Article on Preoperative Anxiety Management in Nursing by jfv11083


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									Review Title: Effectiveness of nurse-led preoperative assessment services

Authors: Sonia Hines1,2, Anne Chang2,3, Ruth Hollin2,4.
  Clinical Research Nurse, 2Nursing Research Centre and The Queensland
Centre for Evidence-based Nursing and Midwifery, Mater Health Services,
  Professor of Clinical Nursing and Director, Queensland University of
Technology and Mater Health Services; 4Research Nurse Intern.

Contact author: Sonia Hines Email:

Background: The admission and assessment of patients for elective surgery
is a task faced by all healthcare organisations that provide elective surgical
services. Several different strategies have been used to facilitate the
management of these tasks. Nurse-led pre-admission clinics or services have
been implemented in many health services as one of these management

The process of preadmission testing and/or screening involves a wide variety
of procedures, depending on the needs of the facility and the patients.
Preadmission clinics or services address several different domains of
practice: collection of biometric and psychosocial data, screening to insure
patients receive the most appropriate care whilst in hospital, screening for
potential problems that may impact on length of stay, and the provision of
education and information on the planned procedure and hospital process.

The main benefit of beginning this process at the preadmission stage appears
to be that it provides increased time for data collection, especially history
taking, which is a vital part of the pre-surgical work-up1. Histories taken on the
day of surgery may be less than complete, due to patient anxiety and the
pressure of time on the nurse.

Historically, medical personnel have provided these services and in some
healthcare systems this remains the case2. However shortages of medical
staff and the high cost of services have meant that nursing staff have taken
over these tasks and indeed, nurses are in an ideal position to manage and
provide these services. Nurse-led preoperative clinics may offer a more
holistic service and a broader range of expertise than medical assessments
alone3. In addition, many patients find nurse-led preoperative assessment as
acceptable as medical assessment2, 4. A comparative study found no
differences in quality or safety between assessments conducted by junior
medical staff and those conducted by appropriately trained nurses2.

Preoperative patient assessment is vital to identify patient risk factors, to
provide information and education and to perform and/or arrange any
necessary measurements or laboratory studies such as blood tests or
electrocardiographs1, 3, 5. Thorough assessment of surgical patients helps to
prepare them physically and psychologically for their hospital experience6.
Preoperative assessment may also address the anxiety many patients feel
regarding anaesthesia and the surgical experience. Explanation of the
procedure and the process the patient will go through may help to increase
patient knowledge and decrease their anxiety. Decreased anxiety is a
significant factor in patients' feelings of satisfaction with the surgical process
as a whole3. The advantage of pre-admission assessment is that patients who
have had their questions answered and their concerns alleviated prior to their
admission will usually enter the process with a lower level of anxiety3.

Early assessment of patients booked for day surgery can also reduce the
number of day of surgery cancellations3, 7, 8, and unexpected overnight stays
and the associated strain on inpatient bed numbers5, 6. Last-minute
cancellation of surgery has costs for both hospitals and patients and is a
largely avoidable occurrence in most cases8.

Preoperative assessment in preadmission clinics may also allow for screening
of patients with a variety of tools for risks such as delirium9, nutrition
problems10, the presence of MRSA11, tobacco use12, or lack of home
support13 which can have a serious effect on length of stay, and the course
and cost of postoperative recovery7. The use of screening tools at the pre-
admission stage allows for a level of preparation for the hospital stay that may
not otherwise be possible. For the paediatric patient, preoperative preparation
can lead to an increase in compliance with procedures14, as well as a
reduction in post-operative pain and sleep disturbance15.

This review aims to examine whether nurse-led preoperative assessment
clinics or services improve surgical outcomes for patients, reduce day-of-
surgery cancellations, and length of stay. An existing review by Bazian16
compared the effectiveness of nurse-led to physician-led services, and
consequently, this outcome will not be included in this review. Preoperative
education has also been the subject of several previous reviews17-20 and this
review aims to fill the remaining gap in the existing evidence.

Review Objective: The objective is to review the available research on the
effectiveness of nurse-led preoperative assessment clinics or services on
patient outcomes.

