Pre-operative nursing education and patient anxiety in cardiac surgery

Nurse Training in Cardiac Procedures

The effects of pre-operative nursing teaching on the stress/anxiety level of patients who will undergo heart surgeries and percutaneous interventions

Patients undergoing any heart-related procedure could expect to experience a certain amount of stress. Stresses go beyond the physical stresses associated with the procedure. Emotional responses before, during, and after the procedure have an impact on the ability of the patient to cope. Additional stress has an effect on the ability of the patient to recover and their willingness to make life changes to accommodate their condition. Stress has a negative impact on the lives of patients and families of patients who have undergone invasive heart-related interventions. This research will examine the effectiveness of nurse training on reducing the stress level of the patient post operative.

Research Problem

Background of the Problem

Stress has a negative impact on the body's ability to heal itself and on the recovery period from traumatic events such as surgery. Until recently, attention from the medical community has focused on the physical stress of the surgical procedure itself. However, the medical community is not beginning to attend to the emotional state of the patient, before and after the procedure. The impact of stress can haven an impact on how the events effect them for the rest of their lives. This research will examine ways to reduce anxiety in patients that must undergo invasive heart-related procedures.

Significance of the Problem

This study is important, as it will provide insight into an important aspect of the healing process and quality of life for the patient. Patients that are more knowledgeable about their disease and the effects of the surgery are more likely to take actions that result in long-term changes in lifestyle. Patients that are knowledgeable about their disease and about health related issues in general will be able to play a more active role in the recovery process.

This study will help to determine the role that patient education plays in the anxiety level of the patient prior to discharge. Reducing stress prior to discharge is expected to have a positive impact on the life of the patient and their caregivers once they arrive home. They will have a greater feeling of control over their circumstances and will be able to better assist in the recovery process than those that are not thoroughly trained in the management of their particular condition. This study will play a significant role in helping patients and families to adjust to the changes that will take place once they are discharged from the hospital. The goal of this research is to lower anxiety regarding their disease and the procedure that they have undergone in a permanent manner.

Theoretical Basis of the Study

The study is based on past evidence that indicates stress has a negative impact on the outcome of several medical procedures. Stress not only effects the emotional state of patients, stress produces chemical reactions in the body that are detrimental to health. Reducing stress before, during, and after a traumatic procedure has positive medical benefits and can dramatically improve a patient's quality of life. Heart surgery is a stressful prospect for most patients that must undergo procedures. This study will focus on finding a way to reduce stress in patients that must undergo a heart procedure.

This study will examine patients that are scheduled for one of several heart-related procedures. Any of these procedures could reasonably be expected to produce a certain level of stress for patients. Patients in this study will be scheduled to undergo CABG, valve surgeries, hear transplant, or have percutaneous interventions such as PTCA, stent placement, or AICD/pacemaker placement.

Education is one of the keys to reducing stress in situations that are unfamiliar. The premise of this study is that pre-operative teachings by the nursing staff will play a significant role in reducing stress in patients undergoing the above procedures. These teachings will be designed to give the patient knowledge regarding the disease process, the risks and benefits or specific surgeries, what to expect before the procedure, what to expect during the procedure, and what to expect after the surgery. It will address cardiac rehabilitation, discharge planning and what will happen in follow up visits.

Experimental Overview

The study will examine a group of patients that are scheduled to undergo any of the procedures previously mentioned. The patients will be divided into two groups. One group will be given a training course during their pre-operative hospital stay by one of the nursing staff. The training program will be designed to address the specific needs of the procedure that the patient will undergo.

The test group will receive the training, while the control group will receive no pre-operative training. After the patients undergo their procedure and spend the required time in the hospital, they will be administered the State-Trait Anxiety Inventory for Adults as part of their pre-discharge routine. This survey instrument is a standard instrument that is useful in addressing stress related to traumatic events such as medical procedures. There is a considerable amount of information available about this survey instrument and its reliability traits. It is expected that there will be significant differences between the control and test groups. The test group is expected to demonstrate reduced anxiety, as opposed to the control group.

