Learning Needs and Educational Strategies for Adult Patients in the Preoperative Period of Myocardial Revascularization: Scoping Review*

Objective: To identify and map learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization. Materials and method: Scoping review conducted between March and April 2021 in national and international databases to identify records published in scientific journals and gray literature, without period. Results: The selected sample consisted of 35 records, composed mostly of articles (32; 91.42 %) published from 1990 to 2021. The learning needs of patients before surgery were categorized into cardiovascular system and coronary artery disease; procedures and routines before, during, and after surgery. In addition, several educational strategies implemented in the studies were identified. Conclusions: The learning needs identified can contribute to planning and implementing patient-centered educational strategies before surgery.


Introduction
Cardiovascular diseases (CVD) are the leading cause of death worldwide, with an estimated 17.9 million lives each year.They represent a group of diseases of the heart and blood vessels that include coronary artery disease (CAD) and other conditions (1).
CAD is caused by the accumulation of plaques formed by deposits of cholesterol and other substances on the walls of the coronary arteries, which provide blood to the heart and other parts of the body.This accumulation causes the interior of the arteries to narrow over time, which can partially or totally block blood flow (2).
Therefore, the identification of individuals at higher risk for developing diseases such as CAD and the guarantee of appropriate treatment can avoid consequences such as premature deaths.Therefore, access to essential medicines and health technologies is important (3).Thus, among the treatments for this condition is myocardial revascularization surgery (MRS), also known as "saphenous bridge" or "breast".It is performed when drug and other alternatives are not sufficient to restore coronary blood supply, and enables proven long-term survival benefits (3,4).
However, MRS can be considered a stressful event for patients due to physical factors, such as pain, and psychological factors such as anxiety, fear, and depression.This can be caused by thoughts of uncertainty about survival, the risks of complications, the environment of the intensive care unit (ICU), in addition to concerns about the postoperative care process and the resumption of routine activities.Therefore, the physical and mental well-being of the individual can be impaired and negatively influence the outcome of treatment and the evolution of the postoperative period (5).
Therefore, identifying the patient's learning needs about surgery and how he/she faces and deals with the preoperative period is an important aspect for the multidisciplinary team that assists him/her to identify risk factors.It can be done through educational activities, in which the health professional must also understand the patient's previous knowledge and follow the appropriate orientations, according to their particularities and using an accessible language.This can create and strengthen the bond, contribute to better clinical results, and reduce hospitalization time, care-related infections, and other postoperative complications (6).
Thus, educational interventions with resources such as images, audio and video are important facilitating tools for the multidisciplinary team.They can contribute to a better understanding of patients about their health condition and the procedures and conducts adopted in the pre-trans-and postoperative phases of surgery, and help establish a relationship of trust and learning between the patient and the professional (5).
Thus, prior to the elaboration of the research protocol on this theme, a search was conducted in national and international databases.No similar study was found, which justifies the realization of this scoping review.Therefore, the objective is to identify and map learning needs and educational strategies for adult patients in the preoperative period of MRS.

Materials and method
This scoping review followed the reference proposed by the Joanna Briggs Institute (JBI), which allows mapping the main concepts, clarifying research areas, and identifying knowledge gaps (7).For formulating the research question, the mnemonic strategy population, concept, and context were used.With this, the following were defined: population (P) -adult patients; concept (C) -learning needs and educational strategies; context (C)preoperative care for MRS in hospitals.Thus, based on these definitions, the guiding question was outlined: what learning needs and educational strategies are used preoperatively for adult patients of MRS in hospitals?
For conducting the study, a protocol entitled "learning needs and educational strategies for adult patients in the preoperative period of MRS": was prepared, according to JBI recommendations.This protocol is registered and available for consultation on the Open Science Framework (OSF), through the digital object identifier system (DOI): 10.17605/OSF.IO/2PBEM, which can be accessed at: https://osf.io/2pbem/.
As eligibility criteria, texts available in full, in any language, without time limits and addressing learning needs and/or educational strategies for adult patients in the preoperative period of MRS were adopted.Opinion articles and texts not available in full were excluded.
Subsequently, with the terms, searches were conducted in pairs of scientific production, according to the eligibility criteria in March and April 2021 in the databases PubMed, CINAHL, Web of Science, Scopus, Latin American and Caribbean Health Sciences Literature (LILACS), The Cochrane Library, and Embase.The restricted databases were accessed through a resource of the Federated Academic Community, available to students, professors, and other public workers of Brazilian institutions.
The grey literature consulted were the Catalogue of Theses and Dissertations of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, the DART-Europe E-Theses portal, Electronic Theses Online Service, the Repositório Científico de Acesso Aberto de Portugal, the National Library of Australia (Trove), the National ETD Portal, the Education Resources Information Center, and Theses Canada.
The search strategy with the MeSH was used in an adapted way, according to the specific fields in each database and Boolean operators: "patient" OR "client" AND "patient education" OR "health education" OR "learning needs" OR "learning" OR "active learning" OR "educational needs assessment" AND "preoperative period" OR "perioperative care" AND "myocardial revascularization" OR "internal mammary artery implantation" OR "coronary artery bypass graft surgery" OR "coronary artery surgery" AND "hospital" OR "intensive care unit" OR "coronary care units" OR "inpatients" OR "hospitalization".
First, the titles and abstracts of the documents retrieved were read to fill out a location spreadsheet.Next, these documents were analyzed in full for inclusion in the review, according to the criteria of eligibility and extraction of the data in a spreadsheet in the Microsoft Excel® software to create a database.
The following variables were analyzed by simple descriptive statistics: type of document (article, thesis, dissertation, or other); year of publication; journal or higher education institution (HEIs); country of origin; language in which it was published; type of study; approach; level of evidence according to JBI classification (8); sample/participants; person responsible for the implementation of educational strategies; unit where it was implemented; period of the educational strategy; duration of the intervention; age; gender, and educational level of the participants.Regarding the learning needs and educational strategies used, methods and resources, a thematic categorization was carried out.The results are made available descriptively, as charts and tables.

