Ambulatory orthopaedic surgery patients’ symptoms with two different patient education methods

Ambulatory orthopaedic surgery patients’ symptoms with two different patient education methods

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  Ambulatory orthopaedic surgery patients’symptoms with two different patient educationmethods Katja Heikkinen MNSc, RN  a, * , Helena Leino-Kilpi PhD,RN (Professor and Head of Department/Nurse Manager)  b ,Tero Vahlberg MSc (Biostatistian)  c , Sanna Salantera¨ PhD,RN (Professor/Nurse Manager)  b a University of Turku, Department of Nursing Science, FIN-20014 Turku, Finland  b University of Turku, Department of Nursing Science, Hospital District of Southwest Finland, Finland  c University of Turku, Department of Biostatistics, Finland  KEYWORDS Patient education;Internet;Ambulatory surgery;Symptom Summary  Aim:  To evaluate changes in ambulatory orthopaedic surgery patients’symptoms during the surgical process and to compare whether the two differentpatient education methods had an effect on patients’ symptoms during the ambula-tory surgical process. Design:  A randomised controlled trial was used. Ambulatory orthopaedic surgerypatients in one university hospital in Finland participated in the study.  Methods:  Patients were randomised to either an experiment group ( n  = 72) thatreceived Internet-based patient education or to a control group ( n  = 75) thatreceived face-to-face education with a nurse. Data were collected at seven differ-ent time points during the surgical process. A structured instrument called ‘‘TheSymptoms’’ with a visual analogue scale was used. Results were statistically ana-lyzed. Results:  Ambulatory orthopaedic surgery patients had few severe symptoms dur-ing the surgical process. Severity of symptoms changed during the surgical process.The severity of symptoms did not decrease after the patient education, and theywere highest on the first post-operative day. There were no differences in the symp-toms of patients in the two groups. Conclusion:  Patients symptoms’ were dependent of the surgical process andwere strongest right after the surgery. Thus, both education methods can be recom-mended equally when working with ambulatory orthopaedic surgery patients.  c  2011 Elsevier Ltd. All rights reserved. 1878-1241/$ - see front matter   c  2011 Elsevier Ltd. All rights reserved.doi:10.1016/j.ijotn.2011.04.004* Corresponding author. Tel.: +358 50 401 9999; fax: +358 2333 8400. E-mail addresses:, Heikkinen).International Journal of Orthopaedic and Trauma Nursing (2012)  16 , 13–  Introduction An increasing number of patients are undergoingoperations in ambulatory surgery settings (OECDHealth Data, 2010). After spending short periodsin hospital, ambulatory orthopaedic surgery pa-tients might experience different levels of pain(Chung, 1995; Jenkins et al., 2001; Rawal, 2010;Apfelbaum et al., 2003; Coll et al., 2004a; Susilahtiet al., 2004; Suhonen et al., 2007; McHugh andThoms, 2002; Idvall et al., 2008); amounts of bleed-ing (Chung, 1995); vomiting (Chung, 1995; Stock- dale and Bellman, 1998; Beauregard et al., 1998;Wu et al., 2002; Susilahti et al., 2004); nausea (Jen-kins et al., 2001; Oberle et al., 1994; Chung, 1995;Beauregard et al., 1998; Wu et al., 2002; Susilahtiet al., 2004); headache (Chung, 1995; Beauregardet al., 1998); sore throat (Chung, 1995; Beauregardet al., 1998); dizziness (Chung, 1995; Beauregardet al., 1998); fatigue (Oberle et al., 1994; Beaure-gard et al., 1998; Susilahti et al., 2004); drowsiness(Chung, 1995; Beauregard et al., 1998); and hoarse-ness (Chung, 1995; Beauregard et al., 1998).The main reasons for unplanned readmissionsafter ambulatory surgery are pain, urinary reten-tion, wound bleeding, infection, and haematoma(Watson et al., 2004). Poorly managed pain mayalso interfere with wound healing, adding to a pa-tient’s suffering, which can prolong his or herrecovery (Bardiau et al., 2003). Despite the factthat ambulatory orthopaedic surgery patientsexperience different symptoms during the surgicalprocess, the severity of symptoms other than painis rarely measured. There seems to be variationsin the intensity of symptoms, and comparing symp-toms is problematic because researchers use dif-ferent instruments (Coll et al., 2004a,b).It is known that patients’ experience of