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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 145-150

The effects of an interdisciplinary supportive educational program on anxiety among patients undergoing cataract surgery

Date of Submission27-Oct-2020
Date of Decision20-Jul-2020
Date of Acceptance16-Dec-2020
Date of Web Publication23-Jul-2021

Correspondence Address:
Sedigheh Farzi
Hezarjarib St., Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan.
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nms.nms_45_20

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  Abstract 

Background: In most ophthalmic surgeries, patients are conscious or semi-conscious, and hence, they may experience varying levels of anxiety during surgery. Objectives: The aim of this study was to evaluate the effects of an interdisciplinary supportive educational program on anxiety among patients undergoing cataract surgery (CS). Methods: This quasi-experimental study was carried out in February–August 2019 using a two-group pretest–posttest design. Participants were 64 patients with cataract who were referred to Feiz Hospital, Isfahan, Iran, for undergoing CS. They were consecutively recruited and randomly assigned to either a control or an intervention group. Data were collected using a demographic questionnaire and Spielberger State-Trait Anxiety Inventory. Participants in the intervention group received an interdisciplinary supportive educational intervention, while their counterparts in the control group received routine care services. State anxiety and trait anxiety were assessed both on the sampling day and after regaining full postoperative consciousness. Data analysis was done via the independent and the paired samples t-, the Mann–Whitney U-, and the Chi-square tests. Results: There were no statistically significant differences between the intervention and the control groups respecting the pretest mean scores of state anxiety (35.25 ± 8.51 vs. 35.72 ± 9.43; P = 0.83) and trait anxiety (38.25 ± 7.002 vs. 39.16 ± 8.58; P = 0.64). However, there were statistically significant differences between the groups regarding the posttest mean scores of state anxiety (28.66 ± 10.39 vs. 34.84 ± 9.36; P = 0.02) and trait anxiety (31.76 ± 8.51 vs. 38.13 ± 10.29; P = 0.01). Conclusion: As a simple and inexpensive intervention, an interdisciplinary supportive and educational program through both face-to-face communication and telecommunication methods is effective in significantly reducing anxiety among patients undergoing CS.

Keywords: Anxiety, Cataract, Educational, Interdisciplinary, Support, Surgery


How to cite this article:
Moladoost A, Salehi A, Farzi S, Dehghani A, Razmjoo H, Mohammadi ZS, Farzi S. The effects of an interdisciplinary supportive educational program on anxiety among patients undergoing cataract surgery. Nurs Midwifery Stud 2021;10:145-50

How to cite this URL:
Moladoost A, Salehi A, Farzi S, Dehghani A, Razmjoo H, Mohammadi ZS, Farzi S. The effects of an interdisciplinary supportive educational program on anxiety among patients undergoing cataract surgery. Nurs Midwifery Stud [serial online] 2021 [cited 2021 Sep 27];10:145-50. Available from: https://www.nmsjournal.com/text.asp?2021/10/3/145/322226




  Introduction Top


Cataract is one of the common causes of blindness in both developing and developed countries and is the second cause of low vision worldwide. It is responsible for more than 51% of cases of blindness in the world.[1] A meta-analysis and systematic review showed that the prevalence of cataract in Iran is 9.27%.[2] Cataract results from the opacification of the lens of the eye and leads to low or blurred vision.[3] The main treatment for cataract is cataract surgery (CS), mostly through phacoemulsification under local anesthesia. CS is one of the most common surgical interventions in ophthalmology.[4] It is an important component of a World Health Organization program, called the Global Eye Health Action Plan 2014–2019, which aims at reducing the number of preventable visual impairments.[5]

