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European Journal of Cardiovascular Nursing
1 –12
© The European Society of Cardiology 2015
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DOI: 10.1177/1474515115602678
cnu.sagepub.com
EUROPEAN
SOCIETY OF
CARDIOLOGY
®
Introduction
Despite the progress of science and technology, cardiac
surgeries continue to be accompanied by complications
that increase morbidity and mortality.1–5 Because of forth-
coming cardiac surgery, patients experience anxiety6 that
can burden perioperative psychosomatic health. Numerous
studies have shown that preoperative anxiety increases
significantly in elective and major operations,7–12 resulting
in postoperative complications for a number of patients13,14
irrespective of the type of surgery.
Preoperative anxiety has been found to be a risk factor
for postoperative mortality in patients undergoing coronary
Can nurse-led preoperative education
reduce anxiety and postoperative
complications of patients undergoing
cardiac surgery?
Antonia Kalogianni1, Panagiota Almpani1, Leonidas Vastardis2,
George Baltopoulos3, Christos Charitos4 and Hero Brokalaki3
Abstract
Background: The effect of preoperative education on anxiety and postoperative outcomes of cardiac surgery patients
remains unclear.
Aim: The aim of the study was to estimate the effectiveness of a nurse-led preoperative education on anxiety and
postoperative outcomes.
Methods: A randomised controlled study was designed. All the patients who were admitted for elective cardiac surgery
in a general hospital in Athens with knowledge of the Greek language were eligible to take part in the study. Patients
in the intervention group received preoperative education by specially trained nurses. The control group received
the standard information by the ward personnel. Measurements of anxiety were conducted on admission-A, before
surgery-B and before discharge-C by the state–trait anxiety inventory.
Results: The sample consisted of 395 patients (intervention group: 205, control group: 190). The state anxiety on the
day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease
in state score during the follow-up period was greater in the intervention group (P=0.001). No significant difference was
found in the length of stay or readmission. Lower proportions of chest infection were found in the intervention group
(10 (5.3) versus 1 (0.5); P=0.004). Multivariate linear regression revealed that education and score in trait anxiety scale
on admission are independent predictors of a reduction in state anxiety.
Conclusion: Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients
undergoing cardiac surgery, but it was not effective in reducing readmissions or length of stay.
Keywords
Preoperative patients’ education, cardiac surgery, anxiety, postoperative complications, length of stay
Received: 27 January 2015; revised: 20 July 2015; accepted: 25 July 2015
1
Faculty of Nursing, Technological Educational Institute of Athens,
Greece
2 Intensive Care Unit of Department of Cardiac Surgery, ‘Evangelismos’
General Hospital, Athens, Greece
3 Faculty of Nursing, National and Kapodistrian University of Athens,
Greece
4 Cardiothoracic Surgery Department, ‘Evangelismos’, General Hospital
of Athens, Greece
Corresponding author:
Antonia Kalogianni, Faculty of Nursing, Technological Educational
Institute of Athens, Ag. Spiridona Str, 122 10, Aigaleo, Athens, Greece.
Email: antonia_cal@teiath.gr
602678CNU0010.1177/1474515115602678European Journal of Cardiovascular NursingKalogianni et al.
research-article2015
Original Article
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2 European Journal of Cardiovascular Nursing
artery bypass grafting (CABG).15,16 Previous studies have
supported the theory that the control of preoperative anxi-
ety can reduce the morbidity and mortality of patients
undergoing cardiac surgery.16 One study reported that pre-
operative anxiety had predictive value for postoperative
mortality and suggested the addition of preoperative anxi-
ety to the risk model in order to refine the risk factors asso-
ciated with increased mortality.14 According to several
studies, a reduction of perioperative anxiety of patients
undergoing cardiac surgery can be achieved by preopera-
tive education.10,17,18
There is also evidence that preoperative education leads
to better recovery and a reduction in the length of hospital
stay.19,20 Preoperative education is defined as ‘providing the
patient with health-related information, psychosocial sup-
port and the opportunity to learn selected skills in prepara-
tion for surgery’.21 The patients’ preoperative education is
designed to prevent risk factors that may lead to complica-
tions by adopting behaviours that will enhance patients’
ability to cope with cardiac surgery. Emphasising the risk
factors and the ways of avoiding them may motivate patients
to modify their behaviour in order to reduce these factors.
