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EMPIRICAL STUDIES

doi: 10.1111/scs.12022

Effect of preoperative nursing visit on preoperative anxiety


and postoperative complications in candidates for
laparoscopic cholecystectomy: a randomized clinical trial
Leila Sadati MS (Nursing Educator)1,2, Abdolreza Pazouki MD (Assistant Professor)2, Abolfazl
Mehdizadeh MD (Professor)2, Saeed Shoar (Medical Student)2,3, Zeinab Tamannaie MD (Research
Coordinator)2 and Shahla Chaichian MD (Associated Professor)4,2
1

Faculty of Para Medicine, Operating Group, Alborz University of Medical Sciences, Karaj, Iran, 2Minimally Invasive Surgery Research
Center, Tehran University of Medical Sciences, Tehran, Iran, 3Student Scientific Research Center, Tehran University of Medical Sciences,
Tehran, Iran and 4Tehran Medical Unit, Islamic Azad University, Tehran, Iran

Scand J Caring Sci; 2013; 27; 994998


Effect of preoperative nursing visit on preoperative
anxiety and postoperative complications in candidates
for laparoscopic cholecystectomy: a randomized
clinical trial
Background: Despite progress in surgery and anaesthesia
techniques, anxiety remains an important problem that
imposes tremendous barriers to postoperative recovery for
surgery patients.
Aims: In this study, we investigated the effects of preoperative nursing visits on anxiety and postoperative complications in candidates for laparoscopic cholecystectomy.
Methods: One hundred consecutive patients were randomly assigned into two equal groups of 50 patients
each. Anxiety was evaluated in both groups using a
translated and validated Spielberger StateTrait Anxiety
Inventory. Patients in the control group received routine
nursing care. Patients in the intervention group received
two preoperative interviews, one on the day before
surgery and one just before entering the operating room.
Pain, nausea, vomiting and other postoperative

Introduction
Anxiety is a temporary emotional state of tension,
nervousness, fear and high autonomic nervous system
activity (1). Anxiety-provoking events that can significantly affect recovery include admission to and environment of the hospital, surgery and anaesthesia (2).
Despite progress in surgery and anaesthesia, anxiety is
an important problem for majority of patients who are

Correspondence to:
Abdolreza Pazouki, Minimally Invasive Surgery Research Center,
Rasoul-e-Akram Hospital, Tehran University of Medical Science,
Niayesh Ave, Sattarkhan St, Tehran 1445613131, Iran.
E-mail: apazouki@yahoo.com

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complications were compared. Pain was measured using


a visual analogue scale.
Findings: All patients were women with a mean  standard deviation age of 46.8  10.6 years. At admission,
state and trait anxiety measurements in the intervention
and control groups were approximately 56 and 55 in both
groups. Just before entering the operating room, these values reduced to 40.30 and 39.04 in the intervention group,
with no significant change in the control group
(p > 0.05). Mean time to reach an Aldrete consciousness
score of 9, frequency of nausea and vomiting in the recovery room, level of postoperative pain, vital sign stabilization and time interval to get out of bed all improved
significantly in the intervention group.
Conclusions: Our study showed that preoperative nursing
visits could decrease the level of preoperative anxiety and
postoperative complications in this patient population.
Keywords: nursing visit, anxiety, postoperative complications, laparoscopic cholecystectomy.
Submitted 14 November 2011, Accepted 16 September 2012

candidates for surgery (3). Anxiety causes an increase in


postoperative pain, analgesic consumption and a much
longer hospital stay that directly affects the cost of health
care (4). Recovery medication and patient education are
recommended to control these deteriorative effects.
Less-invasive laparoscopic surgery has largely replaced
traditional open surgery. Advantages of the smaller laparoscopic incision include reduced manipulation of the
digestive system, less postoperative pain and scarring,
and fewer associated wound complications. However,
laparoscopic surgery can cause anxiety for patients (3).
Several studies have shown that minimally invasive
surgeries result in shorter hospital stays and faster recovery than open surgeries. In 2006, Sawangarom studied
the effect of preoperative phone visit on anxiety levels

