ambulancetransport.pdf

Mental Health Factors

©2021 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2021619

Background Communication is key to understanding the
emotional state of critical care patients.

Objective To analyze the effectiveness of the communi-
cative intervention known as CONECTEM, which incorpo-

rates basic communication skills and augmentative

alternative communication, in improving pain, anxiety,

and posttraumatic stress dis symptoms in critical

care patients transported by ambulance.

Methods This study had a quasi-experimental design with
intervention and control groups. It was carried out at 4

emergency medical centers in northern Spain. One of the

centers served as the intervention unit, with the other 3

serving as control units. The nurses at the intervention cen-

ter underwent training in CONECTEM. Pretest and posttest

measurements were obtained using a visual analog scale to

measure pain, the short-version State-Trait Anxiety Inven-

tory to measure anxiety, and the Impact of Event Scale to

measure posttraumatic stress dis symptoms.

Results In the comparative pretest-posttest analysis of
the groups, significant differences were found in favor of

the intervention group (Pillai multivariate, F
2,110

= 57.973,

P < .001). The intervention was associated with improve- ments in pain (mean visual analog scale score, 3.3 pre- test vs 1.1 posttest; P < .001) and posttraumatic stress dis symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the per- centage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001). Conclusion The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport. (American Journal of Critical Care. 2021;30:45-54) A COMMUNICATIVE INTERVENTION TO IMPROVE THE PSYCHOEMOTIONAL STATE OF CRITICAL CARE PATIENTS TRANSPORTED BY AMBULANCE By Marta Prats Arimon, PhD, BD, RN, Montserrat Puig Llobet, PhD, BD, RN, Juan Roldán-Merino, PhD, MSN, RN, Carmen Moreno-Arroyo, PhD, MSN, RN, Miguel Ángel Hidalgo Blanco, PhD, MSN, RN, and Teresa Lluch-Canut, PhD, BD, RN www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 45 46 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 www.ajcconline.org E ffective communication is key to understanding the difficulties implicit in critical ill- ness.1,2 Critically ill patients often experience psychoemotional symptoms such as sadness, anger, nervousness, worry, fear, stress, anxiety, and pain,3-5 which are related to their inability to communicate.6,7 In addition, the reduced level of awareness of these patients can lead to states of confusion or delirium,8,9 which alter their perceptions of reality.10 The negative feelings contribute to the frustration generated by the lack of commu- nication and can affect the patient’s perception of the quality of nursing care received.1,2,11 The most prevalent negative psychoemotional states among critically ill patients are pain (experi- enced by 70%-89% of patients),12,13 anxiety (30%-60%), and posttraumatic stress (27%).3,14-16 Research on in-ambulance communication between critical care patients and nurses first emerged in Europe.17-19 In the United States, effective commu- nication has been a quality standard for the treatment of critical care patients for several years.20 An increas- ing amount of research on the topic has been per- formed in Spain.21 Inadequate communication due to physical, cognitive, and psychological barriers is one of the main problems affecting critical care patients.10,22,23 Misunderstandings and/or misinterpretations gen- erate insecurity and frustration among nurses and reduce their effectiveness in treating pain, providing emotional support, and meeting patients’ needs.24,25 Research on patient-nurse communication should involve measurement of pain as well as psychoemo- tional variables such as anxiety and the effects of trauma, which can lead to symptoms of posttraumatic stress dis (PTSD) in critically ill patients.26 Patak et al27 and Happ et al28 were among the first authors to propose a set of communicative inter- ventions based on augmentative alternative commu- nication (AAC) and basic communication skills (BCS) for use with critical care patients. These recommenda- tions led to the development of various AAC mod- els.29,30 Nurses received training based on these models,31,32 with the impact assessed in terms of improvement in the treatment of critically ill patients. However, few studies have been conducted in which these techniques have been applied outside of the hospital intensive care unit (ICU).33-35 The adverse conditions prevailing in an ambulance setting, such as limited space and vehicle movement with result- ing discomfort, further hinder communication with the critical care patient36,37 and negatively affect the patient’s physical, psychological, and emotional well- being.38,39 Therefore, additional research on nurse- patient communication in this context is needed. This study was conducted to analyze the effect of implementation of AAC and BCS on the psychoemo- tional state of critical care patients being transported by ambulance. Methods This study had a quasi-experimental design with a control group and an intervention group and involved preintervention and postintervention measurements of pain, anxiety, and PTSD symp- toms. The CONECTEM communicative intervention was used in critical care patients in the intervention group transported by ambulance, whereas the tra- ditional care process was used for control group patients (Table 1). About the Authors Marta Prats Arimon is an associate professor, School of Nursing, Faculty of Medicine and Health Sciences, Univer- sity of Barcelona, Barcelona, Spain; a collaborating pro- fessor, School