A Pilot Study to Evaluate the Effectiveness
of Preoperative Teaching Protocol on Selected Postoperative Outcomes in Terms
of Anxiety and Depression Status Among Women undergone Hysterectomy
K. Thilagavathi1* and Dr. Rajeswari Vaidyanathan2
1Ph.D. Scholar in National Consortium for Ph.D. Nursing, Bangalore,
India
2Research Guide in National Consortium for Ph.D. Nursing,
Bangalore, India
*Corresponding
Author Email:thilagaindia74@gmail.com
ABSTRACT:
Background: The uterus contributes to a woman’s sexual,
reproductive and social identity. They are related to the concepts of feminity, sexuality, procreation and motherhood and are
necessary part of a woman’s body image. Hysterectomy is the second commonest
operation in the women.
Objectives: 1.To
assess and compare anxiety and depression scores between samples in control
group and experimental group.2.To find association between pretest level of
anxiety and depression scores of experimental group with selected demographic
variables.
Design: Quantitative
evaluative approach -Quasi experimental Nonequivalent before and after design
Setting: Pilot study was conducted in the Salem
Polyclinic, Salem.
Participants: A Convenient
sampling technique was used to select the samples. Inclusion
criteria consist of women between the age group of 30-58 years, Women those who
are living with partner, women at premenopausal/postmenopausal age, women who
undergo abdominal/vaginal hysterectomy with or without salphingo
oophorectomy for nonmalignant reasons. Exclusive
criteria include women with debilitating illness and psychiatric illness, and
women undergo hysterectomy for emergency reason. Equally 10 samples in control
group and experimental group were selected for pilot study.
Methods: Three tools were used for data collection namely Proforma for Demographic data, State and trait Anxiety
Inventory to identify anxiety status and Beck Depression inventory to assess depression
status. Demographic data was collected on the preoperative period. State and
Trait anxiety inventory and Beck Depression Inventory was assessed at
preoperative period, at discharge and again 4 months after surgery. Preoperative
teaching protocol was administered in 3 phased manner (preoperative period, at
discharge and at 2 months after surgery) to experimental group.
Results: In Control group 80 % had mild anxiety at
preoperative period, 50% had mild anxiety at discharge and at 4 months after
surgery. But in experimental group 90% had mild anxiety at preoperative period
which was reduced to 40% at discharge and further reduced to 20% at 4 months
after surgery. There
was statistically significant difference (P < 0.05) found between anxiety
scores at discharge between control group and experimental group. In Control group 20 % had mild mood disturbance at preoperative period, discharge and at 4
months after surgery. But in experimental group 30% had mild mood disturbance
at preoperative period which was reduced to 20% at discharge and further
reduced to 10% at 4 months after surgery. There was no significant
difference found between depression scores in control group and experimental group.
There was no significant association found between the between pretest level of
anxiety and depression scores of experimental group with selected
socio-demographic variables (Age and Duration of illness).
Conclusion:
Above study findings reflects the effectiveness of preoperative teaching
protocol. Providing perioperative information in a
structured manner will help the hysterectomy women to reduce anxiety and
depression status after surgery
KEY WORDS: Hysterectomy, Anxiety, Depression, Preoperative teaching protocol,
Postoperative outcomes,
INTRODUCTION:
The uterus contributes to a woman’s
sexual, reproductive and social identity. They are related to the concepts of feminity, sexuality, procreation and motherhood and are
necessary part of a woman’s body image. Hysterectomy is the second commonest
operation in the women. The loss of the uterus through hysterectomy carries
significant negative repercussions in woman. The side effects of this surgical
treatment invariably cause some loss of function such as cessation of
Menstruation, infertility and hormonal imbalance. Baum suggests that surgical
procedures like hysterectomy are stressful and may lead to anxiety and
depression in females undergoing this procedure. The reactions experienced by
women undergoing hysterectomy are similar to those of bereavement; that is an
initial phase of disbelief that it has been removed, followed by sadness and
depression. Anxiety is an individual
experience and it is a concept that is difficult to describe with words. No
matter how major or minor an operation is, it tends to raise a certain level of
anxiety in every patient (Taskin,
2008). Hospitalization for surgical procedure can be experienced as a threat or
stressor and may produce anxiety in patients. Anxiety occurs in the
preoperative phase as the patients anticipate an unknown event with potential
pain and changes in body image, as well as increased dependency on family and
other life changes(Kiyohara,2004).