Results
From the searches performed, 305,361 records were identified in the databases, of which 35 studies were included in the final sample.This process is illustrated in Figure 1.

Final sample n = 35
Source: Own elaboration following JBI recommendations (7).The identified records that came from research with humans showed a sample variation from 1 to 745 individuals, with mean ages from 54.9 to 68.3 years, mostly men, with different levels of schooling, in the preoperative period of MRS.

Discussion
Most of the records that are part of the sample of this study are articles made available in English.The countries that produced the most were the United States and Germany.This corroborates the idea of the important number of studies in these countries, which make them references to world science.It is also emphasized the need for the conduct of studies on the subject in all continents since CVD affects many individuals worldwide, which requires, in several situations, surgical treatment (40)(41)(42)(43)(44)(45).
Regarding methodological quality, randomized clinical trials with a quantitative approach were highlighted.This type of study represents a high level of evidence, which can be used for decisionmaking and the foundation of clinical practice in cardiology by professionals who provide direct care to patients (46)(47)(48).
The study sample showed a variation of age groups, with an average age greater than 54 years.This is in agreement with the fact that aging is one of the main risk factors for CAD, which usually occurs in men over 55 years of age and women over 45 (34,(49)(50)(51).
It was also identified in the records the predominance of men with CVD, which agrees with the epidemiology of cardiovascular diseases.The male gender is placed as a risk factor for CVD, and a higher incidence and prevalence is perceived in this group, with an important mortality (52)(53)(54).
Regarding the learning needs of patients in the preoperative period of MRS, the first category represents the cardiovascular system and CAD with topics related to the physiology of the heart and the disease itself.Thus, it agrees with the importance of the guidance provided by the multidisciplinary team to the patient on this theme since they can contribute to a better treatment + during the hospitalization period, as evidenced in international studies (4, 31, 55-57).
The second category highlighted some care, procedures, and routines before surgery.In this category, reference is made to the knowledge about the hospitalization process, including the characteristics, routines, and the team involved in care.It is relevant to provide detailed information since, in several situations, it is a new context for the individual who will undergo surgery (5,58,59).
Moreover, the preparation of the patient can prolong the hospitalization time because it involves care such as the performance of several tests to better understand the profile of patients, the guarantee of the correct surgical indication, and the aid in the establishment of individual risk scores.They are important and contribute to better knowledge of each patient's case (60)(61)(62).
Fasting and trichotomy are also necessary for the procedure.This concerns the removal of hair in the chest, close to the radial arteries and the saphenous vein to prepare the skin of the area in which incisions will be made, according to the routines established by each service.Currently, it has been recommended to perform it no more than two hours before surgery, with a specific electrical device, because it helps in infection control, a theme that was also identified in this category (63,64).
In addition, the studies cited the importance of an approach to the medications used by the patient and the administration of drugs to reduce anxiety and facilitate sleep on the eve and one hour before surgery.The drug strategy associated with psychological counseling and nursing interventions contribute to reduce the anxiety, fear, anger, and stress that can affect individuals (65,66).This was highlighted in research conducted in China (Hong Kong) and Germany as important to minimize the psychological mechanisms mentioned above, which can be caused by uncertainties about survival, the risk of complications, the process of illness, and the insertion of the individual in the hospital environment (5,36).
The third category comprises the procedure and care during surgery.It was related to the instruction about the proper name of the surgery, which can be RVM or saphenous or breast bridge; in addition, how it is performed and some characteristics, such as extracorporeal circulation, complications, results, risks, prognosis, and survival rate (67,68).It is noteworthy that the previous items should be part of the scope of preoperative orientations since the patient needs to be aware of the interventions that will be performed during the surgery (36).
Additionally, in the same category, the importance of information on anesthesia and post-anesthetic recovery was highlighted.In this case, the patient needs to understand that MRS requires general anesthesia, induced exclusively with intravenous drugs or a combination of inhalation agents, known as volatile agents, used during the procedure (69)(70)(71).
Care, procedures, and routines after surgery represented the fourth category.It includes topics related to routines and important care that need to be adopted by patients and that directly influence postoperative recovery, as well as maintaining good health and quality of life.Topics such as the postoperative environment of the ICU and the invasive devices used also need to be addressed since, in the vast majority of situations, they are not known and will be part of the patient's context, especially in the first hours after leaving the operating room (33,72,73).
With regard to the experience of pain, it is known to be present since incisions are made in the thorax (sternotomy), the saphenous vein region (saphenectomy), and the places where the monitoring lines and invasive devices are inserted, such as the endotracheal tube and the thoracic tube (5,33,74).In this case, the individual needs to be guided on measures to relieve pain, which can be through intravenous or oral medications, usually opioids and antiinflammatory drugs (75,76).
Additionally, events such as nausea and delirium can also happen.The first, ratified in a study conducted in Denmark with 310 patients, highlighted the importance of administering drugs for control (35).Delirium, which can occur postoperatively in the ICU, related to cognitive decline, was investigated in a recent meta-analysis that revealed prevalence in 43 % of patients up to four days, which remains high (39 %) up to one month after MRS (77).
Topics such as wound care, communication, recovery, physical and pulmonary rehabilitation, nutrition and weight control, and correct use of prescribed medications were also highlighted and should be part of the scope of guidance provided to patients.The preceding aims to improve the proposed treatment and the results with surgical intervention (3,4,33,35).
Educational resources and strategies used by several professionals in the hospital environment were also identified, especially in the wards, to provide information to patients about their status, preoperative care, surgical intervention, and postoperative context.Nurses, physicians, psychologists, and physiotherapists were responsible for the implementation of these actions (5,35,36).
It is considered that, in the educational process implemented, several resources can be used to favor the learning of patients (5).The use of drawings, educational booklets with texts and images, videos, slides, audio tapes, interactive software, questionnaires, and other types of illustrations stood out as educational resources for training patients.
It is known that, with the evolution of knowledge and the development of learning resources, new technologies were incorporated into this process.They help provide valid and accurate information that impacts patient education.From this, the patient will understand how actions influence their treatment and may be actively involved in their care (78).
Regarding educational strategies, they were implemented through verbal education, short courses, guided tours, meeting with teams and other patients, and demonstrations about surgery and care.
All the resources and educational strategies identified in this review have their importance depending on the context in which they are employed and how they are used.These findings corroborate a randomized clinical trial conducted in Iran, which did not show significant differences in preoperative education through the implementation of verbal orientations or other re-sources, but reinforced that preoperative training has benefits for the patient, such as reduced anxiety (79).
Limitations in the preparation of this review were the small number of data bases due to the recent restrictions in the portal made available for consultation by Brazilian researchers; the inclusion of many studies with more than ten years of publication; the restricted number of languages in the records; the absence of critical analysis of the methodological quality of the studies.However, because it is a scope review, some of these limitations may be considered because it is not necessary to include extensive literature on the subject.The critical-methodological analysis of the studies is also dispensed with.

