Rhe purpose of this study was to
determine the magnitude and specific foci of anxiety experienced by
patients receiving their initial hyperbaric treatment. The
Spielberger State-Trait Inventoryquestionnaire and a personal
interview were administered to 24 patients to determine anxiety
levels. Upon arrival at the hyperbaric clinic and prior to any type
of health teaching, the State and Trait questionnaire was
administered to the patients. One hour prior to the treatment, the
State questionnaire was repeated to determine any significant
changes in anxiety levels.
No significance was found in anxiety levels between prehealth and
pre-treatment. The Trait questionnaire revealed that this specific
group of patients, regardless of the circumstances,felt they were
not very anxious individuals. Post-treatment, the State
questionnaire was administered again and these anxiety levels did
differ significantly from the pre-health and pre-treatment levels.
The findings indicate the need to continue to validate clients'
perceived needs during hyperbaric treatment, which will help direct
future nursing practice.
Hyperbaric oxygen therapy (HBO) is a recognized adjunct treatment
used fora number of disorders. Someofthe disorders include wound
healingoftraumatic boneand softtissue injuries, microbial
infections, and air orgas embolisms. During HBO treatments, the
patient breathes 100% oxygen intermittently while the pressure of
the treatment chamber is increasedto pressuregreaterthan
oneatmosphereabsolute.
There are two types of chambers for HBO: multiplace and monoplace.
The multiplace is large enough for at least nine people to walk,
sit, or lie on a stretcher. For the chamber to become pressurized,
the chamber door must be closed and then the chamber itselfis
compressed with air. The patient is usually in this environment for
approximately 2 hours. The monoplace chamberis a singlechamber
wherethe patient lies on a stretcher forthe entire treatment. In
this typeofchamber, the patient cannot sit or walkbut can
communicate with staff by a telephone or microphone handset attached
to the chamber. The environment in both chambers can be perceived by
somepatientsas veryconfining.
Patients experiencing treatment in an HBO unit for the first time of
teninterpret the eventasstressful. Inan overly anxious person, the
HBO unit with its high technology, unfamiliar surroundings,and
environmental confinement can leadsomepatients to expresspanic and
terminateor refusetreatment.
Stroke & Hyperbaric Chambers HBOT
Many studies in the literature document elevation ofanxiety levels
whenexperiencing newand/oruncertain events. When an individual is
experiencing a newevent,cognitive thinkingis diminished. When an
individual interprets a situation as stressful, not only is one's
cognitive functioning affected but one's behavioral, psychological,
and emotional responses to the situationare alsoaffected.'
The scientific literature provides few research studies involving
anxiety and a patient'sinitial or subsequent HBO treatments. In the
late 1950s and 1960s, care providers in hyperbaric units recognized
that a relationship existed between the hyperbaric chamberand
patient anxiety. Wildermuth reported that a frequent problem
associated with hyperbaric therapy wasthe patient'sfearand
apprehension of an unknown experience and their reactionto that
fear.
Augenstein's study was one of the first reporting patients'
reactions to the confining space in the hyperbaric chamber and
specific interventions to alleviate the anxiety." In the last
decade, confinement anxiety in hyperbaric chambers has been
reportedin severalstudies.7-10
This previous research on anxiety and HBO treatment provides a basis
fora growing but still in complete body of knowledge. Therefore, the
purpose of this study wasto determine the magnitude of any anxiety
experienced by patients receiving their initialHBO treatment.
Methodology
The non-randomized sample consisted of 24 adults (18 or older) who
were referred for their first HBO treatment to a large mid-west
military medical center. All of the clients met the following health
criteria: notreceiving medications containing
sedatingortranquilizing agents, not experiencing medical trauma or
emergency circumstances, no pre-existing medical diagnosis for
psychological problem, and not
legally blindor deaf. Informed consent was obtained according to
institutional review boardgutdelines.
