Preoperative Education and Patient Outcomes

This assignment examines the impact of preoperative education on patient outcomes following surgery, focusing on pain management and postoperative anxiety. It requires students to analyze relevant research studies, evaluate their methodologies, and synthesize findings regarding the effectiveness of different educational approaches. Students will also explore the clinical implications of these findings and discuss how evidence-based practices can improve patient care.

Running head: CRITICAL APPRAISAL
Critical appraisal
Name of the Student
Name of the University
Author Note

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Table of Contents
Introduction................................................................................................................................2
Literature Search........................................................................................................................3
Identifying the problem and formulating the research...............................................................4
Methodology..............................................................................................................................4
Design....................................................................................................................................4
Tools.......................................................................................................................................5
Sample....................................................................................................................................6
Ethics......................................................................................................................................7
Pilot Study..............................................................................................................................8
Results........................................................................................................................................9
Recommendations and Conclusion............................................................................................9
Application to Practice.............................................................................................................10
References................................................................................................................................12

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Article A: Kalogianni, A., Almpani, P., Vastardis, L., Baltopoulos, G., Charitos, C. and
Brokalaki, H., 2016. Can nurse-led preoperative education reduce anxiety and postoperative
complications of patients undergoing cardiac surgery? European Journal of Cardiovascular
Nursing, 15(6), pp.447-458.
Article B: Sadati, L., Pazouki, A., Mehdizadeh, A., Shoar, S., Tamannaie, Z. and Chaichian,
S., 2013. Effect of preoperative nursing visit on preoperative anxiety and postoperative
complications in candidates for laparoscopic cholecystectomy: a randomized clinical
trial. Scandinavian Journal of Caring sciences, 27(4), pp.994-998.
Introduction
Advancements in medical science have not been equal in every sector. Surgeries are
still accompanied by various complications that can greatly threaten patients’ lives. In
anticipation of their surgeries, patients often suffer from anxiety, which seems to affect the
perioperative psychosomatic health outcomes. Further postoperative outcomes are heavily
dependent on the preoperative status of the patient (Ettema et al. 2014). Empirical findings
have suggested an association between preoperative anxiety and the onset of postoperative
complications (Attias et al. 2016). Efforts are in progress to mitigate this issue, thereby
providing respite for the distressed patients, through the integration of individualized and
generic complementary medicine treatments. In recent contexts, several intervention
strategies have been streamlined to combat postoperative complications and anxiety levels in
the patients concerned. However, there is a dearth of studies containing sufficient evidence in
support of preoperative nursing interventions that might exert positive influences on
combating postoperative complications and anxiety levels in patients. Therefore, in order to
address these aspects, it is crucial to consider their implications when they are put to practice

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in future. Evidence-based practice will help to develop the optimal healthcare delivery
system, which in turn, will bring forth the best outcomes for the patients (Stevens 2013).
The following assignment will deal with the critical appraisal of two articles that are
in alliance with the chosen topic. Critical appraisal is an important component of research,
whereby the quality, reliability and applicability of information presented is assessed using a
specific appraisal framework (LoBiondo-Wood et al. 2014). The Critical Appraisal Skills
Programme (CASP) tool checklist for randomized controlled trials (RCT) will be utilized to
critically appraise the articles that are designed as RCTs.
Literature Search
Undertaking a systematic and extensive literature review is an essential component in
research for appropriate performance of a study. Unbiased and detailed discussion pertaining
to the topic under investigation is particularly important to provide greater insight into the
subject (Aveyard 2014). Hence, higher the number of articles referred to in a study, greater
will be the chances of a good quality discussion. Google scholar was used for the primary
search. It helped to collect basic and relevant information about the role of preoperative
nursing education and visits in reducing complications among patients undergoing
laparoscopic cholecystectomy and cardiac surgery. Essential inquiry for the topics discussed
in the two papers was done by utilising several databases like CINAHL, Medline and
SCOPUS. The bibliography of the relevant articles was also searched to make a list of the
related studies that needed a review. Several keywords were used during the database search.
The keywords were “pre-operative education AND anxiety”, “pre-operative nursing visit
AND complications”, “nursing education AND cardiac arrest”, “anxiety AND
complications”, “preoperative anxiety OR nursing visit”, “laparoscopic cholecystectomy
AND nursing education”. The databases displayed huge results. To narrow down the search,

