F E AT U R E S

Effectiveness of Nurse’s Intentional Presence

as a Holistic Modality on Depression, Anxiety,
and Stress of Cardiac Surgery Patients
■ Zeynab Khajian Gelogahi, MSc ■ Nahid Aghebati, PhD ■ Seyed Reza Mazloum, MSc
■ Samira Mohajer, MSc

One of the important aspects of recovering after bypass surgery is mental disorders of patients. Despite the
importance of intentional presence in interpersonal interactive space in holistic nursing, a few experimental and
clinical trial studies are conducted on this subject. This study determines the effect of intentional presence of a
holistic nurse on anxiety, stress, and depression in patients undergoing coronary artery bypass graft surgery. The
study used a randomized clinical trial conducted on 80 patients referred to heart surgery department from March
2016 to June 2017, who were allocated to the control and intervention groups randomly. DASS 21 (Depression,
Anxiety, Stress scale) questionnaire and a checklist to determine stressor resources were used to measure the
variables. Four 30- to 45-minute sessions of nursing intentional presence were conducted for each patient
individually in the intervention group. The results showed homogeneity between 2 groups in demographic variables
(P > .05). But there was heterogeneity between 2 groups (P < .05) for some stressors. By using analysis of
covariance and excluding the effect of stressors and the first scores before the intervention, statistics represented a
significant decrease in stress, anxiety, and depression scores in the intervention group compared with the control
group (P < .0001). The results of this study indicated that the intentional presence of a nurse as an effective nursing
procedure can reduce the depression, stress, and anxiety of the patients undergoing coronary artery bypass
surgery. KEY WORDS: anxiety, coronary artery bypass graft surgery, depression, holistic nursing, intentional
presence, stress Holist Nurs Pract 2018;32(6):296–306

BACKGROUND diseases that do not respond to medication fall under2

Coronary artery disease is the most common type of
heart diseases that often occurs following coronary
atherosclerosis.1 The vast majority of coronary artery
Author Affiliations: Evidence-Based Research Center (Dr Aghebati, Mr
Mazloum, and Ms Mohajer), Medical Surgical Department (Ms Gelogahi,
Dr Aghebati, Mr Mazloum, and Ms Mohajer), School of Nursing and Mid-
wifery, Mashhad University of Medical Sciences, Mashhad, Iran.
This study was extracted from a thesis of Mashhad University of Med-
ical Science with IRMUMSREC13940234 ethics committee code and
IRCT2015112925288N1 recording code. The researchers appreciate the
School of Nursing and Midwifery of Mashhad University of Medical Sci-
ences, dear management of nursing services and educational supervisor,
matron of Cardiac Surgery and Cardiac ICU of Dr Shariati hospital of
Mashhad, and all participants in the study.
The authors have received honoraria from the vice president research and are
currently receiving a grant from Mashhad University of Medical Sciences.
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article.
Correspondence: Nahid Aghebati, PhD, Evidence-Based Research Center,
Medical Surgical Department, School of Nursing and Midwifery, Mashhad
University of Medical Sciences, Ebne Sina St, Mashhad, Iran (aghebatin@
mums.ac.ir).
DOI: 10.1097/HNP.0000000000000294
coronary artery bypass graft (CABG) surgery. The
prevalence of CABG is 79.26% in North America,
72.0% in Asia, 94.17% in Western Europe, and
14.18% in the rest of the world.3
One of the important complications of CABG is
mental disorders of patients, which plays an
indispensable role in social functioning and restarting
work and activities.3 At the beginning of the recovery
period, the patients show symptoms of anxiety, stress,
and depression.4,5 Then, these symptoms can cause
fatigue, sleep disorders, and mood changes such as
stress, fear, panic, confusion, agitation, irritability,
anger, feelings of worthlessness, and lack of control
and confidence.6
The researchers have conducted multiple
complementary studies using different methods,
including the use of natural sounds (birds, nature, forest,
river, and sea),7 using therapeutic communication,8
reflexology on the feet,9 and saying recommended
spiritual words10 to reduce anxiety and depression

