Nursing Essay

Nursing Essay

  1. Read and familiarize yourself with all the manual therapy resources in Lesson 3 (Web links, Videos, Journal Articles, etc.)
  2. Use the Internet to further explore manual therapy, and answer the following questions:
    1. Identify the actions you can take to safe-guard a patient’s right to manual therapy.
    2. Describe the role of educators, counselors, advocates, and change agents in manual therapy.
    3. List several cases of EBP (evidence-based practice) that support the use of manual therapy.
  3. Your paper should be 4-6 pages, including:
    • title page
    • reference page according to APA Writing Style
    • spacing and margin settings (APA Style)

      Effectiveness of reflexology on anxiety of patients undergoing cardiovascular interventional procedures: A systematic review and meta‐analysis of randomized controlled trials

      Ramesh Chandrababu1 | Eilean Lazarus Rathinasamy2 | C. Suresh3 | Jyothi Ramesh4

      1Manipal College of Nursing, Manipal

      Academy of Higher Education, Manipal,

      Karnataka, India

      2Department of Adult Health and Critical

      Care, College of Nursing, Sultan Qaboos

      University, Muscat, Oman

      3Department of Physical and Health

      Sciences, SRM Institute of Science and

      Technology, Chennai, TN, India

      4Udupi College of Nursing, Sri Krishna

      Educational Trust, Manipal, Karnataka, India


      Dr. Ramesh Chandrababu, Manipal College

      of Nursing, Manipal Academy of Higher

      Education, Manipal, Karnataka, India.



      Aim: To appraise the evidence concerning the effect of reflexology on the anxiety

      in patients undergoing cardiovascular interventional procedures.

      Background: Anxiety, fear, and other unpleasant emotional experiences are com-

      mon among patients before and after cardiovascular interventional procedures. The

      higher anxiety may affect prognosis and recovery of patients.

      Design: A systematic review and meta‐analysis. Data sources: The MEDLINE, CINAHL (Cumulative Index to Nursing and Allied

      Health Literature), Cochrane Central Register of Controlled Trials (Cochrane Library),

      EMBASE, PsycINFO, and Web of Science were searched between 2001–2017. Review methods: Randomized controlled trials evaluated the effectiveness of

      reflexology on anxiety among patients undergoing cardiovascular interventional pro-

      cedures were included. Meta‐analysis was done using Revman 5.3. Results: Ten trials, representing 760 patients with the mean age of 59, fulfilled the

      inclusion criteria. Reflexology significantly decreased the anxiety of patients under-

      going cardiovascular interventional procedures in the treatment group compared

      with the control group.

      Conclusion: Reflexology has some positive effects on anxiety among patients

      undergoing cardiovascular procedures. It may be a useful complementary therapy

      and further research is necessary to create reliable evidence.

      K E Y W O R D S

      anxiety, cardiac surgical procedures, complementary therapies, coronary angiography, meta-

      analysis, nursing, percutaneous coronary intervention, reflexology, systematic reviews


      Cardiovascular diseases (CVDs) have become the leading health

      problems in the developing and the developed countries. CVD is the

      most common cause of morbidity and mortality worldwide. Coronary

      artery disease (CAD) is the most common among all cardiovascular

      disease conditions (Sharif, Shoul, Janati, Kojuri, & Zare, 2012).

      Patients with CAD, who do not respond to routine medical treat-

      ment, will have to undergo cardiovascular procedures that include

      coronary angiography, percutaneous transluminal coronary angio-

      plasty (PTCA), percutaneous coronary intervention (PCI), and coro-

      nary artery bypass graft (CABG) surgery (Hillis et al., 2011).

