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Measuring anxiety in surgical patients using a visual analogue scale

Pritchard M (2010) Measuring anxiety in surgical patients using a visual analogue scale. Nursing Standard. 25, 11, 40-44. Date of acceptance: May 5 2010.

Summary
Since the early days of surgery patients have been anxious about undergoing operations. This feeling remains common today despite advances in medicine and surgical techniques. Numerous studies have shown the effect anxiety has on the human body. It is the responsibility of healthcare professionals to ensure that any patient undergoing an elective surgical procedure is both physically and psychologically prepared. However, with increasing demands on the health service to be more efficient, little time is set aside to meet the psychological needs of the surgical patient. This article focuses on the use of a visual analogue scale to identify pre-operative anxiety in patients, so that healthcare practitioners can implement strategies to reduce anxiety and improve the persons overall experience.

Author
Michael Pritchard advanced nurse practitioner for surgery and orthopaedics, Clatterbridge Hospital, Merseyside. Email: Michael.pritchard@whnt.nhs.uk

Keywords
Anxiety, assessment tools, elective surgery, patient needs, visual analogue scales These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

depends on a number of factors, including the procedure, and the patients past medical history and present health status. Day case patients tend to go home the day of the procedure. Inpatients are generally admitted the morning of their procedure, unless for medical or social reasons they need to be admitted a day or two in advance. The rationale for this is simple, a patient coming from home to hospital on the day of surgery is considered to be less anxious than a patient who has been admitted to unfamiliar and possibly frightening surroundings a day or so before their operation. Inpatient admissions tend to vary in length from a day to, in some cases, several weeks. Patients who were once given premedication (sometimes called a pre-med) before surgery are no longer routinely offered this sedation. Advances in anaesthetic techniques mean that this is no longer required. Patients will see the anaesthetist on the day of surgery and all options with regard to anaesthesia and pain relief will be discussed. This is especially important when combined with the increase in day surgery cases and the need to ensure patients are fully recovered from the anaesthetic before being discharged. However, not giving a premedication may lead to increased patient anxiety.

Effects of anxiety
Patients may experience anxiety for many reasons, including uncertainty about the anaesthetic or surgery, past surgical experiences (good or bad) and the persons own coping style, which could have a bearing on how the patient deals with stress (Kindler et al 2000). It is now widely accepted that anxiety is a normal response in pre-operative patients (Taylor-Loughran et al 1989, Grieve 2002, Osborn and Sandler 2004, Khan and Nazir 2007, Nikumb et al 2009). Some researchers have speculated about the reasons why patients experience anxiety, including fear of having an injection, possible pain or permanent paralysis associated with regional anaesthesia, NURSING STANDARD

NUMEROUS STUDIES HAVE examined pre-operative anxiety in surgical patients (Grieve 2002, Osborn and Sandler 2004, Nikumb et al 2009). Patients undergoing surgical procedures not only face the physical trauma of such surgery, but may also experience significant levels of fear and anxiety (Lepage et al 2001). Advances in surgical and anaesthetic techniques have meant that the health service is able to offer patients different options with regard to having their surgery. Surgery can be undertaken on either a day case or inpatient basis. How patients are selected 40 november 17 :: vol 25 no 11 :: 2010

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glimpsing the surgery and noises heard during the procedure, such as alarms from monitors (Koscielniak-Nielson et al 2002, Matthey et al 2004, Jakobsen and Fagermoen 2005, Mitchell 2009). The role of anxiety in surgical patients and their recovery was first explored by Janis in 1958. It was perceived that moderate levels of anxiety were beneficial to the patient, as it prepared the individual for the distress of undergoing surgery. However, anxiety below or above this level might be considered as maladaptive, negatively affecting a patients recovery (Janis 1958). According to McClean and Cooper (1990), anxiety begins as soon as the surgical procedure is planned (in the clinic) and increases to maximum intensity when the individual enters the hospital. Anxiety can affect the body on a physiological level: patients may display elevated pulse, blood pressure and temperature as well as a heightened sense of touch, smell or hearing (Pritchard 2009). Anxiety may lead to physical responses that affect wound healing as well as the endocrine and immune system (Kiecolt-Glaser et al 1998). On a psychological level, anxiety can cause cognitive and behavioural changes (Cooke et al 2005). Patients may appear aggressive, demanding or so apprehensive that they are physically unable to comply with simple instructions (Pritchard 2009). Anxiety is an individual and subjective emotion; no two patients will respond in the same way. An increasing number of studies have reported on the efficacy of a wide variety of interventions to reduce anxiety such as relaxation and cognitive behavioural techniques (Andrewes et al 1999). Not all these interventions would be practical to use for every patient because of the cost involved. However, interest in the possible influences of pre-operative anxiety on the course and outcomes of surgical procedures has led to an increase in the focus on possible benefits of anxiety-reducing interventions (Markland and Hardy 1993). Anxiety in surgical patients can be measured using assessment tools. These may include the Spielberger State Trait Anxiety Inventory (STAI) (Spielberger et al 1983), Multiple Affect Adjective check list (Zuckerman et al 1983), Amsterdam Preoperative Anxiety and Information scale (Moerman et al 1996) and the Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983). However, some tools, such as the STAI, are complex and require the patient to be given detailed instructions, which might not always be practical in a busy pre-operative clinic, might not always be practical. Therefore, it is vital to choose the most appropriate tool. It is also important to decide when to give the patient the tool to complete; this depends on the phenomena to be NURSING STANDARD