Hypotheses/Research Questions

The purpose of this study is to examine the impact of nurse training on the anxiety level of patients following an invasive heart related procedure. The procedures will be considered in aggregate, rather than addressing a separate hypothesis regarding every different type of procedure. The anxiety produced by each procedure is difficult to differentiate and there are a number of external factors that could influence the perceived stress level of the patient. It is expected that the impending procedure will have an equal chance of producing stress in each of the patients and that the type of procedure will not be a variable in the study. All of the procedures will be assumed to have a similar chance of producing perceived stress in the patient.

The research will examine the following hypotheses.

H1: Patients that receive specific training regarding their particular condition and procedure prior to the procedure will have significantly lower anxiety scores prior to discharge from the hospital than those that did not receive the training prior to having the procedure performed.

H0: Patients that receive specific training regarding their particular condition and procedure prior to the procedure will not have significantly lower anxiety scores prior to discharge from the hospital than those that did not receive the training prior to having the procedure performed.

This research will address a single research hypothesis, but it will involve many facets of the research topic. Therefore, in addition to the hypothesis, the research will address the following research questions.

How does nurse training prior to the procedure affect a patient's anxiety level prior to the procedure?

What impact, if any, does nurse training prior to the procedure have on the patient's anxiety level during the procedure?

What impact, if any, does nurse training prior to the procedure have on the patient's anxiety level after the procedure?

How does nurse training prior to the procedure affect the patient's perceived quality of life?

What impact does nurse training prior to the procedure have on the patient's ability to cope with necessary changes in their life as a result of the procedure?

What impact does nurse training prior to the procedure have on the patient's willingness to adhere to necessary changes in their life as a result of the procedure?

What impact does nurse training prior to the procedure have on the patient's overall feelings of satisfaction with the outcome of the procedure?

Conclusion

This research will examine a side of surgical heart procedures that has only recently begun to be addressed by academic literature. The mind-body connection has only recently begun to achieve an importance that resembles that which is attributed to physiological responses to traumatic procedures. There are many aspects to heart surgery that have an impact on the outcome of the procedure from a physiological standpoint. However, the life of the patient and their loved ones does not end when the physiological illness has passed. The disease itself and the procedure to remedy it have a lasting emotional impact on the patient and those that are close to them.

After the procedure, the patient must adjust to many new ideas and changes. They may have an electronic device or other implant. This not only has an impact on their physical well-being, but has a significant emotional impact as well. They may not feel as if they are "whole" anymore. If the procedure means limiting certain activities to which they were accustomed, this may mean further adjustments and a sense of "grieving" for things that are no longer a part of their life.

Quality of life goes beyond the physical act of living and being able to care for one's physical needs. A patient's emotional well-being may have more to do with how they define their quality of life than physical limitations imposed by the procedure. The procedure itself and the hospital stay associated with it is only one small chapter in the patient's life. They will eventually go home and will have many years after the procedure. It is important for the nursing staff to make a positive impact on how they feel about the procedure. The procedure will represent a lasting memory to the patient. If the patient perceives this to be a time of strength and care from nurturing individuals then it will help them to be able to develop the coping mechanisms necessary to learn to live with the after-effects of the procedure.

If the patient sees this as a negative experience, then it could produce unwanted effects such as depression, post-traumatic stress disorder, or other emotional problems that could have an effect on their ability to cope with the life changes. Those that develop appropriate coping mechanisms will be more likely to have a successful recovery than those that have a negative experience. Fear is often the result of the unknown. We fear what we do not understand or hoave not experienced. The goal of this research is to develop a program that will provide the patient with a greater understanding of their disease and the procedure that they will undergo. It is hoped that this will relieve some anxiety on their part and that this will result in a more positive outlook on the procedure. This research will help the patient to develop effective coping strategies in dealing with their disease and the invasive procedure.