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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

Nursing visit before surgery and anxiety


in laparoscopic gynaecology patients and found that the
intervention group had less anxiety as compared to the
control group (5). According to one study, approximately 30% of patients suffer from postoperative nausea
and vomiting and, of those, 1% are re-admitted for
severe nausea and vomiting. In addition to patient discomfort and risk of aspiration, these symptoms also
increase nursing workload. Therefore, methods to control nausea and vomiting should be applied in the postoperative period (3). In 2005, Blay et al. (6) conducted
a survey on the effect of preoperative education on the
outcomes of laparoscopic cholecystectomy and concluded
that educated patients suffered less pain, nausea and
vomiting compared with uneducated ones. In 2003, Laurion et al. (7) conducted an interventional study that
showed music therapy reduces pain, nausea and vomiting in the postoperative period in women laparoscopic
surgery candidates.
The preoperative nursing visit is one of the safest and
the most effective methods (3) to provide psychological
support and education to the patient. This visit provides
an opportunity to collect data for better patient management during surgery and to educate patients about
cooperating with their surgical team and medical care.
An informed surgical patient experiences less fear and
anxiety (2). As reported by Kiyohara et al. (8), a preoperative visit by an anaesthesiologist and better patient
education can significantly reduce anxiety in patients.
Improved surgical procedures and earlier discharge of
patients means that nursing care today focuses more on
psychological care and anxiety management, which
have become cornerstones of nursing care in surgery
patients (9).
We studied effects of nursing visits on preoperative
patient anxiety and postoperative complications in laparoscopic cholecystectomy patients. We provided information
and education to patients about the operating room,
anaesthesia, surgical procedures, and pre- and postoperative care. This study evaluated the outcomes of this process on preoperative anxiety and postoperative
complications.

Materials and methods


This prospective, semi-experimental, randomized clinical
trial (IRCT Code: IRCT201008253384N2) was conducted
in Imam Khomeini Hospital in Tehran and Alborz Hospital in Karaj, Iran between February 2010 and January
2011. We enrolled 100 consecutive patients who were
candidates for laparoscopic cholecystectomy. Candidates
for inclusion were elective laparoscopic cholecystectomy
patients between 18 and 60 years of age. Patients with
underlying physical or psychological disease, with a history of past surgery or who had taken a particular drug,
were excluded from the study. Patients were divided into

995

two equal groups (intervention and control) via a computer-based randomization process.
A preoperative nursing visit was conducted for each
patient in the intervention group on the day before surgery, while no such an intervention was offered to the
control group. Preoperative anxiety and postoperative
complications including pain, nausea and vomiting were
then compared between the two groups using a 30-minute survey. Anxiety was evaluated using a Spielberger
StateTrait Anxiety Inventory (10) that was translated
and validated for the Iranian population. Two independent psychologists then reviewed the questionnaire for
the presence of any bias or mistranslation. The questionnaire consisted of 20 items in two 10-question sections
measuring either state or trait anxiety. It was scored
based on an anxiety intensity from 1 (no anxiety) to 4
(highest level of anxiety), giving a sum score between 20
and 80. Pain was measured using a visual analogue scale.
Nausea and vomiting were measured using a Johnson 10
scale criteria.
Data collection included reviewing patient medical
records and then conducting face-to-face interviews.
Patients in the intervention group were interviewed on
the day before surgery. These interviews included asking
the patient about any concerns regarding the scheduled
surgery and postoperative process and then answering
those questions in simple and understandable phrases.
Patients in the intervention group were also educated
about the operating room environment and surgery
team, the anaesthesia process, benefits of laparoscopic
surgery versus open surgery, as well as postoperative care
from the recovery room up to patient discharge (to help
facilitate patient cooperation with nurses). Patients in the
control group were scheduled only for conventional preoperative nursing visits.
To evaluate the efficacy of nursing visits, a Spielberger
StateTrait Anxiety Inventory was completed for patients
in both groups. Nurses conducted a 30-minute survey at
the time of admission to the surgical ward and again just
before transferring the patient to the operating room (OR).
Data regarding surgery, anaesthesia and recovery were
recorded. Pain, nausea and vomiting were also evaluated
by a trained nurse after 24 hours. Surgical and anaesthesia procedures, as well as procedures for pain, nausea
and vomiting control, were the same for all patients.
Written informed consent was obtained from all
patients before randomized allocation to either the intervention or the control group. Our Institutional Review
Board approved the study protocol on human subjects.
Data were analysed using Statistical Package for Social
Sciences (SPSS, Version 16; Chicago, Inc, Chicago, IL,
USA). Values are presented as a mean  SD for continuous and as a number (%) for categorical variables. An
independent sample t-test for quantitative variables was
used to compare data between the two groups.