296

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 Effectiveness of Nurse’s Intentional Presence as a Holistic Modality
in patients undergoing CABG. But the results of
the research show that most patients prefer health care
practitioners to listen to their speech carefully and then
take care of them.11 These therapists are often known
as holistic nurses. These groups of nurses consider
every individual a whole being which is unique
and believe that any human is a specific combination
of mind, body, and spirit which are interconnected
in a whole and has components indistinguishable from
each other. This whole is in a dynamic interaction
within, between, and among the people and the
environment. Accordingly, based on the needs of each
unique human being during his interaction with the
environment, he expects special care from his nurse.11
Different studies have been done about applying
holistic nursing in stress management, increasing
self-esteem, motivation and confidence in athletes,12
and self-care of patients bedridden at home,13 which
have had positive effects. But Rosenfeldt et al14 did
not observe any significant difference between holistic
care and routine care in reducing stress and quality of
life of patients undergoing CABG. Although all nurses
with a holistic approach are of the same philosophical
idea in considering human beings as a whole which is
irreducible to its components, a wide range of nursing
interventions and care programs can be planned on the
basis of this worldview in patients.
It is important for the caregiver to guide the person
and family through a reintegration of self, not only by
helping to intervene with the cause of the disease but
also by helping the person maintain a sense of
belonging, control, meaning, worth, and esteem
through the process.15 In other words, presence is the
“core of the nurse-patient relationship.”15
Historically, presence is accepted as an essential
part of nursing theory and is a core relational skill
within the nursing profession.6,16 The premise of the
authors was that presence may be an essential issue
in healing health care systems; however, the concept
of presence has evolved from the philosophical roots
of many disciplines.15 Nurse theorist Sister Madeleine
Clemence Vaillot is credited with the early discussions
of presence in the nursing discipline.17 Also, Parse’s
Human Becoming Theory,18 Watson’s Theory of
Human Science and Human Care,19 and Paterson and
Zderad’s Humanistic Nursing20 have integrated pres-
ence as a major component. Each of these theories con-
siders presence as an intersubjective, interpersonal, and
mutual experience between the nurse and the client.21
Regarding the important role of presence in the
nurse-patient relationship in holistic approaches and
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297
theories, there are many concept analyses and
systematic reviews with the purposes of clarifying,
extracting the attributes, and introducing the practical
levels of the concept of presence. McKivergin and
Daubenmire,15 are the first authors who described the
concept of presence in 3 levels such as physical
presence: Is the nurse’s “being there” for the patient.
Many nursing interventions are carried out at this
level, including the routine tasks that are prescribed
for the patient; psychological presence: Is the nurse
“being with, “The nurse uses himself or herself as an
intervention tool to create a therapeutic psychological
milieu that meets the patient’s need for help, comfort
or support”; and therapeutic presence: To be
therapeutically present, the nurse is asked to relate to
the patient as whole being to whole being, using all of
his or her resources of body, mind, emotions, and
spirit. To do this, new skills are required such as
centering meditating, intentionality, at-one-moment,
imagery, openness, intuitive knowing, communication,
loving, and connecting.15
In addition, Easter,22 in a construct analysis,
introduced 4 modes of being presented including
physical presence, therapeutic presence, holistic
presence, and spiritual presence. Godkin23 in a
literature review proposed a 3-stage, hierarchical
model of nursing presence resulting in healing
presence. Beside presence, clinical presence and
healing presence are the stages of this model, each
promotes to the next, based on the nurse competence.
Covington16 delineates the caring presence as a
concept for holistic nursing to suggest a working
definition. Intersubjectivity and intentionality in the
nurse-patient relationship are the core attributes of her
definition. Hessel24 in a concept analysis of presence
in nursing practice presents the defining attributes,
antecedents, and a theoretical definition for the
concept. Spirituality, nurse-patient relationship,
listening, attentiveness, and intimacy are the attributes
of presence that she has extracted.24 Tavernier25 in an
evidence-based conceptual analysis of presence
described 5 themes for attributes of this concept
including intentionality, mutuality, centeredness,
individuality, and attendance.
McMahon and Christopher26 suggested a midrange
theory of nursing presence based on the literature to
identify development opportunities to improve the
nursing student’s use of presence as a relational skill.
Regarding these authors specifically, nursing presence
is dependent upon the combination of individual nurse
characteristics, individual client characteristics, shared
298 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018
characteristics within the nurse-client dyad, an
environment conducive to relational work, and the