Chapter 2: Literature Review

Research into how the emotional state of the patient and personality traits effect stress an the willingness to adhere to advice after discharge has only begun to appear in mass over the past two years. This research is built on concepts borrowed from other disciplines of psychology that relate to the influence of one's emotional state on their physiological ability to heal and cope with trauma. This represents a paradigm shift in the field from focusing primarily on the physical body to recognizing the role that a person's emotional state plays on their general health.

Currently, literature has been produced by an only a handful of researchers. However, they are beginning to develop the groundwork for clinical application of their theories. This new branch of mental health research will become more specific as the theories are developed. The current state of research in this new field is largely theoretical at this time, with a few instruments under development that may become useful in the future. This research study will take the current body of research one step further and will attempt to apply it in the patient setting.

In areas of research that are better developed, one often finds large groups of literature that address a certain facet of the topic. However, in areas that are just beginning to be recognized as a separate entity, such as this one, it is sometimes more necessary to provide more explanation as to how the new theories apply to the field than in a traditional literature review. This literature review will not only examine the literature in composite, but will provide a detailed discussion of how the research applies to this developing union between mental health and physiological health.

There are several factors that are borrowed from other areas of psychology that are useful in determining the likelihood that a patient will have a positive emotional outcome after the procedure. Early research indicates that identification of certain personality traits and attitudes might predispose certain patients to be at-risk for developing psychological disorders after a traumatic procedure. If clinicians can identify these risk factors, they may be able to take precautions to help the patient adjust to life after surgery. This concept forms the theoretical basis for this research study.

The purpose of nurse training is two fold. It is to inform the patient about the physical sensations, risks, and other factors that will effect them before, during, and after surgery. However, the goal is to reduce the amount of stress associated with the procedure and their disease. Several areas of literature will be useful in the development of the training program, patient assessment, and measurement of the training program. Many of these are borrowed from psychology and applied to the specific population addressed in this study. Literature into factors that influence the emotional states of patients and their relationships to achieving treatment objectives can be divided into several subtopics. The following will address the major categories of literature that exist within this newly emerging discipline.

Factors that Influence the Ability to Maintain Physical Activity

Goal intentions and implementation intentions play an important role in the exercise that rehabilitation patients performed independently (Ziegelmann et al., 2006). This study found that goal intentions were not predictive in whether the patient would follow the prescribe regime of exercise. However, implementation intentions were found to be associated with exercise 12 months after the rehabilitation program was complete. Implementation intentions, rather than goal intentions predicted behavior. Planning was found to be a significant factor in implementation intentions (Sniehotta, Scholz, & Schwarzer, 2006). This study provides an important factor in the recovery process and is easily extrapolated to the sample population of the current study.

Heart patients must make many changes in their lives in order to improve their health and maintain the benefits of the surgery. The study by Ziegelman and associates demonstrates that although the patient has goals, this alone does not predict whether they will be able to elicit permanent changes in their exercise level after discharge. This is an area where nurse training of patients could prove to be an important factor in creating permanent change in the patient that will lead to long-term exercise regimes. It is important for the patient to have a goal, but we now know that the plan and intention to stick with the plan are a key factor in the ability to cope with changes.

Intention is one of the most important predictors of behavior (Sniehotta, et al., 2006). In heart patients, it is important that patients develop a sense of proper intentions regarding their willingness to stick to necessary exercise and diet recommendations. This is perhaps the most important area where the nurse training program will be beneficial to patients. Training will enhance the need to stick to the routine in order to prevent the need for future surgery.

Ziegelmann, Lippke, and Schwarzer, (2006a) explored socio-cognitive predictors of physical exercise in patients released from rehabilitation. This study measured the effect of perceived remaining life expectancy and the willingness to exercise. The study examined those who felt their lifetime was expansive, versus those who felt their lifetime was limited. Individuals who felt their lifetime was limited were less likely to achieve their exercise goals than those who felt that they had many years remaining.

