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Fear and in-hospital social support for coronary artery bypass grafting patients on the day before surgery
Meeri Koivulaa,*, Marja-Terttu Tarkkaa, Matti Tarkkab, Pekka Laippalac, Marita Paunonen-Ilmonena
Department of Nursing Science, University of Tampere, FIN-33014, Tampere, Finland Department of Cardio-Thoracic Surgery, Tampere University Hospital, PO Box 2000, FIN-33521 Tampere, Finland c Tampere School of Public Health, University of Tampere and Tampere University Hospital, FIN-33014, Finland Received 9 April 2001; received in revised form 29 June 2001; accepted 6 July 2001
Abstract The purpose of this study was to ascertain the amount of in-hospital social support received by coronary artery bypass grafting patients and the impact of this support on their feelings of fear and anxiety. As adapted from Kahn’s theory, social support was understood as emotional, informational and tangible support. The bypass grafting fear scale was developed to measure the fear, and the hospital anxiety and depression scale and the state anxiety inventory were used to measure the anxiety. Data were collected pre-operatively with a questionnaire from in-patients (N ¼ 193) and analysed using logistic regression analysis and one-way ANOVA. The majority of patients received plenty of social support from nurses and a great deal of multiprofessional counselling. When the amount of social support was high, patients experienced lower levels of fear and anxiety. It is concluded that social support from nurses can eﬀectively reduce pre-operative fear and anxiety, but that the amount of support should be high. r 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Bypass grafting; Fear; Anxiety; Social support; Counselling
1. Introduction The majority of patients experience varying degrees of fear and anxiety while hospitalised before coronary artery bypass grafting (CABG) surgery (Norris and Baird, 1967; Graham and Conley, 1971; Beddows and ! Cert, 1997; Edell-Gustafsson and Hetta, 1999). Preoperative nursing aims to alleviate patients’ feelings of anxiety, because anxiety can adversely aﬀect surgical patients’ current wellbeing, intensive care and recovery (Johnston, 1980; Magni et al., 1987; Oberle et al., 1990; Stengrevics et al., 1996). Patients’ feelings of fear and anxiety are alleviated in nursing care through diﬀerent forms of social support, such as informational, emotional and tangible support (Teasdale, 1995; Clark, 1997; Fortner, 1998; Lamarche et al., 1998). However,
*Corresponding author. Fax: +358-3-215-6665. E-mail address: numeko@uta.ﬁ (M. Koivula).
research reports are in conﬂict as to the eﬀects of patient education and social support on patients’ fears and anxiety (e.g. Thompson and Meddis, 1990; Lepczyk et al., 1990; Devine, 1992; Linden et al., 1996). The present study set out to ascertain receipt of in-hospital social support and its eﬀects on CABG patients’ pre-operative fear and anxiety. The study examines those forms of in-hospital support available for CABG patients: presence of a family member, multiprofessional counselling, diﬀerent forms of support from nurses and from a pre-operative support group, which some patients attended while waiting for surgery.
2. Literature review Anxiety and stress are increased in situations where a person cannot control the events involved, and it is
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more information is not enough to alleviate anxiety. 1999).. separation from the close ones and psychological complications. A structured counselling programme has been found to signiﬁcantly reduce anxiety in cardiac patients both immediately and in the long run (Thompson and Meddis. ICU nurses and a physiotherapist. encouragement to expressing feelings. 1995. It has been found that patients’ anxiety level increases upon admission to hospital but less so in those who have been oﬀered information while still at home (Beddows and Cert. Noble (1991) emphasises that nurses should develop patient counselling in close collaboration with doctors and increase their counselling skills through additional training. et al. Hildingh et al. (1996) reported that diﬀerent occupational groups used diﬀerent strategies in patient counselling and were unaware of what strategies the other groups used. It has been found that fears. in particular being placed in a ventilator induced fear of death and anxiety in patients (Halm and Alpen. 1989). patients are afraid of being in pain. 1980). Stewart et al. 1997). 1999). an anaesthetist. Kruger (1990) states that the role of nursing in patient education is still unclear. (1987) revealed that nurses mistakenly assumed patients to expect counselling primarily from nurses. 1971. Social support is normally received from a social . The eﬀect of information giving on patients’ emotional state has been studied by testing diﬀerent counselling interventions using the experiment-control group design. 2000). Some reports have been published of the eﬀects of group counselling and peer support on cardiac patients. 1989) and positive results (White and FrasureSmith. 1993). Patients also need support: acceptance of their feelings of fear and helplessness. whereas patients themselves expected to receive information from doctors. having tubes in the mouth. (1990) revealed that anxiety levels were not associated with information-giving or its timing. Otte (1996) found that one-day surgical patients were dissatisﬁed with collaboration in the multiprofessional team and with the ﬂow of information in-patient care.416 M. a pre-operative visit from an ICU nurse is the best way of alleviating fear and acquiring information about intensive care (Watts and Brooks. The counselling and provision of support for CABG patients are delivered in a multiprofessional team including nurses. shared their worries and information and learned from each others’ experiences. 1997). Theoretical background Social support is deﬁned as interpersonal transaction that includes one or more of the following key elements: aﬀect. 1997).. Shuldham (1999a) concluded based on a literature review that research supports the view that patient education reduces post-operative anxiety. Hawley (1998) depicted ‘‘uncertainty of mind’’ apparent in CABG patients involving anxiety and fear. Findings on the association of age and gender with fear of surgery and anxiety are conﬂicting (Graham and Conley. Tilley et al. The support given by a volunteer who had recovered from cardiac surgery has been found to decrease anxiety during hospitalisation (Parent and Fortin. Koivula et al. such as a confused state of mind in the ICU. 1990. the support was conveyed in the group when the group members compared their coping strategies. depression and information from nursing staﬀ are associated with the feeling of uncertainty in patients (Iire. loneliness in the intensive care unit (ICU). Much research has been conducted into the eﬀects of information and counselling provided by nurses on postoperative anxiety of patients (Leino-Kilpi et al. As reported by patients. which have been found to contribute to the wellbeing of members by mutual feelings of caring and belonging (Hildingh et al. Lepczyk et al. Self-help groups are a type of group support. 