Executive SummaryManhattanEndoscopy Center is an ambulatory endoscopy and colonoscopy center located in Mid-townManhattan. According to the Manhattan Endoscopy website (n.d.
) “Thestate-of-the-art facility has been designed to maintain the personal attentionof an office-based procedure while ensuring hospital level safety standards.” Thefacility serves adults age 18-90 years old in the New York City and tristatearea of different backgrounds, and sometimes from other parts of the world whowant a specific gastroenterologist. The facility performs endoscopies,colonoscopies, flexible sigmoidoscopies, and sometimes upper and lowerendoscopic ultrasounds of a patient’s intestinal tract, and anoscopies foreither screening, diagnostic, surveillance, or treatment purposes. As a result,on a daily basis there are a number of anxious patients awaiting their proceduresome who are having their procedure for the first-time and others who have beenthrough it before but still get anxious and patients who are in a sedatedanxious state of mind waiting to see what their doctor will tell them aftertheir procedure. The goal of this project is to promote the positive effects ofdeep breathing exercises to decrease patients’ anxiety levels prior to anyprocedure.
As nurses integrate this breathing technique in patients withassessed high levels of anxiety through teaching and return demonstration, thepatients are happier and satisfied with services due to a holistic treatmentfor their care. “Two third 70.3% of preoperative patientshad anxiety” according to a study done by Nigussie, Belachew, and Wolancho(2014) at Jimma University Specialized Teaching Hospital.
Even with thishigh percentage, according to Informed Health Online (2014), “It is totallynormal to feel anxious before surgery. … It is important to make sure thatfears and anxiety do not become too overwhelming.” There is no single solutionto anxiety there are different methods and strategies to help cope with anxietyand associated symptoms. Therefore, even though patients have consultationswith their gastroenterologists prior to procedure or hear stories from familyor friends about the procedure whether it is their first time or nth time, thereis still a sense of anxiety and increase of cardiovascular parameters. Thepurpose of this project is to reduce or alleviate a patient’s anxiety levelprior to their procedure using the 4-7-8 breathing technique. In addition, thisbreathing technique can be utilized by the patient in other times of stress,tension, or anxiety in their life.
Threeproject objectives:1. Patientswill have a coping technique to help them reduce their own anxiety levels thenext time they come in for a procedure or they encounter a similar scenario.2. Improvecardiovascular parameters such as heart rate, breathing rate, and bloodpressure.3. Increase patient satisfaction byutilizing time in the pre-procedure waiting area to reduce anxiety levels andteach patients the 4-7-8 breathing technique. Scope ofWork:The scope of work for the purpose of this project is thisauthor with the direction and counseling of her preceptor and professor who haveproposed, implemented, and assessed the components, which entail the details ofthis project. The nurses assess the anxiety levels of the patients and willhelp the patients learn the deep breathing technique, to help in the reductionof their level of anxiety.
Depending on the need of nurses and other staffmembers who are interested in learning and evaluating the deep breathingtechnique at MEC will determine the hours needed by the author and preceptor.Usually the author and preceptor were on site during the weekdays during MEC’sbusiness hours. The number of hours during the week depended on the needs ofthe facility and the availability of the author and preceptor.Methodof Approach: The method of approach ofthis project is assessing the patient’s anxiety level prior to their procedureduring the pre-procedure assessment using a scale from 0-10 (see scale on pageprior to references), with zero being the patient is at ease and ten being thatthe patient is panicking. Based on the patient’s anxiety level and the amountof time the nurse has before the patient’s procedure will determine the amountof time for having a learning and demonstration of the 4-7-8 breathingtechnique. In addition, there will a record of the patient’s vital signs beforeand after to measure the effect of the breathing technique as well as keepingin mind conditions which affect the vital signs. Whether there is a timelimitation or not, the patient will be provided with a handout (see page priorto references for a copy of the handout) to take with them reinforcing thesteps of the 4-7-8 breathing technique. The patients will be evaluated afterthe procedure either the same day or the following day to see how their anxietylevel was affected by the breathing exercise using the same scale and be ableto provide more information about the reason for a change in anxiety level orreason for anxiety.
