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anxiety is a challenging in preoperative care of patients awaiting elective surgery
and it is widely accepted as an expected response. Anxiety
can be explained as a reaction to stress or fear and elicits the autonomic
physiological response that helps a person to fight or flight the danger(2).

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have shown that people react differently to anxiety-provoking situations and
related this difference to trait anxiety that described as an established
individual difference in anxiety proneness and how stressful situations are
perceived have described trait anxiety as a relatively permanent personality
characteristic that is not influenced by a stressful situation(17). This implies that surgery does not affect trait
anxiety of the patient. However, state anxiety that has been described as an
unpleasant emotional response while coping with threatening or dangerous
situations (18). State anxiety level varies depending on how
the situation is judged by an individual to be high or low threatening. State
anxiety level is high in a dangerous situation and low in the safe or less
dangerous situation(17).

to study done by Strongman the anxiety is
different from fear in sense that fear is caused by tangible object with known
expected outcome and it can be escaped while anxiety happens when the danger is
not palpable and it cannot be avoided, the author continued showing that
anxiety is characterized by being unsure of the future and how to behave once a
person meets the danger(19). It has been reported that the main purpose of
anxiety is to detect the danger or threat in a potentially harmful environment,
so that a person reacts effectively to escape the danger(20).


Levels of preoperative anxiety are categorized in either high or
low levels of preoperative anxiety, clinically significant or not clinically
significant. However, clinically significant preoperative anxiety and high
preoperative anxiety level are used interchangeably and not clinical
significant and low preoperative anxiety level is used interchangeably. Some
authors classify the levels of preoperative anxiety in no, mild, moderate or
severe preoperative anxiety(17).