How a person perceives their life expectancy has a significant impact on self-regulation of activities that will help to improve the quality of their life (Ziegelmann, Lippke, and Schwarzer, 2006a). If is expected that the educational process developed as a part of this research will have a positive impact on the patient's perception of their life expectancy. The most important factor in this equation is that education could make the patient realize that exercise and adherence to suggestions could help to improve their life expectancy. This factor will be an important element in the educational training program of the nurses.

Age is a factor in the type of intervention that will be most likely to result in prolonged maintenance of exercise programs after physical therapy (Ziegelmann, Lippke, and Schwarzer, 2006b). According to this study, middle aged and older patients benefited from a program where the interviewer assisted in planning. Whereas younger persons benefited from a plan that they developed independently. This study demonstrates that age will have to be considered in the type of training that the patient receives. Certain training styles may be more beneficial than others to certain age groups.

In some patients critical life events, such as cancer surgery were beneficial in improving the patient's sense of well-bring (Schwarzer et al., 2006). This study demonstrates the connection between mental state and one's overall health. The most marked improvement in attitude was in those that started out with a relatively low sense of well-being, as opposed to those that had a relatively high level before their surgery. Self-efficacy and social support also predicted benefit finding in patients who had undergone cancer surgery (Luszczynska, Mohamed, and Schwarzer, 2005). Benefit finding can be distinguished by personal growth, acceptance of life's imperfections, sensitivity to others, and improved family relationships.

Support Systems

Support is a critical factor in the success of heart patients in coping with their illness after discharge (Schulz & Schwarzer, 2004). Gender and age differences, as well as associations with mental health were considered in an assessment of support systems available. Support can be divided into four types, advice giving, assistance, reassurance, and empathic listening (Schwarzer & Gutierrez-Dona, 2005). Support came from four primary sources, friends, family, spouses and groups/organizations (Schwarzer & Gutierrez-Dona, 2005). It is not only the quantity of support that is important, but the quality of support as well. The personality qualities of partners played an important role in the coping ability of heart patients (Schroder & Schwarzer, 2001).

Older women received less suppoft from their spouses than did younger women (Schwarzer & Gutierrez-Dona, 2005). The association between spousal support and depression was significant for men, but not for women in the study (Schwarzer & Gutierrez-Dona, 2005). Understanding the types and sources of support available will be an important factor to determine in the training session. Helping the patient find the support that they need will play an important role in their ability to cope with stressful heart interventions.

Training and Coping Skills

The theoretical basis for the training system stems from related concepts from the field of psychology. Heart surgery patients who are trained in coping skills have lower blood pressure (National University of Singapore, 2005). Depression, anger and a lack of social support have been found to predict increased mortality in patients with heart disease (National University of Singapore, 2005). Patients with adequate coping skills demonstrated reduced psychosocial risk factors (National University of Singapore, 2005).

In a medical study conducted by the national Heart Centre in Singapore developed a program designed to help patients undergoing heart-surgery. The purpose of the study was to find a way to help them lower blood pressure and stress, thus decreasing their risk for high blood pressure. The program was called Lifeskills Workshop and focused on teaching patients appropriate coping skills. The program has demonstrated the ability to lower blood pressure and help patients deal with the stress associated with their surgery.

Heart-surgery patients and their spouses demonstrate information seeking when they have a feeling of self-sufficiency (Tuominen, 2004). Those patients that sought information about their illness demonstrated lower levels of stress than those who did not seek knowledge regarding their condition. This research supports the currently proposed research. However, the proposed research will expand on this study and will use a standardized teaching curriculum.

Theoretical / conceptual framework

The theoretical framework for this study stems from several relevant psychological concepts. The purpose of nurse training proposed in this study is to reduce anxiety levels in patient undergoing any number of invasive heart procedures. Several studies have been found that directly support the idea that information seeking in patients decreased their stress levels.