A general survey can be done to see if the breathingtechnique has made any changes in the anxiety level of patients and how thenursing staff is coping with integrating the implementation of the interventionto their framework after one and six months of having the practice in place.The preceptor and the author are working closely with the staff to teach andimplement the technique into the framework of the nurses in pre-procedure. Theoutcome of this project is a decrease in patient anxiety levels prior to theirprocedure utilizing a technique, which they can also integrate into other areasthey deem necessary to reduce anxiety.Projectdeliverables:For this project, the maindeliverables are seeing how many patients are anxious prior to their procedureand reducing that number through the integration and employment of the 4-7-8breathing technique. Reducing the patient’s anxiety level prior to acolonoscopy or endoscopy procedure will not only reduce their cardiovascularparameters prior and during the procedure but will also help them to comprehendthe information their gastroenterologist will provide them after theirprocedure. Furthermore, a decrease in anxiety level will provide the patientwith a sense of holistic care from the staff at MEC.
Exclusions:Patients with existing psychiatric and mental healthdiagnosis and patients who refuse to participate in using deep breathing as wayto cope with their anxiety level prior to the procedure. According to Naik,Gaur, & Pal, (2017), “Individuals who areunable to perform breathing exercise due to reasons such as nasal pathologyincluding deviated nasal septum, sinusitis and those with a history of chronicrespiratory disease, smokers, alcoholics, were excluded from the study.” Inaddition, to patients who have a cold, nasal congestion or postnasal drip arealso excluded.Constraints:Patients with a language barrier where a translator isneeded, scheduling of procedures, arrival, and registration of patientslimiting the time the nurses can be with the patient, and the amount of staffproperly trained in providing the deep breathing technique to the patient. Theamount of patience the staff and patients have in learning the technique and beable to provide a proper demonstration of the technique for its effectiveusage. Organization Description ManhattanEndoscopy Center (MEC) is a state-of-the-art facility, Joint Commissioncertified and an American Society for Gastrointestinal Endoscopy (ASGE) centerof excellence.
It is New York’s newest and most modern endoscopy center thatwas established by respected physicians who aims to make each patient’sprocedure efficient and pleasant. It is accessible to the New York City but notlimited to patients living in the tristate area. The facility focuses on coloncancer awareness and prevention by offering free screenings for patients withlow income. The facility offers services such as upper endoscopy, endoscopicultrasound, flexible sigmoidoscopy, colonoscopy and anoscopy.
These procedureshelp uncover the reason for a patient’s abdominal pain or epigastric pain,nausea, vomiting, diarrhea, constipation, anemia, rectal bleeding; see if thereis Barrett’s esophagus and monitor it; dilate esophageal strictures or removeforeign bodies; screen for colon polyps; and determine if the patient hascommon gastrointestinal problems such as: IBS/IBD, Crohn’s Disease, CeliacDisease, Ulcerative Colitis, ulcers, a hiatal hernia, hemorrhoids, GERD, H.Pylori, C. Difficile, and see if there is a bowel obstruction such as a tumor. MEC’Smission statement is dedicated to providing high quality, cost-effective,efficient and comprehensive outpatient health care for adults.
Their mission isto serve as community resource for health care matters in facility staffed byhighly experienced physicians with a shared commitment to patient safety. Thevision is healthcare excellence through teamwork, innovation and continuousquality improvement. The values of respect, dignity, integrity and compassionwill be constantly demonstrated to all patients and staff. Myproject is a very efficient and cost-effective practice that is useful inproviding high quality care to patients.