pain var-ies during the surgical process. Post-operative painis usually the strongest during the first and secondday (Oberle et al., 1994; McHugh and Thoms, 2002;Apfelbaum et al., 2003; McGrath et al., 2004).Beauregard et al. (1998) found that almost half ofpatients ( n  = 89) reported moderate to severe painduring the first 24 h after discharge. Pain de-creased over time but was severe enough to inter-fere with daily activities, even seven days aftersurgery. McHugh and Thoms (2002) studied pa-tients’ pain expressions using Verbal DescriptorScale (VDS scale; none, mild, moderate, severepain). Severe pain presented as a problem forapproximately 20% of patients ( n  = 120) on the sec-ond post-operative day and continued to present asa problem for a few of the patients on the fourthpost-operative day. Furthermore, on the fourthpost-operative day, approximately 20% of patientsreported that their pain had not improved. Apfel-baum et al. (2003) reported that approximately80% ( n  = 250) of patients in their study experiencedacute pain after surgery. Half of these patientsexperienced moderate pain and almost 40% experi-enced severe to extreme pain at some time duringtheir post-surgical recovery period. Overall, 82% ofpatients reported that they had experienced somepain until the second week after their discharge.Education supports patients to manage theirsymptoms and recovery (Wong et al., 2010). Sev-eral researchers have studied the benefits of pre-operative education on post-operative symptoms,using meta-analyses and reviews (Devine, 1992;Shuldham, 1999; Coll et al., 2004a; Johanssonet al., 2004, 2005; Wofford et al., 2005). Someresearchers found that pre-operative patient edu-cation is effective in reducing the following post-operative complications: pain (Devine,1992;Shuldham, 1999; Lewis, 2003), nausea, vomiting,and fatigue (Johansson et al., 2004). There are,however, conflicting results concerning pain reduc-tion (Johansson et al., 2004, 2005; Wofford et al.,2005). There are a limited number of studies focus-ing on ambulatory orthopaedic surgery patients’education or the evaluation of different educationmethods. Goldsmith and Safran (1999) studied theuse of Internet-based education for reducing ambu-latory surgery patients’ post-operative pain. Pa-tients receiving extra information about painfrom a website evaluated their post-operative painas lower than patients receiving information thatonly related to the surgical process. It is typicalthat educational interventions focus on one, orvery few areas of knowledge, such as the bio-phys-iological e.g. pain, whilst also measuring painseverity as an outcome (Goldsmith and Safran,1999). Editor’s comment This article compares two methods used to educate patients which is then assessed to see what impactit has on a number of variables over a given length of time. Trying to cover all aspects of education inrelation to the patients orthopaedic experience, and attempting to guage its affect on problems suchas pain, is always difficult. This study uses previous literature and builds upon it to give us a little moreinsight to the care of ambulatory orthopaedic patients. BS14 K. Heikkinen et al.  In our study, an empowering Internet-based pa-tient education method was used, meaning thatthe education used a multidimensional approachrelating to the whole ambulatory surgical process(Leino-Kilpi et al., 1998, 1999). We hypothesizedthat this knowledge would cognitively empower pa-tients to handle the severity of symptoms duringtheir ambulatory surgical process (Leino-Kilpiet al., 1998, 1999; Heikkinen et al., 2008). Aim of the study Our goal was to evaluate changes in ambulatoryorthopaedic surgery patients’ symptoms duringthe surgical process and to compare whether thetwo different patient education methods had an ef-fect on patients symptoms during the ambulatorysurgical process. The experiment group receivedInternet-based patient education, and a controlgroup received face-to-face education conductedby a nurse.Research questions:(1) How did the patients rate their symptoms atseven time points during the ambulatory sur-gical process?(2) Were the symptom scores associated with thephases of the surgical process?