Pre-operative stress in patients and the role of nurses in psychological preparation for spinal surgery

Introduction

Spondyloarthritis is a disease process involving damage to the normal structure of the spine, causing irritating symptoms. The most common is sudden, severe, and radiating pain, limiting or even preventing daily functioning [1-6]. Various treatments are available, but the most effective and definitive approach is surgery [7].
Surgical procedure evokes negative emotions in patients, fear for their health, and loss of independence, therefore mental preparation is an important element for the course of surgery and post-operative period. This preparation reduces pre-operative anxiety, facilitates assimilation of information on post-operative management [8-10], and decreases stress that influences recovery. Accordingly, the patient’s coping strategies with stress and ability to apply them are of great importance [11, 12].
The task of care providers is, among others, to reduce the patient’s stress and mentally prepare for surgery, thus reducing the risk of post-operative complications and providing psychological comfort [13, 14]. The nurse’s relationship with the patient should be supportive and therapeutic. The nurse prepares the patient for surgery, identifies the needs in perioperative period, together with the patient develops a plan to meet the needs, makes efforts to involve the subject in cooperation with the therapeutic team, highlighting the patient’s role in the treatment process. It is important to gain the patient’s acceptance of proposed measures, which requires building trust through the nurse’s open attitude, kindness, patience, and professionalism. Nursing care significantly affects the patient’s well-being before surgery; the presence and company of the nurse in experiencing difficult emotions by the patient is an important part of psychological preparation for surgery [9]. Empathetic attitude of the staff contributes to the reduction of anxiety, whereas the presence of nurse creates a safe space for the expression of true emotions, natural to the patient [15].
The aim of this study was to identify coping strategies used by patients to deal with pre-operative stress, and to determine their opinions and expectations regarding mental preparation for surgery by nurses.

Material and methods

The study was conducted from November 2023 to March 2024 among a group of 70 patients at a hospital in Krakow, following approval of the Research Ethics Committee of the Jagiellonian University CM (number: 118.6120.107.2023) and consent from the facility’s management. Using a diagnostic survey method, the study adopted a form of single meeting with patient before surgery, during which data were assessed. The author’s (A.N.) survey questionnaire was employed as a research tool, and included questions regarding personal information, comorbid diseases, the course of spondyloarthritis, and preparation for surgery by nurses and patients’ expectations. Second tool used was the multidimensional inventory for the measurement of coping with stress (COPE; Carver, Scheier, Weintraub, adapted by Juczyński and Ogińska-Bulik), containing 60 statements and allowing to assess methods of coping with stress [16]. Normal distributions of variables in the COPE questionnaire were verified with Shapiro-Wilk test. Since these variables were not close to normal distribution, non-parametric tests were utilized, such as Mann-Whitney U and Kruskal-Wallis ANOVA. Spearman’s correlation was employed for variables measured on an ordinal scale. P value < 0.05 was considered statistically significant.

Results

The study group consisted of 70 patients before their scheduled surgeries, with 54% of women (n = 38) and 46% of men (n = 32). Age ranged from 25 to 76 years, with a mean age of 52.8 years. Most of the respondents resided in rural areas (39%), while the majority (83%) of the participants were “in a relationship”. High school education accounted for 39% of the respondents, higher education was declared by 37%, and vocational education by 24%. Most of the participants were economically active (70%), and 7% were receiving a health pension.

Course of degenerative spine disease among study participants

Most (72.9%) of the respondents suffered from lumbar degenerative spine disease, while the rest indicated cervical degeneration. On average, the patients had been suffering from the disease for 6 years (mean, 6.01 years), with minimum period of 1 year and maximum of 32 years. The disease severely impaired physical fitness (26.9%), pursuing hobbies (26.9%), and impeded professional work (26.3%). After the onset of symptoms, the time respondents went to see a specialist was as follows: after 4-12 weeks (44.3%), immediately after the occurrence of first symptoms (30.0%), after 3-5 months (14.3%), and more than after 6 months (11.4%). The waiting time for surgery from the time of qualification till the surgery was 7-12 months (34.3%), 3-6 months (32.9%), over 12 months (22.9%), and 1-2 months (10.0%). The patients most often complained of pain (94.3%), numbness and tingling in the lower extremities (52.9%), muscle weakness in the lower extremities (52.9%) and upper extremities (25.7%), and stiffness in the lumbar spine (24.3%). Prior to surgery, treatment included rehabilitation (84.3%), pharmacotherapy (80.0%), therapeutic massage (77.1%), spinal block (24.3%), kinesitherapy (20.0%), spinal thermotherapy (17.1%), acupuncture, and a stay at a sanatorium (2.9%).

