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Identifying and assessing anxiety

in pre-operative patients
Pritchard MJ (2009) Identifying and assessing anxiety in pre-operative patients. Nursing Standard.
23, 51, 35-40. Date of acceptance: July 1 2009.

Summary
Increasing demands for hospitals to be more efficient mean that
patients attending for an operation are generally admitted on the
day of surgery. As a result, healthcare professionals have little time
to talk to the patient to ascertain his or her wellbeing, to check for
any signs of anxiety and ask whether the patient requires further
information about the forthcoming procedure. Healthcare
professionals should be encouraged to use appropriate interventions
to identify and assess anxious patients. There are several
instruments available to measure the patients level of pre-operative
anxiety. This article reviews the Amsterdam Preoperative Anxiety
and Information Scale, which is easy for patients to complete and
may help to identify which individuals need extra support.

Author
Michael John Pritchard, advanced nurse practitioner,
Wirral University Teaching Hospital NHS Foundation Trust,
Clatterbridge Hospital, Wirral, Merseyside.
Email: Michael.Pritchard@whnt.nhs.uk

Keywords
Anxiety, assessment tools, interventions, patient information,
pre-operative care, surgery
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.

ANXIETY RELATED to surgery is widely

accepted as a normal response in pre-operative
patients (Taylor-Loughran et al 1989, Calvin and
Lane 1999, Leach et al 2000, Lee and Gin 2005,
Mitchell 2008). Hospitalisation and admission
for surgical procedures in particular may cause
acute distress and high levels of anxiety in
patients (Maranets and Kain 1999). This may be
linked to a fear of the unknown and a loss of
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control. McCleane and Cooper (1990) suggested

that anxiety begins as soon as the surgical
procedure is planned and increases to maximum
intensity on admission to hospital.
Some researchers have speculated about
the reasons why patients experience anxiety
(Koscielniak-Nielsen et al 2002, Matthey et al
2004, Jakobsen and Fagermoen 2005, Mitchell
2009). Anxiety is caused by a variety of factors,
including concerns about the surgical procedure
and the anaesthetic, and the perceived
consequences of surgery (Box 1). The patients
previous experiences of surgery and the
experiences of other family members or
friends are also important considerations.
Anxiety causes a wide range of responses.
Physiological responses include tachycardia,
hypertension, elevated temperature, sweating,
nausea and a heightened sense of touch, smell
or hearing (Pritchard 2009). Psychological
responses include changes in behaviour such as
increased tension, apprehension, nervousness
and aggression (Markland and Hardy 1993).
Anxiety is a subjective emotion. It may be
influenced by age, gender, the extent and type of
surgery, previous hospital experiences, and
susceptibility to and ability to cope with
stressful experiences (Boker et al 2002). Studies
have reported on the efficacy of a variety of
interventions to reduce anxiety, such as how
much information should be given to patients
and what format to use (Andrewes et al 1999,
Montgomery and Bovbjerg 2004, Osborn and
Sandler 2004). However, questions remain about
how patients grade their levels of anxiety and
how anxiety relates to physiology.
Anxiety is a genuine response to undergoing
surgery. The provision of appropriate information
is essential in reducing anxiety and distress among
pre-operative patients. Mitchell (2009) stated that:
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art & science psychological care

Patient interaction with the nurse and anaesthetist
prior to surgery is vital as [he or she] frequently
seeks answers to a number of questions. There is
emerging evidence that empowering patients and
addressing their psychosocial needs can decrease
the risk of complications, improve post-operative
health outcomes and be cost effective (Lithner and
Zilling 2000, Lack et al 2003, Kindler et al 2005).
Nurses need to be able to provide effective and
supportive pre-operative care for patients in the
limited time available. Therefore the use of a
validated assessment tool to assess patients
anxiety levels before surgery is recommended
(Cooke et al 2005).

