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F E AT U R E S

Effectiveness of Nurse’s Intentional Presence


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

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

BACKGROUND diseases that do not respond to medication fall under2


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

296

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Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 297

in patients undergoing CABG. But the results of theories, there are many concept analyses and
the research show that most patients prefer health care systematic reviews with the purposes of clarifying,
practitioners to listen to their speech carefully and then extracting the attributes, and introducing the practical
take care of them.11 These therapists are often known levels of the concept of presence. McKivergin and
as holistic nurses. These groups of nurses consider Daubenmire,15 are the first authors who described the
every individual a whole being which is unique concept of presence in 3 levels such as physical
and believe that any human is a specific combination presence: Is the nurse’s “being there” for the patient.
of mind, body, and spirit which are interconnected Many nursing interventions are carried out at this
in a whole and has components indistinguishable from level, including the routine tasks that are prescribed
each other. This whole is in a dynamic interaction for the patient; psychological presence: Is the nurse
within, between, and among the people and the “being with, “The nurse uses himself or herself as an
environment. Accordingly, based on the needs of each intervention tool to create a therapeutic psychological
unique human being during his interaction with the milieu that meets the patient’s need for help, comfort
environment, he expects special care from his nurse.11 or support”; and therapeutic presence: To be
Different studies have been done about applying therapeutically present, the nurse is asked to relate to
holistic nursing in stress management, increasing the patient as whole being to whole being, using all of
self-esteem, motivation and confidence in athletes,12 his or her resources of body, mind, emotions, and
and self-care of patients bedridden at home,13 which spirit. To do this, new skills are required such as
have had positive effects. But Rosenfeldt et al14 did centering meditating, intentionality, at-one-moment,
not observe any significant difference between holistic imagery, openness, intuitive knowing, communication,
care and routine care in reducing stress and quality of loving, and connecting.15
life of patients undergoing CABG. Although all nurses In addition, Easter,22 in a construct analysis,
with a holistic approach are of the same philosophical introduced 4 modes of being presented including
idea in considering human beings as a whole which is physical presence, therapeutic presence, holistic
irreducible to its components, a wide range of nursing presence, and spiritual presence. Godkin23 in a
interventions and care programs can be planned on the literature review proposed a 3-stage, hierarchical
basis of this worldview in patients. model of nursing presence resulting in healing
It is important for the caregiver to guide the person presence. Beside presence, clinical presence and
and family through a reintegration of self, not only by healing presence are the stages of this model, each
helping to intervene with the cause of the disease but promotes to the next, based on the nurse competence.
also by helping the person maintain a sense of Covington16 delineates the caring presence as a
belonging, control, meaning, worth, and esteem concept for holistic nursing to suggest a working
through the process.15 In other words, presence is the definition. Intersubjectivity and intentionality in the
“core of the nurse-patient relationship.”15 nurse-patient relationship are the core attributes of her
Historically, presence is accepted as an essential definition. Hessel24 in a concept analysis of presence
part of nursing theory and is a core relational skill in nursing practice presents the defining attributes,
within the nursing profession.6,16 The premise of the antecedents, and a theoretical definition for the
authors was that presence may be an essential issue concept. Spirituality, nurse-patient relationship,
in healing health care systems; however, the concept listening, attentiveness, and intimacy are the attributes
of presence has evolved from the philosophical roots of presence that she has extracted.24 Tavernier25 in an
of many disciplines.15 Nurse theorist Sister Madeleine evidence-based conceptual analysis of presence
Clemence Vaillot is credited with the early discussions described 5 themes for attributes of this concept
of presence in the nursing discipline.17 Also, Parse’s including intentionality, mutuality, centeredness,
Human Becoming Theory,18 Watson’s Theory of individuality, and attendance.
Human Science and Human Care,19 and Paterson and McMahon and Christopher26 suggested a midrange
Zderad’s Humanistic Nursing20 have integrated pres- theory of nursing presence based on the literature to
ence as a major component. Each of these theories con- identify development opportunities to improve the
siders presence as an intersubjective, interpersonal, and nursing student’s use of presence as a relational skill.
mutual experience between the nurse and the client.21 Regarding these authors specifically, nursing presence
Regarding the important role of presence in the is dependent upon the combination of individual nurse
nurse-patient relationship in holistic approaches and characteristics, individual client characteristics, shared

