Cleide Silva Rabelo2, Samya Coutinho de Oliveira2

1 University of São Paulo, SP, Brazil

2 State University of Ceará, CE, Brazil

ABSTRACT:

Objective: To identify the contribution of nursing interventions in order to reduce anxiety in patients in the preoperative period of cardiac surgery. Method: An Intervention Research study, conducted during two months of 2018 with 20 patients. Data collection was carried out in three moments. Results: It was revealed that the cardiac patient in the preoperative period of cardiac surgery is predominantly male, hypertensive, awaiting valve replacement. Significant risk factors for anxiety were shown: the technical language of the professionals, previous experience of cardiac surgery, and its cancellation during hospitalization. Discussion: Previous studies have also presented results similar to those found in this study, confirming the fundamental role of nursing in coping with anxiety which is so common when waiting for surgery. Conclusion: In this context, nursing interventions may contribute to a significant reduction in patients' anxiety, generating positive results for the patient and for the health institution.

Descriptors: Cardiovascular Nursing; Preoperative Period; Cardiac Surgery; Nursing Process; Anxiety.

INTRODUCTION

Based on its holistic care, Nursing must have a broad approach and be adapted to different clinical situations, focused on the physical, biological, emotional, social, and economic dimensions of the people being cared for, in the setting in which it is inserted. Thus, in search for better results, it needs to know beyond the patient's illness. When thinking about nursing care systematized by the continuous process of doing turned to sickness conditions, the conditions of cardiovascular disease can be highlighted, which require more specific care from nurses, due to their particularities and to more intense changes with greater impact on the patient's life. According to the World Health Organization (WHO), it is estimated that 17.5 million people died from cardiovascular disease in 2012, representing 31% of all deaths globally(1). Some Cardiovascular Diseases (CVDs) become so severe that the only way to treat them is by a surgical procedure, which can bring negative human responses, mainly due to their severity, in addition to being a difficult moment for human beings, regardless of its complexity. Emotional imbalances are common, as the patients become more likely to acquire feelings that may contribute negatively to their health status and to the conducts that will be performed. Anxiety is one of the most prevalent feelings at this point. It is important to prove a possible reduction in the anxiety levels of patients who will undergo cardiac surgery so that both professionals and students increasingly know the importance of the concrete, real, and effective professional-patient relationship. The fact that the surgery is related to a vital organ, essential for life, is more likely to make the situation even more complex and delicate than it really is. Thus, various levels of anxiety may arise, which may negatively affect the course of treatment. The preoperative period and its management are of fundamental importance. The value of preoperative guidance has long been recognized. Each client is guided as an individual, considering their anxieties, needs, and hopes as unique(2). Aware of these conditions and based on educational and welcoming practices, the nurse will be able to achieve good results for the patient and the health institution to which they belong. The nursing team, and the nurse in particular, stand out as allies in the care of the patient, adding efforts to minimize preoperative anxiety through a therapeutic listening in which the person who is under care is heard; and anxieties, doubts, and fears are partially or totally eliminated. This occurs through a quality service to the unique needs of everyone who will undergo surgical procedures. Considering the problem presented, it decided to study it in the interest of increasingly qualifying nursing work in the field of cardiovascular disease. The study enabled knowledge and practices that may contribute to the practice of nursing and its relationship with patients in the preoperative period of cardiac surgery, decreasing or even ending the nursing diagnosis of Anxiety. Thus, risks and/or complications during surgery and in the postoperative period due to emotional imbalances which will trigger biological/hemodynamic imbalances may be reduced. Given this context, the guiding question of the study was the following: How can a nursing intervention with educational and welcoming bases contribute to reducing the anxiety of patients in the preoperative period of cardiac surgery? And the objective was to identify the contribution of a nursing intervention to the reduction of anxiety in patients in the preoperative period of cardiac surgery.