Effects of anxiety
Janis (1958) explored anxiety among surgical
patients and its impact on their recovery. He
perceived that moderate levels of anxiety were
beneficial to patients as they prepare themselves
for the stress of surgery. Consequently, levels of
anxiety below or above this level were considered
to be maladaptive and to have a negative effect
on surgical recovery. Janis (1958) hypothesised
that a curvilinear relationship exists between a
persons level of anxiety and pain. He believed
that a lower anxiety level could leave the patient
unprepared for post-operative pain, while a
higher anxiety level could sensitise the patient
to noxious stimuli, making their pain more
acute (Janis 1958).
Anxiety affects the body on a physiological
level by altering the patients vital signs. It affects
patients on a psychological level by causing
cognitive and behavioural changes, for example
anticipation of post-operative pain and separation
from the family, loss of independence and fear of
surgery and death (Caumo et al 2001, Cooke et al
2005, Pritchard 2009). The level of psychological
distress that a patient experiences can make it
BOX 1
Causes of pre-operative patient anxiety
Fear of the unknown.
Fear of medical and surgical treatments.
Concern about pain.
Concern about safety.
Concern about recovery and how this will
influence daily activities and lifestyle.

Loss of control.
Fear of death and dying.
36 august 26 :: vol 23 no 51 :: 2009

difficult for the health professional to manage the

individuals anxiety effectively (Thomas et al
1995). Anxiety can cause patients to be aggressive
or demanding, and they may need the constant
attention of the nursing staff. Patients may also
become so nervous and apprehensive that they are
unable to understand or follow simple instructions.
Anxious patients respond differently from
non-anxious patients to medication. The level of
anxiety that the patient experiences can affect his
or her response to the anaesthetic and analgesia.
For example, patients may require more
anaesthetic to achieve sedation (Maranets and
Kain 1999, Hong et al 2003, 2005) or increased
doses of analgesia to maintain adequate pain relief
(Sjling et al 2003). Vaughn et al (2007) linked
anxiety and pain, stating: If a relationship exists
between pre-operative anxiety and
post-operative pain, then patients with high levels
of anxiety should be identified pre-operatively.
Physiological responses to stress may include
peripheral vasoconstriction, which makes it
difficult to cannulate the patient or obtain blood
specimens. The patient may have a heightened
sense of touch, smell or hearing, which in
unfamiliar surroundings can make the individual
feel even more unwell and uncomfortable
(Pritchard 2009). Research studies have
highlighted increases in acute pain and depression
(Carr et al 2005), and nausea, fatigue and
discomfort (Montgomery and Bovbjerg 2004).
A study by Kiecolt-Glaser et al (1998) found that
anxiety may lower a patients immunity and delay
healing, resulting in prolonged hospitalisation.

Alleviating anxiety
There is general agreement that psychological
preparation for surgery is beneficial to patients
because they will be less anxious, and therefore
more co-operative and compliant in the
post-operative phase of their recovery (Johnston
and Vgele 1993). Horne et al (1994) concluded
that to ignore psychological factors in preparing
adults for surgical or invasive medical procedures
causes unnecessary suffering and adds to the
economic costs of surgery and hospitalisation.
Traditionally, pre-operative anxiety
management has been associated with the
provision of information about the surgery
to alleviate the patients fears and/or concerns.
However, this view has been challenged
(Kiyohara et al 2004, Ivarsson et al 2005).
Kiyohara et al (2004) suggested that increasing
the patients knowledge of the forthcoming
surgery may reduce his or her anxiety levels, but
that not all patients would respond positively to
such information, and in some cases information
provided no benefit. Ivarsson et al (2005) found
that most but not all patients were positive about
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the detailed information they were given.

A number of treatment techniques designed
to reduce pre-operative anxiety, such as the
provision of surgical information in written or
video form, or in an interview conducted by a
healthcare professional, have been studied with
mixed results (Maranets and Kain 1999,
Caumo et al 2001). Therefore the effects of
anxiety-reducing techniques, such as providing
detailed pre-operative information about the
patients surgery or anaesthetic, remain unclear.
One method that has been used to reduce
anxiety is to offer the individual the opportunity
to interact freely with a nurse throughout the
intra-operative period (McCarthy et al 2004,
Marran 2005). Another approach may involve
adapting the care environment to make the
patient more comfortable, for example by
permitting a family member to be present before
the patient goes to theatre, or giving him or her
a side room and allowing relatives to stay.
The use of individualised and patient-centred
nursing approaches to reduce anxiety are
important. For example, if a patient is afraid
of needles it may be possible to take blood after
he or she has been sedated. If the patient needs to
have a cannula inserted, local anaesthetic may be
used to reduce discomfort. It may be useful to give
the patient a variety of information leaflets, not
only about the operation, but also about the
anaesthetic and, if necessary, blood transfusion.
One limitation of this method is that it relies on
the individual reading and understanding the
leaflets, and the anxious patient may not be able
to concentrate on and absorb all the information
provided. It may help if the nurse reiterates this
information and answers any questions the
patient may have. The key here is to adapt as
much as possible to the needs of the individual.

