Conductive Centre of the Revision
The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs Institute
Panel of Review
Rodríguez Gonzalo, Ana. Research management. Ramón y Cajal Hospital; The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs Institute
Cidoncha Moreno, Ma Ángeles. Research management. Health Service Osakidetza; The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs Institute
González Formoso, Clara. Security management. Health Service Primary Care. Vigo; The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs Institute
González Cebrian, Miryam. Care surgery nurse. Marqués de Valdecilla Hospital; The Spanish Centre for Evidence Based Nursing: Collaborating Centre of the Joanna Briggs Institute
Contact for Review
Name: Ana Rodriguez Gonzalo
Phone: +34 659 479 815
According to global data of the Scientific Foundation's Spanish Association Against Cancer, approximately 6 million men and 5 million women were diagnosed with a malignant tumor in 2002. In both sexes, the most common cancer is lung, followed by breast, colorectal, stomach, prostate, liver, cervix and esophagus 1;2.
Patients with cancer experience high psychological distress expressed with anxiety and/or depressive symptoms 3-5. The diagnosis of cancer itself creates psychological disorders such as anxiety, which can affect how a patient manages pain and how he/she recovers from the treatment 3;6;7. The prevalence of this psychological disorder in oncology patients is between 30% and 50% 3;5.
Moreover, patients who are undergoing a surgical procedure are under a stressful situation, which can reduce their psychological well-being 8. If this psychological distress is combined with a cancer diagnosis, anxiety level is higher 4;9-11. In fact prevalence of preoperative anxiety in adults varies between 11% and 80% depending on kinds of surgery, and between 60% and 90% in surgical patients who are also oncology patients, which requires greater attention to this patients to prevent anxiety disorders before surgery 3;12-14. Specifically Lilja (1998)8 indicates that breast cancer patients are more stressed compared to other surgical patients, such as hip replacement patients, when assessed the day before surgery.
Patients waiting for major surgery experience multifarious anxiety reactions, like fear of the unknown, be concerned about the loss of independence, fear of surgical procedure, separation from family, uncertainty about what effect it will have surgery on his everyday life, fear of being incapacitated, fear of change in body image, complications, anaesthesia and/or negative perception of the future 9;15. Therefore, it is important to understand surgical procedures and how they affect the patients and their relatives, to facilitate understanding and selection of care that can reduce suffering 15;16.
Also, if a patient is overanxious, his physical recovery and his well-being can be affected, which will prolong the length of hospital stay, resulting in an increase in the cost of attendance 17-20.
The relationship between preoperative anxiety and subsequent pain has been analysed and preoperative anxiety has been found to affect the patients pain experience after surgery; so patients with high preoperative anxiety level have an increased needs of subsequent analgesia.. On the other hand, perception of pain and anxiety often increases when patients feel a lack of control over the situation and this is very common near surgery 21-24. Several studies evaluating women with breast cancer concluded that patients with high levels of anxiety before surgery, reported more pain after surgery and they needed more analgesia, as reported by Ozalp et al 21;25. Katz et al suggest, moreover, the importance of controlling psychosocial variables in breast cancer to prevent postoperative pain, suggesting the design of preventive activities to anxiety control 21.
Due to the impact and distress generated by a surgical procedure in patients and their families, different studies have highlighted the importance of knowing what are the patients demands and of informing them about surgical process.
In a study by Lithner et al (2000)26 patients before undergoing cholecystectomy requested information related to those factors that were generating anxiety, such as pain and the symptoms after surgery.
Other studies suggest the need to assess the individual patients needs to subsequently implement interventions that help reduce anxiety and give the patient a more positive surgical experience 27, there is therefore, a need to find a balance between giving too little or too much information, responding to individual patients needs, as mentioned Maguire 8;28.
In addition Gillies et al (2001)29 alert us to the risk of providing inappropriate information regarding surgery. The amount of information a patient needs in the preanesthetic visit can vary considerably in each patient, responding to their different needs and expectations30. Perks et al (2009) 13, indicate that also provide information related to the surgery is a patients requirement that contribute to their well-being.
One of the tools that can respond to these demands are preoperative psycho-educational interventions: as educational sessions where patients receive some form of information on the type of surgery, what to expect, express their needs and they are supported. Among the benefits described in this type of intervention, Stern's review (2005)20 notes a reduction in the fear of surgery, decrease in the needs for sedation, increases in knowledge and skills, decrease of emotional distress and improvements in postoperative exercise performance and therefore patients have a better and more speedy recovery, together with n improved communication with patients and response to their needs. This approach can generate more satisfaction with the care provided and reduce postoperative pain 20;31.
