Introduction

Cardiovascular surgery, also called cardiac surgery or heart surgery, represents any surgical procedure that involves heart or blood vessels that carry blood to and from the heart [1]. These procedures are common in people who have heart disease or had a heart attack, stroke, or blood clot, and also those who are at high risk for developing these problems [2]. There are many types of heart surgery. The National Heart, Lung, and Blood Institute outline the most common coronary surgical procedures, which include Coronary Artery Bypass Grafting (CABG), heart valve repair or replacement, insertion of a pacemaker or an Implantable Cardioverter-Defibrillator (ICD), maze surgery, aneurysm repair, heart transplant, and insertion of Ventricular Assist Device (VAD) or Total Artificial Heart (TAH) [3]. CABG, also called coronary artery bypass, coronary bypass, or bypass surgery, is the most common type of heart surgery, so that more than 300,000 people have successful bypass surgery in the United States each year [4]. The high prevalence of these surgeries has many economic and medical consequences in most countries [5]. However, over a quarter of all CABG and/or VR patients are readmitted to hospitals with postoperative complications during the first three months of recovery. A possible explanation for developing postoperative complications during the recovery period is poor self-care behavior of patients [6].

Patient education is a crucial health intervention to encourage self-care behavior, but it may often lack the required effectiveness [7]. Remarkably, the dose, type, and timing of educational intervention may not be optimal in promoting self-care behaviors, which results in the onset of complications and increased hospitalizations that reduce health-related quality of life [8, 9].

The treatment team prescribes various measures that patients should perform and follow before and after heart surgery. Therefore, these patients need a comprehensive and robust education system to provide them with accurate and practical knowledge on actions they ought to undertake [8,9,10]. Nevertheless, previous studies and expert opinions indicate that despite the establishment of patient education systems, patients often do not correctly participate in the treatment and care, and also do not perform the actions required for their recovery [11]. These and similar issues are among the many challenges in this area that indicate the potential for systemic failures, which need to be addressed [12]. Numerous studies in patient training have shown that education related to patient health increases satisfaction and reduces anxiety and length of hospital stay [13, 14]. Accordingly, a thorough study of current educational systems or the development of a comprehensive system for patients after heart surgery is something that may not receive much attention in medical centers, but the need for such system is evident for these patients [10, 15].

Educational approaches are widely applied in many countries for training patients with heart surgery, and some papers have shown its clinical benefits [10, 14, 16] and positive effects on the survival of patients. The format of patient education differs depending on the degree of standardization and individualization [17, 18]. Different approaches and technologies can be used to educate patients after heart surgery. Technologies such as video resources, virtual reality-based environments, and educational media such as CDs, DVDs, and others are widespread in today's society. In addition to these materials, patients can use other sources such as electronic booklets and brochures [9, 19]. Therefore, a comprehensive study is needed to determine the effectiveness and characteristics of educational approaches or technologies used for education of patients with heart surgery.

Material and methods

Research question

- Has the use of educational approaches or technologies been effective in training patients with heart surgery?

- What are the characteristics of interventions used to educate patients with heart surgery?

Search strategy and study selection

In this study, we conducted a systematic literature review of educational approaches or technologies used for training patients with heart surgery, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist (PRISMA) [20]. Major scientific databases, including Web of Science, Medline (through PubMed), and Scopus were searched systematically, using keywords such as “patient education” and “heart surgery”. Consequentially, related articles published between January 1, 2011 and 21 May, 2022, were retrieved. After removing duplicates, titles and abstracts of retrieved articles, the remaining articles were reviewed by three authors (SR, NR and LS) independently based on inclusion criteria. Several titles and abstracts were also reviewed randomly by LS. In the next stage, full-text screening was carried out. The full texts of related citations were also retrieved and reviewed by three authors based on inclusion and exclusion criteria. Through a full-text review, the final decision was made by LS and BM if there was a disagreement between the authors in regard to the selection of eligible studies. A combination of Medical Subject Headings (MeSH) keywords and terms were used in the search strategy (Table 1).

Table 1 Keywords and search strategy for PubMed database
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Criteria used for the selection of articles

Studies with the following inclusion and exclusion criteria were included in this review.

Inclusion criteria

The inclusion criteria for the articles are presented in Fig. 1.

Fig. 1
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Inclusion criteria in this review

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Exclusion criteria

Articles were excluded if they met the following criteria:

  • Studies published in non- English language.

  • Studies that were not original research (such as book chapters, letters to the editor, reviews or meta-analysis, short briefs, reports and commentaries).

  • Studies that did not examine the impact of educational technologies or approaches on patients.

