Executive it before but still get anxious and patients

Executive Summary

Endoscopy Center is an ambulatory endoscopy and colonoscopy center located in Mid-town
Manhattan. According to the Manhattan Endoscopy website (n.d.) “The
state-of-the-art facility has been designed to maintain the personal attention
of an office-based procedure while ensuring hospital level safety standards.” The
facility serves adults age 18-90 years old in the New York City and tristate
area of different backgrounds, and sometimes from other parts of the world who
want a specific gastroenterologist. The facility performs endoscopies,
colonoscopies, flexible sigmoidoscopies, and sometimes upper and lower
endoscopic ultrasounds of a patient’s intestinal tract, and anoscopies for
either screening, diagnostic, surveillance, or treatment purposes. As a result,
on a daily basis there are a number of anxious patients awaiting their procedure
some who are having their procedure for the first-time and others who have been
through it before but still get anxious and patients who are in a sedated
anxious state of mind waiting to see what their doctor will tell them after
their procedure. The goal of this project is to promote the positive effects of
deep breathing exercises to decrease patients’ anxiety levels prior to any
procedure. As nurses integrate this breathing technique in patients with
assessed high levels of anxiety through teaching and return demonstration, the
patients are happier and satisfied with services due to a holistic treatment
for their care.

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            “Two third 70.3% of preoperative patients
had anxiety” according to a study done by Nigussie, Belachew, and Wolancho
(2014) at Jimma University Specialized Teaching Hospital. Even with this
high percentage, according to Informed Health Online (2014), “It is totally
normal to feel anxious before surgery. … It is important to make sure that
fears and anxiety do not become too overwhelming.” There is no single solution
to anxiety there are different methods and strategies to help cope with anxiety
and associated symptoms. Therefore, even though patients have consultations
with their gastroenterologists prior to procedure or hear stories from family
or friends about the procedure whether it is their first time or nth time, there
is still a sense of anxiety and increase of cardiovascular parameters. The
purpose of this project is to reduce or alleviate a patient’s anxiety level
prior to their procedure using the 4-7-8 breathing technique. In addition, this
breathing technique can be utilized by the patient in other times of stress,
tension, or anxiety in their life.

project objectives:

1.     Patients
will have a coping technique to help them reduce their own anxiety levels the
next time they come in for a procedure or they encounter a similar scenario.

2.     Improve
cardiovascular parameters such as heart rate, breathing rate, and blood

3.     Increase patient satisfaction by
utilizing time in the pre-procedure waiting area to reduce anxiety levels and
teach patients the 4-7-8 breathing technique.


Scope of

The scope of work for the purpose of this project is this
author with the direction and counseling of her preceptor and professor who have
proposed, implemented, and assessed the components, which entail the details of
this project. The nurses assess the anxiety levels of the patients and will
help the patients learn the deep breathing technique, to help in the reduction
of their level of anxiety. Depending on the need of nurses and other staff
members who are interested in learning and evaluating the deep breathing
technique 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’s
business hours. The number of hours during the week depended on the needs of
the facility and the availability of the author and preceptor.

of Approach:

The method of approach of
this project is assessing the patient’s anxiety level prior to their procedure
during the pre-procedure assessment using a scale from 0-10 (see scale on page
prior to references), with zero being the patient is at ease and ten being that
the patient is panicking. Based on the patient’s anxiety level and the amount
of time the nurse has before the patient’s procedure will determine the amount
of time for having a learning and demonstration of the 4-7-8 breathing
technique. In addition, there will a record of the patient’s vital signs before
and after to measure the effect of the breathing technique as well as keeping
in mind conditions which affect the vital signs. Whether there is a time
limitation or not, the patient will be provided with a handout (see page prior
to references for a copy of the handout) to take with them reinforcing the
steps of the 4-7-8 breathing technique. The patients will be evaluated after
the procedure either the same day or the following day to see how their anxiety
level was affected by the breathing exercise using the same scale and be able
to provide more information about the reason for a change in anxiety level or
reason for anxiety. A general survey can be done to see if the breathing
technique has made any changes in the anxiety level of patients and how the
nursing staff is coping with integrating the implementation of the intervention
to 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 and
implement the technique into the framework of the nurses in pre-procedure. The
outcome of this project is a decrease in patient anxiety levels prior to their
procedure utilizing a technique, which they can also integrate into other areas
they deem necessary to reduce anxiety.