As cited by Varvogli, & Darviri (2011), Jerath, Edry, Barnes, and Jerathstated “Diaphragmaticbreathing is defined as a manipulation of breath movement, contributing to aphysiologic response characterized by (a) the presence of decreased oxygenconsumption, decreased heart rate and blood pressure, and (b) increased thetawave amplitude in EEG recordings, increased parasympathetic activityaccompanied by the experience of alertness and invigorating.” Deep breathing exercises decreasesanxiety, reduces stress, provides relief of general body aches and it promotesbetter blood flow in the body. In addition, more specific exmaples are statedby Varvogli and Darviri such as “decreasethe fatigue associated with haemopoietic stem cell transplantation patients,… reduce the anxiety and asthmasigns/symptoms of children with asthma, … theslow-breathing technique can have a significant effect on improvement of thehemodynamic changes following the acute stressful tasks, … been used toinfluence autonomic functions in patients with essential hypertension and thusreduce it (2011). The benefitsof deep breathing can correlate with MEC’s mission and vision because itencourages the health care workers in providing excellent pre-surgical services,high quality of care and gives great patient satisfaction. It is important that the nursing staff be effective teachersof the breathing technique to the patients because according to Ray (n.d.
), “Nursestake an active role in reducing stress and anxiety when they are trained inmassage and deep breathing techniques they can administer to anxious patients.”The project’s main objectives are measurable by using an anxiety levelscale. The approach is actionable by simply following the 4-7-8 breathingtechnique. The vision is attainable through observations after the project isimplemented. The project will help internally define performance standards,inspire employees to work more productively by providing focus and common goals(Rigby, 2017) which are effective management tools in achieving the facility’svision. TargetPopulationThe patients at Manhattan Endoscopy Center (MEC) aregenerally healthy individuals between the ages of eighteen years to ninetyyears old.
For this study, I focus on twenty healthy individuals with no mentalhealth issues or psychiatric history. The participants are ten females and tenmales of different ethnicities and cultural background. They are in the agesbetween twenty-five to eighty years old. The participants, who participated inthe study, came to MEC solely for diagnostic purposes and for a routine,comprehensive evaluation of the digestive tract. Ninety percent of theparticipants are anxious and afraid of the uncertainty of the results of theprocedure. Assumptions:A major assumption made during this project is allocationof staff and staff time.
The ability to teach the nursing staff the breathingtechnique properly and to integrate the assessment and teaching of thetechnique into the pre-procedure framework. In addition, the need to simplifythe handout for patients to take home on the 4-7-8 breathing technique andprovide a website with the video of the technique being performed for patientsto practice at home. If there is not enough staff in pre-procedure or time forthe patients to learn the technique and give a return demonstration due toscheduling of their procedure or time constraints of the gastroenterologists,the nursing staff may not have the ability to effectively teach the techniqueand only give the patient the handout with little to no explanation. Anotherassumption is the ability to effectively evaluate the change in anxiety levelsas well as categorize the patient’s explanation for their anxiety level if itis based on the procedure they are about to have or if there are additionalfactors. A major key component is the cooperation of myself, along with thepreceptor, and MEC staff in supporting the successful implantation of thisproject. Everyone must have patience and be able to contribute some time forthe betterment in the care of the patients especially if their anxiety level isdeterring them from having a comfortable experience.Business Case This isan economical project such as mentioned by Jerath, Crawford, Barnes, & Harden, (2015), “Breathingand meditation techniques are simple, easy, and cost-effective yet they are notwidely used as treatments.” Therefore, there are a number of potential ofbenefits reaped from this project with the key beneficiaries being those wholearn and practice the breathing technique and integrate it into their lives tobetter their health and wellbeing.
The estimate cost of this project isunder $500. The cost primarily focused on paper and printing cost. Each patientis given a handout of the 4-7-8 breathing technique, the anxiety level scaleand a pencil. Personal time invested that average between 5-10 minutes of extratime spent with patients in order to do the study. The duration ofthe study is one month. Week 1 started by informing the administration aboutthe project and its purpose to promote deep breathing exercises in the pre-operativearea.
The first week is focused on organizing from the list of incomingpatients who are good candidates for the study. Rely on nursing staff duringthe pre-procedure interview quickly screen patient’s health history which helpseliminate the patients with mental or psychiatric diagnosis. Week 2 to 3 isfocused on implementing the study and collecting data from patient’s reactionto the study.