More specifically, the objectives are to identify: the effectiveness of nurse-led
preoperative assessment services on reducing adverse surgical events,
improving patient satisfaction, decreasing anxiety, reducing inpatient days and
reducing the number of overnight stays for day or ambulatory surgery

Inclusion Criteria

Types of Participants: The review will consider studies that include adult or
paediatric patients who are having any type of surgical procedure, either as a
day-only case or as an inpatient.

Types of Intervention: The review will consider studies that evaluate the
effect of attending or receiving the services of a nurse-led outpatient pre-
admission or preoperative assessment clinic.
Types of Outcome: This review will consider studies that include the
following outcome measures: length of stay, cancellation of surgery, incidence
of non-attendance for scheduled surgery, mortality, morbidity, adverse
surgical events, recognition and fulfilment of postoperative care needs, patient

Types of Studies: The review will consider any randomised controlled trials
published after 1999; in the absence of RCTs other research designs, such as
non-randomised controlled trials and before and after studies, will be
considered for inclusion in a narrative summary to enable the identification of
current best evidence regarding the effectiveness of nurse-led preoperative
assessment services.

Exclusion Criteria: This review will exclude studies of preoperative education
as this has been the subject of a previous review. We will also exclude studies
of emergency admissions. Studies comparing nurse-led with physician-led
preadmission assessments will also be excluded as that has also been the
subject of a previous systematic review.

Search Strategy: The search strategy aims to find both published and
unpublished studies. A three-step search strategy will be utilised in each
component of this review. An initial limited search of MEDLINE and CINAHL
will be undertaken followed by analysis of the text words contained in the title
and abstract, and of the index terms used to describe article. A second search
using all identified keywords and index terms will then be undertaken across
all included databases. Thirdly, the reference list of all identified reports and
articles will be searched for additional studies.

The databases to be searched include:
Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane
EMBASE (1999 to present)
Meditext (1999 to present);
ISI Web of Science (1999 to present).

The search for unpublished studies will include:
(1) Current Controlled Trials

(2) Clinical Study Results

(3) OpenSIGLE

(4) Grey Literature Report


(6) National Institute of Clinical Studies (NHMRC)

Initial keywords to be used will be:
1. preoperative or preadmission or pre$admission
2. assessment or examination or work-up or investigation or screening
3. clinic or service or team
4. nurs*

Assessment of Methodological Quality: Papers selected for retrieval will be
assessed by two independent reviewers for methodological validity prior to
inclusion in the review using standardised critical appraisal instruments from
the Joanna Briggs Institute Meta Analysis of Statistics Assessment and
Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise
between the reviewers will be resolved through a third reviewer.

Data Collection: Data will be extracted from papers included in the review
using the standardised data extraction tool from JBI-MAStARI (Appendix II).*
*The data extracted will include specific details about the interventions,
populations, study methods and outcomes of significance to the review
question and specific objectives.

Data Synthesis: Papers will, where possible be pooled in statistical meta-
analysis using the Joanna Briggs Institute Meta Analysis of Statistics
Assessment and Review Instrument (JBI-MAStARI). All results will be subject
to double data entry. Odds ratio (for categorical data) and weighted mean
differences (for continuous data) and their 95% confidence intervals will be
calculated for analysis. Heterogeneity will be assessed using the standard
Chi-square. Where statistical pooling is not possible the findings will be
presented in narrative form.

Conflict of Interest: None known.

