CHAPTER V

Statement of the Problem

Statistical Analysis of the Data

SUMMARY AND CONCLUSION

Anx1c.1~ .!ilti stress 3 part and parcel of modern

mechanized l i t ( , ' I ' h t ~ ~ ~ ~ occur- a s a response to a threat to the

human body 01- mind C:ertairi situations in life precipitate stress

and anxietb such as serious diseases or deformity of the body

due to acciclt,nts, sur:%ery and hospitalization. The perception of

stress and itllxiCt> differ from person to person though the cause

is the Sam? Solnc. pcc~ple cope with stressful situations positively

where a s othri-s find it difficult to adjust with them stress and

anxiety arr c-xper-icnct:d by all hospitalized patients, irrespective

of age, sex a n d disease conditions. It is aggravated if a patient is

to undergo ;in clcctive major surgery on vital organs such a s

heart or b1-211n. 'The emotion;il disturbances in a normal person,

such a s strcxss. ttnxiety or depression, interfere with the normal

functioning o f t h r i.ard~ovascular system. This may lead to failure of

heart as a pump, resulring in fatal consequences. The condition

becomes moi-c. (~(niiplic;~tt:d anti serious in a cardiac surgical patient

with structui-ally defective heart. In a defective heart the emotional

disturbances coulci (:;u:je fatal consequences, costing the life of

the cardiac. sul-%!(:a1 patient. Incidences of death have been

reported frorn tht. r.ll~iical field a s a result of serious emotional

disturbanct..; C \ ~ , I I k)t'fore ur1d~:rgoing cardiac surgery. Serious

post-operat~v(, ( . i ) i l ! j > l l ( ations of heart, lungs and nervous system

are also rci~oric:tl .ifter cardiac surgery, inspite of the routine pre-

operative p ~ . r p ; i ~ ; i l ~ o n ~ in the liospital. These complications may

lead to a vc.gc.t;~~ive life. H~.nt ,c there is a need to assure the

patients (11' all ilr~e\~entful post-operative recovery from major

cardiac surgical procedures, by preventing serious life-threatening

complicatio~ls. 'I'hls can be donr by timely assessment of stress and

anxiety and also i)y t t k~ng appropriate psychological interventions.

Although the nrrti lor management of psychologcal disturbances has

been stressetl bv s~~ver:~l resean:hers, their findings have been pushed

into the pcripht:n r ~ f i18.ness management. Not much has been done

in the existing clinlcal system to manage the stress and anxiety of

patients. Medic;?l system has in fact failed to provide even the

necessary intomation regarding the disease, to patients.

Hencr thr rese;ircher has made an attempt to develop a

Stress Management Programme for the cardiac surgical patients

and to test its cff(.ctiveness in managing stress and anxiety and

in reducing post-operative complications among the patients.

The problem of tht. study was stated as follows:

Statement of the Problem

"The Effectiveness of' Stress Management programme on Cardiac Surgical patients"

The followirrl: oi~lc ( rrvi-i were iormulated for the study

Objectives of the Study

1 ) To find our the stress rxperienced by cardiac surgical

patients bciore and after cardiac surgery.

2) To firid oul the sta:.c anxiety experienced by cardiac

surgiral patienl s before and after cardiac surgery.

3) To find out the trait anxiety experienced by cardiac surgical

patitAr~ts befort. artd after cardiac surgery.

4) To finti out thc post-operative complications developed in

the cardlac surgical patlents

5) To devc:lop :i stl-eas management programme (SMP) for the

cardiac surgical p,atients.

6) To find ou t the effectivrncss of SMP on the cardiac surgical

patien tb

Based on the experience of the investigator, literature

reviewed and otjjcctive:; stated at~ove, the following hypotheses were

formulated fk)r tlhc study.

Hypotheses

H. 1. Therc will l ~ c . significant differenct: between the pre operative

stress ;itit1 post-operative srress in the experimental group.

H . 2 . Thert 1\$111 bc significant riiffcrence between the pre operative

statc. anxlcty an~d posl-operative state anxiety in the

expenmzl1t;ii gl-( )up.

H .3 . Thert, w~ll be significant difference between the pre

operative trait anxiety and post-operative trait anxiety in

the expcr~mcn t2.l group.

H.4. the^-c will bc. significant d~fference between the experimental

group and contr.01 group in the post-operative stress.

H.5. There will bc significant difference between the experimental

group and i:ontrol group in the post-operative state anxiety.

