RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
A STUDY TO EVALUATE THE EFFECTIVENESS OF
PRE OPERATIVE TEACHING IN REDUCTION OF
ANXIETY AMONG WOMEN UNDERGOING
HYSTERECTOMY IN SELECTED
HOSPITALS, KOLAR DISTRICT,
KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
Ms. USHMITA TANKAN
A.E & C.S PAVAN COLLEGE OF NURSING
KOLAR
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE & ADDRESS / MS. USHMITA TANKAN,1ST YEAR M.SC (NURSING),
A.E & C.S PAVAN COLLEGE OF NURSING,
BANGALORE-CHENNAI BYEPASS ROAD, KOLAR – 563101.
2. / NAME OF THE INSTITUTION / A.E & C.S PAVAN COLLEGE OF NURSING, KOLAR – 563101
3. / COURSE OF THE STUDY AND SUBJECT / M.Sc (NURSING)
OBSTETRICS AND GYNECOLOGICAL NURSING
4. / DATE OF ADMISSION / 03-06-2008
5. / TITLE OF THE TOPIC / A STUDY TO EVALUATE THE EFFECTIVENESS OF
PRE OPERATIVE TEACHING IN REDUCTION OF ANXIETY AMONG WOMEN UNDERGOING HYSTERECTOMY IN SELECTED
HOSPITALS, KOLAR DISTRICT, KARNATAKA.
6. BRIEF RESUME OF INTENDED WORK
INTRODUCTION:
“Man Learns as he lives and experience
Is the greatest teacher in the World”
S.Vivekananda
Hysterectomy is often an “end of the road” decision for women who may be debilitated from months of heavy prolonged bleeding. The first planned hysterectomy was performed by surgeon CJM Langenback, of Gottingen, Germany in 1913. The surgical procedure was performed without Anesthesia or homeostatic clamps and patient survived. According to data released in 1990, Hysterectomies are the second most frequent performed surgical procedure in the U.S1.
Hysterectomy the surgical removal of the uterus is a procedure surrounded by controversy and for good reason. Approximately 600,000 American women have a hysterectomy every year, at a cost of almost 5 billion dollars. By the age of 60, one out of every three women in the U.S has had a Hysterectomy.
An important study was published in 1994 (the Maine Women’s heath study) that examined how women felt both physically and emotionally before and after hysterectomy. More than four hundred women were interviewed before they had a hysterectomy and then followed for a year after their surgery. Likewise, a separate group of 380 women who had similar Gynecologic problems, but chose not to have hysterectomy, were interviewed.
The study found that a substantial number of women had a marked improvement in their symptoms following hysterectomy, including symptoms such as Pelvic pain, Urinary problems, Bleeding, fatigue and Psychological and Sexual problems. And after hysterectomy, many of the women reported a marked improvement in the quality of their lives. Therefore, for some women, especially those who have significant symptoms as a result of gynecologic problems, hysterectomy may be beneficial2.
Information is one of the resources for coping and in use can alter the subject’s evaluation of the threat and thus diminishes its harmful potential. Health information is also gaining importance. The responsibility for providing health information is being recognized as fundamental to health care delivery system. Patients always had the need to know and to understand health alterations and preventive health care measures as well as the health care delivery itself. These needs, however have been solely overlooked as neglected.3
A survey was done in United Kingdom on 129 Hysterectomy women, to assess the major areas for which women wanted information, 28 women (22%) mentioned that sexual feelings and functioning constituted one of the major areas for which they wanted information. About 38 women (29%) highlighted their need for anticipatory guidance related decreased Libido, physical changes, feeling of loss and grief after hysterectomy. This study brings to focus the need for information to women who are undergoing hysterectomy4.