Preparation for surgery by nursing team according to respondents

The patients rated the nursing team’s psychological preparation for the procedure as sufficient in the following areas: assurance of assistance with physiological activities due to temporary immobilization after the procedure (95.9%), assurance of assistance with personal hygiene and changing underwear (94.3%), assurance of the possibility of calling a nurse if necessary (91.4%), monitoring of vital signs during hospital stay (68.9%), and efforts of the entire therapeutic team to provide the best possible care (67.1%). In addition, in the participants’ opinion, the nurses were kind (97.1%), empathetic (47.1%), and understanding (42.9%). Two individuals used the terms “cheerful” and “caring”.

Respondents’ expectations of nursing staff in mental preparation before surgery

In the area of nurses’ behaviors and qualities, professionalism (3.43), kindness (3.39), patience (3.33), empathy (3.19), and understanding received the most indications (3.14). Less received caring (2.93), involvement in the treatment process (2.97), smile and sense of humor (2.61), and openness towards the family (2.59). In the area of nurses’ skills, the respondents mainly highlighted observation of the patient’s condition (3.34), manual dexterity (3.30), and education on pre- and post-operative management (2.89). Less indicated were communication skills (2.77), mental support skills (2.24), and answering every question (2.10).

Respondents’ stress coping strategies based on COPE questionnaire

Among the strategies, the patients most often indicated planning, seeking instrumental support, active coping, seeking emotional support, and religious expression (Table 1).

Relationship between stress coping strategies in patients and their expectations of nurses’ qualities and behaviors as well as their skills in mentally preparing patients for surgery

There was a relationship between stress coping strategies and the respondents’ pre-surgery expectations of nursing staff in terms of their qualities and behaviors, except for strategies for seeking instrumental support (p > 0.05), denial (p > 0.05), and use of alcohol or other psychoactive drugs (p > 0.05) (Table 2).
Expecting nurses to be patient was significantly more often associated with choosing the following strategies: active coping, seeking emotional support, avoiding competitive actions, acceptance, and focusing on emotions and their release. Expecting professionalism was associated with active coping, planning, avoiding competitive actions, and distraction. The belief that the nurse was involved in the treatment process was significantly more often associated with planning, avoiding competitive actions, distraction, positive re-evaluation, and development. Those, who expected nurses to be available to the family used active coping, turning to religion, and acceptance. The respondents’ belief that nurses were empathetic was significantly associated with planning, seeking emotional support, and focusing on emotions and their release. Expecting nurses to be polite was related to the choice of seeking emotional support, positive re-evaluation and development, and focusing on emotions and their release. In the case of understanding, there was an increase in seeking emotional support, focusing on emotions and their release, and acceptance. Indicating caring was associated with the following strategies: seeking emotional support, turning to religion, positive re-evaluation and development, refraining from action, acceptance, focusing on emotions and their release, distraction, and sense of humor. As the expectation of sense of humor from nurses increased, the choice of strategies, such as turning to religion and refraining from action, also increased.
Statistical analysis demonstrated that use of alcohol or other psychoactive drugs (p > 0.05) and denial (p > 0.05) had no significant relationship with the respondents’ expectations of nurses’ skills, contrary to other strategies (Table 3).
The expectation of observation skills was associated with the choice of strategies, including active coping, planning, avoiding competitive actions, acceptance, and distraction. Indicating manual efficiency as the expected skill was related to planning, positive re-evaluation and development, refraining from action, focusing on emotions and their release, distraction, and cessation of action. Individuals, who expected nurses to provide information were significantly more likely to choose the following strategies: active coping, planning, avoiding competitive actions, positive re-evaluation and development, acceptance, and distraction.
As expectations for nurses to provide information about pre- and post-procedure care increased, so did the choice of the following strategies: active coping, planning, avoiding competitive actions, positive re-evaluation and development, refraining from action, acceptance, focusing on emotions and their release, and distraction. Those, who expected answers for all their questions were significantly more likely to choose all statistically significant strategies, except for seeking instrumental support, seeking emotional support, and turning to religion. The expectation of being accompanied by a nurse in suffering was associated with the choice of strategies, such as seeking instrumental and emotional support, refraining from action, acceptance, and focusing on emotions and their release. The expectation of psychological support from nurses was significantly related to the following strategies: active coping, instrumental and emotional support seeking, turning to religion, refraining from action, acceptance, focusing on emotions and their release, distraction, and cessation of action.
The analysis of coping strategies and selected socio-demographic variables was based on the rank of strategy occurrence, revealing five most frequently used strategies among patients.
A significant correlation was found between age and religious expression (p = 0.017); it was significantly more frequently chosen by older patients (Table 4).
A significant relationship was found between gender and selected coping strategies. Women were more likely to use seeking instrumental (p = 0.0251) and emotional support (p = 0.0013), while men were more likely to pursue active coping (p = 0.0233) and planning (p = 0.0243) strategies (Table 5).
There were no statistically significant correlations between the selected coping strategies and subjects’ education (p > 0.05).

