RESEARCH ARTICLES

Coping mecanism by surgical patients in stress situations: ambulatory surgery

Carlos Eduardo Peres Sampaio^I; Thays Macedo Nascimento Costa^II; Dayane de Araújo Ribeiro^III; Deyse Conceição Santoro^IV

^I Nurse, PhD. Associate Professor, Department of Medical-Surgical Nursing, State University of Rio de Janeiro, Advisor for the Research on:Impact of nursing orientations on the anxiety level of surgical patients. Rio de Janeiro, Brazil, Email: carlosedusampa@ig.com.br
^II Nursing Student of 8th Period of the Undergraduate Course in Nursing at the School of Nursing at the State University of Rio de Janeiro, Scholarship holder from the Scientific Initiation Program of the Research Project, Impact of nursing orientations on the anxiety level of surgical patients. Rio de Janeiro, Brazil, Email: thaymacedo1505@hotmail.com
^III Nurse, Graduated from the School of Nursing at the State University of Rio de Janeiro, Volunteer Research Project:Impact of nursing orientations on the anxiety level of surgical patients. Rio de Janeiro, Brazil, Email: dayanear@yahoo.com.br
^IV Nurse, Associate Professor, Department of Medical-Surgical Nursing Anna Nery School, Federal University of Rio de Janeiro, PhD, PhD in Cardiology, Rio de Janeiro, Brazil, Email: deysesantoro@yahoo.com.br

ABSTRACT

Analytic, descriptive study with a quantitative and qualitative approach, that identify the most used coping mechanisms and the feelings of the surgical patients by the analysis of their responses before the surgery. The research was developed in Ambulatorial Surgery Unit in the county of Rio de Janeiro, between June and December of 2012, with a semistructured interview. Participated on this study 12 patients between 16 and 74 years old. Through the analysis of the data, 2 cathegories were elaborated, emphasizing the religion and the family's support as adaptive mechanisms during the surgical period. Most of the patients that undergo ambulatorial surgeries were not well informed about the procedure and the pré-operatory care. Therefore, an strategy must be created to give the nursing orientation of the pré-operatory.

Keywords: Nursing guidelines; surgical patient; anxiety; coping.

INTRODUCTION

Outpatient surgery arose in the early 60s upon advances in surgical and pharmacological techniques. The first outpatient surgery service implemented occurred in 1961 at Butter Worth Hospital. Another unit was inaugurated later at the University of California in Los Angeles¹.

Outpatient surgery is defined as a surgical procedure performed with general anesthesia, local, regional or sedation, which require less intensive post-operative care and of short duration. This modality dispenses hospitalization for enabling discharge in a few hours after the procedure².

Outpatient surgeries discard the need for hospitalization with a maximum stay of 24 hours in the hospital institution, because the patient on the same hospitalization day, undergoes the surgical procedure and is discharged. It comprises small and medium-sized procedures, including: amygdalectomy, rhinoplasty, tenorrhaphy, myorrhaphy, herniorrhaphy, postectomies and orchidopexy performed with anesthesia by grouping various specialties, with maintenance of patient safety^2,3.

To be carried out, it takes into account the following criteria: conditions of the unit; criteria for patient selection and conditions of patient discharge such as: age, physical and mental condition (must be oriented with absence of symptoms, among them are: nausea, vomiting, respiratory difficulties, and others) anesthetic risk; social situation and family; if they have anyone who will help them at their residence; or if they can physically arrive at the institution¹_.

The surgeries at the outpatient level emerged as proposal to reduce the impact of a classical hospital surgery in the patient's life and their family, mainly with respect to negative aspects such as: increase in anxiety, separation from the family, remoteness of social activities and labor, risks of acquiring nosocomial infection among others^1,4,5.

The surgical intervention provokes a range of feelings in the patient, since many times, it is an unexpected event, and when it happens, there is an interruption of the individual's daily life, bringing anguish and feelings of apprehension⁶.

To minimize these feelings, surgical patients use coping strategies to decrease the internal and external demands, which contributes to externalize their conflicts. There are two types of adaptations: problem-focused coping or emotion-focused coping^7,8.

Therefore, this study outlined as its object the coping of perioperative patients, at a clinic in the city of Rio de Janeiro.