Yasmin (2005) conducted
a study to identify a depression and anxiety in patients undergoing
hysterectomy during their pre-surgical and post-surgical phases. Sample
consisted of 50 women. Depression scale and anxiety check list was administered
1-7 days before and 1-7 days after operation. Results showed mean depression
scores at post- surgical phase was 12.88 as compared to mean pre-surgical phase
10.44.Similarly mean anxiety scores at post- surgical phase was 27.10 as
compared to mean pre-surgical phase 13.38.This study findings suggest that
anxiety and depression scores were higher after hysterectomy.
Hysterectomy is a surgical procedure
that significantly affects the quality in which the operated person views
herself, lowers self-esteem and brings about changes in the quality of life (Gallicchiohile, 2005Kim 2001). A
postmenopausal woman, who has completed her reproductive life, may view a
hysterectomy as the removal of an organ that has "turned bad," a
young woman may have a very different viewpoint (Wad et
al, 2001).
Often, the information provided for the
patients does not cover the necessary medical regimen which will help them when
they have to face the problems and solve them properly. Giving systematic
advice and information is very rare.
Actually, the health personnel should
give patients information about what they will have to face on the operation
day, such as the characteristics of the operating theatre, and the medical
procedures before they fall asleep because of the effect of anesthesia. The patients who are given the
systematic instruction will obtain right and sufficient information, and
develop a positive attitude. They will also be willing to follow the medical
practices. When anxiety diminishes, the negative mental and emotional states,
such as irritation, aggression, lack of concentration, and depression will also
reduce. It can help patients to recover more rapidly and reduce the length of
time of hospital stay since giving them appropriate knowledge can make them
change their beliefs and behaviors (Guler,2001).
METHODOLOGY:
Research design:
Quantitative
evaluative approach -Quasi experimental Nonequivalent before and after design
was used in the study.
Population:
A Convenient sampling technique was used
to select the samples. Inclusion criteria consist of women
between the age group of 25-58 years, Women those who are living with partner,
women at premenopausal/postmenopausal age, women who undergo abdominal/vaginal
hysterectomy with or without salphingo oophorectomy for nonmalignant reasons. Exclsive
criteria include women with debilitating illness and psychiatric illness, and
women undergo hysterectomy for emergency reason.10% of total sample size (100)
in main study was considered for pilot study. Equally 10 samples in control
group and experimental group were selected.
Study setting:
Pilot study was conducted in Salem
Polyclinic, Salem.
Data collection Tools:
Four tools were developed for data
collection namely Proforma for socio-demographic
data, State and trait Anxiety Inventory to identify anxiety status and Beck
Depression inventory to assess depression status.
1.Socio
Demographic data:
This data consists of age, Education,
occupational status, Family monthly income, No of children, Diagnosis, Surgery
planned and any associated urinary symptoms.
2.State and Trait Anxiety Inventory:
This is a standardized tool developed by Charles D.Spielberger Ph.D., STAI is a
self-evaluation questionnaire to assess state and trait anxiety of the
subjects. It has about 40 items, among this first 20 items measures state
anxiety and next 20 items measures Trait anxiety. Direct and reverse scoring were used to some items in both type of anxiety.
Interpretations are made as follows; 0-40: Normal; 41-80: Mild anxiety ; 81-120:
Moderate ; 121-160: Severe anxiety
3.Beck
Depression Inventory:
The Beck Depression
Inventory created by Dr. Aaron T. Beck, is a
21-question multiple-choice self-report inventory used to assess the
severity of Depression. Based on the scores the level of depression are
interpreted as Normal (1-10); mild mood disturbance (11-16); Moderate (17-30);
Severe (31-40); Extreme depression (Over 40).
Data Collection Procedure:
Formal permission was obtained from
hospital authorities before the data collection. Informed written consent was
collected from each sample after explaining the nature and purpose of the
study. Demographic data was collected on the preoperative period. State -Trait
anxiety inventory and Beck Depression Inventory was assessed at preoperative
period, at discharge and again 4 months after surgery.Preoperative
teaching protocol was administered in 3 phased manner (preoperative period, at
discharge and at 2 months after surgery) to experimental group.