of Nursing, Faculty of Medicine and Health Sciences, University Ramon Llull, Barcelona, Spain; and a registered nurse, Emergency Department, Hospital Transfronterer de Cerdanya, Puigcerdà (Girona), Spain. Montserrat Puig Llobet is a professor and director of the Mental and Public Health Department and director of the master’s program in nursing interventions in complex chronic patients, School of Nursing, Faculty of Medi- cine and Health Sciences, University of Barcelona and a researcher in the CARINGCF Research Group, Tarrag- ona, Spain and the GIRISAME Research Group, Madrid, Spain. Juan Roldán-Merino is a professor, Campus Docent, Sant Joan de Déu-Fundació Privada, School of Nursing, University of Barcelona; a researcher in the GIESS Research Group and the GEIMAC Research Group, Barcelona, Spain; and coordinator of the GIRISAME Research Group and the REICESMA Research Group, Madrid, Spain. Carmen Moreno-Arroyo and Miguel Ángel Hidalgo Blanco are professors in the Department of Fundamental and Medical- Surgical Nursing and directors of the master’s program in critical care nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona. Teresa Lluch- Canut is a professor of psychosocial and mental health, School of Nursing, Faculty of Medicine and Health Sci- ences, University of Barcelona; and a researcher in the GEIMAC Research Group, Barcelona, Spain. Corresponding author: Montserrat Puig Llobet, PhD, BD, RN, Director, Mental and Public Health Department, School of Nursing, Faculty of Medicine and Health Sciences, Univer- sity of Barcelona, C/ Feixa Llarga s/n 08870–Hospitalet de Llobregat, Barcelona, Spain. (email: [email protected]). www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 47 Setting and Sample The study was carried out at 4 emergency medical system centers in Catalonia, a region of northeastern Spain. Selection of the centers was based on their similar characteristics: location in a rural area with a geographically dispersed population, transfers that Intervention group: CONECTEM communicative intervention Table 1 CONECTEM communicative intervention and routine communicative action of nonhospital nurses STRATEGY 1 Communication with the patient according to the training and guidelines established in the communicative intervention, focusing mainly on the following: • Initiate the patient-nurse interaction • Continuous communication during the journey • The frequency and duration of the interaction depend on the patient’s requirements at the time of transportation • Always maintain eye contact during the interaction • Pause to allow the patient to process the information • Clarify and double-check all messages from the patient in to avoid misinterpretations • Show empathy, be assertive, and use active listening techniques • Refrain from making value judgments about patients and/or their family situation • Pay attention to nonverbal communication: gestures of pain, restlessness, or sighing STRATEGY 2 Communication with the patient according to the training and guidelines established in the communicative intervention, focusing mainly on the following: • Perform the communication actions in Strategy 1 • Highly precise and specific language, using short sentences to facilitate effective communication • Establish a signal for yes, one for no, and one for “I don’t understand” • Use the CONECTEM support material Boards for conveying emotions Boards for conveying requirements International dictionary symbols • The patient is asked to point or indicate what they wish to com- municate. If they are unable to do this, the nurse asks them • Nonverbal communication Pay attention to gestures of pain, restlessness, or sighing Physical contact Relaxing music (use of the CONECTEM musical support material) STRATEGY 3 Communication with the patient according to the training and guidelines established in the communicative intervention, focusing mainly on the following: • Ensure a peaceful atmosphere, ensuring that devices are silenced and their alarms are off, and dim the lighting to help the patient to rest • Be on the lookout for changes in physical signs • Observe facial expressions and motor movements • Verbal communication Initiate the interaction Explain any relevant and suitable procedures and information to the patient Soothing and unhurried tone of voice • Suitable training on physical contact • Relaxing music (use of the CONECTEM musical support material) Communication with the patient in accordance with the social and communication skills of nurses who have received no training or guideline(s) Introduction of the nurse to the patient and explanation of the transportation procedure Interaction at the beginning and end of the transportation Communication at the patient’s request Short patient-nurse interactions related to the patient’s physical condition or the progress of the journey Clichéd questions and sentences How are you doing? We’re almost there. There are x km left. If there is any problem, let me know. Communication with the patient in accordance with the social and communication skills of nurses who have received no training or guideline(s) Lack of verbal communication due to lack of resources Use of nurse’s own resources Lip reading Gesticulation or signs Writing on paper Nonverbal communication at the nurse’s discretion Communication with the patient in accordance with the social and communication skills of the nurses Ensure a peaceful atmosphere to facilitate patient rest Be on the lookout for changes in physical signs Observe patient motor movements No verbal communication with the patient Physical contact and nonverbal communication at the nurse’s discretion Control group: routine communicative