Comparing Levels of Anxiety During Bed and Shower Baths in Patients with Acute Myocardial Infarction

This study compared the levels of anxiety presented by patients with acute myocardial infarction in bed and shower baths and the influence of antecedent variables: age, gender, medications, previous hospitalization and/or bed bath, patients’ preference regarding the professional’s gender, risk factors and anxiety-traits. This crossover study was conducted between February and August 2007 in coronary units. The sample was composed of 71 patients with acute myocardial infarction. The State-Trait Anxiety Inventory (STAI) was applied before the baths (bed and shower baths), immediately after the baths and twenty minutes after the second evaluation. Results revealed that patients were more anxious in the bed bath than in the shower in the three assessments (p <0.0001) and the only variable that interfered with state-anxiety was high blood pressure.


Introduction
Anxiety is one of the most immediate and intense psychological responses to acute myocardial infarction (AMI).Coronary patients might present 26% more anxiety than patients with psychiatric disorders (1) .
The association of anxiety and AMI negatively affects the prognosis of these patients (1)(2)(3) .A high level of anxiety in the first 48 hours after hospitalization increases the chances of developing complications by 4.9 times during hospitalization in comparison to patients with a low level of anxiety (1) .Anxiety activates the sympathetic nervous system increasing cardiac contractility, blood pressure, cardiac frequency and consumption of oxygen, worsening the development of the disease (4)(5) .
Rules established in hospital settings force individuals to constantly adapt, which in addition to patients' need to cope with pain and the threat of death, also causes anxiety (6)(7) .We frequently observe in clinical practice that anxiety becomes more intense depending on the procedure that the patient is undergoing, such as receiving a bed bath.
The exacerbation of this feeling is understandable given the sociocultural context in which we live, where Lopes JL, Nogueira-Martins LA, Gonçalves MAB, Barros ALBL. it is not "appropriate" to undress in front of others.
Additionally, because this is a routine procedure, professionals frequently forget they are managing the body of another, invading individuals' privacy and intimacy, which can trigger adverse reactions such as anxiety and dissatisfaction (8)(9) .
However, there are no studies quantifying and comparing the anxiety generated during bed and shower baths nor the potential variables that can modify this anxiety.
For this reason, this study's objectives were: -to compare levels of anxiety generated during AMI patients' bed and shower baths hospitalized in Coronary Care Units (CCU); -to evaluate the influence of several variables on patients' anxiety in view of bed and shower baths.This study is a special type of clinical trial in which patients received two types of treatment, in a specific or random order.The advantage of this study is that the patients themselves serve as the control group; consequently, fewer individuals are needed compared to conventional clinical trials (17) .

Method
The population sample was composed of 71 patients with AMI (with or without ST-segment elevation), hospitalized in the CCU, including patients of both genders, who signed consent forms.
The following inclusion criteria were used: patients with Killip I and II, literate, with no visual impairment, younger than 80 years old and who agreed to participate in the study.The exclusion criteria were: the presence of arrhythmias (ventricular tachycardia, second or third degree atrioventricular block); ischemic pain; patients with Killip III and IV; invasive procedures at the moment of data collection, such as catheterization, surgery and situations in which patients were not capable of filling out the questionnaires (altered levels of consciousness, visual impairment and/or patients who could not read and/or write).

Data collection was carried out at two different points:
-first point: the second bed bath after hospitalization; -second point: the second shower bath, only after the medical team authorized this procedure.
The patients remained reclined during the bed bath and were assisted by a nursing professional.For the shower bath, a shower chair was used and patients took their bath without direct assistance, though they were under supervision.
It is important to mention that nursing professionals did not receive any type of additional training concerning the baths.These procedures were carried out according to the unit's normal routine and by professionals who were responsible for the patients at the point of data collection.However, aiming to diminish the influence of interpersonal conversation during the procedures, the professionals were instructed to keep to a neutral and superficial conversation.
The instrument used to evaluate anxiety was the State-Trait Anxiety Inventory (STAI).This self-applied inventory is the most complete and commonly used instrument in studies evaluating levels of anxiety and was translated and validated in Brazil.It has two distinct scales with scores that range from 20 to 80 points; the higher the score, the higher the patients' anxiety.In addition to the use of scores to evaluate the results, we opted to categorize anxiety (18)(19) : low anxiety (20-34 points), moderate anxiety (35-49 points), high anxiety (50-64 points) and very high anxiety (65-80).This categorization was considered valid both for the state and trait-anxiety.
The state-STAI evaluates anxiety at the point of the questionnaire's application and was applied at the two previously described points (second bed bath and second shower bath) and three evaluations were carried out for each of these applications: a) before the procedure (aiming to evaluate the patient's expectations); b) immediately after the bath (to evaluate the anxiety presented by the patient at the time of these procedures) and c) 20 minutes after the second evaluation (to evaluate anxiety over time).
Jointly with the state-STAI, vital signs (heart frequency, hypertension and respiratory frequency) were assessed, since anxiety can alter these parameters.
The trait-anxiety evaluates the anxiety profile of patients and was evaluated only once, immediately after the third evaluation of state-anxiety and was considered one of the antecedent variables.
this study were: age, gender, patients' preference for a female or male professional to give the bath, previous hospitalization and/or baths, risk factors for cardiac diseases, trait-anxiety and use of anxiolytics.These variables were correlated with state-anxiety generated during the bed and shower baths.
The following statistical methods were used to analyze the results: the method of repeated measures ANOVA, was used to verify the correlation of stateanxiety generated during the bed and shower baths and also the correlation of antecedent variables with stateanxiety; Person's correlation analyzed the correlation of state-anxiety with trait-anxiety; and Generalized Estimating Equations were used to verify the correlation between state-anxiety and vital signs.The adopted level of significance was 5%.
The research project was evaluated and approved by the Ethics Committee at the hospital where the study was carried out.The study's participants were asked whether they agreed to participate in the study and authorized the use of collected data, and signed free and informed consent forms.

