Patient anxiety while on a waiting list for coronary artery bypass surgery: A qualitative and quantitative analysis☆☆☆

Literature review 

International literature documents a range of difficulties encountered by those on cardiac waiting lists. These vary from angina and fatigue,5 lack of knowledge and support,8 to anxiety and depression,9 as well as unemployment and reduced income.10 Northern Ireland has one of the highest rates of heart disease in the world and a comparatively long waiting list for surgery, with local studies documenting the effects of this situation in relation to mortality and prioritization of patients in such queues.11, 12 On a global level there is a recognized paucity of evidence regarding more subjective aspects of patient experiences while awaiting surgery,7, 8, 13 which is essential to plan effective nursing intervention.

The literature confirms that heart disease in general, and waiting for bypass surgery in particular, is associated with significant psychologic problems. There is some variation in the nature of such problems, with various sources alluding to the stress of cardiac illness.13, 14, 15 Stress has a number of clinical manifestations, including irritability, anxiety, and depression, that have long been recognized in cardiac patients.16 A qualitative study of patients recovering from a heart attack and their spouses found that fear, worry, and pessimism about the future were common.17 More specific studies of patients on the waiting list for bypass surgery have found it to be associated with the presence of nervous reactions,18 as well as anxiety and depression.9 A postal survey of 72 patients awaiting bypass in Iceland found that fatigue, shortness of breath, chest pain, anxiety, and depression were the most prominent symptoms.7 In addition, the uncertainty that may accompany long queues for surgery has been noted to cause considerable anxiety for patients.4, 6, 8

One of the first studies of this population was conducted in New Zealand,10 in which researchers used an interview and the State Trait Anxiety Inventory (STAI) to compile a social evaluation of the waiting list. These authors found that 32% of patients had lost income and 20% claimed financial hardship while waiting for heart surgery, but they did not establish any correlation between time on the waiting list and STAI scores. A more recent Canadian study8 examined the needs of 147 patients awaiting cardiac surgery as well as 125 family members. This group found that the second major concern of this sample was their ability to cope with the waiting period. This was preceded only by their concern regarding the success of the operation. Another Canadian study19 of 21 patients and their spouses who had been waiting an average of 2.4 months for surgery found that uncertainty was inversely related to quality of life and hope for both patients and their spouses. There is also evidence that patients awaiting treatment for coronary artery disease are anxious and depressed and that such problems are related to the severity of pain and breathlessness.6 However, perhaps the most interesting finding from this large cohort of Swedish patients was that uncertainty was more distressing for patients than the pain they felt.

There is consensus in the literature that, although shorter waiting times are a priority, it is also necessary to offer appropriate intervention to help patients cope with the problems of long waiting lists.3, 7, 13 Although a variety of difficulties have been documented in this population, anxiety emerges from the literature as the most salient feature of this experience for patients who suffer an unpredictable illness and indeterminate wait for treatment.10 Anxiety is known to have adverse consequences for cardiac patients;20 therefore more information is needed regarding the nature, cause, and severity of this problem in those awaiting cardiac surgery. Perhaps with greater understanding of this issue, appropriate nursing intervention can be directed toward the specific needs of this population.

Anxiety 

Anxiety is a psychologic construct that has received considerable investigation in the literature since it was described by Freud in 1936.21 At a physiologic level, anxiety stimulates the release of powerful catecholamines that increase the heart rate, blood pressure, and cardiac output, and therefore may cause myocardial ischemia and electrocardiogram changes in those with established heart disease.20 Spielberger and colleagues22 have isolated the concept of anxiety into 2 distinct constructs—one which describes an emotional state and one which refers to a natural disposition toward anxiety in the individual, described as a personality trait. These authors have developed STAI as a means to assess both these characteristics.22

Method 

Procedures 

Patients were recruited from the only 2 hospitals in Northern Ireland that have invasive diagnostic facilities—all of which are referred to one cardiac surgery center. Patients entered this study on the day their coronary arteriography films were reviewed by the cardiologist and the cardiac surgeon who accepted them placed them on the waiting list.

