The effect of electronic video training and preangiography nursing education on anxiety and physiological parameters of patients undergoing coronary angiography

Abstract

BACKGROUND:

Noncommunicable diseases include cardiovascular diseases. One of the methods that is used as a definitive standard method for diagnosing coronary artery disease is angiography. One of the complications of angiography is anxiety. The aim of this study was to investigate the effect of electronic video training and preangiography nursing education on anxiety and physiological parameters of patients undergoing coronary angiography.

MATERIALS AND METHODS:

This quasiexperimental study was performed on 60 patients undergoing coronary angiography in two groups of educational hospital of Shahrekord in 2020. Conventional sampling was performed, and samples were randomly assigned to the intervention and control groups. Electronic video teaching method and nursing education were performed in the intervention group. Data collected and compared using demographic and Spielberger anxiety questionnaire and measuring physiological parameters. The data were analyzed using SPSS 21 with descriptive analytic tests.

RESULTS:

The results of this study showed that after intervention, the variables of blood pressure, respiration rate, and heart rate were significantly different in the intervention and control groups (P </001). In addition, the comparison of anxiety levels in two groups after intervention showed that patients in the intervention group have less covert and overt anxiety compared to the control group (P </001).

CONCLUSION:

Both electronic video training and preangiography nursing education indicate positive effects on anxiety of patients before angiography; therefore, these interventions are recommended to improve quality of nursing care and patient education before angiography.

Introduction

The prevalence of noncommunicable diseases is increasing worldwide.[1] Among these diseases cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke are the leading cause of global mortality and a major contributor to disability. Cardiovascular diseases remain the leading cause of disease burden in the world. The number of CVD deaths steadily increased from 12.1 million in 1990, reaching 18.6 million in 2019.[2] Iran, as a developing country by 2050, will have a high proportion of old citizens (WHO), so policymakers will have to face multimorbidity as a global challenge in the near future.[3] Cardiovascular diseases led to 46% of all deaths and 20%–23% of the burden of disease in Iran.[4]

Due to the prevalence of coronary artery disease, several tests are used to diagnose these diseases, one of which is used as a definitive, and gold standard method for diagnosing coronary artery disease is angiography.[5] Coronary angiography is the most common method for the diagnosis of CAD. Coronary angiography means radiographic observation of coronary arteries after contrast injection, which is an invasive procedure.[6] These procedures were first performed in 1929 by Werner Frossmann and have made significant progress to date. Cardiac and oxygen levels in different parts of the heart and cardiac output are possible with it.[7]

Today, more than one million individuals annually in the United States of America are undergoing cardiac catheterization for diagnosis and treatment. According to the latest information presented by American Heart Association, one million patients in the United States undergo cardiac invasive and diagnostic tests annually (access). In Iran, about 16 to 18 thousand cases of angiography are performed annually.[8]

Coronary angiography is a definitive diagnostic evaluation for coronary artery disease and valvar disease.[9] Because of the invasive nature of the angioplasty, it is a stressful situation in the patients lives.[10] Other complications of this procedure include fatigue, muscle weakness, palpitations, chest pain, headache, sweating, and dilated pupils.[11] According to research, more than 82% of patients suffer from fear and anxiety before coronary angiography.[12] Anxiety and depression are important factors that can effect on physical aspects of quality of life in pectoris angina and other chronic diseases.[13] However, health care providers think that this method is less invasive than surgery, and patients experience less anxiety, so they need less intervention and training.[14]

