Nursing potential in elimination of stress factors in surgical patients Modernization of diagnostic and therapeutic procedures has led to improved quality of healthcare services. When healthcare is provided, it is important not to rely solely on advanced instrumental and material-technical equipment, because the patient certainly expects the other side of care as well, namely the human approach of healthcare workers and the fulfilment of psychological needs. Nurses can make a major contribution to the humanization of healthcare within their own workplaces. Nurses in surgical outpatient and inpatient care must include, in their approach to patients during the perioperative period, the elimination of stress-inducing factors, which can determine in the patient the onset of a strain situation with negative consequences especially for the postoperative course and the risk of postoperative complications. The field of eliminating stress-inducing factors in surgical patients can be improved from a nursing perspective as follows:
Rigorous implementation of the nursing process method in practice on surgical units, so this method is not merely a formal issue that nurses attend to only out of obligation and that is often only a burden for them without benefit to the patient, but one they understand as a method that contributes to individualized nursing care with regard to a specific patient’s needs (biological, psychological, social, spiritual). Nurses themselves need to participate in the improvement and simplification of nursing documentation adapted to workplace specifics, which will contribute to higher-quality nursing care and at the same time meet all practical aspects of efficiency for nurses (reduced time spent on administrative tasks). The documentation should also include a form for a thorough assessment of the patient’s stress experience, i.e., the presence of stressors. In assessing this area, nurses should use, besides the anamnesis interview (stress factors in the patient), patient observation (patient behaviour) and physical examination (changes in vital functions, skin colour, etc.), which the nurse applies not only at admission to the unit, but throughout the whole period of hospitalization. Thorough patient assessment must lead to responsible nursing diagnosis, or diagnoses, and it is useful when a list of nursing diagnoses is available to nurses, with those that may be determined in a patient experiencing stress or at risk of stress. Patient assessment, however, does not end with admission; it must be a continuous process throughout hospitalization so that psychological reactions to the changing health condition can be tracked. Stress factors and stress experience also have to be considered when caring for the patient in outpatient care.
Nurses should attend to the elimination of stress-inducing factors from patient admission to a surgical inpatient ward up to discharge to home care. The first impression is extremely important and can influence the patient’s behaviour and cooperation during the entire period of hospitalization. Nurses should remember how they introduce themselves to newly admitted patients with an appropriate approach. A patient may not be able to identify the nurse who will care for them based on attire alone, as this is no longer exclusively “blue-and-white.” Breaking anonymity helps open nurse-patient communication and creates a climate of trust and security, which has a positive effect on the patient’s psychological experience during the perioperative period.
Nursing care cannot be provided to a surgical patient without a holistic approach, which is also important for eliminating stress-inducing factors. A patient is influenced not only by disease or injury symptoms, but also by the operation itself as part of treatment. At the same time, it is necessary to remember that not only the biological needs change, but also psychological, socio-cultural, and spiritual needs. Whether perioperative nursing care will be only supportive, partly compensating, or fully compensating depends entirely on the patient’s somatic and psychological condition, which nurses monitor throughout care. Nurses must take into account the seriousness of the patient’s health condition, the circumstances of disease onset and surgical indication, social situation, and life roles (for example, a breastfeeding mother, a mother caring for an injured child dependent on her support, a son or daughter caring for a dependent parent, a family breadwinner, and so on).
An important factor for eliminating stress-inducing factors and their consequences in both outpatient and inpatient surgical care is considering the patient’s age, typology, and cultural specifics. Age can influence both the type of stressors and the variety of responses to them. Then nursing and other healthcare team members approach differs for a child at various developmental stages (infant, toddler, preschool child, adolescent, etc.), for a younger or middle-aged adult, and for a senior.
Nursing care for surgical patients is often not possible without cooperation with the patient’s support persons, not only for meeting psychosocial needs but also because of their necessary participation in care of the patient’s family member after discharge or in outpatient treatment. To improve fulfilment of psychosocial needs, it is essential to emphasise hospitality when enabling family visits on a surgical inpatient ward, which is one of the patient’s rights. There are situations where ward operation and the patient’s condition do not allow this (e.g., ICU), and then alternative forms of communication between patient and family should be used (e.g., direct phone contact between family member and patient, relaying messages through healthcare professionals, and so on). For immobile or disabled patients with functioning family support, family motivation and involvement in post-discharge care are important.
