Preoperative Education for Breast Cancer Patients to Decrease Perioperative Anxiety

Background: A breast cancer diagnosis and recommended treatment produces high levels of anxiety in patients. Many patients do not understand the information provided by their physicians. Hearing about a cancer diagnosis, coupled with surgical information, quickly overwhelms patients and their families, leading to low retention of information and greater levels of anxiety. Oncology nurse navigators (ONNs) and surgical admission nurses recognized patients were experiencing high levels of anxiety and were often unprepared for events the day of surgery and oncology referrals. Studies have shown women with a diagnosis of cancer correlate with higher levels of preoperative anxiety.¹ Increased anxiety elicits physiologic stress responses that may impede healing and alter responses to postoperative pain.²

Objective: To determine if a preoperative education program decreases anxiety among patients undergoing breast cancer surgery.

Method: Funds from The DAISY Foundation were secured for educational materials. The Iowa Model for implementing evidence-based practice was followed. Current practice was evaluated, and both timing and lack of information were found to contribute to increased anxiety. A literature review was conducted. IRB approval was obtained. Sessions provided information about procedures, expectations, and recovery. A variety of formats, including visual, auditory, and kinesthetic methods, was used. The primary outcome measure was level of postoperative anxiety in patients undergoing breast cancer surgery. Levels of anxiety were measured using the visual analog scale (VAS).² Patients were asked to rate their anxiety level before surgery and again during a routine postoperative call. No patient identifiers were collected. Agreement to participate in the survey served as consent. Anxiety scores of those attending the preoperative educational session were compared with those who did not attend. The primary outcome measure was to include the difference in mean anxiety scores between patients who did and did not receive preoperative education. In addition to the VAS scores, participant evaluations were collected.

Results: Attempts to measure a reduction in anxiety with the VAS were not successful. Only 28 VAS tools were collected, resulting in poor data compilation due to incomplete surveys and lost follow-up. VAS data collection was aborted for unpredictable circumstances, including VAS administration and new electronic health record implementation and staffing issues. To date, 45 participants have attended class, with 39 completing evaluations reflecting high levels of patient satisfaction with this process.

Conclusions/Implications: Attempts to measure reduction in preoperative anxiety with this validated tool were not successful. Through patient evaluation, we confirmed patient satisfaction with the educational intervention, which can impact levels of anxiety overall. For future efforts, a different tool to measure anxiety, as well as when the tool would be administered, could be considered. With replication, engagement of key staff in implementation and data collections is encouraged. As an accredited center with the Commission on Cancer, this project was utilized as a quality improvement initiative. Future measurable impact could include reduction of emergency department visits, improved patient flow, more efficient use of staff, and increased referrals to ONNs.

References

1. Aviado-Langer J. Measuring preoperative anxiety in patients with breast cancer using the visual analog scale. Clin J Oncol Nurs. 2014;18:489-491.
2. Granziera E, Guglieri I, Del Bianco P, et al. A multidisciplinary approach to improve preoperative understanding and reduce anxiety: a randomized study. Eur J Anaesthesiol. 2013;30:734-742.