The objective of providing preoperative education to
patients undergoing cardiac surgery is to prevent or reduce
anxiety and postoperative complications that are associ-
ated with morbidity, mortality and prolonged hospital stay
as well as hastening postoperative recovery.22 The compli-
cations that may be associated with lack of patients’ preop-
erative education are pulmonary infection,23 atelectasis,24
deep vein thrombosis,24,25 wound infections26,27 and split
of the sternum.28 Sternal dehiscence, wound infections29
and arrhythmia were the most common causes for
unplanned 30-day hospital readmissions after cardiac sur-
gery.30 For example, early mobilisation and muscle train-
ing can improve functional outcomes as well as cognitive
and respiratory conditions, and reduce the risk of venous
stasis and deep vein thrombosis.24 Interventions such as
breathing and coughing exercises before CABG surgery
were shown to be effective and were able to lower the risk
of pneumonia and atelectasis.24,31,32
Extension of the length of stay (LOS) in the intensive
care unit (ICU) has been associated with negative short
and long-term postoperative outcomes.33 Prolonged intu-
bation after cardiac surgery results in significant acute and
midterm morbidity as well as longer ICU and hospital
stays.34,35 Atrial fibrillation (AF) is the most common
arrhythmia during the first to fifth postoperative days after
cardiac surgery,36 and is associated with increased mortal-
ity and a higher incidence of stroke.37 There is an associa-
tion between postoperative AF and anxiety in patients who
undergo CABG.38 A recent study suggested that AF was a
major risk factor for general hospital-based mortality in
patients with anxiety disorders.39
Some studies concluded that preoperative education
can reduce postoperative complications such as pulmonary
and cardiovascular complications and the level of postop-
erative anxiety of cardiac surgery patients.40– 42 However,
similar studies found that preoperative education had no
effect on postoperative complications and the anxiety of
cardiac surgery patients.43,44 Quite a few studies have
reported a reduction in postoperative anxiety as a result of
preoperative education but it was not significant.43–48 Only
one study found that preoperative education increased the
levels of postoperative anxiety of cardiac surgery patients.44
From the literature it is apparent that it has not yet been
established whether preoperative education reduces anxi-
ety, postoperative complications and length of hospital stay.
The primary purpose of this study was to evaluate the
effectiveness of a nurse-led preoperative education on anx-
iety and on complications of patients undergoing elective
cardiac surgery. A secondary objective was to investigate
the effect of education on the length of hospital stay and
frequency of readmissions.
Methods
The study was a randomised controlled trial.
Participants
All patients (n=1859) admitted for elective cardiac surgery
from May 2011 until January 2014 were eligible to take
part in the study (Figure 1). Surgical procedures included
CABG, valve replacement, ascending aortic aneurysm
repair or a combination of these. The study was performed
in the cardiac surgery department of a general hospital in
Athens, in which 650 cardiac surgical procedures are per-
formed each year.
The main selection criterion for patients was the abil-
ity to speak and read Greek. Exclusion criteria were a
history of previous cardiac surgery, taking drugs for anxi-
ety control, mental disorders, serious chronic diseases
and terminal illness, because they probably needed spe-
cific training.
Mental disorders we took into account were alcohol
abuse, diagnosed cognitive disorders (delirium, dementia,
amnesia), diagnosed mood disorders (depression) and psy-
chosis. Chronic diseases we took into account were serious
long-lasting diseases that cannot be cured (chronic hepatitis
B or C with or without cirrhosis, AIDS, Parkinson’s disease,
severe autoimmune disease, blindness and hearing loss).
Three hundred and ninety-five adult patients met the
inclusion criteria and constituted the sample of the study.
At the time of the patients’ admission, one of the research-
ers randomly assigned them into the study groups. Two
hundred and five patients were enrolled into the interven-
tion group and 190 were enrolled into the control group
(Figure 1). Patients with odd admission numbers were
assigned to the intervention group and patients with even
admission numbers were assigned to the control group.
