AORN JOURNAL DECEMBER 1991, VOL 54. NO 6

The Effect of Humorous Distraction on Preoperative Anxiety

A PILOT STUDY

Kathleen B. Gaberson, RN ost surgical patients experience pre- operative anxiety. This anxiety can M interfere with learning, affect the

amount of preanesthetic medication and anes- thetic agents needed, and contribute to postop- erative pain, thereby contributing to the cost of

surgical patient care. A nursing intervention that effectively reduces preoperative anxiety has the potential to reduce the incidence of perioperative complications and shorten hospi- tal stays for surgical patients.

Literature Review

Kathleen B. Gaberson, RN, PhD, is assistant professor, gruduate iiursiiig progrmi, Diqiresrie Universih School of' Nursing, Pittsburgh. She earned her nursirig diplonin at Presbyteriaii- Uni13er.sity Hospital School of Nurs ing , Pittsburgh. and her- hrichelor of science degree in nursittg at Cr i r lo~ , College, Pittsburgh. She earned her master's degree in izursing educa- tion nnd her doctorate in curricirliiin and super- vision cit the Univrr.yic, of Pittsburgh.

The author thanks Kureii Li\*iiigston, RN, for her contributions to this project cis research assistatzt. This stud\. U ~ S siipporterl by LI grant from the Himkelr Fuculh Developnient Fund, Diiyiie~iir University, Pittsburgh.

ittle nursing research documents the effectiveness of preoperative nursing L intervent ions in reducing anxie ty .

Recent studies investigating the effects of tran- quil music on preoperative and postoperative anxiety demonstrated some reduction in anxi- ety.' Methodological flaws were identified in each of these studies, however, and these affect the generalizability of the results.

Since Norman Cousins's account of the role of laughter in his recovery from a collagen dis- ease in 1976,' interest in the use of humor in health care has increased. Humor has been studied as a means of managing stress and relieving anxiety,' enhancing immunity4 and circulatory efficiency,' and teaching postopera- tive exercise routines.' Before this pilot study was undertaken, however, no nursing research had studied the effect of humorous distraction on preoperative anxiety.

Conceptual Framework

he Roy Adaptation Model provided the conceptual framework for my study.' In T this systems model, the person is seen as

a biopsychosocial being who constantly inter-

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Fig 1. Visual Analog Scale. Subjects marked the line at the point that repre- sented their current level of apprehension, tension, nervousness, or worry in anticipation of surgery.

acts with a changing environment. The environ- ment contains conditions, circumstances, and influences that affect the person’s behavior. The goal of nursing is to help the person adapt by managing the environment.

In this study, preoperative patients tried to adapt to the changing circumstances of the sur- gical experience. Preoperative anxiety is a com- mon response to these changes in environmen- tal conditions. Humorous distraction was used as a nursing intervention to help the patient adapt to preoperative anxiety.

Hypothesis, Methodology

designed this study to test the following hypothesis: There are lower levels of preop- I erative anxiety among patients who listen to

humorous audiotapes than among patients who listen to tranquil music audotapes. Patients who do not listen to audiotapes have higher levels of preoperative anxiety than patients who listen to humorous or tranquil music audiotapes.

This research project was a pilot study to test the research procedures and to determine the feasibility of conducting a larger study at a later time. Therefore, the sample size was intention- ally small, and data collection was limited to one site.

Sample. The sample (n) consisted of 15 preop- erative patients who were waiting for same day surgery. Male and female subjects who met in- clusion criteria were recruited from the same day surgery waiting room of a Pittsburgh hospital.

To be eligible for participation as research subjects, patients had to be 21 years of age or

older and be admitted for same day, elective surgical procedures. I obtained consent from the patients’ surgeons for the patients’ partici- pation, and the patients gave written informed consent to join the study.

Potential subjects were excluded from the study if they did not speak, understand, and read English; if they had a hearing loss that pre- vented them from using a tape player with ear- phones; or if they had taken any anti-anxiety medication within 24 hours before admission. Patients having surgery for diagnostic purposes also were excluded from the study, as these patients may have unusually high state anxiety levels as compared to the general population of surgical patients. *

Design. This study used an experimental, three group posttest research design. Subjects who met inclusion criteria were assigned ran- domly to one of two treatment groups or the control group; each group contained five sub- jects. Group one was the control group, group two received the musical intervention, and group three received the humorous intervention.

