|Year : 2017 | Volume
| Issue : 2 | Page : 78-86
Stressors encountered by patients undergoing open-heart surgery at a Cairo University Hospitals
Amaal F Ahmed, Nahla S Khalil, Warda Y Morsy
Department of Critical Care and Emergency Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt
|Date of Submission||24-Apr-2017|
|Date of Acceptance||30-May-2017|
|Date of Web Publication||12-Jan-2018|
Amaal F Ahmed
Critical Care and Emergency Department, Faculty of Nursing, Cairo University, 1214
Source of Support: None, Conflict of Interest: None
Background Coronary artery bypass grafting (CABG) as one of the treatment modalities for patients with coronary artery diseases has a major physical, psychological, and emotional impact on the patients. Therefore, these patients must routinely be assessed for the effect of stressors, especially before and after surgery.
Aim The aim of this study was to assess stressors encountered by patients undergoing open-heart surgery at a Cairo University Hospitals.
Research questions a) What are perceived preoperative stressors in patients undergoing open heart surgery during hospitalization? b) What are the perceived post operative stressors in patients undergoing open heart surgery during hospitalization?
Research design A descriptive exploratory design was utilized.
Sample A convenience sample consisting of 60 patients was included in the current study.
Setting This study was carried out at a Cardiothoracic Department and an ICU of a cardiothoracic surgery, affiliated to one of the Cairo university hospitals.
Tools Demographic data, medical data; and Intensive Care Unit Environmental Stressor Scale (ICUESS) were utilized to collect data pertinent to the current study.
Results Preoperative stressors in the current study were found to be due to: continuous lighting, use of curtains as spacers between beds, nurses working in urgency, repeated awakening patients up to give medicines, workers’ loud voice, the death of other patients, hearing other patients’ complaints and sleep disturbance. However postoperative stressors were due to: inability to sleep, seeing families and friends only for few minutes and seeing each visitor individually, having pain, thirst, presence of nasal, oral and chest tubes, unfamiliarity with time, day or date.
Conclusion and Recommendations Routine preoperative assessment of patients undergoing CABAG is recommended to identify and reduce stressors. Furthermore, preoperative patients’ education should be incorporated into routine nursing practice to reduce anxiety and prevent postoperstive complications.
Keywords: patients open heart surgery, perceived, stressors
|How to cite this article:|
Ahmed AF, Khalil NS, Morsy WY. Stressors encountered by patients undergoing open-heart surgery at a Cairo University Hospitals. Egypt Nurs J 2017;14:78-86
|How to cite this URL:|
Ahmed AF, Khalil NS, Morsy WY. Stressors encountered by patients undergoing open-heart surgery at a Cairo University Hospitals. Egypt Nurs J [serial online] 2017 [cited 2018 Dec 9];14:78-86. Available from: http://www.enj.eg.net/text.asp?2017/14/2/78/223099
| Introduction|| |
Coronary artery bypass grafting (CABG) is one of the treatments for coronary artery disease (Alexiou et al., 2008). CABG surgery is a major incident with a main psychological and emotional impact on patients and their families (Stroobant and Vingerhoets, 2008). Identified patient concerns in CABG surgery are known as stressors. Patients’ concerns related to open-heart surgery are as follows: chances of successful surgery, fear of death, fear of pain, fear about the treatment regimen, weakness, sleep disturbances, activities after surgery, cardiac monitoring, length of hospital stay, and hospital costs (Bergvik et al., 2008).
Patients’ perception of stressors is crucial for meaningful nursing and care programs (Chitty, 2005). Stress leads to the feeling of loss of control of life in patients who have undergone CABG surgery and increases sensitivity to pain and weakness. Consequently, the apparent loss of control prevents the patients from taking proper care of themselves, and thus makes nursing care more complex and prolongs the recovery process (Sarpy et al., 2000). These changes have led researchers to identify the new stressors that can affect patients. Despite the importance of identifying patient needs and psychological stressors in developing strategies of coping and effectively managing stress by nurses, few studies have been conducted in this connection (Parvan et al., 2013).
It is imperative for the critical care nurse to routinely assess patients waiting for CABG surgery for anxiety before the procedure, because impending open-heart surgery is anxiety provoking to most patients, and interventions to prevent or reduce anxiety should be provided. Interventions must be multifactorial, including information and support for pain management and realistic information about surgery schedules and resuming lifestyle after the surgery (Gallagher and McKinley, 2009).