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Kalogianni et al. 3
Educational intervention
The educational intervention was carried out by three nurses
who were specially trained for this purpose. None of the
nurses belonged to the ward personnel. Patients were admit-
ted to the cardiac surgery department 3-4 days before sur-
gery for preoperative assessment and preparation. On
admission day, all patients in the intervention group received
a booklet with information about the cardiac surgery and
perioperative process. The educational intervention included
a mixture of content: procedural, psychoeducational and
skills (Table 1). The nurses emphasised breathing exercises,
the time and method of rising from bed, leg exercises, pain
management, coughing, control of anxiety and movement
of arms. The specially trained nurses also responded to
patients’ questions. The most frequent questions were about
the duration of pain and of their stay in the ICU. Patients
were anxious when they realised that they would have a
chest and endotracheal tube in the ICU. They also wanted
to know when they would be able to resume their daily
activities. The duration of teaching, on the day of admission,
ranged from 20 to 40 minutes and depended on the active
participation of patients. The teaching took place in a sepa-
rate room in the cardiac surgery department, not in the ward.
The relatives of patients could attend the teaching procedure
if the patients consented. The day before surgery the nurses
repeated the educational intervention. They also encouraged
patients to discuss any issue that concerned them. Patients
were mainly concerned about the outcome of the surgery
and its duration or if they could avoid the surgery and
undergo a non-surgical procedure. Nurses focused on meet-
ing the expressed needs of patients and medical queries.
After surgery and ICU hospitalisation, patients returned
to the ward and the educational process was repeated by
the nurses. Patients were also taught about caring for their
surgical wound (chest and leg in the case of venous graft in
CABG).
Patients in the control group received the ordinary
information and care provided by the hospital. The stand-
ard information was unstructured, verbal and limited to
Assessed for eligibility (n=1859)
Excluded (n=1431)
♦Not meeting inclusion criteria (1375)
♦Declined to participate (n=23)
♦Other reasons (n=33)
Analysed (n=190)
♦Excluded from analysis (n=0)
Lost to follow-up (n=0)
Discontinued intervention (n=0)
Allocated to standard care –control group (n=190)
♦Received allocated standard care (n=190)
♦Did not receive standard care (n=0)
Lost to follow-up (n=0)
Discontinued intervention (n=0)
Allocated to intervention –intervention group (n=205)
♦Received allocated intervention (n=205)
♦Did not receive allocated intervention (n=0)
Analysed (n=205)
♦Excluded from analysis (n=0)
Allocation
Analysis
Follow-Up
Randomized (n=395)
Enrollment
Figure 1. Flow of participants through the trial.
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4 European Journal of Cardiovascular Nursing
the bureaucratic procedures. The surgeon and the anaes-
thetist delivered some information about the preoperative
preparation and the surgical procedures the day before
the operation. Additional information may be given by
the nurses of the cardiac surgery department upon request
by patients.
Educational booklet
The educational booklet entitled ‘All I should know before
cardiac surgery’ was conceived taking into account the
professional experience of researchers, documented stud-
ies45,49 and the needs of patients.50,51 It included informa-
tion about anatomy, function and surgical diseases of the
heart, the open heart surgery, the hospital, the periopera-
tive period and process and emphasised the self-care of
patients. The booklet was written in plain and intelligible
language and contained several coloured photographs and
drawings that assist in the better understanding of the
information provided.
Outcomes and data collection
Baseline data were collected by a short form questionnaire
for demographic, clinical, preoperative and intraoperative
characteristics. A baseline measure of trait and state anxi-
ety was performed on the day of admission and before
randomisation.
Descriptive variables
The descriptive variables were demographics, clinical his-
tory and perioperative characteristics. Demographic data
included age, sex, family status, level of education and
place of residence. Clinical data included body mass index
(BMI), body surface area, risk factors such as smoking,
hypertension, diabetes mellitus, hyperlipidaemia, vascular
disease and previous surgical history.
The perioperative risk was calculated using Euroscore I
(European system of cardiac operative risk evaluation).52
Euroscore I is a 17-item system used for calculating pre-
dicted operative mortality for patients undergoing cardiac
surgery.
