Personal Identity and Its Effect on Pre-procedural Anxiety

Personal Identity and Its Effect on Pre-procedural Anxiety 1.0 Introduction In contemporary healthcare systems, one of the key ways of diagnosing and treating medical conditions is through invasive and minimally invasive procedures on patients. Some of these procedures are accessing the intravenuous system for treatment (venipunctures), blood collection for investigations (phlebotomy), lumbar punctures and biopsies. Regardless of age, sex or ethnicity, patients endure anxiety and pain associated with these invasive procedures (American Pain Society, 2001). In spite of minimal tissue damage in these procedures, anxiety about the procedure and associated pain, may cause considerable distress in patients. This may affect the coping mechanism, even in a well functioning individual. This has been studied by McCleane and Cooper (1990), Augustin and Haynes (1996) and Garbee (2000). A number of researches have been conducted to determine and control anxiety in patients who are subjected to such procedures. Based on these studies, patient education programs (McDonald and Green, 2002), alternative therapies (Noreed, 2000), pharmaceutical therapies (Smith and Pittaway, 2002) and musical therapies (Elliot, 2004) have been proposed to a varying extent. An important point to note is that musical therapies, education programs and patient educational programs may be time-consuming and may be of limited practicality in a busy hospital environment. On the other hand, pharmaceutical therapies may cause side-effects associated with drugs. Therefore, a simplistic approach, which could provide comfort and relieve the pre-procedural anxiety, is the need of this surgical era. No research has been found on invoking personal identity and its effect on pre-procedural anxiety. Therefore, this research aims to fulfill this gap. Hospitals and health care institutions are unpleasant environments with a general appearance of illness and death. It is an environment where one is separated by friends and family and is surrounded by strangers. A person who is being subjected to a procedure at a hospital may already contemplate on the potential illness that the person may be subjected to. This may lead to a temporary feeling of anxiety (Coyle, 1999). According to Spielberger et al (1970) anxiety is divided into two factors, state anxiety (also known as somatic anxiety) and trait anxiety. State anxiety is temporary or circumstantial arousal and trait anxiety is the permanent change of personality characteristics associated with anxiety. According to Kent (1998), state anxiety may cause physiological arousal, and activation of the sympathetic nervous system and the hypothalamic pituitary adrenal axis. This is characterized by increased pulse rate, blood pressure, respiratory rate and increase cardiac output (Bally et al, 2003). Research by Hayes et al (2003), asserts that reducing the state anxiety is important before a diagnostic procedure to promote relaxation and to prevent possible complications; such as procedure becoming more painful, difficult, prolonged and increased probability of after effects. When a procedure becomes difficult to administer, doctors may also postpone or cancel the procedure, placing the patient at a dis advantage. Addressing patients’ emotions through an evidence-based management is important for nurses to increase the patient outcome. Psychosocial nursing interventions, emotional presence and establishment of trust between the nurses and the patient, has the potential to mitigate patient’s fear and anxiety or stress to a greater level. 1.1 Pain and Anxiety Associated with Invasive Procedures Studies have concluded that pain associated with a procedure may be severe than that actual illness that needs investigation (Finley and Scheter, 2003). The procedure itself may have an effect on the pain that is experienced by the patient, which is based on the patient’s perception, which in turn, can be influenced by factors including past experience, psychological state, hearsay knowledge and the patient’s level of understanding (Rawe et. al., 2009). According to Brennan, Carr and Cousins (2007), effects of pain can be short and long-term, which are not gender, age or ethnicity-specific. A number of studies have confirmed the psychological effects of pain, which include anxiety, anger and fear as well as physical effects, such as changes in metabolic functions, heart functions and functions related to blood (Ferrell, 2005; Gordon et al., 2005; Mertin, et.al., 2007). Most common long-term effects of pain are, insomnia and depression (Berenholtz, et. al., 2002). Several studies have noted that there is a positive relationship between anxiety and pain, in a clinical setting (Sternbach, 1968; Melzack, 1973). According to Kain et. al. (2001), severity levels of pain are directly proportionate to anxiety levels due to activities in the hippocampal network, which causes behavioural conflict in the brain. This is resolved by sending and amplification signal to the neural representation of the painful event, which causes anxiety in the pe rson. This was verified by Ploghaus et. al. (2001) using a series of event-related functional magnetic resonance imaging (FMRI) studies, which concluded that anxiety-induced hyperalgesia is associated with activation in the entorhinal cortex of the hippocampal formation. Van den Broek, Hejimans and Van Assen (2012) focused on the emotional distress caused by the procedure of implanting a cardioverter defibrillator (ICD), an invasive procedure, in 343 patients.. All subjects demonstrated distress through anxiety and depression immediately after the procedure as well as during follow-up timelines. 