Nurse anesthetists’ strategies in reducing patients’ fear and anxiety before surgery – A systematic review

Abstract

Background:

Nurse anesthetists (NAs) face several challenges in their work, one of which is dealing with patients who experience anxiety and fear before surgery. The increased patient turnover and a shortage of healthcare professionals lead to a heavier focus on physical care, thus leaving limited time to address the psychological needs of patients.

Objectives:

This study aimed to critically evaluate and compile research that describes the things NAs use in reducing patients’ fear and anxiety before surgery.

Materials and Methods:

A systematic search was conducted on PubMed, Medline, CHINAL, Embase, and the Cochrane Library database for qualitative and quantitative literature regarding factors influencing patients’ wellbeing before surgery. An inductive thematic analysis generated categories and subcategories. Twenty-one studies were included.

Results:

The thematic analysis of the articles included revealed two main categories and six subcategories. Some strategies identified to help reduce fear and anxiety in patients before surgery included providing various types of information, offering psychological support, using different relaxation techniques, and ensuring that each patient is allocated sufficient time.

Conclusion:

The results of the presented study showed that strategies such as providing different forms of information, psychological support, and different relaxation therapies gave good results. However, there is a need for further research in health care to identify which nonpharmacological nursing interventions are most effective in alleviating preoperative anxiety. More research is also needed to determine how preoperative care should be structured to help patients feel safe and comfortable before surgery.

Introduction

Nurse anesthetists (NAs) are registered nurses who completed an additional year of specialized training in anesthesia. Their roles responsibilities differ across countries.[1,2] In the Swedish healthcare system, NAs are responsible for independently inducing, maintaining, and completing general anesthesia; they also monitor patients undergoing regional anesthesia in collaboration with an anesthesiologist.[2,3] During anesthesia, NAs monitor and assess vital signs and parameters related to anesthesia depth, ventilation, circulation, temperature, and fluid balance.[4,5,6] In addition to technical skills, NAs are also proficient in nontechnical skills such as teamwork, communication with patients, ensuring patient safety, and prioritizing patient wellbeing.[7,8] In their daily work, NAs encounter certain difficulties, one of which is dealing with patients who experience anxiety and fear before surgery.[9] Increased patient turnover and a shortage of healthcare staff lead to a heavier focus on physical care, thus leaving limited time to address the psychological needs of patients.[10] This can make it difficult for the anesthetist to see and respond to patients experiencing fear and anxiety before surgery, which can result in stress and dissatisfaction for both the patient, their relatives, and the anesthetist.[11] Previous studies show that preoperative fear and anxiety negatively affect the patient’s perioperative process, both psychologically and physically. Anxiety can change the way patients think, act, behave, and even cause their cognitive changes.[12,13] Preoperative fear and anxiety also impact autonomic functions such as increasing heart rate and blood pressure, which in turn may require higher drug doses for induction.[14,15] Women, adults under 30 years of age, and patients with no prior experience of surgical procedures generally show higher levels of anxiety and fear before surgery.[13,14,16] Additional studies show that patients who are afraid and anxious before surgery tend to have complications during the postoperative phase.[10,12] These patients are at a higher risk of nausea, pain, reduced ability to resist infections, and impaired wound healing, which in turn leads to longer hospital stays, higher doses of painkillers, and extended postsurgical recovery time.[11,12] On the other hand, studies show that when patients feel trust and confidence in healthcare professionals, anxiety and fear are alleviated both before and after surgery.[17] One way for NAs to create trust is to focus on the situation together with the patient, where NAs perceive signals related to the patient’s physical and psychosocial needs, considering the vulnerable situation the patient is in.[18] Increased awareness among NAs creates a sense of trust and confidence between NAs and patients. A good relationship and interaction between the nurse and the patient can alleviate preoperative fear and anxiety, leading to an improved postoperative outcome.[13,18] Awareness of the prevalence of preoperative fear and anxiety is essential for reducing it.[13] In addition, developed strategies and guidelines for managing fear and anxiety, as well as training to identify such feelings, are required.[15] The use of individualized care is a rather important strategy to prevent and reduce fear and anxiety.[18] Therefore, this study aims to synthesize both qualitative and quantitative research to identify the strategies NAs use while caring for patients experiencing fear and anxiety before a surgical procedure.