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298 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

characteristics within the nurse-client dyad, an patients referred to Shariati Special Cardiac Center in
environment conducive to relational work, and the Mashhad, Iran, from March 2016 to June 2017.
nurse’s practice decisions. The eventual dose of The convenience method of sampling was applied
presence is determined according to crucial points to choose patients referred to the open heart surgery
during a nurse-client interaction. Specifically, the department for elective CABG surgery according to
nurse combines clinical expertise and previous including criteria. The inclusion criteria were age
experience with presence, interprets both the client’s from 38 to 70 years, being able to read and write, the
subtle cues and obvious requests for presence, ability to communicate with the researcher, lack of
considers the environmental factors, and then pauses psychological disorders, and not using antipsychotic
and finally decides the most appropriate dose of drugs and not being addict. The exclusion criteria
presence at that particular time.26 were refusal to continue participating in the study, any
A nurse with an intentional presence beside the physical disorder that causes imbalance in the
patient can realize his subjective inner world with his patient’s situation, patient’s death, and psychological
own help and based on patient’s individual unique disorders after surgery, late recovery, and prolonged
needs and values and with applying his knowledge and hospitalization. According to the results of a study
art can improve the patient’s physical, social, and done by Mehdipour and Nematollahi10 and using
spiritual being.27 On the basis of research, sample size formula, considering α = .05 and β = .2,
intentionality is one of the main features of presence. the least acceptable sample size was 40 people for
According to a concept analysis,27 intentionality as a each group. Each patient was placed in control or
matrix of continuous known changes is responsible for intervention group randomly by using the table of
any conscious change in human behavior. Each random numbers (Figure 1).
conscious and planned change in humans makes sense The instruments applied in this study include a
in the context of intentionality.27 Thus, the intentional demographic information form, conscious consent
presence in a transpersonal caring relationship is form, DASS 21 Scale, and a stressor’s resources
important. Despite a large number of articles about checklist. The public self-reporting DASS 21 Scale is
presence conceptualization15,22-24,28 and a midrange an international standard instrument30 to measure
theory of nursing presence,26 a few experimental and stress, anxiety and depression. The DASS 21 Scale
clinical trial studies have been conducted on this was translated into Persian by a team of psychologists
subject. According to the studies, there is only 1 in Iran. The validity of this version has been
research study performed by Anderson29 on the confirmed. The reliability of this instrument according
application of nurse presence, which included some to a pilot study of this research was also confirmed
elderly patients with heart failure. The nurse’s since the Cronbach α was 0.87. The stressor’s
presence in that study improved the quality of life, resources checklist was designed by the researchers on
prevented hospitalizations, and ultimately reduced the basis of literature review in 3 parts including
health care costs. Despite achieving a positive result, before operation stressors, after operation stressors,
that study was conducted as a case study and and spiritual concerns and needs. The validity of this
consequently, it is not generalizable due to the lack of checklist was confirmed with 10 faculty members of
statistical tests. nursing and midwifery and medical school through
Regarding previous discussions, due to the special investigating face and content validity. Its reliability
situation of patients undergoing CABG who are was also calculated through agreement between
suffering from anxiety and high stress during evaluators as 0.8.
hospitalization and sometimes encountering depressed Ethical approval was obtained from the Ethics
mood, this study is going to determine the effect of Committee of Mashhad University of Medical
intentional presence of a holistic nurse on anxiety, Sciences (no. IRMUMSREC13940234). All
stress, and depression in patients undergoing CABG. participants were insured that they entirely voluntarily
participated and could withdraw at any time. Their
data were kept confidential. Informed written consent
METHODS was obtained from all participants.
The intervention started after the patient was
The study used a randomized clinical trial hospitalized in the open heart surgery department.
(IRCT2015112925288N1). It was performed on Four 30- to 45-minute sessions of nursing intentional

