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THEORETICALLITERATURE ON PREOPERATIVE ANXIETYPreoperativeanxiety is a challenging in preoperative care of patients awaiting elective surgeryand it is widely accepted as an expected response. Anxietycan be explained as a reaction to stress or fear and elicits the autonomicphysiological response that helps a person to fight or flight the danger(2). Studieshave shown that people react differently to anxiety-provoking situations andrelated this difference to trait anxiety that described as an establishedindividual difference in anxiety proneness and how stressful situations areperceived have described trait anxiety as a relatively permanent personalitycharacteristic that is not influenced by a stressful situation(17). This implies that surgery does not affect traitanxiety of the patient. However, state anxiety that has been described as anunpleasant emotional response while coping with threatening or dangeroussituations (18). State anxiety level varies depending on howthe situation is judged by an individual to be high or low threatening. Stateanxiety level is high in a dangerous situation and low in the safe or lessdangerous situation(17). Accordingto study done by Strongman the anxiety isdifferent from fear in sense that fear is caused by tangible object with knownexpected outcome and it can be escaped while anxiety happens when the danger isnot palpable and it cannot be avoided, the author continued showing thatanxiety is characterized by being unsure of the future and how to behave once aperson meets the danger(19).

It has been reported that the main purpose ofanxiety is to detect the danger or threat in a potentially harmful environment,so that a person reacts effectively to escape the danger(20). 2.2LEVELS OF PREOPERATIVE ANXIETY Levels of preoperative anxiety are categorized in either high orlow levels of preoperative anxiety, clinically significant or not clinicallysignificant. However, clinically significant preoperative anxiety and highpreoperative anxiety level are used interchangeably and not clinicalsignificant and low preoperative anxiety level is used interchangeably. Someauthors classify the levels of preoperative anxiety in no, mild, moderate orsevere preoperative anxiety(17). The categorization levels of preoperative anxiety depend on theused preoperative anxiety assessment tool based on its cut-off score. Thestudies using Hospital Anxiety and Depression Scale (HADS) consider the sumscore ?11 as high preoperative anxiety level and the sum score <11 as lowpreoperative anxiety level(9).

For studies that employ Stateversion of State Trait Anxiety Inventory (S-STAI) to assess preoperativeanxiety consider the sum score > 44 score as significant anxiety or highanxiety level and the sum score ?44 as low anxiety level or not significantanxiety(4, 21) and for the studies using thePre-operative Intrusive Thoughts Inventory (‘The PITI’ or ‘PITI-20’) consider the sum score ?15 as clinically significant preoperativeanxiety level and the sum score <15 as not clinically significantpreoperative anxiety level(22). 2.3. FACTORS ASSOCIATED WITH PREOPERATIVE ANXIETY Preoperative anxiety may be associated with many factors. Theseinclude demographic data, previous surgical experience, types of anaesthesiaand surgical procedures, medical diagnosis, and information about surgery(2, 21).The study conducted in Pakistan foundthat age is contributing factor predicting preoperative anxiety andpreoperative anxiety decreased with an increase in age (p< 0.001) found thatyoung patients are more anxious than old age patients (P<0.

01) and theyreported that, this happened because young people are less experienced and moreprone to anxiety and fear compared to old age people(17). Contrary to those studies found that the anxiety levels increasedwith the age, the old patients presented the higher level of anxiety than youngpatients (p < 0.001), this finding was in line with the results of studyconducted by Basaki that showed that patients who were aged more than 35 yearsold expressed more anxiety than young patients(6, 23). Marital status has been identified by some of the researchers asthe factor affecting preoperative anxiety. The study conducted by Fathi found that widowed or divorcedfemale experienced more anxiety while single and married patients experiencedlower preoperative anxiety levels. This study also showed that high educationlevels and income rate and better social support were significantly correlatedwith lower preoperative anxiety(6, 23). In other hand previous surgery affects the anxiety of the patientsas demonstrated by many studies reported that patients who had at least oneprior surgery presented a low level of anxiety(8, 21).

This may be explained by having ahistory of surgery makes the patient more aware of the surgical process (anaesthesia,intraoperative and postoperative pain control and probable outcomes of surgery)that prevent patient to develop more fear of unknown or rely on a misconceptionabout anaesthesia and surgery. In contrary to those findings, the study fromJUSH found that having previous surgical operation or anaesthesia did notinfluence significantly preoperative anxiety, this was explained as due to lackof understanding on explanation or lack of information on that previousexperience of surgery or anaesthesia and they concluded that nature and qualityof previous surgery is more important factor influencing the anxiety than justhaving previous surgery(4, 24). The study conducted by Shoaei, Matthias and Samarasekera  found that waiting for theoperation was ranked the first anxiety causing factor for preoperative anxiety (Shoaei et al. (2016, p. 707) Matthias and Samarasekera (2011 , p. 5).

Furthermore some studies reported that types of anaesthetictechnique are associated factors with preoperative anxiety. This was supportedby study conducted by Bosc et al. (2015) in patients undergoing oculoplastic and strabismus surgery foundthat patients undergone surgery under general anaesthesia had higher anxietylevels than patients undergone surgery under local anaesthesia (P=0.

002) . Inaddition some other studies reported that patients under general anesthesia aremore anxious than patients under local anesthesia (Jawaid et al. 2007, p. 147; Mitchell 2013, p. 41;Maheshwari and Ismail 2015, p. 197).

 Provision of informationwas reported to be associated with low preoperative anxiety. This is supportedLee et al. (2016, p. 698) who found that surgeon’s explanation of thesurgery performed reduce preoperative anxiety 72.