The effectiveness of providing information to patients who are undergoing surgery, has been a topic of research, however, the benefit of such interventions has yet to be demonstrated.
Authors such as Ehring et al (1987)32, have shown that in surgical areas such as; abdominal, thoracic, perineal and orthopedic, beneficial effects in have been shown in patient's well-being by providing information before surgery, although the benefit was not clear in the case of reducing anxiety 32;33. Ali et al in 198934 showed that this type of intervention decreased anxiety in patients who were undergoing surgery for prostate cancer.
Meta-analyses by Devine et al in 199235 and Hataway et al in 198636 reviewed the impact of preoperative intervention in surgical patients, including primarily abdominal and thoracic surgery. Their findings suggest that the groups who received the pyscho-educational intervention had better results in fear, anxiety, pain and distress, but indicate considerable variability in the type of intervention carried out. They also note that a proportion of patients, about 30%, did not benefit from intervention, especially those patients who suffered from high anxiety levels. Negative or conflicting results of the intervention were related to unstructured interventions or kinds of presentation.
However Lilja (1998)8 noted that providing preoperative information to breast cancer patients did not reduce anxiety before surgery significantly, compared to the control group.
More recently a study by Belleau (2001)10 demonstrated a significant decrease in anxiety levels after surgery in women undergoing mastectomy who had received psycho-educational intervention in three sesions before surgery, but this relationship did not hold day before surgery.
A study by Chaudhri et al. (2005)37 on the effectiveness of an educational intervention several days before colorectal surgery showed that patients in the intervention group had lower levels of anxiety and fewer days of hospital stay.
The trial by Cheung et al (2003)38 evidence that patients will be undergoing hysterectomy for diferent causes and were receiving psycho-educational intervention before surgery, had lower levels of postoperative anxiety and pain. However there was no evidence that they requested lower doses of analgesia, although previous studies suggest that other patients receiving preoperative information reported less pain and required less analgesia 28;39.
Kiyohara et al (2004)40 showed that the level of anxiety before neurological surgery was lower in patients who had information about surgical procedure, but anxiety wasn't lower when they had information about their diagnosis.
These described studies reflect variability in their results found, include only cancer patients 8;10;34;37 or surgical patients, both by oncologic procedures as for other processes 28;32;33;35;36;38-40.
In addition, recent studies have evaluated educational interventions in specific diseases unrelated to cancer patients,that question the effectiveness of these interventions 41-45.
A systematic review by Lee et al (2003)44 examined the effectiveness of educational interventions for patients undergoing hip, knee or outpatient surgery, related to the type of anesthesia and possible complications before surgery, notes reduced preoperative anxiety levels in those subjects who had received an explanatory video and/or pamphlet, versus those who had received no intervention. This difference was not maintained when comparing the video versus printed information44. Also the authors note that the evidence of improved outcomes after the educational intervention is not convincing, due to methodological differences of the trials, the interventions used and the measuring instruments used 41;44.
Chirveches et al (2006)42 after analyzing principally patients who had undergone either general or trauma surgery (excluding cancer patients), indicate that the preoperative visit itself is effective in reducing situational anxiety but did not improve acute pain perception after surgery 42.
A trial by Sorlie et al (2007)45 on the effectiveness of an intervention to reduce the anxiety associated with coronary bypass surgery, focusing on providing information, employing the use of video and emotional expression, showed that patients in the intervention group had lower levels of anxiety which were maintained in a subsequent one-year follow-up. However, a quasi-experimental study by Deyirmenjian et al (2006)43 on the effectiveness of an educational intervention to reduce anxiety before surgery did not show similar effectiveness, noting that it could be that intervention was done just the day before surgery and authors warning about the need to assess previously the social and cultural background of patients.
Although there are many studies demonstrating effectiveness of educational interventions for control of preoperative anxiety, others suggest otherwise. Furthermore, the literature shows different ways of presenting an intervention, indicating great variability in the content, method of organization and presentation36. Factors that may influence the success of an educational intervention could include: feelings of the patient is likely to have before and after surgery, information about anatomy area to be undergo surgery, possible complications, or lifestyle changes after surgery, how operating room is and wich surgical staff functions are20, psychosocial support, vocational skills and/or exercises to be performed after surgery 10;19.