There is probably a gap between the objective periop-
erative risk and the patients’ perception about their periop-
erative risk53 due to a misunderstanding of the information
provided by the surgeon. This fact may have an impact on
anxiety levels. Patients were asked to estimate, according
to their perception, the risk of the surgery as ‘low’, ‘mod-
erate’ or ‘high’.
Intraoperative data included the type of surgery, the
duration of surgery, the duration of cardiopulmonary
bypass and ischaemia time.
Outcome variables
The outcome variables were the level of state anxiety, the
complications in the ICU and in the ward of the cardiac
surgery department, the duration of tracheal intubation in
hours, the length of ICU stay, the length of hospital stay, as
well as the frequency of hospital readmission within 30
days after the operation. The researchers chose these com-
plications, which could potentially be affected by patients’
preoperative education such as atelectasis, respiratory
infection, thrombosis, leg wound infection, split sternum
infection and arrhythmia. The latter probably has a rela-
tionship with the anxiety caused by lack of knowledge.
The LOS was counted in days and it was defined as the
period from operation until discharge.
The state–trait anxiety inventory (STAI) was used for
estimating the patients’ anxiety. This is a self-reported
questionnaire based on a four-point Likert scale with two
subscales within the measure. First the state-anxiety scale
(form Y-1) consists of 20 statements that evaluate how the
respondent feels ‘right now, at this moment’ using items
that measure subjective feelings of apprehension, tension,
Table 1. List with educational interventions.
Preoperative educational interventions Postoperative educational interventions
Suitable physical preparation for operation (body wash with
antiseptic agent, oral hygiene)
Repeat the importance of not feeling pain
Inspiratory muscle training Repeat of respiratory exercises, coughing and using spirometry
Use of incentive spirometry Leg exercises and early mobilisation
Breathing techniques (including forced expiration techniques) Prevention of sternum split and infection
Coughing exercises with incision support Restriction on arm movements
Leg exercises Avoidance of weightlifting
Techniques for anxiety control Prevention of leg infection (whenever indicated)
Deep breathing Stocking and elevation of leg
Music therapy Repeat of techniques for anxiety control
Meditation
Sleep and rest
Highlight the importance of not feeling pain postoperatively
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Kalogianni et al. 5
nervousness, worry and activations/arousal of the auto-
nomic nervous system. The trait-anxiety scale (form Y-2)
consists of 20 statements that evaluate relatively stable
aspects of ‘anxiety proneness’, including general states of
calmness, confidence and security. Scores range from 20
to 80, with higher scores correlating with greater anxiety.
The Greek version of the scale has good internal consist-
ency reliability and validity.54
There was a total of three measures of anxiety in both
groups. The first measurement was performed on the day
of hospital admission and before randomisation. The sec-
ond measurement was made on the eve of surgery, and the
third measurement on the day of discharge.
Ethics
Data were collected after written authorisation by the scien-
tific council of the Evangelismos general hospital. All par-
ticipants in the study were informed about the purpose of
the study, data confidentiality and the voluntary nature of
participation. The conduct of this study met all the basic
principles of ethics according to the Declaration of Helsinki.
Statistical analysis
Continuous variables are presented with mean and stand-
ard deviations. Quantitative variables are presented with
absolute and relative frequencies. For the comparison of
proportions chi-squared and Fisher’s exact tests were used.
For the comparison of continuous study variables between
the intervention and control groups the Student’s t-test was
computed for normal variables. Differences in changes of
state score during the follow-up period between the inter-
vention and control groups were evaluated using repeated
measurements analysis of variance.
Multiple linear regression analysis dependent on the
variable that presented changes in state score was con-
ducted in a stepwise method (P for removal was set at 0.1
and P for entry was set at 0.05) in order to find independ-
ent factors associated with changes in state scale.
Regression coefficients and standard errors were com-
puted from the results of the linear regression analyses.
Possible interactions of variables in the regression model
were not significant. All P values reported are two-tailed.
Statistical significance was set at 0.05 and analyses were
conducted using SPSS statistical software (version 19.0).
Results
The sample consisted of 395 patients (205 in the interven-
tion group and 190 in the control group). The demograph-
ics of the two study groups are presented in Table 2. The
two groups of patients were also similar in terms of sex,
family status, having children, nationality, educational
level, residence, BMI and smoking. The baseline clinical
and perioperative characteristics of the two study groups
were similar (Table 3).