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996

L. Sadati et al.

Table 1 Comparison of state and trait anxiety scores at the time of


admission and prior to entrance to the OR between the two groups
Item

Intervention group

Control group

State anxiety in admission


Trait anxiety in admission
State anxiety prior to OR
entrance
Trait anxiety prior to OR
entrance

56.98
55.58
40.34

56.1
55
56.7

0.2
0.4
0.0

39.04

55.38

0.0

Table 2 Comparison of postoperative features in OR between the


two groups

Time to score 9
consciousnesses (hours)
Nausea/vomiting in
operating room (%)

Intervention group

Control group

18

30

0.0

20

0.04

Table 3 Comparison of postoperative status of patients in both


groups in surgical ward

Results
Data from 100 patients who completed both questionnaires were analysed. All patients were women.
Mean  standard deviation (SD) age was 46.8  10.6 years
and mean  SD BMI was 27.1  3.1 kg/m2. Both the
intervention and control groups had similar educational
backgrounds. According to the calculated Spielbergers
score, state and trait anxiety at the time of admission to
the surgical ward were 56.98 and 55.58 in the intervention group, compared with 56.1 and 55 in the control
group, respectively, with no significant difference
(p > 0.05) (Table 1) between the groups. However, following the nursing visit and just prior to entering the OR,
both state and trait anxiety dropped to 40.34 and 39.04 in
the intervention group, compared with 56.70 and 55.38 in
the control group, with statistically significant differences
(p < 0.05) in the intervention group after the nursing visit
(Table 1).
Mean time to reach an Aldrete consciousness score of 9
was 18 and 30 minutes in the intervention and control
groups, respectively, with a statistically significant difference (p < 0.05). Moreover, only 6% of the intervention
group developed postoperative nausea and vomiting, significantly less than the 20% of the control group
(p < 0.05) (Table 2). Duration of vital sign stabilization,
postoperative pain, nausea and vomiting, and time to
patients first walk were significantly lesser in the intervention group than in the control group (p < 0.05)
(Table 3).

Discussion
Our study showed that state anxiety decreased in the
intervention group, which received a preoperative nursing visit. Similarly, in a study conducted by ValenzuelaMillan et al. (11) on 135 patients, 76% of them were
anxious before the surgery, and the most important contributing factor was the lack of information. In another
study performed by Kiyohara et al. (8), a preoperative
visit by an anaesthesiologist and sufficient education significantly reduced anxiety in studied patients. In 2007,
Asghari et al. (12) indicated that cortisol levels (as an

Postoperative
characteristics

Intervention
group

Control group

Vital sign stabilization


Postoperative pain (VAS)
Nausea and vomiting
Duration of hospital stay
Time to walk on foot
Time to first gas passage

1.49 (hour)
5.1
0%
1.9 (day)
0.9 (day)
16.6 (hour)

2.54 (hour)
5.7
33%
2 (day)
1.2 (day)
18.1 (hour)