Moreover, nurses must help patients manage anxiety throughout the CABG episode because anxiety is distressing for patients and higher levels of anxiety are predictive of poor outcomes. Patients who are more anxious before CABG have more postoperative pain, less long-term relief of cardiac signs and symptoms, more readmissions, and poorer quality of life. Furthermore, patients with more anxiety after the surgery have worse long-term psychological outcomes (Gallagher and McKinley, 2007).
Critical care nurse should provide comprehensive care based on organized system and using nursing science. Nurses evaluate and take care of patients along with healthcare team on the basis of their knowledge, integrated presence planning, programming, and management. The skilled professional nurse individualizes preoperative instruction to meet the specific needs of each patient. Health is understandable by a patient’s perspective; therefore, patients’ perception of health and stressors is crucial for meaningful nursing and care programs (Parvan et al., 2013).
Although heart surgery is one of the most effective methods in treating cardiovascular diseases, more than 50% of patients have problems in personal, social, and professional adaptation after surgery. According to recent studies, psychological factors contribute significantly to negative outcomes of coronary surgery. The main factors are depression, anxiety, personal factors and character traits, social isolation, and chronic life stress (Bokeria et al., 2013).
Therefore, there is a need to evaluate the patient’s own knowledge of CABG surgery stressors to identify the new stressors that can affect patients. Despite the importance of identifying patient’s needs and psychological stressors in developing strategies of coping and effectively managing stress by nurses, few studies have been conducted in this connection. When the stressors are identified by nurses, they can deal with the stressors affecting the patient by manipulating the environment and provide the appropriate care (Mousavi et al., 2011). The current study was conducted to provide an evidence-based data related to this problem that can be incorporated by health professionals into the future plan of care for such patients. Moreover, it might generate an attention and motivation for future research into this area.
The purpose of this study was to assess stressors encountered by patients undergoing open-heart surgery at Cairo University Hospitals.
To fulfill the aim of the study, the following research questions were formulated:
Q1: What are perceived preoperative stressors in patients undergoing open heart surgery during hospitalization?
Q2: What are the perceived post operative stressors in patients undergoing open heart surgery during hospitalization?
| Patients and methods|| |
A descriptive research design was utilized in the current study.
The study was carried out in the inpatient ward and the ICU affiliated to the Cardiothoracic Surgery Department at El-Manial University Hospital. The Cardiothoracic Inpatient Ward includes two sections: one for male patients and the other for female patients. The capacity for each section is 24 beds. The female patients section includes intermediate unit which is concerned with providing close observation for postoperative patients. As regards ICU setting, it consists of two rooms, and each room includes five beds.
This purposive sample included all adult male and female patients undergoing open-heart surgery who were admitted over a period of 3 months and were willing to participate in the study. Patients with psychiatric disorders, depression, or mental disorders or those receiving antipsychotic drugs were excluded from the study.
Two tools were utilized for data collection:
Tool 1: Patients’ demographic and medical data: It covered data such as patient’s age, gender, occupation, marital status, level of education, place of residence, diagnosis, length of hospital stay, frequency of admission to ICU, present and past medical history.
Tool 2: The Intensive Care Unit Environmental Stressor Scale (ICUESS): This tool was developed by Ballard (1981). It was modified and translated by Awad (2006). The tool is a Likert scale-type, consisting of sixty two statements representing five sources of stressors in the ICU including (a) design and physical structure of ICU; (b) rules and regulations; (c) health team personnel and workers; (d) others surrounding patients; and finally (e) patient him/herself. This tool was self-reported, where a patient responded to each statement, according to a scale ranging from 1 to 4. Each number is expressed as follows: 4 = highly stressful, 3 = moderately stressful, 2 = mildly stressful, and 1 = not stressful. The total scores were the sum of the numbers obtained for each statement of the questionnaire.
Validity and reliability of tools
Tools were examined by a panel of three medical and critical care nursing experts to determine whether the included items are clear and suitable to achieve the aim of the current study. Test-retest reliability for Intensive Care Unit Environmental Stressor Scale (ICUESS) was carried out and calculated. It ranged from 0.76 to 0.84.
A pilot study was carried out on 6 patients to test the feasibility, objectivity, and the applicability of the study tools. Based on results of the pilot study, needed refinements and modifications were done and the pilot study subjects were excluded from the current study sample. The needed modification were replacement of some unclear and ununderstandable sentences with more clear sentences as recommended by a panel of reviewers.
