NOVEMBER 2000, VOL 72, NO 5

Norred

Minimizing Preoperative Anxiety With

Alternative CaringHealing Therapies

T he integration of alternative therapies in the OR

can enhance acceptance from holistic patients
and can balance the anxiety and stress experi-
enced by surgical patients. In a qualitative
analysis of the preoperative concerns of surgi-
cai patients, the need for caring was the most common
theme of concern after the feaT of death.‘ Mental stress
may alter heart rate variability and negatively affect
sympathovagal balance, possibly leading to sudden
ing is intrinsic to the therapeutic interpersonal rela-
tionship between the nurse and patient. Ten primary
carative factors form the structure of Dr Watson’s car-
ing theory (Table 1).6 For more than 20 years, Dr
Watson’s philosophy and science of caring has been a
beacon of light and understanding to guide holistic
nursing practice toward a renewed view of healing as
a change in consciousness that integrates physical,
psychosocial, and spiritual needs.’
death in patients with coronary artery disease.’ This The holistic perioperative nurse can be a tool of
analysis of holistic interventions to minimize preoper- healing in patient care through the intentional, com-
ative anxiety is based on the philosophy and science of passionate, caring, therapeutic use of self. Caring and
caring of Jean Watson, RN, PhD, FAAN,’ and inte- concerned nursing efforts help reinforce the patient’s
grative “caring-healing’’ therapies that she considers coping mechanisms.’ The nurse’s therapeutic demon-
components of her caring theory in nursing.“ stration of holistic caring-healing therapies, therefore,
could improve the patient’s innate coping abilities
A N€W -M IN HEAETH CARE and enhance the pharmacologic administration of
Dr Watson believes that a new paradigm is benzodiazepines to relieve preoperative anxiety.
emerging in health care. She states that conventional
medicine has become increasingly technological, typ- PSYCHOLOGICAL CARING-HWNG THERAPIES
ically centering on treatment to cure disease with Psychological caring-healing therapies strive to
medications and surgery.’ In contrast, the caring instill hope or faith.” To meet the psychological or spir-
approach of nursing focuses on conscious compas- itual needs of patients, nurses traditionally incorporate
sionate skills that help patients achieve a healthy state humanistic, altruistic values by using the power of
of mind, body, and spirit. Dr Watson relates that car- prayer, spiritual beliefs, or suggestions or through a
trusting therapeutic nurse-patient
relationship.‘’ The nurse’s relation-
A B S T R A C T ship and interpersonal teaching
This article reviews holistic caring-healing therapies that may enables the patient to provide self-
decreasr y - f - . n * i * r a anxiety for the surgical patient, based on the care, determine personal needs,
philosophy and science of caring developed by Jean Watson, RN, and provide opportunities for per-
PhD, FAAN. Dr Watson reveals a new paradigm emerging in health sonal growth.” Therapeutic com-
care that blends the compassion and caring of nursing in harmony munication is implemented
with the curative therapies of medicine. Hypnosis, aromatherapy, through nonverbal behavior and
music, guided imagery, and massage are integrative caring-healing listening, facilitating nonposses-
therapies that may minimize preoperative anxiety. Alternative thera- sive warmth, initiating self-under-
pies offer a high-touch balance when integrated with high-tech con- standing, and communicating with
ventional surgical treatments. AORN J 72 (Nov 2000) 838-843. personalized responses to develop