Support is an important factor in the ability to cope with the stresses associated with heart surgery. The nurse is an important part of the support team.

Stress has a negative impact on the healing process. We found that self-efficacy and an internal locus of control were important factors in the willingness to make life changes after surgery. The nurse training program is expected to reduce stress in patients. This will have a positive effect on their ability to cope with the changes that they must make after surgery.

The literature review revealed that there are several factors that could influence the willingness of the person to adhere to advice regarding exercise and diet. Research into this area is relatively new and many researchers are just beginning to develop definitions and conceptual framework to describe the mind-body connection as it applies to clinical practice. People that have undergone heart surgery or another traumatic procedure are divided into those that intend to follow the regimen and those that do not intend to follow the prescribed regimen. Education was found to be a factor in turning non-intenders into intenders.

Education plays an important role in many factors regarding the willingness to stick with changes in diet and exercise after heart surgery. Those that do not stick with the prescribed changes significantly decrease their chances of the disease continuing to progress, thus shortening their life span. Education plays an important role in informing patients about the risks of non-compliance with the post surgical recommendations.

There were several personality traits that could help to predict whether a patient would stick to the prescribed regime of exercise and diet or whether they would refuse to change. Those who felt a high degree of self-efficacy and internal locus of control were more likely to stick to changes in exercise levels and diet than those who did not feel that they has as much control. Education may help to change a person's mind about how much they can control in their own disease progress.

Education is a key factor in the success of patients in adjusting to the new routines that are necessary after heart surgery. Nurse training of patients has a sound basis, both in academic research and in the medical community. The role of education in reducing stress among patients that have undergone traumatic surgical procedures has its basis in academic research. The benefits of reducing stress and informing patients of actions that they can take to help improve the outcome of their condition are also strongly rooted in academic studies. This research has a sound theoretical basis.

This research will take the information gained in the research examined as part of the literature review and will use it in the development of a nurse training program for each of the procedures that will be used to define the sample population. The study will operationalize the information gained from the theoretical work accomplished thus far., it will put the theories that are being developed into practice. This research will expand on the existing research and help to fill in the gap represented in the literature in how to operationalize the information.

This study will integrate several related fields of study in order to develop a training program that will help to integrate this knowledge base into a technique that will help to reduce the immediate and long-term stress of heart-surgery patients. This program will attempt to change their attitudes towards the necessity to stick to prescribed diet and exercise plans. It will inform them of the risks and give them support in attaining positive goals post operatively. The training program that will be developed as a part of this research will serve as the basis for expanding other programs to help patients achieve their surgical goals.

Chapter 3: Methodology

Overview

This research focuses on the effectiveness of a nurse training program designed to reduce the stress level of patients undergoing heart surgery. The study will use a quantitative study method that uses two study groups. One will receive nurse administered training prior to their procedure. The other group will not. Prior to their discharge from the hospital, the two groups will given a survey that assesses the stress level associated with the procedure and the changes in their life after the procedure. The differences in stress level will be assessed using the State-Trait Anxiety Inventory for Adults (STAI), an instrument that has been used in the past and for which the reliability and validity are well-documented.

The research method chosen for this study was a survey designed to quantitatively compare two groups of heart surgery patients. In this case, the groups of patients that will not receive nurse training will serve as the control group. The independent variable in this study will be stress associated with the procedure or treatment that they will receive. The most important factor in the procedure is not the procedure itself, but the stress associated with it. There are many factors that could effect the stress level of patients undergoing these types of procedures. Therefore, the individual procedures will not be treated as separate, but will be analyzed in aggregate. The type of procedure will be noted, and cross tabular analysis will be performed to check for bias between the various procedures. However, it is suspected that all of the procedures will display similar characteristics as far as stress is concerned.