Variables. The dependent variable of this study was preoperative anxiety. The indepen- dent variable was a 20-minute wait in the same day surgery waiting room. During that time, subjects in the two treatment groups listened to audiotapes on a tape player. Control group sub- jects did not receive additional intervention.

Instrument. The dependent variable-preop- erative anxiety-was measured with a Visual Analog Scale (VAS), a 10-cm horizontal line with defined ends representing extreme limits of preoperative anxiety (Fig 1). The left end of

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the line was labeled "no I also purchased a num- sensation," and the right Table 1 her of comedy audiotapes. end of the line was labeled Deqpqp&# of h e Sample These tapes were evaluat- "as much as could possibly ed by 17 subjects (similar be." Each subject was characteristic n' to those who would later instructed to mark the line participate i n the pilot at the point that represent- Age study). Each participant ed his or her current level listened to two tapes and of apprehension. tension. 20-29 1 rated them on a five-point nervousness. o r worry in 30-39 3 scale from "not a t all anticipation of surgery. 40-49 3 f u n n y " to "extremely The scorc was the distance 50-59 2 f u n n y " (me t hodo 1 o g y in centimeters froin the left 60-69 2 adapted from previous end of the line to the sub- 70-79 4 research"). Each audio- ject's mark. tape was evaluated by

This instrument was Gender several subjects. The tape reported to be a valid and that received the highest reliable self-report mea- Female 9 rating (3.40) was comedy

routines f rom two Bill sure of preoperative anxi- ety in a previous study." Cosby albums. Re1,enge That study included 40 and Woticlerful1tir.v.~. women admitted for The next s tep was ambulatory surgery, and the subjects' scores on obtaining the consent of surgeons who admitted the VAS and the Spielberger State Anxiety patients to the selected same day surgery unit. Inventory (SAI) were highly correlated ( t - = Each surgeon received a letter describing the 0.84). Those subjects reported that the VAS study and a consent form seeking his or her was easier to use than the SAI. The oral direc- cooperation. The surgeons' consent forms were tions for the VAS were easy to understand. and returned to me. Thirteen surgeons allowed their the subject could respond to the instrument in patients to participate in the study. seconds. The VAS instrument also has the A graduate nursing student assisted me by capability to measure an infinite number o f scheduling data collection days in cooperation points between extremes. rather than requiring with the same day surgery uni t director. Data subjects to respond to the descriptive limits of collection days varied within the week to con- scale points. trol for a possible "day" effect.

On data collection days, the research assis- tant or I checked the same day surgery schedule against the list of consenting surgeons. We read the medical records of patients whose surgeons had consented to determine if these patients met inclusion criteria for the study.

Patients who met inclusion criteria were given a brief oral explanation of the study and asked to participate as research subjects. Those who agreed signed the consent form. One copy of the consent form was given to the subject, one copy was placed on the patient's chart, and I retained one copy. Three patients who were eligible to participate declined to do so.

Male 6

*n = 15

Research Pmceriures

obtained permission to conduct the pilot study from the Research and Human Subjects Committee of the hospital and

from the Duquesne University, Pittsburgh. Institutional Review Board.

The first step was selecting appropriate musical and humorous audiotapes. 1 purchased an audiotape o f slow. quiet. instrumental music. I chose On7t7i S u i t e , by Steven Rergman. because i t met the standards of tranquil music as defined in previous research.'"

I

removal, and inguinal hernia repair. Table 2 shows the means (M) and standard

deviations (SD) for preoperative anxiety by group. The range of possible scores on the VAS was 0 to 10. Although the mean anxiety scores in all groups were fairly low, the humor group reported the lowest levels of anxiety, and the control group reported the highest levels, as predicted by the research hypothesis.

To test the research hypothesis, a one-way analysis of variance (ANOVA) was performed on the group mean scores. Results revealed no significant difference between the group means (Table 3 ) ; the F value (1.48) is not significant at the 0.05 level. Therefore, the research hypothesis was not supported. However, a moderate effect size (0.496) suggests that the lack of significance was due to the small sam- ple size. Therefore, I am encouraged to repeat the study with a larger sample and hope to achieve statistical significance.

Discussion

umorous distraction appears to be at least as effective as tranquil music in H reducing preoperative anxiety.