An effective communication including a psychotherapeutic approach should, as an obvious part of nursing care for a surgical patient both on the ward and in outpatient care. Supportive conversation is essential especially before and during painful procedures (e.g., examinations, dressing changes, etc.), before and after surgery, particularly in radical and mutilating operations. Effective communication should not be limited to the interaction with outpatient or hospitalized patients, but also with their support persons. A specific area of communication with the surgical patient is the delivery of negative information (e.g., histology results confirming the presence of oncological disease). Passing this type of information lies within the physician’s competencies. Bad news should be communicated to the patient gradually and with regard to patient typology to avoid retraumatization. Nurses have an important role in working with the patient after negative news has been delivered. In this stage of care, nurses must apply an appropriate approach and communication skills, as well as observational abilities focused on detecting behavioural changes and creating space for the patient’s emotional processing.
The education of the surgical patient has an unquestionably positive effect on eliminating stress factors. Thoroughly educated patients cooperate better during perioperative care in outpatient or inpatient settings and actively prevent postoperative complications themselves. They also adapt better to temporary or permanent changes in life situation. Nurses should use, in addition to spoken-word methods, printed materials and demonstration methods, as well as various alternative educational methods. Word as an educational means should be supplemented with written information (an educational leaflet) so the patient can return to important information at any time, including at home. Nurses should also participate in creating written educational materials, because they best know which information is essential to communicate to patients. Nurses should not forget demonstration when education requires or benefits from it, as this contributes to better retention of patient knowledge and skills. Documentation of education is also necessary to ensure continuity of educational activities carried out with the patient. A suitable educational environment contributes not only to educational efficiency but also to elimination of stress-inducing factors. It should be stressed that education itself can become an additional stressor for the patient, and this should be prevented by following principles of effective education. To make education more efficient, we recommend developing and adhering to educational standards and creating educational sheets for both nurse and patient. A surgical patient undergoing operative therapy, however, should not be educated only by nurses, but also by the attending physician, the operating surgeon, anesthesiologist, and other healthcare professionals depending on health status or type of surgery.
The nurse (like the attending physician) does not have to be the only source of information for the patient, but it is appropriate—and often essential—to recommend other information sources such as educational leaflets, brochures, and, nowadays, the internet. The internet can be a useful source for surgical patients of all ages (including seniors), provided basic conditions are met, namely computer and information literacy and technical equipment with internet access. It is necessary, however, to emphasize that information should be selected critically so patients do not treat everything found online as infallible or universally applicable. Through the internet, patients can find information on, for example, lifestyle in relation to various surgical diseases and prevention, preoperative preparation and postoperative care, and different surgical services (free choice of healthcare facility). Many healthcare institutions provide important information for surgical patients on their web portals (e.g., personal items needed during hospitalization, preoperative preparation, and similar). The internet is also a valuable source when searching for contact or details about self-help groups that nurses may recommend during education. When creating or choosing already prepared educational materials for patients, the same principle applies: careful selection of an appropriate leaflet or brochure for each patient based on multiple perspectives (age, health and psychological state, socio-cultural specifics, etc.). Nurses in surgical units where patients of other nationalities are often treated should remember the importance of producing information materials in foreign languages as well (for example, members of national minorities, tourists, etc.).
Privacy and patient safety must not be missing in nursing care for a surgical patient, both on inpatient units and in outpatient care. A surgical disease or injury, especially when treated operatively, is an intervention into the most intimate sphere of a person. Accordingly, it is necessary to ensure the patient’s privacy in outpatient as well as institutional care: in the patient room, in the examination room or dressing area, in the operating room, ICU, and elsewhere. Patient safety should not be underestimated either. A patient may be weakened by the disease or injury itself, affected by effects of anesthetics or other medications, and may also exhibit altered behaviour due to disease symptoms (e.g., unbearable pain) or severity of condition (e.g., diagnosis of an incurable disease).
Closely linked with both patient safety and elimination of stress-inducing factors is modification of the environment and workflow on surgical units. Nurses often do not have the ability to select patients for wards based on health or psychological status, but they have broad possibilities to ensure patient comfort and to adjust the immediate surroundings. Patients in acute, critical, or immediate postoperative states are placed in intensive care. Even there, nurses must not underestimate the impact of environment and workflow on the patient’s psyche (numerous pieces of equipment), amplified by the patient’s anxiety about their health status and functioning in later life.
Eliminating stress-inducing factors in nursing care of surgical patients is not possible when various barriers in nurses’ work are present, and these are confirmed not only by nurses themselves but also by patients. In this regard it is necessary to call on managers of surgical units or healthcare institutions so that leadership efforts also focus on removing barriers in nursing care—most importantly by optimal staffing, improving and streamlining nursing documentation, ensuring suitable working conditions, observing psychohygiene and working hours, and reducing administrative burden through broader use of information technologies.
Care of the surgical patient is based on team collaboration among surgeons, anesthesiologists, nurses, support staff, as well as physiotherapists, nutrition assistants, consultant physicians (e.g., internists, otolaryngologists, neurologists, etc.), and others. Teamwork is impossible without effective communication, cooperation, and responsible nursing documentation. Only this ensures continuity of care and maximum benefit to the patient. Part of teamwork should also be genuine interest in the patient’s psychological state, not only in somatic changes based on surgical disease or injury. Findings and observations from one healthcare professional in caring for a surgical patient should be passed on to the entire nursing and healthcare team as shared information.
