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.