Results
The sample was composed of 71 patients; 31 (43.7%) of them were female.The average age was 58.8 years, while patients between 53 and 61 years predominated.
In relation to risk factors related to cardiovascular diseases, the most frequently found were: sendentariness (74.6%), hypertension (73.2%) and family history of cardiovascular disease (71.8%).preferred that male professionals give them the bath and two (5%) preferred female professionals.

The majority of patients included in
Statistically significant differences were found in the three evaluations (p<0.0001)concerning anxiety generated in bed and shower baths analyzed through the repeated measures ANOVA as shown in Figure 1.
The study revealed that patients with AMI presented levels of anxiety significantly higher in the bed bath than in the shower bath, especially before the bed bath as shown in Figure 1.We verified that there were not variations in patients' vital parameters (cardiac frequency, respiratory frequency and systolic and diastolic blood pressures) measured at the three previously described points and which could be related to the state of anxiety of patients as shown in Table 1.anxiety due to the baths, as shown in Tables 2 and 3.

Discussion
The data obtained in relation to anxiety indicate two main results.The first is that anxiety generated from a bed bath is higher than that generated from a shower bath in the three evaluations.This fact might have occurred because patients perceived the bed bath as a threat to their safety due to invasion of privacy and intimacy, which increased their level of anxiety (8) .
These manifestations are due to the cultural universe in which being socially appropriate implies wearing clothes; one should not expose his/her body in the presence of another and nudity is related to sensuality and sexuality (13,21) .
The second main result is that anxiety generated by patients' expectation of receiving a bed bath was higher than anxiety generated during the bath itself.This same result was found in another study in which anxiety was higher before a bed bath (score 43.98%) diminishing right after the procedure (score=37.89) (22).
The act of "awaiting" some event causes diverse expectations, feelings and emotions (7) .During hospitalization, especially in intensive care units, there are several stressors and situations that alter life habits, generating expectations in patients that might make the waiting period distressing and lead to stress and anxiety (23) .
increased levels of anxiety to be detectable through changes in cardiac frequency and blood pressure.The verbalization of anxiety, agitation and increased blood pressure and cardiac frequency are the most important indicators of anxiety (24) .However, these parameters were not influenced by anxiety during bed or shower baths, even in moderate levels.Nonetheless, it is worth noting that the evaluated patients were using medications such as anti-hypertensive medications and betablockers, which might have interfered in the results.
In regard to the antecedent variables, we observed that the only variable that influenced the anxiety of patients was hypertension, showing that hypertensive patients presented higher levels of anxiety than nonhypertensive patients in bed and shower baths.Similar results were obtained in another study (25) , in which the levels of state and trait anxiety of hypertensive patients were significantly higher than the population in general.
There is no consensus in the literature concerning the relation of other antecedent variables and patients' anxiety.Among these variables, a somewhat surprising result was the fact that anxiety did not alter in situations in which patients' preferences regarding the gender of the professionals were unsatisfied.
Nurses are recommended, due to their academic training, to take into account not only the patients' conditions and level of dependency but also their preferences.Patients should be allowed to participate in the planning and delivery of care related to their lives and health whenever possible (26) .
The results obtained in this study revealed that anxiety did not increase when patients' preferences were contradicted.This contributes to the profession since there is a predominance of female professionals in nursing and male professionals are not always available to satisfy the patients' preferences.
In view of the presented contexts concerning the anxiety generated in the baths and considering the individual differences of each patient, it is the nurses' role to pay more attention in the planning and realization of such procedures.From this perspective, we believe that professionals should be encouraged to provide clear and objective orientation in their nursing activities related to bed baths, seeking to clarify the factors that trigger stress and anxiety.

Conclusion
The level of anxiety during bed baths is significantly higher than that generated during shower baths.
Therefore, factors that influence it should be modified This crossover study was carried out in the CCU of the Heart Institute at the Hospital das Clinicas of the University of Sao Paulo Medical School (HCFMUSP) between February and August 2007.

Figure 1 -
Figure 1 -State-anxiety according to the type of bath at the three points of evaluation.São Paulo, SP, Brazil 2007

Figure 2 -
Figure 2 -Patients' anxiety according to hypertension during the bed baths.São Paulo, SP, Brazil 2007 through strategies in order to provide information to patients in relation to this procedure.Despite the bath's relevance and the fact it is the most performed nursing activity, it has been little explored.Studies comparing levels of anxiety during several nursing procedures are extremely important for the daily practice of nursing care.Professionals should be concerned not only with the patients' physiological aspect but also with their psychological aspect, seeking emotional balance concomitantly with seeking the physical recovery of patients.

Table 2 -
Results of the repetitive measures ANOVA for the state-anxiety according to gender, age, previous hospitalization and bed bath, preferences, benzodiazepines and risk factors.São Paulo, SP, Brazil 2007

Table 3 -
Results of Person's correlation between stateanxiety of bed bath and shower bath and trait-anxiety.