For this project, the main
deliverables are seeing how many patients are anxious prior to their procedure
and reducing that number through the integration and employment of the 4-7-8
breathing technique. Reducing the patient’s anxiety level prior to a
colonoscopy or endoscopy procedure will not only reduce their cardiovascular
parameters prior and during the procedure but will also help them to comprehend
the information their gastroenterologist will provide them after their
procedure. Furthermore, a decrease in anxiety level will provide the patient
with a sense of holistic care from the staff at MEC.


Patients with existing psychiatric and mental health
diagnosis and patients who refuse to participate in using deep breathing as way
to cope with their anxiety level prior to the procedure. According to Naik,
Gaur, & Pal, (2017), “Individuals who are
unable to perform breathing exercise due to reasons such as nasal pathology
including deviated nasal septum, sinusitis and those with a history of chronic
respiratory disease, smokers, alcoholics, were excluded from the study.” In
addition, to patients who have a cold, nasal congestion or postnasal drip are
also excluded.


Patients with a language barrier where a translator is
needed, scheduling of procedures, arrival, and registration of patients
limiting the time the nurses can be with the patient, and the amount of staff
properly trained in providing the deep breathing technique to the patient. The
amount of patience the staff and patients have in learning the technique and be
able to provide a proper demonstration of the technique for its effective

Organization Description

Endoscopy Center (MEC) is a state-of-the-art facility, Joint Commission
certified and an American Society for Gastrointestinal Endoscopy (ASGE) center
of excellence. It is New York’s newest and most modern endoscopy center that
was established by respected physicians who aims to make each patient’s
procedure efficient and pleasant. It is accessible to the New York City but not
limited to patients living in the tristate area. The facility focuses on colon
cancer awareness and prevention by offering free screenings for patients with
low income. The facility offers services such as upper endoscopy, endoscopic
ultrasound, flexible sigmoidoscopy, colonoscopy and anoscopy. These procedures
help uncover the reason for a patient’s abdominal pain or epigastric pain,
nausea, vomiting, diarrhea, constipation, anemia, rectal bleeding; see if there
is Barrett’s esophagus and monitor it; dilate esophageal strictures or remove
foreign bodies; screen for colon polyps; and determine if the patient has
common gastrointestinal problems such as: IBS/IBD, Crohn’s Disease, Celiac
Disease, 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’S
mission statement is dedicated to providing high quality, cost-effective,
efficient and comprehensive outpatient health care for adults. Their mission is
to serve as community resource for health care matters in facility staffed by
highly experienced physicians with a shared commitment to patient safety. The
vision is healthcare excellence through teamwork, innovation and continuous
quality improvement. The values of respect, dignity, integrity and compassion
will be constantly demonstrated to all patients and staff.

project is a very efficient and cost-effective practice that is useful in
providing high quality care to patients. As cited by Varvogli, & Darviri (2011), Jerath, Edry, Barnes, and Jerath

stated “Diaphragmatic
breathing is defined as a manipulation of breath movement, contributing to a
physiologic response characterized by (a) the presence of decreased oxygen
consumption, decreased heart rate and blood pressure, and (b) increased theta
wave amplitude in EEG recordings, increased parasympathetic activity
accompanied by the experience of alertness and invigorating.” Deep breathing exercises decreases
anxiety, reduces stress, provides relief of general body aches and it promotes
better blood flow in the body. In addition, more specific exmaples are stated
by Varvogli and Darviri such as “decrease
the fatigue associated with haemopoietic stem cell transplantation patients,
… reduce the anxiety and asthma
signs/symptoms of children with asthma, … the
slow-breathing technique can have a significant effect on improvement of the
hemodynamic changes following the acute stressful tasks, … been used to
influence autonomic functions in patients with essential hypertension and thus
reduce it (2011). The benefits
of deep breathing can correlate with MEC’s mission and vision because it
encourages 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 teachers
of the breathing technique to the patients because according to Ray (n.d.), “Nurses
take an active role in reducing stress and anxiety when they are trained in
massage and deep breathing techniques they can administer to anxious patients.”
The project’s main objectives are measurable by using an anxiety level
scale. The approach is actionable by simply following the 4-7-8 breathing
technique. The vision is attainable through observations after the project is
implemented. 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’s


The patients at Manhattan Endoscopy Center (MEC) are
generally healthy individuals between the ages of eighteen years to ninety
years old. For this study, I focus on twenty healthy individuals with no mental
health issues or psychiatric history. The participants are ten females and ten
males of different ethnicities and cultural background. They are in the ages
between twenty-five to eighty years old. The participants, who participated in
the study, came to MEC solely for diagnostic purposes and for a routine,
comprehensive evaluation of the digestive tract. Ninety percent of the
participants are anxious and afraid of the uncertainty of the results of the


