JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Influence of gender and anaesthesia type on day surgery anxiety

Mark Mitchell
Accepted for publication 25 June 2011

Correspondence to M. Mitchell:
e-mail: m.mitchell@salford.ac.uk
Mark Mitchell MSc PhD RN
Senior Lecturer
College of Health and Social Care, University
of Salford, Greater Manchester, UK

M I T C H E L L M . ( 2 0 1 2 ) Influence of gender and anaesthesia type on day surgery

anxiety. Journal of Advanced Nursing 68(5), 10141025. doi: 10.1111/j.13652648.2011.05801.x

Abstract
Aim. To investigate the possible influence of gender and anaesthesia type on anxiety
prior to day surgery.
Background. Elective surgery undertaken on a day, short stay or day of surgery basis
is growing and much emphasis also placed on enhanced recovery for in-patient
surgery. During such brief episodes preoperative apprehension can be considerable but
the opportunity to help reduce anxiety is minimal and formal plans uncommon.
Method. As part of a larger study, a questionnaire was distributed to 1606 patients
undergoing day surgery, with anaesthesia (20052007). Participants were requested
to return the questionnaire by mail 2448 hours following surgery, with 674 returned.
Data were analysed using descriptive statistics and multivariate analysis of variance.
Results. Of the total patients 824% experienced anxiety on the day of surgery with
the wait, anaesthesia and possible pain being common anxiety-provoking aspects. The
majority preferred to receive information between 14 weeks in advance and participants experiencing general anaesthesia required information at a statistically significantly earlier stage. General anaesthesia patients were statistically significantly more
anxious than local anaesthesia patients and desired more information. Female patients
were statistically significantly more anxious, anxiety commenced earlier and they
preferred to wait with a relative/friend or talk with other patients.
Conclusions. Anxiety was experienced by the majority of participants but was more
prevalent amongst general anaesthesia and female patients. For general anaesthesia
patients, a comprehensive level of information may be required a number of weeks
prior to surgery and gender differences associated with the preoperative wait may
require greater consideration.
Keywords: anxiety, day/ambulatory surgery, gender, general and local anaesthesia,
patient information

Introduction
Elective surgery has undergone considerable change over
recent years resulting in the continued reduction of in-patient
surgery and the considerable rise of day, short stay and day
of surgery admissions (Vijay et al. 2008, Martin et al. 2010).
1014

However, this modern approach to healthcare may be

constraining Nursings ability to give the professional care
deemed necessary (Fraczyk & Godfrey 2010). For example, it
has been suggested that patients are quite anxious prior to
day surgery and may desire a greater degree of information to
help manage their experience of a brief hospital stay (Jlala
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JAN: ORIGINAL RESEARCH

et al. 2010). The continued national and international

expansion of minimal in-patient stay (Naresh Row 2010),
the rise in day surgery for malignancies (de Kok et al. 2010),
continued introduction of enhanced recovery programmes
(Houghton 2010) and decreased time available for nurse/
patient interaction, present many challenges for contemporary surgical nursing care.

Background
The volume of day surgery being undertaken on a national
and international basis continues to rise. Recent figures
suggest levels in North America of 83% (of all elective
surgery), Canada 83%, Australia 75%, Demark 79%,
Holland 70%, Sweden 66%, England 62%, Germany 60%
and Finland 50% (Mattila & Hynynen 2009, Toftgaard
2009) although in some countries 23-hour stay is classified as
day surgery. Throughout more affluent nations the complexity of day-case procedures is also expanding. Surgery on
suspected malignancy (Marla & Stallard 2009), prostatectomy (Martin et al. 2010), parathyroidectomy (Parameswaran
et al. 2010), neurosurgery (Boulton & Bernstein 2008),
surgery on older people (Lacquiere et al. 2006) and the
development of specialist day surgery units have all helped to
increase the scope. Moreover, many surgical procedures can
increasingly be performed using local anaesthesia (Armellin
et al. 2007) enabling patients to spend less time in hospital.
Much emphasis in day surgery progress has focussed on
advances in medical capability (Hamer et al. 2008), capacity
and costing (Manners et al. 2010) whereas studies investigating nursing knowledge are limited (Pearson et al. 2004a).
The worldwide economic drive for improved medical organization of surgery and minimal stay has ensured a major
proportion of nursing time is focused on efficiency, throughput and initiatives which seek greater clinical streamlining
(Smith et al. 2006). Flanagan (2009) asserts day surgery care
has become fractionalised into its differing areas (preassessment, ward and operating department) and the ambulatory
nursing care role essentially invisible. It is suggested beyond
managerial issues, surgical nursing practice is striving to
define its new role (Williams et al. 2009). Previous nursing
research has focussed on the physical experience of surgery
(Mitchell 2007) but less so on the social and psychological
impact (Mottram 2011). However, much psycho-social care
is needed to enable patients to cope successfully with brief
admission, anaesthesia, surgery and discharge (Demir et al.
2008).
Preoperative patient anxiety has been identified for a
number of years and numerous recommendations made but
many based on in-patient research (Seers et al. 2008) and
 2011 Blackwell Publishing Ltd