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Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 299

FIGURE 1. Flow diagram of patients’ participation according to CONSORT guideline.

presence were performed for each patient individually session. Regarding the creation of trust and empathy
in the intervention group as follows. with the patient during the previous session, the nurse
Session 1 (before the surgery): The objectives of explained the types of usual nursing interventions
this transpersonal caring relationship included with the patient. After asking his permission
creating a space of sympathy and trustworthiness for to start the intervention, she simultaneously restarted a
the patient, receiving stressful resources, and trying to conversation with the patient about his sources of stress
initiate an empathic communication with him. and tried to use appropriate methods of training or
The nurse openly welcomed the patient and began a relaxation according to the patient’s concerns (Table 2).
friendly conversation with him. Then, she introduced Session 3 (in intensive care unit [ICU]):
herself and other personnel to him. After the patient Establishing a friendly relationship; controlling the
had been placed in his bed, the nurse delivered him the hemodynamic status, airway and respiratory function,
necessary personal and primary care, such as an and pain; and checking surgical wounds, the patient’s
intravenous line, taking blood sample, beginning position and concerns arising from the ICU
serum therapy, and so forth. Simultaneously, the nurse environment were the objectives. Since the nurse was
tried to create a space of intimacy in which the patient known to the patient, she went to the patient in the
could trust the nurse and declare his emotions and ICU and talked to him kindly while holding his hand.
anxieties. During this relation, the nurse insured the Then, she carefully informed the patient about his
patient sure that she was listening to him carefully by condition since his transfer to ICU. Further, she also
shaking her head and establishing eye contact with used the following phrases to comfort and relax the
him. Regarding the type of individual patient’s stress patient, “everything is under control,” “the surgery is
resource, the nurse tried to reduce his stress and done well,” or “there is nothing to worry about.”
anxiety as shown in Table 1. Whenever the nurse felt Finally, she reminded the patient that he could ask
that the patient was tired of the conversation process, nurses to provide what he needed in accordance with
she would postpone its continuation to another time. previous trainings.
Session 2 (before the surgery): Resuming a friendly Session 4 (before discharging): Considering the
conversation with the patient, performing usual empathic space and the mutual trust between the nurse
preoperative nursing care was the objective of this and the patient, this session focused more on patient’s

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300 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

TABLE 1. The Stressor Resources and Relative Intentional Nursing Interventions


Type of Stressor Stressor Nursing Intervention

Before operation Waiting a long time for the Notifying the exact time of the surgery to the patient, according
surgery to be done to the program.
Being far from family and work Explaining about
The short time of hospitalization.
The opportunity to visit relatives at the time of hospital
meeting.
Ability to return to work after the recovery period.
Hospitalization before surgery Explaining the reasons for hospitalization before surgery.
Having chest pain Ensuring that the nurse is always accessible to relief his pain.
Lack of trust to the results of the Ensuring about the skillfulness of the surgeon and the specialist
surgery nurses.
Giving the patient some statistics of improved patients.
A previous experience of a Remembering to believe in the Lord’s destiny and having a
friend’s or a family’s death positive attitude concerning the result of the surgery.
Staying at ICU Showing a video about ICU to the patient.
The researcher recorded a 10-min video in ICU environment
without patients by using her cell phone. It began with 1 of the
ICU nurse’s welcome and she tried to introduce herself with a
calm tune. Then she showed different parts of ICU and their
application using simple words. She explained about each of
the connectors, including arterial and venous pressure control
lines, drains, chest tubes, and monitoring device for the
patient. Finally she filmed a patient who was being
discharged from ICU in favorable condition, shaking hands
and saying goodbye.
Fear of operating room Explaining about general anesthesia, he is completely
unconscious and unable to feel pain during the surgery.
Unconsciousness, being Ensuring the maintenance of privacy and covering his body with
uncovered while surgery a long perforated shun to expose the surgical area.
High surgery expenses Referring the patient to the supportive systems and social
worker.
After operation Presence of a family member to Ensuring the patient that a skilled nurse will be present in the
help him do the personal ICU at all times.
tasks Allowing the presence of a family member in the open heart
surgery department.
Being roommate with a stranger Hospitalizing the patient in the private room in the department, if
possible.
Informing about the isolation patients’ units in ICU.
Various nursing cares Ensuring the patient that each of the nurses will describe her
actions clearly before performing them.
The operation side effects Creating a positive attitude toward the patient and ensuring him
(bleeding, not regaining of the skillfulness of surgical team.
consciousness)
Motionlessness and limitations Training about
The amount and type of immobility.
The way of movement.
Postoperative activities.
Surgical pain Ensuring that the nurse will come promptly when the bell is
ringing.
Prescription of sedative medicine and training in the Benson
relaxation technique.
Sleep-related problems Training the Benson relaxation technique (15 min before
sleeping).
Physical and mental situation’s Training how to retrieve energy when doing the Benson
change relaxation technique.
(continues)