nurse’s practice decisions. The eventual dose of
presence is determined according to crucial points
during a nurse-client interaction. Specifically, the
nurse combines clinical expertise and previous
experience with presence, interprets both the client’s
subtle cues and obvious requests for presence,
considers the environmental factors, and then pauses
and finally decides the most appropriate dose of
presence at that particular time.26
A nurse with an intentional presence beside the
patient can realize his subjective inner world with his
own help and based on patient’s individual unique
needs and values and with applying his knowledge and
art can improve the patient’s physical, social, and
spiritual being.27 On the basis of research,
intentionality is one of the main features of presence.
According to a concept analysis,27 intentionality as a
matrix of continuous known changes is responsible for
any conscious change in human behavior. Each
conscious and planned change in humans makes sense
in the context of intentionality.27 Thus, the intentional
presence in a transpersonal caring relationship is
important. Despite a large number of articles about
presence conceptualization15,22-24,28 and a midrange
theory of nursing presence,26 a few experimental and
clinical trial studies have been conducted on this
subject. According to the studies, there is only 1
research study performed by Anderson29 on the
application of nurse presence, which included some
elderly patients with heart failure. The nurse’s
presence in that study improved the quality of life,
prevented hospitalizations, and ultimately reduced
health care costs. Despite achieving a positive result,
that study was conducted as a case study and
consequently, it is not generalizable due to the lack of
statistical tests.
Regarding previous discussions, due to the special
situation of patients undergoing CABG who are
suffering from anxiety and high stress during
hospitalization and sometimes encountering depressed
mood, this study is going to determine the effect of
intentional presence of a holistic nurse on anxiety,
stress, and depression in patients undergoing CABG.
METHODS
The study used a randomized clinical trial
(IRCT2015112925288N1). It was performed on
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
patients referred to Shariati Special Cardiac Center in
Mashhad, Iran, from March 2016 to June 2017.
The convenience method of sampling was applied
to choose patients referred to the open heart surgery
department for elective CABG surgery according to
including criteria. The inclusion criteria were age
from 38 to 70 years, being able to read and write, the
ability to communicate with the researcher, lack of
psychological disorders, and not using antipsychotic
drugs and not being addict. The exclusion criteria
were refusal to continue participating in the study, any
physical disorder that causes imbalance in the
patient’s situation, patient’s death, and psychological
disorders after surgery, late recovery, and prolonged
hospitalization. According to the results of a study
done by Mehdipour and Nematollahi10 and using
sample size formula, considering α = .05 and β = .2,
the least acceptable sample size was 40 people for
each group. Each patient was placed in control or
intervention group randomly by using the table of
random numbers (Figure 1).
The instruments applied in this study include a
demographic information form, conscious consent
form, DASS 21 Scale, and a stressor’s resources
checklist. The public self-reporting DASS 21 Scale is
an international standard instrument30 to measure
stress, anxiety and depression. The DASS 21 Scale
was translated into Persian by a team of psychologists
in Iran. The validity of this version has been
confirmed. The reliability of this instrument according
to a pilot study of this research was also confirmed
since the Cronbach α was 0.87. The stressor’s
resources checklist was designed by the researchers on
the basis of literature review in 3 parts including
before operation stressors, after operation stressors,
and spiritual concerns and needs. The validity of this
checklist was confirmed with 10 faculty members of
nursing and midwifery and medical school through
investigating face and content validity. Its reliability
was also calculated through agreement between
evaluators as 0.8.
Ethical approval was obtained from the Ethics
Committee of Mashhad University of Medical
Sciences (no. IRMUMSREC13940234). All
participants were insured that they entirely voluntarily
participated and could withdraw at any time. Their
data were kept confidential. Informed written consent
was obtained from all participants.
The intervention started after the patient was
hospitalized in the open heart surgery department.
Four 30- to 45-minute sessions of nursing intentional
 Effectiveness of Nurse’s Intentional Presence as a Holistic Modality
FIGURE 1. Flow diagram of patients’ participation according to CONSORT guideline.
presence were performed for each patient individually
in the intervention group as follows.
Session 1 (before the surgery): The objectives of
this transpersonal caring relationship included
creating a space of sympathy and trustworthiness for
the patient, receiving stressful resources, and trying to
initiate an empathic communication with him.
The nurse openly welcomed the patient and began a
friendly conversation with him. Then, she introduced
herself and other personnel to him. After the patient
had been placed in his bed, the nurse delivered him the
necessary personal and primary care, such as an