The motivation for studying this object came from scientific Project Initiation of Rio de janeiro State University titled: Impact of nursing orientations on the anxiety level of surgical patients. The action allowed to observe that the majority of patients increase their level of anxiety due to waiting for the surgery. From this perspective, the aim of the study is to understand the relevance of coping strategies used by outpatient surgery patient with views to effective communication with the patient, family/nurses in pre-, trans-, and post-operative period, with a focus on pre-surgery⁷.

Thus, it was established as the goal of study: identify the mechanisms of coping most used by patients and their feelings before the surgical procedure.

LITERATURE REVIEW

The anxiety can be defined as a universal phenomenon, experienced by almost all surgical patients, which may influence the response of the patient toward the treatment causing negative effects on recovery¹.

The surgical time brings a range of feelings that can be both positive and negative for the hospitalized patient, now many use mechanisms of adaptations to minimize these feelings.

The feelings may be developed during the pre-operative period, leaving the patient emotionally shaken by contributing to makes them vulnerable and dependent. Many patients present high level of stress, regardless of the degree of complexity of the surgery which may have a relationship with the misinformation of surgical procedures, anesthesia and guidelines pre-operative nursing. These guidelines aims to reduce the anxiety of patients and surgical risks avoiding possible complications after surgery⁹.

The adaptations (coping) are expressed in stress situations, which require the use of special actions, such as the guidelines of nursing professionals is of extreme importance, informing the patient about the surgical procedure to be performed.

A recent study carried out with mothers of children undergoing outpatient pediatric surgery revealed that the main mechanisms of adaptations (coping) were performed: the attachment to religiosity, and avoid reflected the fear experienced by a companion for child ⁸. The presence of the companion along the child provides support, security, affection and emotional support. The nurse can contribute in this process, through incentive and encouragement to externalize the emotions, understanding them as an attempt to adaptation⁸.

The family has a great influence on how the patient will react in a time of great tension, as is the case with the surgical procedure. Therefore, many rely on coping mechanisms such as seek the support of family, believing a belief, listen to music that calms^10.11.

METHODOLOGY

This is an analytical descriptive study with a quanti-qualitative approach. This research modality of describes the characteristics of a given population or phenomenon, analyzing their relations, emphasizing those that aim to study a particular population group¹²_.

The quantitative approach values ​​the phenomenon in its different variables, applying the statistical method. The qualitative research has as its focus the meanings or senses the phenomena experienced, as well as the approach that the subjects attribute the phenomena depending primarily on their own cultural assumptions of the enviorment¹³.

The scenario chosen to conduct the study was the unit of outpatient surgery and surgical clinic of a polyclinic in the city of Rio de Janeiro, characterized as a health unit type III, standalone, specialized and outside the hospital setting. The study occurred in the period of June to December 2012. The study subjects were composed of 12 patients undergoing general outpatient surgery. Inclusion criteria were patients the outpatient general surgery classified within ASAI (American Society of Anesthesiology) and ASA II.

As an instrument a semi-structured interview was used with six questions, which gave the opportunity for the interviewee to talk about the subject. The good interview begins with the formulation of basic questions, with the aim of achieving the goal of research. It is necessary to analyze the script identifying the suitability in terms of language, structure and sequence of the questions in the script¹³.

It was ensured the anonymity of subjects, as well as total freedom to answer the participant may discontinue their participation at any time, without any prejudice, according to the Resolution No.196/96 of the National Health Council, which deals with research on human beings and observation of ethical principles¹⁴.

The subjects were identified with the letter E (interviewee), followed by the number in order to participate in the study and their age. Thus, were denominated: E1, E2...

The project was approved by the ethics in Research Committee of the Pedro Ernesto University Hospital, State University of Rio de Janeiro (CEP/HUPE/UERJ) with protocol No. 3014/95/2011.

Before the completion of the interviews the Free and Informed Consent was formalized. The study participants were instructed about the stage of the studies, as well as the right to withdraw from participation in the research when and if they so wish. Given the project, information all invited subjects voluntarily agreed to participate in the studies.

Descriptive statistics were applied to analyze the demographic profile and previous surgical experience of the subjects.