Reading materials and pamphlets are given to participants. Week 4is the culmination of the study wherein the data collected are being summarizedand interpreted. Evaluation on the study and its effects on the patients aredocumented. ProjectTeam Structure:The author of this project is the project manager, as wellas creator and implementer and sole person responsible for outcome of theproject such as creating the proposal, gaining approval from the medicaldirector, gastroenterologists, anesthesiologists, and director of nursing,learning, practicing, and teaching the 4-7-8 breathing technique, andpresenting the project. With the preceptor’s input of the project, other staffmembers are included in the implantation of this project.
Aside from thepreceptor, the charge nurse, and nursing staff as well as per diem nursingstaff are in charge of learning, practicing, and teaching the breathingtechnique to the patients. In addition, they will help in reporting and keepingtrack of patients’ anxiety levels, before and after the procedure, and trackinghow many refuse to participate. The director of nursing as well as thegastroenterologists provides the approval in interacting with the patients andoffers support in executing the project. In addition, they oversee the impactof the project on the patients, staff, and work flow throughout the time of theproject and hopefully in the future.Communicationand Change Plan The purpose of the project is discussed first to theadministrative leaders in the Manhattan Endoscopy Center (MEC) for approval.The study is incorporating deep breathing exercises in the pre-op area before aprocedure.
The duration of the study is between 5 to 10 minutes per patient.The management was informed that the study will not impede nor conflict withthe nurse’s daily tasks at MEC. The patients’ reactions after the study areoptimistic. The positive report led to approval of the management to implementdeep breathing exercise at the center.The proposal on encouraging patients to practice deepbreathing exercises before their procedures has positive outcomes that canbenefit both the patients and the providers.
The proposal was to put thepatient in the pre-op area that is quiet, relaxing and calming to do breathingexercises prior to going to the operating table. The pre-op nurse is encouragedto include at least 5 to 10 minutes of deep breathing exercises in thechecklist prior to take the patient in the operating room. The leadership inthe MEC agreed on implementing this step. Conducting a session of deep breathingexercises is easy and simple way for any trained or untrained staff to do. Theaim for this study is to reduce patient’s level of stress. Deep breathing isefficient as it reduces the ventilation in the dead space of the lungs. Shallowbreathing replenishes air only at the base of the lungs in contrast to deepbreathing that replenishes the air in all parts of the lung.
It decreases theeffect of stress and strain on the body by shifting the balance of theautonomic system predominantly toward the parasympathetic system and improvesthe physical and mental health (Naik et al, 2017). A short session of deepbreathing exercises is added to the framework of pre-operative checklist inwhich the pre-op nurses implemented.Quality Plan The3 main objectives of the study are to decrease anxiety level of patients beforetheir procedures and to improve their learning capabilities about the scheduledprocedure. The goal is to satisfy patient with services given at MEC withoutimpeding on medical diagnostics procedures. – Decreasing patient’s anxiety afterdeep breathing exercises that is implemented by the staff and will be measuredthrough post-op follow up call. The nurse follows-up questions are related tooverall experience at MEC and the anxiety level score.
– Improving patient’s coping techniqueand the use of the 4-7-8 breathing exercise in other aspects of life wherestress levels are high. This is measureable through MEC survey that is mailedor emailed to the patients after the procedure. – Enhance cardiovascular parameters byeffective breathing technique that is measurable by checking the vital signsafter the 5-10-minute session of the 4-7-8 breathing technique. Project Controls1. Feedback from the staff about thepatient’s anxiety level after the implementation of the 4-7-8 breathingtechnique. 2.
Keeping a record of patients’participation of the study including those who refused to participate in thestudy. Compare the levels of anxiety to both variables and create a statisticaldata to manage progress. 3. Effective communication forscheduling purposes. Reminding the staff about the new implementation of 4-7-8breathing exercises will automatically become a routine procedure.