1999). Fortner. reassuring discussions and touching (Teasdale. Shuldham et al. / International Journal of Nursing Studies 39 (2002) 415–427 thought that information-giving reduces uncertainty (Teasdale. 1993. aﬃrmation and instrumental support. 3. While in intensive care. (1996) found that a single post-discharge education class for a group of patients had a signiﬁcant eﬀect on knowledge and healthpromoting behaviour. However. but no research reports are available on how emotional and tangible social support from nurses inﬂuence bypass surgery patients during their inhospital period. 1993). 1999b). 1995). Plach et al. 1995. Information and support received from a cardiac patients’ support group helped patients and their families to set realistic goals for the future (Wiggins. Mott. 1997). 1989).. More knowledge of the eﬀects of patient counselling as experienced by patients is needed in order to develop multiprofessional counselling of CABG patients. 1995) concerning the eﬀects of social support on stress and anxiety in bypass surgery patients. The information given by nurses should be objective and tangible in order to make a frightening situation more bearable and familiar for the patient (Clark. Breemhaar et al. emotional support. Shuldham. The need for social support and especially of emotional support increases in stressful situations (Hildingh et al. Data with a male samples have yielded negative results (Kulik and Mahler. 1998). surgeon.. (2001) reported that a support group provided cardiac patients and their spouses with informational support. (1997) found that only 16% of myocardial infarction patients aged over 65 years attended a support group although their need for support was increased. being thirsty and not being able to sleep (Cochran and Ganong. Heikkil. aﬃrmation and aid (Kahn and Antonucci. In contrast..
Yocom. the language of the questionnaire was adjusted to make the questions more clear and understandable. Anxiety is deﬁned as a vague. In the pilot test. or in providing instructions to help the patient act in the hospital environment. 1994). Clinical research-based knowledge of factors associated with fear and anxiety is needed in nursing care (Whitley. On the basis of the feedback of the 16 respondents. uncertainty and tension (Beck et al. Permission to conduct the study was obtained from the hospital’s ethical committee. nleikkausrekisteri. voluntary participation and the principles of completing the questionnaire. 1985. This study focuses on the amount of multiprofessional counselling as assessed by patients. and fear is deﬁned as the feeling of dread related to an identiﬁable source (Whitley. Support from next of kin is important to a patient referred to surgery. repeat surgery. Koivula et al. but contacts to the social support network are limited while the patient is hospitalised. patients are unequal in the sense that all patients’ signiﬁcant others cannot be present in hospital. The researcher saw each patient suitable for the study in the hospital during cardiac examinations or contacted them by telephone. which performs 700–800 CABG surgeries annually (Syd. 4.1. emotional support appears. Here. In nurses’ professional action.. The support group oﬀers expert information and peer support from people who are in a similar life situation or have gone through the same operation. three months post-operatively. 1992). informational support refers to illness. However. 1998). Patients were informed of the purpose of the study. Stengrevics et al.and health-related information given by nurses. which is organised in the hospital on a regular basis. patients responded to a postal survey while waiting for bypass surgery. 1996).M. which is the primary purpose of this study. time. Informed consent was obtained from all patients.. assistance or entitlements. 1987. As from the beginning of 1998. Anxiety is an emotional process while fear is a cognitive one (Beck et al. 1993). both valve replacement and CABG surgery. admiration. all patients who met the following criteria were invited to participate in the study: scheduled elective CABG. In Kahn’s and Antonucci’s theory. 1985). patients waiting for bypass surgery and their families have an opportunity to attend a support group. ability to understand the instructions related to the study and to answer the questionnaire independently. / International Journal of Nursing Studies 39 (2002) 415–427 417 network and the family (McMurray. the source of which is often unspeciﬁc and unknown to the individual. The intensity of anxiety and fear may vary from mild to panic. and the patient is usually able to contact their relatives only by telephone. in the form of asking about feelings. 1984). Kahn and Antonucci deﬁne tangible aid as giving things. write and speak Finnish. Some questions were removed from the questionnaire because all patients gave similar responses in the pilot study. information giving is a central way of supporting the patient’s independent decision-making. tangible aid appears in practical nursing procedures performed by nurses if the patient cannot cope alone. patient education to make the patient better understand their care. 29 questionnaires were mailed and 16 patients responded. and in phase three. 1994). In the hospital where this study was conducted. Design The study was carried out at Tampere University Hospital in Finland. The a present study constituted the second phase of a threephase follow-up study. respect or love. excess perspiration. but testing of the questionnaire. money. Multiprofessional counselling means the whole of patient education.. In professional nursing. This study sees social support from nurses as multidimensional by applying Kahn’s and Antonucci’s theory to professional nursing. Aﬀective support refers to expressions of liking. such as tremor. because it supplements the emotional support received from professional practitioners by providing the experience of togetherness and love. whereas strong anxiety is detrimental to recovery (Magni et al. Method 5. Research questions How much social support do CABG patients receive in hospital pre-operatively? What is the impact of pre-operative social support on the fear and anxiety of patients? 5. uneasy feeling. heart palpitations and worry. in phase two they responded to a questionnaire in the hospital on the pre-operative evening. The questionnaire was pilot tested prior to the study on patients placed on the waiting list for CABG (n ¼ 16). To make answering to the questionnaire in the pre-operative evening rapid and . In phase one. listening to the patient and showing respect for patients. Mild anxiety may beneﬁt the patient’s recovery from surgery (Salmon. The patients voluntarily took part in the pilot study knowing that it was not the study proper. ability to read. which is composed of the counselling from and collaboration between the professionals that are involved in the care. and counselling for relatives. and this should be taken into account while choosing nursing interventions (Whitley. In professional nursing. aﬃrmation refers to expressions of agreement or acknowledgement of the appropriateness of some act or statement of another person.. 1998). The following cases were excluded from the study: acute surgical patients. An anxious person experiences subjectively unpleasant feelings. for instance.