CAROL L. NORRED, RN

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Table 1
DR WA’MON’S CARATWE FACTORS IN NURSING’
Formation of a humanistic-altruisticsystem of values.
Instillation of faith-hope.
Cultivation of sensitivity to ones self and to others.
Development of a helping, trusting relationship.
Promotion and acceptance of the expression of positive and negative feelings.
Systematic use of the scientific problem-solving method for decision making.
Promotion of interpersonalteaching-learning.
Provision for a supportive, protective, and/or corrective mental, physical,
sociocultural, and spiritual environment.
Assistance with the gratification of human needs.
Allowance for existential-phenomenologic forces.
NOTE
1 . J Watson, Carative factors in nursing, in Nursing: The Philosophy and
Science of Caring (Niwot, Colo: Universify Press of Colorado, 1985) 9-10.
a helping, trusting relationship.” A perioperative nurse
who asks the patient what he or she is most concerned
about before or during the preoperative interview, then
patiently listens to the expression of fears, exhibits kind-
ness and caring concern for the patient’s well-being.
After developing a therapeutic trusting relation-
ship, the nurse can help the patient relax before sur-
gery with the caring-healing therapies of holistic
nursing. Therapeutic communication using hypnotic
suggestions may decrease the patient’s anxiety before
surgery, as well as after surgery. Researchers report
that “hypnosis is an approach for achieving a focused
awareness and expanded consciousness with dimin-
ishing perception of peripheral sensations, thoughts,
and feelings.”” Hypnosis has shown promise for
decreasing analgesic requirements and anxiety during
conscious sedation and has been demonstrated to
lessen acute and chronic pain.
In a randomized, controlled study of 60 patients
undergoing local anesthesia with sedation for plastic
surgery, hypnosis was used as an approach to reduce
perioperative discomfort during conscious sedation.
Despite significant reductions in alfentanil and mida-
zolam administered to the hypnosis group ( P < .OOl),
perioperative anxiety and pain were significantly
lower in the group receiving hypnosis compared to
the control group that received stress-reducing strate-
gies ( P < .OOl).“ In another study, patients ungoing
coronary artery bypass surgery, who were taught self-
hypnosis, were significantly more
relaxed postoperatively (P = .032)
and required less pain medications
( P = .046) than the control group
that received no therapy.I5
General anesthesia or seda-
tion induces a hypnotic state;
therefore, a nurse’s calming words
(eg, “You will be more relaxed
and comfortable with each breath
that you take”), while instructing
the patient to progressively relax
and take deep slow breaths, could
relieve anxiety during sedation or
induction of anesthesia.
VISUAL THERAPIES
Caring-healing therapies can
include both visual and imagery
processes to affect emotions and
“help to calm, soothe, relax, and
enhance images of harmony and
wholeness of being.”I6 Therapeutic communication
with guided imagery is a cognitive tool that acts as a
mechanism for perceptional, emotional, and bodily
change. Use of guided imagery has been promoted to
facilitate the healing process; to control acute or
#!8ftfk F%!!;h t h physical and psychological; and to
decrease anxiety and fear.” Patients undergoing elec-
tive colorectal surgery who listened to guided
imagery tapes for three days before surgery, during
induction, and for six days postoperatively experi-
enced considerably less preoperative and postopera-
tive anxiety and pain and required almost 50% less
narcotics after surgery than patients in a control
group.IXListening to guided imagery audiotapes is a
simple method to help patients use their imaginations
to create images of temporary escape and relaxation
that elicit a sense of well-being.
AROMATHEWY
Nurses recognize the influence of the patient’s
environment on well-being, and they value factors in
the external environment, such as comfort, privacy,
safety, and clean aesthetic s u r r ~ u n d i n g sDr
. ~ ~Watson
suggests using aromatherapy to create a relaxed
environment.’” Aromatherapy may have therapeutic
effects on psychological states, such as depression
and anxiety.” Though few clinical studies have doc-
umented the antianxiety effects of aromatherapy, one
researcher reports that the scent of essential oil5 (eg,