Measuring anxiety
It has been suggested that pre-operative
management of patients anxiety may be improved
if the healthcare professional has more knowledge

about potential predictors of pre-operative anxiety

(Caumo et al 2001). The use of an assessment tool
to identify a patient who is anxious or in need of
information could be incorporated into the
patients care plan. This would allow healthcare
professionals to assess the patients level of anxiety
and develop supportive strategies. These strategies
may involve discussing the surgical procedure
again with the patient and answering any
questions, or changing the order of the theatre list
to allow a particularly anxious patient to go first.
The overall aim of these measures is to ensure that
the patient is physically and psychologically
prepared for the procedure.
A variety of tools are available to measure
anxiety, including the Hospital Anxiety and
Depression Scale (Zigmond and Snaith 1983),
the Short-Form 36 Health Status Questionnaire
(Ware and Sherbourne 1992), the General
Well-Being Questionnaire (Bradley and Gamsu
1994) and the State-Trait Anxiety Inventory
(STAI) (Spielberger et al 1983). These tools are
effective in identifying patients with anxiety in
the context of a pre-operative assessment.
The drawback of such tools is that they are
complex and time consuming to use. This article
reviews the Amsterdam Preoperative Anxiety and
Information Scale (APAIS), which is an effective
and easy tool to use when time is limited.

The Amsterdam Preoperative Anxiety and

Information Scale
In a review of the literature, Moerman et al
(1996) found that the assessment tools available
to measure anxiety were either not specific
enough to identify patients anxiety and their
need for information, or they were considered
too lengthy to use in a pre-operative
environment. Moerman et al (1996) developed
the APAIS, which is a six-item questionnaire.
The aim of this questionnaire was two-fold:
to identify those patients who are anxious and to
identify the level of information required by
each individual (Figure 1).

FIGURE 1
The Amsterdam Preoperative Anxiety and Information Scale (Moerman et al 1996)
Not at all 1

1. I am worried about the anaesthetic

  

 

2. The anaesthetic is on my mind continually

  

 

3. I would like to know as much as possible about the anaesthetic

  

 

4. I am worried about the procedure

  

 

5. The procedure is on my mind continually

  

 

6. I would like to know as much as possible about the procedure

  

 

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Extremely

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art & science psychological care

The APAIS is a simple tool designed to be
used in the clinical area. Each question has a
five-point Likert scale ranging from 1 (not at all)
to 5 (extremely). Scoring is straightforward and
patients mark their feelings with regard to each
question. The tool allows the healthcare
professional to identify what the patient is feeling
at that time. The scores from questions 1, 2, 4
and 5 are added together to show the patients
level of anxiety, while the scores from questions 3
and 6 are added together to identify the patients
need for information (Table 1). Moerman et al
(1996) felt that it would be beneficial clinically
for anaesthesiologists to know the level of
information the patient requires.
For the purpose of measuring anxiety using
the APAIS, Moerman et al (1996) developed a
cut-off point based on a comparison with the
STAI (Spielberger 1983) by performing several
analyses of the two tools, including construct
(content) validity and criterion. Using the STAI
as a reference point, the sensitivity (proportion
of correctly identified cases), specificity
(proportion of correctly identified non-cases)
and the predictive value (probability of a
high-scale score being a case) were calculated
at different cut-off points on the anxiety scale.
From this, Moerman et al (1996) suggested
that a patient with a score of 11 or more on the
anxiety scale is experiencing anxiety. This figure
was reached as an acceptable balance between
false-positive and false-negative results.
The cut-off point was considered acceptable for
research purposes and also for use in the clinical
area by medical staff. In clinical practice, the
cut-off point of 11 should alert nursing staff that
a patient may require anti-anxiety medication.
On the information scale, patients scoring
2-4 are classified as having little or no information
TABLE 1
Amsterdam Preoperative Anxiety and Information Scale scores
Anxiety scores
(questions 1, 2, 4, 5)

Information scores
(questions 3, 6)

Score of 4 = not anxious

Score of 2 = no need for information

Score of 20 = highly anxious

Score of 10 = high need for information

Cut-off point = 11*

Cut-off point = 5
If above 5, give the patient the information
on the topic he or she wants. If below 5, give
no more information than is legally required.