Thorough performance of all nursing procedures, combined with an appropriate patient approach, can help eliminate stress-inducing factors. For all examinations and painful or otherwise unpleasant procedures (for example, wound dressing changes), the patient must be prepared psychologically as well. Observance of nursing standards should be a given, including in the psychological domain (for example, a standard for psychological preoperative preparation). A major contribution to monitoring stressors and the patient’s psychological state also lies in conducting nursing rounds, during which nurses as a nursing team assess the patient’s current condition, reflect on current needs, and exchange information with one another.
Perioperative nursing care, preoperative, intraoperative, and postoperative, must also have a preventive character regarding possible intraoperative and postoperative complications, on whose development stress experienced by the patient may also have a role. Skilled nurses must anticipate stressors based on the disease, patient personality, scope and type of surgical procedure, its (possible) consequences, and the method of anesthesia. In procedures carried out under general anesthesia or neuraxial blocks, a nurse from anesthesiology monitors and cares for the patient (also psychologically). The situation differs in procedures performed under local anesthesia. Even though these are usually small operations, psychological care must not be underestimated. In addition to responsible preparation of materials and assistance during the procedure, the nurse must meet the patient’s psychological needs to reduce stress.
A major contribution to eliminating stress-inducing factors is consistent psychological preoperative preparation, which should of course continue in the postoperative period by addressing not only somatic but also psychological needs, which are modified to varying degrees after surgery. Nurses should not forget the important stage of discharge and subsequent care, when the patient must adapt to new conditions associated with their postoperative state (for example, postoperative pain, physical disability, change in lifestyle, and so on). All patient data from nursing perspective, including psychological state, should also be documented in the nursing discharge or transfer report to ensure continuity of care in psychological terms as well.
An effective way of eliminating stress-inducing factors and alleviating stress in the surgical patient, particularly in radical and mutilating procedures or after diagnosis of an incurable disease, may be cooperation with a clinical psychologist of the facility. A clinical psychologist has a justified place in the healthcare team caring for surgical patients because they can effectively influence patients’ psychological experience positively, thereby reducing consequences of severe disease and surgical procedures.
In surgical specialties we relatively often encounter people in material hardship, homeless people, older adults living alone, dependent individuals, or people disabled by injury or surgery, for whom their life situation can be a major stressor, especially around discharge to home care. Addressing such problems lies beyond the competencies of surgical nurses, which is why cooperation with the facility’s social nurse is important. Such cooperation can contribute to comprehensive problem-solving (for example, home-care support services, meal delivery, and so on). To address social problems of hospitalized surgical patients, and other patients too, not only social nurses but also hospital social departments can contribute; their development is essential and should be supported.
Nursing care of the surgical patient does not end with discharge to home care, but continues in outpatient form or by transfer to another unit or healthcare/social facility. Therefore, cooperation and communication among nurses of surgical wards and nurses from individual types of healthcare institutions is necessary—not only from surgical specialties (surgical clinic, oncological surgery clinic, mammology clinic, vascular surgery clinic, etc.), but also from other specialties and services, such as paediatric or adult general practice, diabetology, paediatrics, endocrinology, and others. In care, especially at discharge, collaboration between nurses in outpatient or inpatient surgical care and nurses from home healthcare agencies is indispensable (e.g., immobile patient, patient with chronic wound, etc.).
Nurses (also from surgical workplaces) can further develop their “psychological” care for patients through additional education. Nurses with a master’s degree in nursing can expand professional competence through certified training in psychotherapeutic practice. At present, training in psychotherapy is provided by the Slovak Institute for Training in Cognitive Behavioural Psychotherapy. Following the example of the Czech Republic (UNV Prague), training in socio-psychological intervention could be made available to nurses, carried out by hospital psychological departments. Such training could help not only by improving the quality of care for patients’ mental health but also by protecting nurses’ own mental health (burnout prevention).
The specifics of care for the psychological dimension of surgical patients must be presented in various nursing seminars, workshops, national and international conferences, or published in professional nursing journals. This can significantly contribute to experience exchange among nurses working in surgery and increase nurses’ awareness of the latest knowledge and trends in nursing care of surgical patients, not only in the area of somatic needs but also psychological, socio-cultural, and spiritual needs. Oral or written presentation of this topic can also substantially help beginning and less experienced nurses in surgical nursing care.
PhDr. Bc. Mariana Magerčiaková, PhD. Katolícka univerzita v Ružomberku, Fakulta zdravotníctva, Katedra ošetrovateľstva