Ambulatory orthopaedic surgery patients’ knowledge expectations and perceptions of received knowledge: Ambulatory orthopaedic surgery patients’ knowledge

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Title. Ambulatory orthopaedic surgery patients’ knowledge expectations and perceptions of received knowledgeAim.  This paper is a report of a study to compare orthopaedic ambulatory surgery patients’ knowledge expectations before admission and their

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  Ambulatory orthopaedic surgery patients’ knowledge expectations andperceptions of received knowledge Katja Heikkinen, Helena Leino-Kilpi, Ari Hiltunen, Kirsi Johansson, Anne Kaljonen, Sirkku Rankinen,Heli Virtanen & Sanna Salantera ¨ Accepted for publication 22 June 2007 Correspondence to K. Heikkinen:e-mail: katheik@utu.fiKatja Heikkinen MNSc RNLecturerDepartment of Nursing Science, Universityof Turku and Turku University of AppliedSciences, Turku, FinlandHelena Leino-Kilpi PhD RNProfessor and ChairHead of Department of Nursing Science,University of Turku and Nurse Manager,Turku University Hospital, Turku, FinlandAri Hiltunen MDHead of the OutpatientDepartment of Orthopaedic andTraumatology Clinic, Clinic TurkuUniversity Hospital, Turku, FinlandKirsi Johansson MNSc RNLecturerAnne Kaljonen BScStatisticianSirkku Rankinen MNSc RNResearch AssistantHeli Virtanen MNSc RNLecturerSanna Salantera ¨ PhD RNAdjunct ProfessorDepartment of Nursing Science, Universityof Turku, Turku, Finland HEIKKINEN KHEIKKINEN K .,  LEINOLEINO - KILPI HKILPI H .,  HILTUNEN AHILTUNEN A .,  JOHANSSON K JOHANSSON K .,  KALJONEN AKALJONEN A ., RANKINEN SRANKINEN S .,  VIRTANEN H. & SALANTERA S. (2007)VIRTANEN H. & SALANTERA ¨ S. (2007)  Ambulatory orthopae-dic surgery patients’ knowledge expectations and perceptions of received knowl-edge.  Journal of Advanced Nursing   60 (3), 270–278 doi: 10.1111/j.1365-2648.2007.04408.x Abstract Title. Ambulatory orthopaedic surgery patients’ knowledge expectations and per-ceptions of received knowledgeAim.  This paper is a report of a study to compare orthopaedic ambulatory surgerypatients’ knowledge expectations before admission and their perceptions of receivedknowledge 2 weeks after discharge. Background.  Advances in technology and population ageing are driving up thenumber of ambulatory orthopaedic surgical procedures. Shorter hospital stayspresent a major challenge for patient education. Methods.  A descriptive comparative cross-sectional study (pre- and post-test) de-sign was adopted. The data were collected from 120 consecutive patients in 2004,using the Hospital Patient’s Knowledge Expectations Scale and Hospital Patient’sReceived Knowledge Scale. All patients participated in a preoperative educationsession given by a nurse. Results.  Patients expected more knowledge than they actually perceived that theyreceived on all dimensions except the bio-physiological. They perceived that theyreceived least knowledge about experiential, ethical, social and financial dimensionsof knowledge. Knowledge expectations correlated with age and professional edu-cation. Perceptions of received knowledge correlated with earlier ambulatory sur-gery, and both expected knowledge and perceptions of received knowledge wererelated to the level of basic education. Conclusion.  Patients’ knowledge expectations are greater than the knowledge theyperceived that they receive, and they cannot become empowered if they lackimportant knowledge. Further research is needed to learn about meeting patients’knowledge expectations. Keywords:  expectations, Hospital Patient’s Knowledge Expectations Scale, Hospi-tal Patient’s Received Knowledge Scale, knowledge, nursing, orthopaedic surgery,patient teaching ORIGINAL RESEARCH  JAN 270    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  Introduction Day-case surgery is continuing to increase (OECD HealthData 2007) and to be used for more complex procedures(Keskima ¨ki 2003, OECD Health Data 2007). For example,arthroscopic surgery has rapidly expanded and is now usedfor many procedures that formerly required opening upthe knee. At present, more than 1 Æ 5 million arthroscopicprocedures are performed each year around the world(The Whitaker Foundation 2006). In Finland, this num-ber is about 21,000 each year (National Research andDevelopment Centre for Welfare and Health, Stakes2006).New surgical techniques combined with shorter careperiods mean that patients need to learn more in less timethan before (Dougherty 