The dependent variable will be the nursing training that the test group receives prior to performance of the procedure. One group will receive the treatment and will serve as the test group. The group that does not receive treatment will serve as the control group. Effectiveness of the treatment procedure will be determined by the difference between the control and test groups.

If the nurse training is successful, the test group will demonstrate lower stress levels on the SAIT than the control group.

Sample Population

The sample population for this study will consist of patients that are scheduled for one or more of the following procedures at an area hospital: CABG, valve surgeries, heart transplant, PTCA, stent placement, AICD/pacemaker placement. The patients will be between 40-70 years old and will be either male or female. They will not be selected for socioeconomic status, race, or for other demographic criteria. However, this information will be gathered so that inter-group analyses can be performed in order to determine if there are differences between groups that may account for differences found in the course of the experiment. They will be eligible for in-patient procedures requiring at least a 48-hour hospital stay at the minimum. The sample population will consist of a total of 50 patients scheduled to undergo a listed procedure. Fifty patients will serve as the control group and fifty patients will serve as the test group.

Only patients who have never undergone these procedures in the past will be selected to take place in the study. Familiarity with the procedure can help to reduce anxiety, therefore patients who have experienced the procedure would be expected to have a lower stress level than those for whom this is a new experience. Using patients that have been through the experience one or more times in the past could add a source of bias to the sample population that could effect the ability to draw valid conclusions.

The sampling method can have a dramatic effect on the accuracy of the findings. Sample participants will be randomly selected and assigned to either the test or control group using random methods. The research will only select for those patients that meet the inclusion criteria. However, after the population of eligible sample participants has been identified, the participants finally chosen to participate in the study will be randomly chose. Assignment to either test or control group will be random as well. The test and control groups will be of equal size in this case.

The sample selection techniques will be what is known as probability-based sampling (Simpser, et al., 2005). Using this sampling technique, participants are pre-screened to make certain that they meet a number of eligibility requirements. This differs from non-probabiliy, or convenience samples, in that the researcher creates a pool of eligible participants, as opposed to a sampling technique where the researcher has no control over the sample population. In this study, the researcher already knows some of the characteristics of the sample population. In this case, the patients are going to undergo a surgical procedure on their heart in a hospital setting.

The sample population will have a varied knowledge level regarding the procedure that they will undergo. Some may have obtained information prior to admittance into the hospital. The sources of this information may be from friends, doctors, or the internet. The level of information that patients have prior to the procedure could effect the results of the test. However, it is also recognized that some of the information that patients receive from other sources may add to the anxiety of the patient, as they do not have thorough understanding from a person to whom they can direct questions. Some sources of information may be incorrect or incomplete, which could effect the anxiety of the patient. There is also a chance that the information that patients received prior to the procedure reduces anxiety by giving the patient a false sense of security.

There is no way to control for the prior level of knowledge of the patient. Therefore, this issue will have to be addressed as a part of the study design. In order to control for the effects of prior knowledge, all patients will be treated as if they have no prior knowledge. They will be provided correct and complete information from the nursing staff. This will help to correct for missing or incorrect knowledge obtained from other sources. The nurse will be able to address any concerns from prior knowledge and make certain that the patient has correct knowledge regarding the procedure. This will reduce the effects of prior knowledge so that the sample population has the same level of knowledge regarding their procedure.

Study Procedure

This study will take place over a period of time sufficient for all of the patients to have their procedures and arrive at the day of hospital discharge. As a part of the final research, a nurse training program will be designed for each of the procedures considered in the sample population. Each of the programs will contain the same elements. However, the information within those elements will be specific to that particular disease or procedure. The training programs will contain the following information and sections: explaining the disease process, risk/benefits of specific surgeries, what to expect before, during & after surgery, cardiac rehab, discharge planning & follow up. The training program is designed to provide the patient with complete and accurate information about their particular condition.