METHOD

This is an Intervention Research carried out in conjunction with the researched population, aiming at the procedural modification of the research object through interventions in the daily routine of the institutions(3). In this case, the intervention aimed at reducing anxiety levels in patients undergoing preoperative cardiac surgery. The study was carried out in a public state hospital from the SUS, located in Fortaleza-Ceará. Given the need to perform the collection in the preoperative period, the interviews were carried out in the cardiology sectors, ward type, called units B, C and G. Data collection took place between May and June 2018, preceded by the approval of the Research Ethics Committee. Twenty patients in the preoperative period of cardiac surgery participated in the study; with risk or presence of the nursing diagnosis of “Anxiety” in the Nursing Process (NP); who had a surgical schedule and at least three days before the procedure, and who were older than 18 years old. Preoperative heart transplant patients, due to the different complexity of the surgery; those who have speech difficulties or cognitive deficits that hinder the necessary communication for the study, and those using anxiolytics, were excluded from the research. A convenience sample was chosen, in the period reserved for the collection of information that occurred in the months of May and June 2018, due to limitations such as time and resource. In the convenience sampling (non-probabilistic), the sample elements are selected for convenience or ease for the researcher(4). For this study, a sample of 20 patients was attained, considering the high rate of suspension of surgical interventions resulting from the financial crisis in the hospital. Data collection was divided into three stages. Initially, three days before the surgical procedure, the medical records were used so that the researcher could identify patients in the preoperative period of cardiac surgery and with a surgical schedule, who had a nursing diagnosis of “Anxiety”, focusing on the problem or vulnerability in the registry of nurses in the institution. With the diagnosis identified, the interview proceeded mediated by a form prepared by the researcher. This instrument was composed of questions of social, demographic, and clinical characterization of the patients, in order to analyze the profile. On the same occasion, a scale-type instrument was used, adapted from defining characteristics referring to the nursing diagnosis of “Anxiety”, present in the NP as a way to measure the diagnosis. This instrument was applied in two moments of analysis of the anxiety level; first as basic information before the implementation of nursing interventions for anxiety and after its completion. The aim was to assess the signs and symptoms of anxiety before and after proposed interventions using the elaborated scale, and the interviewees' speeches and their behavior. Thus, the perceptions of “agitated”, “nervous”, “restless”, “irritated”, “undecided”, “worried”, “afraid”, “angry”, and feelings of “muscular tension”, “difficulty to concentrate”, “difficulty in solving problems”, “dizziness”, “sweating”, “fatigue”, “insomnia”, “change in intestinal pattern”, and “change in eating pattern” were evaluated. The second stage, which corresponded to the second meeting with each study participant, was characterized by an educational intervention, which took place two days before the surgery. For that, a nursing intervention script based on the Nursing Interventions Classification (NIC) was used(5). The third and last stage, held in a third meeting with each patient one day before the scheduling of their surgical procedure, was constituted by reapplying the anxiety assessment scale, with a view to analyzing the patients' response to the implemented interventions.

For the independent (age, family income, and years of study) and dependent variables (marital status, employment status, and comorbidities), descriptive analysis was used. The research was analyzed and approved by the Ethics Committee of the Dr. Carlos Alberto Studart Gomes Hospital of Messejana, under CAAE 87213318.4.0000.5039 and opinion No. 2,621,395.

