|Year : 2021 | Volume
| Issue : 4 | Page : 236-242
Application of Neuman’s Systems Model on Anxiety of Older Adults Waiting for Colonoscopy
, Zahra Fotokian1
, Mehri Jahanshahi1
, Sahar Risman Tabi2
1 Nursing Care Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2 Department of Gastroenterology and Hepatology, Mazandaran University of Medical Sciences, Sari, Iran
|Date of Submission||02-Sep-2020|
|Date of Decision||22-Dec-2020|
|Date of Acceptance||16-Jan-2021|
|Date of Web Publication||25-Nov-2021|
Nursing Care Research Center, Health Research Institue, Babol University of Medical Sciences, Babol.
Source of Support: None, Conflict of Interest: None
Background: Older adults waiting for colonoscopy are anxious due to the lack of knowledge about the procedure, its preparations, and aftercare. Objectives: The aim of this study was to evaluate the effect of the Neuman systems model (NSM) on anxiety of older adults waiting for colonoscopy. Methods: A pre- and postintervention study was conducted on 72 older adults who were waiting for colonoscopy. The participants were randomly allocated to either a control (n = 36) or an intervention group (n = 36). The intervention was performed in four steps, namely determining the potential and actual stressors, setting the goals, nursing interventions, and evaluation, according to the four-step nursing process in the NSM. A need assessment checklist based on the NSM and the Geriatric Anxiety Scale was completed before and after the intervention. Data analysis was performed using Fisher’s exact, independent, and paired t-tests. Results: At baseline, the mean score of total anxiety was 35.66 ± 7.58 in the intervention group and 35.29 ± 6.52 in the control group. After the intervention, these values changed to 26.71 ± 7.48 and 34.06 ± 7.23. Before the intervention, there was no statistically significant difference between the anxiety scores of the two groups in cognitive, affective, and somatic dimensions and total anxiety scores (P > 0.05). However, after the intervention, statistically significant differences were found between the two groups in the mean scores of the aforementioned components (P < 0.001). Conclusion: Implementing an educational program based on NSM reduced anxiety in older adults waiting for colonoscopy. Nurses should be trained about the NSM to be able to use similar programs in reducing the anxiety of patients waiting for colonoscopy.
Keywords: Aging, Anxiety, Betty Newman systemic model, Colonoscopy
|How to cite this article:|
Larijani F, Fotokian Z, Jahanshahi M, Tabi SR. Application of Neuman’s Systems Model on Anxiety of Older Adults Waiting for Colonoscopy. Nurs Midwifery Stud 2021;10:236-42
|How to cite this URL:|
Larijani F, Fotokian Z, Jahanshahi M, Tabi SR. Application of Neuman’s Systems Model on Anxiety of Older Adults Waiting for Colonoscopy. Nurs Midwifery Stud [serial online] 2021 [cited 2022 Jan 21];10:236-42. Available from: https://www.nmsjournal.com/text.asp?2021/10/4/236/331296
| Introduction|| |
The age of the population is increasing in developing countries. The world’s population over the age of 65 is projected to double in the next 40 years. About half of this population will live in Asian countries. With aging, the risk of developing chronic diseases such as gastrointestinal diseases and gastrointestinal cancers increases.,, Timely diagnosis through early screening techniques is the most effective way to reduce cancer mortality.
Gastrointestinal cancers are common in older adults.,, A study found that 47.5% of colorectal cancers occur among older adults. Another study reported that more than 90% of colorectal cancers are diagnosed after the age of 50. Therefore, it is recommended that all people over the age of 50 be screened for colorectal cancer.,,
Colonoscopy is the gold standard for the screening and diagnosis of colorectal cancers., However, this diagnostic procedure induces more side effects in older adults than in young people., Poor understanding and poor adherence to preparation instructions cause water and electrolyte imbalance, intestinal impurity, and failure to diagnose neoplastic lesions.
Fear and anxiety are common in older adults who are waiting for colonoscopy. Lack of knowledge and unfamiliarity with the technique and the procedure are common causes of this anxiety and can result in inadequate preparations. A recent study by Yekefallah et al. showed that candidates for endoscopic procedures suffer from moderate to very severe anxiety due to lack of knowledge about the procedure and uncertainty of the required preparations. Parker et al. have also reported that 21% of people on the waiting list for colonoscopy experienced moderate-to-severe anxiety which consequently resulted in painful, difficult, and incomplete procedures and increased the need for sedatives. Therefore, it is necessary for nurses to use appropriate methods for reducing anxiety in patients who are waiting for invasive procedures such as colonoscopy.