Protection of human rights
An official permission to conduct the study was obtained from the research ethical committee and directors of ICUs at a Cairo university hospital. Thereafter, written consent was obtained from patients to be included in the study after explanation of the nature and purpose of the study. Participation in the study was voluntary; each individual had the right to withdraw from the study. Moreover, confidentiality and anonymity of the participants were assured by coding the details of the study participants.
The current study was carried out in two phases: preparation and implementation phases.
The study was conducted after obtaining the primary approval from the research ethical committee at Faculty of Nursing, Cairo University. In addition, the investigator obtained approvals from heads of the cardiothoracic care units. Later, the study tools were developed through extensive review of relevant literature.
The researchers visited the selected researchable settings in the afternoon shifts, then obtained a schedule list of patients prepared for cardiac surgery. Later, the purpose and nature of the study were explained to patients who met the inclusion criteria to gain their cooperation and support to carryout the study. Each patient was interviewed for 30 minutes to fill out the sociodemographic and medical data sheet (tool 1). More over, medical data were obtained from the patients’ files and their significant others. Initial vital signs were documented.
At the first day of meeting with patient, Preoperative Environmental Stressors Scale (tool 2). Later, Postoperatively after extubation, during the first three days in the Intensive Care Unit, the researcher reassessed and filled out postoperative Environmental Stressors Scale (tool 2).
Statistical data analysis
The collected data were scored, tabulated, and analyzed using personal computer utilizing statistical package for the social science program, version 20. Descriptive as well as inferential statistics were utilized to analyze data pertinent to the study. The level of significance was set at P 0.05 or less.
| Results|| |
Sociodemographic characteristics of the sample
Most patients were male. Their ages ranged between 50 and 59 years with a mean age of 45.9±11.7. The study sample included married, illiterate, and individuals from urban areas ([Table 1]).
|Table 1 Frequency distribution of the studied sample in relation to age, educational level, place of residence, marital status, and profession (N=60)|
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Patients’ perceived stressors before open heart surgery
[Table 2] showed that frequent preoperative stressors related to the design and structure of the unit were; continuous lighting (63.4%), not being in a separate room (58%), existence of a strange noise (46%) and curtain spacers between beds instead of wall (60%). Moreover, the preoperative environmental stressors related to team work of the unit were: nurses working in a hurry (100%), waking up patients repeatedly (80%), health workers speak in a loud voices (80%). In relation to sources of stressors related to neighboring patients, it revealed that death of bedside patients and Hearing other neighboring patients’ cry out (98.4% and 63.3%, respectively) were the most frequent.
|Table 2 Frequancy distribution of preoperative environmental stressors among the studied sample (N=60)|
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On the other hand, the most frequent stressors related to the patient himself were: being unable to sleep as usual and fear of infectious diseases (55% and 43%, respectively). However, the most frequent sources causing moderate level of stress were: being in pain; being bored; being exposed to infectious diseases; and fear from death in percentages of 78.3%, 73.4%, 56.7% and 46.7%, respectively.
Patients’ perceived stressors after open heart surgery
As shown in [Table 3] the most frequent postoperative stressors related to the design and composition of the unit were: having lights on constantly; spacers between beds are curtains not walls; and not being in a separate room (63.4%, 60% and 58.4%, respectively). Concerning stressors related to rules and policy of the unit; times of family visits and the quality of food were the most reported stressors (90% and 58.4%, respectively). Also measuring vital signs and presence of men and women in the same ICU rooms represented moderate level of stress level (61.7% and 51.7%, respectively).
|Table 3 Frequancy distribution of postoperative environmental stressors among the studied sample (N=60)|
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As well, the postoperative environmental stressors pertinent to the team work of units and resulted in moderate level of stress were as follows; nurses don’t introduce themselves (83.4%), measuring urine frequently (86.7%), always work in a hurry (80%), nurses constantly doing things around beds (73.4%), nurses observe safety of devices continuously (66.7%) and nurse don’t listen to patients’ complains (60%). In addition, the most frequent sources of stress were being thirsty; in pain; lack of family and friends next to the patient” and presence of tubes inside the nose or mouth (100%, 95%, 90% and 88.4%, respectively). Furthermore, other perceived stressors were hearing the alarm sounds of cardiac monitors (83.4%); reliance on others for self-care (83.4%), not knowing the place (78.3%), being bored (73.4%) and inability to communicate with others (61.7%).