RESULTS

The study participants were predominantly male (60.0%), aged over 51 years old (80.0%), residents of the inland of Ceará (65.0%), with complete or incomplete elementary education (65.0%), co-residing with a spouse (55.0%), with their own home (75.0%), and Christians (100.0%). For the majority, the source of personal income comes from retirement, with a family income of one minimum wage (80.0%). The most prevalent etiology of cardiac surgery was secondary to acute myocardial infarction with or without an ST-segment supra, coronary artery disease classified by three-vessel or multi-vessel, heart failure, and stenosis or valve failure. Valve surgery was the predominant surgical intervention (50.0%), followed by myocardial revascularization (45%) and by aortic aneurysm (5.0%). The interviewees were in the preoperative period of a cardiac surgical procedure (55.0%), with 90.0% of the patients reporting previous hospitalizations. Most of the respondents had comorbidities (65.0%), among them, hypertension (69.2%) was the most prevalent. Concerning lifestyle, there was smoking history (65.0%) and alcoholism (70.0%). Before planning the intervention, the researcher asked each participant: “What can I do to make you feel good before going to surgery?” Thus, the interventions developed during the study were based on the NIC and individualized according to each patient’s needs. It was noted that, among the patients who had already undergone cardiac surgery, the needs were different from those who were going for the procedure for the first time. In those who already knew the perioperative process, the needs revolved around knowing how to take better care at home so that the problem does not recur, as well as carrying out a more dynamic intervention, including: reading God's word, listening to religious music to try to ease the nervousness, or even giving them a crossword puzzle in order to distract them until the date of the surgery. As for those who were operated on for the first time, the questions and fears were around the surgical procedure itself, showing them the cardiac anatomy in a simple way so that they understood the focus of the problem and what would be done to solve it, where the incision would be performed, preparations before going to the operating room, duration of the surgery, time spent in the Intensive Care Unit (ICU) and when they would be discharged. In general, the patients reported that they did not understand the language used by the professionals who cared for them, as they knew the technical terms, but did not know what they actually meant. P1 reported:

People come by and talk about my surgery, but with some complicated words, you know? Then I can't understand it very well.

P3 presented the following speech:

Does the coronary artery bypass that they are going to perform equal a valve? Does it need to be changed?

This showed that perhaps no one had explained to him about his surgery or cleared his doubts. Another point reported by the patients was the sensation of thirst in the postoperative period. P2 said:

Is thirst after surgery normal? The other time I felt thirsty and was desperate because I thought it was something abnormal that was happening.

It was noticed that the doubts of the patients who would undergo valve replacement revolved around clinical issues, especially regarding the differences between a mechanical valve and a biological one, as well as the implications of each after the placement of one of them. Thus, the interventions were based on making them better understand the process and trying to resolve their doubts. P2 decided which type of valve to place after the intervention and reported the following after the study:

You helped me a lot to decide, really, because I had a lot of doubts. Thank you very much, I'm already recommending your conversation to other patients, as it was very enlightening, I'm more relaxed.

In general, the patients with a companion responded better to the interventions performed and were happier due to the care and love they received at the hospital. Those who would have companion at moments before the surgery clearly expressed an improvement in mood due to the arrival of a loved one. The importance of these individuals was reported, mainly at the time of the interventions, where they were cited as allies in the recovery of the person they were monitoring at all times. Another problem that made some patients even more anxious was the surgical reschedules that often happened, and the responses to that were different. P7 reported:

I just know that if this surgery doesn't happen on Wednesday, I'll pack my things and go.

His irritation, anger, and restlessness were very noticeable and little reduced in scale, even after the intervention. The comfort massage was stimulated, as the patient complained a lot about muscular tension. Thus, the researcher guided the daughter who was accompanying P7 and also availed body moisturizer. P11 said:

My concern is for no one to get in front of me; the surgery I already know because I've already been through it, my fear is the surgery to be postponed again.

The main request for an attempt to reduce their anxiety was for the researcher to check the surgical chart to see if they had remained for the informed date or if any changes had occurred. Within the sample of the study, P16 was the patient with the highest number of surgical reschedulings (5 times). As he had already undergone surgical preparation, he had few doubts about the surgery and the care he should have at home. In this case, his request was for the researcher to explain the whole process to his sister, as she would take care of him. Other frequent doubts from which interventions arose were related to the guidelines regarding food after surgery. P11 said:

In the other surgery I did I left here with a list of medications, but without knowing anything about food, so I ate everything wrong and did everything I couldn't do, I couldn't stay still.

This gap was filled with the request for a visit by the nutritionist in service and with the information that the researcher herself sought in order to clear doubts on the subject. The researcher intervened clearly with all the patients, even using drawings so that understanding was facilitated, using positive words of confidence and comfort, being silent whenever there was a need. Table 1 shows the impact on the characteristics of the Anxiety nursing diagnosis before and after the interventions performed.

Table 1 - Distribution of the patients who answered “yes” to the objective and subjective characteristics of anxiety before and after the nursing interventions, according to the scale stage used for evaluation, Fortaleza, CE, Brazil, 2018 (n=20)

Source: Elaborated by the authors, 2018.