A major assumption made during this project is allocation
of staff and staff time. The ability to teach the nursing staff the breathing
technique properly and to integrate the assessment and teaching of the
technique into the pre-procedure framework. In addition, the need to simplify
the handout for patients to take home on the 4-7-8 breathing technique and
provide a website with the video of the technique being performed for patients
to practice at home. If there is not enough staff in pre-procedure or time for
the patients to learn the technique and give a return demonstration due to
scheduling of their procedure or time constraints of the gastroenterologists,
the nursing staff may not have the ability to effectively teach the technique
and only give the patient the handout with little to no explanation. Another
assumption is the ability to effectively evaluate the change in anxiety levels
as well as categorize the patient’s explanation for their anxiety level if it
is based on the procedure they are about to have or if there are additional
factors. A major key component is the cooperation of myself, along with the
preceptor, and MEC staff in supporting the successful implantation of this
project. Everyone must have patience and be able to contribute some time for
the betterment in the care of the patients especially if their anxiety level is
deterring them from having a comfortable experience.

Business Case

            This is
an economical project such as mentioned by Jerath, Crawford, Barnes, & Harden, (2015), “Breathing
and meditation techniques are simple, easy, and cost-effective yet they are not
widely used as treatments.” Therefore, there are a number of potential of
benefits reaped from this project with the key beneficiaries being those who
learn and practice the breathing technique and integrate it into their lives to
better their health and wellbeing. The estimate cost of this project is
under $500. The cost primarily focused on paper and printing cost. Each patient
is given a handout of the 4-7-8 breathing technique, the anxiety level scale
and a pencil. Personal time invested that average between 5-10 minutes of extra
time spent with patients in order to do the study.

The duration of
the study is one month. Week 1 started by informing the administration about
the project and its purpose to promote deep breathing exercises in the pre-operative
area. The first week is focused on organizing from the list of incoming
patients who are good candidates for the study. Rely on nursing staff during
the pre-procedure interview quickly screen patient’s health history which helps
eliminate the patients with mental or psychiatric diagnosis. Week 2 to 3 is
focused on implementing the study and collecting data from patient’s reaction
to the study. Reading materials and pamphlets are given to participants. Week 4
is the culmination of the study wherein the data collected are being summarized
and interpreted. Evaluation on the study and its effects on the patients are

Team Structure:

The author of this project is the project manager, as well
as creator and implementer and sole person responsible for outcome of the
project such as creating the proposal, gaining approval from the medical
director, gastroenterologists, anesthesiologists, and director of nursing,
learning, practicing, and teaching the 4-7-8 breathing technique, and
presenting the project. With the preceptor’s input of the project, other staff
members are included in the implantation of this project. Aside from the
preceptor, the charge nurse, and nursing staff as well as per diem nursing
staff are in charge of learning, practicing, and teaching the breathing
technique to the patients. In addition, they will help in reporting and keeping
track of patients’ anxiety levels, before and after the procedure, and tracking
how many refuse to participate. The director of nursing as well as the
gastroenterologists provides the approval in interacting with the patients and
offers support in executing the project. In addition, they oversee the impact
of the project on the patients, staff, and work flow throughout the time of the
project and hopefully in the future.

and Change Plan 

The purpose of the project is discussed first to the
administrative leaders in the Manhattan Endoscopy Center (MEC) for approval.
The study is incorporating deep breathing exercises in the pre-op area before a
procedure. 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 with
the nurse’s daily tasks at MEC. The patients’ reactions after the study are
optimistic. The positive report led to approval of the management to implement
deep breathing exercise at the center.

The proposal on encouraging patients to practice deep
breathing exercises before their procedures has positive outcomes that can
benefit both the patients and the providers. The proposal was to put the
patient in the pre-op area that is quiet, relaxing and calming to do breathing
exercises prior to going to the operating table. The pre-op nurse is encouraged
to include at least 5 to 10 minutes of deep breathing exercises in the
checklist prior to take the patient in the operating room. The leadership in
the MEC agreed on implementing this step. Conducting a session of deep breathing
exercises is easy and simple way for any trained or untrained staff to do. The
aim for this study is to reduce patient’s level of stress. Deep breathing is
efficient as it reduces the ventilation in the dead space of the lungs. Shallow
breathing replenishes air only at the base of the lungs in contrast to deep
breathing that replenishes the air in all parts of the lung. It decreases the
effect of stress and strain on the body by shifting the balance of the
autonomic system predominantly toward the parasympathetic system and improves
the physical and mental health (Naik et al, 2017). A short session of deep
breathing exercises is added to the framework of pre-operative checklist in
which the pre-op nurses implemented.

