Strategies to Decrease Anxiety

of the Neurosurgical Patient

with a NP/MD Team Approach
to Perioperative Care
Laura Ellen Prado, MSN, NP
Emory University DNP Student
Committee Members
Kate Moore, PhD, DNP
Kristy Martyn, PhD, NP
Regis Haid, MD

Purpose
Quality improvement project
Mixed Methods
Assessed the effect of a NP/MD team approach
to Perioperative Care on Post-operative
Anxiety among neurosurgical patients.

Background
Donker et al. (2012) study in Netherlands
showed a preoperative NP had a significant
effect on alleviating anxiety of vascular surgery
patients

Used STAI to measure pre- and post-op anxiety

Significant decrease in anxiety scores
-5.4 points in the NP group
-3.8 points in the Surgeon group

Background
Preoperative anxiety can influence
postoperative outcomes
Higher levels of immediate post-op pain
Predictor of chronic pain
Immune response and healing
(Vaughn, Wichowski, & Bosworth, 2007)
(Theunissen, Peters, Bruce, Gramke &
Marcus, 2012)
(Horowitz, Neeman, Sharon & Ben-Eliyahu,
2015).

Anxiety
DSM-V defined as anxiety as anticipation of
future threat

State Trait Anxiety Inventory (STAI)

State anxiety
Anxiety related to current situation

Trait anxiety
Characteristic of person

Anxiety
Presurgical Psychological Screening tools
MMPI
Used to identify ideal surgical candidates

Postoperative success of major scoliosis surgery

not just related to surgical success, but related
to patient characteristics (Smith, et al 2013)
Anxiety negatively influences outcomes (along
with depression, BMI, tobacco use, pain severity)

Opportunity to identify those to provide

interventions

Continuity of Care
Anxiety can be alleviated through continuity of
care
Evidence
Midwifery care
Couples undergoing fertility treatment to have
provider throughout the entire continuum of care

Sandall, Soltani, Gates, Shennan & Devane

2015).
Gameiro, Canavarro & Boivin, 2013)

Methods

IRB
Submitted to Emory University IRB and
Piedmont IRB

IRB approval not required as it qualified as a

quality improvement project

Project
Aim
Sample
Size
Eligible
patients

Quality improvement to assess the effect of

a NP/MD team approach to
Perioperative Care on Post-operative
Anxiety of neurosurgical patients.

26 enrolled
20 completed

18 years and older

Able to read, write and speak English
Neurosurgery with NP/MD Team

Data Collected
Gender
Age
Self admitted past medical history of anxiety/depression
Antidepressant or anti-anxiolytic medication use
Tobacco use
Alcohol use
Preoperative time
Interactions with NP

Methods
Administer STAI

Pre-op appoint

Normal preoperative
appointment

Perioperative period

Intraoperative

Immediate post-op

Post-op
STAI

3-open ended questions

Post-operative Survey
Many people express anxiety or concern prior to
surgery. If you expressed anxiety or concern prior to
surgery, please describe the factors that may
contribute to your anxiety or concern.

If you experienced anxiety or concern about your

surgery, what made you feel less concerned or
anxious?

At this point in your recovery, do you feel surgery has

been successful?

Mixed Methods
Quantitative
Data

Qualitative
Data

STAI

Causes &
Relief of
Anxiety

Patient
Characteristic
s&
Satisfaction

Content
analysis

Time spent
with NP

Analyzed by
SPSS

Results

Enrolled
Private neurosurgical practice
Underwent cervical or lumbar surgery
26 enrolled
20 completed

Quantitative Findings

Patient Characteristics
55.5 years

70% female

No tobacco
45% average
ETOH

20% preexisting
dx of
anxiety/depressio
n
15% on
medication

46.5 minutes for

preoperative visit

STAI Results

Means & % Improvement

STAI Y1 mean scores of state anxiety
42 to 34
70% improvement post-op

STAI Y2 mean scores of trait anxiety

36. to 31.8
65% improvement post-op

Significance
Paired t-test
A p-value of < .05 statistically significant

STAI Y1
p-value .011

STAI Y2
p-value .028

Effect Size
Cohens D for effect size
STAI Y1
0.63 or moderate to large effect size

STAI Y2
0.53 or moderate effect size

NP Pre-Op Time
Pearson Correlation of >0.3 or positive
correlation of decrease in pre to postoperative
STAI scores and time spent in pre-operative
appointment with NP

Qualitative Findings

Qualitative Data

Cause of Anxiety
Fear of the unknown
Concerns regarding pain
Knowledge deficit
Others reaction to surgery

Causes of Anxiety
Interrelated
Pain

Fear of the unknown

Knowledge
Deficit

the unknown of being

100% pain free
will I be pain free?
fear of the unknown :
pain, paralysis,
recuperation, never
having had major surgery
before!
people love to share
stories of surgeries that
dont work out

Others
reaction

Relief of Anxiety
NP/MD team
Education
Faith

What Relieved Anxiety

Interrelated
NP/MD
team

Education
Faith
getting as much information/details
about what to expect after surgery from
the NP, MD
While I was concerned about my
surgery I knew that I had the BEST
surgical team in the country. MD
reputationand the care and kindness I
received from him and NP diminished
my concerns
My conversations with NP helped to
calm my nerves and answer my
questions

Discussion

Summary of Findings
Statistically significant decrease in Post-op STAI
scores
Correlated with the time the NP spent in the
preoperative appointment.