Waiting time for angiography, worry about the procedure, results of diagnosis, and lack of knowledge about angiography have caused most patients admitted to angiography to have fear and anxiety.[10] Unfamiliarity with the treatment environment and advanced medical equipment has been reported as the other cause of this anxiety.[15] Fear and anxiety before and during the intervention increase myocardial oxygen demand and lead to ischemic pain, which in turn puts more pressure on the heart, and causes physiological complications such as increased heart rate, cardiac output, and respiratory rate. Eventually, angiography technique will fail and make it difficult to definitively diagnose the disease and may have side effects such as dysrhythmia, spasm, or coronary artery rupture.[16] High levels of anxiety cause distress to patients and their families and disrupt patients’ cooperation during this procedure.[17] Patient’s knowledge may decrease their psychological problems and also promote the patients and nurses’ satisfaction, comfort, and tolerance related to an invasive procedure. One of the ways to increase awareness in patients undergoing invasive procedures is education through film.[18] Film combines visual and auditory information to increase patient awareness and reduce anxiety. It is effective in easy understanding and storage of information in patients.[19] The verbal information by nurses and physicians is the common routine for patient’s education before invasive procedure in many hospitals in Iran, but it has some deficient, such as require significant amount of time. Also, the preferences of learners have changed, and there is no reason to stay stuck on outdated learning methods. Using videos in training program also ensures higher information retention, as it requires learners to utilize more than one sense in the learning process.[20]

By using anxiety control methods, nurses make every effort to reduce patients’ physical and psychological stress.[21] Furthermore, comparison of the effect of video information vs. verbal information on the levels of comfort, satisfaction, tolerance, and hemodynamic parameters (heart rate and blood pressure) has not been evaluated yet. Hence, given that decrease of anxiety and stress is among nursing cares, and regarding the high prevalence of coronary angiography and importance of anxiety on treatment outcomes, this study aimed to determine the effect of video training and preangiography nursing education on anxiety and physiological parameters in patients undergoing coronary angiography.

Material and Methods

Study design and setting

The quasiexperimental study was performed at educational hospital of Shahrekord. Research sample consisted of persons who experienced coronary angiography for the first time, without right heart catheterization. Inclusion criteria were patients should not have undergone other invasive procedures such as echocardiography through esophagus before angiography and have not suffered from valvar heart disease and not have a disease with critical condition. Also, they should not use sedatives and psychotropic drugs or any antianxiety medication before angiography.

Study participants and Sampling

Sampling was done in the available form, and the samples were assigned to the intervention and control groups randomly. To prevent bias, patients of two groups do not have contact to each other and samples of the intervention group were collected for two weeks, and then after a period of one week, again for two weeks in the control group, samples were taken. The sample size was calculated based on Uzun et al. study[22] with a 95% confidence level and 90% statistical power, was obtained as 25 people for each group. To ensure the sample size’s adequacy, we selected 30 people in each group and a total of 60 people as a sample size.

Data collection tool and technique

Data gathering was through demographic and Spielberger Anxiety Questionnaire. The Spielberger Anxiety Questionnaire section consists of two separate sections for examining covert anxiety (including 20 questions and questions in four-choice, very low, low, high, and very high) and in the section on overt anxiety, including 20 questions and four-choice questions, almost to never). Each overt and covert anxiety option is given a score of one to four. The validity and reliability of the Spielberger questionnaire have been investigated in several studies. Rabiee et al. and Roohy et al. reported the reliability of the Spielberger test as 89% and 90%, respectively.[21,23]

The content of the educational video is collected from selected text books, journal, and reference content relevant to angiography. Also, showing calming images for patients using a virtual reality camera for 5 minutes and the stages during which the patient encounters at the beginning and then continues to work, and the duration of angiography and subsequent care, is shown to the patient. Complications of angiography care before, during, and immediately after angiography and after discharge of patients are provided, and in case of anxiety, the necessary training is provided. The video also consisted of showing calming images for patients using a virtual reality camera for 5 minutes.[24]

For the nursing intervention part, several methods were used to decrease patient anxiety. In this method, patient trusted to health care team and reducing anxiety is recommended according to the patient’s condition and level of understanding. The researcher, based on the studies performed and with the patient’s participation, plans and necessary trainings are designed based on nursing diagnoses and necessary measures based on the patient’s desire and readiness. These measures include one or more ways to reduce anxiety (use of deep breathing, distraction, deviation of thought, repetition of religious words).

The researcher instructs the patient several times and asks him/her to perform these measures independently. On the day of angiography, the patient is transferred to the angiography room and after meet the members of the treatment team, the researcher stays with him until the treatment is relieved, but in relation to control group, only receive routine intervention. In both groups, questionnaire completed before and after intervention; also the researcher monitors the patient’s vital signs (blood pressure, heart rate, and respiration rate) three times at 5-minute intervals.