DATA ANALYSIS:
Collected data was analyzed with
Descriptive and Inferential Statistics. Data were presented in tables and
diagrams.
Figure 1 :
Bar diagram showing the level of anxiety scores among samples in control group
and experimental group
Figure 2 :
Bar diagram showing the level of depression scores among samples in control
group and experimental group
RESULTS:
Table 1 Shows that in regard to age
majority (40%) in control group belong to 51-55 years and in experimental
group, 50% belong to 46-50 years.50% of them are illiterate in control group
and 40% in experimental group. In control group majority 50% were coolie
workers and in experimental group 50% of them are housewives. In regard to
Family monthly income, 60% in control group earn about Rs.2001-4000 and 70%
earn about the same income in experimental group. In control group, 60% had 2
children and 70% in experimental group had 2 children. Majority had 50% had
mass descending per vagina as a chief complaint. In regard to diagnosis equally
50% in control and experimental group had fibroid uterus and genital prolapse.
In control group and experimental group
equally 50% underwent abdominal and vaginal hysterectomy. In control group 70%
and 80% in experimental group were not attained natural menopause before
surgery.50% of them in control group had associated urinary symptoms, in which
20% had Stress urinary incontinence, 20% had urge and remaining 10% had both of
these types. In experimental group, 60% had associated urinary symptoms, in which
20% had stress and 40% had urge urinary incontinence. Associated Co –morbid
illness, only 10% in control group had hypertension. In experimental group, 10%
had hypertension, 10% had diabetes.
Figure .1 shows that in Control group 80
% had mild anxiety at preoperative period, 50% had mild anxiety at discharge
and at 4 months after surgery. But in experimental group 90% had mild anxiety
at preoperative period which was reduced to 40% at discharge and further
reduced to 20% at 4 months after surgery.
Table 2 shows that mean anxiety score
was 46.6 with SD 4.49 in control group and in experimental group it was 47.2
with SD 4.48 in preoperative period. At discharge in control group had a mean
anxiety score of 43 with SD 6.30 and experimental group had a mean score of
42.6 with SD 6.27.At 4 months after surgery, mean anxiety score was 41.8 with
SD 1.77 and experimental group had a mean score of 40.4 with SD 4.72.In student
t test there was Statistically significant difference was found between control
group and experimental group at discharge (P≤0.05).But in preoperative
period and 4 months after surgery it was not significant.
Figure .2 shows that in Control group 20
% had mild mood disturbance at preoperative period, discharge and at 4 months
after surgery. But in experimental group 30% had mild mood disturbance at
preoperative period which was reduced to 20% at discharge and further reduced
to 10% at 4 months after surgery.
Table 1: Frequency and percentage of samples based on
Demographic variables n1=n2=10
|
S.No
|
Demographic variables
|
Control
group
|
Experimental group
|
|
f
|
%
|
f
|
%
|
|
1.
|
Age in Years
a.35-40 years
b.41-45 years
c.46-50 years
d.51-55 years
|
01
02
03
04
|
10
20
30
40
|
---
01
05
04
|
---
10
50
40
|
|
2.
|
Educational status
a.Illiterate
b.Primary school
c.Secondary school
|
05
03
02
|
50
30
20
|
04
03
03
|
40
30
30
|
|
3.
|
Occupation
a.Housewife
b.Coolie worker
c.Clerical work
|
05
04
01
|
50
40
10
|
03
05
02
|
30
50
20
|
|
4.
|
Family monthly income in rupees
a.≤2000
b.2001-4000
c.4001-6000
|
1
6
3
|
10
60
30
|
7
3
|
70
30
|
|
5.
|
No of children
a.1
b.2
c.3
|
1
6
3
|
10
60
30
|
7
3
|
70
30
|
|
6.
|
Chief complaints
a.Lower abdominal pain
b.Irregular bleeding
c.Mass descending per
vagina
|
1
4
5
|
10
40
50
|
2
3
5
|
20
30
50
|
|
7.