H.6. There will br significant difference between the experimental

group anti c.ontrol group 111 the post-operative trait anxiety.

H 7. Thew will be slpnificant difference between the experimental

group and (ontrol groulr in the occurrence of post-operative

complicat~ot~\

Methodology

1 . The cxprr i t~i~ntal design, Pretest-Posttest-Control-Design,

was used 1o1- th t present study.

The \tud\ was conducted on 100 patlents undergoing

cardiac surgrn in thiz {Govt Medical Colleges of Kottayam and

Trlvandrun~

The sample was selected a s per the criteria described below.

Male and fcnlale patients undergoing elective major surgery on

heart, not having any other debilitating diseases such as Diabetes

mellitus, Hypertension, Tuberc:ulosis, Renal failure and Liver

failure of Cancer, were selected a s sample for the study. The age

ranged betwccn 18 to 50 years.

1. Ma1ay;llarn version of stress check list. (developed by the

investigator, l9<)6{1.

2. Malav;ilaln version of State Trait Anxiety Inventory.

(Developed by spil/berger and Transled and standardized by

Mohar~ llas and JXumar, 1~294).

3. Post-operative complication Check list (developed by the

investlgator. I W6:1.

4 S(res\ Mdndgenlent Progrdnme developed by the investigator

( 19'11,)

, - 1 hr ',tt-rss managemrnr programme consisted of guided

Somatops\(,liic I-c1;u:at:ion (GSPR) technique developed by

Sreedhar ( I q(4hi and two types of deep breathing exercises-

diaphragnx~t ic hrrat lling exercises and pursed lip breathing

exercises. SMF' also included information module consisting of

information ;ibouc cardiac surgery and its management and ways

to adjust w i ~ h t ht, managemen1

Procedures:.

A pilot study was conducted on 30 patients selected from

Medical Collcgt? Kottayam, using the same inclusion criteria

mentioned rarlier, after chart review. These patients were divided

into two groups of 15 each, the experimental group and the

control group. Cardiac patients from both the groups were pre

tested for stress, state anxiety and trait anxiety using SCL and

STAI respcctivelv. 'l'lic: experimental group was given training in

stress management programme for a week prior to cardiac

surgery alor~g with roul:ine hospital pre operative preparations.

The control group was given only routine hospital pre operative

preparatiori I>uc~rrlts sf both groups were tested for stress, state

anxiety and 1r;ilt anxiety using SCL and STAI on the seventh

post-operativt, da)' The post-operative complications were

assessetl I n 11os1 operative colnplication check list. Based on the

results o f t l i c p ~ i o ~ stu~Jv, thr following conclusion.were drawn.

I The xirrss i:heck.list, S'I'AI and post-operative checklist

werc tou~id adc~cluate fol- 111e present study.

r The S U P u,ds found slmplc, feas~ble and appropriate for the

present \tud\

Y The nlcusc appropriate t inie for data collection was between

2 p . 1 ~ irrrti h.p.rn on all days. The dressing room was found

to bc u s ~ f u l to provide SMP to patients.

i The hedl 1 I ate, resp~ratory rate, blood pressure and pulse

rate wrrc. fount1 to be reduced considerably after relaxation

proc rss, indtcallng a complete relaxation of mind and body.

The c.artliai: surgical patients welcomed the new SMP

training a s a novel experience, and they co-operated whole

heartedly in the pilot study. The language of SMP was simple and

clear a s reporrcd by the patients of the experimental group. The

patients rrporteti that the iristructions of SCL, STAI and SMP

were well ~indrrstood and werr easy to follow. Hence no changes

were mad? in 111t: t(101:j or technique of data collection, a s they

were founti adr.cy~.~atr, ftzasible and appropriate for the final study.

Patients st~lr~ctrti l o r pilot stlldy were excluded from the final

study.

Final Study:-

Writt<,ii 11~~1-nlrs:;ion was obtained from the authorities of

the selectcd l ic~si~~ials for conducting the study. Hundred patients

undergoing rIt-~.~rvr rrrajor surgery on the heart were selected a s

per the critt.ri:i ~ricrltii~ned earlier and after chart review. Consent

was taken lrorri ~.:ic.h patient to participate in the final study after

explaining the detail:; of the study. After testing the stress and

anxiety of tlhest. pati(:nts using SCL and STAI respectively they

were dividrti inlo gr-rjups of 50 patients each-the experimental

group and i:orilrc,l group. Thc patients belonging to the control

group recc~veti only routine hospital pre-operative preparations.