Influence of gender and anaesthesia type on anxiety

demanding much nursing time (Saadat et al. 2006). Anxiolytic premedication has been recommended to ease anxiety
(Jakobsson et al. 2008) but premedicated patients can take
additional nursing time and closer attention prior to transfer
to theatre resulting in its limited use (Walker & Smith 2009).
With the increase in the volume of day surgery, time available
to nurses has become restricted and thus new approaches
essential.
A lack of adequate patient information has been linked
with increased anxiety and reduced satisfaction (McMurray
et al. 2007). Following a survey of 131 patients Suhonen
et al. (2008) state The major goal of patient management in
day surgery is to promote patient comfort and satisfaction by
reducing the anticipated side-effects of surgery and anaesthesia (p. 170). Ward et al. (2007) concluded that the majority
of patients preferred to be offered simple choices about care
and experienced greater control at the mere prospect of being
asked if they had a preference. In a comparison study by
Oldman et al. (2004), one group received a standard hospital
information leaflet on anaesthesia and a second the same
leaflet plus the drug manufactures patient information leaflet
on Propofol (Diprivan). It has been a legal requirement
(European Directive) since 1999 for manufacturers to supply
patient information leaflets, even those administered solely by
physicians such as anaesthetic drugs. Following admission,
anxiety was measured using a Visual Analogue Scale (VAS)
and State Trait Anxiety Inventory (STAI) (Spielberger et al.
1983) then again 20 minutes after reading the drug information. While manufactures details could be considered anxiety
provoking as they listed possible side effects of Propofol (pain
on injection, decreased arterial pressure, twitching and
shaking, slow or stopping of heart, sexual arousal), no
important differences between the two groups were established. However, 18% felt they had been given too much
information, 65% did not wish to receive such detail and
36% welcomed the information. It was concluded that
patients should be given a choice of anaesthetic information.
In a review by McDonald et al. (2004) patient education
was deemed beneficial in reducing anxiety and Jakobsson
et al. (2008) emphasized the importance of adequate, extensive information to help manage care once home. Gilmartin
and Wright (2008) interviewed 20 patients at home following
day surgery and established information provision and
anxiety to be dominant features. What stands out in the
accounts is the psychological effects resulting from long
periods of preoperative waiting were worsened by increased
nervous tension and boredom (p. 2423). Tsapakis et al.
(2009) surveyed 148-day surgery patients and concluded
patients whose mood was low before surgery continued to
have a low mood after surgery.
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M. Mitchell

Khan and Nazir (2007) highlight possible gender differences in anxiety prior to surgery. Rosen et al. (2008) found
women to be statistically significantly more anxious than men
although 57% of all patients rated themselves as not calm
because of the situation. In a dental surgery study by Lai
et al. (2008), the provision of intra-operative music was
statistically significantly related to lower anxiety but women
reported higher levels of anxiety and Haugen et al. (2009)
reported female patients undergoing emergency surgery to be
statistically significantly more anxious than male patients.
Gender differences in anxiety have been established during
in-patient studies (Karanci & Dirik 2003) and in a number of
older day surgery studies (Cowan et al. 2000) but recent
investigations in day surgery are limited.
The rise in the volume of day surgery and minimal surgical
stay is unequivocal and an irreversible national and international development. However, little nursing knowledge has
thus far helped to inform such advances (Pearson et al.
2004b) and limited evidence available about anxiety associated with gender and anaesthesia type. A more formal
approach to anxiety management may now be required as a
result of the continued increase in day, short stay, day of
surgery and enhanced recovery programme admissions
(Department of Health 2010).

more. Patients undergoing dental and ophthalmic surgery

were excluded as they may experience additional anxiety.