Pre operative instruction has been shown to help patients, deal more effectively with surgery. Pre-operative instruction tends to decrease complications increase patients satisfaction, shorten the length of hospitalization and promote psychological well being.5
6.1 NEED FOR STUDY :
Each year about 50 million surgeries performed in our country (Sharma Vijay 2006) patients undergoing major surgeries suffer from varying degrees of stress because of many reasons. One of the major causes of generation of Pre-operative stress in clients is lack of knowledge regarding surgery.6
‘Women’ you are magnified for the womb that shelter and nourish the seed of life. It is the womb that transcends you from the status of a woman into that of a mother. So hysterectomy which is the surgical removal of the uterus can be devastating for women especially for those who find it difficult to accept “an end to their fertility”. However, for some it is seen as a relief from pain, discomfort or debilitating heavy blood loss.7
Positive support is a powerful resource for coping because it builds up person’s self esteem, confidence in herself and her ability to cope. Negative support on the other hand determines and weakens an individual self esteem and makes it more difficult for her to act in stressful circumstances.3
A study was conducted to evaluate the acceptance of gynecological laparoscopic operations. A comparative analysis has been performed in a group of 32 women by analyzing the emotional component, by evaluating the pre and post operative anxiety level (State anxiety) and the constitutional ones (Trait Anxiety) using the (STAI) Y test significant correlations have been searched between pre and post operative traits and state anxiety, through the person’s correlation test. The result showed that post operative state Anxiety is higher when the level of education is low (P<0.005). The study suggested that Higher Anxiety levels have been detected in the pre operative phase, in less educate patients and when the decision to operate has been attributed to the doctor.8
A study was conducted to determine the importance of Psychological intervention for surgical patients. A range of diverse intervention techniques is used to relieve the distress of invasive procedures. Intervention was based on cognitive behavioral program “Stress Inoculation” built on the assumption that it is possible to “immunize” against stress. The experimental group of 20 patients had a 30 minutes conversation with a psychologist in when they were taught various coping devices, including cognitive reappraisal of events surrounding the operation, Calming self talk and cognitive control through selective attention. The 20 in the control group met with the psychologist for the same length of time but the content of the conversation was completely unrelated to the operation. The study suggested that experimental group needed less post surgical analgesia than the control group and coped better with the surgical situation in opinion of the surgeons.9
Pre operative discussion between a doctor and a patient or guardian, should be in general terms. It should removed patients anxiety and fear for operation.10
Any women who have to undergo hysterectomy need to know exactly, what surgery is planned, what parts of her body are to be removed and the reasons for the same. She need to explore the effect of surgery in relation to her reproductive cycle, Sexuality, hospital stay, convalescence and her eventual return to a normal life style. A comprehensive program of nursing interventions that begins before the patient undergoes surgery and continues through the patient recovery process is effective means of assisting women to cope with hysterectomy.11
Hysterectomy is perceived by patients as a highly stressing situation that generates strong emotions with well known negative effects on post operative recovery.
The present research aimed to compare the effects of two different kinds of psychological preparation programs on women undergoing hysterectomy at the Carlos Lleras Restrepo clinic. The former group consisting of 30 women received a preparation program based upon their coping strategies. The second group also consisting of 30 women was provided with written information as the only method for preoperative psychological preparation. The results showed that patients in the first group has lower levels of anxiety (P<0,01) less post operative pain (P<0,05) and a lower incidence of complications compared to those who were prepared just by providing written information12.
After reviewing many literatures the investigator came to the conclusion that women, who had undergone hysterectomy, were inadequate in handling physiological and psychological changes after Hysterectomy. This is because the information provided was not adequate.
Based on the personal experience of the investigator during her clinical posting, found that hysterectomy has an emotional significance to women, it requires pre operative teaching.
Hence the investigator is interested to conduct the study on effectiveness of preoperative teaching in reduction of anxiety among women undergoing Hysterectomy.
6.2 REVIEW OF LITERATURE
A review of related literature is an essential aspect of scientific research. It involves the systematic identification, location, scrutinizing and summary of the written material that contains information on research problem.
According to Hungler and Polit the term “Literature Review” is used in two ways by research community .The term is also used to designate or written summary of the state of the art on a research problem.13
Literature relevant to present study is mentioned under the following headings:-
Section I : Studies related to Hysterectomy.
Section II : Studies related to Anxiety among Hysterectomy women.
Section III : Studies related to effectiveness of the Pre operative Teaching in the reduction of Anxiety among Hysterectomy women.