Subjects who experienced no intervention dur- ing their wait before surgery reported the high- est levels of preoperative anxiety.

Consistent with other findings," the self- reported anxiety levels of all subjects in this

Table 2 Means and Standard DeviQtions for Anxiety

Group n M SD

Control 5 2.76 1.23 Music 5 1.48 1.55 Humor 5 1.40 1.42

Subjects were assigned randomly to one of the three groups. Each subject in a treatment group was given a tape player and a headset and listened to a humorous audiotape or a tran- quil music audiotape for 20 minutes. Earpieces of the headsets were cleaned with alcohol wipes between uses. Subjects in the control group received no additional intervention dur- ing the 20-minute waiting period.

During the 20-minute intervention period, necessary demographic data were obtained from subjects' medical records (eg, age, gen- der, type of surgery). After the intervention (ie, waiting or listening to audiotape), we gave the subjects oral instructions for completing the VAS and asked them to mark the scale. If a subject was called into the same day surgery unit before data collection was complete, he or she was eliminated from the sample.

After data collection, we asked all treatment group subjects if they had ever heard the audiotapes before; all subjects reported that the music and humor audiotapes were Table 3 new to them. ANOVA Summary

Table for Anxiety

Source df MS*' F' Ptr he ages of subjects ranged from 23 years to 76 years; there were nine Between groups 2 2.91 1.48 267 women and six men (Table I). The

surgical procedures scheduled included cataract extraction, breast cyst excision, eyelid repair, carpal tunnel release, joint fusion, osteotomy, endarterectomy, metatarsal head resection, shunt insertion, leg vein excision, intermeddulary nail

Results

12 1.97 Withill groups

'df = degrees of freedom * * MS = between group mean square ?F = F ratio

"P = probability

T

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study were lower than might be expected from a review of the literature. This phenomenon may be attributed to the use of a self-report measure. Subjects may use denial as a coping mechanism, although casual observation of subjects during the 20-minute waiting period and completion of the VAS revealed no behav- ioral manifestations of excessive anxiety.

Statistically significant results were not anticipated because the purpose of the study was to test research procedures, and the sample size was limited. The research procedures were valid, and I now have a realistic estimate of how much time it will take to recruit and col- lect data from a larger sample. The procedures of this pilot study will be repeated in a larger multi-site study.

Recommendations

lthough the results of this study were not statistically significant, they sug- A gest a trend that may have implications

for clinical practice. Further research is needed to test the effect of humorous distraction on preoperative anxiety before findings can be generalized beyond this sample. Although my next research project will replicate this pilot study, the following changes in methodology are suggested for additional studies.

Although I randomly assigned subjects to groups to control for any differences in the type of surgical procedure, this variable may be fur- ther controlled by limiting the sample to patients who are undergoing one surgical pro- cedure. Another way to control this variable might be to use a stratification technique. All subjects scheduled for a given surgical proce- dure would comprise a layer of the sample, and subjects within that layer would be assigned randomly to treatment groups.

Similarly, I did not control for the distribu- tion of subjects to groups by gender other than by random assignment. Future studies might use stratified random sampling to assign equal numbers of men and women to each group.

In this study, subjects were unable to choose a musical selection or humor audiotape to allow

for different preferences. A four-group design in which one group is permitted to select either a musical or humorous audiotape might be used to test whether the tape of preference has an effect on level of preoperative anxiety.

Conclusion

A nursing intervention that reduces pre- operative anxiety can reduce the inci- .dence of perioperative complications

and shorten hospital stays for surgical patients. Further nursing research should study the effects of humorous distraction on preoperative anxiety. Results of this research would be of interest to nurses and hospital administrators as well as to perioperative nurses, surgeons, and anesthesia personnel.

Notes I . V A Moss, “The effect of music on anxiety in

the s u rg i c a1 pat i en t , ” Pe riope rat i v e Nu rs in g Ouarterly 3 (March 1987) 9-16; G Kaempf, M E Amodei, “The effect of music on anxiety: A research study,” AORN Journal 50 (July 1989) 112-1 18; V Steelman, “Intraoperative music therapy: Effects on anxiety, blood pressure,” AORN Journal 52 (November 1990) 1026-1034.

2. N Cousins, Anatomy of an Illness a s Perceived by the Patient: Reflections on Healing and Regeneration (New York City: W W Norton & Co, 1979).