Data collection
Data were collected over a 2-year period (20052007). The
principal investigator (MJM) contacted each Day Surgery
Unit (DSU) regularly to supply the questionnaires. The
clinical staff distributed the questionnaires to patients
following admission. Potential participants were invited to
enter the study and an information leaflet about the survey
provided prior to the final decision to take part. Questionnaires were provided to take home for completion and return
after 2448 hours in a freepost self-addressed envelope. The
General Anaesthesia questionnaire had 59 items and the
Local/Regional Anaesthesia version 61 items (additional
items associated with the experience of conscious surgery)
with the vast majority utilizing a Likert-type Scale format.
Anxiety associated with the environment, hospital personnel
and anaesthesia type (local, regional and general) were the
main themes and anxiety measured using a Likert Scale
format with a higher score representing increasing anxiety
(Figure 1). However, only the items from both questionnaires
considering participants preoperative experiences will be
addressed herein (Table 1).

The study
Validity and reliability
To investigate the possible influence of gender and anaesthesia type on anxiety prior to day surgery.

Design
A cross-sectional questionnaire study was undertaken. The
survey was part of a larger study investigating day surgery
patients experience of the environment, hospital personnel
and anaesthesia (local, regional and general). This paper will
only focus on anxiety in relation to gender and anaesthesia
type. Patient experiences of hospital personal, anaesthesia
type and impact of the environment are reported elsewhere
(Mitchell 2008, 2010).

Participants
A convenience sample of patients scheduled for elective
surgery in three public day surgery units was invited to take
part. Potential participants were those who were undergoing
general and local anaesthesia; having non-life-threatening,
intermediate surgery; English-speaking; and aged 18 years or
1016

Questionnaires were complied based on the literature and

international studies (Leino-Kilpi et al. 2009, Lemos et al.
2009), together with studies based within the United
Kingdom (Mitchell 1997, 2000, 2007). Items were required
to be brief and concise to ensure maximum return (Brattwall
et al. 2010). Both had clear content validity (all items related
to preoperative anxiety confirmed by experts in this field)
(Table 1). This means of data collection was used as patients
remain in hospital for very brief periods, and recovery time
350

311

300

Participants

Aims

250
200
150

139

117

100

70
30

50
0

Not
anxious

A Little
anxious

Quite
anxious

Very
Extremely
anxious
anxious

Figure 1 Anxiety on day of surgery (n = 674).

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JAN: ORIGINAL RESEARCH

Influence of gender and anaesthesia type on anxiety

Table 1 Questionnaire items preoperative anxiety

Overall anxiety
1) How anxious were you on the day of your surgery?
2) When did you anxiety first start?
3) Generally, what aspects of your experience made you most anxious?
4) Have you ever had an anaesthetic before this one?
5) How much written information would you prefer prior to an operation?
6) When would you prefer to receive written information about an operation?
Possible anxiety and hospital personnel
7) How would a nurse explaining your operation on the day of surgery affect your anxiety?
8) How would a nurse explaining what was to happen immediately before and after your operation affect your anxiety?
9) How would a nurse telling you about the timing of events affect your anxiety?
10) How would a doctor explaining your operation on the day of surgery affect your anxiety?
11) How would being told, The hospital carries out many operations safely each day affect your anxiety?
12) How would being told, All the doctors and nurses working in day surgery are very experienced affect your anxiety?
13) How would being told, All medical equipment used in your care is modern and in good working order affect your anxiety?
14) How would being told, The chance of the anaesthetic not working properly is very rare affect your anxiety?
15) How would being told, The drugs (medicine) used to ease pain and sickness are very good affect your anxiety?
16) How would being involved in decision-making, where possible, affect your anxiety?
17) How would the qualified doctors and nurses appearing calm and not rushed affect your anxiety?
Possible anxiety and the ward environment
18) How would a modern looking ward affect your anxiety?
19) How would seeing modern looking medical equipment affect your anxiety?
20) How would talking to other patients while waiting affect your anxiety?
21) How would reading information about your operation while waiting affect your anxiety?
22) How would listening to music or reading a book/magazine while waiting affect your anxiety?
23) How would having a partner/friend to talk to while waiting affect your anxiety
24) How would talking to a nurse while waiting affect your anxiety?
25) How would a nurse just being nearby while you are waiting affect your anxiety?
26) How did seeing other people in pain or being sick affect your anxiety?
27) How did not being able to smoke affect your anxiety?
28) How did a lack of privacy to ask questions affect your anxiety?

