Copyright Priory Lodge Education Ltd. 2007
Preoperative fear and anxiety have always been the concern of the patients as well as the anaesthesiologists and the surgeons. Preoperative patients have various kinds of anxiety (Badner et al, 1990, Hashimato et al 1993, Millar et al 1995, Moerman et al 1996,). However we do not know much about their psychological burden. Much study has been conducted on pre-anaesthetic assessment and the methods to relieve patient anxiety and fear (Badner et al, 1990, Hashimato et al 1993, Kindler et al 2000, Klopfentein et al 2000, Mc Gaw et al 1998, Millar et al, 1995, Moerman et al 1996, Nomura et al, 2000, Shafer et al 1996, Sanjuan et al 1999). But do we really know what the patients are afraid from? Do they want to be informed? Will this information help relieve their anxiety and what personal factors effect their anxiety or anaesthetic choices?
The aim of this study was to assess the fears, worries, anxiety and the demand for getting information of the patients, as well as their choices regarding anaesthesia and surgery.
Material and Methods
This study was conducted in the University Hospital Anaesthesiology Department in a city with a population of 2 200 000.
During routine preoperative screening, 536 adults (>19 years) were questioned one day before surgery, about their anxiety or fears or worries and information requirements by using a questionnaire consisting of open and closed ended questions. Interviews were performed face to face by the same anaesthesiologists.
In addition, visual analog scale (VAS:0-100) was used to measure the level of anxiety of the patients by asking them to express the amount of their fears, anxiety and stress in number and mark it on the VAS scale (Kindler et al, 2000).
The answers were categorised and then analysed using the Chi-square test. The relationship between the patients gender, education, income and previous anaesthetic experience were assessed with the answers given to questions 1-9 in the questionnaire with using regression corelation analysis. p<0.05 was considered as significant.
Of the 536 patients audited 271 were male (50.6%) and 265 female (49.4%). The numbers of male and female patients were similar (p>0.05). The mean age was 44.7±15 (range 19-80). Eleven percent (60) of the patients were shceduled for operations for malignancies, 76.7% (411) for non-malignancy. Twelve percent (65) of the patients were undiagnosed.
Sixty six percent of our patients correctly defined the mean of anaesthesia.
Education: Correctly defining the word anaesthesia correlated with the degree of education. 98.1% of university graduates, 82% of secondary school graduates and only 51.9% of illiterates and primary school graduates knew the meaning of anaesthesia.
Illiterate or primary school graduates had more fears or worries about surgery when compared with the higher educated patients (p<0.05). There was no significant correlation between the educational status of the patients and fear from anaesthesia.
Fifty three percent of university graduates preferred local or regional anaesthesia compared to 42.9% of secondary school and 35.2% of primary school graduates (p=0.004).
As education gets higher, the percent of patients that want to get informed also increase. The percent of patients who requested information on anaesthesia were 27.8%, 39.6% and 41.8% in the primary school, secondary school and university graduate groups respectively (p=0.007).
Gender: Gender did not influence the percent of patients who correctly defined anaesthesia (male 57.7%, female 46.0%) (p>0.05).
Women expressed more fear or worries about both anaesthesia and surgery when compared to men (p=0.0001). 17.7%, 24.0% of men and 34.3%, 43.4% of women feared anaesthesia and surgery respectively. The most feared aspect was “not waking up” after anaesthesia and surgery which was similar between the sexes.
Despite 54.2% of men, only 25.7% of women preferred local or regional anaesthesia (p=0.00001).
Income: As income increases, percent of patients with anaesthetic fear also increases. The percent of patients who expressed fear were 17%, 29.7% and 40.7% in the low, average and high income groups respectively (p=0.00165). The increase in fear from surgery was not significant between the income categories (p>0.05).
As personal income increases, the percent of patients requesting information increases. The percent of patients who requested information on anaesthesia were 25.5%, 37.7% and 44.4% in the low, average and high income groups respectively (p=0.01).
Previous experience: 37.4% of patients without previous anaesthetic experience and 27.8% with previous anaesthetic experience requested information about anaesthesia (p=0.017).
VAS scores: Women scored higher than men and subjects with an educational level of primary school or lower scored higher than did high school and higher education graduates in VAS measurement (p<0.05). There was no correlation between the increase or decrease of income and demand for information and VAS scores (p<0.05). VAS scores were lower in subjects with a history of surgery and anesthesia(p<0.05).
Fear is considered as a normal feeling that always accompanies people throughout life. It is a compound phenomenon that has psychological, motor, somatic-vegetative and metabolic components. Even the thought of operation and anaesthesia increase the feeling of anxiety. The dimension of fear has inconvenient influence on the time of recovery, quantity of complications and the discomfort felt by patients. The incidence of preoperative anxiety was reported as high as 60% of surgical patients (Hashimato et al 1993).