Discussion

Spondyloarthritis represents a contemporary health problem and for some patients, surgery is the only option to improve their quality of life [6, 17]. Our study showed that most of the respondents struggled with degenerative disease of the lumbar spine. According to the data, such conditions are diagnosed in 75-85% of the general population, while cervical problems affect about 40% of patients [18]. Degenerative disease mainly affects individuals aged between 55 and 60 years (the onset of disease is reported around the age of 30) [1, 18], which is comparable with the results of our study, where the average age of the subjects was 52.8 years, with the youngest being 25 years old. Degeneration affects both men and women in similar percentages [18]. By comparison, in our study, more than half of the participants were women.
The results of our study revealed that the main complaint experienced by patients due to degeneration was pain. Similar results were shown by Kozłowski et al. [19], with Gajewski et al. outcomes confirming the presence of pain among the subjects [20]. Pain in the vast majority of the patients had a negative impact on daily functioning, limiting physical fitness and occupational performance. In Rosiek et al. study, the subjects confirmed limitations in mobility or daily hygiene activities [21]. The above-mentioned study results indicate the presence of complaints and their association with daily functioning.
Various forms of treatment are implemented prior to decision for surgery. In our study, the patients most frequently used rehabilitation and pharmacotherapy. In comparison, other studies most often reported pharmacotherapy and physiotherapy [22].
Preparation of patients before surgery is the subject of many studies. Rosiek et al. documented that the greater the patient’s anxiety before cardiac surgery related to ignorance, the greater the severity of pre-operative stress [21]. Mental and physical preparation, including extensive pre-operative education, constitute a method of reducing pre-operative anxiety [23], and therefore nurses should consider patients’ expectations of mental preparation for surgery.
In our study, the participants confirmed sufficient preparation for surgery by nurses. The patients appreciated their assurance of assistance with physiological or self-care activities as well as the ability to call if needed. Niechwiadowicz-Czapka emphasized the importance of informing the patient about necessary activities for his comfort [10]. Expert recommendations indicated a key role in prehabilitation through psychological preparation prior to surgery. Individual psychological support, recognition of needs, conversation, and presentation of techniques to reduce anxiety, all improve the patient’s well-being and cooperation with the physician [24]. A disturbing fact is that in our study, only 55.7% of the patients rated as “sufficient” the assurance provided by nursing in the administration of pain medications. Gawęda et al. proved that almost all patients experience pain after surgery [25]. Given these data, it seems that information about pain treatment should be clearly emphasized.
According to the respondents, the qualities of nurses, such as kindness, empathy, and understanding, are important in the patients’ mental preparation for surgery. Less indications were given to qualities, including supportive, comforting, or caring. In a study conducted by Sierpińska and Dzirba, patients described nurses as kind, sympathetic, and smiling, showing forbearance, cordiality, and kindness [26], while Jurkiewicz and Kobos demonstrated the importance of nurses’ caring and kindness [27]. Similar results were obtained by Kołpa et al. in a study on the image of a nurse in a same-day surgery unit, where a high percentage of the respondents appreciated nurses’ kindness and emotional support [28].
Main expectations regarding nurses in the current study were professionalism, kindness, and patience as well as observation of the patient’s condition, manual dexterity, and education on pre-and post-operative management. In a study conducted by Moczydłowska et al., the most desirable qualities of nurses were arousing trust, selflessness, responsibility, caring, and patience. In terms of skills, the patients expected observation, extensive knowledge, diligence, and accuracy in performing procedures, while manual skills ranked last. A significant percentage of the respondents agreed that the nurse should play the role of educator [29]. Similarly, Blöndal et al. showed that patients expressed a desire for more accurate information about post-operative complications and pain management after surgery [30], while more than half of the patients in Aust et al. study believed that proper communication on pre- and post-operative information would reduce their pre-operative stress levels [31].
Patients were coping with stress in different ways while waiting for surgery. The most common strategies were planning, seeking instrumental and emotional support, active coping, and religious expression. In comparison, Hasan et al. reported that patients most often selected active coping, planning, and seeking instrumental support before thoracic surgery [32]. In a study by Nagoor-Thangam et al., half of the patients reported using planning and active coping strategies [11].
Our research revealed that with age, the patients were more likely to use the strategy of religious expression. This may be related to the fact of high religiosity in Poland and its relationship with age. A research by the Central Statistical Office (CSO) in 2018 found that about 94.0% of the Polish population declared a religious affiliation, and higher religiosity was present among older people [33].
The current study showed a relationship between gender and coping strategies. The strategies undertaken and gender differences can be due to discrepancies in the emotional sphere of both genders, cultural context, or the generally existing stereotype of social roles of men and women. A study conducted by Kornaszewska-Polak found that women were more emotion-expressive than men, which may prompt them to seek emotional support. Men, on the other hand, were more likely to rely on logistical problem solving, being reserved in expressing emotions, and strive for independence [34]. In contrast, a study by Starczewska et al. showed no relationship between gender and education with coping strategies [35]. Also, our study found no relationship between education and stress coping strategies. In contrast, Szymoniak reported a statistically significant relationship between higher education of female patients and task-based coping strategies [36].
In addition, our study assessed the relationship between patients’ stress coping strategies and their expectations regarding the qualities, behaviors, and skills of nurses in preparing them mentally for surgery. The findings may lead to the conclusion that the presentation of positive qualities and behaviors by nurses builds a relationship with the patient, which is directly related to stress coping strategies. It is worth emphasizing that nurses’ skills, including instrumental and educational skills resulting from their competencies, not only ensure the physical safety of the patient, but also become a variable, which is important for the patient’s mental state.
Patient mental preparation for surgery by the nursing team is significant, and should continue to be the subject of in-depth research. Focusing on this aspect may allow for collection of data, which will guide the actions and attitudes of nurses towards improving the quality of care and patient satisfaction through a comprehensive, holistic approach to the patient, and strengthen the position of nurses as professionals in the therapeutic team.
Available research demonstrate that adequate prehabilitation, including psychological preparation, reduces pre-operative anxiety and has a positive impact on the post-operative period [14, 23, 24], with nurses playing a special role in this area [10].