Patients want information, ability to give

postoperative expectations and understand the
process to minimize anxiety. The continuity of
care by the NP/MD team provided this.

Strengths
Provided evidence for quality improvement of
anxiety in this setting

Qualitative consistent with the quantitative data

Congruent with Donker, et al (2012) findings
Well thought out responses by patients on the
survey

Limitations
Small sample size
Not generalizable as expected with QI projects

NP conducted the project assessing the effect of the team

she is a part of
QI project
Conducted with DNP Project Team

Short time frame of data collection

Future assessment needed with more time post-operatively

Patient opportunity to offer suggestions to improve

anxiety not included in design
Some did provide suggestions

Clinical significance
Continuity of care
Importance of provider providing the care
Back school through RN, PT should not be a
substitute for the provider

Patient satisfaction influencing reimbursement

Implications for Practice

Setting aside appropriate amount of time for
preoperative education

Including certain information in the preoperative

appointment

Further Implications
NP worth in a surgical setting to decrease
anxiety during the perioperative period and is
valuable member of the team

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: American Psychiatric Publishing.

Bailey, L. (2010). Strategies for decreasing patient anxiety in the perioperative setting. AORN J, 92(4), 445-457;
quiz 458-460. doi:10.1016/j.aorn.2010.04.017

Consumer Assessment of Healthcare Providers & Systems (CAHPS). (2016). As retrieved from:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/

Craske, M. G., Rauch, S. L., Ursano, R., Prenoveau, J., Pine, D. S., & Zinbarg, R. E. (2009). What is an anxiety
disorder? Depress Anxiety, 26(12), 1066-1085. doi:10.1002/da.20633

Gameiro, S., Canavarro, M. C., & Boivin, J. (2013). Patient centred care in infertility health care: direct and indirect
associations with wellbeing during treatment. Patient Educ Couns, 93(3), 646-654. doi:10.1016/j.pec.2013.08.015

Horowitz, M., Neeman, E., Sharon, E., & Ben-Eliyahu, S. (2015). Exploiting the critical perioperative period to
improve long-term cancer outcomes. Nat Rev Clin Oncol, 12(4), 213-226. doi:10.1038/nrclinonc.2014.224

Jangland, E., Gunningberg, L., & Carlsson, M. (2009). Patients' and relatives' complaints about encounters and
communication in health care: evidence for quality improvement. Patient Educ Couns, 75(2), 199-204.
doi:10.1016/j.pec.2008.10.007

Lee, J. S., Park, Y. M., Ha, K. Y., Cho, S. W., Bak, G. H., & Kim, K. W. (2016). Preoperative anxiety about spinal
surgery under general anesthesia. Eur Spine J, 25(3), 698-707. doi:10.1007/s00586-015-3788-2

Louw, A., Butler, D. S., Diener, I., & Puentedura, E. J. (2013). Development of a preoperative neuroscience
educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil, 92(5), 446-452.
doi:10.1097/PHM.0b013e3182876aa4

References
Marek, R. J., Block, A. R., & Ben-Porath, Y. S. (2015). The Minnesota Multiphasic Personality Inventory-2-Restructured Form
(MMPI-2-RF): incremental validity in predicting early postoperative outcomes in spine surgery candidates. Psychol Assess,
27(1), 114-124. doi:10.1037/pas0000035

Missios, S., & Bekelis, K. (2016). Outpatient continuity of care and 30-day readmission after spine surgery. Spine J.
doi:10.1016/j.spinee.2016.06.012

Rosiek, A., Kornatowski, T., Rosiek-Kryszewska, A., Leksowski, L., & Leksowski, K. (2016). Evaluation of Stress Intensity and
Anxiety Level in Preoperative Period of Cardiac Patients. Biomed Res Int, 2016, 1248396. doi:10.1155/2016/1248396

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2015). Midwife-led continuity models versus other models of
care for childbearing women. Cochrane Database Syst Rev(9), Cd004667. doi:10.1002/14651858.CD004667.pub4

Smith, J. S., Shaffrey, C. I., Glassman, S. D., Carreon, L. Y., Schwab, F. J., Lafage, V., . . . Bridwell, K. H. (2013). Clinical and
radiographic parameters that distinguish between the best and worst outcomes of scoliosis surgery for adults. Eur Spine J,
22(2), 402-410. doi:10.1007/s00586-012-2547-x

Spielberger, C. D., Auerbach, S. M., Wadsworth, A. P., Dunn, T. M., & Taulbee, E. S. (1973). Emotional reactions to surgery. J
Consult Clin Psychol, 40(1), 33-38.

Spielberger CD. Manual for the State-Trait Anxiety Inventory (STAI). PaloAlto, CA: Consulting Psychologists Press 1983
Vaughn, F., Wichowski, H., & Bosworth, G. (2007). Does preoperative anxiety level predict postoperative pain? AORN J,
85(3), 589-604. doi:10.1016/s0001-2092(07)60130-6

Young, A. K., Young, B. K., Riley, L. H., 3rd, & Skolasky, R. L. (2014). Assessment of presurgical psychological screening in
patients undergoing spine surgery: use and clinical impact. J Spinal Disord Tech, 27(2), 76-79.
doi:10.1097/BSD.0b013e31827d7a92