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inclusion criteria contained time limit of 5 years. Articles published prior to 2012 were not
selected. Peer reviewed articles published only in English were included (Parahoo 2014).
Following a thorough reading of the abstracts of the identified studies, 2 articles were finally
chosen for this critical appraisal report.
Both the articles that have been critically appraised show in-depth analysis and insight
in terms of investigating the topic under consideration. The literature review sections of both
articles are satisfactory in terms of presenting an overview of the chosen topic and are
proficient at mentioning the relevant contexts that are of use for this study. Article A shows
greater insight and in-depth analysis of information compared to Article B, in relation to the
number of relevant articles that have been referenced. Article A contains 66 references in
total, while Article B presents a meagre figure of 17 references. For Article A, the literature
review section is supplemented with discussions on similar topics, thereby adding more value
to the study and relevance of the topic searched. The rationale for referring to similar articles
is evident through the discussions that are carried out. However, there is no mention of the
selection of any form of theoretical framework in the study. For Article A, the timeline for
the references spans from 1984 to 2015, while, for Article B, the timeframe is 1970 to 2012.
In both articles, the critical appraisal is both evident and adequate.
Identifying the problem and formulating the research
In any research, the identification of the research problem of is one of the vital steps
as it leads to the expansion of the study by adopting suitable research methodologies. In this
regard, the problem recognition facilitates the subsequent steps that ultimately help to
structure the sections of the research. At times, the problem identification might be difficult.
However, accurate identification culminates in steering the consecutive steps in an
appropriate manner (Best and Kahn 2016).

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For both Articles A and B, the study’s purpose has been stated clearly. The problem
has been identified succinctly and the studies’ rationales have been explained effectively in
both cases. For Article A, after conducting a proper review of relevant literature, the pivotal
problem that calls for prompt attention has been identified. The primary purpose of the study
has been presented precisely, alongside the secondary objective. In contrast, Article B
provided a very sketchy depiction of the purpose and objective associated with the study. No
clear statement about the research hypothesis has been presented (Sadati et al. 2013).
Furthermore, for both articles, the identification of the gaps in the research, as obtained
through the literature review, are different. Article A offers a distinct presentation of the gaps
in the research, while Article B does not show any such obvious differentiation. Moreover,
the logical flow of the presentation of the objectives is more evident in the case of Article A,
as opposed in Article B. It is essential to present the research objectives, as it gives accurate
direction to further research procedures.
Methodology
Design
Articles A and B have both presented the study design to be used clearly. As depicted
in these articles, it has been found that both studies will adopt an RCT approach, whereby all
the necessary measures will be undertaken to proceed with the work. Article A has clearly
articulated that it is an RCT (Kalogianni et al. 2016). However, Article B has plainly stated
that the study is a prospective, semi-experimental RCT. The details pertaining to the
randomized allocation of the study participants have been represented clearly, so that there is
no ambiguity regarding the procedure to be adopted in the course of the study. The variable
number of participants who were assigned to the standard care and the intervention has been
clearly stated in Article A. However, no such intention can be seen in the case of Article B.

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The randomization process has been carried out using a computer-based application in the
case of Article B, while, for Article A, the admission number, whether it is odd or even,
determined the participants’ allocation into the intervention and the control group. All the
prerequisites for randomization related to the studied population, the comparator and the
intervention given, in addition to consideration of the outcomes, have been mentioned.
However, no information regarding the concealment of the allocation from the researcher has
been provided in either of the articles. Furthermore, the issue of blinding, as applicable in
these studies, has not been highlighted. An RCT comprises of an experimental study design
in which the subjects of the study are randomly allocated into groups, one comprising of
those who are receiving the intervention treatment and the other containing those who are
subject to the standardized treatment. The comparisons of the two groups are conducted
through suitable follow up that caters to measurement of the parameters. In modern research,
RCTs have garnered much attention in understanding population-based parameters and
formulating interventions in alliance with the outcomes of such observations (Booth and
Tannock 2014). Through evaluating the purpose of the studies as described in both the
articles, it might be decided that the RCT is the best research method, as it helps in presenting
the cause and effect relationship accurately.
Tools
The use of the appropriate tools is an integral part of research as it aids in
understanding the research path and in gaining important insights into the research procedure.
The correct way to perform the research is generally presented by virtue of these tools.
Incorrect use of the tools might jeopardize a study’s outcomes, thereby diminishing its
reliability and validity. Erroneous results might creep into the research if the tool used for
determining a specific outcome variable is not appropriate (Cohen, Manion and Morrison
2013). For Article A, mention has been made of the use of a short form of questionnaire for