Anxiety is usually treated with anxiolytic drugs. However, these drugs are associated with several side effects, and the side effects might be more severe in older adults., Therefore, nurses are responsible to reduce the anxiety of their clients – especially older adults – through safe and preferably nonpharmacological interventions.,
The Neuman systems model (NSM) is a nursing theory based on the individual’s reaction to stress. According to the NMS, people are always threatened by stressors of extrapersonal, interpersonal, and intrapersonal origins. If the individual’s three defense lines (i.e. the flexible and normal lines of defense, and the lines of resistance) cannot properly respond to these stressors, stress, anxiety, energy depletion, system instability, and illness occur. The purpose of the nurse is to alleviate the stress and anxiety and retain the system’s stability through primary, secondary, or tertiary prevention interventions. Before the client system reacts to stressors and to prevent a stressor invasion, nursing actions – mainly healthy lifestyle education – should be implemented as primary prevention to promote wellness of the client system. The nurse implements secondary prevention actions whenever reactions occur to stressor and symptoms are present. Tertiary prevention interventions – such as education and rehabilitation – are nursing actions after a therapeutic modality to maintain and reestablish the client system stability.
A number of studies reported the beneficial effects of implementing the NSM in identifying the stressors and coping patterns and alleviation of stress and anxiety in patients with laryngeal cancer, prehypertension, and stroke. However, these studies are mostly descriptive, or case reports, and no experimental study is available in this area. Due to the widespread use of colonoscopy in older adults, and considering the nurses’ responsibility for prevention or alleviation of stress and anxiety in this vulnerable population, the question is whether the application of the NSM can reduce the level of anxiety in older adults awaiting colonoscopy?
This study aimed to evaluate the effect of the NSM on the anxiety of older adults waiting for colonoscopy.
| Methods|| |
Design, setting, and participants
The present study used a pre- and postintervention design. The study population included all older adults waiting for colonoscopy and referred to the endoscopy department of Imam Sajjad Hospital in Ramsar, Iran. Seventy-two older adults waiting for colonoscopy participated in the study between 2019 and 2020.
The sample size was estimated based on a pilot study on eight older adults waiting for colonoscopy in which their total anxiety score was decreased from 8.88 ± 1.8 to 7.94 ± 2.25 and using the following formula: N = (Z 1-α/2 + Z 1-β) 2 (δ12 + δ22)/(μ1-μ2) 2. Then, with a δ12 = 1.8, δ22 = 2.25, μ1 = 8.88, μ2 = 7.94 and considering a confidence level of 0.95, and a power of 0.8, the sample size for each group was estimated at 28. However, given the possible attrition, we recruited 36 ones per group.
Inclusion criteria were age between 60 and 74 years, fluency in the Persian language, receiving no anxiolytic and antipsychotic drugs in the last 6 months, no hearing and cognitive impairments, experiencing no severe stress such as losing a close relative in the last 3 months, no history of endoscopy or colonoscopy, and obtaining at least 50% of the total score of the NSM need assessment checklist. The participants were excluded if they did not cooperate at any stage of the study or did not refer for colonoscopy [Figure 1].
The list of older adults who were candidates for colonoscopy has regularly been obtained from the endoscopy unit. Then, the researcher made a call to the candidates, explained them the goals of the study, and invited them to participate in the study. If a candidate agreed to participate, she/he was invited to the hospital conference room to complete the study questionnaires. Then, their training needs were assessed using a checklist based on the NSM. Older adults who obtained at least 50% of the score of the need assessment were included in the study. Sampling continued until the sample size reached 72. The participants were randomly allocated to an intervention or a control group. To this end, a numerical list of 72 hypothetical participants was created, and odd and even numbers were respectively allocated to either the control or the intervention group. The sampling was completed in about 3 months.
Data collection instruments
Data collection instruments included a demographic questionnaire, Geriatric Anxiety Scale (GAS), and a need assessment checklist based on NSM. The demographic questionnaire included questions on the participants’ age, sex, marital status, employment status, place of residence, adequacy of income, insurance status, and other people who lived with them.