(3) Did either of the two different patient educa-tion methods have an effect on the patients’symptom scores? Methods Study design and sample Ambulatory orthopaedic surgery patients were ran-domly allocated to either an experiment or controlgroup. All ambulatory orthopaedic surgery patients( n  = 173) attending one of five university hospitalsin Finland during the period July 2005 to September2006 were eligible for inclusion in this study. Theinclusion criteria were: patients age over 18 years,Finnish-speaking, access to the Internet at homeand able to use it, those with no cognitive disabil-ities, those capable of completing the instruments,and those who were able to give informed consent.The only exclusion criteria related to those pa-tients who were rated at being above the AmericanSociety of Anesthesiologists (ASA) classification ofII or above – otherwise a normal healthy patient.These patients were excluded due to pre-operativeeducation. All patients fulfilling the inclusion crite-ria received an invitation to participate in ourstudy along with the letter they received concern-ing the ambulatory surgery operation. The firstinstrument (baseline) was included with the invita-tion. The response rate was 86% (149/173).Patients were randomized either to the experi-ment group ( n  = 72), which received patient educa-tion through the Internet, or to a control groupreceiving oral education by nurses ( n  = 77). Two pa-tients in the control group were excluded from thestudy because they did not participate in the pa-tient education. Randomization was stratified on:gender, age, and the location of the operation.Neither the patients nor the study co-ordinatorwere aware of the educational assignment untilafter the randomisation. Experiment group Patients in the experiment group participated in anInternet-based patient education program de-signed for this study. It was a structured pro-gramme and based on six areas of knowledge:bio-physiological, functional, experiential, ethical,social, and financial (Leino-Kilpi et al., 1998,1999), all of which are defined as being importantin the cognitive empowerment process (Heikkinenet al., 2008). The website contained different top-ics related to the surgery: instructions for patientspreparing for the operation, events that occur onoperation day, follow-up care, and ethical andfinancial aspects. Patients visited the website 1–121 days (mean = 14 days) before the operation.They used the website from one to six times andspent an average of 81 min using the site (rangedfrom 10 to 300 min). Patients were able to contacta nurse via email or phone. However, only a fewpatients used this option. Control group Patients in the control group participated in face-to-face sessions with a nurse (in total, eight nurses)that were held in a room in the ambulatory surgeryunit. Patients were given a leaflet about the con-tent of the session. Education with a nurse hadthe same theoretical content as the Internet-basededucation. All participatory nurses were trained forthis study. They knew the content of the website,and they had a printed version of the website con-tents available to them. The ‘control’ educationsession lasted on average 22 min (range 10–40 min), and it took place on average 9 days beforethe operation (range 1–55 days).Ambulatory orthopaedic surgery patients’ symptoms with two different patient education methods 15  Instruments and data collection The data were collected using a structured instru-ment called ‘‘The Symptoms’’, which comprisedof two questionnaires (S), one a pre-operative(S PRE ) and one a post-operative (S POST ) version.These were used in total seven times in order tosee if there were any changes in patients’ evalua-tions of their symptoms during the ambulatory sur-gical process. The survey was used at the followingtimes: (1) before pre-operative patient education(baseline); (2) after pre-operative patient educa-tion, but still pre-operatively; (3) on operationday before surgery; (4) one day after the opera-tion; (5) three days after the operation; (6) twoweeks after the operation; and (7) four weeks afterthe operation.The S PRE  asked about five symptoms that mightoccur pre-operatively: headache, pain in the areaof planned surgery (pain in the operated area),pain elsewhere, sleeplessness, and difficulties withmovements. The S POST  asked about 16 items,including the five symptoms in the S PRE  and elevensymptoms that occur