explored. For example, if exploring how the patient is feeling before surgery, using the tool after the procedure may not be as informative. The tool could be implemented in a pre-operative assessment unit, or if the tool is simple enough to use, it can be given to the patient when admitted to the ward or before going to theatre. However, if intending to assess anxiety levels just before going to theatre, the tool should not be time-consuming or complex. Therefore, the ideal tool is one that requires little instruction and is simple and easy to use.

Visual analogue scale

Visual analogue scales (VAS) are commonly used to gain data in both the research and clinical settings. VAS, such as in Figure 1, are often used to measure the intensity or frequency of various symptoms, such as pain. The scale is generally completed by the patient, but has also been used to elicit the opinions of healthcare professionals. This type of scale was first used by two employees of the Scott Paper Company (Hayes and Patterson 1921). It was developed as a method for supervisors to rate their workers performance using quantitative descriptive terms on a standard scale. Freyd (1923) published guidelines for the construction of these scales, which included the length of the line (with no breaks or divisions), the use of anchor words to represent the extremes of the trait being measured and varying the direction of the favourable extremes to prevent a tendency to repeat an answer. There are now several different scales available, but they generally fall into two categories. The first is a continuous scale where the individual places a single mark on a straight line. This is usually a line that is 100mm long horizontally, although occasionally a vertical orientation can be used. This approach was thought to provide a greater measurement of subjective phenomena (Pfennings et al 1995), because it allows more freedom to express a uniquely subjective experience from a set of categories (Brunier and Graydon 1996). The other type of VAS is the ordered-categorical scale, where the individual makes a single choice from a set of questions. The most common of which is a Likert scale, offering symmetrical extremes individually numbered on a five-point scale usually in the format of: 1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree. This is only one example, but could easily be written as a four-point scale: never, sometimes, most of the time, always. These choices are usually presented horizontally and evenly spaced, requiring the individual to make a selection. Both types of VAS november 17 :: vol 25 no 11 :: 2010 41

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are of equal value. The question for the researcher is which type of VAS suits the requirements of their research. The scales are validated tools that have been used successfully in several studies (Duggan et al 2002, Sjling et al 2003, Khan and Nazir 2007, Wetsch et al 2009).

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Measuring pre-operative anxiety

VAS are simple and effective tools that can be used to measure pre-operative anxiety, and have been used by anaesthetists to identify patients who require additional support. Patients are asked a series of questions relating to the anticipated surgery and then asked to mark how they rate each question. This method has a number of advantages, the most important of which is that it is simple to use and therefore is unlikely to cause patients any further stress or anxiety. One such tool available to healthcare professionals is that developed by Kindler et al (2000) (Figure 1). Kindler et al (2000) observed that with increasing pressure on healthcare providers to improve and become more efficient, anaesthetists are given little time to assess their patients psychological needs before surgery. Many of the anxiety tools available are useful, however for practical reasons these tools are either difficult to complete or are complex to analyse in terms of the results in the time available in the busy clinical environment. Kindler et al (2000) believed that if a simple tool could be developed, it would allow the anaesthetist to assess the individuals needs with regard to anxiety and anesthetic concerns in the short period of time available before the patient FIGURE 1

underwent his or her procedure. With this in mind, Kindler et al (2000) developed a VAS (Figure 1). The tool has been constructed in such a way that it can be used in both the pre-operative phase to assess anxiety and identify patient concerns before surgery and, with a slight adaption by removing two questions waiting for the operation and being at the mercy of medical staff it can be used in the post-operative phase to find out how anxious the patient was. Because of its simple structure, no specialist knowledge, skills or extra equipment is required to use the tool. Although Kindler et als (2000) tool is not unique, what makes it attractive for nurses to use is the way it is set out. There are ten simple questions, which can be divided into three areas of concern for the elective surgical patient: fear of the unknown, fear of feeling ill and fear for ones life. Fear of the unknown consists of four specific questions relating to waiting for the operation, being at the mercy of medical staff, the result of the operation and not knowing what is happening while unconscious. Fear of feeling ill consists of four questions relating to post-operative pain, post-operative nausea and vomiting, awareness during anaesthesia and fear of the discomfort of post-operative awakening. Fear for ones life consists of two questions relating to not awakening from anaesthesia and physical and/or mental harm after the operation. The tool can be completed in about five minutes. The VAS offers some unique options for nurses interested in carrying out research to improve services. As the tool is divided into three distinct areas of concern (as above), each area can be individually explored. More importantly, the tool can be used to explore the patients journey and also to highlight areas of concern identified by the patient and areas for future improvement.

