What Does the Literature Tell Us About Anxiety?
Over the years there has been a great deal of research supporting the contention that the majority of patients suffer from anxiety prior to invasive procedures. Anxiety, as defined by Wilson-Barnett, is the fear of the unknown, disproportionate to the threat and related to the future.1 It is characterized by an individual’s inability to specify the source of the threat.2 Anxiety has been shown to lead to high levels of stress, creating delays in recovery and increased length of stay within the hospital.3 Historically, nurses have handled patient physiological needs with great confidence, but patient psychological needs, such as the manifestation of anxiety, have not received the same attention.4
One area in which evidence-based practice can offer great value is in addressing pre-cardiac catheterization anxiety. Evidence-based practice encompasses research, clinical expertise and patient preference.5 However, while searching the literature for data on pre-cardiac catheterization and patient anxiety, it became apparent that there is very little published on these topics. If we look at the data we do have, what can we learn about how cardiac cath lab staff can reduce patient anxiety pre-cardiac catheterization? It has been noted that pre-procedure psychological preparation reduces hospital-induced anxiety.6 Cupples and Martin both found that patients who received educational information pre-operatively were shown to have less nausea, vomiting, pain and post-op complications, and have deceased lengths of stay.7,8 In this article, we will review what current literature states as best practice for educating patients with the goal of anxiety reduction pre-cardiac catheterization.
Prior to educating patients, it is useful to have a baseline understanding of the cath lab patient population in order to appropriately tailor your cath lab’s pre-procedure educational approach. The age range for most patients in the relevant literature ranged from age 18 to 80-plus. The studies were composed of both men and women, with a diverse ethnic background of African-American, Caucasian, Asian, Hispanic, Native American, and other.9–12 Smith and Cason found that the majority of the patients, however, were Caucasian males.13
The Best Method of Education for Pre-Cath Anxiety Reduction
There are two different approaches taken by patients as they face the reality of an upcoming medical procedure. Studies have shown that patients are either “monitors” or “blunters.” Monitors are patients who truly desire educational materials. They specifically request educational literature and will ask several questions during the procedure. Blunters are patients who indicate, “I don’t want to know anything else about this procedure, I just want to get it done!”11,12,14
Patient education material is either sensory- or procedural-oriented. Procedural material describes the steps involved in the cardiac catheterization. Sensory information focuses on what the patient will see, hear, feel, smell or taste during the procedure. Sensory information helps the patient reduce anxiety by communicating a better understanding of what to expect during the procedure. It can take away the ambiguity regarding the event they are about to undergo.9
Current literature supports the delivery of both procedural and sensory information in order to reduce patient anxiety.9,11–13 Both procedural and sensory information can be presented through different medias. Many organizations allocate written pamphlets and/or videos that deliver both procedural and sensory information. It is important to note that when utilizing a pamphlet for catheterization education, it should include procedural and sensory information written at the fifth-grade reading level.13
If a video is used for education, it is better received if the presentation is from the patient’s perspective, thus permitting the patient to rehearse the procedure cognitively.11 Another valid method for delivering procedural and sensory information is in a face-to-face interaction between the patient and a cath lab staff member. One advantage to a face-to-face interaction is that cath lab staff have an opportunity to evaluate the patient’s comprehension of the information. Importantly, the interview also provides a social visit with the patient. In a 1991 study by Peterson, a social visit had the same impact in reducing anxiety for blunters as delivering procedural and sensory information.12
Simply put, the best time for patient education is as early as possible. Harkness et al found that 60% of patients felt their anxiety increased over time and that 68% of these patients preferred contact within the first two weeks of learning that they would need a heart catheterization.10 The reality in a cath lab setting, however, is that patients arrive through various pathways, meaning that the time available before the procedure for education varies substantially. Patients come as an outpatient admission from a cardiologist’s office days to weeks in advance, as a same-day admission from a family practice admit or as an emergency admit for acute myocardial infarction. Regardless of how patients arrive at the cath lab, the need for pre-cardiac catheterization education still exists. Delivery of the information as soon as possible is in the best interest of the patient, the patient’s family, the cardiologist and the support staff.
What Don’t We Know?
We found that there are some deficiencies in cardiac cath lab literature. First, there is the lack of current data related to patient anxiety and the impact of patient education on decreasing anxiety. Second, current patient education materials need to be evaluated to ensure they are actually at a fifth-grade reading/comprehension level. Also, a suitability assessment of materials should be done to assess for content, literacy demand, graphics, presentation, learning stimulation or motivation, and cultural appropriateness. Finally, more studies need to be performed that examine educational differences between males and females. Many researchers write that there was little difference between males and females in relation to study results, yet one study did identify female monitors and blunters as suffering significantly more anxiety pre-procedurally.11
Cardiac Cath Lab Staff Should Know…
Higgens et al concur that patients who acquire knowledge pre-procedurally are able to cope better during the actual procedure.15 Cath lab staff should attempt to identify whether patients are a monitor or a blunter. Ask your patient: “How much information would you like for us to give you related to your heart cath?”11 If the patient identifies himself or herself as desiring information (a monitor), deliver procedural and sensory information by a pamphlet and/or video (days to weeks prior to their heart cath, recognizing some patients may not know how to read and the video may be the patient’s best form of education). If the patient identifies himself or herself as a blunter, it is still advisable to give them educational material, as their family may be monitors and desire to review the material.
Prior to the (non-acute) patient entering into the cath lab procedure room, the literature supports having a healthcare worker (cath lab staff) engage in face-to-face (social interaction) contact with the patient. During this social visit, the staff member can ask the patient if they have questions related to the educational information that was distributed by the cath lab. For the patient who is a monitor, the staff member can deliver follow-up sensory information. For patients who are blunters, a social visit alone will help reduce their anxiety.12
Patients’ anxiety pre-procedure is a real experience. Cardiac cath lab staff can make a genuinely positive impact on the physiological and psychological health of their patients by taking the time to consider their current educational processes. As we noted, there are gaps in the literature related to pre-cardiac catheterization anxiety. Despite this, cardiac cath lab staff should review the current means to educate their patients prior to cardiac catheterization and consider what the literature supports as evidence-based practice to provide excellence in patient education.
Timm Reed can be contacted at firstname.lastname@example.org
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