especially post-operatively:vomiting, nausea, dizziness, tiredness, problemswith urination, problems with digestion (like con-stipation), problems with washing and with hy-giene, swelling of the operation area, redness ofthe operation area, bleeding of the operation area,and fever.Both the S PRE  and S POST  evaluation of symptomswere undertaken using a vertical Visual AnalogueScale (VAS; 100 mm). Scores on the left side (0)indicated low intensity or severity, and those onthe right side (100) indicated intolerable intensityor severity of symptoms. The questions in S PRE and S POST  were based on theoretical literature(e.g., Oberle et al., 1994; Chung, 1995; Beauregardet al., 1998; Susilahti et al., 2004) and on state-ments by an expert panel (three nurses, two physi-cians, and three researchers). The instrument waspiloted by 17 ambulatory surgery patients. Demo-graphic characteristics obtained from the baselineincluded: age, gender, basic and vocational educa-tion, employment status, employment in social andhealth care, the number of ambulatory surgeries,and long-term illness. Statistical analysis SPSS for Windows (version 16.0) was used to ana-lyze the data. Continuous variables are presentedas means and standard deviation, and categoricaldata are presented as frequencies and percent-ages. The Pearson Chi-Square test was used tomake comparisons of the samples demographiccharacteristics among people in the groups.Each patient’s estimations of his or her symp-toms (measured with the S PRE  and S POST ) weregrouped into three classes: low (0 6 29.9 mm),moderate (30.0 6 69.9 mm), and high(70.0 6 100 mm). The decision to use this rangeof scores was based on earlier studies about theuse of VAS in the context of pain (Collins et al.,1997; Kelly, 2001). Usually scores over 30 is indica-tive of a patient needing special attention and sup-port from the health professional (Ene et al.,2008).The estimations of symptoms were used asdependent variables in an ordinary logistic regres-sion with generalized estimating equations, whichaccounts for an association between repeatedmeasurements. Ordinary logistic regression in-cluded the effect of the method of patient educa-tion used, the measurement of time, and theinteraction between the method of patient educa-tion and the measurement of time. All tests wereconducted at the 5% significance level (Burns andGrove, 2005). Results Description of patients There were no statistically significant differencesbetween the groups ( n  = 147: 72 in the exp. groupand 75 in cont. group) in the demographic variables(  p  = 0.189–0.976). Fewer patients were women(46% exp. group/44% cont. group). Patients’ agesranged from 18 to 69 years in the experiment groupand 18–67 in the control group (mean 44.2 years inthe exp. group and 43.5 years in the cont. group).Most of the patients had no long-term illness (79%in both groups), and most of the patients in bothgroups were in the  ASA I  group (68% in the in the cont. group). Most of the patientshad undergone a  shoulder arthroscopy operation ;(62% in the exp. group/57% in control group). Therest had undergone a  knee arthroscopy operation .More than half of the patients had experienced ear-lier ambulatory surgery (58% exp./57% Patients’ evaluations of their symptoms Ambulatory orthopaedic surgery patients scoredtheir symptoms low. Before the patient education(baseline), several patients in both groups ratedtheir symptoms as moderate or high. More than16 K. Heikkinen et al.  half of the patients scored their pain at the opera-tive area as moderate or high. A third of the pa-tients (30%) scored their pain as being locatedelsewhere other than the operation area and rateddifficulties with movements to be moderate orhigh. After the patient education (2nd measure-ment), the scores relating to difficulties withmovements decreased and was statistically signifi-cant (  p  = 0.018). After the operation (3rd measure-ment), many patients reported moderate or highscores of pain in the operated area and difficultieswith movement were common (40–60%). Fourweeks post-operatively (7th measurement),approximately 10% of patients in both groupsscored their pain as being somewhere else withsleeplessness and difficulties with movementsrated as moderate. Approximately 30% of patientsin the experiment group and approximately 10%of patients in the control group were experiencingmoderate pain in the operated area (Table 1).Patients’ symptoms changed in a statisticallysignificant way during the surgical process(  p 6 0.001–0.043).  