Regarding the methodology of intervention, wide variability is also noted and can be structured or unstructured, it can be performed with audiovisual media, brochures, questionnaires, direct or telephone interviews with health staff. It can be conducted individually or in a group. There is disagreement about the benefit of group intervention compared to individual, as well Shuldham et al19 point out, though Hataway36 in his review indicates that individual statements were better than group and suggests that we must take into account the level of anxiety and fear of the patient at the time to develop and design preoperative instructions, including psychological component. Shuldham19 also states that retention of preoperative information of a patient is greater when the instructions are individualized 10; and when videos and leaflets are combined20;46. The review of Stern et al (2005)20 on effectiveness of preoperative educational interventions with regard to knowledge retention and ability to adapt to changes after surgery, demonstrates the usefulness of information leaflets to improve patients skills. This is the most commonly used style of educational method., however the in depth use of video has not been explored. The authors also believe that giving instructions on behavioral patterns is useful for patients to improve their knowledge, noting the desirability of delivering an educational intervention before hospital admission. They found no significant differences between individual or group intervention20. A strategy recently tested is a computer education program for patients who are going to undergo breast reconstruction. Patients reported that in addition to quickly understanding the basics of breast reconstruction, it helped to have realistic expectations about the outcome 47.
Regarding the right moment to do educational preoperative intervention there is a greater discrepancy, considering that probably the most effective psycho-educational intervention is taking place between 5-14 days pre-admission10,19, being reinforced later the day of admission and the day before surgery10, as indicated by Belleau et al10, in assessing the effectiveness of preoperative intervention in patients undergoing a mastectomy.
Meeting the needs of cancer patients about to undergo a surgical procedure, it may provide a rationale for design and implementation of intervention strategies that help patients improve their quality of life and better recover 3;10;15. Thus, we propose a systematic review to examine the effectiveness of psycho-educational interventions to reduce the impact of the surgery, improving their levels of perioperative anxiety and postoperative pain in oncology patients.
The review question is: How effective are preoperative interventions at reducing perioperative anxiety on cancer patients compared with conventional treatment?
To assess and summarize the best available scientific evidence on the effectiveness of preoperative psycho-educational interventions to reduce perioperative anxiety in oncology patients.
- To identify effective interventions in the presurgical visit to the prevention and control of postoperative pain of oncology patients.
- To identify characteristics of effective interventions to decrease perioperative anxiety and postoperative pain.
Types of studies:
This review will consider all randomized clinical trials, enabling the identification of current best evidence on the effectiveness of the preoperative visit in oncology patients, which is disseminate in Spanish and English. In the absence of randomized clinical trials (RCT), it will consider for inclusion other research designs such as controlled clinical trials without randomization (CCTs).
Types of participants:
This review will consider studies that include patients over 18 years who will undergo major surgery for diagnosed process of cancer or for cancer suspicion. We define major surgery as surgery that requires general anesthesia and hospital stay. Participants will be considered, regardless of the type of cancer and the type of surgery.
Types of interventions:
This review will consider psycho-educational interventions used in the preoperative visit of patient undergoing major surgery for diagnosed process of cancer or for cancer suspicion. We consider preoperative visit, the structured visit performed before surgery, which provide at least psycho-educational intervention versus conventional therapy, where patients receive some form of information before an operative procedure. We define conventional treatment consisting of: a non-standard visit focused on the retention of fasting, operating field preparation, administration of sedatives or take no action. We define psycho-educational treatment as educational sessions where patients receive some form of information on the type of surgery, what to expect, express their needs and they are supported.
Types of Outcomes Measure:
This review will consider studies that include the following outcomes: preoperative and postoperative anxiety assessed by specific standardized and validated anxiety instruments and postoperative pain.
There are no exclusion criteria used in this review.
Search strategy for identification of studies
The search strategy aims to find both published and unpublished studies. It will use a search strategy of three steps. In the first step there will be a limited search of MEDLINE, CINAHL and PsycINFO, followed by analysis of the words in the title and abstract to identify keywords, and index term used to describe relevant articles.
In the second step there will be a second extensive search using all keywords and index terms identified in the following databases: COCHRANE LIBRARY (Cochrane Central Register of Controlled Trials, CENTRAL,), EMBASE, CINAHL, CUIDEN, PsycoINFO, PUBMED, Science Citation Index (ISI WEB OF KNOWLEDGE), BIREME, IME.