Mean values of state score for the two study groups on
hospital admission-A, the day before surgery-B and before
discharge-C are shown in Table 4. Also, the mean trait
score was measured once on hospital admission and did
not differ between the two study groups. Specifically, it
was 51.0 (SD 7.7) for the control group and 50.7 (SD 7.6)
for the intervention group (P=0.697). The day before sur-
gery state score decreased only in the intervention group
and thus the aforementioned group reached lower state
levels the day before discharge. Before discharge both
study groups had lower state levels as compared with the
corresponding levels on hospital admission and the day
before surgery. The mean state scores were lower for the
intervention group before discharge. Overall, as defined
from the significant interaction effect of time with groups
(P=0.001), the mean decrease in state score during the
follow-up period was greater in the intervention group as
compared with the control group.
The complications in the ICU and ward were similar for
the two groups but lower proportions of chest infections
were found in intervention group (Table 5).
There was no significant difference in hospital readmis-
sion between the two groups (Table 5) or the duration of tra-
cheal intubation and length of ICU and hospital stay (Table
6). When multiple linear regression analysis was conducted
in a stepwise method with dependent variables, the change in
state score showed that being in the intervention group was
independently associated with a greater decrease in state
score (Table 7). Also, it was found that patients who esti-
mated they were having a low-risk surgery had a lower
decrease in state score as compared with patients who esti-
mated they were having a high-risk surgery. Furthermore,
increased trait scores on hospital admission were associated
with a greater decrease in state score during the follow-up.
Discussion
According to the results of the study, preoperative educa-
tion reduced the state anxiety of patients undergoing heart
surgery, and had an effect on postoperative complications
but did not affect hospital readmissions or LOS. The base-
line characteristics of the intervention and control groups
were similar.
Effect of education on anxiety
This study revealed that education provided by nurses 3–4
days before the heart operation reduced the anxiety of
patients undergoing heart surgery. This finding is consist-
ent with that reached by Chinese researchers, who found a
significant reduction in postoperative anxiety after the pre-
operative education of patients who underwent coronary
artery surgery.40,41 Other researchers have reported that
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6 European Journal of Cardiovascular Nursing
although there was a reduction of anxiety in educated
patients, this was not statistically significant.33,46–48 The
findings of the present study are not consistent with those
of previous studies.45–47,55,56 This is probably due to the dif-
ference in the timing and the manner of education delivery.
Previous studies took advantage of the long waiting time
for surgery to deliver longer-term preoperative education,
the effectiveness of which remained controversial regard-
ing anxiety.43,57 Only one study showed that preoperative
education increased the postoperative anxiety of patients.44
Education focused on the individual needs of each
patient, in conjunction with the opportunity given to the
patients to express concerns, questions and fears, can prob-
ably mobilise mechanisms of anxiety reduction, associated
with a sense of control that patients acquire through the
educational process and the interpersonal relationship with
nurses. It should be noted that Greek patients, due to a
shortage of nursing staff and inadequate preoperative
education, are not usually prepared to protect themselves
mentally and emotionally towards an oncoming threat
such as cardiac surgery.58,59
This study used the STAI scale for measuring anxiety.
State anxiety decreased significantly, gradually from admis-
sion to discharge in both groups, with the intervention group
recording the highest reduction. Gradual reduction of anxi-
ety has been reported by studies regardless of whether they
used the STAI scale45,46 or different scales of anxiety assess-
ment.10–12,51 However, studies report that levels of anxiety
peaked the day before surgery and were reduced progres-
sively after surgery to levels before admission.9,41,60
Effect of education on patients’ complications,
LOS and readmission
In the present study only the rate of sternal infection was
significantly higher in the control group compared to the
Table 2. Demographics for the two study groups.