Inclusion criteria

1. English language

2. Qualitative and quantitative approach

3. Original studies

4. Peer-reviewed publications.

Exclusion criteria

1. Mixed-method

2. Case reports studies.

Search strategy

Using SweMeSH terms, we refined the search. The keywords such as “nurse anesthetist” “preoperative,” “strategies,” “patients,” “fear,” “anxiety,” “surgery,” “qualitative,” “quantitative,” and “review” were used. The searches were conducted in PubMed, Medline, CHINAL, Embase, and the Cochrane Library.[19] Initially, we screened titles and then abstracts. Full texts of the relevant studies were then analyzed. A total of 79 studies were reviewed, and 21 were included [Table 1]. We consulted an expert at the University Library in Gothenburg to refine the selection criteria. The selected studies focused on factors influencing patients’ preoperative fears and anxieties.[20] The Population, Intervention, Comparison, Outcome (PICO) model was used to guide the article selection process [Table 2]. Inclusion criteria included: English language, qualitative and quantitative approach, original studies, and peer-reviewed publications. We excluded mixed-method and case report studies. The authors independently screened abstracts for inclusion and exclusion. The final studies were analyzed using a five-step model process,[21] where key findings were identified, compared, and grouped into themes and subthemes according to Graneheim and Lundman. The analysis followed ethical guidelines for research [Table 2].[21]

Table 1.

Search terms and search results of databases

Database	Hits
PubMed	197
Medline	135
CHINAL	203
Embase	43
Cochrane library	89
Total	667

Table 2.

PICO framework

PICO framework	Research question and facilitation of literature review
P – Population	The patient before surgery.
I – Intervention	The professionals’ strategies in reducing fear and anxiety before surgery.
C – Comparison	Experience of preoperative strategies in reducing fear and anxiety in patients’ wellbeing.
O – Outcome	Different kinds of results regarding patients’ wellbeing before surgery.

Literature quality evaluation and data extraction

This systematic review followed the PRISMA guidelines [Figure 1].[22] We analyzed qualitative and quantitative studies to address the strategies in reducing patients’ fears and anxieties before surgery.[15] The search for relevant studies took place between January and October 2023, focusing on articles published between 2005 and 2021. The PICO model was used to guide the article selection process [Table 2].

Figure 1.

PRISMA - Preferred reporting items for systematic reviews and meta-analyses guidelines

Results

After a thorough review of all selected studies, three categories and six subcategories emerged from the results of the articles. These categories were: providing information to patients, offering psychological support, and implementing various relaxation methods.

Having information

The studies reviewed in this category showed that providing verbal communication and offering various types of video information to patients significantly reduced anxiety and fear in those who were about to undergo surgery.

Verbal information

In the subcategory of verbal information, the studies highlighted the impact of providing thorough, high-quality, and professional information on reducing anxiety and fear in patients preoperatively. In these studies, patients received information from an anesthesiologist about the surgical procedure, what would happen before the operation, and what would happen afterward.[23] The verbal information was given either in a group setting[24,25] or individually between healthcare professionals and patients.[23,26,27,28] Other studies[24,26,29] showed that participants who received preoperative verbal information reported lower levels of anxiety after receiving the information, compared to participants who did not receive the information. However, Dias et al.[27] showed that anxiety decreased in both the group that received information and the control group that did not, with no significant difference between the groups. Similarly, Klaiber et al.[25] found no clear effect of the intervention as anxiety levels were nearly the same both before and after the participants received the information.

Video information

The subcategory of video information included three scientific articles. In the studies, patients were asked to watch a recorded video that provided information instead of receiving verbal information directly from a nurse. In some of these studies, participants/patients watched an additional video after the informational video, which led them in prayer.[30] According to Awaludin et al.,[30] this prayer video would be effective for all participants regardless of their religion. All three studies showed that participants in the intervention group who watched the video reported that their anxiety significantly lowered after watching it, compared to their anxiety levels before watching the video. Participants in the control groups who did not watch the intervention video reported similar anxiety levels in both the initial and follow-up measurements. Before the intervention video was shown, participants in the control groups rated their anxiety approximately the same as those in the intervention group.[31,32] Video material was usually combined with brochures, photographs, department tours, and verbal information.[30,31,32]