1.2 Psychological Techniques used to Reduce Pre-procedural Anxiety Healthcare personnel have discovered a number of methods to reduce anxiety of patients through psychological intervention techniques. One of the methods employed by clinical nurses is through therapeutic touch. Cox and Hayes (1997) performed a quasi-experimental study based on patients at a district General Hospital in East London, which concluded that therapeutic touch aids in reducing anxiety of the patients. Another method which has been researched is, on the effect of music as an intervention for reducing the pre-procedural anxiety in hospitalized adult patients (Gillen, Billey Allen, 2008). This was performed through Randomized Controlled Trials (RCTs) of 832 adult patients The researchers concluded that psychological outcomes show anxiety was reduced to a greater extent as a result of music listening interventions, demonstrated by reduction of blood pressure, respiration rate and heart rate. A study performed by Hawley (2009), explored nurse strategies which were perceived as comforting by patients. The sample size was 14 patients in the emergency department of a hospital in New York. The study concluded that positive talk, vigilance and attending to physical discomforts were among the top five factors that reduced anxiety. Hawley (2009) concluded that the study â€Å"supports the provision of comfort as an integral part of emergency nursing practice and a critical aspect of care.† A research with 580 mentally alert adults were selected for a study by Whelchel (2004) to identify the effect of caring behaviour by nurses on ED patients. At the end of the study and data analysis, the researchers reported that treating the patients like an individual, was considered to be the most important trait in reducing the anxiety of emergency room patients, followed by knowing what they were doing, being kind and considerate, treating the patient with respect, giving the patient their full attention, knowing how to administer injections and insert intravenous catheters. 1.3 Self Esteem and Anxiety From the beginnings of scientific psychology, the idea that people wish to maintain high levels of self-esteem has been a central theme in many studies (Horney, 1937; James, 1890). The idea of self-esteem generally means one’s own evaluation of him or herself. Self-esteem is also seen as a critical function for social and mental well-being of a person. Self-esteem induces and maintains personal goals and motivations and according to a study by Mann et. al. (2001), conclusive evidence exists that self-esteem leads to better mental health. Mann et.al. (2001) assert that a series of psychological problems, both internalizing and externalizing can be caused by poor self-esteem. The researchers conclude that self-esteem acts as a protective factor and is a core element in the promotion of mental health. Greenberg, Pyszczynski and Solomon (1986) argue that self-esteem provides a buffer against anxiety, focusing primarily on the fear of human beings towards mortality. Through empirical evidence, the researchers have concluded high-level of self-esteem reduces anxiety and behaviour that relates to anxiety. Three studies were conducted by Greenberg, et. al. (1992:1, 1992:2, 1993) to identify the direct evidence for the effect of self-esteem on anxiety. In the first study (Greenberg et. al., 1992:1), participants received positive and negative feedback about their personality, which was false. Then one group was shown a video which threatens of death, whereas the second group was shown a neutral video. The dependent variable in this study was state anxiety and the hypothesis was that bolstering self-esteem would reduce anxiety in response to the threat. The study concluded that participants with low self-esteem had the highest anxiety. A second study was partaken with participants being given bogus feedback on an intelligence test (Greenberg el. Al. , 1992:2). Following the feedback, participants were told that they would receive an electric shock or a neutral stimulation. The dependent variable was physiological arousal and the hypothesis was that the participants with bolstered self-esteem would experience reduced physiological arousal in anticipating electric shocks. The conclusion of the study was that neutral self-esteem-threat the participants having highest anxiety. A third study by Greenberg et. al. (1993) was with participants, who were provided with either positive or neutral feedback regarding their personality and a emotionality scale test, where the dependent variable was emotionality and the hypothesis was high self-esteem would reduce the participants’ anticipation of a short life-expectancy. The study concluded that participants with negative feedback information led to low self-esteem. Based on these studies, researchers Greenberg et. al. (1992:1, 1992:2, 1993) developed anxiety-buffer hypothesis which led to the conclusion that self-esteem provides protection against anxiety and one who has an increased self-esteem becomes less-prone to anxiety when exposed to threatening situations later. 1.4 Personal Identity and Name Personal Identity deals with oneself and issues that arise by the virtue of being an individual and it has its own attributes that make a person unique and different from the rest. Personal identity has its own properties, such as name, appearance, preferences which make a person unique. At present, an estimated 120 million babies are born on earth in a year (Deluzain, 1996). Sooner or later, they undergo the process of receiving a name. Names are part of all cultures and they are equally important to the person who receives the name as well as the society which the person lives in. The most important part of a person’s identity is the name. It is of important for the individual and the society as a whole. Inspite of its importance, not many people know or interested in knowing the effect of name on us and our children in this world although we are considered as the â€Å"consumers of names†. Researches show that one of the reasons for couples to have children is to perpetuate the family name (Arnold and Kuo, 1984; Callan and Kee, 1981; Ramu and Tavuchis, 1986). A research by Howard et. al. (1997) concluded that students felt proud when professors in their university remembered them by the name. A century ago, anthropologists identified that there has never been an ancient civilization, which did not allocate first names to people, in the recorded history. Many ancient