After the patient education ,patients’ scores related to difficulties with move-ment decreased at a statistically significant rate(  p  = 0.018). On  the operation day  , all symptomscores decreased (  p 6 0.001–0.013) compared tothe baseline.  Two weeks post-operatively  , all pa-tients’ symptom scores decreased statistically, sig-nificantly (Table 1).The method of patient education (the experi-ment and control group) had no significant effecton most symptom scores (  p  = 0.084–0.589). How-ever, this did impact on the scores in response tothe questions regarding pain in relation to ‘some-where else’ other than the operated area(  p  = 0.033). Four weeks post-operatively patientsin the experiment group scored their pain in a re-gion ‘somewhere else’ higher than patients in thecontrol group. Interaction between the method ofpatient education and symptoms at different mea-surement times were tested (logistic regression),and no significant interactions were found(  p  = 0.258–0.903). This result indicates that thechange in symptom scores was similar at differenttime points in both groups throughout the ambula-tory surgical process.The symptoms that were measured only post-operatively were vomiting; nausea, dizziness,tiredness, problems with urination, problems withdigestion (like constipation), problems with wash-ing and with hygiene, swelling of the operationarea, redness of the operation area, bleeding ofthe operation area, and fever. Patients gave thesesymptoms rather high ratings shortly after theoperation. On the first post-operative day, almosthalf of the patients in both groups scored theirtiredness, problems with washing and hygiene,and swelling of the operation area as moderate orhigh. Four weeks after the operation (7th measure-ment), approximately 7% of patients in both groupsgave moderate scores to tiredness but low scoresto other symptoms (0–5.6%).Patients evaluations on post-operatively evalu-ated symptom scores changed significantly duringthe ambulatory surgical process at different mea-surement times: dizziness (  p 6 0.001), tiredness(  p 6 0.001), problems with digestion (  p  = 0.001),problems with washing and with hygiene (  p 6 0.001), swelling of the operation area (  p 6 0.001), redness of the operation area (  p  = 0.038)and bleeding of the operation area (  p  = 0.033). Onthe third post-operative day, the scores on dizzi-ness (COR = 0.13,  p  = 6 0.001), tiredness (COR =0.37,  p  = 6 0.001), problems with washing and withhygiene (COR = 0.55,  p  = 6 0.001), swelling of theoperation area (COR = 0.45,  p  = 6 0.001), rednessof the operation area (COR = 0.31,  p  = 0.025),bleeding of the operation area (COR = 0.18,  p  = 0.033) decreased. Four weeks post-operatively,the decrease was statistically significant on the fol-lowing scores: tiredness (COR = 0.12,  p  = 6 0.001),problems with digestion (COR = 0.21,  p  = 6 0.001),washing and hygiene (COR = 0.03,  p  = 6 0.001),swelling of the operation area (COR = 0.05,  p  = 6 0.001), and redness of the operation area (COR =0.23,  p  = 0.02).The method of patient education (the experi-ment and control group) had no significant effecton post-operatively evaluated symptom scores(  p  = 0.283–0.981). The interaction between themethod of patient education and symptoms (mea-sured only post-operatively) at different measure-ment times were tested with logistic regression,and no significant interactions were found(  p  = 0.159–0.959), indicating that the change insymptom scores was similar in both groups at dif-ferent time points throughout the ambulatory sur-gical process. Discussion We evaluated the changes in ambulatory orthopae-dic surgery patients’ reported symptoms during thesurgical process and compared two different pa-tient education methods: Internet-based patienteducation (experiment) and face-to-face educa-tion conducted by a nurse (control) to see whetherthey had an effect on patients’ symptoms duringthe ambulatory surgical process.Ambulatory orthopaedic surgery patients’ symptoms with two different patient education methods 17
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