once home can be brief. A pilot study was undertaken for the
first 10% of respondents resulting in slight amendments to
the questionnaires prior to continuation.

Ethical considerations
All surgeons, anaesthetists and nursing staff in the three
public Day Surgery Units involved gave their agreement for
the study prior to Ethical Committee approval. All participants were given information concerning the study and it was
emphasised that a decision to withdraw at any time, or a
decision not to take part, would not affect their care.

Statistical analysis
Analysis was undertaken using Statistical Package for Social
Science (SPSS Inc., Chicago, IL, USA) v16 and statistical
significance set at P 005. Data were preliminarily examined using descriptive statistics. Following this a Multivariate
analysis of variance (MANOVA ) test for all between group
 2011 Blackwell Publishing Ltd

comparisons was used. Multivariate analysis of variance was

deemed appropriate as more than one independent variable
(gender or anaesthesia type) was to be explored against a
number of dependent variables such as anxiety on the day of
surgery, anxiety first start, what aspects of your experience
made you most anxious, etc. (Table 1).

Results
Overall, 1606 questionnaires were distributed and 674
returned (response rate 419%). Participants ages ranged
from 18 years to 75 years, with the average age being
43 years (385 female patients and 287 male patients).
Participants underwent a variety of procedures with general
surgery (hernia repair, cholecystectomy) and orthopaedic
surgery being most frequent (Table 2). The number of
participants undergoing general anaesthesia was 460
(628%) with 214 (318%) undergoing local anaesthesia.
A total of 824% of patients were anxious on the day of
surgery (Figure 1) with anxiety for the majority commencing
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M. Mitchell

350

Procedure

Cases, n (%)

300

General surgery
Orthopaedic surgery
Gynaecological surgery
Urological surgery
ENT surgery
Uncertain
Dental surgery
Medical investigations
Missing (patient did not complete)

181
166
114
72
71
33
6
2
29

(28)
(26)
(18)
(11)
(11)
(5)
(09)
(03)
(4)

Participants

Table 2 Surgery type (n = 674)

308

250
200
133

150

95

92

100

33

50
0

Figure 3 Preferred level of information (n = 674).

300

250

Participants

206

150
109
100
50

81
46

200
156
100

28
0

<2
weeks
before

Few
days
before

Few
Few
Not
hours minutes anxious
before before

153

150

50

0
>2
weeks
before

267

250
Participants

191

200

Any
Full
Medium Standard Mixture
None
information
account account account

51
14
None

28
Few
hours
before

Few
days
before

1
week
before

23
weeks
before

>4
weeks
before

Figure 4 Preferred to receive written information (n = 674).

Figure 2 When anxiety began (n = 674).