Summary Theimportance of the project is to show that effectiveness of deep breathingexercises decreases patients’ anxiety level and improves their perception ofthe procedure at MEC. “A multitudeof breathing exercises and yoga have been in use to achieve a significantreduction in stress acquired by the hectic and imbalanced lifestyle. However, asingle and uncomplicated tool suitable for beginners and individuals withhealth ailments is the need of the hour” (Naik et al, 2017). The project willhelp the organization achieve its goals on increasing patient’s satisfactionwithout any disruption to budget, policies and protocols. Reducingpre-procedural anxiety levels may prevent the pain experienced by patientsduring the performance of the esophagogastroduodenoscopy (EGD), and thus increase the patients’satisfaction, that is considered as a measure of a high-quality endoscopy (Pontoneet al, 2015).
Studies and implementation on quality improvements projects suchas the implementation of the 4-7-8 breathing technique to patients prior to aprocedure, is a requirement of ASGE to maintain MEC’s status as center ofexcellence. Anxiety Scale*0 – At ease, Comfortable1 – Slightly Nervous2 – Nervous3 – Apprehensive4 – Anxious5 – Worried6 – Very Worried7 – Somewhat Fearful8 – Fearful9 – Somewhat Panicked10 – Panicked *Based on scale from iCounselor:Anxiety App on iTunes Handout Provided to Patients aboutthe 4-7-8 Breath Relaxation Exercise References: iCounselor. (2009, November 03).ICounselor: Anxiety on the App Store. Retrieved fromhttps://itunes.apple.com/us/app/icounselor-anxiety/id336555160?mt=8 Jerath, R., Crawford, M.
W., Barnes, V.A.
, & Harden, K. (2015). Self-Regulation of Breathing as a Primary Treatmentfor Anxiety. AppliedPsychophysiology and Biofeedback,40(2), 107-115.doi:10.1007/s10484-015-9279-8 Manhattan Endoscopy Center.
(n.d.).Retrieved from http://www.manhattanendo.com/ Naik, G., Gaur, G.
S., & Pal, G. K. (2017). Effect ofModified Slow Breathing Exercise on Perceived Stress and Basal CardiovascularParameters.
International Journal of Yoga. Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769199/.
Nigussie, S., Belachew, T., &Wolancho, W. (2014). Predictors of preoperative anxiety among surgical patientsin Jimma University Specialized Teaching Hospital, South Western Ethiopia.
BMC Surgery,14(1).doi:10.1186/1471-2482-14-67 Pontone, S., Pontone, P., Tonda, M.
,Brighi, M., Florio, M., & Pironi, D. (2015). Does anxiety or waiting timeinfluence patients? tolerance of upper endoscopy? Saudi Journal ofGastroenterology,21(2), 111. doi:10.
4103/1319-3767.153839 Ray, L. (n.d.). Role of Nurses forStress & Anxiety Patients. Retrieved from http://work.chron.
com/role-nurses-stress-anxiety-patients-7487.html 4-7-8 Breath Relaxation ExercisePDF. (2010). Retrieved from https://www.
cordem.org/files/DOCUMENTLIBRARY/2017%20AA/Handouts/Day%20Three/Biofeedback%20Exercises%20for%20Stress%202%20-%20Fernances%2C%20J.pdf Rigby, D. K. (2017). An executive’sguide. Management Tools 2017.
Retrieved from http://www.bain.com/Images/BAIN_BOOK_Management_Tools_2017.pdf What can help relieve anxiety beforesurgery? (2014, May). Retrieved from https://www.
ncbi.nlm.nih.gov/pubmedhealth/PMH0072741/ Varvogli, L., & Darviri, C. (2011). StressManagement Techniques: evidence-based procedures that reduce stress and promotehealth.
Health ScienceJournal,5(2), 74-89. Retrieved fromhttp://www.hsj.gr/medicine/stress-management-techniques-evidencebased-procedures-that-reduce-stress-and-promote-health.php?aid=3429