After the interviews, the data were analyzed and interpreted according to the Bardin's content method with the aim of organizing the analysis into three groups: The pre-analysis corresponds to the period of intuitions, systematizing the initial ideas, being conducted the analysis plan; The exploration of the material and the treatment of the results obtained and interpretation, in which the results are treated in such a way as to be meaningful and valid for enabling the categorization¹⁵.

RESULTS AND DISCUSSION

The sample of this study consisted of 12 patients, being 7 (58.3%) female patients and 5 (41.6%) male patients, the ages ranged between 16 and 74 years. With respect to previous surgical experience, 7 (58.3%) patients had previously undergone surgeries and 5 (41.6%) had not. The content of the statements were analyzed and two categories emerged.

1st Category - Coping strategies used by outpatient patients in the pre-operative period.

According to the data obtained in semi-structured interviews, it was noticed that the strategies used by patients facing the time of surgery were clinging to religion and their families.

It was observed in the interviewees' statements in the following reports:

I think of God and ask for God's help. (E1, age 60)

I pray and think of my family. (E2, age 47)

I have confidence in the supreme power. (E3, age 74)

The surgery brings feelings of fear and apprehension to patients, due to several factors, among them: remoteness from their family, fear of the surgical procedure and work. During this period, the patients lose control of themselves, and come to trust his life to strange people, losing their privacy and having to adapt to a different environment, developing a yearning for home and their family.

To minimize these feelings, surgical patients use coping strategies, created by themselves to decrease the internal and external demands, which contributes to minimize their conflicts⁷.

Coping a response to stress, with the purpose of reducing its aversive qualities. These strategies can be understood as a way of coping with minimizing the emotions ahead the negative situations experienced by patients ¹⁶.

In the interviewees' statements, it can be noticed that one of the strategies used as adaptation for the pre-operative situation was the attachment to religion. Many also reported: seek help from God and have confidence in the Supreme. Such resources are applied by patients to get through this moment of suffering and doubt regarding the time of surgery. Thus many end up seeking of religion a way of comfort and hope and positive thoughts for the surgery's success. Similar results were observed in a study that evaluated the adaptations that caregivers of children undergoing ambulatory surgical procedures present, namely, the approach to the spiritual dimension⁸.

Faith and hope deposited in God are strategies used by patients as constructive way of thinking. They consider faith in God is a way of coping necessary and already rooted in Brazilian culture, occupying a prominent place in people's lives, to provide optimistic thoughts, helping to minimize the internal stress¹⁷.

Another strategy used by patients in the preoperative period to minimize anxiety, was thinking of their family. It is in the family that many patients seek support and comfort therefore the hospital for being the space of the disease, treatment, suffering from pain and contributes to both the patient as well as the concerned family.

The hospital is responsible for removal of the patient from their daily routine, moving it to a different environment, with routines and rules. This alone is an unpleasant experience and can develop negative aspects such as distancing from family environment and social life ¹⁸.

In the interviewees' statements, one can identify the strategies used to reduce anxiety at the time of surgery.

Thinking of my family. (E6, age 16)

Talking to my sister to distract me. (E9, age 35)

The family is a very important link for the recovery of the surgical patient, because at that moment occurs the development of feelings of anguish. The family serves as a support chain, bringing tranquility and hope to patients who will undergo surgery¹⁰.

The patients use strategies such as conversation with the family or thinking of their family, in an attempt to overcome the feelings of nostalgia lived, seeking a more welcoming environment. Often, in a moment of solitude, are exacerbated anxiety and pessimism, favoring the development of signs and symptoms such as increased heartbeat, dry mouth and feelings of anguish⁶.

Therefore, the family plays a fundamental role to minimize the pain and suffering of the patient who is undergoing surgical treatment, being essential to the presence of nurses, providing guidance and acceptance. The nurse helps to guide and exercises caregiver role, observing the basic needs the client valuing the perioperative full care nursing. The formation of a bond generates a relationship of patient/nurse trust, a time that he needs someone who respects their feelings and gives them support to cope with the stressful moments⁶.