Table 3 Most anxiety provoking aspects (n = 674)

Anxiety provoking aspects

Cases, n (%)

Waiting
Pain
Anaesthesia
Unknown
Operation
Operation successful
Unconsciousness
Nausea and vomiting (PONV)
Family
Work
Past experience

384
238
221
211
205
187
107
81
78
52
41

(57)
(35)
(32)
(31)
(30)
(28)
(16)
(12)
(12)
(8)
(6)

a few days or hours before surgery (Figure 2). The most

anxiety provoking aspects were waiting, possible pain,
anaesthesia, unknown and the operation (Table 3). A total
of 83% had previously undergone general anaesthesia and
58% local anaesthesia. A majority of 308 (47%) preferred
information offering a full account and this information was
commonly required (86%) 14 weeks prior to surgery
(Figures 3 and 4).
1018

A one way between-groups MANOVA was performed to

investigate preoperative anxiety associated with anaesthetic
type and gender. First, there was a statistically significant
difference between anaesthesia type on the combined dependent variables, F (4, 647) = 796, P = 0001; Pillais Trace =
0047; partial g2 = 0047. When the results for the dependent
variables were considered separately four items reached
statistical significance using a Bonferroni adjustment of
00125 anxiety on the day of surgery F (1, 650) = 1102,
P = 0001, anxiety first start F (1, 650) = 1664, P = 0001,
preferred level of written information F (1, 650) = 9/56,
P = 0002, and written information preferred to be received
F (1, 650) = 1031, P = 0001 (Table 4). The average scores
for all four items were statistically significantly higher for the
general anaesthesia patients indicating greater anxiety and a
desire for more information (Table 5).
Second, there was a statistically significant difference between gender on the combined dependent variables, F (9, 636) =
774, P = 0001; Pillais Trace = 0099; partial g2 = 001.
When the results for the dependent variables were considered
separately several reached statistical significance using a
Bonferroni adjustment of 0005 anxiety on day of
surgery F (1, 644) = 3430, P = 0001, anxiety start
F (1, 644) = 2221, P = 0001, informed anaesthetic not
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Influence of gender and anaesthesia type on anxiety

working rare F (1, 644) = 776, P = 0006, modern looking

ward F (1, 644) = 425, P = 0007, modern looking equipment F (1, 644) = 828, P = 0004, talking to other patients
F (1, 644) = 624, P = 0013, reading information about
operation F (1, 644) = 1091, P = 0001, listening to music/

Table 4 Multivariate analysis of variance for anaesthesia type

(n = 674)
Dependent
variable

Sum of
Mean
squares d.f. square F

Anxiety on day
of surgery
Anxiety start
Preferred
information level
Preferred to receive
information

11592

11592 11018 0001* 0017

29787
20826

1
1

29787 16639 0000* 0025

20826 9556 0002* 0014

13691

13691 10306 0001* 0016

Alpha

Partial
g2

*P value statistically significant at a 0013.

Table 5 Descriptive statistics for anxiety and anaesthesia type

(n = 674)

Item
Anxiety on day
of surgery
Anxiety start
Preferred information
level
Prefer to receive
information

Type of
anaesthesia

Mean

SD

GA
LA
GA
LA
GA
LA
GA
LA

24678
21791
22639
18010
48248
44378
37317
34179

105439
095800
135941
128849
145385
152557
111209
123874

451
201
451
201
451
201
451
201

reading a book F (1, 644) = 372, P = 0054 and partner or

friend being with you F (1, 644) = 659, P = 001 (Table 6).
Average scores for anxiety on day of surgery, anxiety start
and informed anaesthetic not working rare were statistically
significantly higher for female patients and for items partner or
friend being with you and talking to other patients statistically
significantly lower. The average anxiety scores for modern
looking ward, modern looking equipment, reading information about operation and listening to music/reading a book
were statistically significantly lower for male patients (Table 7).

Discussion
Study limitations
Limitations of the study were associated with gender numbers and response rate. First, more female patients than
malepatients were surveyed (385 female patients and 287
male patients) possibly reflecting the level of gynaecological
surgery undertaken (Table 3). However, the statistical test
employed was sufficiently robust to compensate for this. The
response rate could be deemed low but such a response rate is
common in postal surveys, especially with a surgical population who once home, quickly resume their normal lifestyle
(Pandit & Davies 2005).

Anxiety and information provision

Participants desired much information prior to surgery and
this became a prominent feature when considering gender
and anaesthesia type. A full account of information was
desired by 46% and a medium account by 14% (Figure 3).

Table 6 Multivariate analysis of variance for gender (n = 674)

Dependent variable
Anxiety on day of surgery
Anxiety start
Anaesthetic not
working rare
Modern looking ward
Modern looking equipment
Talking to other patients
Reading information
about operation
Listening to music or
read a book
Partner or friend being
with you

Sum of
squares

d.f.