intravenous line, taking blood sample, beginning
serum therapy, and so forth. Simultaneously, the nurse
tried to create a space of intimacy in which the patient
could trust the nurse and declare his emotions and
anxieties. During this relation, the nurse insured the
patient sure that she was listening to him carefully by
shaking her head and establishing eye contact with
him. Regarding the type of individual patient’s stress
resource, the nurse tried to reduce his stress and
anxiety as shown in Table 1. Whenever the nurse felt
that the patient was tired of the conversation process,
she would postpone its continuation to another time.
Session 2 (before the surgery): Resuming a friendly
conversation with the patient, performing usual
preoperative nursing care was the objective of this
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299
session. Regarding the creation of trust and empathy
with the patient during the previous session, the nurse
explained the types of usual nursing interventions
with the patient. After asking his permission
to start the intervention, she simultaneously restarted a
conversation with the patient about his sources of stress
and tried to use appropriate methods of training or
relaxation according to the patient’s concerns (Table 2).
Session 3 (in intensive care unit [ICU]):
Establishing a friendly relationship; controlling the
hemodynamic status, airway and respiratory function,
and pain; and checking surgical wounds, the patient’s
position and concerns arising from the ICU
environment were the objectives. Since the nurse was
known to the patient, she went to the patient in the
ICU and talked to him kindly while holding his hand.
Then, she carefully informed the patient about his
condition since his transfer to ICU. Further, she also
used the following phrases to comfort and relax the
patient, “everything is under control,” “the surgery is
done well,” or “there is nothing to worry about.”
Finally, she reminded the patient that he could ask
nurses to provide what he needed in accordance with
previous trainings.
Session 4 (before discharging): Considering the
empathic space and the mutual trust between the nurse
and the patient, this session focused more on patient’s
300 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018
TABLE 1. The Stressor Resources and Relative Intentional Nursing Interventions
Type of Stressor Stressor
Before operation Waiting a long time for the
surgery to be done
Being far from family and work
Hospitalization before surgery
Having chest pain
Lack of trust to the results of the
surgery
A previous experience of a
friend’s or a family’s death
Staying at ICU
Fear of operating room
Unconsciousness, being
uncovered while surgery
High surgery expenses
After operation Presence of a family member to
help him do the personal
tasks
Being roommate with a stranger
Various nursing cares
The operation side effects
(bleeding, not regaining
consciousness)
Motionlessness and limitations
Surgical pain
Sleep-related problems
Physical and mental situation’s
change
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Nursing Intervention
Notifying the exact time of the surgery to the patient, according
to the program.
Explaining about
The short time of hospitalization.
The opportunity to visit relatives at the time of hospital
meeting.
Ability to return to work after the recovery period.
Explaining the reasons for hospitalization before surgery.
Ensuring that the nurse is always accessible to relief his pain.
Ensuring about the skillfulness of the surgeon and the specialist
nurses.
Giving the patient some statistics of improved patients.
Remembering to believe in the Lord’s destiny and having a
positive attitude concerning the result of the surgery.
Showing a video about ICU to the patient.
The researcher recorded a 10-min video in ICU environment
without patients by using her cell phone. It began with 1 of the
ICU nurse’s welcome and she tried to introduce herself with a
calm tune. Then she showed different parts of ICU and their
application using simple words. She explained about each of
the connectors, including arterial and venous pressure control
lines, drains, chest tubes, and monitoring device for the
patient. Finally she filmed a patient who was being
discharged from ICU in favorable condition, shaking hands
and saying goodbye.
Explaining about general anesthesia, he is completely
unconscious and unable to feel pain during the surgery.
Ensuring the maintenance of privacy and covering his body with
a long perforated shun to expose the surgical area.
Referring the patient to the supportive systems and social
worker.
Ensuring the patient that a skilled nurse will be present in the
ICU at all times.
Allowing the presence of a family member in the open heart
surgery department.
Hospitalizing the patient in the private room in the department, if
possible.
Informing about the isolation patients’ units in ICU.
Ensuring the patient that each of the nurses will describe her
actions clearly before performing them.
Creating a positive attitude toward the patient and ensuring him
of the skillfulness of surgical team.
Training about
The amount and type of immobility.
The way of movement.
Postoperative activities.
Ensuring that the nurse will come promptly when the bell is
ringing.
Prescription of sedative medicine and training in the Benson
relaxation technique.
Training the Benson relaxation technique (15 min before
sleeping).
Training how to retrieve energy when doing the Benson
relaxation technique.
(continues)
 Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 301

