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Pre-operative Education to Reduce Anxiety: Literature Review

Background: Surgical procedure is one of the stressors that can end up with psychological disorders such as anxiety. Anxiety can lead to increased blood pressure and the risk of bleeding. Receiving detailed information on the surgical procedure is a patient's right. The information provided is expected to reduce patient anxiety and foster good relations between health workers and patients. Considering the importance of this step, we study the effect of pre-operative information before surgical procedures based on the published literature. This study aimed to summarize the previous research that elaborates on the relationship between education pre-operative and anxiety. Method: A literature review was used in this study. Google Scholar, PubMed, and ProQuest databases were chosen as data sources. We sough article published during 2016-2021. In total, 450 articles were screened using inclusion and exclusion criteria for analysis. Results: Eight articles reported that there was an effect of education on patient anxiety. Conclusion: Providing education is an effective approach to reduce patient anxiety.


INTRODUCTION
Surgery is an invasive treatment action that displays body parts, makes an incision, then repairs and closes the wound with suturing (1). Surgery is a high-risk action that requires an operating room to minimize infection during surgery (2). The stages of surgery start from preoperative, intraoperative, and post-operative. Pre-operative preparation is one of the phases that determines the success of the surgery. Pre-operative preparation starts from the patient entering the treatment room until the patient arrives in the operating room (3). The readiness of the patient includes physical and mental readiness. Physical readiness examines physical health, nutritional, fluid, and electrolyte balance, gastric and colonic hygiene, personal hygiene, and bladder emptying. Mental/psychic pre-operation readiness is psychological readiness in dealing with surgery. Patients who do not have mental readiness will experience anxiety before surgery (4). Anxiety also has medical risks such as increased breathing, vasoconstriction of blood vessels, increased blood pressure which causes surgical bleeding. Several reasons can cause pre-operative anxiety, including fear of physical changes, uncertainty, surgery pain, death risk (5).
The prevalence of anxiety disorder worldwide varies 2.5 to 7 percent by country (6). It is estimated that globally 284 million people experienced an anxiety disorder in 2017. About 63 percent (179 million) are women, and 105 million are men. According to a survey in the United States, 18.1% or about 42 million people live with anxiety (7). In Indonesia, the results of Basic Health Research 2018 show that 6,2% of people aged 15-24 years and 15.941-157.695 people in Indonesia experience anxiety (8). Causes of anxiety such as potential stressors, knowledge, social support, environmental adaptation process, and operating experience influence patient anxiety (9). To make s surgical procedure successful need psychology preparations cover the patients. Patients need to be educated, and all treatment alternatives should be explained (10). Mental or psychological support is required for patients who experience anxiety by providing information about the surgery to be conducted. Providing details on operating time, information on the operation site's situation or things experienced during the surgical procedure can reduce anxiety and make the patient more prepared to undergo surgical procedures. The role of the nurse as an advisor is vital to perform these actions (4). Accordingly, we want to know the effect of pre-surgery education on patient anxiety patients. This paper aims to summarize the previous research that elaborates on the relationship between education pre-operative and anxiety.

Search Strategy
This literature study searched research articles in reputable databases such as PubMed, ProQuest, and Google Scholar. A set of keywords, namely "education pre-surgery," "patient anxiety," "effect of education," and "effect of pre-surgery education," were used to search for articles. Title, keywords, abstracts, language, year of published and method were screened for the first step for relevant articles. In the second step, we screened the article according to the relevant variable, and last we selected the article based on the full-text availability. Figure 1 shows the flow chart of the article review employed in this paper.

Inclusion and Exclusion Criteria
In our analysis, the article should fulfill the following inclusion criteria: article published in English or Indonesian, the article discussed Indonesia or globally, published 2016-2021, abstract and the full text is freely accessible, the research sample was elective surgery patient (planned surgery). While the exclusion criteria were qualitative research, the article did not mention the instrument used for measuring anxiety, study in the emergency setting, full text not freely available.