Conclusions
The study identified that patients have several learning needs that should be considered by health professionals in planning and implementing the guidelines and care before myocardial revascularization surgery.They are related to the cardiovascular system and coronary artery disease itself; care, procedures, and routines before, during, and after surgery.
Therefore, the interprofessional team should implement, through various strategies, according to the available resources, educational activities that favor patient-centered teaching about their disease and the therapeutic plan to be implemented.Among the strategies, conventional education can be considered through verbal orientations, courses, guided tours, meetings with staff and patients, and demonstrations about surgery and care.
From this, it is possible to achieve a better patient's support to the conducts and guide the actions so that satisfactory clinical results are accomplished in the various stages of MRS surgery.
Based on the findings of this review, it is expected that professionals act in a way that is directed to implement educational activities based on the needs identified.In addition, we suggest conducting further studies to identify learning needs and educational strategies of patients who will undergo other types of surgeries, including different cardiac surgeries.

Figure 2 .
Figure 2. Learning needs of adult patients in the preoperative period of myocardial revascularization.Natal, Rio Grande do Norte, Brazil, 2021

Figure 3 .
Figure 3. Educational resources and strategies for patients in the preoperative period of MRS.Natal, Rio Grande do Norte, Brazil, 2021

Table 1 .
Detailed characterization of the studies analyzed according to journal or HEI, year of publication, study design-approach-level of evidence and country of origin.Natal, Rio Grande do Norte, Brazil, 2021 The selected sample (n = 35) consists of 32 articles (91.42 %), a doctoral dissertation (2.86 %), a master's thesis (2.86 %), and an academic project (2.86 %).It has records from 1990 to 2021, whose year with the highest number was 2019, with four studies(11.43 %).The predominant countries were the United States and Germany, with five studies each (14.29 %), and the most frequent language was English, with 31 records (88.57%).Regarding methodological characterization, 16 randomized clinical trials (45.70 %), 28 quantitative studies (80 %) and 16 clinical trials belonging to evidence level 1C (45.70 %) stood out.Table1presents the detailed characterization of the studies according to journal or HEIs, year of publication, design of the study-approach-level of evidence and country of origin.*WE:withoutlevel of evidence according to JBI classification.Source: Own elaboration.