TABLE 1. The Stressor Resources and Relative Intentional Nursing Interventions (Continued)
Type of Stressor Stressor Nursing Intervention

Losing job Training about post-operative self-care techniques, confirmation

Spiritual concerns
Surgical connectors and
catheters (chest tubes, CBD
line, intravenous lines, etc)
The need to respect the beliefs
The need for praying
Need to attract attention and
conversation
The need for privacy during
surgery
about returning to the work after the recovery period.
Explaining the application of the various connectors and
catheters used to control the patient’s situation and the time
and method of extracting them.
Trying to respect the beliefs of the patient and creating a
respectful atmosphere to maintain his dignity.
Creating facilities for the patient to pray.
Daily presence of a holistic nurse at the bedside of the patient
and creating an empathetic communication with him.
Creating a situation to meet relatives.
Ensuring the patient that his privacy is completely preserved by
the nurses.

Abbreviations: CBD, chest bottle drainage; ICU, intensive care unit.

needs, educating and informing based on
postoperative and discharge needs.
Overall, in each session, the nurse tried to know the
patients internal needs and feelings by empathy in the
process of transpersonal caring relationship.
Considering the environmental factors and patients’
tolerance, the nurse decided on the appropriate level of
presence for that special occasion.
The researcher tried to do each intervention for each
patient according to his individual stress sources and
needs. All of the interventions listed in Table 1 were
not used for all of the patients. The nurse’s intentional
presence/being was the main intervention in this study.
The intentional presence process was performed on
the basis of the theory of nursing presence26 and the
intentionality as a capacity of transpersonal caring27
(Figure 2). After finishing the therapeutic intentional
presence sessions, at the time of the patient’s
discharge, DASS21 Scale was retaken by the patient.
Conscious consent form, DASS21 Scale,
and stress resources checklist were completed by the
patients of control group at admission time. Usual care
procedures were performed for patients; the hospital’s
educational pamphlets along with another pamphlet
related to relaxation were given to the patients. Then,
patients filled the DASS 21 Scale while discharging.