DISCUSSION

Regarding the sociodemographic profile, this study obtained results similar to those already found in other studies nationwide. In a cross-sectional survey conducted in São Paulo, involving 100 patients undergoing cardiac surgery, it was observed that, among the patients, there was a predominance of males (56.0%), aged between 50 and 70 years old (67.0%) with a mean of 58.7 (SD=10.5). Previous diseases, such as systemic arterial hypertension, type 2 Diabetes Mellitus, and dyslipidemia appeared more frequently, and the most frequently performed surgery was myocardial revascularization (MR) (58.0%)(6). In a study carried out in a general hospital in the inland of São Paulo, a reference in cardiac surgery in the city and in the region, there was prevalence among male patients (56.0%), aged over 50 years old (84.0%), married (72.0%), and with a higher prevalence of Systemic Arterial Hypertension as a previous disease in both genders(7). The profiles of the patients who would undergo cardiac surgery for the first time and of those who had already undergone it are different, thus influencing the causes related to anxiety. In a study carried out with patients undergoing elective cardiac surgery, the anxiety and depression scores were higher among those undergoing their first surgery, but no statistically significant difference was found between the groups(8). However, there are not many studies of this nature, which impairs a better comparison. The research carried out allowed us to consider that the preoperative period of cardiac surgery, whether for the first time or not, is accompanied by the manifestation of the nursing diagnosis of anxiety. For this reason, it is essential that nurses keep the responsibility for identifying the diagnosis by means of the NP, as well as for developing a care plan to reduce this patient's response to that situation. The language used with the patient must be simple and clear, so as not to leave doubts about the surgical process, both before and after. The patients should know about their surgery and about all the stages that are included in it, including its risks. Given the identification of the individual needs of each patient, when carrying out the preoperative visit, the nurse contributes to alleviating feelings that are present at that moment. Such feelings include fear, anxiety, apprehension, and anguish, among others. When aware of them, nurses can do a lot in the sense of knowing how to listen, clarifying doubts, in order to contribute to having a quiet, less stressful surgical experience, with adequate coping(9). The doubt about the length of hospitalization is frequent and can make a lot of psychological difference for the patient. The length of stay in the hospital after the procedure is relevant information in order to try to reduce anxiety, and was a common doubt. The lack of guidance regarding the surgery and the lack of support on the part of the health team, as impediments to an adequate therapeutic relationship, cause patients to remain in an anxious and depressed state throughout the hospitalization(10). In the family context, the patients with companions obtained better results in terms of reducing anxiety in this study. A national study showed that the welcoming provided by the presence of the family is more significant for coping than the nurse's sole contact, assessed by lower levels of anxiety(11). Surgical cancellations/reschedulings were undoubtedly the reason that most caused increased anxiety in the patients included in the present investigation. In a study carried out with the objective of determining the factors related to cancellation of surgeries and their contributions to nursing care, it was concluded that the most common reasons for the justification for suspensions were lack of anesthetist (18.2%) and hypertensive crises (12.7%); a high rate of reasons not declared in medical records was also found (34.5%)(12). For some patients, canceling a previously scheduled procedure can have disastrous effects, even if they are clarified; the greater the number of suspensions to the same person, the greater the degree of the patient’s insecurity(13). In relation to the person being cared for, anxiety levels decreased after the intervention performed, which certainly contributes to a reduction in risks and/or complications during surgery and in the postoperative period, due to emotional imbalances which trigger biological/hemodynamic imbalances. Corroborating this statement, it should be noted that psychological stressors are related to postoperative complications, as preoperative anxiety and depression symptoms influence and enhance the occurrence of physiological complications, in addition to increasing the length of hospital stay and postoperative mortality(14). Although nursing in Brazil has been improving its evidence-based care and empowering itself to promote care guided by a systematization process that uses its own taxonomies and methodologies, improving the practice of care in different scenarios(15). The findings of these studies demonstrated the need for greater empowerment of these professionals on the theme discussed, as well as the publication of new studies and investigations, since nurses still do not use the tools created to improve care adequately. The health team tends to gain with the establishment of trust between professional and patient, thus reducing the high levels of stress and anxiety existing in health units where the user is not properly assisted. Thus, even the setting will become more harmonious. Health institutions may gain in a possible reduction of expenses through complications that may be avoided and by performing surgeries at the correct time and without complications. The gain in the postoperative period may also be significant since, regardless of knowledge, educated and informed about their health status, the patients may be discharged from hospital more quickly. The large number of surgical reschedules, reflecting the financial crisis experienced by the hospital, was an important limitation of the study. There was a remarkable increase in the defining characteristics for the nursing diagnosis of Anxiety in those who did not have the surgery performed on the date of the first appointment. In addition, irritation and concern were noticeable, not with the state of health, but with the occurrence or not of the surgery in rescheduling. Another factor that limited the increase in the sample was the number of elective surgeries scheduled. In most cases, the patient only arrived for hospitalization 48 hours before the surgical schedule, thus being excluded from the study inclusion criteria. Regarding the completion of the Systematization of Nursing Assistance, SNA/NP, of the hospital where the research was carried out, in the units of data collection some nurses do not completely fill in the tool used for a better care. Thus, some patients may not have been included in the research just because they did not complete, for example, the diagnoses contained in the SNA/NP.