(1998). Internal consistency as measured by Cronbach alpha was good (see Table 2) and on the same level as reported previously from Finland (Heikkil. and 13 incomplete responses were rejected. Twenty-three patients returned a blank sheet. The scores of the HAD-A can be classiﬁed as normal (0–7). The study group was a voluntary sample of population treated during a given period. the respondent self-assesses their feelings at the moment on a 4-point Likert scale with responses ranging from 1 (not at all) to 4 (very much so). The bypass grafting fear scale (BGFS) is based on the literature on surgical and coronary heart disease (CHD) patients’ fears (Norris and Baird. Dependent variables Anxiety was measured by two instruments. Socio-demographic characteristics of the sample are shown in Table 1. unwillingness to participate and inability to complete the questionnaire. 1994). 47 failed to participate in the present study (20%). Koivula et al. restlessness and anxious thoughts. Raw scores can be categorised into three classes: low anxiety (20–39).. Based on the literature 14 fears were chosen for the BGFS scale. Carr and Powers. The HAD is a 14-item instrument developed to study anxiety and depression in non-psychiatric hospital patients (Snaith and Zigmond. 1983). The respondent self-assesses sensations during some previous days on a 4-point scale ranging from 0 to 3. because they were asked in the ﬁrst phase of the study some weeks earlier. which has been a shown to be valid (Heikkil. a 1998). Thirty patients refused to participate and explained their refusal citing reasons such as: poor physical condition.418 M. Permission for using the STAI was obtained. medium (11–14) and high (15–21) anxiety. 1994). poor eyesight. the hospital anxiety and depression (HAD) scale and the STATE-Anxiety Inventory. 1967. The ﬁnal sample was 193 patients. a et al. Nurses distributed the questionnaires to patients the previous evening before CABG and the patients returned their responses to nurses in a closed envelope. / International Journal of Nursing Studies 39 (2002) 415–427 easy. Of the 240 patients who consented to participate in the overall study. 1999. housewife 45 64 83 36 157 157 9 15 12 51 68 47 21 51 126 3 13 % 24 33 43 19 81 81 5 8 6 27 36 25 12 26 65 2 7 . Eleven patients failed to receive the questionnaire because they had undergone emergency surgery. died. Permission to use the instrument was obtained from the copyright holder who delivered the Finnish version.. the shortened version of the questionnaire was used in this study. . Heikkil. The question about the fear of hospital environment was removed because all respondents in the pilot study had minimal fear and the question about the fear of returning to work was removed because it was often left unanswered. Sample A total of 270 patients on the waiting list were invited to participate in the study. Costruct and divergent a validity and test-retest reliability of the STAI are described by Spielberger et al. 1999). 5. The face validity and construct validity of HAD have been reported by the developers (Snaith and Zigmond. background questions were not asked. . The BGFS measures the intensity of 12 fears found to be relevant to CABG patients.. In this material. Biley. Spielberger a et al. refused to continue in the study or nurses had forgotten to hand them the questionnaire. the BGFS was internally consistent as measured by Table 1 Sociodemographic variables N Age o55 56–65 65> Gender Female Male Marital status Married/cohabiting Divorced Widowed Single Vocational education No In-service training Diploma-level Degree-level Employment status Sick-leave Retired Unemployed Self-employed.2. Graham and Conley. 1998). The study used the translation into Finnish devised by Heikkil. 1971. 80% of those who consented to participate. The HAD-A sub-scale has seven items focused upon anxious mood. et al. two of which were removed based on the pilot study (n ¼ 16). In the STATE-A sub-scale. medium anxiety (40–59) and high anxiety (60–80) (Heikkil. In the shortened questionnaire. (1983). Spielberger’s STAI assesses situational anxiety (STATE-A) and individual tendency to experience anxiety (TRAIT-A). 1989. In this material internal consistency reliability was good as measured by Cronbach alpha (Table 2). both with 20 items. low (8–10). Rakoczy. 1986. 5.3. An instrument was designed to measure the fear of CABG patients. Respondents assessed the intensity of their fears on a scale ranging from 1 (no fear) to 10 (extremely high fear). 1977.