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Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 301

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

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


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

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

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

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

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


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

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302 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

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

RESULT In comparing the intervention and control groups,


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

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

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

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

Abbreviation: ICU, intensive care unit.

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

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304 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

DISCUSSION

P < .0001

P < .0001

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

presence of a holistic nurse significantly decreased the


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

undergoing CABG. An important point in this study


was the heterogeneity of 2 groups’ mean scores before

P = .072

P = .025

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

t = 2.0
t Test
After

stress, anxiety, and depression in the intervention


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

P < .0001

P < .0001

higher than those of the control group before


t = 5.2

t = 5.6

t = 6.4
Before
t Test

intervention in stress, anxiety, and depression,


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

P < .0001

P < .0001

P < .0001

further explain, the Iranian people do not freely


t = 5.7

t = 7.9

t = 5.5

express negative feelings about stressful situations or


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

11.5 ± 5.4

12.1 ± 8.1
M ± SD

to the nurse about their exact feelings and stress


After

resources. So, in the control group before the


operation, the patients thought that declaring their
Control

exact emotions and stressors would have an effect on


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

6.67 ± 4.7
8.2 ± 6.5
M ± SD
Before

their actual feelings. In intervention group because the


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

P < .0001

P < .0001

P < .0001

trusted the researcher/nurse and expressed their actual


t = 6.73
t = 7.8

t = 4.3

feelings and spoke accurately about their stressors.


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

9.7 ± 5.48
9.9 ± 3.8
M ± SD

recovery of 30 patients with heart failure. However,


After

that study result, which illustrated an improvement in


Intervention

Abbreviation: ANCOVA, analysis of covariance.

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


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

on the contrary, was done as a clinical trial and


14.9 ± 5.8

12.9 ± 5.3
M ± SD
Before

showed significant effectiveness of the intentional


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

voice,” thus these results are comparable with another


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

Stress

presence positively affected the stress and anxiety of


patients with cancer. The results indicated that the

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Effectiveness of Nurse’s Intentional Presence as a Holistic Modality 305

patients’ stress reduced 70% using relaxation What is new and important?
technique, which confirms the effect of the
researcher’s presence in reducing his amount of stress, r The cardiac surgery success can be effected by the
significantly. mental situation of the patient.
In comparison with the study by Rosenfeldt et al14 r The holistic nursing modalities can be used to
on the quality of life of patients undergoing CABG that reduce the mental disorders of the cardiac surgery
implemented holistic care as light physical activities patients.
and a stress-reducing program, there was no significant r The intentionality and presence of the nurse play
difference between the holistic and the routine nursing an important role in the transpersonal caring
care groups. In that study, a CD was given to the relationship.
patient for training and the nurse did not have effective r The intentional presence of the nurse from the
presence with the patient. Also, 2 stress-reducing beginning of admission to the end of discharge
programs were conducted before surgery as there time can reduce the cardiac surgery patient’s
were no special caring actions done due to surgery depression, anxiety, and stress.
before, during, and after hospitalization considering
the fact that surgery is a disordering factor that
strongly affects the quality of life. Thus, comparing REFERENCES
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306 HOLISTIC NURSING PRACTICE • NOVEMBER/DECEMBER 2018

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