action Glasgow Coma Scale score 15 (patients with no communicative difficulties) Glasgow Coma Scale score 9-14 (patients with communication difficulties regarding comprehension and/or expression) Glasgow Coma Scale score ≤8 (sedated or intubated patients, unconscious patients, patients with no verbal response) 48 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 www.ajcconline.org are lengthy in both time and distance, and narrow, winding roads in their territory. The study population consisted of all critically ill patients transferred by ambulance to the 4 emer- gency medical centers chosen. One of the centers (most convenient for the principal investigator) was selected for implementation of the CONECTEM com- municative intervention (the intervention group), with patients from the other 3 centers constituting the control group. The nurses caring for the inter- vention group were previously trained in BCS and AAC to prepare them for the CONECTEM interven- tion in the ambulance. The study sample, recruited from consecutive cases, was nonprobabilistic. Critically ill patients were included in the study if they were aged 18 or older and required transfer by ambulance to a secondary or tertiary hospital for either diag- nosis or treatment. Patients were excluded if they were transferred by helicopter. The sample size was esti- mated on the basis of the prev- alence of anxiety in critical care patients, which is 60%, accord- ing to the literature.40 With an of .05 and a power of 80% to detect a difference of 25% between the 2 groups and with estimated losses of 10%, 69 patients were needed in each group. (Ultimately, 68 patients participated in the intervention group and 52 patients in the control group—see Results.) Data Collection The emergency medical team nurses from each of the 4 participating sites were tasked with data collec- tion. The nurses working at the center where the inter- vention was carried out collected the data for the intervention group. Nurses working at the other 3 cen- ters collected the data for the control group. Data col- lection began once the patient was in the ambulance and concluded upon their arrival at the destination. The mean transfer duration was 1.5 to 2 hours. Three psychoemotional responses typical in this situation were assessed: pain, anxiety, and symptoms of PTSD. The nurses assessed the study variables using validated scales before and after the CONECTEM intervention in the intervention group, and before and after trans- port in the control group. Sociodemographic and health variables were also collected (sex, age, type of disease, degree of consciousness, and whether or not the patient was fitted with an endotracheal tube). The data collection process lasted 6 months. Instruments The Glasgow Coma Scale (GCS)41 was used to identify the most suitable CONECTEM intervention strategy for each patient based on their degree of con- sciousness. This tool was chosen because it is com- monly used by nurses working outside the hospital, permitting quick assessment and taking into account a person’s verbal and motor responses, which influ- ence communication. The following instruments were used to assess the psychoemotional variables of pain, anxiety, and PTSD symptoms, respectively: Visual Analog Scale. The visual analog scale (VAS)42 was used to measure the intensity of the pain described by the patient. The VAS can take the form of centime- ters or numbers from 0 to 10. Pain was also dichoto- mized into 2 categories: absence (VAS score of 0) and presence (VAS score of 1-10). State-Trait Anxiety Inventory. A modified version of Spielberger’s State-Trait Anxiety Inventory43 was used to measure anxiety. This scale consists of 6 items divided into 2 categories for anxiety: present (anx- ious, nervous, worried) and absent (calm, comfort- able, “I feel calm”). Impact of Event Scale. The Impact of Event Scale44 comprises 15 items: 6 measures of intrusion, 8 of avoidance, and 1 of hyperactivity. The score for each item ranges from 0 to 5, with 0 indicating never, 1 rarely, 3 sometimes, and 5 often. A total score is cal- culated, with higher values indicating greater stress levels. A total score of less than 8.5 indicates mild stress; 8.5 to 19, moderate stress; and greater than 19, severe stress. If the patient has a GCS score of less than 9 and is receiving mechanical ventilation, it has been recom- mended that the patient’s pain be measured using the Behavioral Pain Scale45 and the patient's agitation- sedation state be measured using the Ramsay Sedation Scale and the Richmond Agitation-Sedation Scale.46 A case report form was used to collect data on sociode- mographic and health variables. Intervention and Intervention Protocol The CONECTEM intervention consists of BCS such as visual contact, message clarification, empa- thy, and active listening47 and uses AAC techniques such as panels with icons representing requirements and emotions and the international dictionary signs. 