Anxiety is one of the most common negative consequences associated with surgery.[6] The major causes of anxiety among the candidates for CS are unfamiliarity with the environment,[7] fear over surgical failure, surgical complications,[8] and postoperative blindness.[8],[9] Moreover, patients in most ophthalmic surgeries are awake and conscious or semi-conscious, and hence, they may experience high levels of anxiety and stress.[8] A study reported that the mean score of anxiety among patients undergoing CS was 65–75 in the possible range of 20–80.[10] Anxiety and stress, in turn, can increase pain sensitivity, blood pressure, heart rate, and intraocular pressure[6] and negatively affect treatment outcomes and quality of life. Nonetheless, anxiety is often overlooked by health-care providers.[11]

As ophthalmic surgeries do not need general anesthesia and patients are often conscious or semi-conscious during surgery, effective anxiety management is of great importance and can significantly influence surgery outcomes. A potentially effective strategy for anxiety management among the candidates for surgical interventions is to involve them in the process of care which necessitates the provision of adequate support and education to them. Patient involvement is of greater importance in case of elective surgeries, in which decisions are made mostly collaboratively.[4] Active collaboration between patients and health-care providers improves care quality, facilitates recovery, and reduces health-care-related costs and patient mortality rate.[12]

Objective

The aim of this study was to evaluate the effects of an interdisciplinary supportive educational program on anxiety among patients undergoing CS.


  Methods Top


Design and participants

This quasi-experimental study was carried out in February–August 2019 using a two-group pretest–posttest design. The study population consisted of patients who were referred to Feiz Hospital, Isfahan, Iran, for undergoing CS. Isfahan is a big city in the center of Iran and Feiz Hospital is the main center of ophthalmology in Isfahan province. Candidates for CS were referred to this hospital 2 days before surgery to undergo routine outpatient preoperative examinations and laboratory tests. In the morning of the surgery day, they are admitted to the day clinic of the hospital, go to the surgery room, spend postoperative period in the day clinic, and are discharged from the hospital in the same afternoon if they are fully conscious, have no significant postoperative complications, and have stable hemodynamic status. For follow-up assessments, they were referred to the hospital 1 day, 1 week, and 2 weeks after the surgery. Participants were selected consecutively. Inclusion criteria were age over 18 years, being a candidate for CS for the first time, ability to read, write, and speak Persian, no participation in any other educational or supportive program during the study, no known history of mental disorders such as depression or anxiety, and no membership in health-care delivery teams. Exclusion criteria were irregular attendance at the intervention sessions and inability or reluctance to continue the study for any reason.

The formula in [Figure 1] was used for sample size calculation. Accordingly, with a confidence level of 0.95 (i.e., a Z1-α/2 of 1.96), a power of 0.90 (i.e., a Z1 of 1.28), a between-group mean difference (d) of 3, and a standard deviation of 2 and 4.5 in the intervention and the control groups,[13] 29 patients per group were determined to be needed. Considering a withdrawal rate of 10%, the final sample size was determined to be 32 patients per group. The 64 eligible CS candidates were selected from the list of patients referred to an ophthalmic surgeon (i.e., the third author). Before the sampling started a list of 64 supposed patients was prepared and then, the supposed patients were randomly numbered 1–64 and then, those with odd and even numbers were, respectively, assigned to either a control or an intervention group [Figure 2].
Figure 1: Sample size calculation formula

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Figure 2: The CONSORT flow diagram of the study