Mean square

Alpha

Partial g2

34525
39890
10713

1
1
1

34525
39890
10713

34296
22209
7756

0000*
0000*
0006*

0051
0033
0012

2864
6193
5082
10102

1
1
1
1

2864
6193
5082
10102

4248
8276
6241
10914

0040*
0004*
0013*
0001*

0007
0013
0010
0017

2214

2214

3721

0054*

0006

5742

5742

6590

0010*

0010

*P value statistically significant at a 0005.

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1019

M. Mitchell

Table 7 Descriptive statistics for anxiety and gender (n = 674)

Item

Gender

Mean

SD

Anxiety on day of surgery

Female
Male
Female
Male
Female
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male

25718
21047
23360
18339
33035
20623
19278
22087
20108
24309
26101
29675
27148
20786
19603
19322
21227

103518
095925
131084
137835
119556
082020
082215
087993
084478
090663
089664
098578
092953
075671
079071
091679
095520

369
277
369
277
369
369
277
369
277
369
277
369
277
369
277
369
277

Anxiety start
Anaesthetic not working rare
Modern looking ward
Modern looking equipment
Talking to other patients
Reading information about
operation
Listening to music/reading
a book
Partner or friend being
with you

Therefore, 60% of participants who responded desired a high

level of information provision. Moreover, anxiety associated
with the unknown was a common anxiety provoking aspect
(31%) suggesting the degree of information was less than
desired (Table 2). Lemos et al. (2009) established information provision prior to day surgery to be effective in the
management of anxiety and it helped increase satisfaction. In
a review of the literature by Rhodes et al. (2006) preadmission contact with the nurses and the provision of education
and information were highly beneficial. Heikkinen et al.
(2007) interviewed 120-day surgery patients and concluded a
greater level of information was needed. Mottram (2009)
found patients had little knowledge of events and were very
anxious on the day of surgery. In a qualitative analysis of
patient/anaesthetist preoperative interaction (Kindler et al.
2005), the conversation focussed largely on biomedical issues
with little psycho-social discussion. However, as a result of
the nature of the anaesthetists role, such information was
deemed necessary and time limited. Lack et al. (2003) suggest
while patients are frequently informed about their surgery by
the surgeon in the out-patient clinic, little information is
given about the anaesthetic until the day of surgery.
The provision of a satisfactory level of information for all
patients has proven difficult and more tailored individual
programmes recommended (McDonald et al. 2004). However, for some the provision of too much information can
cause an increase in anxiety likewise too little information
(Krohne et al. 2000). Such patient groups have been termed
vigilant copers (monitors/high information seekers) or the
opposite - avoidant copers (blunters/low information seekers)
(Stoddard et al. 2005). Providing an extensive level of written
1020

information to all patients could be undertaken thus allowing

individuals to determine the areas and level appropriate for
them. The majority of participants in the present study
(86%), preferred to receive information 14 weeks prior to
surgery (Figure 4). Timing of information delivery was
viewed as crucial by Crook et al. (2005) as it was desired
in advance so that arrangements could be made with
employers and family about the length of incapacitation.
The questionable quality of some patient information leaflets
has been highlighted but Gafermoen and Jakobsen (2009)
suggest day surgery information to be superior in quality to
other areas of health care.
An area of controversy lies with the level of exposure to risk
information. In the reported study, five such questions were
posed (Items 1015) (Table 1). For 48%, only one item was
stated as having the potential to increase anxiety - Told the
chance of the anaesthetic not working properly is very rare.
(Item 13). In comparison to male patients, female patients
statistically significantly did not want to be informed of this
(Table 5). However, following a survey of patients in a
preassessment clinic, Edward et al. (2008) recommended
patients be informed of what happens in theatre, potential
risks, side effects of anaesthesia, pain control, medication and
fasting. In a randomized controlled trial involving patients
scheduled to undergo major surgery (some for suspected
malignancies) by Cand et al. (2008), viewing a video was
determined to help improve understanding of anaesthesia and
the risks involved. Following viewing patient knowledge was
deemed to have increased but not anxiety. Farboud et al.
(2009) conducted a survey of doctors, patients and nonmedical staff in day surgery about the communication of risk
during consent signing. Statistically significantly more patients
and non-medical staff, in comparison to doctors, believed rare
events to be more likely than their odds would suggest. That is,
patients and non-medical staff had an exaggerated notion of
the risk involved prior to surgery and required additional
clarification of common misconceptions. Farboud et al. (2009)
concluded this may be more effectively undertaken by expressing the risk as odds or in percentage terms.

