Self-Directed Audio Relaxation in Surgical Patients: A Pilot Study Tanya G. Island, CRNA, MS, BSN, BS March 13, 2015

Introduction Preoperative preparation of patients Preoperative preparation of patients often focuses on hospital requirements and medico-legal considerations. Patients are subjected to testing, treatments, and focused assessments based on the scheduled surgical procedure. The presentation will describe the various aspects of a proposal describing the planned pilot study. Preoperative preparation of patients Emphasis on hospital requirements Process revolves around documentation and medico-legal considerations Minimal emphasis on mind-body preparation leads to anxiety Preoperative area  high traffic, ambient noise, lack of privacy, variable duration of wait time

Purpose The purpose of this capstone project is to evaluate the efficacy of a self-directed audio relaxation intervention for pain, anxiety, and patient satisfaction outcomes measures for the outpatient surgical population at Memorial Hermann Surgical Hospital – First Colony. The project aims are to translate evidence regarding effectiveness of self-directed audio relaxation interventions to the practice setting of a community hospital in Sugar Land, Texas. Evaluated efficacy of a self-directed audio relaxation intervention Aimed to translate evidence regarding effectiveness of self-directed audio relaxation intervention to community hospital practice setting

Problem Statement Surgical patients experience wide array of emotions Inadequate mind-body preparation Heightened emotional distress Lack of privacy Unfamiliar surroundings Fear of anesthesia vs surgery Need for additional information & education

Research Questions & Hypotheses Hypotheses and Null Hypotheses The self-directed audio intervention will decrease anxiety and pain scores experienced by surgical patients. The self-directed audio intervention will improve patient satisfaction scores after surgery. The self-directed audio intervention was successfully piloted at a community hospital, demonstrating translation of evidence-based practice into clinical practice. The null hypothesis stated that the self-directed audio intervention will not improve pain, anxiety, and patient satisfaction outcomes in surgical patients at a community hospital. This conclusion would indicate that no statistically significant benefit was derived from using the self directed audio intervention in surgical patients at a community hospital. Will a self-directed audio relaxation intervention: Reduce VAS anxiety scores? Reduce VAS pain scores? Increase patient satisfaction scores? Can an evidence-based relaxation intervention be successfully implemented in a community hospital surgical population?

PICOT Statement In surgical patients scheduled for outpatient surgery at a community hospital in a southern Texas city, how did a self-directed audio relaxation guided imagery intervention compare to pharmacological anxiolytic and narcotic medication administration in the outcome measures of pain, anxiety, and patient satisfaction during the 2-month pilot study investigation window of January to February 2015?

STETLER MODEL OF RESEARCH UTILIZATION DEFINE – ASSESS – PLAN – IMPLEMENT – EVALUATE STETLER MODEL OF RESEARCH UTILIZATION (Reprinted from Nursing Outlook, Vol. 49, Stetler, C. B., Updating the Stetler model of research utilization to facilitate evidence-based practice, pg. 272–279, copyright © 2001, see Appendix A for reprint license from Elsevier)

Literature Review Assessment of anxiety with valid and reliable tools (APAIS, VAS anxiety) Effects of anxiety on anesthesia requirements Therapeutic interventions shown to help reduce preoperative anxiety

Population, Sample & Instrumentation Surgical patients scheduled for outpatient procedures at a community hospital Ages 18-65, no regional anesthesia blocks, no comorbid psychiatric or pain disorders Outcomes evaluated: APAIS VAS pain VAS anxiety Patient satisfaction

Implementation Phase Dates Tasks I 1 Sep 14 to 18 Dec 14 Evaluation of clinical problem of interest Input and meetings from facility staff SWOT analysis Proposal preparation Coordination with facility exec leadership Capstone Proposal Defense & IRB approval II 18 Dec 14 to 22 Dec 14 Equipment selection, trials, and acquisition Preparation and approval of cost estimate III 3 Jan 15 to 13 Feb 15 Pilot study implementation Data collection IV 16 Feb 15 to 28 Feb 15 Statistical analysis of data Summarize conclusions Answer research questions V 1 Mar 15 to 13 Mar 15 Presentation to stakeholders Capstone Project Paper Capstone Poster Presentation Capstone Podium Presentation Phase I – project proposal and preparation of pilot study, evaluation of problem Phase II – equipment selection, acquisition and cost proposal Phase III – project implementation Phase IV – statistical analysis Phase V – dissemination of findings to stakeholders

Equipment

Results The project sought to improve mind-body preparation of surgical patients scheduled for outpatient surgery – IT DID (DECREASED ANXIETY AND INCREASED PT SAT)  The project sought to alleviate emotional distress and reduce anxiety associated with waiting for scheduled surgical procedures – IT DID (DECREASED ANXIETY)  The project sought to overcome physical and structural limitations of the facility in which the investigation was conducted by providing a distraction in a curtained holding area with high ambient noise and limited privacy – IT DID (HIGH PATIENT SAT) Statistical significance for anxiety reduction and patient satisfaction improvement No significant relationship between audio intervention and VAS pain

Results Frequency Cumulative Percent Male 34 45.9 Female 40 54.1   Frequency Cumulative Percent Male 34 45.9 Female 40 54.1 Study results for pain and anxiety were not normally distributed, and statistical analysis was conducted using Wilcoxon Signed Rank Test (Pallant, 2010). Patient satisfaction was analyzed using Mann Whitney U Test because no pre-intervention data points existed, due to nature of the analysis (Pallant, 2010). The analysis of pain and anxiety focused on comparisons between two related groups with pre-intervention and post-intervention reference points. Mean preoperative pain score was 15.62 with a standard deviation of 21.46, indicating a non-normal distribution (see Appendix H). Mean postoperative pain score was 20.49 with a standard deviation of 28.3. Mean preoperative anxiety score was 29.69 with a standard deviation of 31.3, also indicating a non-normal distribution (see Appendix H). Mean postoperative anxiety score was 10.62 with a standard deviation of 19.3. (see Appendix H). Both pain and anxiety scores were significantly skewed leftward (see Figure 6). Patient satisfaction score indicated a mean score of 4.45 and a standard deviation of 0.8 (see Appendix H). This variable had significant rightward skewness and a non-normal distribution. Wilcoxon Signed Rank Test failed to reveal a statistically significant reduction in pain following use of the self-directed audio relaxation intervention, z = -1.504, asymptotic significance .133, p < .001. Alternatively, Wilcoxon Signed Rank Test revealed a statistically significant reduction in anxiety following use of the self-directed audio relaxation intervention, z = -4.781, p < .001, with a medium effect size (r = .39). The median score on the VAS anxiety decreased from pre-intervention (Md = 20) to post-intervention (Md = 0) (see Table 3). Mann-Whitney U tests were conducted on the patient satisfaction study variable using postoperative survey results. The relationship between audio intervention and patient satisfaction (Md = 5, n = 74) was found to be statistically significant with moderate effect, U = 335, z = -1.931, p = .053, r = .22 (see Table 4).

Photos taken with express written consent of patients Photos taken with express written consent of patients. Patients also consented to reproduction in written and visual modalities for purposes of education, publication, and research.

Recommendations Perform a cost-benefit analysis to determine if additional audio units can be made available in preoperative holding area Conduct further analysis on a screening mechanism to rapidly identify who is most in need of a relaxation intervention Conduct inservices with staff to educate about non-pharmacological relaxation interventions

Conclusions Self-directed audio relaxation intervention improved patient perception of anxiety and improved patient satisfaction Currently under consideration by executive leadership team for expansion of pilot study

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