Statistical analysis

SPSS21 software was used to analyze data. Frequency and percentage and mean and standard deviation (SD) were used to describe data for categorical and continuous variables, respectively. Based on the Kolmogorov–Smirnov test, none of the scores of PSQI dimensions had normal distribution; hence, nonparametric tests were carried out. Independent t-test and Chi-square test were used to compare the two groups in terms of demographic characteristics. The paired t-test was used to compare the level of anxiety and hemodynamic variables before and after the intervention in both groups, and the independent t-test was used to compare the level of anxiety and hemodynamic variables between the two groups.

Ethical consideration

Ethics Committee of Shahrekord University of Medical Sciences approved the study (approval code: Ethics IR. SKUMS.REC1398.42). Informed consent was obtained from all participants. All the data obtained from the study are kept secure and confidential. After the end of the interventions and measurement of variables in the posttest phase, the application presented to the experimental group was also provided to the control group.

Results

In this study, 72 candidates referred to educational Hospital of Shahrekord enrolled in study, and data of 60 patients were analyzed. The flowchart of the patients included in the study is shown in Figure 1.

Figure 1.

Flow of patients through the trial

Findings about demographic characteristics showed that 70% of the samples in intervention group and 66.6% in control group were males and mean age of participants in the intervention group was 56.65 ± 8.16 and in the control group was 51.96 ± 8.10. There were no significant differences between the two groups in terms of demographic characteristics [Table 1].

Table 1.

Patients’ demographic characteristics in each group

Variable				Intervention group (n=30)		Control group (n=30)		P
Gender [n (%)]		Female		9 (30)		10 (33.7)		0.658
		Male		21 (70)		20 (66.6)		0.478
Marital status [n (%)]		Married		26 (86.6		27 (90)		0.568
		Single		4 (13.3)		3 (10)		0.421
Age (mean±SD)				50.56±8.16		51-.96±8.10		0.456
Education [n (%)]		Illiterate		19 (63.3)		19 (63.3)		0.651
		Diploma		8 (26.6)		7 (23.3)		0.329
		Bachelor degree		3 (10)		4 (13.3)		0.742

Table 2 shows the description of physiological parameters score in studied patients. The independent sample t-test results showed that there were no statistically significant differences with regard in blood pressure, respiratory rate, and pulse between two groups before intervention (P > 0.05). However, these differences were significant between two groups after intervention (P < 0.05 for all comparisons).

Table 2.

Comparison of physiological parameters score before and after intervention in two groups

Variable		Time		Intervention group		Control group		P
Blood pressure		Before		124.25±9.67		126.18±4.84		0.48
		After		109.13±0.66		124.21±5.41		0.04
Respiratory rate		Before		26.12±5.85		24.03±5.3		0.14
		After		20.01±8.75		23.79±9.74		0.03
Pulse		Before		80.19±9.56		79.21±8.97		0.18
		After		70.16±6.94		78.73±8.79		0.05

The mean overt anxiety score before the intervention in the control group was 43.00 ± 9.82 and 44.53 ± 7.64 in the intervention group. However, it was 37.13 ± 4.63 in the intervention group and 43.03 ± 3.90 in the control group. The independent sample t-test results showed that the anxiety scores between two groups have no significant difference before intervention, but after intervention, the difference was significant. The same results were showed for covert anxiety that reported in Table 3.

Table 3.

Comparison of anxiety level before and after intervention in two groups

Variable		Time		Intervention group		Control group		P
overt anxiety		Before		44.53±7.64		43.00±9.82		0.267
		After		37.13±4.63		43.03±3.90		0.003
		P		0<001		0.95
Covert anxiety		Before		43.03±5.81		44.70±7.52		0.48
		After		39.25±3.23		43.03±3.90		0.02
				0.04		0.87

Discussion

The aim of this study was to investigate the effect of electronic video training and preangiographic nursing care on anxiety and physiological parameters in patients undergoing coronary angiography. The results showed that the mean score of overt and covert anxiety of patients significantly decreased after watching the educational video compared to the control group. Also, this intervention behind the nursing education can put positive impact on physiological parameters and can decrease them. Most hospitalized patients experience some degree of anxiety before coronary angiography[25]; therefore, using nonpharmacological intervention can be very helpful for reducing anxiety.[16] The findings indicated that the level of anxiety before intervention was higher in both groups that these results are consisted with Tahmasbi et al.[26] and Uzun et al.[22] which conclude that the patients before angiography suffer from high anxiety. Nurses have an important role for supporting patient and giving information to patients to reduce their anxiety and improve the quality of treatment.[27] In the current study, nursing education and care along with electronic video increase the patient information and have positive effects to reduce the patients’ anxiety.