Anxiety and anaesthetic type

The majority of participants in the present study were
anxious on the day of surgery (824%) although the degree
of anxiety varied (Figure 1). Apprehension frequently commenced a few days or hours prior to surgery (Figure 2). A
total of 83% of participants reported they had previously
undergone general anaesthesia and 58% local anaesthesia,
thus prior exposure had not diminished anxiety. In addition,
34% remained anxious 2448 hours after surgery and it has
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JAN: ORIGINAL RESEARCH

What is already known about this topic

Researchers have recommended information provision
to be an essential aspect of anxiety management prior to
day surgery.
Differing levels of anxiety have been recognized
between in-patients undergoing general and local
anaesthesia and between male patients and female
patients.
Enhanced recovery programmes emphasize the need for
high quality information provision and informed patient
decision-making.

What this paper adds

General anaesthesia patients experienced a greater
degree of anxiety and desired more information at an
earlier stage in comparison to local anaesthesia patients.
In comparison to male patients, female patients
experienced a greater level of anxiety, had a preference
for greater social interaction and a greater desire for the
presence of a partner/friend during the preoperative
wait.
In comparison to female patients, male patients
preferred to read information about their surgery to
help reduce anxiety, listen to music or read a book in a
modern looking environment during the preoperative
wait.

Implications for practice and/or policy

An increased emphasis on the quantity and quality of
patient information remains challenging as almost half
of participants desired a detailed account and almost all
required this information prior to admission.
Patients undergoing surgery and general anaesthesia
may require greater psychological support prior to day
surgery in comparison to local anaesthesia patients.
Gender difference in preoperative activities to help limit
the effects of anxiety may require greater consideration,
that is, positive statements, modern ward environment
and the choice of social support.

been suggested patient concerns can last for many months

(Barthelsson et al. 2009). Osborn and Sandler (2004) suggest
anxious patients require an increased level of sedation to
induce and maintain a clinically acceptable level of relaxation
to avoid the risk of intra-operative movement. To help limit
apprehension, Ward et al. (2007) proposed patients be given
 2011 Blackwell Publishing Ltd

Influence of gender and anaesthesia type on anxiety

a choice of anaesthetic induction method as this was deemed

a source of much anxiety.
Anxiety in the present study arose largely from the wait,
possible pain, anaesthesia, the operation and the unknown
(Table 3). In a study by Crockett et al. (2007) of 128-day
surgery patients six themes were identified concerning anxiety - preoccupation with anxiety, outcome concerns, unconsciousness, loss of control, dependence on others and pain/
discomfort. Fekrat et al. (2006) questioned 67 inpatients and
26 anaesthetists and determined major concerns to be
whether surgery would work, body being damaged by
surgery and dying during anaesthesia and surgery whereas
Markovic et al. (2004) suggested anxiety arose from waiting,
lack of a significant other, lack of information and walking to
theatre. Previous studies have therefore highlighted numerous
aspects giving rise to anxiety but apprehension associated
with anaesthesia and waiting remain the most common.
Participants in the present study undergoing general
anaesthesia were statistically significantly more anxious than
participants undergoing local anaesthesia and their anxiety
started statistically significantly sooner (Tables 4 and 5).
General anaesthesia participants desired a greater level of
information and preferred to receive this statistically significantly sooner than participants undergoing local anaesthesia.
In a study of 1259 patients undergoing varicose vein stripping
by Armellin et al. (2007), all patients had light general
anaesthesia coupled with local anaesthesia infiltration. This
proved highly satisfactory as all patients desired the same
anaesthesia when surgery was later performed on the
opposite leg. Matthey et al. (2004) proposed hernia repair
to be common in day surgery achieving excellent results using
local anaesthesia although this type of anaesthesia is not
always desired by patients when given a choice. However,
Raeder (2006) suggests local anaesthesia with intravenous
sedation to be a growing trend in day surgery as it reduces
pain and the risk of postoperative cognitive dysfunction.