0.0
0.001
0.01
0.23
0.002
0.07

indicator of anxiety) were significantly reduced in


patients who had a preoperative nursing visit at an ear,
nose and throat ward compared with the control group.
Sawangarom and Hughes show comparable results
with our study (5, 13). They found that anxiety in
patients who received a preoperative nursing visit was
6.37 at admission and then decreased to 6.00 upon entry
into the OR. In the control group, anxiety increased from
6.96 at admission to 8.00 upon entry to the OR (5). Laurion et al. (7) indicated that preoperative music therapy
in patients who were candidates of laparoscopic gynaecologic surgery could decrease postoperative nausea and
vomiting. Our study revealed similar results, with
patients in the intervention group showing significantly
lower rates of postoperative nausea and vomiting. Blay
et al. (6) conducted a study to investigate the effect of
preoperative education on postoperative complications of
laparoscopic cholecystectomy, and they found lower rates
of nausea and vomiting in the intervention group in
comparison with the control group. Lin et al. (14) demonstrated that nursing care is effective in controlling
patient anxiety level. Participants in their study suffered
less pain 4 hours after surgery and significantly less pain
24 hours after surgery, and they changed position more
comfortably and cooperated more efficiently in postoperative deep respiration and coughing exercises.
In our study, patients in the intervention group
became alert earlier and cooperated more efficiently with
nurses, and their vital signs stabilized faster than in the
control group. Mean time to achieve an Aldrete consciousness score of 9 (15) in the intervention and control
groups was 18 and 30 minutes, respectively. Time

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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

Nursing visit before surgery and anxiety


intervals to vital signs stabilization, to get out of bed and
to start eating were significantly less in the intervention
group. Physical recovery, postoperative complications,
postoperative pain and nausea were also significantly better. Length of stay and flatus were not significantly different between the two groups.
These favourable results may be attributed to better
understanding of the benefits of mobility and more efficacious walking. There may also be less interference of
pain and anxiety with the patients daily function, leading to fewer symptoms. The supportive and informative
preoperative nursing visits may result in better patient
perception of surgery, anaesthesia and recovery. Evidence suggests that the beneficial impact of a preoperative nursing visit on physical recovery and postoperative
complications are immediate rather than long-term (16).
Arthur et al. (17) showed that patients receiving preoperative intervention spend 2 hours less in the intensive
care unit and are discharged 1 day earlier. Duration of
hospital stay did not differ significantly between our
groups, which could be because laparoscopic patients
remain under close postoperative observation for a specific duration.
One limitation of this study was its relatively small
sample size. Conducting the study in two distinct centres
with similar features of nursing visits may weigh against
the benefits of a larger population studied in a single centre. Another limitation of our study was the low score of
trait anxiety in the intervention group just before entering the OR. As emphasized by Spielberg, this is a consistent feature that is unaffected by simple intervention.
This inconsistency may be caused by the limited interview time on the day of surgery, resulting in insufficient
data gathering time.

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997

Conclusion
Our study showed that preoperative nursing visits can
decrease rates of anxiety and postoperative complications
and should be integrated into routine care for laparoscopic cholecystectomy patients.

Author contribution
Sadati and Pazouki involved in the study conception/
design. Sadati and Shoar contributed to the data collection/analysis. Shoar and Tamannaie drafted the manuscript. Pazouki, Shoar, Chaichian and Mehdizadeh
involved in critical revisions for important intellectual
content and administrative/technical/material support.
Sadati, Chaichian, Pazouki and Mehdizadeh supervised
the work. Chaichian, Shoar and Tamannaie shared their
statistical expertise.

Ethical approval
This project has been accepted by ethical committee of
Tehran University of Medical Sciences; ethical code: 891/1.

Funding
This study has been funded and supported by Tehran
University of Medical Sciences (TUMS); grant No: 487.

Declaration of interests
There has been no duplicate publication or submission
elsewhere, and no ethical problem or conflict of interest
is declared.

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Scandinavian Journal of Caring Sciences 2013 Nordic College of Caring Science

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