1996, Bernier  et al.  2003). Wellaware of the growing challenge, the Association of Peri-operative Registered Nurses (AORN 2005) has committeditself to promoting patient safety in ambulatory settings,among other things by means of ‘preoperative teaching’.Ambulatory orthopaedic surgery patients are usually satisfiedwith their care (Harju 1991, Cardosa  et al.  1994, Sigurdar-dottir 1996, Bain  et al.  1999). However, the care of patientsis not always uncomplicated (Ruuth-Seta ¨la ¨  et al.  2000,McGrath  et al.  2004, Watt-Watson  et al.  2004, Chung et al.  2007).Knowledgeable patients seem to cope better with surgerythan less knowledgeable patients (Goldsmith & Safran 1999,Rankinen  et al.  2007), and knowledge also relieves anxiety(Kratz 1993, Grieve 2002). Patients are encouraged to settheir own goals and to take an active part in decision-makingand care so that they have a sense of empowerment. Inambulatory care, the empowering process starts with preop-erative preparation: information should be provided to assistpatients in achieving their goals (Anderson 1991, Pellino et al.  1998). In this study, we analysed patient education bycomparing knowledge expectations and perceptions of received knowledge of ambulatory orthopaedic surgerypatients. Our baseline assumption was that the more thecorrespondence is between patients’ expected and receivedknowledge, the stronger is the possibility of having a sense of empowerment. The knowledge that makes it possible tobecome empowered can be divided into six dimensions: bio-physiological, functional, experiential, ethical, social andfinancial (Leino-Kilpi  et al.  1998, 1999). We also assumedthat patients themselves are able to identify gaps in their ownknowledge, and that they know what kind of knowledgewould be useful for them. Giving information is thus notenough; nurses need to analyse patients’ knowledge expec-tations and their perceptions of received knowledge to be ableto support them in becoming empowered (Leino-Kilpi  et al. 1998, 1999, Rankinen  et al.  2007).In this study, we used the term knowledge to includeinformation also. Knowledge consists of both informationand personal understanding of it. Understanding involves aperson’s own knowledge base and the processing of knowl-edge (Chambers dictionary of synonyms and antonyms 1989,MOT Collins English Dictionary 1.0). Background Ambulatory orthopaedic surgery patients’ knowledgeexpectations Earlier studies provide only a limited view on orthopaedicpatients’ knowledge expectations, and the emphasis hasbeen on the bio-physiological and functional dimensions.Samples in these studies have been quite small and the datacollected by questionnaires (Linden & Bergbom Engberg1995,  n  = 105; Majasaari  et al.  2005,  n  = 60), interviews(Thatcher 1996,  n  = 6) or diaries (Dewar  et al.  2004, n  = 238).It has been suggested that all ambulatory surgical patientsneed a great deal of similar preoperative (such as how toprepare for the operation) and postoperative information(Dewar  et al.  2004). Linden and Bergbom Enberg (1995)used a questionnaire to ask ambulatory surgery patients( n  = 105) what kind of oral and written information they hadwanted and received. Patients who had undergone arthro-scopic knee surgery wanted to talk with the surgeon aboutthe bio-physiological dimension of knowledge, such as thecauses of their discomfort and the condition of the knee, andabout the functional dimension of knowledge, such as whenthey could return to normal activity and work, what activitieswere allowed and their optimal condition during the firstpostoperative week. Thatcher (1996) also found that patientsprimarily expected knowledge about activities or rest beforeand after the operation.Family members of ambulatory orthopaedic patients havealso been investigated. In the questionnaire study byMajasaari  et al.  (2005), more than half of the patients( n  = 60) believed that their family members perceived thatthey had received adequate information during the ambula-tory surgery process. One in five families perceived that theyhad received no information at all, and some wanted moreexplanation and greater privacy. More than two-thirds of thepatients (68%,  n  = 60) evaluated the information provided ascomplete, good or adequate, but 23% described it as less than  JAN: ORIGINAL RESEARCH  Ambulatory orthopaedic surgery patients’ knowledge   2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  271  adequate (on a five-point scale: complete, good, adequate,inadequate and no information). Ambulatory orthopaedic surgery patients’ perceptions of received knowledge Earlier studies have evaluated the amount and adequacy of functional, social, bio-physiological and experiential dimen-sions of knowledge received by ambulatory orthopaedicsurgery patients. These studies have predominantly usedquestionnaires (Linden & Bergbom Engberg 1995,  n  = 105;Sigurdardottir 1996,  n  = 72) or interviews (Thatcher 1996, n  = 6; Fitzpatrick  et al.  1998,  n  = 30; Bernier  et al. 2003,  n  = 116) for the collection of data. In one study,the data were collected using diaries (Dewar  et al.  2004, n  = 238).Patients are generally satisfied with the education process(Fitzpatrick  et al.  1998), and the availability of writteneducational materials increases patient satisfaction (Sigur-dardottir 1996, Thatcher 1996, Dewar  et al.  2004). How-ever, the evaluation of perceptions of received informationdoes sometimes cause difficulties. Patients may not recall theinformation they have been given, because they have been tooanxious to absorb it (Dewar  et al.  2004).Patients have also been reported to receive knowledgeabout the functional dimension of knowledge, such as clinicalskills (Sigurdardottir 1996), about the social dimension, suchas patients’ role and psychosocial support (Bernier  et al. 2003), and about the bio-physiological dimension of knowl-edge, such as the surgical procedure and technology of care(Bernier  et al.  2003) and complications (Fitzpatrick  et al. 1998).Patients’ information needs are not always met (Sigurdar-dottir 1996, Bernier  et al.  2003). Earlier studies have reporteda lack of received knowledge on the functional dimension,such as skills training (Bernier  et al.  2003), and what to do orwho to contact if they develop symptoms they do not knowabout (Linden & Bergbom Enberg 1995). Linden andBergbom Enberg also reported that patients claim to havereceived no information about recommended activities orhow to take care of their personal hygiene. One-quarter of these patients ( n  = 105) did not receive any written informa-tion about analgesics, while 32% perceived that they receivedno information about how to take care of the wound. Lack of knowledge on the bio-physiological dimension has also beenreported, such as information about the operation (Sigurdar-dottir 1996) and complications (Fitzpatrick  et al.  1998).Patients have also reported receiving less knowledge on theexperiential dimension of knowledge, such as sensations ordiscomfort (Bernier  et al.  2003). The study Aim The aim of the study was to compare orthopaedic ambula-tory surgery patients’ knowledge expectations before admis-sion and their perceptions of received knowledge 2 weeksafter discharge. Design A descriptive comparative design was used (Burns & Grove2005). Empirical data were collected twice: before theambulatory surgery in connection with a preoperativeeducation session and 2 weeks after the operation. Allpatients participated in a preoperative education session.The education session consisted of individual face-to-faceeducation with a nurse. One nurse delivered this educationsession, which lasted about 30 minutes and took place in aseparate room in the day surgery unit. Patients were given aleaflet about the content of the session. This contentwas divided into six dimensions – bio-physiological,functional, experiential, ethical, social and financial – con-sidered as helping patients to become empowered intheir care (Leino-Kilpi  et al.  1998, 1999, Rankinen  et al. 2007). Participants The study population consisted of all ambulatory surgerypatients in one university hospital in Finland during a 6-month period in 2004 (March to August). The inclusioncriteria were age over 18 years, Finnish speaking, no cogni-tive disabilities, capable of completing the questionnaire andgiving informed consent. Altogether, 200 patients wereeligible but 50 declined to participate, and five questionnaireswere discarded because of missing data. The final responserate was thus 73% (145/200). From these patients, onlyorthopaedic patients ( n  = 120) were selected, which made thegroup more homogeneous, based on previous results with theinstrument (Rankinen  et al.  2007). A power analysis wasperformed and this showed that 120 patients were needed fora power level of 0 Æ 80, an anticipated moderate relationship( r  = 0 Æ 30) and a probability level of 0 Æ 05 (Cohen & Cohen1984). Data collection The data were collected with two structured