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Instruments

A demographic questionnaire and Spielberger State-Trait Anxiety Inventory (STAI) were used for data collection. The items of the demographic questionnaire were age, gender, education level, employment status, marital status, and income. STAI contains forty items in two twenty-item dimensions, namely state anxiety and trait anxiety. The items of the state anxiety dimension are related to feelings and anxiety at a specific point of time and are scored on a 4-point Likert scale as follows: 1: “Not at all;” 2: “Somewhat;” 3: “Moderately so;” and 4: “Very much so.” The items of the trait dimension are on general feelings and anxiety symptoms and are scored on a 4-point Likert scale as follows: 1: “Almost never;” 2: “Sometimes;” 3: “Often;” and 4: “Almost always.”[14] The possible total scores of these dimensions are 20–80 with higher scores showing a higher level of anxiety. The total score of the state anxiety dimension is interpreted as follows: scores 20–31: mild anxiety; scores 32–42: low-to-moderate anxiety; scores 43–53: moderate-to-severe anxiety; scores 54–64: relatively severe anxiety; scores 65–75: severe anxiety; and scores 76–80: very severe anxiety. The total score of the trait anxiety dimension is also interpreted as follows: scores 20–31: mild anxiety; scores 32–42: low-to-moderate anxiety; scores 43–52: moderate-to-severe anxiety; scores 53–62: relatively severe anxiety; scores 63–72: severe anxiety; and scores 73–80: very severe anxiety.[15] A former study in Iran confirmed the acceptable validity and reliability of this inventory.[16] In the present study, reliability assessment revealed that the Cronbach’s alpha values of the state and the trait anxiety dimensions of the inventory were 0.940 and 0.902, respectively. Participants’ anxiety was assessed at two time points, namely on the sampling day and after regaining full postoperative consciousness.

Intervention

The study intervention was an interdisciplinary educational supportive program implemented in 2 days before CS by an ophthalmic surgeon and a nurse. On the 1st day (i.e., 2 days before CS), a 45-min educational session was held for participants in the intervention group, in which the surgeon provided them with explanations about the surgical procedure for CS. Then, patients had the opportunity to ask their questions and express their concerns. After that, the nurse introduced the hospital, its operating room, and its day clinic environment for them on a hospital tour. After that, the nurse used a flip chart to provide them with 30-min explanations about preoperative and postoperative care, home care, and time schedule for postoperative visits. After that, the surgeon and the nurse encouraged them to ask their questions, express their concerns, and share their experiences. An educational pamphlet was also provided to them which included explanations about cataract, its causes, CS, preoperative and postoperative care, factors contributing to postoperative pain, and nonpharmacological methods for postoperative pain management such as distraction. Finally, the nurse informed them that she would contact each of them through telephone in the next day and made an appointment for the contact. On the second day (i.e., 1 day before CS), the nurse called participants at predetermined time points between 08:00 and 21:00 and reviewed the educational materials provided on the 1st day, soothed them, provided them with supportive counseling, asked them to read the pamphlet, and reminded them of the necessity of fasting before surgery. Moreover, their questions were answered and their concerns were addressed. On average, each telephone contact lasted 30 min.[17][Table 1] provides a summary of the study intervention.
Table 1: The study protocol

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Participants in the control group only received care services which were routinely provided to all CS candidates in the study setting and included patient education through an educational video shown on the day of CS. After the posttest assessment of anxiety, participants in this group were also provided with the educations and educational pamphlet which had been provided to their counterparts in the intervention group.

Ethical considerations

The Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran, approved the study (code: IR.MUI.MED.REC.1397.331). Information about the aim of the study was provided to participants and they were ensured that their data would remain confidential and they would be free to withdraw from the study at will. Verbal and written consents were also obtained from all participants. Study questionnaires were anonymized using numerical codes.

Data analysis

The SPSS program for Windows (v. 16.0, SPSS Inc., Chicago, IL, USA) was used for data analysis. The Kolmogorov–Smirnov test was conducted to test normality. The independent sample t-, the Mann–Whitney U-, and the Chi-square tests were used for between-group comparisons regarding participants’ demographic characteristics as well as the mean scores and the levels of state and trait anxiety. Moreover, the paired sample t-test was conducted for within-group comparisons regarding the mean scores of state and trait anxiety. The measures of descriptive statistics (namely absolute frequency, relative frequency, mean, and standard deviation) were used for data description. P < 0.05 was considered significant.