*There is no explanation regarding what should be done for patients

who score above or below the cut-off point for the anxiety score and it is
therefore up to the clinician to decide what action to take.

38 august 26 :: vol 23 no 51 :: 2009

TABLE 2
Subscales of the Amsterdam Preoperative
Anxiety and Information Scale
Anaesthesia-related anxiety

Sum A = 1+2

Surgery-related anxiety

Sum S = 4+5

Information desire component

3+6

Combined anxiety component

Sum C = Sum A +
Sum S (1+2+4+5)

(Boker et al 2002)

requirements, patients scoring 5-7 are classified as

having an average information requirement and
patients scoring 8-10 are considered as having
high information requirements (Moerman et al
1996). Patients with a score of 5 or above should
be given information on the topics about which
they wish to be informed, and in accordance with
their score. A score below 5 should be a signal to
provide the patient with no more information than
is legally required (Moerman et al 1996).
The advantages of the APAIS are its brevity
and its ability to be used in a wide range of
clinical settings. It has been used in several
countries and has proven an effective and
useful tool when compared to other anxiety
measures (Nishimori et al 2002, Berth et al
2007). The main limitation identified was
that the tools did not distinguish well between
fear of anaesthesia and fear of surgery
(Moerman et al 1996).
Boker et al (2002) further subdivided the
anxiety and information questions in the
APAIS to assist analysis. The anxiety questions
(1, 2, 4 and 5) were separated. Questions 1 and
2 now related to anxiety about anaesthesia
(Sum A), questions 4 and 5 now related to
surgical anxiety (Sum S) and a combined
anxiety total (Sum C) was identified. The
information component remained the same
with the score taken from questions 3 and 6.
Boker et al (2002) developed a further subscale
of the combined anxiety component, made up
of questions 1, 2, 4 and 5 (Table 2).
Boker et al (2002) suggested that the
APAIS had the potential to be used to assess
the need for consultation and pre-medication
and that anxiety testing is feasible in the
pre-operative period. The authors concluded
that the anxiety component of the APAIS
(Sum C), because of its brevity, showed
potential as a new practical tool to assess
patients pre-operative anxiety levels (Boker
et al 2002).
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The simple structure of the APAIS means

that it only takes a patient about five minutes to
complete, which is ideal during a busy clinical
outpatient appointment.

Use of the Amsterdam Preoperative

Anxiety and Information Scale
Since its development in 1996, the APAIS has
been used in Canada (Boker et al 2002), South
Korea (Shin et al 1999), Germany (Berth et al
2007), the Netherlands (Van den Bosch et al
2005) and Japan (Nishimori et al 2002). These
studies have proven that the tool is easy to use in
any language and its results remain consistent
when compared with other anxiety measures.
The studies also conclude that the APAIS is
a simple and effective tool that can identify
patients who are anxious or in need of
information about their forthcoming procedure.
The APAIS can be used by nursing staff during
a pre-operative clinic or following admission to

the ward. The tool allows the patients responses

to be divided into two categories anxiety and
the need for information while its subscale
allows the healthcare professional to identify
whether the patients anxiety is related to
anaesthesia, surgery or the need for information.

Conclusion
The effects of anxiety and stress on the body
are widely accepted as a normal response in
pre-operative patients. Consequently, there has
been a growing interest in the possible influences
of pre-operative anxiety on surgical outcomes.
The levels of anxiety that a patient experiences
can affect his or her response to the anaesthetic
and analgesia. It may also increase pain, cause
depression, nausea and fatigue, and delay
healing, which can impede the patients discharge
from hospital.
It is vital that healthcare professionals
actively manage patients anxiety in the

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