3. R Safranek, T Schill, “Coping with stress: Does humor help,” Psychological Reports 5 1 (August 1982) 222; N F Dixon, “Humor: A cogni- tive alternative to stress?’ in Stress and Anxiety vol 7 , ed I G Sarason, C D Spielberger (Washington, DC: Hemisphere Publishing Corp, 1980) 281-289.

4. A A Stone et al, “Evidence that secretory IgA antibody is associated with daily mood,” Journal of Personality and Social Psychology 52 (May 1987) 988-993; K M Dillon, B Minchoff, K H Baker, “Positive emotional states and enhancement of the immune system,” International Journul of Psychiatry in Medicine 15 no 1 (1985-1986) 13-18.

5. W F Fry, W M Savin, “Mirthful laughter and blood pressure,” Humor: International Journal of Humor Research 1 no 1 ( 1 988) 49-62.

6. J Parfitt, “Humorous preoperative teaching: Effect on recall of postoperative exercise routines,” AORN Journal 52 (July 1990) 114-120.

7. C Roy, Introduction to Nursing: An Adaptation Model, second ed (Englewood Cliffs, NJ: Prentice-Hall, 1984).

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8. D W Scott, “Anxiety, critical thinking and information processing during and after breast biop- sy,” Nursing Research 32 (JanuarylFebruary 1983)

9. J Vogelsang, “The Visual Analog Scale: An accurate and sensitive method for self-reporting pre- operative anxiety,” Journal o,f Post Anesthesia Nursing 3 (August 1988) 235-239.

24-28.

10. H L Bonny, N McCarron, “Music as an adjunct to anesthesia in operative procedures,” AANA Journal 52 (February 1984) 55-57.

11. C D Wilson, 3 Rust, J Kasnel, “Genetic and family origins of humor preferences: A twin study,” Psjchologicd Reports 41 (October 1977) 659-660.

12. Steelman, “Intraoperative music therapy: Effects on anxiety, blood pressure,” 1032.

Nurses Promote Child Immunization Programs The American Nurses Association (ANA) is conducting a national campaign to promote childhood immunizations. The campaign, “Keeping the Promise-Reaching America’s Children,” is part of nursing’s efforts to imple- ment Nursing’s Agenda for Health Care Reform, according to an article in the July/ August 1991 issue of The American Nurse. The ANA states that nurses are the primary contacts with children and families, and the campaign by nurses will ensure that youngsters receive the vaccines necessary to prevent dis- ease.

The campaign has several elements for 1991/1992. In cooperation with the Children’s Action Network and the American Academy of Pediatrics, ANA will implement media and public awareness events. In addition, immu- nization events, including screening, immu- nization assessments, actual immunizations, and follow-up information, are planned for eight target urban areas. The target cities are Chicago, Detroit, Houston, Los Angeles, Miami, New York City, Philadelphia, and Washington, DC.

The ANA also will solicit proposals from state and district nursing associations for pro- grams to reach children in rural areas. Grants of up to $5,000 will assist with the develop- ment of education materials and the purchase of supplies and vaccines. The ANA also will participate in the federal childhood immuniza- tion initiative. Nurses interested in becoming involved in the immunization campaign should contact their state nurses association.

We Should Learn to Live with Asbestos Asbestos can never be completely eliminated from our environment, and we should learn to live with it the best way possible, according to the American Medical Association’s Council on Scientific Affairs. After studying potential risks of asbestos exposure and current manage- ment options, the council concluded that it would be wiser for America to use its resources to learn to live with asbestos safely than to try to remove it completely from the environment. Improved procedures for manag- ing its use, containment, and disposal are real- istic priorities to prevent asbestos-related injury.

According to the council’s report in the Aug 7, 1991, issue of the Journal of the American Medical Association, the present plan of mov- ing asbestos from one area to another will not eliminate the problem. The risk of exposure will rise again at another place. The cost of asbestos removal is very high. The council reports that the cost of removing asbestos from 107,000 schools in 1988 was $3.4 billion. If all commercial and public buildings were includ- ed in the cleanup, the cost estimates increase to $53 billion to $1 50 billion.

The council’s report also pointed out that current Environmental Protection Agency reg- ulations do not require the removal of all asbestos. Asbestos must be removed only if the damage is extensive and severe, and other actions (eg, special maintenance, repair, encap- sulation, enclosure) will not control the release of fibers.

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