CONCLUSION

The study showed that, in the context of the preoperative period, the interventions to reduce anxiety may and should be conducted by nurses since, given their greater proximity to the patient, they are in a prominent position to establish an interaction that generates positive results. From the follow-up based on the NP there is the possibility of increasing trust between patient and professional and, consequently, a possible reduction of the emotional imbalances generated by cardiac surgery, aiming at improving the results of the line of care as a whole. The nursing interventions offered at the time of waiting, which precedes the surgery, reduce the anxiety of patients and family members. It is not possible to completely eliminate anxiety in the face of an unknown situation; however, it is possible to comfort and relieve the tension of those who experience the moment of waiting through individually planned actions. The research contributed to positively reach the path of patients, as well as of the health institution and of the team responsible for care, with an emphasis on nurses.

There are still few studies related to the theme. Thus, students and professionals must be encouraged to research more on this theme, which is present in hospitalizations, seeking ways to increasingly make the Nursing Process an effective tool for nursing care and, in this context, reducing the anxiety that is very present in cardiovascular disease with a focus on cardiac surgery.

REFERENCES

1. Organização Mundial da Saúde. Doenças cardiovasculares. 2016.

2. Smeltzer SC, Bare BG. Brunner/Suddarth: tratado de enfermagem médico-cirúrgica. 13. ed. Rio de Janeiro: Guanabara Koogan; 2017. 2v.

3. Mendes R, Pezzato LM, Sacardo DP. Pesquisa-intervenção em promoção da saúde: desafios metodológicos de pesquisar “com”. Cienc Saúde Colet [Internet]. 2016 [cited 2020 Abr 14]; 21(6):1737-45. Available from: http://www.scielo.br/pdf/csc/v21n6/1413-8123-csc-21-06-1737.pdf doi: https://dx.doi.org/10.1590/1413-81232015216.07392016

4. Oliveira MO, Luce FB, Sampaio CH, Perin MG, Santini FO, Santos MJ. Análise da qualidade dos artigos científicos da área de marketing publicados no Brasil: as pesquisas survey na década de 2000. Rev Eletrôn Adm [Internet]. 2017 [cited 2020 Jan 22];23(1):54-87. Available from: http://www.scielo.br/pdf/read/v23n1/1413-2311-read-23-1-0054.pdf  doi: https://doi.org/10.1590/1413-2311.024.55683

5. Bulechek GM, Butcher HK, Dochterman JM. Classificação das Intervenções de Enfermagem (NIC). 6.ed. Rio de Janeiro: Elsevier; 2016.