Comparison of patients’ pre and postoperative environmental stressors by demographic characteristics
[Table 4] it is apparent from table that there is significant statistical differences among the the study subjects in relation to preoperative and postoperative environmental stressors by their gender (t = 2.520, P = 0.015) and educational level (F = 4.99; P 0.002 and P = 3.61 P 0.01). On the other hand, there is no significant statistical differences among the the study subjects in relation to preoperative and postoperative environmental stressors by their age or profession (F = 1.59, P = 0.189 and F = 1.59, P = 0.188, respectively).
|Table 4 Comparison of the means among the studied subjects in relation to environmental stressors by their gender|
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[Table 5] presents comparison of the means among the studied subjects in relation to pre and postoperative environmental stressors, by their age groups. It revealed no significant differences among the the different age groups.
|Table 5 Comparison of the means among the studied subjects in relation to environmental stressors, by their age groups (N=60)|
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[Table 6] presents comparison of the means among the studied subjects in relation to the environmental stressors, by their educational level. It revealed significant differences among them (where F = 4.99; P = 0.002 and 3.61; P = 0.011, respectively).
|Table 6 Comparison of means among the studied subjects in relation to environmental stressors, by their educational level (N=60)|
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| Discussion|| |
Demographic characteristics of the participants
The current study revealed that more than half of the studied sample comprised male participants, which is in accordance with Parvan et al. (2013), who studied patient’s perception of stressors associated with coronary artery bypass surgery and revealed that most patients were male. Furthermore, nearly one-third of the patients’ ages ranged from 50 to 60 years. This finding is in accordance with Koranyi et al. (2014), who studied psychological interventions for acute pain after open-heart surgery (systematic review), who found that the mean age of the participants was from 52 to 68 years.
Stressors encountered by patients before open-heart surgery
The present study showed that frequent stressors encountered by patients before open heart surgery were; continuous lighting, spacers between beds are curtains not walls, nurse works in a hurry, patient being awaked by nurses repeatedly to take medication, health workers talk in a loud voices, death of next patients, hearing of other patients’ cry out due to pain and sleep disturbance. The possible explanation for that these interrelated and interdependent findings that make patients stressful were suffering from anxiety such as fear of death, fear of unknown origin, financial loss and results of operation. These findings are consistent partially with Parvan et al. (2013), who studied patient’s perception of stressors associated with CABG surgery and found that pain and discomfort, ‘the need to undergo heart surgery’, ‘death due to illness or surgery’, and ‘being away from home and work’ were stressors. The possible explanation as interpreted by Voss et al. (2004) is that any preoperative intervention refers to the stress of waiting for surgery. Waiting for surgery is a major concern for patients and is strongly associated with anxiety, and hence waiting for surgery is very stressful. In addition, often long periods of waiting for heart surgery can exacerbate the stress and anxiety (Carli and Zavorsky, 2005). This can adversely affect the physical and social functioning (Sampalis et al., 2001).
Similarly, Raia (2008), who studied preoperative stressors among open-heart surgery patients, supported our study findings and mentioned that separation from the family, sleeping in a strange bed, inability to sleep, and fear of surgery failure, anesthesia, pain, fear of loss of control, and death were stressors.
ICU stay is considered the most stressful period for the patient because they find themselves in a new situation, surrounded by equipment and exposed to noise, extrenous factors that cause stress and emotional change.
The present study illustrated that the most frequent stressors postoperatively were the same in preoperative period of time such as continuous lighting, spacers between beds are curtains not walls, nurse works in a hurry, patient being awaked by nurses repeatedly to take medication, health workers talk in a loud voices, death of next patients, hearing of other patients’ cry out and sleep disturbance. Moreover, the other new stressors were; seeing family and friends only for a few minutes, being in pain, being thirsty, presence of tubes inside nose, mouth, chest tubes, disorientation with time and place. The possible rationale for that finding from the researcher’ point of view is that open heart surgery is a physical and psychological stress and the nature of the surgery is along with adapting problems and hospital schedules. “not being able to sleep”, there is current evidence in the literature that the environment of intensive care is considered a disturbing stressor for the patients’ sleep pattern due to monitoring, nursing care interventions during the 24 hours of the day, noises and uninterrupted exposure to light. During this period of time, the patients feel suffering lack of control, and hospitalization that separates them from their relatives, friends and everyday life events. Moreover, Patients concerns related to open heart surgery surgery are chances of successful surgery, fear of death, fear about the recovery process, fear of pain and discomfort, weakness, sleep disturbances, resumption of normal life activities after surgery, cardiac monitoring, drug addiction, length of hospitalization and hospital costs. The current finding in agreement with Kobra et al. (2013), who studied patient’s perception of stressors associated with coronary artery bypass surgery and revealed that the highest frequencies of stressors were pain, discomfort, fear from death due to illness or surgery, being away from home/work and having chest tube.