85 0. The item measuring information from ICU nurses was deleted from the sum score because of 20 unanswered items (see Table 6).5 2.5 2.7 3. the minimum score of which is 12 and maximum 120.8 5. The multiprofessional counselling scale (MCS) was developed to measure the amount of information the patient has received from ward and ICU nurses.3 2. range. three measuring emotional support and three measuring tangible aid.2 2. a continuous variable is formed. a physiotherapist.4 20.3 SD 10. (See Table 4) The correlation’s between the sub-scales were 0. The mean. The MCS had good internal consistency as measured by Cronbach alpha. Support from the pre-operative support group was measured by a simple question asking whether the patient had attended one or not.6 3.66.9 3.3 2. The respondent was asked to assess the amount of information concerning surgery from ﬁve diﬀerent professionals. so that the ﬁrst and second quartiles (50%) represented no (12) or low (13–35) fear. The respondent is asked to assess the social support received from nurses on the pre-operative day with a 5-point scale from 1 (not at all) to 5 (very much). range and reliability estimates in this material are shown in Table 4. / International Journal of Nursing Studies 39 (2002) 415–427 419 Cronbach alpha (0.7 2.90 Table 3 Fear and anxiety of CABG patients in hospital the day before surgery Scale BGFS STATE HAD-A Minimal (%) 4 78 Low (%) 46 72 14 Medium (%) 25 24 7 High (%) 25 4 1 Total (%) 100 100 100 . surgeon and an anaesthetist.5 1.4. The BGFS correlated with anxiety instruments: correlation coeﬃcient for HAD-A was 0. which lends support to the instrument’s concurrent validity.8 2.8 4. 1980).66 and for STATE-A 0.0 39. In this material. deviation.6 2. The subjects were divided into classes according to quartiles.0 3. 5.1 3. Koivula et al. The face validity of the instrument is based on the theory of social support (Kahn and Antonucci.7 2. the third quartile (25%) represented medium (36–51) fear and the fourth quartile (25%) of the respondents with the highest scores represented high fear (52–120).M. reliability Scale STATE HAD-A BGFS: Operation Anaesthesia Pain Death Myocardial infarction Economic problems Sexual problems Deterioration of health Uncertainty Being away from relatives Dependence on staﬀ Recovery from operation Possible range 20–80 0–21 12–120 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 Items 20 14 12 1 1 1 1 1 1 1 1 1 1 1 1 N 190 193 189 189 188 188 187 189 188 188 189 189 188 189 189 Mean 35.4 3.90). The 5-point scale ranged from 1 (not at all) to 5 (very much).49–0. The mean and standard deviation of each independent item are shown in Table 2.4 2.6 2. The contents of the measure are shown in Table 5. The measure consists of ten items: four measuring informational support.9 2. When the 12 questions concerning the diﬀerent sources of fear are summated.2 Min–Max 20–68 0–16 12–99 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 1–10 Cronbach alpha 0. Predictors The Social Support from Nurses (SSN) scale was developed for this study to measure the amount of inhospital social support.93 0. the internal consistency reliability was good in all the sub-scales and in the total scale. means. Support from next of kin was also measured by a question asking whether Table 2 Fear and anxiety measures.8 4.6 2.2 3.84.2 2. A sum score of multiprofessional counselling was formed by summating four items.3 2.
0 (SPSS Inc. reliability Scale Social Support from Nurses: Informational Emotional Aid Total SSN Multiprofessional counselling Possible range 4–20 3–15 3–15 10–50 4–20 Items 4 3 3 10 4 N 193 193 193 193 191 Mean 16. The majority of patients experienced low situational anxiety (STATE). Patients rated the instructions of how to act in hospital as good or very good.2 12. living in a partner relationship or alone. One-third of patients reported that their family had received no or little information (Table 5). a vocational diploma or degree or none. odds ratio (OR) is o1 or >1 based on conﬁdence intervals (CI) of 95% were taken into the model as variables predicting high fear and anxiety (Munro. The level of statistical signiﬁcance was set equal to or less than 0.0 17. deterioration of health and uncertainty. To do this. Results 6. Over half of the patients had received very much information of their illness. Logistic regression analysis was performed to study the association of social support.72 0.77 0. Since the relationships detected in the logistic regression analysis were non-linear. Occurrence of fear and anxiety Patients were most of all afraid of pain. social status. 6. Statistical analysis was carried out using SPSS/Win Software version 7. Those independent variables whose po0:05. 