The experirnen~al group was given S M P training for a week prior

to surgery In adiiition to the I-outine pre-operative preparations.

On the sevt.iith post-operative day after cardiac surgery, both the

groups wr.7-c. ~c~s tc r i for stress and anxiety. Post-operative

complicatio~~s arrrong t.hese patients were assessed by POCCL.

The averagc. itnrr, taktn to work on a single patient was 1-2

months allti thc data collection lasted for 4 years.

Statistical Analysis of the Data

Thc ri;it:~ w a s zlnalysed using paired 't' test. and 't' test. The

followirlg r-(.s~.~ltb \\;cr(: obtairiccl

Results:.

1. Therr was s ~ g r l i f i c a ~ ~ ~ difference between pre-operative

stress ailti post-operative stress in the experimental group.

2. Therr was sigr~ificant difference between pre-operative state

anxltrty ;tilt1 po:;t-operative state anxiety in the experimental

group

3. Therc was significant difference between pre-operative trait

anxiety and po:it-operative trait anxiety in the experimental

group.

4. There u a s s~gnificant dtfference in post-operative stress

betwecn ttlr exl)erimental and control groups.

5. There was significant difference in post-operative state

anxiety between the experimental and control groups.

6. There was significant difference in post-operative trait

a n x l r t ~ ~ brtween the exper \mental and control groups.

7. There was s~gnificant difference in the occurrence of post-

operative cr~rnplications between the experimental and

control g l - o ~ i p s .

8 . The SMF' was found i ( 1 be effective in reducing stress

experic.~li.c.<i the pa t i e i~ t~ undergoing malor cal-diac surgery.

9. Thr S M t ' \vws i;)~lnd to bt, effective in reduc:ing state anxiety

and I I - ~ I I kliixirty of tllc patients undergoing major cardiac

surgr't-5'

10. Thr SMP was found to br effective in reduclng post-operative

complications of the patients undergoing major cardiac

surgr'n:

Findings of the Study

1. The srrcss experienced by cardiac surgical patients after

sux-ger3 was found to bc lower than the stress experienced

by them before the surgery.

2. Tht. statt. anxiety experienced by cardiac surgical patients

after SLIT-grry aras found to be lower than the state anxiety

expcrie~lceti by them bcfore surgery.

3. The 11-uit anxiety experienced by the cardiac surgical

patirrirs after surgery was found to be lower than the trait

anxlcty cxperi~:nsced by them before surgely.

4. Thr str-t:ss experienced after cardiac surgery by the

exp(.r~rnerital group (\hrho was given SMP) was found to be

lowc,r than th::.t of the cc~ntrol group.

5. 'Thc stalc ;tnxir:ty exprrr~rnced after cardiac surgery by the

cardiac s~irgic;il patients who received SMP was found to

1 x lower than rhat of thosr who did not rec:eive the SMP.

6. Thp trail anxiety experienced after cardiac surgery by the

cardiac surgic:4 patients who received SMP was found to

be lower than that of those who did not receive the SMP.

7. The occurrenc:e of pmt-operative complications in the

cxperimcntal group was found to be significantly lower

thar: that 111 the control group.

8. The S M P was found to be effective in reducing pre-operative

stress and anxiety among the patients undergoing elective

major cardiac surgical procedures.

9. The SMI' was found to be effective in reducing the

cornpiications following rnajor cardiac surgeries.

Implications of the Study

Thc aim of thr: s,tudy was to develop a stress management

programlnr for the cardiac surgical patients arid to find out its

effectiveness 111 reducing str-rss and anxiety and in promoting

unevent i~~i rcc:oveq. Cardiac: surgery precipitate stress and

anxiety i l l parit-nts which !h;.ivr a fatal effect on their diseased

heart. ' l ' t -~ ( ' proli.ssiona1 cart' givers no doubt art: actively engaged

in meeting t h l . ~ilivs~ological ,is well a s physic,al needs of the

cardiac snigrc.,rl i:~atit:nlrs in ihc intensive care units. Though the

physiologrc.;rl , i 1 1 1 1 ~'hysical homeostasis are maintained by

pharmacologi( i r l agents, the, ~~sychological needs and problems

are generally ~ieglected. Majority of the cardiac surgical patients

undergoing c:ardiac surgen without any psychological support

suffer fronr ~nc:rcas~:d strain and consequently develop fatal

complicatiorls iollowi~xg cardiac: surgery.