3 %, Aust et al. (2016,p. 4) reported 15 that 63.7% of the patients believed that information wouldaid them to cope with their anxiety. In addition, Kalogianni et al. (2016,p. 447) found that anxiety and postoperative complications were reduced inpatients undergoing cardiac surgery due to preoperative education delivered bynurses and Maheshwari and Ismail (2015, p. 197)found that patients gaining information from anaesthetistswere less anxious than patients receiving information other than anaesthetist.

Moreover, Ebirim and Tobin (2010, p. 3) reported that postponement was the mostcommon reason for anxiety and reported postponement among the factorsassociated with anxiety(8).2.2THE COPING MECHANISM OF THE PATIENT FOR PREOPERATIVE ANXIETYThestudy done by Duangpaeng and Hengudomsub afterdetecting the presence of the preoperative anxiety, the nursing care plan aimedto prevent, manage and reducing should be developed(25).Aperioperative nurse has a responsibility to monitor patients’ anxiety, identifywhat causes their anxiety, and then determining possible solutions topreventing or decreasing it and helping them prepare for the surgery.

Perioperative nurses can use non-pharmacological and pharmacological interventionsto reduce anxiety(26).In a study conducted by Maghsoodi found thatthe establishment of therapeutic communication sessions with patients iseffective in reducing the severity of their anxiety(27).The authors also showed that the communication and therapeutic relationshipwith the patient in the more purposeful manner can speed up the recoveryprocess.

It is during communication, a patient and a nurse interact and apatient expresses his/her feeling and nurse help a patient to cope with thestressful situation. A nurse a therapeutic atmosphere which increases thelikelihood of a more positive surgical experience is established(26). Ina study conducted by Kushnir, Friedman, andEhrenfeld coping with preoperative anxiety in caesarean section, theyfound that listening to favourite music immediately before a caesarean sectionis effective for reducing anxiety. The findings showed that the women listenedto their favourite music before caesarean section reported an increase inpositive emotion and decrease in negative emotion and perceived the situationless threatening compared to women who did not listen to the music(28).Similarly to the study done by Johnson, Raymond andGoss in their study perioperative music or headsets to decrease anxietyfound that music is a inexpensive, easy to administer and satisfier of mostpeople intervention to decrease anxiety(29), Wakim, Smith and Guinn (2010, p. 231). In study by Guo,East and Arthur found that preoperative education is effective inreducing the levels of anxiety  and foundthat an empathic patient-centered approach significantly reduces the anxiety,improves surgical recovery and wound healing and raises the satisfaction of thepatient with the quality of the information provided(30, 31).

In this approach the patient is encouraged to express his or her feelings andpsychological support and tailored information are provided to the patient andthe patient’s questions are addressed in a calm, supportive and confidentmanner within an atmosphere of privacy, care, concern, with a nonjudgmental andrespectful attitude. Support from family, friends, and health care providersand anxiolytic or antidepressant medications can help with relieving severeanxiety but the medications are associated with risks of potential side effects,dependence and withdrawal(30).2.3 THE IMPACT OF PREOPERATIVE ANXIETYMany researches indicate that preoperative anxiety affects negativelyevery step of the perioperative process. The study conducted by Kim showed that for the patientsaged 45 or older had high preoperative anxiety levels and their anxiety scorescorrelatedsignificantly with the changes in pulses rate (P = 0.047 by Pearson correlation), in addition preoperativeanxiety scores predicted a 20 % or more change in blood pressure ((AUC = 0.

729,P = 0.024) and in heart rate (AUC=0.767, P=0.049)(32). In other the study found that patients with higher preoperativeanxiety required a greater amount of propofol to reach light sedation (r2=0.053P=0.021) and moderate sedation (r2=0.

127 P=0.010) postoperativelythe analgesic requirement increases the wound healing delays, health care costrises, and the hospital stay is prolonged(33). This was supported by studyconducted by Ali, Altun and Hakan which found that preoperative anxiety scores significantlycorrelate with the duration of hospitalization (r = 0.370, p = 0.001) andpatients with a high anxiety had longer extubation time than patients with lowanxiety (P=0.03), in addition, the patients with high anxiety had moreagitation (p=0.029) and shivering (P=0.

044) as side effects of anaestheticagents than patients with low anxiety(17). In a study conducted onpatients undergone total knee arthroplasty found that patients with highpreoperative anxiety or depression had more than 6 times high risk to bedissatisfied than patients without anxiety or depression and patients withpost-operative deep infection had 3 times risk to be dissatisfied, thosedissatisfied patients had 1 day more of hospital stay than satisfied patients andPreoperative anxiety is associated with the risk of infection and with postoperativenausea and vomiting(3, 8, 34).2.4. RESEARCH GAP IDENTIFICATION In Ethiopia on preoperativeanxiety only two studies was conducted in two teaching hospital JimmaUniversity Specialized Teaching hospital and Gondar University Specializedcompressive hospital. Those research showed that preoperative anxiety affectsnegatively every steps of surgical process and find out preoperative anxietyprevalence and factors affecting preoperative anxiety, however the, levels ofanxiety, coping mechanism of patients, impact of preoperative anxiety and setup of hospital environment were not addressed(4, 5). Many literatures agreed on theimportance of preoperative assessment before surgery in order to maximize thesurgical outcome and minimize the negative effect of anxiety to the surgery. In Ethiopia hospitals are improving perioperative nursingspecialties in particularly improving with the aim of maximizing the patientsurgical outcome by teaching speciality nurses in different college bydifferent level of education (Ethiopia hospitalguide line).

The St. Luke’s Catholic hospital andCollege of nurses is a referral hospital that cares for the patients comingfrom different districts and it is considered as a public hospital that providea high quality of care. Therefore this current study will be aimed to assesspreoperative anxiety level and the associated factors for patients awaitingsurgery at SLCHCN, Woliso, Ethiopia.

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