|
Duration of chief complaints
a.≤ 6 months
b.≥ 6months-1 year
c.1-3 year
|
1
7
2
|
10
70
20
|
1
5
4
|
10
50
40
|
|
8.
|
Diagnosis
a.Fibroid uterus
b.Genital prolapse
|
5
5
|
50
50
|
5
5
|
50
50
|
|
9.
|
Type of
surgery planned
a.Total abdominal
hysterectomy
i) with bilateral tubectomy
ii)without bilateral tubectomy
b.Vaginal hysterectomy
|
3
2
5
|
30
20
50
|
2
3
5
|
20
30
50
|
|
10.
|
Attained natural menopause
a.Yes
b.No
|
3
7
|
30
70
|
2
8
|
20
80
|
|
11.
|
Associated urinary symptoms
a.Yes
b.No
|
5
5
|
50
50
|
6
4
|
60
40
|
|
12.
|
Type of urinary incontinence
a.Stress
b.Urge
c.Mixed type
|
2
2
1
|
20
20
10
|
2
4
--
|
20
40
---
|
|
13.
|
Co-morbid illness
a.None
b.Hypertension
c.Diabetes mellitus
|
9
1
---
|
90
10
----
|
8
1
1
|
80
10
10
|
Table 2:
Mean, SD and student t test value of anxiety scores among samples in Control
group & experimental groupn1=n2=10
Level of
significance p < 0.05
*-Significant not
significant df =18
|
Measurement
|
Control
group
|
Experimental group
|
Student t
test value
|
|
Mean
|
SD
|
Range
|
Mean
|
SD
|
Range
|
|
Preoperative
period
|
46.6
|
4.49
|
40-54
|
47.2
|
4.48
|
40-56
|
0.05**
|
|
Discharge
|
43
|
6.30
|
40-50
|
42.6
|
6.27
|
40-52
|
0.02*
|
|
4 months
after surgery
|
41.8
|
1.77
|
40-46
|
40.4
|
4.72
|
40-42
|
0.45**
|
Table 3: Mean, SD and student t test value
of Depression scores among samples in Control group & experimental groupn1=n2=10
Level of significance p <
0.05 not significant df =18
|
Measurement
|
Control
group
|
Experimental
group
|
Student t
test value
|
|
Mean
|
SD
|
Range
|
Mean
|
SD
|
Range
|
|
Preoperative
period
|
5.2
|
4.75
|
2-15
|
6.7
|
5.34
|
2-16
|
0.66**
|
|
Discharge
|
4.8
|
4.05
|
2-13
|
5.9
|
4.41
|
2-14
|
0.59**
|
|
4 months
after surgery
|
4.6
|
4.27
|
2-13
|
4.9
|
3.85
|
2-12
|
0.16**
|
Table 4 :Association
between the level of anxiety and
Depression scores at preoperative period among samples in experimental group
and their selected demographic variables (age, Duration of complaints) n1=n2=10
|
Variables
|
Demographic variables
|
df
|
X2
|
|
1.Anxiety
|
a.Age in years
|
2
|
0.19**
|
|
b.Duration of Complaints
|
2
|
0.19**
|
|
2.Depression
|
a.Age in
years
|
2
|
2.23**
|
|
b.Duration of
Complaints
|
2
|
2.23**
|
Level of significance p <
0.05 **-not significant
Table 3 shows that Mean Depression score
was 5.2 with SD 4.75 in control group and in experimental group it was 6.7with
SD 5.34 in preoperative period. At discharge, control group had a mean score of
4.8 with SD 4.05 and experimental group had a mean score of 5.9 with SD 4.41.At
4 months after surgery, mean score was 4.6 with SD 4.27 and experimental group
had a mean score of 4.9with SD 3.85.However in student t test there was no
significant difference found between control group and experimental group at
preoperative period, discharge and 4 months after surgery.
Table 4 shows there was no significant
association found between preoperative level of anxiety and depression scores
in experimental group with selected demographic factors mainly with age and
duration of illness.
CONCLUSION:
Pilot study findings suggest that
providing information in a structured manner will enable the women to have
decreased anxiety and Depression status in a post-operative period.
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LM, et al.: Surgery information reduces anxiety in the
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Yasmin N Farooqi:Depression and Anxiety in
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L, Harvey LA, Kjerulff
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