Thr ,.wrriiac sul.gical patients, their relatives, and professional

care givers i-emalri embmassed, helpless and ignorant to solve the

problems I-rlated to stress and anxiety associated with cardiac

surgical interventions. Yet no attempt was made so far in our

present c1ilirc;il sct u p to address these problems.

The ztr-1.s~ managenlent programme developed by the

investigator consrst of information regarding various aspects of

cardiac srlrger)., Guided Somato Psychic Relaxat~on techniques

and two types o f breathing r-xercises. Each component had its

own cffect or, the cardiac surgical patients to adjust to the

stressful s~tuw~iotis t,efore, ciuring and after cardiac surgery. The

informati011 iiil~dult consist of detailed description of pre-

operative l)t.oc.i~irlrc~:, instrrcc:iions while transferr-ing patients to

the oper;iriolr tllcaatre, and information regarding post-operative

rnariagernt~il~. 'I'l~t, ~ ~ n k n o w ~ l routine hospital pr-ocedures are

taught to tlrc: patients using i~iiormatwn module. The information

module hc.lli the. pati~lit to face the cardiac surgery wi1.h courage and

self-confider~c.r The informat~on module reduces fear for the

unknown e~~couraging whole hearted co-operation and compliance

with the prc~~opc:rativc: hospital procedures.

Guidcd sonlato psychic relaxation is taught to the patient

prior to cardlac s u r g t q which helps the patient to relax his body

muscles which in turn provide more blood supply. The wound

healing is hastened due to increased supply of oxygen and

nutrients t o the mutila.ted tissues of chest and internal organs.

This results in an uneventful recovery following serious cardiac

surgical intt:~-vrni ion?;.

By PI-act~c:ing deep breathing exercises the patient learns to

take slow, strati! deep breaths with minimal chest movements

which reti11c.e~ pain during breathing and helps to bring out

secretions ;iccumula~:ed in thc lungs following cardiac surgery.

Deep breathing exercise refreshes and relaxes the patients due to

increased oxygen ab:sorptior~ which help in wound healing and

preventing r-rspu.ato~y infection which are common following

<>(.I-, ' cardiac sur,

'rhc, I dc:jigned stress management programme is

found to t j t ( , f i ( . t tivc: In prevc.nting complications following cardiac

surgery anti t t i t ' patient is ensured with an uneventful recovery

following c:;~irdlwt surgeiy.

The rools of tl7e study, the stress check list, state trait

anxiety invcntoi-v and post-operative complications checklist

could be uscd for sinlilar cliriic.al studies in future.

Thc S~ndlngs of the prcsrnt study are helpful in guiding the

professioniil c,;i~-c gi\:ers in managing stress and anxiety in the

clinical scr ilp and reveal ways and means to prevent post-

operative comp1lcation:j.

Thc pat~'11ts who hati undergone stress management

programmr coulti use these techniques even after discharge from

the hospital t o tical wi-th stress and anxiety of daily life. Thus the

stress management package programme is found to be effective

in preventing ser-IOU:; complic;\tions following cardiac surgery.

Limitations of the Study

u Sin(.? tiit> occurrence o f valvular diseases of the heart is

morc: common among St:males, the number o f male patients

sel(,c.tc-ti 101- the study was less than that. of the female

paucnt:,

LI 'I'hc. present : . t ~ ~ d y was conf'ined to two medical colleges of

Krr;ila sLate, selected at random due to time constraint.

o Thc prcsrnt study excluded patients undergoing coronary

artcry bypass surgen since none of these patients fulfilled

thr criteri;t set fix sample selection.

Suggestions for Further Research

. Similar studies may be conducted on patients undergoing

car-diac sur-gery for congenital defects of the heart and who

fail below 18 years of age.

. Simllar studies rnay be conducted on all patients undergoing

general surgenr under General Anesthesia, with appropriate

rnod~ficatlon of the information module of SMP.

. Similar sludies may be conducted on patients undergoing

cororian. ar-ter\i bypass surgery.

. Similar studies may be conducted on chest: surgery patients,

using thr same tools.

. The effec,tivrne:ss of breathing exercises on chest surgery

[nay he srudietl on a group of patients undergoing thorasic

surgr.r\'

. Thc eflt.c~ilvc?ess of GSPR in reducing pre-operative anxiety

may bt, ~t.str t l on pa t~er~ts undergoing elective major surgery

unclc-r (;rrler;il Anesthrsia.