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gathering the data relevant to the demographic, clinical, preoperative and intra-operative
features (Kalogianni et al. 2016). The baseline data pertinent to these characteristics was
accumulated in the process. The descriptive variables were evaluated by the use of the
European System for Cardiac Operative Risk Evaluation (EuroSCORE) for assessing the
perioperative risk. Relevant findings have supported the use of this scale for accurately
predicting operative mortality following cardiac surgery (Guida et al. 2014). Furthermore, the
patients’ anxiety has been evaluated by virtue of the State-Trait Anxiety Inventory (STAI).
The validation of this tool’s use has been confirmed through a study that presents its
applicability in situations relating to cognitive anxiety and depression together (Balsamo et
al. 2013).Thus, it is evident that the tools that have been used in Article A are quite practical
and appropriate. Furthermore, a questionnaire has the potential of increasing the reliability
associated with a particular study, as it leads to the production of optimal results through
direct and in-depth analysis of the event (Denscombe 2014). In Article B, the patients’
medical records were reviewed, as well as face-to-face interviews being conducted to obtain
the relevant information for the topic under investigation (Sadati et al. 2013). The Spielberger
STAI scale evaluated the efficacy of the nursing visits in the study through reference to a
survey procedure. The validity linked to this scale has been proved in study that, in turn,
further accentuated the benefits associated with its usage (Skapinakis 2014). Thus, it mightbe
said that the tools are effective in bringing forth desirable and accurate results due to their
validity and reliability.
Sample
Sample selection and size is vital as it forms the foundation of any research. The
fundamental purpose of research is generally achieved through accurate sampling that serve
to represent the population as a subset. Statistically, the larger the sample size, the more
likely it is that the distribution will be normal, thereby giving a true picture as a population

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subset (Pett 2015). For Article A, it has been stated that 395 adult patients who met the
inclusion criteria were recruited for the study, of which 190 patients who were allocated to
standard care made up the control group. The remainder, 205 patients, who were subjected to
intervention were placed in the intervention group. The final analysis was carried out with
this same population. No additional information regarding the characteristics of the
population was presented in the article. Furthermore, in Article B, 100 patients who
underwent laparoscopic surgery comprised the sample size, of which 50 were randomly
assigned to each of two groups. The age group for the population was 18 years old to 60
years old. Therefore, assessing the characteristics and the sample size in relation to the
chosen population, it might be said that the sampling for Article A is more statistically
relevant as a large sample size is attributed to less mean deviation. A power calculation has
been carried out in both of the articles, which has been found to have beneficial impacts in
terms of minimizing the occurrence of type II errors in statistics and, thus, increases the
reliability of the findings procured (Malterud, Siersma and Guassora, 2016). Studies have
suggested that a large sample size contributes to better reliability of empirical results
(Marshall et al. 2013). Therefore, a large sample size, in the case of Article A, argues in
favour of increased reliability of the study outcomes because of statistical rigour. Thus, it is
evident that better sample handling has been carried out for Article A, in contrast to Article
B.
Ethics
The success of any research is dependent on ethical and legal abidance being
maintained throughout the research procedure. Following the ethical and legal guidelines in
research is of paramount importance, as violations in this respect might have negative
repercussions. Researchers need to be extremely cautious in fulfilling the ethical and legal
propriety normally associated with any research to preserve the clarity and transparency

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regarding theresearch methodology (Denzin and Giardina2016). On reviewing the content of
both articles, it is apparent that no breach of ethical or legal standards has occurred as all the
formal procedures have been followed diligently. For Article A, it is mentioned that written
authorization from the competent authority has been obtained. The participants were made
aware of the study’s purpose and voluntary participation was ensured. Efforts were taken to
maintain the confidentiality of the data obtained. All the ethical virtues were maintained as
proposed in the appropriate guidelines. For Article B, it is stated that informed consent was
sought from the study participants prior to randomization, while the entire study was
approved by the Institutional Review Board in alliance with the protocols relevant to human
subjects (Ippoliti 2015). However, no information regarding the anonymity or confidentiality
of the data retrieved has been mentioned in the study, which decreases the reliability and
authenticity of the study undertaken. Thus, it is clear that Article A has followed more
stringent ethical regulationsthan Article B has.
Pilot Study
Prior to undertaking a full-length study to provide an insight into the topic of interest,
a pilot study is often conducted. A pilot study is normally comprised of a small-scale
preliminary study that is generally pursued to gauge the feasibility of the proposed study
(Watt-Watson et al. 2016). The time, cost and adverse outcomes that might appear in due
course are understood by virtue of this study. Statistical variability is also assessed and
prediction of an appropriate sample size is also possible through conducting a pilot study
(Zainal 2017). However, in the given context, no such efforts have been undertaken for either
Article A or Article B. Therefore, it may be considered that the variability in the results for
both the studies might be difficult to address as no pilot study has been carried out to measure
the applicability of the research based on the chosen sample. Research being conducted on a
small scale would have provided benefits in terms of interpreting the results in a more