Group P value
Control Intervention
N (%) N (%)
Gender
Men 140 (73.7) 145 (70.7) 0.513a
Women 50 (26.3) 60 (29.3)
Age, mean (SD) 65.1 (11.0) 65.9 (10.7) 0.500b
Family status
Married 155 (84.2) 154 (75.1) 0.397a
Widow/widower 12 (6.3) 20 (9.8)
Divorced 10 (5.3) 16 (7.8)
Single 13 (4.2) 15 (7.3)
Children
No 16 (8.4) 26 (12.7) 0.170a
Yes 174 (91.6) 179 (87.3)
Nationality
Greek 180 (94.7) 196 (95.6) 0.685a
Other 10 (5.3) 9 (4.4)
Educational level
Primary school 110 (57.9) 123 (60.0) 0.184a
High school 53 (27.9) 43 (21.0)
University or higher 27 (14.2) 39 (19.0)
Residence
Athens 86 (45.3) 102 (49.8) 0.456a
Rural 99 (52.1) 95 (46.3)
Other city 5 (2.6) 8 (3.9)
Body mass index, mean (SD) 27.6 (3.8) 28.2 (4.9) 0.177b
Smoking
No 95 (50.0) 97 (47.3) 0.098a
Yes 62 (32.6) 76 (37.1)
Former 33 (17.4) 59 (15.6)
Years of smoking, mean (SD) 35.0 (10.6) 35.0 (13.3) 0.930b
aPearson’s chi-square test.
bStudent’s t-test.
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Kalogianni et al. 7
intervention group, indicating that preoperative education
may have an impact on the reduction of postoperative
complications. No other study has reported similar
findings. Risk factors for chest infection are associated
with the patients’2,3,61,62 preoperative, intraoperative3 and
postoperative processes. As there was no statistically
Table 3. Clinical history and perioperative characteristics of the two study groups.
Group P value
Control Intervention
N (%) N (%)
Diabetes
No 138 (72.6) 137 (66.8) 0.210a
Yes 52 (27.4) 68 (33.2)
Hypertension
No 40 (21.1) 32 (15.6) 0.162a
Yes 150 (78.9) 173 (84.4)
COPD
No 174 (91.6) 177 (86.3) 0.098a
Yes 16 (8.4) 28 (13.7)
Chronic renal failure
No 184 (96.8) 196 (95.6) 0.522a
Yes 6 (3.2) 9 (4.4)
Hyperlipidaemia
No 92 (48.4) 102 (49.8) 0.791a
Yes 98 (51.6) 103 (50.2)
Ejection fraction (%), mean (SD) 53.0 (10.1) 51.9 (10.6) 0.304b
Angiopathy
No 182 (95.8) 200 (97.6) 0.324a
Yes 8 (4.2) 5 (2.4)
Euroscore, mean (SD) 6.2 (6.1) 6.3 (5.9) 0.822b
Diagnosis
Coronary heart disease 97 (51.1) 113 (55.4) 0.364c
Valvular disease 54 (28.4) 62 (30.4)
Coronary heart disease and valvular disease 16 (8.4) 13 (6.4)
Aneurysm 11 (5.8) 4 (2)
Aneurysm and valvular disease 9 (4.7) 11 (5.4)
Aneurysm, coronary heart disease and valvular disease 2 (1.1) 1 (0.5)
Other 1 (0.5) 0 (0)
Type of surgery
CABG 104 (55.6) 114 (56.2) 0.493c
VR 55 (29.4) 70 (34.5)
CABG and VR 18 (9.6) 13 (6.4)
Ascending aortic aneurysm repair 8 (4.3) 5 (2.5)
Other 2 (1.1) 1 (0.5)
Self-estimated surgery risk
High 26 (13.8) 34 (16.7) 0.717a
Low 102 (54.0) 105 (51.5)
Moderate 61 (32.3) 65 (31.9)
Previous surgery
Scheduled 80 (85.1) 107 (79.3) 0.261a
Urgent 14 (14.9) 28 (20.7)
Duration of surgery (min), mean (SD) 258.8 (78.2) 256.1 (66.3) 0.710a
COPD: chronic obstructive pulmonary disease; CABG: coronary artery bypass grafting; VR: valve replacement.
aPearson’s chi-square test.
bStudent’s t-test.
cFisher’s exact test.
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8 European Journal of Cardiovascular Nursing
Table 4. Changes in state scale for the two study groups during the follow-up period.