TABLE 2. Comparison of the Frequency of Demographic Data of the Patients in Intervention and Control
Groups
Intervention Control Statistical Test

Age (M ± SD) 56.5 ± 9.8 57.3 ± 8.4 t test, t = 4.13; P = .681

Sex
Male, F (%) 23 (42.5%) 25 (37.5%) χ 2 = 0.208; P = .82
Female, F (%) 17 (57.5%) 15 (62.5%)
Education, F (%)
Literacy 23 (57.5%) 26 (63.4%) Mann-Whitney U test;
P = .649
Primary 13 (32.5%) 8 (19.5%)
Diploma 2 (5%) 5 (12.2%)
High 2 (5%) 1 (2.5%)
Marital status, F (%)
Married 38 (95%) 35 (87.5%) χ 2 = 0.508; P = .235
Single 2 (5%) 5 (12.5%)
Having chronic disease
Yes, F (%) 19 (47.5%) 17 (47.5%) χ 2 = 0.1; P = .822
No, F (%) 21 (52.5%) 23 (57.5%)

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302 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

FIGURE 2. The process of holistic nurses’ intentional presence in cardiac surgery ward. (1) Both the nurse and the patient
were Iranian, Muslim, and from the Khorasan-e-Razavi province. (2) One special critical care nurse during 4 intentional
sessions took care of the patient. (3) Patients’ needs were evaluated by the following: (a) stressor checklist (before and after
the surgery), (b) physiological needs checklist such as vital signs, hemodynamic status, wound condition, and all the
individual patient’s needs (before, during, and after the surgery); (c) psychological and spiritual needs checklist (before and
after the surgery). (4) The individual needs and stressors of each patient were determined with the holistic nurse before,
during, and after the surgery in the intensive care unit and the ward. Thus, the nurse used an appropriate procedure to
provide care to the patient.

RESULT In comparing the intervention and control groups,

The results of the independent t test and Mann-
Whitney χ 2 showed homogeneity between 2 groups in
demographic variables (P > .05) (Table 2).
In the evaluation of before operation stressors, the
results of χ 2 test showed that the intervention group
has significantly higher level of stress in some stressors
(such as waiting a long time for surgery to be done,
hospitalization before surgery, having chest pain, fear of
operating room, unconsciousness, and being uncovered
during surgery) than the control group (P < .05).
they were significantly different in only the operation
stressors “motionless and limitations” and “physical
and mental situations’ change” (Table 3).
Also, some spiritual stressors, such as need to respect
beliefs, need to attract attention and conversation,
need for privacy during surgery, and fear of death,
showed significantly more frequency in intervention
group than in the control group (P < .05) (Table 3).
There was a significant difference between the 2
groups before intervention in stress mean scores
despite the random selection of the patients for each

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 Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 303

TABLE 3. The Frequency of the Stress Resources in the Coronary Artery Surgery Patients in Intervention
and Control Groups
Control Experimental
Type of Stressor Stressor Group, F (%) Group, F (%) χ 2 Test, P

Before operation Waiting a long time for the surgery to be 12 (30) 21 (52.5) P =.014
done
Being far from family and work 28 (70) 31 (77.5) P = .445
Hospitalization before surgery 28 (70) 30 (75) P < .0001
Having chest pain 2 (5) 7 (17.5) P < .0001
Lack of trust in the results of the surgery 22 (50) 22 (50) P=1
A previous experience of a friend’s or a 17 (42.5) 11 (27.5) P = .16
family’s death
Staying in the ICU 14 (35) 15 (37.5) P = .816
High surgery expenses 16 (40) 21 (52.5) P = .262
Fear of surgery 16 (40) 20 (50) P = .314
Fear of operating room 14 (35) 23 (57.5) P = .033
Unconsciousness, being uncovered while 10 (25) 27 (67.5) P < .0001
surgery
After operation Needing an attendant to do personal tasks 21 (52.5) 25 (62.5) P = .498
Having a stranger as a roommate 10 (25) 12 (30) P = .617
Different nursing care strategies and drug 8 (20) 15 (37.5) P = .084
interventions
The operation side effects (bleeding, not 16 (40) 20 (50) P = .396
regaining consciousness)
Motionlessness and limitations 14 (35) 24 (60) P = .018
Surgical pain 23 (57.5) 21 (52.5) P = .653
Sleep-related problems 13 (32.5) 15 (37.5) P = .639
Physical and mental situation’s change 17 (42.5) 26 (65) P = .044
Losing job 19 (47.5) 24 (60) P = .262
After operation connectors (chest tubes, 17 (42.5) 25 (62.5) P = .073
intravenous lines)
Spiritual concerns Need to respect the beliefs 17 (42.5) 28 (70) P = .044
Need for praying 21 (52.5) 28 (70) P = .108
Need to attract attention and conversation 16 (40) 32 (80) P < .0001
Need for privacy during surgery 18 (45) 37 (92.5) P < .0001
Fear of dying after surgery 40 (100) 34 (85) P = .011
Worry about the future 25 (62.5) 25 (62.5) P=1