2nd Category: Perceptions of surgical patients on the surgery and their feelings

This category presents the perception of surgical patients on the procedures to be performed and their feelings during the treatment period. The patients highlighted the lack of information regarding the surgical procedure, in the following declarations:

I don't know about this procedure. (E6, age16)

I don't know about this surgery. (E9, age 35)

Lack of confidence, by not knowing about this surgery. (E3, age 74)

In the interviewees' statements, there is a clear concern about the surgical misinformation, revealing ignorance on the procedure to be performed and a lack of confidence in surgery.

This ignorance is probably due to the failure on the steps of transmitting the guidelines for nursing staff to patients. Outpatient surgery requires less intensive postoperative care and of short duration, being discharged within a few hours after completion of the surgical procedure. In This way, the completion of the nursing consultation is the determinant for the treatment's success for clients undergoing outpatient surgery, because it is the moment at which the nurses identifies whether patients have a profile for completion of outpatient surgery, because only the procedures with ASA classification I and II make clients eligible for this treatment.

Nursing consultation preoperative emerges as a crucial tool to minimize the risk of postoperative complications, occurrence of canceled surgeries and reducing anxiety generated by facing the surgical intervention. In this consultation, feelings, expectations and level of information of the patient and family about the procedure should be identified, aiming at the appropriate orientations⁸.

The professionals must attend the full surgical patients, since they may present a high level of stress and develop feelings that can compromise their emotional state. Coupled with these feelings, the misinformation regarding the surgical procedure further increases their stress leve, therefore the importance of the nursing staff's care towards the pre-surgical patient, being responsible for orientations and the development of care actions in accordance with the basic individual needs and the specifics on the surgery ⁹.

Therefore, a large proportion of patients undergoing outpatient surgery were not adequately informed about this treatment and the possible preoperative care, which has contributed to increasing the level of stress and anxiety of the subjects. Thus, there should be a strategy to provide guidelines for nursing in the preoperative period for the patient, clarifying doubts about the procedure and provided a greater well-being, reducing anxiety, surgical risks and possible postoperative complications.

In relation to the feelings, were identified, in the interviewees' statements, the positive emotions, such as: calm, tranquility and the creation of a favorable expectations from the medical team. The negative feelings were related to concern about the surgical procedure to be performed, as demonstrated by the speeches.

I believe in doctors. (E3, age 74)

Keeping calm and quiet . (E12, age 43)

Concern with the surgery itself. (E11, age 60)

Fear of experiencing some kind of sequel. (E8, age 47)

It is worth mentioning that the concern with the surgery, often by being the first surgical procedure, the patient is tense, mainly because they don't know how a surgical room is and how their postoperative recovery will be.

The surgical event causes in patients sensations of stress and anxiety, having to deal with the fact of being sick, experiencing this traumatic situation and the need to organize, since there is a rupture in their everyday life. Concern with the surgery causes feelings of fear and threat on the part of the patient, by submitting to an invasive technique, leading to a situation of dependence^19,20.

In pre-operative nursing care, when the explanations occur about the surgery, they provide a calm and peaceful environment, decreasing the anxiety and fear of the unknown. There is a need to listen carefully to the patient, removing their doubts and promoting the necessary comfort.

For this reason, during the outpatient surgery it is important that the nurse-patient relationship and the pre-operative nursing consultation promote full assistance and the trust bond, favoring for the well-being of clients.

To achieve comprehensiveness in care, it is of utmost importance to know the individual being assisted towards a good recovery for the patient after surgery and return to their socialization with the family and work environment^1,2,19.

CONCLUSION

This study presented contributions to improve perioperative nursing care, even presenting limitations as in the reduced sample size. Therefore, faith and hope deposited in God are coping strategies used by patients facing the outpatient surgery. It was identified that the family plays a fundamental role to minimize the pain and suffering experienced by the client before the surgical time, because the distancing of family members and the disruption of daily activities are major stressors in this period, triggering adapter mechanisms.

Another important finding was identified that the majority of these patients were not adequately informed about the surgery to be performed and possible preoperative care, which contributed to increase their level of stress and anxiety.

It is concluded that, in order to overcome such shortcomings, a strategy should be created to provide the guidelines for nursing care in the pre-operative period for the patient, clarifying their doubts as to the procedure, providing information and welcoming both patients as well as the family, with views on the well-being and reduction of anxiety, and the surgical risks and possible postoperative complications.

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