The dimension of the fear can be measured in many ways. The questionnaires are one of the methods of taking an objective measurement. Mostly used questionnaires are “Amsterdam Preoperative Anxiety Information Scale (APAIS)”, “Spielberg’s State-Trait Anxiety Inventory (STAI-State)” (Moerman et al 1996), “Hospital Anxiety and Depression Scale (HAD)” and “100mm visual analogue scale (VAS)”( Millar et al, 1995), “Multiple Affect Adjective Check List (MAACL) (Badner et al, 1990). The STAI is used frequently. Recently, VAS became popular in evaluating preoperative anxiety and fear (Badner et al, 1990, Kindler et al 2000, Klopfentein et al 2000, Millar et al, 1995, Shafer et al 1996). In fact, many studies indicate that monitoring of anxiety can be very useful in decreasing fear. Determining the factors affecting anxiety and fear can be useful to correctly define and decrease them. We aimed both to measure anxiety or fear of patients and also to evaluate the factors effecting anxiety and fear. We used a simple questionnaire and VAS .
In our study most of the patients stated that they had no anxiety or worry about anaesthesia (71.3%) or surgery (64.4%). This may partially be a reflection of the belief in faith. We considered that the religious culture influences people more in stress-full conditions. Religious belief requires belief in faith and destiny. This belief may have had an increasing influence on the high rate of patients without fear. To trust to University hospital conditions was second important factor which effecting patients without any worries about the anesthesia whereas to trust to surgeon which effecting patients without any worries about the surgery. Nomura et al (2000) stated that, preoperative patients feel various kinds of anxiety. In Nomura’s study, the patient’s anxiety varied depending on their previous experiences of anaesthesia, anaesthetic methods previously received and age of the patients. In addition, type of surgery is also important according to Nomura et al. While the patients undergoing orthopaedic operations were more anxious about postoperative pain, the patients undergoing gynaecological procedures were more anxious about accidents due to anaesthesia. Our questionnaire did not include type of the operation but we found no relationship between malignancies and fear or anxiety.
Young patients were found to be more anxious in previous studies (Kindler et al 2000, Mc Gaw et al , 1998). In our study there was no difference in the reasons of anxiety and fear between the age groups.
Patients with higher education requested more information on anaesthesia and also preferred regional anaesthesia to general anaesthesia in our study. Education was only considered in one previous study (Mc Gaw et al , 1998). In Moerman et al study (1996), patients with a high information requirement had a high level of anxiety and patients who had never underwent an operation had a higher information requirement than those who had previous operation.
In our study, female gender feared more about anaesthesia when compared with male patients. Our results are inconsistent with previous studies (Badner et al, 1990, Kindler et al 2000).
According to a study conducted in Spain (Sanjuan et al, 1999), the most common fear is “not waking up”. In a study from Switzerland (Badner et al, 1990), three kinds of fear were noted among surgical patients; 1- the fear of the unknown, 2- the fear of feeling ill, 3- the fear for one’s life. In a study from Jamaica, the most common fear was death on the operating table. In our population, most of patients had no worries about anaesthesia or surgery. If he/she worried about anaesthesia, most feared was not waking up. When asked about surgery, our patients worried from ” failed surgery”. The type and reason of fear may vary with nationality.
Income was not investigated as a factor in previous studies. More patients in the high income group have fears on anaesthesia when compared with the lower income group.
Determining the reasons and factors influencing preoperative fear and anxiety in our population may help us in the management of our patients. Proper management of fear and anxiety by the anaesthesiologist may provide better preoperative assessment, less pharmacological premedication, smoother induction and maybe even better outcome. Further studies on preoperative anxiety are needed to evaluate the impact of anxiety and fear management on surgery and outcome.
In summary, most of the patients did not have fear or felt anxious about both the anesthetic and the surgical procedures, preoperatively. This was found to result from religious believes. Women and patients from a lower education level were the most to feel anxious and fearful, preoperatively. Anesthesia was defined properly by 66% of the patients, but they were not aware of both the anesthetic procedure and the role and identity of the anesthetist. Although, the feeling of trust for the surgical team was one of the factors that prevented fear and anxiety, we observed that most of the patients did not have enough information about their illnesses (especially malignancies) and the surgical procedures they would run through. Informing the patients on the anesthetic and the surgical consequences of their planned operation, preoperatively, can play an important role in preventing anxiety and fear. Especially the women and patients from lower educational level must be informed in more detail. We think VAS could be used to measure preoperative anxiety, as there was a positive correlation between VAS scores and the results obtained with the anquette method.
We concluded that visuel analog scale may be useful for assesing the preoperative anxiety and fear. Nationality and religious belief can effect the behaviour related with preoperative anxiety and fear. Further studies are needed.
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Copyright Priory Lodge Education Ltd. 2007
First Published October 2007