The GAS is a 25-item self-report scale designed for the screening of anxiety in older adults. Items are categorized into three subscales for assessing somatic (9 items), cognitive (8 items), and affective symptoms of anxiety (8 items). All items are scored on a 4-point scale as follows: 0: “Never,” 1: “Sometimes,” 2: “Often,” and 3: “Always.” The score ranges between 0 and 75. Higher scores indicate more anxiety. Participants are asked to rate each question according to how they felt last week. The reliability of the Persian version of this scale has been confirmed by Bolghan-Abadi et al. and the Cronbach’s alpha for of the total scale and its somatic, cognitive, and affective subscales was 0.92, 0.84, 0.81, and 0.80, respectively.
The need assessment checklist was developed through a literature review., The checklist consists of 33 items in five subscale, namely physiological (9 items), psychological (11 items), sociocultural (5 items), evolutionary (3 items), and spiritual (5 items) dimensions. All items are scored as 1: “Yes” or 0: “No.” Content validity of the need assessment checklist was confirmed by 10 nursing instructors at the nursing department of Babol University of Medical Sciences. For test–retest reliability assessment, 10 older adults waiting for colonoscopy completed the checklist twice with a 2-week interval (r = 0.78).
The intervention was performed in four steps namely determining the potential and actual stressors, setting the goals, nursing interventions, and evaluation, according to the four-step nursing process in the NSM.
In the first stage, participants in both the study groups completed the demographic questionnaire, GAS, and need assessment checklist a week before colonoscopy. In the second step, appropriate goals and nursing interventions were identified for each patient in the intervention group to strengthen their normal and flexible defense lines. Then, in the third stage, nursing interventions (training and counseling) were performed for the participants in the intervention group based on the specific needs of each client. Nursing interventions were performed in the form of teaching relaxation and distraction techniques, encouraging family members to talk to the older adults about their feelings, and providing necessary explanations about the patient’s fears, concerns, and questions. The educational session for each patient lasted for 30–50 min. During the week before colonoscopy, the researcher called each participant and if necessary, a telephone consultation was conducted. In addition, one or two additional training sessions were arranged for each patient as needed and the duration of these additional sessions varied from 15 to 30 min. In the final step (i.e. 7 days after the first session), the evaluation was done by measuring the anxiety through completing the GAS.
Participants in the control group were provided with routine colonoscopy preparation instructions (colon preparations, diet, medications, and transportation, through a face-to-face educational session and a pamphlet). All participants in the control group also completed the GAS at the end of the study (i.e. before the colonoscopy procedure). In both groups, all instruments were completed through face-to-face interviews conducted by the first researcher.
This study was approved by the Ethics Committee of Babol University of Medical Sciences, Babol, Iran (code: IR. MUBABOL.HRI.REC.1398.1261). Moreover, the study was registered in the Iranian Registry of Clinical Trials (code: IRCT20200211046461N1). Participants completed a written consent form, were assured of the data confidentiality, and could withdraw from the study at any stage.
Study data were analyzed using the SPSS software version 16.0 (SPSS Inc., Chicago, IL, USA). The normality of the data was tested using a Smirnov–Kolmogorov test. Between-group comparisons respecting categorical and numerical variables characteristics of the participants were made using the Fisher’s exact test and the independent-samples t-tests, respectively. Within- and between-group comparisons respecting the mean anxiety scores were made using the paired and the independent samples t-tests.
| Results|| |
Overall, 70 older adults waiting for colonoscopy completed the study. The mean age of the intervention and control groups was 64.06 ± 4.058 and 63.40 ± 4.14 years, respectively. Most of the participants were married. The education level of the participants was mostly high school diplomas and most of the participants in the two groups lived in rural areas. The results of Chi-square and Fisher’s exact tests showed no statistically significant difference between the groups respecting participants’ personal characteristics [P > 0.05, [Table 1]].
|Table 1: The frequency distribution of the participants’ characteristics|
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Six nursing diagnoses related to stressors induced by colonoscopy were determined, based on the need assessment checklist. Accordingly, imbalance of fluid and electrolytes, activity intolerance, fear, anxiety, lack of knowledge about colonoscopy procedure, sleep disturbance, and disturbance in social interactions were the most important nursing diagnoses in the present study. The most common nursing diagnoses were related to psychological, fear, and anxiety dimensions (78%) [Table 2].
|Table 2: Nursing process based on Betty Neuman system model for 70 elderly candidates for colonoscopy|
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At baseline, the mean score of total anxiety was 35.66 ± 7.58 in the intervention group and 35.29 ± 6.52 in the control group. After the intervention, these values changed to 26.71 ± 7.48 and 34.06 ± 7.23, respectively. The independent t-test showed that before the intervention, there was no statistically significant difference between the anxiety scores of the two groups in cognitive, affective, and somatic dimensions and total anxiety scores (P > 0.05). However, after the intervention, statistically significant differences were found between the two groups in the mean scores of the aforementioned components [P < 0.001, [Table 3]].