      Patients with the higher anxiety before coronary angiography

      and PCI may have unfavourable physical and psychological experi-

      ences (Gallagher, Trotter, & Donoghue, 2010). Fear, anxiety, and

      other unpleasant emotional experiences are common before coro-

      nary angiography and other cardiovascular interventions. Surprisingly,

      anxiety level before coronary angiography was reported to be higher

      Received: 28 December 2017 | Revised: 24 June 2018 | Accepted: 27 June 2018 DOI: 10.1111/jan.13822

      J Adv Nurs. 2019;75:43–53. © 2018 John Wiley & Sons Ltd | 43



      than before the cardiac surgery (Moradi & Adib‐Hajbaghery, 2015). Patients undergoing coronary angiography experience higher anxiety

      and depression that may affect their prognosis and recovery (Delewi

      et al., 2017; Korkmaz, Korkmaz, Yildiz, Gündoğan, & Atmaca, 2017).

      There is a significant association found between anxiety and slow

      coronary blood flow (Durmaz et al., 2014; Yalvac et al., 2017).

      The anxiety during pre and postoperative period positively corre-

      lated with a higher risk of atrial fibrillation, length of hospital stay,

      and readmission after cardiac surgery (Albert et al., 2009; Tully,

      Baker, Turnbull, & Winefield, 2008). The higher level of anxiety

      experienced by patients awaiting cardiac surgical procedures, which

      can negatively affect their existing disease condition and surgical

      intervention may lead to longer recovery (Guo, 2015). Anxiety, pain,

      stress, and sleep problems are usual after a surgical procedure. All

      these factors may disturb treatment process and quality of life of

      patients undergoing surgery (Mitchinson et al., 2007). Postopera-

      tively, a better quality of life among patients undergoing cardiac sur-

      gery associated with lower anxiety level (Tung, Hunter, Wei, & Wei,


      1.1 | Background

      An emphasis has been made on the nonpharmacological interven-

      tions and complementary therapies to decrease or eliminate the anx-

      iety in recent years. These therapies comprise a wide range of

      methods that are noninvasive, relatively simple, and cost‐effective and with lesser or no side effects compared with drugs (Lu, Chen, &

      Kuo, 2011). Reflexology is a systematic practice where applying

      some pressure on any particular points on feet and hands gives

      impacts on the health of the related parts of the body (Wang, Tsai,

      Lee, Chang, & Yang, 2008).

      When a reflex point or zone is stimulated, the body cells react

      by generating a reflex effect on the corresponding nerves, tissues

      muscles, and organs. Reflexology effects are well‐known to liberate the symptoms of stress by increasing blood flow, decreasing tension,

      calming the mental state, accelerating immunity, and promoting a

      sense of well‐being (Embong, Soh, Ming, & Wong, 2017). Reflexol- ogy improves the blood and energy circulation, gives a sense of

      relaxation and maintains homoeostasis. Endorphin is a body’s natural

      pain‐relieving chemical released as a response to reflexology (Embong, Soh, Ming, & Wong, 2015).

      Decreasing anxiety has higher clinical importance and is one of

      the essential goals of comprehensive nursing care. Various tech-

      niques, commonly invasive and pharmacological interventions are

      used to reduce the anxiety of patients. Anxiety stimulates the sym-

      pathetic nervous system activities through biochemical and physio-

      logical responses and results in the release of epinephrine and

      norepinephrine. As a consequence, heart rate, respiration rate, blood

      pressure, and demand for myocardial oxygen are increased. The

      increased workload of the heart also increases the risk of dysrhyth-

      mia and ischaemia (Adib Hajbaghery, Moradi, & Mohseni, 2014).

      Nurses are in the vital position to assess patient’s needs for

      these complementary therapies, to analyse strength and quality of

      evidence to implement evidence‐based interventions. Nurses who are caring patients undergoing cardiovascular interventional proce-

      dures should aim at decreasing patients’ anxiety because anxiety can negatively affect patients’ experiences of intensive care, well‐being, and recovery. The effect of reflexology proven generally in all the

      disease conditions, but still, it is not yet clearly understood in

      patients undergoing cardiovascular procedures.

      As per our knowledge, this is the first systematic review and

      meta‐analysis on the effect of reflexology on patients undergoing

      Why is this research or review needed?