In total, 329 patients were referred for CAB in the 6-month study period. Patients were deemed eligible for the study if they required non-urgent bypass surgery. Exclusion criteria included patients requiring immediate surgery, private patients, those requiring re-operation or concurrent valve surgery, and those referred to a cardiac surgeon appointed during the time of the study (n = 89). Thus there were 240 eligible patients. From this group, a total sample of 70 patients were chosen with the use of random number tables to select 3 patients per week during the 6-month recruitment period.

The semi-structured interview and STAI were first administered to these patients within 2 to 4 weeks of their referral to a cardiac surgeon (Time 1,n = 70); second test administration occurred after they had been waiting 6 months for surgery (Time 2, n = 49); then they were tested again after waiting 1 year (Time 3, n = 28). Attrition mainly resulted from patients having had their surgery performed (n = 36), although death (n = 4) and refusal to participate (n = 2) also contributed. Of the 4 deaths in this group of 70 during the 18 months of data collection, 3 were registered on the patient's death certificate as resulting from a cardiac cause. The clinical and demographic characteristics of this population are described in Table I.

Table I. Patient characteristics

		Baseline n = 70 (%)	6 mo n = 49 (%)	12 mo n = 28 (%)
	Age
	< 55	17 (25)	14 (29)	8 (29)
	55-60	17 (25)	11 (23)	7 (25)
	61-65	19 (27)	13 (27)	6 (21)
	> 66	16 (23)	10 (21)	7 (25)
	Sex
	Males	59 (84)	43 (87)	26 (93)
	Females	11 (16)	6 (13)	2 (7)
	Angina Grade33
	Class I	6 (9)	4 (8)	1 (4)
	Class II	20 (29)	13 (26)	6 (21)
	Class III	21 (30)	17 (35)	11 (39)
	Class IV	23 (32)	15 (31)	10 (36)
	Smoking
	Never	12 (17)	11 (23)	7 (25)
	Ex-smoker	51 (73)	35 (70)	19 (68)
	Current smoker	7 (10)	3 (7)	2 (7)
	Employment status
	Employed and working	4 (5)	5 (10)	1 (3)
	Unemployed due to heart disease	28 (40)	23 (46)	16 (58)
	Unemployed other reasons	13 (19)	6 (13)	2 (7)
	Retired	22 (32)	12 (25)	8 (28)
	Homemaker	3 (4)	3 (6)	1 (4)

Ethical issues 

Ethical approval for the study was granted by the local university ethics committee. The study was carefully explained to all participants, and their questions answered before written consent was obtained. Each participant was explicitly advised that inclusion in this study would not alter their treatment or length of wait, and that if they did decide to participate they could freely withdraw at any time. Procedures to maintain confidentiality were explained, as was the intent to publish anonymous interview extracts. During interviews the principle of non-maleficence was paramount, and if participants became distressed the interview was terminated and referral to appropriate support services offered.

Data analysis 

Quantitative data were collated from each phase, coded, entered onto MicroSoft Excel and SPSX, and analyzed with standard nonparametric statistics, one-way analysis of variance (ANOVA) (n = 70) and repeated—measures ANOVA (n=28), with follow-up Tukey tests as appropriate.

Qualitative interviews were undertaken in the participants' homes with the use of an inductive research approach to gather rich and descriptive data.29 In line with this methodology, there was no rigid interview schedule; instead a series of open questions were used to elicit information. For example, questions such as the following were asked: “Can you tell me how you are feeling, at the moment?” “Do you have any concerns?” “Can you tell me about these?” The process of analysis outlined by Colazzi31 was used to identify themes emerging from the qualitative interviews.

Interviews were transcribed verbatim, read carefully, common themes were identified, and information grouped under theme titles. A record was kept of the relationships between themes as these emerged from the data. To enhance rigor, an audit trail was maintained, documenting the analytic procedures in detail. The credibility of the findings was enhanced by having a second researcher blindly cross-code a sample of interview transcripts.30 Member checking was achieved by returning a collective summary of this analysis to interview participants, who were then asked to comment on its appropriateness.32 Qualitative results are presented from the total sample (n = 70).

Results 

State anxiety levels 

High levels of state anxiety were noted in this sample at all stages of data collection (Table II). A repeated-measures ANOVA revealed no significant difference in scores over time. Table II displays participants' state anxiety results over time and indicates that scores were similar at baseline (47) and 6 months (48), but showed a nonsignificant rise after a 1 year wait for surgery (52).