Abbreviation: ICU, intensive care unit.

group and the homogeneity in demographic variables
(P < .0001) (Table 4).
However, this difference was reasonable
considering the heterogeneity of some stressors. Thus,
using analysis of covariance and excluding the effect
of stressors and stress mean scores before the
intervention, the mean score was 9.9 ± 3.9 for the
intervention group and 14.9 ± 5.8 for the control
group after the intervention. Therefore, statistics
represented a significant decrease in stress mean
scores in the intervention group compared with the
control group (P < .0001).
Because of the lack of homogeneity between the 2
groups in terms of anxiety before the intervention (P
< .0001), by using the analysis of covariance test and
excluding the effect of stressors and the effect of the
first anxiety mean score, the mean score of anxiety
reached 9.2 ± 3.8 in the intervention and 11.57 ± 5.4
in the control group. Statistics represented a
significant decrease in anxiety mean scores in the
intervention group compared with the control group
(P < .0001) (Table 4).
The results of measuring depression
after intervention in both groups showed a significant
decrease in the amount of depression in the intervention
group to 5.8 ± 10.1 and significant increase in the
amount of depression in the control group to 8.1 ±
12.10. These results along with the covariance
analysis test were gained by exclusion of the effect of
the depression before operation (P < .0001) (Table 4).

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304 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

DISCUSSION

P < .0001

P < .0001

P < .0001
ANCOVA
The results of this study showed that the intentional
TABLE 4. Comparison of the Means and Standard Deviations of Patients’ Stress, Anxiety, and Depression Scores in Intervention and Control

presence of a holistic nurse significantly decreased the

amount of stress, anxiety, and depression of patients
Statistical Test Between Groups

undergoing CABG. An important point in this study

was the heterogeneity of 2 groups’ mean scores before

P = .072

P = .025

P = .21
t = 1.8 intervention, which was evidence for higher levels of
t = 2.2

t = 2.0
t Test
After

stress, anxiety, and depression in the intervention

group compared to the control group and is reasonable
considering the higher range of some stressors in the
intervention group compared to the control one. While
the mean scores of the intervention group, which were
P < .0001

P < .0001

P < .0001

higher than those of the control group before

t = 5.2

t = 5.6

t = 6.4
Before
t Test

intervention in stress, anxiety, and depression,

decreased significantly using covariance analysis test
and excluding the effect of previous mean score and
stressors, the control group mean scores increased. To
Paired t Test

P < .0001

P < .0001

P < .0001

further explain, the Iranian people do not freely

t = 5.7

t = 7.9

t = 5.5

express negative feelings about stressful situations or

stressors, as a matter of trust. Therefore, because of
the limited relationship between the researcher and
control group, they could not trust themselves to speak
12.0 ± 6.0

11.5 ± 5.4

12.1 ± 8.1
M ± SD

to the nurse about their exact feelings and stress

After

resources. So, in the control group before the

operation, the patients thought that declaring their
Control

exact emotions and stressors would have an effect on

the quality of their surgical process. Then they hid
6.8 ± 4.18

6.67 ± 4.7
8.2 ± 6.5
M ± SD
Before

their actual feelings. In intervention group because the

researcher explained the process of intentional
presence to the patient and tried to create an empathic
space in the transpersonal relationship, the patients
Paired t Test

P < .0001

P < .0001

P < .0001

trusted the researcher/nurse and expressed their actual

t = 6.73
t = 7.8

t = 4.3

feelings and spoke accurately about their stressors.