      • Patients undergoing cardiovascular intervention proce- dures who experience higher anxiety may have adverse

      physical, psychological consequences and that may affect

      their prognosis and recovery. There is a significant asso-

      ciation between anxiety and slow coronary blood flow.

      • An emphasis has been given to nonpharmacological interventions to eliminate or decrease anxiety in recent


      • Reflexology is one of the nonpharmacological interven- tions; the effect of reflexology proven in general health

      conditions. However, the efficacy of reflexology on the

      anxiety in patients undergoing cardiovascular procedures

      remains unclear.

      What are the key findings?

      • Reflexology is significantly associated with decreasing anxiety of patients undergoing cardiovascular interven-

      tional procedures.

      • However, there is a low quality of evidence due to the unclear risk of bias, inconsistency, and imprecision in

      some of the trials included in this meta-analysis.

      • None of the reviewed trials reported any harmful effects of reflexology intervention.

      How should the findings be used to influence


      • Reflexology may serve as a useful complementary ther- apy for decreasing anxiety of patients undergoing the

      cardiovascular procedures.

      • There is a need for rigorous research to prove the effi- cacy of reflexology and, the higher methodological quali-

      ties of randomized controlled trials are necessary to

      create a reliable and higher quality of evidence.

      • Future research must also focus on scientific reasons behind reflexology interventions in the area of cardiac

      interventional procedures measuring biomarkers such as

      endorphins, as exact mechanisms are not yet understood





      cardiovascular interventional procedures. As complementary thera-

      pies are given higher importance globally, the findings of this review

      will provide new insight on the effectiveness of reflexology on anxi-

      ety to the scientific community. Therefore, this meta‐analysis on the effect of reflexology was decided to conduct and this article pro-

      vides evidence of the randomized controlled trials describing clinical

      effects of patients following cardiovascular interventional proce-


      2 | THE REVIEW

      2.1 | Aim

      This systematic review and meta‐analysis aimed to appraise the evi- dence concerning the effectiveness of reflexology on the anxiety of

      patients undergoing cardiovascular procedures.

      2.2 | Design

      This is a quantitative systematic review with meta‐analysis examining the effectiveness of reflexology on anxiety among patients undergo-

      ing cardiovascular interventional procedures. The guidelines of

      Cochrane Collaboration were adopted to carry out this systematic

      reviews and meta‐analysis (Higgins & Green, 2011) and reported using Preferred Reporting Items for Systematic Reviews and Meta‐ Analyses (PRISMA) statement (Moher et al., 2015).

      2.3 | Search methods

      A comprehensive search strategy was developed using the search or

      key terms connected to PICO (population or patient, intervention,

      comparator or control, and outcomes) and two authors indepen-

      dently searched MEDLINE, CINAHL (Cumulative Index to Nursing

      and Allied Health Literature), CENTRAL (Cochrane Central Register

      of Controlled Trials – The Cochrane Library), EMBASE, PsycINFO, and Web of Science between 2001–2017. We explored for random- ized controlled trials (RCTs) that used reflexology as an intervention

      for patients following the cardiovascular procedures.

      The following combinations of MeSH (Medical Subject Heading)

      terms or keywords were used: reflexology, foot reflexology, zone

      therapy, anxiety, coronary angiography, percutaneous coronary inter-

      vention, cardiac surgery, CABG surgery, cardiac surgical procedures,

      and randomized controlled trial. A manual search of references from

      all relevant trials that fulfilled inclusion criteria as well as related sys-

      tematic reviews, meta‐analyses, and review articles was also con- ducted. Duplicate records and trials were excluded by screening the

      titles and abstracts. All the remaining original full‐text articles were screened to assess the inclusion criteria.