1.      Beck A. Nurse-led pre-operative assessment for elective surgical
patients. Nurs Stand. 2007;21(51):35-8.
2.      Stables R. H., Booth J., Welstand J., et al. A randomised controlled trial
to compare a nurse practitioner to medical staff in the preparation of patients
for diagnostic cardiac catheterisation: the study of nursing intervention in
practice (SNIP). European Journal of Cardiovascular Nursing. 2004;3(1):53-9.
3.      Gilmartin J. Day surgery: patients' perceptions of a nurse-led
preadmission clinic. Journal of Clinical Nursing. 2004;13(2):243-50.
4.      Prasad Venkata, Smith Andrew. Preoperative assessment: from
tribalism to cooperation. The Lancet. 2001;358(9295):1747-8.
5.      Green A. M. Nurse directed pre-admission clinics. Ambulatory Surgery.
6.      Hunt M. Nurses can enhance the pre-operative assessment process.
Nurs N Z. 2006;12(10):20-1.
7.     Clark K., Voase R., Fletcher I. R., et al. Improving patient throughput
for oral day case surgery. The efficacy of a nurse-led pre-admission clinic.
Ambulatory Surgery. 1999;7(2):101-6.
8.     Vaghadia H. Can nurses screen all outpatients? Performance of a
nurse based model. Canadian Journal of Anesthesia. 1999;46(12):1117-21.
9.     Litaker D., Locala J., Franco K., et al. Preoperative risk factors for
postoperative delirium. General Hospital Psychiatry. 2001;23(2):84-9.
10.    Schwartz DB, Gudzin D. Preadmission Nutrition Screening: Expanding
Hospital-Based Nutrition Services By Implementing Earlier Nutrition
Intervention. Journal of the American Dietetic Association. 2000;100(1):81-7.
11.    Diller Ricarda, Sonntag Anne K., Mellmann Alexander, et al. Evidence
for cost reduction based on pre-admission MRSA screening in general
surgery. International Journal of Hygiene and Environmental Health.
12.    Wolfenden L., Dalton A., Bowman J., et al. Computerized assessment
of surgical patients for tobacco use: accuracy and acceptability. Journal of
Public Health. 2007.
13.    Liebergall M., Soskolne V., Mattan Y., et al. Preadmission screening of
patients scheduled for hip and knee replacement: impact on length of stay.
Clin Perform Qual Health Care. 1999;7(1):17-22.
14.    Brewer S., Gleditsch S. L., Syblik D., et al. Pediatric anxiety: child life
intervention in day surgery. Journal of pediatric nursing. 2006;21(1):13-22.
15.    Kain Z. N., Mayes L. C., Caldwell-Andrews A. A., et al. Preoperative
anxiety, postoperative pain, and behavioral recovery in young children
undergoing surgery. Pediatrics. 2006;118(2):651.
16.    Bazian Ltd. Preoperative assessment by nurses. Evidence-Based
Healthcare and Public Health. 2005;9(6):376-80.
17.    McDonald Steve, Hetrick Sarah E , Green Sally. Pre-operative
education for hip or knee replacement
Cochrane Database of Systematic Reviews. 2004(1).
18.    Johansson K., Nuutila L., Virtanen H., et al. Preoperative education for
orthopaedic patients: systematic review. Journal of Advanced Nursing.
19.    Lee A., Chui P. T., Gin T. Educating patients about anesthesia: a
systematic review of randomized controlled trials of media-based
interventions. IARS; 2003. p. 1424-31.
20.    Hodgkinson B, Evans D , O’Neill S Knowledge Retention from Pre-
Patient Information. . The Joanna Briggs Institute for Evidence Based Nursing
and Midwifery. 2000;Report No. 6.
Appendix I: JBI Critical Appraisal Checklist for
Experimental Studies
Reviewer ___________________            Date __________
Author _____________________           Year __________     Record Number ______

                                                              Yes     No     Unclear

1. Was the assignment to treatment groups truly random?

2. Were participants blinded to treatment allocation?

3. Was allocation to treatment groups concealed from the

4. Were the outcomes of people who withdrew described
and included in the analysis?

5. Were those assessing outcomes blind to the treatment

6. Were the control and treatment groups comparable at

7. Were groups treated identically other than for the named

8. Were outcomes measured in the same way for all

9. Were outcomes measured in a reliable way?

10. Was appropriate statistical analysis used?

Overall appraisal:           Include          Exclude           Seek further info.

Comments (Including reasons for exclusion)
  Appendix II: JBI Data Extraction Form (Quantitative

Author                                       Record Number




Method               ___________________________________________

Setting              ___________________________________________

Participants         ___________________________________________

Number of Participants

Group A                                Group B


Intervention A       ___________________________________________



Intervention B       ___________________________________________


Outcome Measures
Outcome Description                 Scale/Measure

Dichotomous Data
Outcome                Treatment Group          Control Group
                       Number/total number      Number/total number

Continuous Data
Outcome                Treatment Group          Control Group
                       Mean & SD (number)       Mean & SD (number)

Authors Conclusion

Reviewers Conclusion

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