Search for gray literature searches the following databases:
- OpenSIGLE (System for Information on Grey Literature in Europe)
- CINDOC del CSIC (Centro de Información y Documentación Científica del Consejo Superior de Investigaciones Científicas)
- Dissertation Abstracts International
- Proceedings First Database
- Database for Spanish Dissertations: TESEO
- National Library of Medicine Gateway
- Grey Literature Report (through New York Academy of Medicine website)
- Google Scholar
- AHRQ: Agency for Health Care Research and Quality
- CURRENT CONTENTS
- EXPANDED ACADEMIC INDEX
Will include papers presented at conferences and meetings of oncology, as well as guides and documents to disseminate scientific societies. Oncological scientific societies include:
- ACS (American cancer society)
- ECCO (European cancer organization)
- UICC (International union against cancer)
- AECC (Asociación española contra el cáncer).
- ONS (Oncology Nursing Society).
Finally, the third step is a search of the reference list of all reports and relevant articles selected, carrying out a secondary search of articles from the references to find additional studies.
There will be a manual search reverse of the most prestigious journals in the field of surgery, oncology and / or oncological surgery:
- American surgical oncology
- Surgical oncology
- Oncology Nursing Forum
We search from the beginning of the database until December 2010.
The search aims to identify studies published in both Spanish or English languages and the searches will be conducted in both Spanish and English
Defining MeSH search terms:
- Intervention (MeSH)
- Education OR Early Intervention (MeSH)
- Psychotherapeutic processes (MeSH)
- Neoplasms (MeSH)
- Anxiety (MeSH)
- Pain Postoperative (MeSH)
- Operative OR Surgery OR Surgical procedures (MeSH)
MeSH terms will be expanded and adapted to combine the rules of each database. Equivalent terms will be used in Spanish for databases using the Spanish language.
If necessary, authors of studies identified as potentially suitable for inclusion, will be contacted for provision of data that may be missing or to for clarification of methodological details or to request further published or unpublished data.
Two reviewers independently will review the title and abstract to assess whether they meet the criteria of inclusion in articles; where it is not clear will be necessary to follow the same process with the full article.
Assessment of methodological quality
The articles selected for retrieval will be evaluated by two independent reviewers based on their methodological validity before being included in the review using standardized instruments critical appraisal of the Joanna Briggs Instrument Systematic Review of Effectiveness (JBI-MAStARI) (Appendix I).
We will use a predefined critical appraisal score as a cutoff for inclusion in the review, the affirmative answer (Yes) for 5 questions out of a total of 10 questions is required. Any disagreements that arise between the reviewers will be solved by discussion, If still unable to reach an agreement, we will go to a third reviewer.
Assessment of methodology studies will focus on selection bias, information and performance.
Data will extract from the articles included in the review using a data extraction standardized tool JBI-MASTARI (Appendix II).
Data will be extracted by two independent reviewers to assess whether they reach the same results. All results are subject to the double entry of data to avoid transcription errors.
Extracted data will be include specific details about characteristics of the interventions - such as when it is performed, intervention team, number of meetings-, populations, details of research designs and relevant results to the question review and specific objectives.
The comparison of the studies will be according to the study population, type of intervention, type of surgery and outcome variables measures.
Clinical heterogeneity will be assessed.
Statistical heterogeneity of included studies will be tested using the standard chi-square test and considered; because the low power of the test to detect heterogeneity if the number of studies is relatively low or when individual studies are small, a P- value of 0.10 will be used (p <0.1). The I2 index will also be used, considering the values of 0%, 25%, 50% and 75% as none, low, moderate and high heterogeneity I2.
If studies are homogeneous, data will be pooled in a statistical meta-analysis using the software program JBI SUMARI. If there is statistical heterogeneity, results will be analysed by clinically homogeneous subgroup, first considering age and type of surgery, or use the model of random effects analysis, as appropriate.
The effect measures used: the Odds Ratio (for categorical outcome data) or RR and weighted mean differences (for continuous data), with a confidence intervals of 95%.
Where statistical pooling is not appropriate or possible, the findings will be summarised in narrative form.
Nursing management of Ramon y Cajal Hospital for their support. Ma Consuelo Company and Angel Alfredo Martinez for their assistance in the preparation of this protocol.
