Effectiveness of nursing care intervention for alleviation of anxiety, pain and functional improvement amongst patients undergoing ambulatory surgery: A systematic review and meta-analysis

Background & Objective: Ambulatory surgeries are increasingly prevalent, yet they often result in postoperative pain and anxiety, impacting patient recovery and satisfaction. Effective management of these complications is crucial, and nursing care interventions have been proposed as a potential solution. This meta-analysis aims to evaluate the effectiveness of nursing care interventions in reducing pain and anxiety and improving functional status among patients undergoing ambulatory surgery. Methods: A comprehensive literature search done on December 2023 of PubMed Central, MEDLINE, Scopus, Google Scholar, Cochrane library, CINAHL, and trial registries was done for studies from inception till November 2023, that met predefined eligibility criteria. Standardized mean differences (SMD) for continuous outcomes and odds ratios (OR) for binary outcomes were calculated using a random-effects inverse-variance model. Sensitivity analysis was performed to assess the robustness of the findings, and heterogeneity was evaluated using I² statistics. Results: Nine studies were included. Pooled analysis revealed a significant reduction in pain (SMD = -1.224, 95% CI: -2.445 to -0.003, p=0.049) and anxiety (SMD = -1.53, 95% CI: -2.77 to -0.28, p=0.016) among patients receiving nursing care interventions, with substantial heterogeneity (I² = 98.2% for pain and 96.6% for anxiety). However, no significant improvement was observed in the functional status (SMD = -0.28, 95% CI: -0.35 to 0.91, p=0.385). Sensitivity analysis confirmed the stability of these results. Conclusion: Nursing care interventions are effective in significantly reducing pain and anxiety in patients undergoing ambulatory surgery. However, their impact on improving functional status remains inconclusive. Our findings underscore the importance of integrating nursing care into postoperative management protocols in ambulatory surgeries and highlight areas for future research, particularly concerning functional recovery.


INTRODUCTION
In recent years, the landscape of surgical procedures has evolved significantly, with ambulatory surgery becoming increasingly prevalent.This shift towards outpatient surgical settings is driven by advances in medical technology, anaesthesia, and a focus on costeffectiveness and patient-centred care. 1 Nevertheless, patients undergoing outpatient surgery frequently encounter postoperative challenges, such as anxiety and pain 2,3 which are not only detrimental to the immediate recovery but can also have lasting impacts on the overall health and well-being of the patients.
0][11] While there is an understanding that pain is not merely a physical sensation but is also influenced by psychological and social factors, 12 there is a noticeable gap in comprehensive analyses, particularly in the context of ambulatory surgery.
This meta-analysis aims to summarize the existing data and to evaluate the effectiveness of various nursing care interventions in managing anxiety, pain and functional status in patients undergoing ambulatory surgery.

METHODS
PubMed Central, MEDLINE, Scopus, Google Scholar, Cochrane library, CINAHL, trial registries were searched for relevant studies from inception till November 2023, with no language restrictions.Additionally, reference list of retrieved studies was manually searched.Search terms: "Daycare Surgery", "Ambulatory Surgery", "Outpatient Surgery", "Nurses", "Nursing", "Randomized Controlled Trial", "Nursing Care" along with Boolean Operators "AND", "OR" and "NOT" Study selection: Two researchers independently conducted literature searches, screening titles, abstracts, and keywords.Abstracts and full texts of relevant papers were further screened to select studies meeting the review's inclusion criteria.Any selection disagreements were resolved through consensus.The review was reported using the PRISMA checklist, ensuring adherence to established standards. 13The study was registered at PROSPERO, No. CRD42023494270.

Inclusion criteria:
• Studies performed in adult participants undergoing day (ambulatory, outpatient) surgery which does not require overnight stay postoperatively.

• Top of Form • Bottom of Form
Data collection: The primary investigator meticulously gathered key characteristics, such as extraction date, study title, and authors, study design, participant demographics, and setting, participant count in each arm, baseline and endline measures, and inclusion/ exclusion criteria, specifics of intervention and comparison groups, and follow-up duration, primary and secondary outcomes, timing of assessments, and other quality-assessment details.The primary investigator systematically compiled this data, and the accuracy was further verified by discussion of the investigators.Risk of bias assessment: Two investigators were responsible for assessing the quality of the included studies using the Cochrane risk of bias (RoB-2) tool for RCTs 14 and risk of bias in non-randomized studies (ROBINS-I) tool 15 for non-RCTs.Based on the various parameters within these tools, risk of bias was graded as low, high or some concerns.Statistical analysis: STATA version 14.2.was used for analysis.For continuous outcomes, means, standard deviations, and sample sizes from both groups were used to calculate the standardized mean difference (SMD) with a 95% confidence interval (CI).Binary outcomes were analysed using event frequencies in both arms, deriving odds ratios (OR) with a 95% CI.The random-effects model, employing the inverse variance method, was used. 16Assessment of heterogeneity was  done through chi-square and I 2 statistics. 16Sensitivity analysis identified the impact of individual studies on overall estimates.P<0.05 was considered statistically significant.

RESULTS
A total of 2,062 records were identified by the search across five databases.After screening and assessing for eligibility, 79 reports were excluded for not meeting the criteria related to day care surgery, nursing intervention specificity, or data availability.Nine studies were included in the analysis (Fig. 1).