The Spielberger State-Trait Inventory (STAI) questionnaire was used
to determine anxiety levels. This tool consist sof two scales: part
one (State) contains 20 Likert-type questions which measurea
subject'sanxiety level at the present moment (in terms of intensity
categories: not at all, somewhat, moderately so and very much so);
part two (Trait) contains 20 Likert-type questionswhich measure a
subject'sanxiety level by asking how they generally feel (interms
offrequency categories ofalmost, never, sometimes, often, and almost
always). According to Spielberger, a the total score for each tool
is the weighed sum ofall 20 responsesand rangesfrom a minimum
scoreof20-39 (low anxiety] and 40-59 (moderate anxiety), to a
maximumscoreof60-80 (high anxiety).
The questionnaires werea dministered to the subjects as follows.
Part one (State) and part two (Trait) weregivento the subjects after
arrival at the clinic, before seeing health care providers or
receiving any health care teaching. Part one (State) was repeated 1
hour before the patients' initial HBO treatment and again
immediately after the initial HBO treatment. According to Buros,
test-retest reliabilities for trait anxiety were examined in male
and female undergraduates over a 6-month period. Scores of 0.73 and
0.77, respectively, indicated
a very stable measurement. Test-retest reliabilities for state
anxietyhad scoresof0.83 to 0.92,respectively. 12Correlations with
other standard trait anxiety instruments, such as the Institute for
Personality and Ability Test and the Taylor Manifest Anxiety
Scale,havebeen documented.
Inaddition to the STAI, each subject was requested to participate in
a personal interview immediately following the initial HBO treatment
(see Table I). Thesame trained interviewer conducted each interview
by reading the questions and tape recording each subject'sresponse.
What concerns did you have regarding your first hyperbaric
treatment?
What helpedyou prepare foryour first hyperbaric treatment?
Describeyour feelings experienced during your first hyperbaric
treatment.
Describehowyou feelnowthat your first hyperbaric treatment is
completed.
Results
Inferential statistics were used to determine the magnitude of
anxiety experienced by 24 subjects undergoing their first HBO
treatment. Subjects ranged in age from 27 to 81 (mean = 55).
Twenty-two of the subjects were men and two were women. Subjects
were hospitalized patients from a Veterans Hospital, a military
medical center,and out patients referred for treatment. Twenty
subjects had specific wound problems which needed HBO treatment, two
had compromised skin grafts,and twohad thermal burns. Incomputing
the 24survey responses, one subject omitted 5 items out of the 20
for the State anxiety at each of the three time points; therefore,
this subject's answers were excluded in the analysis.
In general, the results of both the State and Trait anxiety levels
indicated a low anxiety level. There was only a slight increasein
the State anxiety level (36.4-37.4) from before any health teaching
was provided until the time ofthe initialtreatment. However, after
the treatment, the State anxiety levels decreased significantly.
A subject's age was found to be somewhat linearly correlated with
the State anxiety scale after the treatment (r = 0.50), while the
relationships with the State anxiety at the other time points, l.e.,
before teaching and before the treatment, and the Trait anxiety
levels were not significant.
HBOT Hyperbaric Chambers & Brain Trauma Treatment
To determine if any difference occurred in the magnitude of anxiety
experienced by these 23 subjects during the three time points,a
one-factor (time) analysis ofvariancewith a repeated measure on time
factor(Le., before teaching,before treatment, and after
treatment)wasused.The dependent variable was the subject's State
anxiety.The results indicated that the hypothesis of no time effect
was rejected at the significance level of 0.05; thus, there was some
difference in anxiety among the three time points.By further
analysis during Tukey'smultiple rangetest at the experiment-wise
significance level of0.05, anxiety levels werenot foundto be
significantly different between pre-teaching and pre-treatment;
however, the anxiety levels pre-teaching and pre-treatment as
comparedto post-treatment are significantly reduced by a score of
5.2 and 6.2,respectively.
To help determine the specific foci of anxiety, the clients
responded to four questions following their initial treatment.