State scale P valuebP valuebP valuebP valuec
On hospital
admission A
Day before
surgery B
Before
discharge C
A vs. B B vs. C A vs. C
Group Mean (SD) Mean (SD) Mean (SD)
Control 37.7 (10.6) 36.9 (10.7) 34.6 (10.2) 0.669 0.032 0.001 0.001
Intervention 36.1 (9.6) 34.0 (8.4) 29.1 (6.5) <0.001 <0.001 <0.001
P valuea0.116 0.002 <0.001
aP value for group effect.
bP value for time effect.
cRepeated measurements analysis of variance. Effects reported include differences between the groups in the degree of change over the follow-up
period.
Table 5. Percentage of patients with complications and hospital readmission.
Group P value
Control Intervention
N (%) N (%)
Complications in intensive care unit 54 (28.4) 63 (30.7) 0.615a
Respiratory infection 2 (1.1) 0 (0.0) 0.231b
Atelectacis 9 (4.7) 8 (3.9) 0.683a
Psychosis 3 (1.6) 3 (1.5) >0.999b
Neurological disorders 5 (2.6) 4 (2.0) 0.743b
Arrhythmia 33 (17.4) 38 (18.5) 0.763a
Other complication 22 (11.6) 14 (6.8) 0.101a
Complications in ward 29 (15.3) 23 (11.2) 0.235a
Respiratory infection 3 (1.6) 4 (2.0) >0.999b
Atelectasis 1 (0.5) 0 (0.0) 0.481b
Deep vein thrombosis 0 (0.0) 0 (0.0) –c
Chest infection 10 (5.3) 1 (0.5) 0.004a
Leg infection 2 (1.1) 2 (1.0) >0.999b
Arrhythmia 4 (2.1) 7 (3.4) 0.429a
Other complication 18 (9.5) 12 (5.9) 0.183a
Readmission 12 (6.3) 9 (4.4) 0.394a
aPearson’s chi-square test.
bFisher’s exact test.
cNot computed due to no distribution.
Table 6. The duration of tracheal intubation and the length of stay in the intensive care unit and hospital.
Group P value Student’s t-test
Control Intervention
Mean (SD) Mean (SD)
Extubation time (h) 11.8±7.8 13.2±7 0.056
ICU LOS 2.3±1 2.2±0.7 0.370
Hospital LOS 9.9±5.4 10±4 0.842
LOS: length of stay; ICU: intensive care unit.
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Kalogianni et al. 9
significant difference in preoperative and intraoperative
data between the groups and both groups received appro-
priate preoperative preparation, this finding may indicate
that preoperative education played a role in preventing
sternal infection. It is possible that the emphasis placed on
reducing the risk factors of surgical site infections,27,63
such as control of blood glucose, as well as body and oral
cavity hygiene, have played a role in the reduction of ster-
num infections in the intervention group. However, further
investigation is necessary.
In the present study, preoperative education did not
appear to affect the incidence of the total measured
complications of patients. This finding is consistent
with Deyirmenjian et al., who found no significant
reduction in complications.44 However, recent studies
report a significant reduction in postoperative compli-
cations.40,41 This result may be explained on the one
hand by the fact that postoperative complications also
depend on non-educational interventions, and on the
other hand by the fact that the duration of preoperative
education may have not been sufficient for it to modify
the risk factors associated with the occurrence of post-
operative complications.
In the context of this study, preoperative education did
not reduce the duration of patients’ intubation in the ICU,
but a previous study found that the intervention group had
a significant reduction in intubation time.44 Our findings
suggest that preoperative educational intervention may not
be enough to modify the factors that impact on the dura-
tion of intubation time.