RESULTS
Based on the results of a literature search, eight articles were found that matched the criteria. The research article identifies patient education and anxiety in various hospitals in Indonesia and outside Indonesia. Eight articles were published as review articles, five from Indonesia, and three journals were published outside Indonesia (Polandia, Iran, and Taiwan). The most significant number of samples used was 213, and the smallest number of samples was 15. A research instrument is a tool used to collect or obtain data in conducting research. A total of 3 articles used State-Trait Anxiety Inventory (STAI) anxiety instrument, three articles used the HARS (Hamilton Anxiety Rating Scale) instrument, 1 article used Zung Self-Rating Anxiety Scale (SAS/ZRAS), and 1 article used T-MAS. There are differences in the research design used, 6 studies using quasi-experiments and 2 studies using pre-experiments. All articles explain that educating and providing information to patients can reduce patient anxiety. We found that five articles using Wilcoxon signedrank test, and three studies using the T-test for analysis purposes. All articles explained that educating and providing information to patients before getting an operation can reduce patient anxiety. In the experiment group, the level of state anxiety 48 hours post-surgery was significantly lower, <7/10 sten to the procedure. In the control group, the level of post-operative anxiety was substantially higher ³ 7 sten to the procedure. So, information support psychologists before thoracic surgery reduce post-operative anxiety levels.

DISCUSSION
The education program is vital in the pre-operative period. It is one of the alternative programs that can reduce patient anxiety (11). Anxiety mostly comes from operation effects; therefore, increasing patients' pre-operative education can relieve their anxiety and stabilize their emotions (12). Mental intervention in pre-operative patients can relax, promote the operation's success, improve the recovery and finally improve patients and their families (9).
According to the analysis, almost all of the articles report that education effectively reduces anxiety before surgery. In Madiun regional hospital, the study followed the research expectations; health education can decrease anxiety patients. Communication is established between health workers and patients, so health education makes the patient feel cared (13).
In coronary artery bypass grafting, patients with intervention had significantly lower anxiety than other groups without orientation. The reason is that the patients who participated in orientation education before surgery became familiar with operating room conditions, which helps them adapt to the new environment and feel secure. Health education had positive effects on anxiety in coronary artery bypass grafting candidates. It can be used effective technique for relieving anxiety (14). Primary surgery patients show that health education with leaflets can reduce anxiety. Health education intervention was succeeding. A patient who experienced severe anxiety became anxiety mildly, felt moderate anxiety became mild anxiety and felt mild anxiety became less anxiety (15).
At the thoracic surgery, the previous study showed that the patient whose preparation for surgery needs the information to support psychology. These results advocated training for the nurse to provide individually tailored information support to patients before thoraces surgery. Patients with elevated levels of trait anxiety should be identified before surgery, and offers a dedicated educational program to prepare them for the surgical procedure adequately tho their emotional status (16). Previous research mentioned that health education affects the anxiety of hernia surgery patients. Health education is one of the nonmedical therapies that reduce pre-operative anxiety. Education intervention is an additional intervention, especially for nurses, in reducing patient anxiety (17). According to Masriani's research, the result showed an effect of health education on the anxiety level of pre-cardiac catheterization patients at the hearth service installation in Syaiful Anwar hospital. Health education is an effort to change the respondent's behavior, including change in thinking and acting to reduce anxiety. The research found an anxiety decrease after received health education (18).
Rizki found that there was an effect of health education with leaflet media. The intervention group has been shown to decrease anxiety compared to before the health education was given. The provision of health education using leaflet media can be used as an alternative for presenting information to prepare patients before surgery to decrease anxiety levels (19). Hence, Hsueh stated that education is necessary for patients with a certain characteristic. Medical staff may design multiple healthcare programs for a patient with different characteristics. This study showed that multimedia health information about colonoscopy procedures effectively reduces anxiety and pain in colonoscopy patients (20).

CONCLUSION
Anxiety is an unpleasant psychological condition caused by the surgery that the patient will experience. Non-pharmacological interventions with comprehensive and structured education can be applied as an intervention to reduce patient anxiety. Providing education and adequate information is effective in reducing patient anxiety.