|Table 3: Comparison of mean dimensions of anxiety among the intervention and control groups’ participants|
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| Discussion|| |
The results showed that the implementation of the nursing process based on the NSM reduced cognitive, somatic, and affective symptoms of anxiety as well as the total anxiety scores. Our intervention included distraction and drawing attention toward the positive aspects of the examination. All of these interventions can reduce people’s anxiety. A former study also reported that the implementation of the nursing process based on the Betty Neuman model could reduce anxiety in men with laryngeal cancer. A systematic review also concluded that the implementation of NSM in the intensive care units has decreased the occurrence of delirium in patients and developed a relaxing environment. Other studies also reported that the implementation of the NSM was effective in reducing anxiety in patients with multiple sclerosis and before orthopedic surgery. All these findings confirm the beneficial effects of the implementation of NSM in reducing anxiety in all patients including older adults. Neuman considers patient education, counseling, and psychological support as the most important preventive measures that nurses can implement to reduce the impact of stressors on their clients. All these measures not only strengthen the patients’ flexible and normal defense lines but also can make the clients’ resistance lines stronger.
Based on the results, “fear and anxiety” and “lack of knowledge” were among the most common nursing diagnoses in older adults waiting for colonoscopy. The possibility of diagnosing dangerous diseases was one of the important sources of fear and anxiety in older adults awaiting colonoscopy. A study showed that fear of pain and the possibility of infection transmission through the endoscope cause anxiety before lower gastrointestinal endoscopy. Another study also reported that – due to the lack of time and lack of a coherent plan – health-care professionals often do not properly prepare the client and do not give sufficient information to them on how the examination is done. It seems that routine preparations for colonoscopy mainly focus on bowel preparations, and little information is given to the patients about the procedure. However, implementation of the nursing process based on the NSM and patient education about the procedure, the examination environment, colonoscopy device, and how it works increases the patients’ awareness of the examination and its goals, eases the acceptance of the diagnostic method, helps clients to cooperate, and reduces their anxiety and fear. Consistent with this conclusion, Hsueh et al. have reported that a multimedia guide to the colonoscopy procedure could effectively reduce the examination-related anxiety and pain of patients.
In the present study, the willingness to participate in the study was considered as an inclusion criterion. It is possible that older people who were willing to participate in the study had lower levels of anxiety, which can be considered as a limitation.
One of the strengths of the present study is that it examined anxiety of older adults using a coherent model and based on a need assessment tool. This fact shows the beneficial effects of the implementation of the nursing process based on NSM.
| Conclusion|| |
The results showed that the implementation of an educational program based on NSM reduced anxiety in older adults awaiting colonoscopy. It is recommended that nurses use similar programs based on NSM in clinical settings to reduce anxiety and improve the health of the older adults waiting for colonoscopy. The use of this model for identifying the patients’ stressors can improve the quality of nursing care, decrease the patients’ anxiety, and increase the patients’ cooperation during colonoscopy examinations. Then, the likelihood of complications and adverse effects would be decreased.
This article was derived from a master thesis of aging nursing with project number 724132331, Babol University of Medical Sciences, Babol, Iran. The authors would like to acknowledge the research deputy at Babol University of Medical Sciences for their support. We also are thankful to all patients who participated in this study.
Financial support and sponsorship
This study was supported by a research deputy at Babol University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Eliopoulos C. Gerontological Nursing. 8th ed. Philadelphia: Walters Kluwer Health. Lippincott Williams & Wilkins (Publisher); 2013.
Sargazi M, Salehi S, Sargazi V. Status sdscreening examinations of elderly people admitted to hospital in Zahedan. J Holist Nurs Midwifery 2014;24:20-6.
Dolatkhah R, Somi MH, Bonyadi MJ, Asvadi Kermani I, Farassati F, Dastgiri S. Colorectal cancer in Iran: Molecular epidemiology and screening strategies. J Cancer Epidemiol 2015;2015:643020.
Lin OS. Performing colonoscopy in elderly and very elderly patients: Risks, costs and benefits. World J Gastrointest Endosc 2014;6:220-6.
Hashimoto T, Osada T, Goto SP, Sakamoto N, Murakami T, et al
. Increasing use of colonoscopy over a decade has detected an increased prevalence of colorectal tumors on the elderly. J Gastrointest Dig Syst 2016;6:2-7.