In the present study, preoperative patient education did
not affect the LOS in either the ICU or hospital. This
result is consistent with the findings of numerous stud-
ies.33,41,43,44,46,55,64 However, previous studies have
reported a reduction in the LOS after educational inter-
vention.36,40,65 Preoperative educational intervention for
patients undergoing cardiac surgery was not enough to
reduce the LOS. This finding may be explained by the fact
that there was no difference in the incidence of total post-
operative complications in either group. Postoperative
complications are a common cause of prolonged LOS.33
There was no significant change in the 30-day readmis-
sion rate for either group. There has been no evidence to
demonstrate that preoperative education can reduce the
readmission rate in cardiac surgery patients. Nevertheless,
postoperative complications such as surgical site infec-
tions, sternum split and arrhythmias are common causes
for hospital readmissions.30
Finally, multivariate linear regression showed that this
type of education, the self-estimated risk of surgery and
the score in trait anxiety scale on hospital admission are
independent predictors of a reduction in state anxiety. Less
change in state anxiety was experienced by patients who
thought that they would undergo a low-risk surgery com-
pared with patients who thought that they would undergo a
high-risk surgery. There are no relevant findings in similar
studies. This finding may be related to the temperament
and character of patients. Patients who, regardless of
whether they received medical information or not, judged
the surgery to be low risk, probably do not react to a
stressor with a great increase in anxiety and thereby the
change in anxiety was not intense. On the contrary, patients
who judged the surgery to be high risk may initially react
to a stressor such as cardiac surgery with a great increase
in anxiety and after the influence of factors such as contact
with operated patients may experience a reduction in anxi-
ety levels.
A greater reduction in state anxiety was observed in
patients with a high level of trait anxiety on the day of
admission in hospital. Patients with high trait anxiety
tend to show increased state anxiety because they tend to
react more strongly to a stressor.66 Cardiac surgeries are
potent stressors and cause a large increase in the levels of
state anxiety.
The impact of alleviative factors on these patients is
likely to be equally strong and reduce state anxiety more.
Table 7. Multiple linear regression analysis results using the stepwise method with dependent variable the change in state score
during the follow-up period.
aSEbP value
Group
Control 0.00c
Intervention 5.97 1.02 <0.001
Self-estimated surgery risk
High 0.00
Low −4.13 1.55 0.008
Moderate 0.31 1.12 0.783
Trait (after hospital admission) 0.58 0.07 <0.001
aRegression coefficient.
bStandard error.
cIndicates reference category.
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10 European Journal of Cardiovascular Nursing
Factors that may have a relieving effect on patients are
the preoperative information, familiarisation with the
hospital environment and communication with nurses or
other patients.
Strengths and limitations of the study
This study was the first one to be conducted in Greece that
investigated the effect of nurse-led preoperative education of
patients undergoing cardiac surgery on anxiety and postop-
erative outcomes, and highlighted the positive contribution
of preoperative patients’ education in controlling anxiety.
However, there were some limitations such as the
small sample size and the fact that data were collected
by one cardiac surgery centre only. The surgical opera-
tions that the study population underwent cover the
whole spectrum of cardiac surgery and not just CABG
as in most studies. The inter-rater reliability between
the three nurses delivering the education as well as the
treatment fidelity were not measured. Anxiety was
assessed with a single tool in the preoperative stage and
before discharge. An additional measurement after dis-
charge might reveal interesting items related to the
mental and emotional health of patients. The research-
ers measured those complications that could be influ-
enced by preoperative education and anxiety.
Anxiety-related complications such as restlessness,
insomnia/nightmares, need for bolus sedation, pain
scores or similar were not measured.
The recording of every postoperative complication and
the correlation with anxiety levels might show a signifi-
cant relationship between anxiety and the short-term mor-
bidity of patients.
Conclusions
The preoperative education delivered by nurses reduced
the preoperative and postoperative anxiety of patients
undergoing cardiac surgery. It also had an effect on the
reduction of postoperative complications. The preopera-
tive education had no effect on LOS or hospital readmis-
sions. The preoperative education, the self-estimated risk
of surgery and the score in trait anxiety scale before
admission are independent predictors of a reduction in
state anxiety. The knowledge of these parameters allows
the planning and implementation of preoperative educa-
tional, psychological and behavioural interventions in
order to control the anxiety of cardiac surgery patients.
Further research is needed and investigation into new
areas, such as factors that influence anxiety and test inter-
ventions that can control anxiety levels for the benefit of
cardiac surgery patients.
Implications for practice
Anxiety of patients undergoing cardiac surgery
needs to be assessed
Patients with increased preoperative anxiety
need psychoeducational care
Skilled nurses must provide specialist patients’
education
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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