parallelinstruments (Leino-Kilpi  et al.  1998, 1999): the Hospital K. Heikkinen  et al. 272    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  Patient’s Knowledge Expectations Scale and the HospitalPatient’s Received Knowledge Scale, which had been devel-oped earlier (Leino-Kilpi  et al.  2005, Rankinen  et al.  2007).Both of these 32-item (plus 13 sub-items – total 45)instruments measure empowering knowledge and includesix subscales: bio-physiological (seven items + 13 sub-items;e.g. knowledge about illness, symptoms, treatment andcomplications), functional (seven items; e.g. mobility, rest,nutrition and body hygiene), experiential (three items; e.g.emotions and hospital experiences), ethical (nine items; e.g.rights, duties, participation in decision-making and confi-dentiality), social (two items; e.g. families, other patientsand patient unions) and financial (four items; e.g. costs andfinancial benefits) dimensions of knowledge (Leino-Kilpi et al.  1998, 1999).Content validity of the instruments was based on thetheoretical literature on knowledge as well as on statementsby an expert panel (three nurses, two physicians and threeresearchers). The instruments were piloted with a sample of 10 ambulatory surgery patients, but no changes wereneeded.The reliability (internal consistency) of the instruments wasestimated using Cronbach’s alpha coefficient, which was0 Æ 930 for the total of 32-item Hospital Patient’s KnowledgeExpectations Scale and 0 Æ 771 (experiential) – 0 Æ 953 (eco-nomical) for its subscales, and 0 Æ 901 for the total HospitalPatient’s Received Knowledge Scale and 0 Æ 762 (functional) –0 Æ 970 (economical) for its subscales. The required Cronbach’salpha coefficient for a new measure is 0 Æ 7 (Burns & Grove2005).The Hospital Patient’s Knowledge Expectations Scale wascompleted before the preoperative education session, 2 weeksprior to their ambulatory surgery, and the Hospital Patient’sReceived Knowledge Scale 2 weeks after surgery. Both wereassessed on a four-point scale (1 = strongly disagree to4 = strongly agree), with higher scores indicating higherlevels of knowledge expectations and perceptions of receivedknowledge. The response option ‘not applicable’ (0) wasexcluded from further analysis.The following patient demographic characteristics wereincluded: gender, age, basic and professional education,employment status, employment in social and health care,long-term illness, earlier ambulatory surgery and level of anxiety.A nurse on the ward gave the first questionnaires topatients before the education session. Patients returned thefirst questionnaire in sealed envelopes to the nurse. Thesecond questionnaire was given to patients after surgery andthey returned it by mail to the researcher. Ethical considerations All relevant permissions and ethics approval to conduct thisresearch were obtained from the organization concerned(ETENE 2004). Patients were informed (in writing) of thepurpose of the study and the principles of voluntary andanonymous participation and gave written informed consent. Data analysis The data were analysed statistically using  SASSAS  System forWindows, release 9.1 (SAS Institute Inc., Cary, NC, USA).Summary variables of the Hospital Patient’s KnowledgeExpectations Scale and the Hospital Patient’s ReceivedKnowledge Scale were constructed on six dimensions of knowledge – bio-physiological, functional, experiential, eth-ical, social and financial – by calculating the means for thecorresponding items. In addition, the total index of knowl-edge was calculated by using the means of the six summaryvariables. The summary variable was accepted if the patienthad answered at least 50% of the items. Differences in meansbetween knowledge expectations and perceptions of receivedknowledge were tested by using the  t  -test for dependentsamples. A one-way analysis of variance with contrasts wasused to test the effect of the demographic variables onknowledge expectation and perceptions of received knowl-edge.In addition, variables hereafter called HIT variables werecalculated from the differences between knowledge expecta-tions and perceptions of received knowledge in six summaryvariables and classified into three classes using themean ± SDSD  as limits: (1) received more knowledge thanexpected (difference > mean +  SDSD ); (2) as expected(mean  SDSD  £  difference  £  mean +  SDSD ); and (3) less thanexpected (difference < mean  SDSD ). These HIT variables wereexplained using a multinomial logistic regression