Also, open heart surgery experience make patients more prone to be anxious and stressful in the postoperative period for several reasons: presence of oral and nasal tubes as they make the patients unable to talk and affecting communication with ICU staff and needs continuous clearance by endotracheal suctioning in order to keep the airways patent during the intubation period. In the present study, the endotracheal intubation appeared to be common and most frequent stressor. That findings were in line with with Lisboa et al. (2012) who found that the endotracheal tube appeared to be an unpleasant and very stressful experience.
In the present study, being in pain appeared to be the most frequent stressors among patients underwent open heart surgery. In author opinion, “being in pain” as it was referred to by the all patients underwent open heat surgery. The feeling of pain may have many reasons such as surgical incision in the chest, presence of chest tubes, Muscle pain in the neck, shoulders, back or chest due to lying on back on the operating table and in the care unit. This finding was agreed with Lisboa et al. (2012) who analyzed the sources of pain and revealed that many undertaken invasive procedures caused pain and physical discomfort to their patients.
Comparison of patients’ environmental stressors by demographic characteristics
The current study finding showed significant statistical differences among the the study subjects by their gender in relation to preoperative and postoperative environmental stressors. So the men showed preoperative high level of stress than women. This finding is agreed with Fathi et al. (2014) who mentioned that the candidates for CABG showed high levels of stress prior to the surgery, and after the operation their anxiety levels gradually decreased. But our finding contradicted with Knopman et al. (2001) who confirmed that women experienced more stressed than men preoperatively. This may be related to the differences in social roles and responsibilities in home management performed by women compared with men. Women traditionally have more responsibility in home management than men, and may feel greater disruption than men when they cannot resume their roles upon returning home after surgery. This may also explain the greater need for home care after discharge and the more frequent hospital readmissions among women in our study.
Our study findings demonstrated that our patients demonstrated no significant differences regarding perception of preoperative and postoperative environmental stressors. The possible explanation for this finding is due to the fact that the patients were under considerable psychological strain before and after heart surgery as well as sharing the same stressful experience. However, our findings contradicted with another study done by Kim (2010) that revealed younger patients showed a higher level of anxiety and stress in comparison to elder patients.
Furthermore, the current study finding showed significant statistical differences among the the study subjects by their educational level. It revealed that the lower the educational level of patients, the higher environmental stressors in the preoperative and post operative periods. The possible explanation for that finding is that people with more education are often spared the health-harming stresses that accompany prolonged social hardship while those with less education often have fewer resources such as social support, sense of control over life, and high self-esteem to buffer the effects of stress. The current study finding is supported by Garbossa et al, (2009) who studied effects of physiotherapeutic instructions on anxiety of CABG patients and mentioned that the lower the educational level of individuals demonstrated the higher anxiety score in the preoperative period.
| Conclusion|| |
The main emphasis of this study was to assess stressors encountered by patients before and after open heart surgery during their hospital stay. Moreover, preoperative stressors were found to be due to: continuous lighting, use of curtains as spacers between beds, nurses working in urgency, repeated awakening patients up to give medicines, workers’ loud voice, the death of other patients, hearing other patients’ complaints and sleep disturbance. However, postoperative stressors were due to: inability to sleep, being in pain, presence of nasal and oral endotracheal tubes, chest tubes, being thirst, being away from home and, unfamiliarity with time. Finally, there is significant statistical differences among the patients who underwent open heart surgery in relation to environmental stressors by their demographic characteristics such as gender, and educational level.
Routine assessment of patients’ anxiety levels before surgery is recommended to determine which patients are at risk for increased anxiety after surgery.
Preoperative education should be incorporated into routine practice to prepare cardiac patients for surgery to reduce anxiety.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]