Wolf AM, Fontham ET, Church TR, Flowers CR, Guerra CE, LaMonte SJ, et al
. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018;68:250-81.
Alizadeh A, Rostamnejhad M, Baladast M, Esfehani maraghe S, Shahnazi T, Safari N, et al
. Colonoscopy and biopsy values in determining the etiology of chronic diarrhea. J Ilam Univ Med Sci 2013;21:118-24.
Trevisani L, Zelante A, Sartori S. Colonoscopy, pain and fears: Is it an indissoluble trinomial? World J Gastrointest Endosc 2014;6:227-33.
Hsueh FC, Chen CM, Sun CA, Chou YC, Hsiao SM, Yang T. A study on the effects of a health education intervention on anxiety and pain during colonoscopy procedures. J Nurs Res 2016;24:181-9.
Day LW, Velayos F. Colorectal cancer screening and surveillance in the elderly: Updates and controversies. Gut Liver 2015;9:143-51.
Banihashem N, Alijanpour E, Basirat M, Shokri Shirvany J, Kashifard M, Taheri H, et al
. Sedation with etomidate-fentanyl versus propofol-fentanyl in colonoscopies: A prospective randomized study. Caspian J Intern Med 2015;6:15-9.
Yekefallah L, Ashktorab T, Ghorbani A, Pazokian M, Azimian J, Samimi R. Orlando’s nursing process application on anxiety levels of patients undergoing endoscopy examination. Int J Epidemiol Res 2017;4:53-60.
Parker J, Kennedy P. Factors predictive of distress in people awaiting a lower gastro-intestinal endoscopy. Psychol Health Med 2010;15:26-33.
De Oliveira PP, Amaral JG, Rodrigues AB, da Silva MR, Onofre PS. Nursing process to men with laryngeal cancer based on Neuman model. Enfermería Global 2017;16:188-207.
Hannoodee S, Dhamoon AS. Nursing neuman systems model. In: Stat Pearls. Treasure Island (FL): Stat Pearls Publishing; 2020. Available from https://www.ncbi.nlm.nih.gov/books/NBK560658/. [Last Accessed on 2020 Jul 25].
Lawson TG. Systems model. In: Alligood MR, editor. Nursing Theorists and Their Work. 9th ed. St. Louis: Elsevier; 2018.
Kabore T, Fongwa MN. Lazrd J. Predictable risk factors for pre-hypertension among adults using neuman systems model. MOJ Public Health 2018;7:288-95.
Sultan B. Application of betty neuman theory in care of stroke patient. Ann Nurs Pract 2018;5:1092.
Cha JM, Kozarek RA, La Selva D, Gluck M, Ross A, Chiorean M, et al
. Risks and benefits of colonoscopy in patients 90 years or older, compared with younger patients. Clin Gastroenterol Hepatol 2016;14:80-60.
Gould CE, Segal DL, Yochim BP, Pachana NA, Byrne GJ, Beaudreau SA. Measuring anxiety in late life: A psychometric examination of the geriatric anxiety inventory and geriatric anxiety scale. J Anxiety Disord 2014;28:804-11.
Bolghan-Abadi M, Segal DL, Coolidge FL, Gottschling J. Persian version of the Geriatric Anxiety Scale: Translation and preliminary psychometric properties among Iranian older adults. Aging Ment Health 2013;17:896-900.
Khatiban M, Oshvandi K, Borzou SR, Moayed MS. Outcomes of applying neuman system theory in intensive care units: A systematic review. Crit Care Nurs 2016;9:e8886.
Alligood MR. Nursing Theory: Utilization and Application. 5th ed. St. Louis: Elsevier Inc.; 2014.
Ahmadi Z, Sadeghi T. Application of the betty neuman systems model in the nursing care of patients/clients with multiple sclerosis. Mult Scler J Exp Transl Clin 2017;3:2055217317726798.
Nasiry Zarrin Ghabaee D, Bagheri-Nesami M, Abbaspour H. Application of neuman systems model in nurse anesthetists to reduce patients’ anxiety level: A randomized clinical trial. J Mazandaran Univ Med Sci 2015;25:122-31.
Sadat Hosseini A, Cheraghi M, Shali M, Javaheri F. Neuman theory application in solution of Iranian nursing education and care challenges. Iran J Syst Rev Med Sci 2020;1:1-14.
[Table 1], [Table 2], [Table 3]