Conflict of interest
Authors declare no conflicts of interest in the review conducted.
2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics. CA Cancer J Clinic. 2005;55:74-108.
3. Palapattu GS, Haisfield-Wolfe ME, Walker JM, BrintzenhofeSzoc K, Trock B, Zabora J, et al. Assessment of perioperative psychological distress in patients undergoing radical cystectomy for bladder cancer. J Urol. 2004 Nov;172(5 Pt 1):1814-7.
4. Ramirez AJ, Richards MA, Jarrett SR, Fentiman IS. Can mood disorder in women with breast cancer be identified preoperatively? Br J Cancer. 1995 Dec;72(6):1509-12.
5. Rodríguez B, Ortiz A, Palao A, Avedillo C, Sánchez-Cabezudo A, Chinchilla C. Síntomas de ansiedad y depresión en un grupo de pacientes oncológicos y en sus cuidadores. Eur J Psychiat. 2002;16(1):27-38.
6. Patrick DL, Ferketich SL, Frame PS; Harris JJ; Hendricks CB, Levin B et al. Symptom Management in Cancer: pain, depression and fatigue. J Natl Cancer Inst. 2003;95:1110-16.
7. Thielking PD. Cancer pain and anxiety. Current Pain Headache Reports. 2003;7:249-261.
8. Lilja Y, Ryden S, Fridlund B. Effects of extended preoperative information on perioperative stress: an anaesthetic nurse intervention for patients with breast cancer and total hip replacement. Intensive Crit Care Nurs. 1998 Dec;14(6):276-82.
9. Alves ML, Pimentel AJ, Guaratini AA, Marcolino JA, Gozzani JL, Mathias LA. Preoperative anxiety in surgeries of the breast: a comparative study between patients with suspected breast cancer and that undergoing cosmetic surgery. Rev Bras Anestesiol. 2007 Apr;57(2):147-56.
10. Belleau FP, Hagan L, Masse B. Effects of an educational intervention on the anxiety of women awaiting mastectomies. Can Oncol Nurs J. 2001;11(4):172-80.
11. Fawzy FI. Psychosocial Interventions for Patients with cancer: What Works and What Doesn't. Eur J Cancer. 1999;35(11):1559-64.
12. Matsushita T, Matsushima E, Maruyama M. Anxiety and Depression of Patients with Digestive Cancer. Psychiatry Clin Neurosci. 2005;59:576-583.
13. Perks A, Chakravarti S, Manninen P. Preoperative anxiety in neurosurgical patients. J Neurosurg Anesthesiol. 2009 Apr;21(2):127-30.
14. Valenzuela-Millán J, Barrera-Serrano JR, Ornelas-Aguirre JM. Ansiedad preoperatoria en procedimientos anestésicos. Cir Ciruj. 2010;78(2):151-156.
15. Moene M, Bergbom I, Skott C. Patients' existential situation prior to colorectal surgery. J Adv Nurs. 2006 Apr;54(2):199-207.
16. Cunningham MF, Heath CH, Agre P. A Perioperative Nurse Liaison Program. J Nurs Care Qual. 2003;18(1):16-21.
17. Devine EC, Cook CT. A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay. Nurs Res. 1983;32:267-274.
18. Mc Donald S, Hetrick S, Green S. Educación prequirúrgica para el reemplazo de cadera o rodilla (Revisión Cochrane traducida). In: La Biblioteca Cochrane Plus, 2008 Número 4. Oxford: Update Software LTD. Available at: http://www.update-software.com
. (Traducida de The Cochrane Library, 2008 Issue 3. Chichester, UK: John Wiley & Sons, Ltd.).
19. Shuldham C. A review of the impact of pre-operative education on recovery from surgery. Int J Nurs Stud. 1999;36:171-7.
20. Stern C, Lockwood C. Knownledge retention from preoperative patient information. Int J Evid Based Healthc. 2005;3(3):45-63.
21. Katz J, Poleshuck EL, Andrus CH, Hogan LA, Jung BF, Kulick DI, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain. 2005;119:16-25.
22. Schwartz-Barcott D, Fortin JD, Suzie H. Client nurse interaction: testing for its impact in preoperative instruction. Int J Nurs Stud. 1994;31:23-35.
23. Taenzer P, Melzack R, Jeans ME. Influence of psychological factors on post-operative pain, mood and analgesic requirements. Pain. 1986;24:331-342.