29,48 Other AAC techniques such as writing The impact of the communicative inter- vention on critically ill patients transported by ambulance was evaluated in relation to pain, anxiety, and symptoms of posttrau- matic stress dis . www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 49 on a board or using advanced technology were ruled out because of the difficulty and complexity of per- forming them during the ambulance transfer (ie, vehicle movement, narrow roads, the time needed to show the patient and nurses how an electronic device works, and the patient’s condition). The inter- vention was designed by a group of experts who approved its application during ambulance trans- port. Before use of the CONECTEM intervention, the nurses who wished to participate in the study underwent a training program that qualified them to carry out the intervention in the ambulance. The training was organized into 3 modules: the anthro- pology of communication, the psychoemotional state of the critically ill patient, and the BCS and AAC used in CONECTEM. The training lasted 6 hours spread over 2 days. The training methods used were role playing and case management. To be able to per- form the CONECTEM intervention, nurses were required to pass a theoretical-practical posttraining test with a score of at least 70%. The intervention was split into 3 different strate- gies according to the patient’s level of consciousness. Each strategy entailed a certain level of verbal and non- verbal communication. In contrast, nurses caring for patients in the control group used routine communi- cative action that relies on the nurse’s social and com- munication skills. The CONECTEM intervention and the routine communicative action are described in greater detail in Table 1. Statistical Analysis In the descriptive analyses, number and percentage were used for categorical variables, whereas median and SD were used for quantitative variables. The normality of the quantitative variables was verified with the Kolmogorov-Smirnov test. Either the t test or the Mann- Whitney U test was used for analysis of the quantitative variables, depending on the data distribution. Either the 2 test or the Fisher exact test was used for analysis of the categorical variables. To analyze the impact of the intervention on the dependent variables (pain and PTSD symptoms), we performed multivariate analysis of covariance of the pretest-posttest differences between the intervention group and the control group (intro- ducing the pretest score as a covariable). Finally, we conducted repeated-measures analysis of variance for the pain and PTSD symptom variables. The Pearson product-moment correlation was used to calculate the relationships between pain, anxiety, and PTSD symp- toms. A P less than .05 was considered to indicate statis- tical significance. IBM SPSS Statistics, version 17.0, was used for the statistical analysis. Ethical Considerations The project was approved by the independent ethics committee of Spain’s regional university (INF-2014-17) and by the board of directors of Spain’s emergency medical system (20150120_21). The study was guided by the Helsinki Declaration on ethical principles for medical research involving human participants. Each patient or guardian and each nurse working in the intervention and control groups signed an informed consent form to partici- pate in the study and was assured of confidentiality and data anonymity. Results Participant Flow Twelve nurses of the 22 eligible for work with the intervention group were enrolled and trained in the CONECTEM intervention. All nurses in this group carried out the intervention in the ambulance. A total of 138 critically ill patients were consecutively enrolled in the study: 69 patients in the intervention group and 69 in the control group. Seventeen patients were excluded from the control group because of missing information on the measurement scales, and 1 patient was excluded from the intervention group because of not being an interhospital transfer (see Figure). Baseline Data The mean (SD) age of the 120 patients in the final sample was 63.4 (17.7) years. Of the 120 patients, 48 (40.0%) were female. The most common disease Assessed for eligibility Patients (n = 332) Analyzed (n = 52) Analyzed (n = 68) Selected for control group (n = 69) Excluded (n = 192) Did not meet inclusion criteria (n = 190) Declined to participate (n = 2) Figure Flow diagram of study participants. Consecutively enrolled (n = 138) Selected for intervention group (n = 69) Excluded because forms were incomplete (n = 17) Excluded because not an interhospital transfer (n = 1) E n ro ll m e n t S e le ct e d F o ll o w -u p A n a ly ze d 50 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 www.ajcconline.org types were heart condition (55 patients [45.8%]) and neurological disease (25 patients [20.8%]). Ninety-eight (81.7%) of the patients were conscious and oriented (GCS score, 15), 18 (15%) were con- scious and disoriented (GCS score, 9-14), and only 4 (3.3%) were intubated and receiving mechanical ventilation (GCS score, ≤8) (Table 2). The psychoemo- tional variables were analyzed for patients with a GCS score of greater than 9 (n = 115), as intubated patients were somewhat underrepresented. The prevalence of pain was 68.7% (95% CI, 59.8%-76.7%), with a mean score of 2 of 10 on the VAS scale. A total of 80.9% (95% CI, 72.9%-87.3%) had anxiety. Regarding PTSD symptoms, 68.7% (95% CI, 59.8%-76.7%) of patients had moderate to severe symptoms, and 31.3% (95% CI, 23.3%-40.2%) had Variable Total sample (N = 120) Intervention group (n = 68) Control group (n = 52) Table 2 Baseline characteristics at pretest for intervention and control groups Age, mean (SD), y Sex Female Male Type of disease Heart Respiratory Neurological Metabolic Polytrauma Medical Glasgow Coma Scale score, mean (range) Glasgow Coma Scale score distribution 15 14 13 9 3 Orotracheal intubation Yes No Score on visual analog scale for pain, median (range) Pain Present (score 1-10) Absent (score 0) Behavioral Pain Scale No pain Pain present State-Trait Anxiety Inventory Present Absent Score on Ramsay Sedation Scale, median (range) Score on Impact of Event Scale, median (range) Impact of Event Scale No or few symptoms Moderate symptoms Severe symptoms Score on Richmond Agitation-Sedation Scale, median (range) .76 a .85 b .85 b .46 c .75 b .58 b .08 c .42 b >.99
b