The categorization levels of preoperative anxiety depend on the
used preoperative anxiety assessment tool based on its cut-off score. The
studies using Hospital Anxiety and Depression Scale (HADS) consider the sum
score ?11 as high preoperative anxiety level and the sum score <11 as low preoperative anxiety level(9). For studies that employ State version of State Trait Anxiety Inventory (S-STAI) to assess preoperative anxiety consider the sum score > 44 score as significant anxiety or high
anxiety level and the sum score ?44 as low anxiety level or not significant
anxiety(4, 21) and for the studies using the
Pre-operative Intrusive Thoughts Inventory (‘The PITI’ or ‘PITI-20’) consider the sum score ?15 as clinically significant preoperative
anxiety level and the sum score <15 as not clinically significant preoperative anxiety level(22). 2.3. FACTORS ASSOCIATED WITH PREOPERATIVE ANXIETY Preoperative anxiety may be associated with many factors. These include demographic data, previous surgical experience, types of anaesthesia and surgical procedures, medical diagnosis, and information about surgery(2, 21). The study conducted in Pakistan found that age is contributing factor predicting preoperative anxiety and preoperative anxiety decreased with an increase in age (p< 0.001) found that young patients are more anxious than old age patients (P<0.01) and they reported that, this happened because young people are less experienced and more prone to anxiety and fear compared to old age people(17). Contrary to those studies found that the anxiety levels increased with the age, the old patients presented the higher level of anxiety than young patients (p < 0.001), this finding was in line with the results of study conducted by Basaki that showed that patients who were aged more than 35 years old expressed more anxiety than young patients(6, 23). Marital status has been identified by some of the researchers as the factor affecting preoperative anxiety. The study conducted by Fathi found that widowed or divorced female experienced more anxiety while single and married patients experienced lower preoperative anxiety levels. This study also showed that high education levels and income rate and better social support were significantly correlated with lower preoperative anxiety(6, 23). In other hand previous surgery affects the anxiety of the patients as demonstrated by many studies reported that patients who had at least one prior surgery presented a low level of anxiety(8, 21). This may be explained by having a history of surgery makes the patient more aware of the surgical process (anaesthesia, intraoperative and postoperative pain control and probable outcomes of surgery) that prevent patient to develop more fear of unknown or rely on a misconception about anaesthesia and surgery. In contrary to those findings, the study from JUSH found that having previous surgical operation or anaesthesia did not influence significantly preoperative anxiety, this was explained as due to lack of understanding on explanation or lack of information on that previous experience of surgery or anaesthesia and they concluded that nature and quality of previous surgery is more important factor influencing the anxiety than just having previous surgery(4, 24). The study conducted by Shoaei, Matthias and Samarasekera  found that waiting for the operation was ranked the first anxiety causing factor for preoperative anxiety (Shoaei et al. (2016, p. 707) Matthias and Samarasekera (2011 , p. 5). Furthermore some studies reported that types of anaesthetic technique are associated factors with preoperative anxiety. This was supported by study conducted by Bosc et al. (2015) in patients undergoing oculoplastic and strabismus surgery found that patients undergone surgery under general anaesthesia had higher anxiety levels than patients undergone surgery under local anaesthesia (P=0.002) . In addition some other studies reported that patients under general anesthesia are more anxious than patients under local anesthesia (Jawaid et al. 2007, p. 147; Mitchell 2013, p. 41; Maheshwari and Ismail 2015, p. 197).  Provision of information was reported to be associated with low preoperative anxiety. This is supported Lee et al. (2016, p. 698) who found that surgeon's explanation of the surgery performed reduce preoperative anxiety 72.3 %, Aust et al. (2016, p. 4) reported 15 that 63.7% of the patients believed that information would aid them to cope with their anxiety. In addition, Kalogianni et al. (2016, p. 447) found that anxiety and postoperative complications were reduced in patients undergoing cardiac surgery due to preoperative education delivered by nurses and Maheshwari and Ismail (2015, p. 197) found that patients gaining information from anaesthetists were less anxious than patients receiving information other than anaesthetist. Moreover, Ebirim and Tobin (2010, p. 3) reported that postponement was the most common reason for anxiety and reported postponement among the factors associated with anxiety(8). 2.2 THE COPING MECHANISM OF THE PATIENT FOR PREOPERATIVE ANXIETY The study done by Duangpaeng and Hengudomsub after detecting the presence of the preoperative anxiety, the nursing care plan aimed to prevent, manage and reducing should be developed(25). A perioperative nurse has a responsibility to monitor patients' anxiety, identify what causes their anxiety, and then determining possible solutions to preventing or decreasing it and helping them prepare for the surgery. Perioperative nurses can use non-pharmacological and pharmacological interventions to reduce anxiety(26). In a study conducted by Maghsoodi found that the establishment of therapeutic communication sessions with patients is effective in reducing the severity of their anxiety(27). The authors also showed that the communication and therapeutic relationship with the patient in the more purposeful manner can speed up the recovery process. It is during communication, a patient and a nurse interact and a patient expresses his/her feeling and nurse help a patient to cope with the stressful situation. A nurse a therapeutic atmosphere which increases the likelihood of a more positive surgical experience is established(26). In a study conducted by Kushnir, Friedman, and Ehrenfeld coping with preoperative anxiety in caesarean section, they found that listening to favourite music immediately before a caesarean section is effective for reducing anxiety. The findings showed that the women listened to their favourite music before caesarean section reported an increase in positive emotion and decrease in negative emotion and perceived the situation less threatening compared to women who did not listen to the music(28). Similarly to the study done by Johnson, Raymond and Goss in their study perioperative music or headsets to decrease anxiety found that music is a inexpensive, easy to administer and satisfier of most people intervention to decrease anxiety(29), Wakim, Smith and Guinn (2010, p. 231).  In study by Guo, East and Arthur found that preoperative education is effective in reducing the levels of anxiety  and found that an empathic patient-centered approach significantly reduces the anxiety, improves surgical recovery and wound healing and raises the satisfaction of the patient with the quality of the information provided(30, 31). In this approach the patient is encouraged to express his or her feelings and psychological support and tailored information are provided to the patient and the patient's questions are addressed in a calm, supportive and confident manner within an atmosphere of privacy, care, concern, with a nonjudgmental and respectful attitude. Support from family, friends, and health care providers and anxiolytic or antidepressant medications can help with relieving severe anxiety but the medications are associated with risks of potential side effects, dependence and withdrawal(30). 2.3 THE IMPACT OF PREOPERATIVE ANXIETY Many researches indicate that preoperative anxiety affects negatively every step of the perioperative process. The study conducted by Kim showed that for the patients aged 45 or older had high preoperative anxiety levels and their anxiety scores correlated significantly with the changes in pulses rate (P = 0.047 by Pearson correlation), in addition preoperative anxiety scores predicted a 20 % or more change in blood pressure ((AUC = 0.729, P = 0.024) and in heart rate (AUC=0.767, P=0.049)(32). In other the study found that patients with higher preoperative anxiety required a greater amount of propofol to reach light sedation (r2 =0.053P=0.021) and moderate sedation (r2=0.127 P=0.010) postoperatively the analgesic requirement increases the wound healing delays, health care cost rises, and the hospital stay is prolonged(33). This was supported by study conducted by Ali, Altun and Hakan which found that preoperative anxiety scores significantly correlate with the duration of hospitalization (r = 0.370, p = 0.001) and patients with a high anxiety had longer extubation time than patients with low anxiety (P=0.03), in addition, the patients with high anxiety had more agitation (p=0.029) and shivering (P=0.044) as side effects of anaesthetic agents than patients with low anxiety(17).  In a study conducted on patients undergone total knee arthroplasty found that patients with high preoperative anxiety or depression had more than 6 times high risk to be dissatisfied than patients without anxiety or depression and patients with post-operative deep infection had 3 times risk to be dissatisfied, those dissatisfied patients had 1 day more of hospital stay than satisfied patients and Preoperative anxiety is associated with the risk of infection and with postoperative nausea and vomiting(3, 8, 34). 2.4. RESEARCH GAP IDENTIFICATION  In Ethiopia on preoperative anxiety only two studies was conducted in two teaching hospital Jimma University Specialized Teaching hospital and Gondar University Specialized compressive hospital. Those research showed that preoperative anxiety affects negatively every steps of surgical process and find out preoperative anxiety prevalence and factors affecting preoperative anxiety, however the, levels of anxiety, coping mechanism of patients, impact of preoperative anxiety and set up of hospital environment were not addressed(4, 5). Many literatures agreed on the importance of preoperative assessment before surgery in order to maximize the surgical outcome and minimize the negative effect of anxiety to the surgery. In Ethiopia hospitals are improving perioperative nursing specialties in particularly improving with the aim of maximizing the patient surgical outcome by teaching speciality nurses in different college by different level of education (Ethiopia hospital guide line). The St. Luke's Catholic hospital and College of nurses is a referral hospital that cares for the patients coming from different districts and it is considered as a public hospital that provide a high quality of care. Therefore this current study will be aimed to assess preoperative anxiety level and the associated factors for patients awaiting surgery at SLCHCN, Woliso, Ethiopia.

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