After an adequate sample population is identified from patients scheduled for one of the listed procedures, and the population is divided into the test and control groups, the nursing staff will receive training as to how to administer the nursing training. They will be provided with a manual and training procedure that gives them step-by-step instructions, scripts to follow, and visuals to help in the training process.

When one of the patients in the test sample population is admitted to the hospital for the procedure, a nurse trained to administer the teaching material will administer the program to them as part of the pre-operative process. It will take place on the night before the procedure, prior to any narcotic medications being administered. The control group will be noted, but will not receive the training. Both groups of patients will then go through the normal preparation and process of their particular procedure.

Procedures and recovery times will vary from patient to patient and from procedure to procedure. There are various stages in the recovery process and patients will vary in their movement through the various stages. The most uniform stage in the recovery process is just prior to discharge from the hospital. At this point, patients are considered able to come home with varying degrees of adjustment. The acute recovery stage is over and the patient is stable enough to go home. They will also have begun the process of integrating the memories of the surgery and new life changes mentally. The trauma of the surgery will have somewhat subsided and the adjustment period will be in the beginning stages.

Just prior to discharge is considered to be the optimal time to obtain an accurate assessment of the patient's stress level. The STAI will be administered as part of the discharge procedures for both the test and control group. The results of the study will be kept by the researcher at the hospital in a locked file until all of the sample participants have undergone their assigned treatment and have been discharged. It is estimated that this will take approximately three months, but may take more or less time, as required by scheduling of patient procedures. When all of the STAIs have been administered, the researcher will begin analyzing the data of the test and control groups.

Research Instrument

This study will involve the use of two research instruments. The first will be the nursing training materials administered to the test group prior to their procedure. The second will be the survey instrument administered to both groups prior to discharge from the hospital. The training program will be discussed in detail as part of the final research project. Each of the disease-specific training programs will be uniform, except for specific information about the disease and the procedure itself.

The pre-discharge survey will utilize a standard measure of event-related stress commonly referred to as the State-Trait Anxiety Inventory Form Y (STAI). The STAI is a definitive instrument for measuring anxiety levels in adults. This instrument differentiates between two types of anxiety. "State anxiety" is a temporary condition that is related to anticipation of a specific event. "Trait anxiety" is a more generalized, long-term condition that has a more chronic attribute. This differentiation between these two types of anxiety was a primary reason for choosing this survey instrument.

Patients undergoing surgical procedures have a certain level of state anxiety associated with it that often quickly passes soon after the surgery. However, they may have trait anxiety regarding the long-term effects of their disease or life changes after the procedure. These two types of anxiety related to the procedures experienced by the sample population will be analyzed separately using their survey instrument. The STAI serves the purpose of the study and its structure is well-suited to this research study. Specific information about the STAI can be found at http://www.mindgarden.com/products/staisad.htm.

The STAI assesses feelings of apprehension, tension, nervousness, and worry. Scores increase in response to physical danger and the level of psychological stress. Scores decrease in relation to relaxation training. In this research the relaxation training will consist of the pre-operative nurse training administered to the test group. The STAI is a good fit for dependent and independent variable of the study. Psychoneurotic patients and those that are depressed typically demonstrate high scores on the STAI.

From a statistical standpoint, the STAI will allow the researcher to examine the distribution of scores on the scale and make a direct comparison between the test and control groups. The STAI has proven reliability and validity across a variety of research scenarios. The STAI is designed for several norm groups including those in high school and those in college. It is designed for 13- to 39-year-olds, 40-49 years old, 50-69 years olds. The last two age groups will be selected to participate in this research study. The scale uses Likert-scale responses to a variety of statements.

The STAI has several sub-categories that specifically relate to the study at hand. It evaluates how respondents felt at a specific point in time and how they anticipate they will feel in a number of hypothetical situations in the future. The STAI is sensitive to changed in transitory anxiety, such as that experienced by patients in stress-reduction programs. It assesses the level of stress induced by stressful situations such as surgery, dental procedures, job interviews or other life events that can cause stress. It has also been used to identify persons who differ in motivation and drive level (Spielberger, 2007), which could play an important factor in motivating individuals to stick to diet and exercise regimes after a heart procedure.