.05
b

>.99
c

.06
c

.007
b

>.99
c

63.9 (17.8)

20 (38)

32 (62)

28 (54)

3 (6)

12 (23)

1 (2)

3 (6)

5 (10)

15 (3-15)

44 (85)

6 (12)

0 (0)

0 (0)

2 (4)

2 (4)

50 (96)

2 (0-7)

32 (64)

18 (36)

2 (100)

0 (0)

36 (72)

14 (28)

5.5 (5-6)

23 (0-50)

8 (16)

13 (26)

29 (58)

−4.5 (−5 to −4)

62.9 (17.8)

28 (41)

40 (59)

27 (40)

6 (9)

13 (19)

1 (1)

7 (10)

14 (21)

15 (3-15)

54 (79)

9 (13)

2 (3)

1 (1)

2 (3)

2 (3)

66 (97)

3 (0-10)

47 (7)

18 (28)

2 (68)

1 (33)

57 (88)

8 (12)

6 (3-6)

14 (0-59)

28 (43)

11 (17)

26 (40)

−5 (−5 to −1)

63.4 (17.7)

48 (40.0)

72 (60.0)

55 (45.8)

9 (7.5)

25 (20.8)

2 (1.7)

10 (8.3)

19 (15.8)

15 (3-15)

98 (81.7)

15 (12.5)

2 (1.7)

1 (0.8)

4 (3.3)

4 (3.3)

116 (96.7)

2 (0-10)

79 (68.7)

36 (31.3)

4 (80.0)

1 (20.0)

93 (80.9)

22 (19.1)

6 (3-6)

18 (0-59)

36 (31.3)

24 (20.9)

55 (47.8)

−5 (−5 to −1)

P

No. (%) of patients

a
Independent t test.

b
2 analysis.

c
Mann-Whitney U test.