Effect of nursing care intervention on patient-reported outcomes:
Pain: Pain was reported in five studies with a total of 852 participants.Pooled SMD was -1.224, with 95%CI of -2.445 to -0.003, and p-value of 0.049, indicating statistically significant reduction in pain score due to nursing care intervention (Fig. 2A).The analysis exhibited substantial heterogeneity, as reflected by an I² statistic of 98.2%, suggesting considerable  variability among the included studies.Studies have also reported the difference in terms of patients reporting pain score (visual analog scale [VAS] score > 3) as dichotomous variable.This analysis revealed a pooled OR of 0.54 (95%CI: 0.38 to 0.78; p=0.001) with I² statistic of 0% (Fig. 2B).This indicates that ambulatory surgery patients receiving nursing care intervention had substantially lower odds of having VAS score > 3 compared to patients in standard care.
Anxiety: Anxiety was assessed in four studies with 387 participants.Pooled SMD was -1.53, with 95%CI of -2.77 to -0.28, and p-value of 0.016, indicating statistically significant reduction in anxiety score in patients who got nursing care intervention (Fig. 3).The analysis exhibited substantial heterogeneity (I² = 96.6%)among the included studies.Functional status: Pooled analysis of three studies, reporting data of the functional status, with 323 participants, showed SMD of -0.28, with 95%CI of -0.35 to 0.91, and p-value of 0.385, indicating no statistical significance (Fig. 4).The analysis exhibited substantial heterogeneity, with I² statistic of 87.5%, suggesting substantial variability between the studies.Sensitivity analysis: Sensitivity or leave one out analysis revealed no substantial variations in the magnitude or direction of any outcomes, indicating the absence of single-study effects on the results.

DISCUSSION
The current meta-analysis critically evaluated the impact of nursing care interventions on patientreported outcomes in ambulatory surgery settings.Our findings revealed significant reductions in both   pain and anxiety levels in patients receiving these interventions, while no statistically significant change was observed in functional status.
Our analysis indicated a substantial reduction in pain scores (SMD = -1.224), a result corroborated by the lower rates of patients reporting higher pain scores (VAS > 3) in the intervention group.Similarly, anxiety levels showed a significant decrease (SMD = -1.53),associated with the nursing care interventions.These results align with the growing body of evidence supporting the efficacy of nursing interventions in managing postoperative discomfort and stress for various types of surgeries. 23,24he observed effects of nursing interventions on pain and anxiety are consistent with earlier reports emphasizing the role of personalized nursing care in postoperative recovery, such as studies by Pereira et al. 19 and Sawhney et al. 9 However, we further extend this knowledge by aggregating data across multiple studies, thereby providing a more comprehensive understanding.The divergence in findings related to functional status highlights the complexity of postoperative recovery, indicating that factors beyond pain and anxiety might influence this outcome.
The significant reductions in pain and anxiety can be attributed to several factors inherent in nursing care.These include personalized attention, effective communication, and the implementation of evidence-based pain management strategies. 25The biopsychosocial model of care, which addresses the interplay between physical, psychological, and social factors, is likely instrumental in these outcomes. 26,27The efficacy of such interventions underscores the vital role of nursing staff in the postoperative recovery process, beyond traditional medical management.
8][19][20][21][22] Studies have suggested that while immediate postoperative outcomes, such as pain and anxiety, can be effectively managed through nursing interventions, [23][24][25][26][27] the long-term recovery of functional status may require a multidisciplinary approach that extends beyond the scope of nursing care alone. 28,29his includes physical therapy and sustained patient education, emphasizing the complexity of postoperative recovery and the multifactorial nature of functional improvement status. 30 major strength of our study lies in its comprehensive approach, and the use of meta-analysis to synthesize data from different sources.The sensitivity analysis further strengthens our findings by confirming their robustness.
Limitations: Nevertheless, our study has limitations.High heterogeneity indicates variability in study designs, interventions, and participant characteristics.Additionally, limited number of studies included in some analyses might affect the generalizability of our findings.
Our findings have significant implications for nursing practice.They reinforce the importance of nursing care interventions in managing pain and anxiety post-surgery, suggesting that such practices should be integrated into standard postoperative care protocols.
Furthermore, the results underline the need for ongoing research to optimize nursing interventions, particularly in enhancing postoperative functional recovery.Future research should also focus on exploring the specific components of nursing interventions that most effectively contribute to improved outcomes.Studies examining the impact of these interventions on different types of surgeries and patient demographics are also warranted.

CONCLUSION
This meta-analysis demonstrates that nursing care interventions significantly reduce pain and anxiety in ambulatory surgery patients, underscoring the importance of such interventions in postoperative care.However, the impact on functional status remains unclear, indicating a need for further research in this area.Our findings highlight the critical role of nursing in enhancing patient outcomes and inform future practices and studies in surgical care.

Fig. 2 :
Fig.2: Forest plot showing the effectiveness of nursing care interventions for alleviation of pain in ambulatory surgery patients.(A) pain as numerical score (B) pain as categorical variable (VAS >3).

Fig. 3 :
Fig.3: Forest plot showing the effectiveness of nursing care interventions for alleviation of anxiety in ambulatory surgery patients.

Fig. 4 :
Fig.4: Forest plot showing the effectiveness of nursing care interventions for improvement of functional status in ambulatory surgery patients.

Table - I
: Characteristics of the included studies (N=9).

Characteristics of the included studies:
As summarized in Table-I, the included studies encompassed a diverse range of participants, interventions, and settings.The sample sizes varied from 40 to 292 participants per study, with a total of 1668 patients.The mean age of participants across studies ranged from 42.2 to 61 years.Nursing interventions varied from attentional focus and symptom management to predictive nursing and preoperative education.In terms of the risk of bias (Table-IIA & B), three studies were rated high, two had some concerns, and four were considered low risk of bias.