Responses as to what helpedthe client preparefor their initial HBO
treatment were varied. Forty-eight percent stated that the detailed
orientation, which included a video about RBO and a personal
interview with one ofthe RBO
physicians and a tour ofthe chamber, helped them understand what
they would experience. Twenty-two percent stated the staff helped by
providing specific information as to physiological changes they
might experience during the treatment (such as ear painand visual
changes), while17% indicatedthat other patients offered reassurance
since they had already experienced their initial therapy and had not
experienced problems.
Thirteen percent stated that there was nothing specific which helped
them prepare for their initial therapy. When questioned about their
concerns regarding the initial HBO treatment, 52% stated that they
had no concerns while 48% expressed concern over feelings of
confinement. possible physiological changes and fear of the unknown.
In response to the third question. where patients described their
feelings during their first HBO treatment. 83%ofthe clients
expressed positive feelings (see Fig. 3). Only 17% stated that they
were nervous. disappointed in the treatment, or uncertainas to how
they feltat that time.
Discussion
The results of this study are consistent with previous work which
reported an increase in magnitude of anxiety before a new treatment
but a decreaseafter the treatment.13 There are several variables
which could have contributed to the reduction of anxiety: client
teaching which included a video explaining HBO therapy. the
orientation/tour of the department and chamber. the client's actual
experience inside the hyperbaric chamber. or various means of
distraction (reading. music. or meditation). Perhaps it was a
combination of all these variables.
For many years. the literature has indicated a decrease in anxiety
for hospitalized patients who had received preoperative teaching. As
previously noted. there was not a significant decrease in anxiety
between pre-teaching and pre-treatment; however. the majority of the
patients during the interview indio cated that health teaching
helped them prepare for their treatment. Perhaps a combination of
experiencing the actual treatment along with the health teaching
provided for the statistically significant reduction of anxiety
scores following the treatment.
Familiarization ofthe hospital environment could have contributed to
the reduction of anxiety after the treatment. This would help
support the lack of significance noted in this study between
pre-teaching and pre-treatment. since the patient had not actually
experienced the treatment.
Several of the patients indicated during the interview that they
wererelieved their first treatment was completed and felt hope and
contentment regarding their therapy. For some patients. HBO therapy
was the final treatment which of fered any hope for their condition
before the initiation of invasive procedures such as amputations or
major wound debridementreo quiring general anesthesia.
Perhaps the contentment noted by the patients was attributed to some
part of the health teaching. the development of the nurse-client
relationship during the treatment. or the patient's realization that
they had not experienced any stgniftcant problems during the
treatment.
Generalizability of these findings cannot be justified because of
limitations noted in the study sample. The subjects were not
randomized. with 19ofthe 23 subjects from the Veterans Hospital.
Because the majority of the subjects were war veterans. the life
experiences ofthese individuals do not represent the general
population since they had to deal with many anxiety-provoking events
during war time. In a potentially stressful situation. a non-combat
individual may experience increased anxiety.where as a combat
veteran might experience little or noanxiety.
Recommendations
Anxiety is often described as a reaction to an uncertain event. By
defining the uncertain event. the threat of what was presumed
dangerousis decreased.
Hyperbaric Oxygen Chamber Can Boost Brain Repair
Since there are few studies in this area. this pilotstudy warrants
replication with a larger randomized sample reflecting adiverse age
group and including more women. Additionally, investigation into the
benefit of specific health teaching strategies is indicated,
especially for those patients who have high anxiety levels. Also,
research focused on the effect of various time intervals between
health teaching and the initial treatment may prove beneficial to
health care providers. Research findings to validate patients'
perceived needs during HBO treatment will help direct future nursing
practice.
Acknowledgments
This research was conducted at Wright Patterson Air Force Base
Medical Center, Ohio. This research was funded by a Professional
Development Grant, Wright State University, Dayton, Ohio. The
authors extend thanks to Sandy Pratt, MSN, RN, who collected the
data and spent many hours developing graphics for slides and this
article. The authors extend thanks to Helen Wyskiver for her typing
of the manuscript.
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