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Non-ed

lavender) has a therapeutic effect on brain waves
and can alter behavior to encourage the healing
process through relaxation and the relief of stress.22
A drop of lavender on a surgical mask provides a
therapeutic aroma that can offset unpleasant odors
and relieve anxiety during the patient’s periopera-
tive experience.
MWlCTHERAPY
Soothing music in a preoperative holding area or
OR may suggest an environment of sensitivity and
caring to anxious surgical patients. Dr Watson sug-
gests music or sounds of nature for therapeutic heal-
ing purposesZ3Music therapy complements conven-
tional medicine “to effect changes in behavior, emo-
tions, and physiology and to reduce psychophysio-
logic stress, pain, anxiety, and isolation.’’2J
By providing a comforting auditory milieu,
intraoperative music may decrease patient anxiety
and consequently minimize patient-controlled con-
scious sedation and analgesic requirements. In two
randomized controlled trials, patients who listened to
favorable music required significantly less propofol
for sedation with spinal anesthesia (P < .001) and had
significantly less alfentanil requirements during
lithotripsy compared to a control group (P < .005).”
Music is a safe, inexpensive, and effective non-
pharmacologic treatment that has great potential to
decrease preoperative anxiety and stress.:‘ Soothing,
calming music can harmonize the work environment
and decrease patient anxiety. Stereo equipment or
individual patient headphones can be used to deliver
an appropriate music selection in preoperative hold-
ing rooms and OR environments.
to anxious surgical patients. Whether giving a brief
massage or holding a nervous patient’s hand, a nurse’s
caring touch is a valuable therapeutic tool to relieve a
surgical patient’s anxiety.
COWCUlSlON
Combining high-touch holistic therapies with
high-tech surgery can contribute an enhanced balance
of care to surgical patients. Proponents of blending
alternative therapies with traditional health care
believe that a holistic approach will help improve
patient well-being. Most conventional medical prac-
tices focus on treating disease with pure science and
state-of-the-art medical technology. A common sense
approach to health care mandates using humanistic,
simpler, less invasive, and less costly therapies as
adjuncts to conventional medicine.
By understanding the process of the natural heal-
ing arts and combining that understanding with the
knowledge of scientific medicine, innovations will
create a more skilled, effective, and compassionate
approach to improve patient care. Current holistic
education and research will further the art of nursing
and the understanding of the infinite intelligence of
the human body and the natural process of healing.
To minimize the patient’s experience of anxiety
before and during surgery, holistic nursing therapies
complement the conscious and compassionate use of
self as a caring modality in the therapeutic nurse-
patient relationship. Recognizing that preoperative
anxiety is a common and distressing problem for
most surgical patients, incorporating skilled holistic
nursing interventions can be humane acts of caring
for the surgical patient. A

TOUCHTHERAPY
Tactile therapies use touch with conscious intent
to help or heal.27 T~~~~can convey reassurance,
fort, and caring in a way that words cannot.’x Patients
who received massage in an intensive care exhib-
ited improvements in mood, body image, self-esteem,
and levels Of mietY-3 Tactile interventions
such as massage, therefore, may provide reassurance
Carol L. Norred, RN,MHS, CRNA, is a clinical instructor
in the School of Medicine. university of Colorado Health
Sciences Center Depariment of Anesthesiology,Denver
Editors note: The amofs jnstih/tiona/predoctora/&ojnjng js fund-
ed through a N&ona/ Raearch &mice Award fundeed by the
National Center for Complernentuy and Alternative Medicine and
Lung and Blood Institute (HL T32 07085).
the National ~ e a d

NOTES 1995) 159-174. 3. J Watson, “Carative factors in

I. M L Cohen, “The experience
of surgery; phenomenological clini-
cal nursing research,” in I n Search
of Nursing Science, ed A Ornery, C
E Kasper, G G Page (Thousand
Oaks, Calif: Sage Publications,
2. R McCraty et al, “The effects
of emotions on short-term power
spectrum analysis of heart rate vari-
ability,” American Journal of
Cardiology 76 (Nov 15, 1995) 1089-
1093.
nursing,” in Nursing: The Phil-
osophy and Science of Caring
(Boulder, Colo: Colorado Associated
University Press, 1985) 7-21.
4. J Watson, “Reconsidering
Nightingale: Professional ontological