The results of present study are consistent with the results of Saleh Moghadam’s study. He showed in his study that after the video education intervention, the mean score of overt and covert anxiety in patients in the intervention group was significantly reduced compared to the control group.[28] Also, in the study of Shahmari et al.,[29] they performed interventions to investigate the effect of video education in the native language on the level of anxiety of patients undergoing angiography. The results of their study showed that education through film has reduced the level of anxiety of patients in the intervention group compared to the control group. The study by Hanifi et al.[10] aimed at evaluating the effect of the familiarization program on hemodynamic variables in patients undergoing cardiac catheterization showed that the hemodynamic variables of patients in the experimental group who underwent the familiarization program were often lower than the control group due to less anxiety.

All of these results show the importance of using nonpharmacological intervention for reducing anxiety. Emami–Sigaroudi studied the effect of aromatherapy with lavender and damask rose on sleep quality in patients undergoing coronary artery bypass graft surgery, and the results show that using both these methods indicated positive effects on sleep quality of the CABG patients.[30]

Some studies compare the effectiveness of video-based multimedia training versus face-to-face training. For example, Karimian evaluates the effect of video-based multimedia training on knowledge, attitude, and performance in breast self-examination. They conclude that both video-based multimedia and face-to-face training methods significantly increased the participant’s knowledge, attitude, and skills about breast self-examination. In subcategories, the results showed that the face-to-face training improved negligence and forgetfulness in applying BSE and correcting or modifying the previous knowledge around the issue.[31]

Although these studies show the positive effect of nursing intervention to reduce anxiety, the results of the study by Talaei et al.[32] showed that familiarizing patients with the operating room environment did not reduce their level of anxiety. This contradiction in the results seems to be due to the reasons that the measurement of anxiety has been done at the time of preparing the patient for surgery, which is currently the peak of patients’ anxiety. The result of the study by Gökçe et al. indicated that the music therapy does not reduce anxiety and pain in patients undergoing angiography. The reason for this can be the longtime of music therapy from before the start of angiography to after the end of this procedure.[20]

Also, in contrast with other reported study, Gholamizadeh reported that there was no significant difference between the mean anxiety scores before and after intervention in the both groups. Their study aimed to investigate the impact of multimedia education program on the level of anxiety in patients admitted to chemotherapy wards. Authors conclude that the condition and deterioration of the patients as well as the criterion for entering the study were factors that might be effective in these results.[33]

In summary, the data obtained in this study constitute an evidence-based and important source of information for future studies and clinical practices. This research confirms the effect of this method as a nonpharmacological solution on patient satisfaction and anxiety.

Limitation and recommendation

As one of the limitations of this study, the required data were gathered via self-report data collection; therefore, it is necessary to conduct more comprehensive studies that evaluate nurses with more objective methods. Also, low sample size was another limitation, so the authors suggest that multicentral studies be conducted with a high number of participants. Authors recommend that education protocols should be established to reduce the state trait anxiety levels of the patients who are scheduled for invasive procedures, to plan the education before, during, and after.

Conclusion

Electronic video training and preangiography nursing education had impressive impact on anxiety and physiological parameters in patients undergoing coronary angiography. Also, the use of these methods causes reduction in anxiety and physiological parameters in patients undergoing coronary angiography. It is recommended to use video training and nursing education with advantages of this method such as safe, easy, inexpensive, nonpharmacological therapy, and noninvasive approach application to reduce patients’ anxiety before conducting diagnostic and invasive procedures.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Shahrekord University of Medical Sciences and was funded by the Vice Chancellor for Research of Shahrekord University of Medical Sciences All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (ethics code of IR.SUMS.REC.1398.142) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.