24. Vaughn F, Wichowski H, Bosworth G. Does Preoperative Anxiety Level Predict Postoperative Pain? AORN J. 2007;85(3):589-604.
25. Ozalp G, Sarioglu R, Tuncel G, Aslan K, Kadiogullari N. Preoperative emotional states in patients with breast cancer and postoperative pain. Acta Anaesthesiol Scand. 2003 Jan;47(1):26-9.
26. Lithner M, Zilling T. Pre and postoperatiave information needs. Patient Educ Couns. 2000;40:29-37.
27. Rosén S, Scensson M, Ulrica N. Calm or not calm: the question of anxiety in the perianesthesia patient. J Perianesth Nurs. 2008;23(4):237-246.
28. Maguire P. Psychological aspects. Br Med J. 1994;309:1649-1652.
29. Gillies MAM, Baldwin FJ. Do patient information booklets incease perioperative anxiety? Eur J Anaesthesiol. 2001;18:620-2.
30. Lee A, Gin T. Educating patients about anaesthesia: effect of various modes on patient's knowledge, anxiety and satisfaction. Curr Opin Anaesthesiol. 2003;18:205-8.
31. Smith AF, Shelly MP. Communication skills for anesthesiologists. Can J Anesth. 1999;46(11):1082-8.
32. Ehringer Mikulaninec C. Effects of mailed preoperative instructions on learning and anxiety. Patient Educ Couns. 1987;10:253-265.
33. Wallace L. Pre-operative state as a mediator of psychological adjustment to and recovery from surgery. Br J Med Psychol. 1986;59:253-261.
34. Ali NS, Khalil HZ. Effects of psychoeducational intervention on anxiety among Egyptian bladder cancer patients. Cancer Nurs. 1989;12(4):236-242.
35. Devine EC. Effects of psychoeductional care for adult surgical patients: a meta-analysis of 191 studies. Patient Educ Couns. 1992;19:129-142.
36. Hathaway D. Effect of Preoperative Instruction on Postoperative Outcomes: A Meta-Analysis. Nurs Res. 1986;35(5):269-275.
37. Chaudhri S, Brown L, Hassan I, Horgan AF. Preoperative intensive, community-based vs. traditional stoma education: a randomized, controlled trial. Dis Colon Rectum. 2005;48(3):504-9.
38. Cheung LH, Callaghan P, Chang AM. A controlled trial of psycho-educational interventions in preparing Chinese women for elective hysterectomy. Int J Nurs Stud. 2003;40:207-16.
39. Good-Reis D, Preper B. Structured versus unstructured teaching. AORN J. 1990;51:1334-9.
40. Kiyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, Ogawa NY, et al. Surgery Information Reduces Anxiety in the Preoperative Period. Rev Hosp Clin Fac Med S Paulo. 2004;59(2):51-6.
41. Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The effect of anesthetic patien education on preoperative patient anxiety. Reg Anesth Pain Med. 1999;24(2):158-164.
42. Chirverches E, Arnau A, Soley M, Rosell F, Clotet G, Roura P, et al. Efecto de una visita prequirúrgica de enfermería perioperatoria sobre la ansiedad y el dolor. Enferm Clin. 2006;16(1):3-10.
43. Deyirmenjian M, karam N, Salameh P. Preoperative patient education for open-heart patients: A source of anxiety? Patient Educ Couns. 2006;62:111-7.
44. Lee A, Chui PT, Gin T. Education Patients About Anesthesia: A Systematic Review of Randomized Controlled Trials of Media Based Interventions. Anesth Analg. 2003;96:1424-1431.
45. Sorlie T, Busund R, Sexton H, Sorlie D. Video information combined with individualized information session: Effects upon emotional well-being following coronary artery bypass surgery. A randomized trial. Patient Educ Couns. 2007;65:180-8.
46. Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The Effect of Anesthetic Patient Education on Preoperative Patien Anxiety. Reg Anesth Pain Med. 1999;24(2):158-164.
47. Heller L, Parker PA, Youssef A, Miller MJ. Interactive digital education aid in breast reconstruction. Plast Reconstr Surg. 2008 Sep;122(3):717-24.
JBI CRITICAL APPRAISAL FORM FOR EXPERIMENTAL STUDIES
JBI DATA EXTRACTION FORM FOR EXPERIMENTAL STUDIES