An example of a visual analogue scale measuring pre-operative anxiety

1. Waiting for the operation 2. Being at the mercy of medical staff 3. Results of the operation 4. Post-operative pain No anxiety.................................................................................Maximum anxiety No anxiety.................................................................................Maximum anxiety No anxiety.................................................................................Maximum anxiety No anxiety.................................................................................Maximum anxiety

5. Discomfort after waking up after the operation No anxiety.................................................................................Maximum anxiety 6. Post-operative nausea and vomiting 7. Not knowing what is happening No anxiety.................................................................................Maximum anxiety No anxiety.................................................................................Maximum anxiety

8. Physical and/or mental harm after the operation No anxiety.................................................................................Maximum anxiety 9. Not awakening from anaesthesia 10. Awareness during anaesthesia (Lines are not drawn to scale)
(Adapted from Kindler et al 2000)

No anxiety.................................................................................Maximum anxiety No anxiety.................................................................................Maximum anxiety

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Nurses tend not to view conducting research as being high on their list of priorities. Scullion (2002) and Oermann et al (2006) listed a number of reasons for this, including a lack of time and difficulty understanding what the research findings mean for practice. However, nurses carry out a number of patient assessments when they admit individuals to the ward. They carry out risk, nutritional and physical assessments. After the patients surgery, nurses carry out further assessments relating to pain, wound inspection and post-operative observations, such as modified early warning scores. These assessments are important to understand the effectiveness of care given to patients and how it can be improved, if necessary. Therefore, psychological assessments should not be ignored. The use of a VAS such as that developed by Kindler et al (2000) to assess the patients level of anxiety by simply marking a horizontal line is appealing. With the limited time available any tool that can be used quickly and with little disruption to the patient admission process is advantageous. Such a tool offers nurses a valid and simple method to identify anxious patients. Its simplicity means that the tool is ideally used during the patients pre-operative visit. If the patient does not attend the pre-operative assessment unit, it can be used during the admission process. If on completion of a VAS the patient indicates that he or she is anxious about the forthcoming procedure, the nurse can then attempt to address these concerns. This may be in the form of offering more information, asking the patients surgeon for advice, moving the patient up the theatre list or contacting the manager on the ward that the patient is being admitted to see if a side room could be made available, or if a family member could stay with the patient. It might be appropriate to speak to the patients anaesthetist to inform him or her of the patients concerns. Kindler et als VAS can also be used in the post-operative period by removing the two questions related to the pre-operative period. The advantage of using the VAS after the procedure is that nurses can assess how well they have dealt with patients concerns. If nurses meet patients needs, this can be documented for the next time these patients are admitted. If nurses do not meet these needs, they have an opportunity to address these issues so that the next time a patient is admitted, his or her experience can be improved. The most important advantages of using a VAS is that it requires no specialist knowledge, is simple to use and could easily be incorporated into the surgical assessment process. NURSING STANDARD

Managing pre-operative anxiety

Pre-operative anxiety management has been mainly associated with the provision of information. A number of studies have highlighted the complex nature of information giving (Kiyohara et al 2004, Ivarsson et al 2005). Kiyohara et al (2004) suggested that informing and extending the patients knowledge about the surgical procedure may reduce the individuals anxiety levels. Ivarsson et al (2005) found that most, but not all, patients were positive about the detailed information they were given. Pritchard (2009) suggested that anxiety management is a key area that healthcare professionals need to address. However, research suggests that between 15-30% of patients are unwilling to discuss their prognosis (Leydon et al 2000, Jenkins et al 2001, Fried et al 2003). The management of anxiety involves balancing the concerns of the patient with the demands of treatment using strategies to allay fears and anxiety (Pritchard 2009) (Table 1). According to Charmandari et al (2005), the stress response in humans is an important means of adapting to altered environmental conditions and a prerequisite for responding to potential threats. Kindler et al (2000) suggested that the advent of managed care (the term used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care) has placed greater demands on all healthcare practitioners. In the present environment of attempting to increase patient throughput, pre-operative anxiety can go unnoticed. Nurses spend more time with patients than any other healthcare professional and are therefore best placed to identify anxious individuals before they undergo surgery, and put measures in place to alleviate any tensions. TABLE 1 Managing patient anxiety
Patient concerns Fear of the unknown Fear of the treatment Concern about how ill health will change the patients life Loss of control or role within the family Death or fear of dying
(Adapted from Pritchard 2009)

Nursing interventions Support of the patient and information provision Fostering a relationship of trust between the patient and nurse Creating a supportive environment Information provision and offering reassurance Adapting surgical procedures and treatments

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Conclusion
Anxiety is now widely accepted as a normal response in pre-operative patients. Healthcare professionals need to be aware of particularly

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anxious patients and should be able to implement strategies to reduce such anxiety. Researchers are now looking at the techniques that can not only reduce patient anxiety, but also improve the individuals overall surgical experience. Nurses can use a VAS to identify patients experiencing increased anxiety and can implement strategies to allay any patient fears, offer additional support and improve the quality of care provided NS

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