5.5. The ﬁrst quartile of the distribution of social support was named as minimal social support. whereas one-third felt they had many opportunities (Table 5). / International Journal of Nursing Studies 39 (2002) 415–427 next of kin were available in hospital the day before surgery.1. range. Maximal anxiety levels did not appear (Table 2). a series of one-way ANOVA analyses were also performed. the variables of social support were classiﬁed into four classes using quartiles and median as class limits.2 2.87 0. and patients felt that they had been appreciated in hospital much or very much. 1997).5 41. The majority of patients reported that information from nurses was exactly what they needed and helped them understand their care. Nearly all the patients had some fears. The Bonferroni procedure was used to detect diﬀerences between classes. retired or in the labour force. Raw scores of the variables were described by percentiles. Data analysis Descriptive statistics were used to study demographic data.2 3.420 M. The mean value of fear was used as the cut-oﬀ point in the BGFS scale. in the STATE scale. Being dependent on staﬀ and economic problems (Table 2) induced the lowest levels of fear. the proportion of anxious persons was 22% and for the majority the anxiety was low (Table 3). Chicago. fear and anxiety (Munro. The variables of fear and anxiety were ﬁrst coded as dichotomous (0/1) ones. All the background variables and the variables of social support were entered together in the logistic regression model using the forward stepwise method. but for one quarter.1 Md 16 12 13 41 19 SD 2.71 0. the scores were dichotomised into low anxiety and medium/high anxiety. fear and anxiety incidence and the intensity and social support available to patients in hospital. mean.6 2. and in HAD-A into those who displayed a normal response and those who experienced varying degrees of anxiety. Nearly all the patients had received much or very much tangible aid.7 Min–Max 5–20 3–15 3–15 11–50 4–20 Cronbach alpha 0. 1997). IL. the third quartile as medium and the fourth quartile as high social support. marital status.7 6.05.82 . Nearly all the patients had received fairly much or plenty of emotional support. Nurses had inquired sensations of almost all the patients and listened to them much. In the HAD. 6. the second quartile as low. To avoid small classes the background variables were recorded as dichotomous: aged under or over 65 years. the anxiety was fairly intense. and one quarter had medium and one quarter intense fear (Table 3). More Table 4 Preoperative social support measures. histograms and reliability of all the summated variables were studied. USA). Sum scores were formed and descriptives. One out of ten patients felt that they had had only few opportunities to discuss with nurses. Pre-operative social support for CABG patients in hospital The majority of patients received much informational support from nurses. Koivula et al.2.2 12.
One quarter (25%) of patients reported that a family member was present on the preoperative evening.3) and multiprofessional counselling (OR 1. Ample informational support from nurses was also associated with a signiﬁcantly lower fear level as compared with a small amount of informational support. 6. More than half of the patients reported that nurses had responded to their need for help very quickly and a little less than half that the response was fairly quick (Table 5). A little less than half of the patients had received much counselling from an ICU nurse. All the patients had received counselling from ward nurses. Multiprofessional preoperative counselling for CABG patients was high for most patients. since a high amount of counselling was associated with low fear and a medium amount was associated with the most intense fear (Table 8). patients’ fears were signiﬁcantly lower as compared with no support at all. / International Journal of Nursing Studies 39 (2002) 415–427 421 than half of the patients rated the assistance from nurses as very good and fewer than half as fairly good. The impact of social support on fear and anxiety of patients Table 7 shows the variables that were used in the logistic regression model to account for the fear and anxiety. The association of the amount of multiprofessional counselling with the intensity of fear was not as clear.1) from nurses were associated with fear (Table 7). Koivula et al. whereas the majority had received much counselling. One in ten patients reported that the amount of counselling from a physiotherapist was non-existent or very low. whereas the majority reported having received fairly much or much counselling. It was found that emotional support (OR 1. The majority of patients felt that the amount of counselling was very high or medium. A little over one in ten of patients had received no or little counselling from a surgeon or an anaesthetist.M. A little over one-third (39%) of patients had attended a pre-operative support group organised in the hospital while waiting for surgery. whereas one-third had received no or little counselling (Table 6).3. Table 5 Social support from nurses for CABG patients the day before surgery Social support items in SSN scale Social support from nurses No/low (%) Informational support information about treatment of illness information is what is needed information helps to understand treatment information about treatment to family Emotional aid nurses inquire about sensations and listen possibility of discussing feelings is given patients feel they are treated with respect Tangible aid hospital gives advice on how to act nurses help in all matters if patient is unable to cope nurses are quick to help when needed 0 1 1 29 3 11 1 2 3 3 Moderate (%) 46 48 50 55 56 62 54 51 42 42 High (%) 54 51 49 16 41 27 45 47 55 55 Table 6 Multiprofessional counselling for CABG patients the day before surgery Counselling professionals n Amount of information received by patient No (%) Ward nurses Surgeon Anaesthetist Physiotherapist ICU nurses 189 186 186 185 167 0 8 5 7 27 Low (%) 7 5 7 3 7 Medium (%) 33 22 27 29 23 High (%) 60 65 61 61 43 . It was found based on the analyses of variance that when the amount of emotional support was high.