Quality Plan

3 main objectives of the study are to decrease anxiety level of patients before
their procedures and to improve their learning capabilities about the scheduled
procedure. The goal is to satisfy patient with services given at MEC without
impeding on medical diagnostics procedures.

Decreasing patient’s anxiety after
deep breathing exercises that is implemented by the staff and will be measured
through post-op follow up call. The nurse follows-up questions are related to
overall experience at MEC and the anxiety level score.

Improving patient’s coping technique
and the use of the 4-7-8 breathing exercise in other aspects of life where
stress levels are high. This is measureable through MEC survey that is mailed
or emailed to the patients after the procedure.

Enhance cardiovascular parameters by
effective breathing technique that is measurable by checking the vital signs
after the 5-10-minute session of the 4-7-8 breathing technique.

Project Controls

Feedback from the staff about the
patient’s anxiety level after the implementation of the 4-7-8 breathing

Keeping a record of patients’
participation of the study including those who refused to participate in the
study. Compare the levels of anxiety to both variables and create a statistical
data to manage progress.

Effective communication for
scheduling purposes. Reminding the staff about the new implementation of 4-7-8
breathing exercises will automatically become a routine procedure.


importance of the project is to show that effectiveness of deep breathing
exercises decreases patients’ anxiety level and improves their perception of
the procedure at MEC. “A multitude
of breathing exercises and yoga have been in use to achieve a significant
reduction in stress acquired by the hectic and imbalanced lifestyle. However, a
single and uncomplicated tool suitable for beginners and individuals with
health ailments is the need of the hour” (Naik et al, 2017). The project will
help the organization achieve its goals on increasing patient’s satisfaction
without any disruption to budget, policies and protocols. Reducing
pre-procedural anxiety levels may prevent the pain experienced by patients
during the performance of the esophagogastroduodenoscopy (EGD), and thus increase the patients’
satisfaction, that is considered as a measure of a high-quality endoscopy (Pontone
et al, 2015). Studies and implementation on quality improvements projects such
as the implementation of the 4-7-8 breathing technique to patients prior to a
procedure, is a requirement of ASGE to maintain MEC’s status as center of


















Anxiety Scale*

0 – At ease, Comfortable

1 – Slightly Nervous

2 – Nervous

3 – Apprehensive

4 – Anxious

5 – Worried

6 – Very Worried

7 – Somewhat Fearful

8 – Fearful

9 – Somewhat Panicked

10 – Panicked


*Based on scale from iCounselor:
Anxiety App on iTunes










Handout Provided to Patients about
the 4-7-8 Breath Relaxation Exercise




iCounselor. (2009, November 03).
ICounselor: Anxiety on the App Store. Retrieved from


Jerath, R., Crawford, M. W., Barnes, V.
A., & Harden, K. (2015). Self-Regulation of Breathing as a Primary Treatment
for Anxiety. Applied
Psychophysiology and Biofeedback,40(2), 107-115.


Manhattan Endoscopy Center. (n.d.).
Retrieved from http://www.manhattanendo.com/


Naik, G., Gaur, G. S., & Pal, G. K. (2017). Effect of
Modified Slow Breathing Exercise on Perceived Stress and Basal Cardiovascular
Parameters. 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 patients
in Jimma University Specialized Teaching Hospital, South Western Ethiopia. BMC Surgery,14(1).


Pontone, S., Pontone, P., Tonda, M.,
Brighi, M., Florio, M., & Pironi, D. (2015). Does anxiety or waiting time
influence patients? tolerance of upper endoscopy? Saudi Journal of
Gastroenterology,21(2), 111. doi:10.4103/1319-3767.153839


Ray, L. (n.d.). Role of Nurses for
Stress & 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’s
guide. Management Tools 2017. Retrieved from http://www.bain.com/Images/BAIN_BOOK_Management_Tools_2017.pdf


What can help relieve anxiety before
surgery? (2014, May). Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072741/


Varvogli, L., & Darviri, C. (2011). Stress
Management Techniques: evidence-based procedures that reduce stress and promote
health. Health Science
Journal,5(2), 74-89. Retrieved from