Chapter 4: Data Analysis

The STAI allows for the data collected from both test and control groups to be manipulated in a variety of ways. Likert type answers facilitate analysis by frequency distribution. Analyses can be performed within an between the two test groups for comparison. It can use to help determine interrelationships between categories of patients. For example one could compare males to females, various age groups, results by race, or results by procedure. This will allow the researcher to not only examine the research questions, but to examine many different factors between the various categories that can be found within the sample population.

Data will be presented graphically and in summary tables similar to the following.

Sample Table 1

Interrelationships Among the Categories, Sections, and Total SSI and Means and Standard Deviations for the Nine Categories

Stressors

1. Frustrations.80(*)

2, Conflicts

3. Pressure

4. Changes

5. Self-imposed

Reactions to Stressors

6. Physiological

7. Emotional

8. Behavioral

9. Cognitive

Mean

Standard Deviations

Limitations of Study

As with any research of this nature, it is possible the situations may exist that are beyond the control of the researcher, but that may significantly limit the ability to draw meaningful conclusions. Differences in demographics have already been discussed as a potential source of bias in this study. These biases will be identified through categorical analysis techniques. If demographic differences are found to be a factor in this study, they may serve as grounds for subsequent research studies.

Another source of potential bias is within the survey instrument itself. Some types of survey questions may be considered leading. For example, a question that begins, "do you have" a certain object may lead the participant to think that the research wants them to indicate a certain answer. Using the STAI will decrease this source of bias, as it has been edited through numerous applications so that this type of bias has been reduced to the greatest extent possible by authors of the survey. The STAI is considered to have excellent internal validity.

Chapter 5: Discussion and Conclusions

The purpose of this study is to reduce stress associated with invasive heart procedures among patients with a varied backgrounds and demographic profiles. The results of this study will help nurses to reduce stress produced by the procedure itself and by the changes that the person will experience after the procedure. Literature indicates that reducing stress helps to improve short-term and long-term patient outcomes. Stress is an important factor in heart disease, so the results of this study will have an impact on the prevention of further disease.

This study will result in the development of procedures that will lead to clinical interventions designed to improve patient outcomes. The theoretical basis for this study stems from several areas of psychology, particularly motivational theories and those involving self-efficacy and locus of control. Only recently have these areas of psychology begun to be applied to the area of physical medicine. However, this new area holds many possibilities as the mind-body connection takes a prevalent place in the medical profession. This new paradigm represents and integration of the fields of psychology and physical medicine. It treats the patient as a whole, rather than only treating the physical, while ignoring the emotional processes that are involved.

The literature review revealed that this new integration of psychological and standard medicine offers many new avenues for research. The proposed research represents practical application of these new theories into clinical practice. If the hypothesis that nurse training of patients undergoing heart procedures reduces stress, it is likely that this practice will be of interest to many facilties. There is the potential that this type of training will become standard for any person undergoing a traumatic procedure.

Many clinicians already consider patient education to be an important factor in building relationships. However, the effectiveness of this training has not yet been examined empirically. This study will provide quantitative evidence of the effects of information sharing and preparation of the patient before a procedure. Patients that experience lower levels of stress have been shown to have faster recoveries and better prognosis for the future. They are also more likely to take actions to help reduce their chances of disease reoccurrence. They will be more likely to lead active healthy lives in the future.

Changing a person's attitude through stress reduction is an important factor in the ability of the body to heal. Imparting knowledge is an important technique for reducing the stress associated with new life experiences, such as heart surgery. This study will provide important evidence that will lead to procedural changes, through formal patient education, that will help to improve the lives of patients facing a number of invasive heart procedures.