Anxiety and gender

Two issues arose concerning anxiety and gender - the
approaching surgery and waiting activities. First, female
patients were statistically significantly more anxious than
male patients on the day of surgery and their anxiety began
statistically significantly sooner (Tables 6 and 7). Inpatient
studies have revealed that female patients experience higher
levels of anxiety than male patients (Perks et al. 2009) but
support for this has only been established in a few older day
surgery studies (Cowan et al. 2000). Mackenzie (1989)
interviewed 200 day surgery patients and determined female
patients to have higher anxiety and a positive correlation
1021

M. Mitchell

emerged between the nurses ratings of participant anxiety

and participants ratings of anxiety. In a survey by Birch et al.
(1993) anxiety was expressed more by female patients,
younger and novice patients and Rosen et al. (2008) determined female patients to be statistically significantly more
anxious. Fekrat et al. (2006) found participants and medical
staff rated female patients as statistically significantly more
anxious than male patients. However, Shafer et al. (1996)
suggest female patients to be more truthful when completing
preoperative anxiety measures and not necessarily more
anxious. In the present study, both male patients and female
patients had a tendency to give a less than accurate picture of
their anxiety as both sets of scores were negatively skewed,
that is, both had an inclination to underscore.
With regard to gender and waiting activities a number of
differences were established. Female patients, in comparison to
male patients, statistically significantly indicated a preference
to spend their time waiting by talking with other patients,
passing the time with a partner/friend and did not wish to be
informed that the chance of the anaesthetic not working
properly is rare. Krohne and Slangen (2005) established close
emotional support prior to surgery decreased anxiety for
female patients but the opposite was true for male patients close emotional support for male patients led to an increase in
anxiety. Majasaari et al. (2005) interviewed 60 day surgery
patients and confirmed almost 50% considered it important to
have a family member present during their hospital stay
although the possible gender variation was not mentioned. In
the present study male patients, in comparison to female
patients, statistically significantly indicated being in a modern
looking ward, surrounded by modern looking equipment
would help limit their anxiety. While little research is available
about the ward environment, Tsai et al. (2007) revealed
patient satisfaction with the physical environment in an
outpatient waiting area was associated with gender, age,
visiting frequency and visiting time. In the present study, male
patients in comparison to female patients, statistically significantly indicated spending time reading information about
their surgery or listening to music/reading a book would be
calming. While research studies examining the impact of the
physical environment are very limited, an increase in nonpharmacological methods of anxiety management, increased
social support and improvements in the environment to aid
patient/nurse interaction have all been suggested (Suhonen
et al. 2007).

Conclusion
The majority of patients undergoing elective surgery will
increasingly experience day, short stay or day of surgery
1022

admission. Patients can experience much anxiety and modern

healthcare practices will ensure an ever-decreasing window of
opportunity for nurse/patient interaction. Previous nursing
practice, associated with psychological aspects of care, relied
heavily on lengthy hospital admission. The evidence presented herein helps to demonstrate the changing needs of
surgical patients with regard to gender, anaesthesia type and
the possible direction in which nursing may need to develop.
Such nursing knowledge and its brief application can have a
muchneeded impact on anxiety management in the growing
area of minimal hospital stay. Inclusion of such considerations into integrated care pathways may be an essential first
step in aiding this process. The impact of the modern surgical
environment can play an important role although this is an
area in which little research has been undertaken. Given the
nurses workload and the continued clinical streamlining of
care, future studies may wish to consider the wider impact of
the environment on patient anxiety and the option of a family
member remaining with the patient until called to theatre as
is common in paediatric day surgery.

Funding
Partial funding for the study came from a Fellowship Award
by the British Association of Day Surgery. This funding was
gratefully received and contributed to the successful completion of the study.

Conflict of interest
No conflict of interest has been declared by the author.

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