The results of Anderson’s study29 also showed that
applying emotional support and therapeutic presence
by a professional nurse had positive effects on the
9.22 ± 3.6

9.7 ± 5.48
9.9 ± 3.8
M ± SD

recovery of 30 patients with heart failure. However,

After

that study result, which illustrated an improvement in

Intervention

Abbreviation: ANCOVA, analysis of covariance.

the quality of life, is not generalizable since it was a

case study without any statistical analysis. This study,
13.85 ± 5.1

on the contrary, was done as a clinical trial and

14.9 ± 5.8

12.9 ± 5.3
M ± SD
Before

showed significant effectiveness of the intentional

presence of the nurse.
One of the main components of the intentional
presence process in this study was to advise stressful
“patients to relax using the presence of the nurse
Depression

voice,” thus these results are comparable with another

study by Aghebati et al,31 who found that nursing
Anxiety
Groups

Stress

presence positively affected the stress and anxiety of

patients with cancer. The results indicated that the

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Effectiveness of Nurse’s Intentional Presence as a Holistic Modality
patients’ stress reduced 70% using relaxation
technique, which confirms the effect of the
researcher’s presence in reducing his amount of stress,
significantly.
In comparison with the study by Rosenfeldt et al14
on the quality of life of patients undergoing CABG that
implemented holistic care as light physical activities
and a stress-reducing program, there was no significant
difference between the holistic and the routine nursing
care groups. In that study, a CD was given to the
patient for training and the nurse did not have effective
presence with the patient. Also, 2 stress-reducing
programs were conducted before surgery as there
were no special caring actions done due to surgery
before, during, and after hospitalization considering
the fact that surgery is a disordering factor that
strongly affects the quality of life. Thus, comparing
the results of these 2 studies, the effectiveness
of the intentional presence of the nurse is clear.
Dawson and his colleagues12 did a randomized
clinical trial study to investigate the application of
psychological strategies as holistic care on
physiologic markers of injured athletes. The 2
dimensions of holistic care (cognitive and somatic)
reduced cortisol production. Reducing the production
of cortisol reduced the levels of anxiety, stress, and
pain. Compatibility and balance emerged after
relaxation exercises while fatigue and depression were
reduced. But the competitive spirit of athletes in the
intervention group was increased. Thus, this study is
consistent with the study by Dawson et al on the effect
of relaxation on the reduction of stress, anxiety, and
depression. In that study, the injured athletes listened
to the relaxation and mental imaging exercises
through a tape. In contrast in the present study, the
individual needs and stressor resources were
considered individually for each patient in the process
of the nurse’s intentional presence in transpersonal
caring relationship.
CONCLUSION
The results of this study indicated that the intentional
presence of a nurse as an effective holistic nursing
modality can reduce the depression, stress, and anxiety
of the patients undergoing coronary artery bypass
surgery. Because of the simplicity and inexpensiveness
of this method, it can be applied as a complementary
therapy for these patients. Also, the researchers did not
observe any side effects originated from intervention.
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305
What is new and important?
r The cardiac surgery success can be effected by the
mental situation of the patient.
r The holistic nursing modalities can be used to
reduce the mental disorders of the cardiac surgery
patients.
r The intentionality and presence of the nurse play
an important role in the transpersonal caring
relationship.
r The intentional presence of the nurse from the
beginning of admission to the end of discharge
time can reduce the cardiac surgery patient’s
depression, anxiety, and stress.
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