Section I : Studies related to Hysterectomy:-
A prospective study was conducted to evaluate the changes in health status and quality of life and psychological outcome measures. It is a prospective, randomized, double blind study .179 women undergoing Hysterectomy for benign disease were randomly allocated to total Hysterectomy (n= 146) or subtotal Hysterectomy (n=133). All women showed an improvement in psychological symptoms following both operations. The study concluded that Hysterectomy, whether total or subtotal may improve quality of life and psychological outcome.14
A study was conducted to identify incidence, indication and complications of obstetric Hysterectomy within high risk population. It is Transversal, retrospective study from July 1st 2004 to June 30, 2006. There were reviewed 103 patient files with obstetric Hysterectomy. Incidence was calculated and clinical and socio demographic characteristic, Indication and complication of obstetric Hysterectomy identified and expressed in frequency, percentages and central tendency measurements. Incidence of obstetric Hysterectomy was 8 cases within every 1000 Obstetric consultations. There were concluded that caesarean history induces higher obstetric Hysterectomy incidence in women with high risk pregnancy, due to its relation to placental hemorrhage possibility.15
A study was conducted to explore women’s view of decision making related to Hysterectomy .Study done in a teaching hospital and a district general hospital in northeast Scotland. A purposive sampling was interviewed post operatively. 194(66%) returned questionnaires. Most responded positively to structure questions. Almost all (97%) reported satisfaction with the decision made. Women’s perceptions of decision making process, including the way their view of the course of action selected. The study showed that it is required to ensure that women are adequately informed and involved in decisions about gynaecology treatments.16
A study was conducted to test null hypothesis of no significant difference between Laproscopic Hysterectomy (AH) and Vaginal Hysterectomy (VH). By using a randomized sampling technique study was conducted 43 surgeons from 28 centres thoughtout the U.K and two centres in both South Africa took part in study. Patients with gynaecological symptoms that justified hysterectomy. Of 1380 patients recruited to the study, 876 were included in the AH trial and 504 in the VH trial. The result shows that compared with AH, LH was associated with higher rate of major complications. The study concluded that Abdominal Laproscopic Hysterectomy (ALH) is associated with a significantly higher risk of major complications and takes longer to perform than Abdominal Hysterectomy (AH).17
A study was conducted to evaluate the effectiveness of hysterectomy in treating chronic pelvic pain and to identify risk factors for persistent pelvic pain. A group of 308 women who had hysterectomy for chronic pelvic pain, a part of a large, prospective multi centre cohort study. Persistent pain was defined as trichotomous variables. The result shows that overall, 74% women experienced complete resolution of pelvic pain, 21% reported continued but decreased pain 5% reported either unchanged or increased pain after hysterectomy. The study showed that most women with chronic pelvic pain have long term improvement after hysterectomy.18
Section II : Studies related to Anxiety among Hysterectomy women:-
A study was conducted to assess the extent of anxiety, fears, depression related to hysterectomy. 102 women undergoing a hysterectomy for reasons other than cancer were interviewed pre operatively. All of them filled out the Spielberger’s State and Traits Anxiety Scale (STAI). Women who had high anxiety scores were more likely to be depressed, both before and after the operation .The result shows that depression occurred more often in women who had emergency hysterectomies and in women who had expressed some fear of possible change after the operation.19
A prospective study was conducted to determine the changes in negative mood states of women undergoing surgical hysterectomy in relation to cognitive pre disposition and familial support. Levels of anxiety and depression were documented by questionnaire response from a sample of 89 women who were to undergo surgical hysterectomy 3 weeks later. 54% (n=48) of the sample reported anxiety and 26% (n=23) reported depression at clinical levels during the pre operative period. Regression analysis indicated that post operative outcomes with respect to negative effect could be predicted from pre operative mood status was found to be related to an intrapersonal dimensions of ‘ dispositional resilience’ and to “ family cohensiveness”.20
A study was conducted to determine whether psychological variables such as pre operative anxiety can serve as predictors for the post operative pain response. The study sample included who underwent prior to surgery, characteristic such a traits anxiety, coping style and perceived stress were evaluated pre operative anxiety is a significant positive predictor of the immediate post operative pain(beta=0.30), which in turn , is a positive predictor of pain on the wards (beta=0.54) . The result of this study indicate that pre operative anxiety may have a critical role in the chain of events that control the post operative pain response.21
A study was conducted to identify the patterns and frequency of anxiety pre and post operatively. The sample consisted of women undergoing planned gynaecological surgery. The study used a mixed method approach. Anxiety was assessed using the State Trait Anxiety Inventory. This study found higher rates of anxiety than previously reported and anxiety level raised before admission that patients with high levels of anxiety may be identified pre operatively and interventions designed to reduce anxiety could be targeted to this vulnerable group.22