Limitations of the research

The limitations of the study relate to small sample size due to deliberate selection of participants as well as specifics of the study and organizational conditions of the facility (the ongoing renovation of the operating theater prevented enrolling more potential patients until the end of the planned date), and refusal to participate in the study due to too much stress. According to some patients, their participation in the study could exacerbated their anxiety regarding the surgery.

Conclusions

The patients rated the mental preparation for surgery by nurses as sufficient, while their expectations included professionalism, courtesy, patience, observation skills, manual dexterity, education on pre- and post-operative management, and mental support skills.
The most common coping strategies used by patients to deal with pre-operative stress were planning, seeking instrumental support, active coping, seeking emotional support, and religious expression. Older individuals were significantly more likely to choose the religious expression strategy. Women were more likely to declare seeking emotional and instrumental support, while men mostly declared active coping and planning. No relationship was observed between education and stress coping strategies.
No relationship was found between seeking instrumental support, denial, use of alcohol or other psychoactive drugs and expectations of nurses in the area of their qualities and behaviors. There was also no relationship between use of alcohol/other psychoactive drugs or denial and patients’ expectations of nurses in the area of skills.
The patients’ expectations of the nursing team prior to surgery in terms of mental preparation should be an ongoing element of evaluation by nurses before undertaking therapeutic interventions due to individual perceptions of current situation, cause of disease, and treatment process.

Disclosures

This review received no external funding.
The study obtained approval of the Research Ethics Committee of the Jagiellonian University CM (number: 118.6120.107.2023).
The authors declare no conflict of interest.

References