cultures believed that not having a name is equivalent to not having an identity or honour (Frommer, 1982). At present, in most countries, parents are required to register the birth of a child through the child’s name. This is a legal requirement, which is the first time a child is given a legal identity. The birth certificate received by the parents becomes an essential document for admitting a child to school, obtaining healthcare and other basic services from the society. The existence of a name of a person is not only important to the person psychologically, but it is also of religious, social and legal importance because our identities are associated intuitively through the name. When one’s name is mispronounced, it may sound resentful to the person. Most people, especially when communicating with persons of different cultures, take extreme care to ensure the names are not mispronounced. Studies have revealed that mispronunciation of the name amounts to distortion of one’s identity (Deluzain, 1996). Freud identified the psychological effects of distortion of one’s name, deliberately or accidentally. According to Freud’s observations, people of aristocratic class, who wielded economic and political power tended to mispronounce their doctors’ names (Deluzain, 1996). The explanation for this was the aristocrats’ psychological need to show their superiority over the doctors, who wielded the power of one’s life and death. A similar event is seen in Shakespeare’s play, King John, where the character Philip Faulconbridge was found to be the illegitimate son of Richard the Lionheart, which made him King John’s half-brother. In the aftermath, King John orders Philip Faulconbridge’s name to be changed to Richard Plantagenet and deliberately refers to Philip as Peter (Shakespeare, 1623). This is a clear example of how Shakespeare presented the idea that mis-representation of a person’s name amounts to mis-representation of the person. The psychological significance of names are so high, that two separate researches have concluded that people have a strong affiliation with letters of the alphabet in their own names than ones which are not in their names (Koole, Dijksterhuis, and van Knippenberg, 2001; Nuttin, 1985; Greenwald and Banaji, 1995). The research by Greenwald and Banaji (1995) concluded that people positively associate themselves with letters in their names, as they are considered to direct reflection of the person, although there doesn’t appear to be any pragmatic reason for this association. This positive association of one’s name and even the letters of the name with oneself has a general tendency to make a person feel good (Greenwald and Banaji, 1995; Hetts and Pelham, 2001). The connection between name and identity is also emphasized by research that portrays changing of one’s name leading to changing of one’s personal identity (Lawson, 1984; Kang, 1972). In certain villages in China, men are allocated an additional name based on the social transitions, such as marriage. On the contrary, women do not receive additional names, which imply that they never attain complete personhood (Watson, 1986). A research by Howard et. al. (1997) concluded that students felt proud when professors in their university remembered them by the name. A century ago, anthropologists identified that there has never been an ancient civilization, which did not allocate first names to people, in the recorded history. Many ancient cultures believed that not having a name is equivalent to not having an identity or honour (Frommer, 1982). 1.5 Self-Esteem and Personal Identity The idea that people strive to keep a high level of motivation maintain high-level of self-esteem is widely accepted and is considered as a postulate or an accepted fact. Theories suggest that behaviours such as aggression, love, deviance and even altruism are due to ultimate belief that humans wish to be seen as valuable (Heine et al, 1999). Studies have been done only recently to determine whether this is always true and whether it is universal (Baumeister, 1998; Heine et al, 1999). However, still, a significant majority of psychological theories consider the need of humans to maintain high-levels of self-esteem as a postulate. Coyle (1999), presented a concept called personal identity threat in healthcare settings which is one of the key concepts of patient dissatisfaction in healthcare. According to Coyle’s research, people who were generally unhappy with the overall healthcare experience they receive, is mainly due to them being treated as non-persons, which is also termed dehumanization. This study asserts that the person’s name has a significant effect on one’s own identity. According to Coyle’s research (1999), people who were generally unhappy with the overall healthcare experience they receive, is mainly due to them being treated as non-persons, which is also termed dehumanization. 40 out of 41 patients interviewed by Coyle stated that they were treated as, an ‘object’ and on deep exploration, Coyle identified that the patients were referred by numbers on a file (such as patient number 49) instead of the name, which gave the patient the notion of being dehuma nized. This study asserts that the person’s name has a significant effect on one’s own identity. The above studies indicate that self-esteem is connected with personal identity, where invoking personal identity increases one’s self-esteem. One of the most key attributes of personal identity of an individual is the name. A number of studies, particularly by Greenberg et. al. (1992:1, 1992:2, 1993, 1996) concluded that self-esteem acts as an anxiety buffer. The aim of the present study is to investigate the effect of addressing a patient by name on pre-procedural anxiety level of in-ward patients, who are undergoing basic blood investigations in a large private hospital in Colombo. The hypothesis tested in this research was, talking to patients by addressing them by name, before an invasive procedure, reduces the pre-procedural anxiety level of hospital patients, than talking to them without referring by name or not talking to them at all.