Psychological support

In the subcategory of psychological support, several studies examined different methods that healthcare professionals use to reduce preoperative anxiety and fear in patients. These studies used different methods to achieve the goal. One study used a motivational interview in which participants were allowed to express their concerns and encouraged to make healthy lifestyle changes.[33] Another study involved an intervention group where participants were allowed to share their fears before surgery and received advice on how to deal with these fears.[34] Lou and Zheng[35] used a multiprofessional team approach, providing psychological support tailored to the patient’s specific illness. In three of the articles, participants who received the information and the supportive measure reported lower self-rated anxiety afterward compared to those who did not receive the intervention. Pulkkinen et al.[36] investigated whether patients assigned to a new perioperative practice model where they had access to their own nurse anesthetist preoperatively, intraoperatively, and postoperatively experienced reduced anxiety. The study found that such practice did not lead to a reduction in patient anxiety.

Relaxation therapies

The main category of therapies includes various types of nursing interventions used by NAs with the aim of providing a relaxing and calming effect on patients in the preoperative phase. According to the results of the studies reviewed, music, aromatherapy, massage, and relaxation topped the list as the most relevant and appropriate methods for reducing patients’ fear, anxiety, and concerns before surgery.

Music

In the first subcategory, music, previous studies demonstrated that listening to music preoperatively significantly reduced patients’ experience of anxiety and worry before surgery. Patients were placed in a private, undisturbed room and listened to music for 30 minutes prior to surgery. They wore headphones and were placed in a private room away from other patients and the operating room. The music was instrumental and classical and had a slow tempo. It was also combined with nature sounds such as rain and the ocean. As a result, patients’ blood pressure and heart rate decreased preoperatively due to the calming music.[37,38]

Relaxation

In the studies that matched the search on different relaxation methods before surgery, previous studies showed that these methods included various forms of breathing, meditation and music exercises, guided daydreaming, and the opportunity to rest in order to help patients relax before surgery.[39,40] Patients were given the opportunity to combine these methods with religious practices in the form of repetition of prayers.[41] Creating a good care relationship and encouraging patients to express their emotions during relaxation exercises resulted in decreasing patients’ preoperative worry and anxiety.[42] In addition, allowing patients to choose their preferred relaxation exercises gave favorable results. Patients reported that meditation reduced worry and anxiety enabling them to relax despite being in a stressful situation and hospital environment. These methods improved patients’ sleep quality the night before surgery.[39,40]

Touch

In this subcategory, it was found that 10 minutes of hand and foot massage before surgery resulted in reduced anxiety and worry, improved vital parameters, and increased patient safety.[41,42] In addition to the massage, patients were in a comfortable position in an undisturbed room.[42] The massage also resulted in lower blood pressure and heart rate.[41] Topademir and Saritas[43] performed the so-called “Reiki” treatments on patients, where the practitioner places their hands on the affected areas of the patient’s body. According to these authors,[43] this is a common treatment method in several cultures. However, the results of the study showed that the participants rated their anxiety almost the same after the treatment as before.[41,42,43]

