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Resource Manual for Nursing Research: Generating and Assessing Evidence for Nursing Practice

Background
In a review and meta-analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion-focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect.

Objectives

To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic.

Search methods

We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the ‘awaiting classification’ section of this review.

Selection criteria

We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery.

Data collection and analysis

One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion. 

Where possible we used random-effects meta-analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges’g) to combine data from different outcome measures. If data were not available in a form suitable for meta-analysis we performed a narrative review.

Main results

Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty-one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta-analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD -0.20, 95% confidence interval (CI) -0.35 to -0.06), length of stay (mean difference -0.52 days, 95% CI - 0.82 to -0.22) and negative affect (SMD -0.35, 95% CI -0.54 to -0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached. 

Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall, we rated the quality of evidence for each outcome as ‘low’ because of the high level of heterogeneity in meta-analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta-analysis, so we rated the quality of evidence as ‘very low’.

Authors’ conclusions

The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well-conducted and clearly reported research.

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Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia

Aims. This paper presents a systematic review whose aim was to describe the scope and methods of the current literature on preoperative patient education and to identify the effects of this education.

Background.  Preoperative patient education is a common and important intervention in surgical nursing, yet there is very limited systematic evidence on its precise role.

Methods.  The Medline, CINAHL, Eric, Psycinfo and Social Sciences Index databases and the Cochrane Library were searched, covering the period from the beginning of each database to April 2003. Studies were included if they concerned adult orthopaedic patients, preoperative nursing patient education and were based on randomized controlled or clinical trials. Meta-analysis was carried out where appropriate.

Results.  We identified 11 articles involving 1044 participants. Most studies included one experimental and one control group; only two had more than one experimental and control group. The educational interventions varied widely, but the majority were based on written materials alone, or written materials in combination with other teaching methods. The most common outcome measures related to pain, knowledge, anxiety, exercises and length of stay, and the least common to self-efficacy and empowerment. The methodological quality of the studies varied. Almost all reported one or more statistically significant effects. Based on the findings of the meta-analysis, preoperative education appears to have some impacts on patients’ anxiety and knowledge levels.

Conclusions.  The review clearly highlights the need for well-designed, methodologically sound research into the outcomes of patient education. It also points to the need to study patient education from the point of view of empowerment.

Preoperative education for orthopaedic patients: systematic review.

Study Design. Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy. Objective. To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery. Summary of Background Data. One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain. Methods. Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire). Results. At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain ( P = 0.183), leg pain ( P = 0.075), and function ( P = 0.365). In a majority of the categories regarding

Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up.

Objective: Evaluate content and educational delivery methods of preoperative education in total joint arthroplasties of the hip and knee (THA and TKA) addressing postoperative pain. Data sources: Systematic searches conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (pearling) was undertaken. Data extraction: Data were extracted utilizing the participants, interventions, comparisons, and outcomes approach. Study selection: All randomized controlled trials (RCTs) evaluating the effect of preoperative education on postoperative pain in THA and TKA surgery were considered for inclusion. Limitations: Studies published in English; published within the last 20 years and patients over the age of 18. No limitations were set on specific outcome measures of pain. Data synthesis: This review included 13 RCTs involving a total of 1,017 subjects who underwent THA or TKA. Educational delivery methods comprised verbal one-onone or group education sessions, delivered within 4 weeks of surgery lasting an average of 30 minutes, and accompanied by other written materials. The educational content centered on descriptions of preoperative preparation, hospital stay, surgical procedure, immediate/intermediate experiences, expectations following surgery, rehabilitation, encouragement/reassurance, and answering common question associated with the surgical experience. Conclusions: Preoperative education centered on a biomedical model of anatomy and pathoanatomy as well as procedural information has limited effect in reducing postoperative pain after THA and TKA surgeries. Preoperative educational sessions that aim to increase patient knowledge of pain science may be more effective in managing postoperative pain.

Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods.

The investigators examined whether elders who have been taught pain management communication skills and pain management information obtain greater postoperative pain relief than elders not taught this information. Thirty-one elders were randomly assigned preoperatively to a control or communication group in this posttest-only experiment with repeated measures. Communication group participants were taught pain management, pain communication skills, and the use of two pain-intensity scales. Control group participants were taught to use the two pain-intensity scales. Pain was measured with the McGill Pain Questionnaire Short Form. The communication group elders reported less postoperative pain over the course of their hospital stay. Pain management knowledge alone may have enabled the elders to obtain greater pain relief. Nurses may want to incorporate similar pain management information and pain communication skills when teaching elders how to obtain greater postoperative pain relief.

Joan Moore

Papers

Testing a preoperative pain management intervention for elders