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mild symptoms. The pretest sociodemographic and
psychoemotional variables did not differ significantly
between the 2 groups, with the exception of PTSD
symptoms, with a greater percentage of patients in
the intervention group having few or no symptoms
(P = .007) (Table 2).

Effectiveness of the CONECTEM Intervention in
Improving Psychoemotional State

The results of multivariable analysis of covari-
ance with pretest-posttest differences showed statis-
tically significant differences between groups (Pillai
multivariate, F

2,110
= 57.973, P < .001). The univariate analysis of variance results showed an association between the intervention and improvement in pain and PTSD symptoms in the intervention group (P < .001; Table 3). In the comparison of anxiety (improvement or nonimprovement) between the 2 groups, a greater percentage of patients with improvement was found in the intervention group (62% vs 4%), with the difference being statistically significant (P < .001; Table 4). Correlations Among Pain, Anxiety, and PTSD Symptoms in the Posttest Period The Pearson product-moment correlation test indicated significant correlations among the 3 psy- choemotional variables: pain and anxiety (r = 0.37), pain and PTSD symptoms (r = 0.33), and PTSD symp- toms and anxiety (r = 0.51) (P < .05 for all). These correlation coefficients demonstrated moderate cor- relation among the 3 variables. Discussion Effectiveness of CONECTEM Communication Strategies The ability of nurses and critical care patients to interact is fundamental to their effective communi- cation.20,30 The results of this study demonstrate that the actions constituting the various CONECTEM communication strategies were effective in improv- ing the psychoemotional state of the critical care patients transported by ambulance. Other studies based on BCS have also indicated improvement in patient communication and level of satisfaction with care.49-51 In addition, the use of AAC techniques with critical care patients facilitates nurse-patient communication52 and relieves pain53 and psychoemo- tional symptoms such as anxiety54 and depression,55 helping to improve nursing treatment.6,11,56 However, we found no studies on critical care patient–nurse AAC in the nonhospital setting, making it impossible to compare the effects of AAC on patients in this set- ting with the effects on patients subsequently admit- ted to the ICU. Although Eadie et al34 reported that AAC in the ambulance improved communication between paramedics and patients, the literature is still insufficient to compare the scope of AAC in this field and what effects it might have on a patient who is later admitted to a hospital ICU. Effectiveness of the CONECTEM Intervention in Improving Pain, Anxiety, and PTSD Symptoms Pain. Pain is one of the most common symptoms in critical care patients, regardless of their disease, with a prevalence of 70% to 87%.57-59 In this study, the prevalence of in-ambulance pain in critical care patients was 68.7%. Given the difficulty of measuring pain in critically ill patients, several studies have been conducted on how to increase the effectiveness of the communication of pain between patient and nurse.60,61 Nurses’ training in communication skills affects their ability to accurately gauge the patient’s degree of pain and determine whether or not the patient needs anal- gesic treatment.32,54,62 In the same vein, the results of Scale Table 3 Pretest-posttest differences in scores on the visual analog scale for pain (VAS) and the Impact of Event Scale (IES) VAS IES a ”Pretest” and “posttest” refer to before and after the intervention. b ”Pretest” and “posttest” refer to before and after transport. c From pretest to posttest analysis of variance. <.001 <.001 38.449 44.659 0.1 (1.1) 0.3 (4.1) 2.1 (1.9) 22.7 (12.2) 2.2 (2.2) 22.4 (13.1) 1.9 (1.9) 6.6 (6.4) 3.3 (2.6) 17.8 (15.1) 1.1 (1.6) 11.2 (10.5) PF 1 , 11 3 cDifferenceDifferencePretesta PretestbPosttesta Posttestb Score in control group (n = 50), mean (SD)Score in intervention group (n = 65), mean (SD) Anxiety Table 4 Comparison of anxiety between …