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competencies as advanced caring-
healing arts,” in Postmodern Nursing
and Beyond (Edinburgh, England
Churchill Livingstone, 1999) 201-235.
5. Ibid.
6. Watson, “Carative factors in
nursing,” 7-2 1.
7. J Watson, “Seeing through
Venus’s mirror,” in Postmodern
Nursing and Beyond (Edinburgh,
England: Churchill Livingstone,
1999) 49-56.
8. Watson, “Carative factors in
nursing,” 7-21.
9. Watson, “Reconsidering
Nightingale: Professional ontological
competencies as advanced caring-
healing arts,” 201-235.
10. Watson, “Carative factors in
nursing,” 7-21.
1I. J Watson, “The promotion of
interpersonal teaching-learning,” in
Nursing: The Philosophy and
Science of Caring (Boulder, Colo:
Colorado Associated University
Press, 1985) 69-80.
12. J Watson, “Development of a
helping-trust relationship; promotion
and acceptance of the expression of
positive and negative feelings,” in
Nursing: The Philosophy and
Science of Caring (Boulder, Colo:
Colorado Associated University
Press, 1985) 23-50.
13. J Anselmo, L G Koheier,
“Relaxation: The first step to restore,
renew and self-heal,” in Holistic
Nursing: A Handbook for Practice,
third ed, B M Dossey, L Keegan, C
E Guzzetta, eds (Gaithersburg, Md:
Aspen Publishers, 2000) 497.
14. M E Faymonville et al,
“Psychological approaches during
conscious sedation. Hypnosis versus
stress reducing strategies: A prospec-
tive randomized study,” Pain 73
(December 1997) 361-367.
1.5. C Ashton Jr et al,“Self-hypno-
sis reduces anxiety following coro-
nary artery bypass surgery,”Journal
of Cardiovascular Surgery 38
(February 1997) 69-7.5.
16. Watson, “Reconsidering
Nightingale: Professional ontological
competencies as advanced caring-
healing arts,” 201-235.
17. B G Schaub, B M Dossey,
“Imagery: Awakening the inner heal-
er,” in Holistic Nursing: A Handbook
for Practice, third ed, B M Dossey, L
Keegan, C E Guzzetta, eds
(Gaithersburg, Md: Aspen
Publishers, 2000) 539-579.
18. D Tusek, J M Church, V W
Fazio, “Guided imagery as a coping
strategy for perioperative patients,”
AORN Journal 66 (October 1997)
644-649.
19. Watson, “Carative factors in
nursing,” 7-21.
20. Watson, “Reconsidering
Nightingale: Professional ontological
competencies as advanced caring-
healing arts,” 201-235.
21. S Jellinek, “Odom and mental
states,” InternationalJournal of
Aromatherapy 9 no 3 (1999) 11.5-120.
22. M Lis-Balchin, “Essential oils
and ‘aromatherapy’: Their modem
role in healing,” Journal of the Royal
Society ofHealth 117 (October 1997)
324-329.
23. Watson, “Reconsidering
Nightingale: Professional ontological
competencies as advanced caring-
healing arts,” 201-235.
24. C E Gumtta, “Music therapy:
Hearing the melody of the soul,” in
Holistic Nursing: A Handbook for
Practice, third ed, B M Dossey, L
Keegan, C E Guzzetta, eds
(Gaithersburg, Md: Aspen
Publishers, 2000) 587.
25. M E Koch et al, “The sedative
and analgesic sparing effect of
music,” Anesthesiology 89 (August
1998) 300-306.
26. M F Cunningham, B Monson,
M Bookbinder, “Introducing a music
program in the perioperative area,”
AORN Journal 66 (October 1997)
674-682.
27. Watson, “Reconsidering
Nightingale: Professional ontological
competencies as advanced caring-
healing arts,”201-235.
28. S Watson, S Watson, ‘The
effects of massage: A holistic
approach to care,” Nursing Standa1.d
I1 (Aug 13, 1997) 4.5-47.
29. C Dunn, J Sleep, D Collen,
“Sensing an improvement: An exper-
imental study to evaluate the use of
aromatherapy, massage and periods
of rest in an intensive care unit,”
Journal of Advanced Nursing 2 1
(January 1995) 34-40.

Call for Consulting and Management Resumes

AORN provides interim management and consulta-
tion services upon request. We currently are accept-
ing curriculum vitaes (CVs) and resumes from indi-
viduals interested in becoming independent contrac-
tors for AORN. These positions would be available
on a contract basis only and average from one to six
months in length.
Prerequisites include a master’s degree, flexibil-
ity, adaptability, and ability to perform in a variety
of settings. Applicants must possess the knowledge
base, experience, and skills needed to provide client
organizations with needed expertise.
If you would like to be considered for this
program, please forward your CV or resume to Pat
Niederlitz, OpportunityTMprogram manager, AORN,
2170 S Parker Rd, Suite 300, Denver, CO 80231-
5711, or send an e-mail to ptn@aorn.org. If you
have any questions, please contact Pat at (800) 755-
2676 x 243 or Deb Smith at x 266 or via e-mail at
dsmith@ aorn.org.

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AORN JOURNAL