  • Studies that their full text was not available.

Data extraction

A form in Excel was designed to extract data from included articles. Some classifications were used to classify and analyze the included papers. This classification comprised of general information and specific details. General information included author’s names, publication date, country and journal’s name. Specific information included number of participants, mean age, gender, study participants, intervention group (I), comparison (C) group, study design, content of patient education and theory, applied intervention, effectiveness, main finding, and key outcome.

Data analysis

In order to describe and compare the articles’ results, a narrative synthesis was applied, but meta-analysis was not done due to the diversity of outcomes. We classified outcomes into three main categories of clinical, economical, and patient-reported outcomes. The effect of educational materials on patients with heart surgery was summarized based on three categories: Positive without statistical argument, Positive (statistically significant), No effect (not statistically significant).

Risk of bias and quality assessment

For risk of bias appraisal and quality assessment, we used The Effective Public Health Practice Project (EPHPP) tool to evaluate the quality of selected articles. This tool was preferred because of its ability to evaluate the quality of various quantitative studies related to public health issues or the use of technology in the health industry. In each study, the risk of bias was reckoned for six components; (1) selection bias; (2) study design; (3) confounders; (4) blinding; (5) data collection method; and (6) withdrawals and dropouts [21]. These six components were ranked as strong, moderate, and weak on the three-point Likert scale. Overall methodological quality is rated as weak (two or more poor ranking of individual scale), moderate (one weak individual scale rating), and strong (no weak scale rating). For bias and quality assessment, two authors (SR and NR) investigated each paper, and any disagreements were resolved by discussion with LS and MZ.

Results

Earlier searches in various scientific databases yielded 1878 studies. After duplicate removal, 1014 citations were remained, from which 921 were omitted due to their irrelevancy in the abstract and titles screening stage. After reviewing the full-text of the related citations and applying the exclusion and inclusion criteria, 29 studies were included in this systematic review. The flow diagram related to the identification of eligible articles is shown in Fig. 2. It should be noted that a summary of the key results of papers is described in Table 2 based on the predefined classification elements.

Fig. 2
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The PRISMA diagram for the records search and study selection

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Table 2 General characteristics of the included studies (N = 29)
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Study characteristics

All selected papers that met the inclusion and exclusion criteria had been published in 27 reputable journals. All the names of journals are listed in Table 3, based on their frequency and quartile. Notably, 23 (79.31%) included investigations were published in top quartile one journals. It should be noted that the oldest and newest papers had been published in 2013 and 2021, respectively. The distribution of papers based on publication year is depicted in Fig. 3. As seen in the figure, the largest number of articles (n = 7, 24.13%) had been published in 2016.

Table 3 Distribution of journals by quartile and frequencies
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Fig. 3
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The distribution of papers by publications year

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The distribution of articles based on the countries

The selected papers had been published in 14 countries. The distribution of studies based on country is shown in Fig. 4, based on the worldwide map. As it turns out, Iran and Canada had the highest frequency (n = 10, 34.48%) compared to other countries.

Fig. 4
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The distribution of papers by countries

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Distribution of papers based on sample size and type of studies

The number of participants in the studies ranged from 11 to 600 (IQR1: 57.5, median: 88, IQR3: 190). It should be noted that the study design was mostly experimental in the form of Randomized Controlled Trial (RCT), (n = 18, 62.06%). The distribution of studies based on the study design and type is shown in Table 4.

Table 4 Distribution of papers based on study design
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Distribution of papers based on type of applied materials

In the selected studies, different technologies and educational contexts had been used. The distribution of articles based on the type of applied approaches is shown in Fig. 5. As can be seen in the figure, booklet (electronic booklets), telephone and video resources had been the most widely used educational resources.

Fig. 5
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Distribution of articles based on the type of used solutions

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Effectiveness of educational interventions

The effectiveness of educational interventions on patients with heart surgery was summarized based on three categories:

  • No effect (not statistically significant)

  • Positive without statistical argument

  • Positive with statistically significant

As can be seen, in the 22 (75.86%) studies, the employed educational interventions had a statistically significant effect on key outcomes such as increasing the level of knowledge of patients, reducing the length of hospital stay, increasing the level of satisfaction of patients and their families, and so on. Notably, in six examinations (20.68%), the applied educational approaches had positive effects on above-mentioned measures without statistical argument. In one study, the educational platform provided to patients did not affect the quality of care and patients' level of knowledge. Table 5 lists the key factors along with their effectiveness.