  Results Top


Participants’ age range was 26–82 years in the intervention group and 42–94 years in the control group. No statistically significant differences were found between the two groups regarding participants’ demographic characteristics except for their marital status [Table 2].
Table 2: Between-group comparisons regarding participants’ demographic characteristics

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The paired sample t-test showed that in the control group, there were no statistically significant differences between the pretest and the posttest mean scores of state anxiety (P = 0.48) and trait anxiety (P = 0.74). However, in the intervention group, the posttest mean scores of state and trait anxiety were significantly lower than their corresponding pretest values, respectively (P < 0.05).

The independent sample t-test showed no statistically significant differences between the groups regarding the pretest mean scores of state and trait anxiety (P > 0.05). However, the posttest mean scores of state and trait anxiety in the intervention group were significantly lower than the control group [P < 0.05; [Table 3]].
Table 3: Within-and between-group comparisons regarding the mean scores of state and trait anxiety

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The Mann–Whitney U-test showed no statistically significant between-group differences regarding the pretest levels of state and trait anxiety (P > 0.05). However, the posttest levels of state and trait anxiety in the intervention group were significantly less than the control group [P < 0.05; [Table 4]].
Table 4: Within- and between-group comparisons regarding the levels of state and trait anxiety

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  Discussion Top


The findings showed no significant between-group differences regarding the pretest mean scores and levels of state and trait anxiety, while the posttest means scores and levels of state and trait anxiety in the intervention group were significantly lower than the control group. Moreover, most participants in both groups had low-to-moderate anxiety at pretest, while most participants in the intervention group had mild anxiety at posttest.

Hospitalization, particularly for surgical procedures, is usually associated with stress.[18] Our findings showed that the interdisciplinary educational supportive program significantly reduced anxiety among patients undergoing CS. In line with these findings, several earlier studies reported the positive effects of supportive educational interventions on anxiety among different patient populations. For example, a study showed that preoperative education significantly reduced anxiety among patients undergoing CS.[18]

Another study showed that providing patients with face-to-face education about surgical procedures and relaxation techniques such as deep breathing significantly reduced anxiety among patients undergoing CS.[19] Similarly, a study found patient education effective in significantly reducing anxiety and distress among patients undergoing CS.[6] Besides reducing anxiety among patients,[18],[20] education and support can improve their experiences of CS[19] and enhance their satisfaction. Other studies also reported that preoperative anxiety among the candidates for CS can be managed using techniques such as music therapy,[7] multimedia-assisted informed consent procedure,[20] and video-based patient education.[21]

Alleviation of anxiety among candidates for surgeries also promotes their collaboration with surgeons during surgical procedures.[6] Patient care delivery is a complex process[22] and hence needs interprofessional collaboration.[23] Interprofessional collaboration among different health-care providers improves health-care providers’ satisfaction, workplace climate,[24] and patient outcomes.[12]

The strength of this study was the use of an interdisciplinary program for patient education and support. Meanwhile, the study had some limitations. For example, its sample size was rather small and postoperative anxiety was measured only at one time point. Future studies are recommended to assess the effects of interdisciplinary supportive educational programs on larger samples of patients and in longer follow-up assessment periods.


  Conclusion Top


This study concludes that interdisciplinary supportive educational intervention is effective in significantly reducing anxiety among patients undergoing CS. Therefore, as a simple, inexpensive, and effective intervention, interdisciplinary support and education through both face-to-face communication and telecommunication methods are recommended for improving patients’ knowledge about CS, managing their concerns, and reducing their stress and anxiety.

Acknowledgment

The authors wish to thank the Eye Research Center of Isfahan University of Medical Sciences, Isfahan, Iran, and to express their sincere gratitude to patients who participated in the study.

Financial support and sponsorship

This study was approved and financially supported by the Research and Technology Administration of Isfahan University of Medical Sciences, Isfahan, Iran (code: 297140).

Conflicts of interest

There are no conflicts of interest.



 
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Hashemi H, Rezvan F, Khabazkhoob M, Gilasi H, Etemad K, Mahdavi A, et al. Trend in cataract surgical rate in iran provinces. Iran J Public Health 2014;43:961-7.  Back to cited text no. 1
    
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