2) situational anxiety (Table 7).61) 0.136 0.741 0.267 0.06–7. Reliability The sample of this study represents CABG patients of one hospital with a catchment area of about one million inhabitants.25) 2.10-6-58) (1.5) as the others (Table 7). Women reported anxiety four times as often (OR 4. 8) as those living in a partner relationship.003 0. the pre-operative support group reached signiﬁcance.834 0.1. Of the background variables. Low emotional support from nurses was associated with a slightly increased (OR 1.51 (1.253 0. However.007 0.017 1. Those who were still in the labour force expressed anxiety twice as often (OR 2. Those with no vocational training reported anxiety twice as often (OR 2.554 OR (95% Cl) STATE p 0.35 (1.25) 2. According to ANOVA. was associated with less intense anxiety as compared with a low amount of support (Table 8).6) as those living in a partner relationship.40) 1.336 0.49) 1. marital status. the development of new instruments spared the trouble of translation and generated culturally adequate measurement tools. patient reported more often (OR 1.39)b Signiﬁcant p-values highlighted.06–1.1) (1. tangible and total support.042 0.308 0.16 2.279 0.77 2.754 0.26 (1.82 (1. The BGFS .029 0.17–5. and attainment of vocational education and employment status were associated with anxiety.6) as men.833 0. The study used several instruments developed for the study.5) as those who were retired. fear and anxiety.220 0. According to ANOVA.63 (1.2) occurrence of anxiety (Table 7).013 0.23 (1.041 0.12–1. ample overall support from nurses involving both emotional.47) 1. More knowledge should be obtained of the validity of the SSN scale in diﬀerent phases of care and in diﬀerent patient groups to further reﬁne it. gender.14) (1.132 0. ample emotional support from nurses was associated with signiﬁcantly lower situational anxiety levels in-patients as compared with a small amount of support.944 0.001 0. Ample social support from nurses involving informational.031 0.69 2. informational and tangible support had a signiﬁcant association with milder anxiety than if the amount of support was low (Table 8). the anxiety in those who had attended the support group was not signiﬁcantly higher than among those who had not attended it (Table 8).422 M. 7. When support from nurses and multiprofessional counselling were removed from the logistic regression model.691 0.314 4.07–6. Women reported situational anxiety twice as often (OR 2.03–6. The sample may be biased because some patients refused to participate or failed to respond. No suitable instruments for measuring social support were available. The reasons for non-response on the evening before surgery could include tension. Signiﬁcant when social support from professionals ignored.587 OR (95% Cl) 0. The ﬁrst phase of the study yielded a slightly better response rate (88%) than the present study (80%).00–1. marital status and emotional support from nurses were associated with situational anxiety (STATEA).37) 2. / International Journal of Nursing Studies 39 (2002) 415–427 Table 7 Eﬀects of in-hospital social support on preoperative fear and anxiety (logistic regression)a Variables in model Fear and anxiety BGFS p Background Age Gender Marital status Vocational education Employment status Social support from nurses: Emotional Informational Aid Multiprofessional counselling Preoperative support group Next of kin a b HAD-A OR (95% Cl) p 0.61–11. The scale of multiprofessional counselling generated new knowledge and revealed several areas that need to be developed.7) as those with a vocational training. Those who had attended the support group reported anxiety twice as often (OR 2. Koivula et al.12 (1. Gender. When the amount of emotional support from nurses was low.104 0.034 0.1) as did men.57 (1.591 0. Those living alone reported situational anxiety nearly three times as often (OR 2.217 0. Discussion 7.982 0.036 0.24–6.296 0. Those living alone expressed anxiety twice as often (OR 2.02–1.
0 3.9 20.8 3.5 45.1 0.7 4. which would explain the low amount of intense anxiety.3 22.7 19.7 42.5 33.4 3.6 37.5 18. The majority of patients reported low or no anxiety.0 8.1 20. High (n ¼ 73) Pre-operative support group 1.9 3.4 3.0 6.3 21. scale proved to be a reliable instrument for measuring the intensity of CABG patients’ most common fears.9 32.5 5.9 20.3 0.5 0. Medium (n ¼ 37) 4.9 36.0 12..3 38.6 22. 4o2b 0. Low (n ¼ 65) 3.7 34.4 21.2 31.6 39. Minimal (n ¼ 41) 2. 1996).2 3.286 Signiﬁcant p-values highlighted.6 3.8 0.9 18.5 5.6 4. Many patients have a anxiously waited for cardiac examinations and surgery (Underwood et al.5 9. 7.1 11. / International Journal of Nursing Studies 39 (2002) 415–427 Table 8 Association of in-hospital social support with fear and anxiety (one-way ANOVA)a Fear and anxiety BGFS Mean Social support from nurses: Informational 1.6 9.7 3.767 11.9 0.6 41..7 19.078 5. Pre-operative social support in hospital Patients received from nurses a great deal of social support in all its forms. High (n ¼ 38) Multiprofessional counselling 1.5 3.6 37.042 4o2b 0.6 38.7 3.2 3.2 43.9 5.2 38.1 4.5 45.4 20.7 37. Low (n ¼ 50) 3.3 3.3 18.0 9.0 4. Minimal (n ¼ 46) 2.1 4.4 0.013 Mean SD p 0. Yes (n ¼ 44) 2.2 37. Low (n ¼ 38) 3.5 18. The instrument’s content validity should be further checked because a structured measurement tool fails to adequately capture patients’ individual sources of fear. Medium (n ¼ 55) 4.1 23.3 9.160 12. No (n ¼ 112) a b 423 HAD-A SD p 0.4 41.1 41.2 0.6 10. Low (n ¼ 59) 3.2 9.7 16. Signiﬁcant diﬀerence between groups by Bonferroni procedure. 1993..037 3.0 39.7 35.4 9.4 36.044 3. Koivula et al. Other study using the same anxiety measurement tools has shown that breast cancer patients experience anxiety twice as often (45%) as CABG patients in this study (Millar et al. High (n ¼ 36) Aid 1.3 11.077 3.445 5.9 18.3 37.7 31.5 5. Yes (n ¼ 73) 2. High (n ¼ 50) Total social support 1. Minimal (n ¼ 39) 2.6 0.1 33. Fear and anxiety in hospital before CABG Two diﬀerent instruments yielded slightly diﬀering results on the occurrence of anxiety.6 34.5 4o2b 0.5 40.6 10. 7.2.8 44.1 37.2 39.7 0. No (n ¼ 129) Next of kin present 1.9 39.6 12.5 3.6 39. more medium and intense anxiety before coronary angiography has been detected using both HAD (28%) and STATE (38%) (Heikkil. Minimal (n ¼ 39) 2. Medium (n ¼ 41) 4.289 4o1b. 4o2b 0. However.0 3.4 36.5 35. whereas half of the patients reported fairly strong or intense fear.365 3.1 35.5 36. High (n ¼ 39) Emotional 1. and surgery may be a long-awaited solution to long-term uncertainty.001 4o2b 0.4 5.4 9.2 22. 1995).1 37.0 0.005 38. 1998).6 5.3 8. Medium (n ¼ 44) 4.5 3.8 32..2 3.3 4.0 36.5 9.7 38. Low (n ¼ 56) 3.9 20.4 19.8 44.018 4o1b.8 4.2 STATE Mean SD p 0.370 4o2b 0.4 10. Bengtson et al.2 20.6 4.0 3.7 31.6 3. Medium (n ¼ 56) 4.2 9.8 23. As compared with this study that measured anxiety before CABG surgery. et al. Minimal (n ¼ 41) 2. the position of the .047 5.6 5.6 10.2 9.3.2 2.4 9.1 20.9 42.8 34.2 20.6 4.082 4.265 5.8 0.M.4 4.001 4o1b 0.8 31.5 11.484 5.3 35.9 2.