6. Dordetto PR, Pinto GC, Rosa TC. Pacientes submetidos à cirurgia cardíaca: caracterização sociodemográfica, perfil clínico epidemiológico e complicações. Rev Fac Cienc Med Sorocaba [Internet]. 2016 [cited 2020 Jan 29];18(3):144-9. Available from: http://revistas.pucsp.br/RFCMS/article/view/25868/pdf doi: http://dx.doi.org/10.5327/Z1984-4840201625868

7. Dordetto PR, Pinto GC, Rosa TC. Pacientes submetidos à cirurgia cardíaca: caracterização sociodemográfica, perfil clínico epidemiológico e complicações. Rev Fac Cienc Med Sorocaba [Internet]. 2016 [cited 2020 Jan 29];18(3):144-9. Available from: http://revistas.pucsp.br/RFCMS/article/view/25868/pdf doi: http://dx.doi.org/10.5327/Z1984-4840201625868

8. Kazitani BS, Furuya RK, Dantas RA, Dessotte CA. Ansiedade e depressão pré-operatória: diferenças entre pacientes submetidos à primeira cirurgia cardíaca. Rev Rene [Internet]. 2018 [cited 2020 Jan 29];19:e3079. Available from: http://www.periodicos.ufc.br/rene/article/view/31323 doi:  http://dx.doi.org/10.15253/2175-6783.2018193079

9. Silva WL, Barros AT, Santos RD, Silva LA, Miranda LN. Cirurgias cardíacas: assistência de enfermagem a portadores de cardiopatia no período perioperatório. Cien Bio Saúde Unit [Internet]. 2017 nov [cited 2020 Abr 14];4(2):323-336. Available from: https://periodicos.set.edu.br/index.php/fitsbiosaude/article/view/4565/2625

10. Gonçalves KK, Silva JI, Gomes ET, Pinheiro LL, Figueiredo TR, Bezerra SM. Anxiety in the preoperative period of heart surgery. Rev Bras Enferm [Internet]. 2016 [cited 2020 Jan 15];69(2):374-80. Available from: http://www.scielo.br/pdf/reben/v69n2/en_0034-7167-reben-69-02-0397.pdf doi: https://doi.org/10.1590/0034-7167.2016690225i

11. Assis CC, Lopes JL, Nogueira-Martins LA, Barros AL. Acolhimento e sintomas de ansiedade em pacientes no pré-operatório de cirurgia cardíaca. Rev Bras Enferm [Internet]. 2014 [cited 2020 Jan 20];67(3):401-7. Available from: http://dx.doi.org/10.5935/0034-7167.20140053

12. Sampaio CE, Gonçalves RA, Júnior HC. Determinação dos fatores da suspensão de cirurgia e suas contribuições para assistência de enfermagem. Ver Pesqui [Internet]. 2016 jul/set [cited 2020 Jan 22];8(3):4813-20. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-789209 doi: http://dx.doi.org/10.9789/2175-5361.2016.v8i3.4813-4820

13. Botazini NO, Toledo LD, Souza DM. Cirurgias eletivas: cancelamentos e causas. Rev SOBECC [Internet]. 2015 out/dez [cited 2020 Jan 22];20(4):210-9. Available from: http://dx.doi.org/10.5327/Z1414-4425201500040005

14. Gomes ET, Bezerra SM. Validation of the Spiritual Well-Being Scale for hospitalized patients in the preoperative period. J Bras Psiquiatr [Internet]. 2018 jul [cited 2020 Jan 22];67(3):179-185. Available from: http://www.scielo.br/pdf/jbpsiq/v67n3/1982-0208-jbpsiq-67-03-0179.pdf doi: http://dx.doi.org/10.1590/0047-2085000000199 .

15. Gomes ET, Oliveira RC, Bezerra SM. Ser-paciente-à-espera-da-cirurgia-cardíaca: o período pré-operatório na perspectiva heideggeriana. Rev Bras Enferm [Internet]. 2018 out [cited 2020 Jan 15];71(5):2392-97. Available from: http://www.scielo.br/pdf/reben/v71n5/0034-7167-reben-71-05-2392.pdf doi: http://dx.doi.org/10.1590/0034-7167-2017-0506

Received: 04/21/2020

Revised: 05/26/2020

Approved: 05/26/2020