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unbiased manner and the potential limitations that might hinder the study’s progress and
outcomes could have been avoided.
Results
The accurate representation of study results is essential from a research perspective as
it offers a broader overview of the topic in a distinct and comprehensive manner. The
interpretation of the collected data is crucial as it aims to provide a sound depiction of the
topic under investigation (Jackson 2015). For Article A, the tables act as the representation of
the data accumulated in course of the research procedure. A total of 7 tables have been
incorporated, which increase the visibility of the results, thereby making it easier for the
reader to understand the implications. Rigorous statistical analysis, consisting of the
Student’s t-test, the chi-square testand Fisher’s exact tests, alongside multiple linear
regressions, was carried out to interpret the data in a meaningful way (De Winter 2013). All
statistical computations were supported by the level of significance, or the p value, which
helped to measure the presence of statistical significance in the data when compared between
the two groups. On the contrary, the number of tables that appeared in Article B was much
lower and there was only one statistical operation, comprised of the independent sample t-
test. Thus, it might be said that, owing to the enhanced statistical rigour maintained in the
case of Article A, the results obtained are much stronger in comparison to the results
presented in Article B (Polit 2013).
Recommendations and Conclusion
Article A has clearly acknowledged the strengths and limitations associated with the
study, thereby adding to its authenticity and the plausibility of the results. In alliance with the
results presented, the conclusion is self-explanatory and holds promise for future
implications. According to the results, preoperative education, as offered by nursing

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practitioners, is capable of reducing anxiety and postoperative complications for patients
undergoing cardiac surgery (Guo, East and Arthur 2012). However, although the implications
for practice are well discussed in the article, it did not account for any positive impact on
reducing the duration of stay. Furthermore, in Article B, it was revealed that preoperative
nursing visits have the potential to mitigate the levels of preoperative anxiety, in addition to
postoperative complications, in patients undergoing laparoscopic cholecystectomy. The study
limitations were well presented; however, no implications for future research were discussed.
Thus, the rationale of the recommendations has been indicated in both studies, corroborating
with the respective results.
Application to Practice
In the healthcare sector, it is increasingly emphasized that the healthcare practitioners
should adopt suitable strategies and interventions to guide their professional practice so that
the patients’ outcomes might be enhanced. Continuous development in practice is achieved
through participation in the decision-making process and critically reflecting on the resulting
situations (Louw et al. 2013). The healthcare professional’s experiences, encompassing the
nurses, medical practitioners and other healthcare workers, are helpful in facilitating the
emergence of a framework that favours evidence-based learning (Teunissen 2015). Hence, it
is imperative that the healthcare practitioners should be able to evaluate and acknowledge the
criticality of the articles in order to gain a proper understanding of the topic. In contemporary
nursing, critical reflection and thinking are considered to be crucial elements in guiding
professional practice and that they pave the way for innovation and the emergence of
competence in their professional pursuit. Moreover, the most rational and appropriate

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judgments might be rationalised through catering to the situational demands based on
prudence and pragmatism (Sims, Hewitt and Harris 2015).
Both articles have provided significant insights into the impact of preoperative
nursing education and visits in ameliorating anxiety and other postoperative complications in
patients who have undergone cardiac surgery and laparoscopic cholecystectomy. The articles’
findings are of significance in clinical practice as they hold the scope of transforming the
situation relevant to the patients concerned. However, the active engagement and
participation of all the members of the multidisciplinary healthcare team are solicited to
provide optimal outcomes with opportunities for continuous development through proper
education and training (Reeves et al. 2013).
Within the clinical setting, the implications of the research, as indicated in the articles,
might have an impact on the care given to patients, as nursing interventions prior to surgery
might offer resolutions in mitigating anxiety and postoperative complications.

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References
Attias, S., Boker, L.K., Arnon, Z., Ben-Arye, E., Bar'am, A., Sroka, G., Matter, I., Somri, M.
and Schiff, E., 2016. Effectiveness of integrating individualized and generic complementary
medicine treatments with standard care versus standard care alone for reducing preoperative
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Ettema, R.G., Van Koeven, H., Peelen, L.M., Kalkman, C.J. and Schuurmans, M.J., 2014.
Preadmission interventions to prevent postoperative complications in older cardiac surgery
patients: a systematic review. International journal of nursing studies, 51(2), pp.251-260.
Guida, P., Mastro, F., Scrascia, G., Whitlock, R. and Paparella, D., 2014. Performance of the
European System for Cardiac Operative Risk Evaluation II: a meta-analysis of 22 studies
involving 145,592 cardiac surgery procedures. The Journal of thoracic and cardiovascular
surgery, 148(6), pp.3049-3057.
Guo, P., East, L. and Arthur, A., 2012. A preoperative education intervention to reduce
anxiety and improve recovery among Chinese cardiac patients: a randomized controlled
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pp.447-458.
LoBiondo-Wood, G., Haber, J., Cameron, C. and Singh, M., 2014. Nursing Research in
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Sadati, L., Pazouki, A., Mehdizadeh, A., Shoar, S., Tamannaie, Z. and Chaichian, S., 2013.
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in candidates for laparoscopic cholecystectomy: a randomized clinical trial. Scandinavian
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