Table 5 Effects of educational interventions on key factors
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Methodological quality assessment

The appraisal of qualities and risk of bias is shown in Fig. 6. According to the rating, 23 (79.31%) studies were strong in terms of cofounders and drop-out. Most studies (n = 19, 65.51%) were strong in terms of study design, and data collection (n = 19, 65.51%). Based on the global rating scores, 62.06% of the investigations were considered strong, 20.68% were considered moderate, and 17.24% were considered weak. Due to the nature of the interventions, which were educational approaches for patients after heart surgery, blinding of participants was not possible in most studies, but in some studies, blinding was performed as an evaluator.

Fig. 6
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Risk of bias appraisal and quality assessment

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Discussion

Based on this review, educational approaches have the capacity and potential for self-monitoring and effective treatment of patients. In this systematic review, 29 papers (23 experimental and six observational-analytical) were reviewed in terms of the effects of educational interventions on patients with heart surgery.

These papers assessed a wide range of outcomes related to educational technologies, which were categorized into three main categories of patient-reported measures, clinical outcomes and economical outcomes. In general, most of the studies (28/29, 96.55%) had a significant impact on key outcomes such as improving the quality of care. In contrast, only one study did not report the intervention as effective.

Two of the most important consequences of educational platforms include reducing the level of anxiety and stress of patients after heart surgery and improving the care process [44]. Increasing the level of knowledge and awareness of patients after surgery such as heart surgery leads to changes in behavioral patterns, health and lifestyle [45]. Consequently, patient education is a structured, individual, and systematic process that assesses and transmits information to patients and their families that changes their health behavior and promote their well-being status [46]. The use of appropriate training technologies also reduces the cost of treatment and follow-up of individuals, and leads to a reduction in the workload of medical staff and care organizations [47]. Due to the progress of silent diseases, patient education has slowly become a significant concern, and hospitals and medical centers want to participate in the implementation of better education for patients and their families, and use the best emerging and advanced technologies for this purpose [9]. The use of educational approaches to educate patients after or before heart surgery has become common in recent years. Based on the results of selected studies, people who were trained both before and after heart surgery had significantly higher levels of preoperative knowledge than those who received training only after operation [48].

Studies by Kim et al. and Liu et al. distinguished the anxiety levels of patients who received and did not receive preoperative training; studies have revealed that patients who underwent preoperative training had lower levels of anxiety than those who did not. The patients in the intervention group cooperated more with health specialists and followed the procedures of the professionals [7, 49].

According to the studies, most of the solutions used to educate patients were based on video resources (as shown in Fig. 4). Educational videos do not require an actor or camera equipment, and it is relatively easy to add, remove or modify content in animated videos. The flexibility of videos to adapt clinical practices is a crucial variable [50]. Based on the studies reviewed in this study, video-based education can certainly support patient learning. However, more cumulative research is required to make evidence-based advances in the principles of video-based training in hospitals setting [51]. Based on the reviewed studies, virtual reality-based systems or environments have been used to educate patients. This technology causes patients to be immersed in the built environment, and facilities the learning of educational content in the best possible way [52]. Adopting a patient education system through the use of interactive technologies such as virtual and augmented reality in any organization is a significant and positive change that leads to improved quality of treatment and care [53].

There are strengths and limitations to this study. Strengths included using a search strategy with mesh terms that led to the identification of valuable studies. Also, the three authors extracted the data and screened the selected papers. This study also has two limitations. The first limitation is that non-English studies were excluded. Second limitation is that, the articles were retrieved based on a search of three databases, so some related studies may have been lost.

Implications for practice

Educational approaches or technologies used to educate patients with various heart surgeries have replaced traditional approaches and teaching methods in recent years. However, due to the growing global need to use computer-based tools, this issue extends rapidly in modern countries. Therefore, it is suggested that developing countries should also provide a suitable platform for these studies. On the other hand, the cost of technology and innovative materials, as well as time, place and implementation methods vary greatly depending on the details of the application, but most of them are expensive and require enough space such as virtual environments or video resources. Furthermore, it is recommended that governments should plan for this type of training and related expenditures to improve patients’ knowledge or quality of life.

Conclusion

In this systematic review, 29 articles related to the application of educational approaches and their effect on patients after heart surgery were analyzed. Almost all educational approaches and technologies have the functionality of reducing patient stress or anxiety and enhancing their satisfaction. Educational approaches have good potential to improve the quality of life and knowledge of patients. Therefore, technology and educational contents can be used as approaches to treatment management and care that aim to help control therapeutic interventions. Also, health policymakers are currently considering these technologies, because using them will reduce the financial burden on healthcare organizations.