Table II. Differences in state anxiety scores over time

	Repeated measures ANOVA	No. of cases	Mean state	SD
	Baseline	28	47.14	13.07
	6 Months	28	48.26	12.47
	1 Year	28	51.78	14.24

A one-way ANOVA was used to determine whether there were significant differences in state anxiety levels by angina grade. A main effect (F = 11.7; df(3,67); P = .001) was obtained, indicating differences by grade. Follow-up Tukey tests revealed significant differences between the state anxiety scores of those with grade 1 and grade 3 angina and those with grade 1 and grade 4 angina, those with grade 2 and 4 angina and those with grade 3 and 4 angina. These results are shown in Table III, which indicates that state anxiety levels increase as participants' angina levels increase.

Table III. Differences in state anxiety scores by angina grade

	Angina grade (Time 1)	No. of cases	Mean state anxiety*
	I	6	34.16
	II	20	39.95†
	III	21	45.66†
	IV	23	56.14‡
	*Determined by one-way ANOVA with follow up Tukey test. † Denotes P ≤ .05. ‡ Denotes P ≤ .01.

A one-way ANOVA was used to determine whether there were differences in state anxiety scores by the change in level of income participants reported since going on the waiting list for surgery. Results indicated (F = 3.43; df(3,68); P =.02) significant differences in state anxiety scores in relation to changes in income level. Follow-up Tukey tests revealed significant differences between the state anxiety scores of those who reported their income remained the same and those whose income decreased considerably (Table IV). Additional tests revealed no significant differences by age or sex of participants and state anxiety scores.

Table IV. Differences in state anxiety scores in relation to income category

	Income category (Time 1)	No. of cases	Mean state anxiety*
	Increased slightly	2	36.00
	Remained the same	22	42.30
	Decreased slightly	13	47.45†
	Decreased considerably	23	51.78
	*Determined by one-way ANOVA with follow-up Tukey test. †P < .05

Trait anxiety levels 

The trait anxiety scores of this group were high at all stages of data collection. A repeated-measures ANOVA found no significant change in participants' trait anxiety scores over the 3 periods. Trait anxiety scores were similar at baseline (46) and 6 months (46), but they revealed a nonsignificant rise after 1 year to 49 (Table V).

Table V. Differences in trait anxiety scores over time

	Repeated measures ANOVA	Mean trait anxiety	SD
	Baseline (n = 28)	46.64	11.68
	6 Months (n = 28)	46.65	12.57
	1 Year (n = 28)	49.28	11.82

A one-way ANOVA was conducted to examine possible differences in trait anxiety by the grade of angina reported.33 A main effect (F = 8.10; df(3,67); P <.001) revealed differences in anxiety levels by angina severity. Follow-up Tukey tests revealed significant differences in trait anxiety scores between grades 1 and 4 angina, and grades 2 and 4 and grades 3 and 4 angina levels (Table VI). Thus, those with the most severe angina expressed the highest levels of trait anxiety.

Table VI. Differences in trait anxiety scores in relation to angina grade

	Angina grade	No. of cases	Mean trait anxiety*
	I	6	39.00
	II	20	39.55
	III	21	41.33†
	IV	23	52.90†‡
	*Determined by one-way ANOVA with follow-up Tukey test. † Denotes P ≤ .01. ‡ Denotes P ≤ .05.

A one-way ANOVA was used to assess differences in participants' trait anxiety scores by reported income. Results revealed no statistically significant differences by income category (F = 2.59; df(3,65); P = .06), although trait anxiety scores increased as reported income decreased. The mean anxiety scores for those whose income remained the same was 41.15, rising to 43.27 for those whose income decreased slightly and to 49.13 for those whose income decreased considerably. Finally, analysis revealed no differences by age or sex in participants' trait anxiety scores.

Discussion 

It is apparent from the preceding data that anxiety was a pervasive feature of the experience of waiting for coronary bypass surgery. The combination of qualitative and quantitative findings generate a more holistic interpretation of the anxiety felt by this sample than it would have been possible to achieve from either method in isolation. The qualitative data enables us to define the main sources of anxiety as expressed by this sample. These are pain, uncertainty, physical incapacity, the impending surgery, and dissatisfaction with treatment.