analysis,where the risk describes the probability of not receiving theexpected knowledge, using the first of each category of theexplaining variable (demographic variables such as age andgender) as reference category (with risk = 1). For example,the risk of missing the expected knowledge was 5 Æ 433 timeshigher in the oldest age category compared with youngpeople ( P  = 0 Æ 041) (see Table 4.).The effect of sociodemographic variables (gender, age,basic education, professional education, employment status,previous ambulatory surgery, long-term disease and anxiety)and education from the pre- to postoperative phases onknowledge expectations and perceptions of received knowl-edge was tested using a multinomial logistic regression  JAN: ORIGINAL RESEARCH  Ambulatory orthopaedic surgery patients’ knowledge   2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd  273  analysis. In all tests, the level of statistical significance was setat  P < 0 Æ 05 (Burns & Grove 2005). Results Sample characteristics A total of 120 ambulatory orthopaedic surgery patients wereenrolled in the study (Table 1). Most of the operations werearthroscopies (43%) of the knee ( n  = 24), shoulder ( n  = 23),ankle ( n  = 2) or elbow ( n  = 2). Other operations includedhardware removal and various hand operations. Over half (54%) of the participants were women (Table 1). The averageage of participants was 45 Æ 85 years (range 19–83,  SDSD  13 Æ 95).Nine years of schooling was the single largest category of basic education (46%); in professional education the largestcategory was a first degree. Half of the patients (53%, n  = 63) had had earlier ambulatory surgery. Knowledge expectations and perceptions of receivedknowledge Patients had high knowledge expectations (Table 2). Themean for all dimensions was 3 Æ 350 (Scale 1–4). Questionsabout knowledge expectations and perceptions of receivedknowledge were answered by 113 of the 120 patients. Thehighest knowledge expectations were recorded in the bio-physiological (mean 3 Æ 597) and the lowest in the experiential(mean 3 Æ 022) dimension. The second lowest knowledgeexpectations were seen in the social dimension (mean3 Æ 154). In the bio-physiological dimension, the highestexpectations were found for knowledge of possible compli-cations (mean 3 Æ 823) and how to prevent complications(mean 3 Æ 789), and in the functional dimension in aspects suchas what kind of physical exercise is allowed (mean 3 Æ 791). Inthe experiential dimension, expectations were the lowestconcerning feelings of anxiety or fear (mean 3 Æ 031) and whothey could tell about their feelings (mean 2 Æ 96).Patients perceived that they received less knowledge thanthey had expected (Table 2). The mean for all dimensionsof received knowledge was 2 Æ 877. The most knowledge wasreceived on the bio-physiological dimension (mean 3 Æ 614)and the least on financial (mean 1 Æ 954). In the bio-physiological dimension, patients perceived that theyreceived most knowledge on eating and drinking (mean Table 1  Sample characteristics ( n  = 120)Variables Frequency Per centGender 120Female 65 54Male 55 46Age in years 12019–34 29 2435–50 43 3651–65 40 3366–83 8 7Basic education 1176 years’ schooling 28 249 years’ schooling 54 4612 years’ schooling 35 30Professional education 112None 17 15Secondary level 48 43Upper secondary/college 30 27Polytechnic/university 17 15Employment status 120Employed 77 64Retired 20 17Homework 4 3Student 6 5Unemployed 11 9Sick leave 2 2 Table 2  Differences between ambulatory orthopaedic surgery patients’ knowledge expectations and received knowledge (scale 1–4) on thedimensions of knowledgeDimensions of knowledge (32 items plus 13 sub-items)  n Expected ReceivedDifference  P Mean  SDSD  Mean  SDSD Bio-physiological knowledge (7 items plus 13 sub-items) 108 3 Æ 597 0 Æ 476 3 Æ 614 0 Æ 403 +0 Æ 017 0 Æ 76 nsFunctional knowledge (7 items) 96 3 Æ 488 0 Æ 528 3 Æ 270 0 Æ 597   0 Æ 218 0 Æ 007Experiential knowledge (3 items) 83 3 Æ 022 0 Æ 871 2 Æ 562 0 Æ 967   0 Æ 460 0 Æ 002Ethical knowledge (9 items) 100 3 Æ 360 0 Æ 633 2 Æ 597 0 Æ 860   0 Æ 763  < 0 Æ 001Social knowledge (2 items) 78 3 Æ 154 0 Æ 819 2 Æ 417 1 Æ 005   0 Æ 737  < 0 Æ 001Financial knowledge (4 items) 85 3 Æ 307 0 Æ 858 1 Æ 954 0 Æ 988   1 Æ 353  < 0 Æ 001Total 113 3 Æ 350 0 Æ 601 2 Æ 877 0 Æ 715   0 Æ 473  < 0 Æ 001 t  -test for dependent samples. K. Heikkinen  et al. 274    2007 The Authors. Journal compilation    2007 Blackwell Publishing Ltd
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