but it would also be important to ascertain it in the multiprofessional team. Breemhaar et al. 1996). 1997) or failed to meet the patient’s individual need for information or that the information given by diﬀerent occupational groups was conﬂicting (Cortis and Lacey. The ﬁndings of this study should be used to organise nursing care so that nurses have enough time to discuss with patients because both emotional and informational support are transmitted in discussions and especially in the way the patient is addressed (Yates.. Those patients who had received a great deal of social support from nurses reported the lowest fear and anxiety. Patients who had received fairly much multiprofessional counselling reported the highest levels of fear. These ﬁndings show that almost all the occupational groups implemented the multiprofessional counselling quite well. The majority of patients estimated that they had received much counselling.4. This study did not address the role of the Hospital Chaplain as support provider. 2000). This may result in a situation where a large proportion of patients are left without speciﬁc information concerning intensive care. These results indicate that ample informational support from nurses is also related to lower fear levels. Bengtson et al. 1995). It is diﬃcult to interpret the association between multiprofessional counselling and fears because the association was non-linear. Those patients who reported having received a small amount of emotional support reported on average higher levels of fear and the highest anxiety. and patients were uncertain about the roles and responsibilities of various health care providers. McMurray. that this study only addressed the support provided on the pre-operative day. 1998).424 M. while Wiens (1998) found that almost all the female patients had a relative present in the hospital. (1996) found that nearly 90% of CABG patients suﬀer from pain . Counselling by an ICU nurse is an exception since one-third of patients had not received it. Work pressure and number of staﬀ in the ICU might sometimes prevent the ICU nurse from making the pre-operative visit. On the other hand.. / International Journal of Nursing Studies 39 (2002) 415–427 family in care attracts attention because one-third of patients reported that their next of kin had received no or little counselling..’s (1984) study showed that cardiac patients’ fears were not correlated with their experience of counselling. the patient did not know when the doctor would come. In the study by Breemhaar et al. 2001. 1996. It seems that the ICU nurse’s pre-operative visit to the patient is not a systematic practice. though. and it might be impossible for signiﬁcant others to be present in the hospital because of long distances. 1997). Timing of data collection could be the reason for the lack of support from a surgeon and anaesthetist. Patients completed the questionnaire on the pre-operative evening. It seems that nurses on the hospital ward are in a better position to counsel the patient during admission and on the pre-operative day. 7. The results of this study suggest that it would be advisable to improve the position of next of kin also in the preoperative phase. because other health team members assume that the ICU nurse will provide that information. which may be the reason why they gave a negative response to the question concerning the counselling given to the family. although hospital wards also suﬀer from haste. 2000). but could remain undone in busy situations. Easton and Andrews. It should be remembered. Earlier research suggests that CABG patients rate the support provided by their family as most important (Lamarche et al. Koivula et al. Stanton et al. Patients may also have spiritual needs and they had not received the spiritual support they needed (Halm et al. The connection of social support to fear and anxiety The results suggest that emotional support from nurses was associated with fear and anxiety. 1998. 1998). but it has also been found that diﬀerent countries diﬀer in the use of spiritual support as a coping method (Kaba and Shanley. This is partly explained by the fact that only one quarter of patients had a signiﬁcant other present in the hospital. and that counselling for relatives can be supplemented as the care process continues and the relatives contact the hospital. An emerging literature has demonstrated a salutary impact of religious belief and practice on patient wellbeing (Astrow et al. 1996). This study addressed only the amount of multiprofessional counselling. These results provide evidence of the eﬃcacy of support provided by nurses and of the fact that intensive fear can be alleviated with plenty of emotional support. The reasons for the fact that a rather large amount of counselling failed to relieve the patient’s fear and might even increase it could be that the counselling did not ﬁt in with the patient’s coping style (Mitchell.. One should also bear in mind that all patients do not have a family.. The pre-operative visit requires that the ICU nurse leaves the intensive care unit and meets with the patient on the hospital ward. 2000). whereas the quality of counselling as experienced by patients is also of importance (Cortis and Lacey. the Finnish hospital culture does not favour the presence of relatives in hospital given the hospital’s cramped facilities. Nurses’ hasty work pace and impersonal routine work are experienced by patients as anxiety inducing (Hawley. The catchment area of the hospital under study is geographically wide. (1996). and it is thus possible that a surgeon or an anaesthetist has seen the patient only after the completion of the questionnaire. accommodation costs and work-related obstacles. surgical patients rated the following as the most common problems in patient counselling: the doctor’s visit to the patient was often interrupted. and that especially the patient’s spouse experiences fears and has the need for support and information (Stewart et al. but with the gravity of the illness.