      2.3.1 | Participants

      The trials included adult (aged above 18 years) patients undergoing

      the cardiovascular interventional procedure that includes coronary

      angiography, percutaneous coronary intervention, coronary artery

      bypass graft, and open heart surgery. The patients who had a ran-

      dom allocation to either a treating group that received reflexology or

      a control group that received the usual care.

      2.3.2 | Interventions

      Patients in the experimental group had to receive reflexology inter-

      ventions. The trials evaluated the effect of reflexology or

      reflexotherapy interventions among patients undergoing cardiovascu-

      lar interventional procedures were included.

      2.3.3 | Comparison

      The control group who received regular or routine postoperative

      care of the hospital.

      2.3.4 | Outcomes

      Anxiety was the primary outcome analysed in this systematic review

      and meta‐analysis. We assessed biophysiological parameters that include pain, heart rate, respiration rate, systolic blood pressure,

      diastolic blood pressure, oxygen saturation (SpO2), satisfaction, mean

      arterial pressure, and quality of life (QOL) as secondary outcomes.

      2.3.5 | Study design

      Randomized controlled trials (RCTs) that were published in English

      and included reflexology interventions for patients undergoing car-

      diovascular interventional procedures.

      2.4 | Search outcome

      The search strategy identified 4,526 studies through electronic data-

      bases. Fifty‐two duplicate records were excluded. After assessing the titles and abstracts, 4,454 studies were omitted, as they did not meet

      the criteria of the review according to PICO. After assessing the full

      text, another ten articles were excluded, as they did not match the

      inclusion criteria of the systematic review and meta‐analysis. The rea- sons for excluding trials were non‐RCTs; the study did not include reflexology as an intervention and involved patients undergoing car-

      diovascular procedures as mentioned in inclusion criteria. Although an

      RCT evaluated the effect of reflexology on anxiety during minimally

      invasive varicose vein surgery, we decided to exclude as the trial did

      not meet inclusion criteria (Hudson, Davidson, & Whiteley, 2015).

      Finally, ten trials were involved in qualitative and narrative synthesis.

      Five trials were included in the meta‐analysis. The flow diagram of study selection process is presented in Figure 1.

      2.5 | Quality appraisal

      The Cochrane risk of bias tool was used to assess the risk of bias of

      included trials (Higgins & Green, 2011). No trial demonstrated




      selection bias, as there were 100% low risk of bias and 60% of the

      unclear risk of bias noted in the allocation concealment and perfor-

      mance bias was about 25%. All the trials demonstrated 100% of low

      risk in attrition bias (incomplete outcome data) and low risk of bias

      in the selective reporting. The details regarding the percentages

      across all included trials and judgements about each risk of bias item

      are presented in Figure 2.

      2.6 | Data extraction

      Two authors independently extracted the data from trials included and

      dissimilarity was resolved by discussing with a third reviewer. A data

      extraction form, which included author, year of publication, country,

      design, sample size, gender and mean age of patients, details of the inter-

      vention, outcomes, instruments, reliability, and trial findings were used.

      Records identified through database searching

      (n = 4517)

      S cr

      e e n in

      g In

      cl u d e d

      E lig

      ib ili

      ty Id

      e n tif

      ic a tio

      n Additional records identified through other sources

      (n = 9)

      Records after duplicates removed (n = 4474)

      Records screened (n = 4474)

      Records excluded (n = 4454)

      Full-text articles assessed for eligibility

      (n = 20)

      Full-text articles excluded, with reasons

      (n =10) Non RCTs – 2

      Did not include reflexology as study intervention – 6 Study did not involve

      cardiovascular procedure – 2 Studies included in narrative synthesis

      (n = 10)

      Studies included in quantitative synthesis

      (meta-analysis) (n = 5)

      FIGURE 1 Flow diagram of study selection [Colour figure can be viewed at]

      Random sequence generation (selection bias)

      Allocation concealment (selection bias) Blinding participants and personnel

      (performance bias) Blinding of outcome assessment (detection bias)

      Incomplete outcome data (attrition bias)

      Selective reporting (reporting bias)

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