The strong association between anxiety and angina is confirmed by both qualitative and quantitative methods in this study. A statistically significant relationship was noted between the level of pain patients felt and their state and trait anxiety scores (Table III, Table VI). From a purely quantitative perspective this is an interesting, and perhaps clinically significant finding. However, we can gain much deeper understanding about how closely pain and anxiety are linked for this population through the insight provided by the qualitative data. During interviews, patients disclosed that angina was not just a physical sensation; it had far-reaching consequences that limited their lifestyle, reminding them of both their heart problem and need for major surgery. Pain also carried with it an inherent threat of sudden cardiac death. From these findings we can understand why chest pain and anxiety have such significance in this population. Many nurses have considerable expertise in assisting patients to deal with anxiety, and the nurse's role in relation to chest pain management is currently developing. Thus, this data may assist nurses to plan more effective intervention to alleviate these problems.8

Nurses with expert skills are ideally placed to help patients deal more effectively with angina and reduced exercise tolerance. Such intervention must be individualized to the needs of each patient but may include spacing activity and more effective use of anti-anginal therapy. Many nurses also have the opportunity to reassess changes in symptoms, such as the increase in the frequency or severity of angina. This may indicate progression of coronary disease, and nurses have a responsibility to take appropriate action in these circumstances.

In line with other sources in the literature, uncertainty was an important source of anxiety in this sample.6, 34 This study identified the major factors leading to uncertainty. First, patients felt that they had been given inadequate information regarding when to expect surgery, which left many anxiously expecting a letter or telephone call, only to be disappointed on a daily basis. Nurses can offer patients up-to-date, if general, advice on the expected delay until surgery, which may reduce some of the related anxiety. Participants were also anxious about the uncertain outcome of their operation. How difficult would the experience be for them? Would the operation be a success? How quickly would they recover? Nurses can use these results as a rationale for offering patients information about the surgery, either verbally or in booklet or video form. Finally, patients in this study expressed anxiety about how much exercise was safe as they awaited surgery, and many were afraid to conduct normal household duties in case these precipitated a heart attack. The nursing implications of this have previously been discussed.

The quantitative data from this study allows us to check for changes in anxiety across the waiting period and facilitates comparison with similar patient populations. It is important to note that anxiety remained consistently high at every stage of data collection. Participants in this study also had significantly higher levels of anxiety than those noted in the small study conducted more than a decade ago in New Zealand.10 However, it is difficult to meaningfully interpret the difference between the levels of state anxiety noted in our study and those from Mulgan and Logan10 because of the sparse clinical details given in their report. There also may be differences in the results between these 2 studies because Mulgan and Logan's research was completed on the basis of a once-only data collection from patients at various stages of the waiting period, in contrast to the longitudinal nature of this study.

One of the most debilitating consequences of heart disease expressed by this sample was physical incapacity, illustrated in the fact that only 6% were employed and working and almost 50% reported a recent decrease in income. This concurs with other sources.6, 7, 9, 10 A statistically significant association was noted between reduced income and higher levels of state anxiety (Table IV). Through the qualitative data it is possible to understand the close relationship between incapacity, reduced income, and anxiety for this sample, and one gets a sense of the vicious circle of factors that combine to make patients' lives more difficult at this time.

Limitations 

The results of this study should be interpreted cautiously because its aim was to explore the nature and intensity of anxiety felt by this particular sample. Thus, these results may not be reliable in the conventional sense. However, the transferability of these findings to other settings may be evaluated by assessing the rigor of the methodology and the characteristics of this particular sample (Table I). It is also important to note that although anxiety was the sole focus of this article, it is by no means the only difficulty these patients encounter. Other problems, such as uncertainty,4 clearly have significance for this population and should not be ignored.

Conclusion 

Previous literature has reported high levels of anxiety in those awaiting CAB in many parts of the developed world.6, 8, 13 In this study, qualitative and quantitative methods were combined to convey a more holistic analysis of anxiety in this population. Results confirm a statistically significant relationship between angina and anxiety in this sample. The main sources of anxiety have also been identified. Therefore, it has been possible to provide much needed information on the anxiety felt by those who wait for CAB and also to identify nursing intervention that may help alleviate this distressing problem.