Discussion

The present study aims to synthesize qualitative and quantitative research, critically evaluate, and compile research describing different strategies and approaches used to manage patients experiencing fear and anxiety in the preoperative surgical process. To achieve this, an analysis of qualitative and quantitative articles was chosen as the method. A systematic literature review was conducted with the aim of answering the research question about the strategies anesthesia nurses use to manage and treat patients with fear and anxiety before a surgical procedure. Through the review, of various qualitative and quantitative studies, evidence was gathered to address the study objective. Since the presented study, several authors have discussed which studies should be taken and which should not. Selecting different studies is a subjective process as each author in the study has their own interpretations that can influence the process. A possible limitation of choosing a systematic literature review may be the limited amount of qualitative or quantitative studies that were available on the specific topic. The analysis of the reviewed studies resulted in two main categories and six subcategories. The first category focused on information and the second on relaxation therapies. The selected studies analyzed in the first category highlighted the use of information as a strategy by anesthesia nurses and anesthesiologists to alleviate patients’ fear and anxiety before surgery. Verbal information included the details about the surgical process from start to finish, including the preoperative, postoperative, and rehabilitation process, and it was provided both individually and in groups, and the use of information to patients in various intervention studies.[23,24,25,26,27,28,29] The studies showed that different strategies with a focus on communication early on create trust and establish confidence between patients and caregivers. There are two additional studies[44,45] that are in line with the presented study and that also showed that preoperative information can help shift the patient’s focus away from the procedure, which in turn alleviates fear, anxiety, and suffering. Establishing routines that support early communication in the care relationship has been shown to have a major positive impact on reducing preoperative anxiety.[44] These studies emphasize that one of the most important tools for anesthesia nurses is the ability to communicate information to patients.[44,45] Another strategy for alleviating preoperative fear and anxiety was showing videos to patients. The videos were about the surgical procedure, and they were presented in groups or individually. The use of videos proved to be a good strategy for reducing fear and anxiety in patients. This type of information was usually combined with various brochures, photographs, a tour of the department, and verbal information as additional support.[30,31,32] Our results are in line with a meta-analysis[46] that strengthens the effectiveness of providing recorded information to patients before surgery in alleviating anxiety and suffering.[46] Using different psychological strategies was not excluded, all contributing to alleviating fear and anxiety in patients. In one of the studies reviewed, participants gave motivational interviews in which they were allowed to express their concerns and were encouraged to make healthy lifestyle changes. In another study, the intervention group was allowed to share their fears before surgery and was given advice on how to deal with these fears. Some patients even received psychological support tailored to their specific condition.[33,34,35,36] The results of the literature review showed that various relaxation therapies such as music, massage, and touch have a good effect in relieving preoperative worry and anxiety. Having surgery during the day and listening to music beforehand in a private room away from the operating room, with the sounds of the sea and birds, reduced fear and anxiety in patients.[37,38] This result is also supported by two additional studies,[47,48] one of which showed that music contributes positively to relaxation and calmness. This can be created by synchronizing the rhythm of the music with a heartbeat, which leads to a sense of satisfaction. The other study showed that music can stimulate the release of endorphins in the brain, which creates an atmosphere of peace and tranquility.[47,48] The studies analyzed in the results section showed that different relaxation methods, which in certain groups of patients could be combined with religious practices in the form of prayer, reduced fear and anxiety preoperatively. In addition, all patients who engaged in these relaxation methods reported better sleep before the operation.[39,40,41,42,43] In the same way, patients who spent some time with healthcare staff and received different types of touch, such as handholding, massage, and other cultural touch practices, also showed positive results in some studies. However, some studies indicated that these touches did not always yield positive outcomes.[39,40,41,42,43] All these methods made patients calm and relaxed, fear and anxiety disappeared, blood pressure was lower, heart rate was lower, and patients slept better and felt better in general. However, it is important to note that not all patients appreciate massage and touch as it may feel too intimate or cause discomfort instead of providing a relaxing and soothing effect. Wang et al.[47] describe this and also state that gloves and massage oils can even cause allergic reactions. In addition, patients may experience soreness or pain at the points to be massaged, which of course leads to discomfort instead of relaxation. It is important that the person performing the massage shows great respect and is knowledgeable and responsive to the situation and the nursing strategy.[48] Furthermore, Eriksson[49] believes that violation of the patient’s dignity is one of the main causes of patient suffering. Therefore, it is important that anesthesia nurses are aware of this and responsive to how the patient wants to be treated. In today’s society and the way of life, where stress, pressure, and global uncertainties prevail, healthcare is not immune to these challenges. The once-common short preoperative meetings between anesthesia nurses and patients have almost completely disappeared.[50] We hear daily of staff shortages, managers lacking proper training, and expensive temporary staff. As a result, music and various relaxation methods have been sidelined a long time ago in many departments around Europe. This raises the question: How in this challenging environment can we effectively alleviate patients’ fear and anxiety and help them feel safe and secure throughout the surgical process?

In conclusion, the results of the presented study showed that strategies involving different forms of information, psychological support, and relaxation therapies gave good results in reducing preoperative fear and anxiety. The results can also be used not only in preoperative care but also in other healthcare contexts where patients experience anxiety. The results can contribute to an increased understanding among healthcare professionals regarding cost-effective methods to alleviate preoperative fear and anxiety. Despite the good results, there is a need for further research within healthcare to determine which types of nonpharmacological nursing measures are most effective in alleviating preoperative anxiety. Further research is also needed to explore how preoperative care should be designed to help patients feel safe and comfortable before surgery.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.