D. The ICU nurse’s pre-operative visit should be oﬀered systematically and appropriate resources should be safeguarded. et al. a according to which there were no diﬀerences in anxiety between men and women in the diﬀerent phases of coronary angiography as measured by STAI. Both the HAD-A and STATE-A showed that women and persons living alone experience anxiety more frequently in hospital pre-operatively.M.. spirituality. 8.. Religion. Koivula et al. The result manifests the association of patients’ ﬁnancial situation with psychological wellbeing. Conclusions The ﬁndings of the present study permit the conclusion that nurses can signiﬁcantly inﬂuence pre-operative wellbeing in CABG patients by alleviating fear and anxiety through social support. . The American Journal of Medicine 110 (4). A. and thus the result can be accounted for by sample bias. Women’s higher age is often related to poorer overall health and slower recovery from surgery (Khan et al. for example. Wiens (1998) found that women experience vague feelings of threat when referred to surgery and that in that situation they especially appreciate the relationship with their family and friends. According to this study. and therefore all occupational groups should contribute to the success of multiprofessional counselling. which in combination with a poor health status cause insecurity and increase anxiety in women. nor in the availability of relatives in hospital (p ¼ 0:56). The present study did not use medical diagnostic data on patients’ illnesses. but was based on self-reported scales. The absence of a partner relationship and also retirement may lead to inadequate receipt of social support (Oxman and Hull. In this material. Puchalski. no signiﬁcant diﬀerences were found in the amount of in-hospital social support between women and men (p ¼ 0:2820:44).. Some patients might have suﬀered from long-term psychological problems. which will be reported later. women were more frequently (p ¼ 0:012) retired (83%) than men (61%). The ﬁnding diﬀers from that yielded by Heikkil. The inﬂuence of the support group appeared in the model only when the counselling and support received from hospital staﬀs were ignored. Sulmasy. which are related to fear and anxiety. 283–287. which was the point of measurement in this study. since earlier research shows that female cardiac patients experience higher fear levels (Graham and Conley. Each patient and their next of kin have a right to receive diverse information pre-operatively. and practical considerations. Anxiety Disorders and Fobias. However. It would be advisable to oﬀer ample social support and information to those who experience intense fear and anxiety because this beneﬁts patients. Fewer than half the patients had attended the support group. it would be important to further explore the contribution of the pre-operative support group to CABG patients’ rehabilitation. the anxiety of those attending the support group was not signiﬁcantly more intense. et al.. No diﬀerences were found between men and women in attendance to a pre-operative support group (p ¼ 1:00). Beck. The fear was expected to be associated with gender. References Astrow. More research should be conducted into the eﬀects of multiprofessional counselling. Greenberg. Harper Collins. since those who had attended the group displayed anxiety more frequently than those who had not. 1990). 1997).. The results of the present study can be explained by diﬀerences in surgery-related risk factors among men and women. into the exact content of the counselling provided by diﬀerent occupational groups and how diﬀerent occupational groups assess the intensity of the patient’s fear. 2001. Showing of greater anxiety in those who attended a support group would require data comparison between phase 1 and phase 2. R. G. and health care: social. A Cognitive Perspective. 1971. These results show that anxiety levels were high in those who were still in the labour force and without vocational education. it is diﬃcult to discern its eﬀect on the patient’s sensations on the pre-operative day from other forms of social support. It is also possible that participation in the support group induced anxiety in patients.. / International Journal of Nursing Studies 39 (2002) 415–427 425 limiting their life and that the intensity of these pains is associated with anxiety. Emery.. In addition. ethical. The impact of the support group was contrary to our expectation. number of children and depression. women were signiﬁcantly (p ¼ 0:024) older (proportion of those over 65=61%) than men (proportion of those over 65=39%). in-hospital social support could have removed the fear experienced by women had they received a signiﬁcantly higher amount of support. USA. On the day before surgery.. A. Lukkarinen and Hentinen (1997) found that poor ﬁnancial situation in cardiac patients correlated with age. marital status. As the support group had convened during the waiting period. However. 1985. educational attainment. but this was not the case in this a study. It is probable that anxious patients who felt they needed support while waiting for surgery sought support from the group. gender. (1999) study. 1999). C. Heikkil. It can be inferred that patients who fail to attend a preoperative support group could beneﬁt from eﬃcient preoperative counselling and support by hospital staﬀ. Women also lived signiﬁcantly more frequently (p ¼ 0:41) alone (31%) as compared with men (16%).
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