Ambulatory orthopaedic surgery patients' emotions when using two different patient education methods.
A randomised controlled trial was used to evaluate elective
ambulatory orthopaedic surgery patients' emotions during
internet-based patient education or face-to-face education with a nurse.
The internet-based patient education was designed for this study and
patients used websites individually based on their needs. Patients in
the control group participated individually in face-to-face patient
education with a nurse in the ambulatory surgery unit. The theoretical
basis for both types of education was the same. Ambulatory orthopaedic
surgery patients scored their emotions rather low at intervals
throughout the whole surgical process, though their scores also changed
during the surgical process. Emotion scores did not decrease after
patient education. No differences in patients' emotions were found
to result from either of the two different patient education methods.
KEYWORDS Patient education / Internet / Ambulatory surgery / Emotion
Orthopedic surgery (Research)
Patient education (Methods)
Patient education (Research)
Health behavior (Research)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: July, 2012 Source Volume: 22 Source Issue: 7|
|Topic:||Event Code: 310 Science & research Canadian Subject Form: Health behaviour|
Admission to a hospital for surgery provokes a great deal of patient anxiety(Speilberger et al 1973, Cochran 1984, Kiviniemi 2006, Mitchell 2008, Mitchell 2010) and fear (Shuldham 1999) And it is known that fear of the unknown can cause preoperative anxiety (Graham & Conley 1971). There are also studies that suggest that different types of surgeries might have an effect on emotions, and that major surgery causes greater anxiety than minor surgery (Koivula et al 2002). Many emotions, such as nervousness, worry, impatience and uncertainty still remain understudied; emotions such as anxiety or fear have previously been evaluated as a single emotion (Hathaway 1986, Shuldham 1999, Grieve 2002, Rhodes et al 2006).
Prior efforts at scoring patients' emotions and understanding the extent to which they varied during the surgical process have not been entirely successful because of variations in the instruments used (Shuldham 1999, Lee et al 2003) and short measurement times (Shuldham 1999,
Mitchell 2008). It is known that preoperative anxiety can be an indicator of postoperative anxiety; one study showed that patients who experienced anxiety before surgery continued to feel anxious afterwards (Carr et al 2005). Anxiety seems to be an emotion that patients commonly experience (85% of 673 surgery patients) on the day of surgery (Mitchell 2010), and it also occurs among 13% (n=351) of postoperative patients (Gillies & Parry-Jones 1997, Gillies et al 1999). Research has found that anxiety can continue to increase until the fourth postoperative day (Carr et al 2005).
Surgery-related depression in patients has also been studied. Gillies et al (1999) found that, although less than four per cent (n=351) of adolescent patients were depressed preoperatively, 29% of patients were depressed postoperatively. They used the Hospital Anxiety and Depression (HAD) scale Moreover, Carr et al (2005) found that 45% of patients (n=85) experienced psychological distress prior to surgery. They also found that patient evaluations of distress continued to rise postoperatively, and that on the tenth postoperative day patients were still experiencing distress.Based on these results, they suggest that other events happening during the surgical process, such as ultimately being discharged from the hospital, might have an effect on anxiety (Carr et al 2005).
Patient education is a major component of the ambulatory orthopaedic surgery process (Salmon 1993, Koivula et al 2002, Hering et al 2005). Through patient education, patients can be taught to manage their emotions and recovery. For example, Salmon (1993) found in the early 1990s that it is imperative to properly handle patient emotions because emotions might inhibit the recovery process; other scholars have also found this to be the case (Mitchell 2010, Wong et al 2010) Patients may benefit from different educational methods.
Several reviews and meta-analyses have been done on the effects of educational interventions such as oral or written education, on surgical patients' emotions (Devine & Cook 1986, Hathaway 1986, Devine 1992, Shuldham 1999, Lee et al 2003, Johansson et al 2004, 2005, Wofford et al 2005). These reviews and metaanalyses found patient education to be effective in allaying patients' anxiety or fear.There are, however, conflicting results between studies concerning allaying emotions (Johansson et al 2004, 2005, Wofford et al 2005). Previous studies also prove that there are advantages to internet-based patient education in terms of patient outcomes; however, thus far scholars have not studied internet-based education methods as much as they have oral or written education (Lewis 2003, Johansson et al 2004, 2005, Wofford et al 2005).Hering et al (2005) studied the effect of Internet-based education on anaesthesia in ambulatory orthopaedic surgery patients and found that it had no effect on patients' anxiety scores.
Purpose of the study
The goal of this study was to evaluate changes in ambulatory orthopaedic surgery patients' emotions during the surgical process and to compare whether either of two different patient education methods: Internet-based patient education (experimental) or face-to-face education conducted by a nurse (control), had an effect on patients' emotions during the ambulatory surgical process.
The research questions were as follows:
1. How did the patients rate their emotions at seven points in time during the ambulatory surgical process?
2. To what extent did the emotion scores correlate with the different phases of the surgical process?
3. Did either of the two different patient education methods have an effect on the patients' emotion scores?
A randomised controlled study design was used. All ambulatory orthopaedic surgery patients (n=173) in one of the five university hospitals in Finland between July 2005 and September 2006 were eligible for inclusion in the study The final response rate was 86% (149/173). We invited patients who fulfilled the inclusion criteria to participate in the study via a letter of invitation to the ambulatory surgery operation. At the same time, they received the first instruments: the Emotions Questionnaire and demographic variables (baseline). The inclusion criteria consisted of the following elements: being over 18 years of age, being Finnish-speaking, having access to the internet at home and the capability to use it, not having any cognitive disabilities, and being capable of completing the instruments and the informed consent form. Otherwise, we only excluded patients when they had a physical status classification system (ASA-classification) of over II (n=11), because patients with an ASA classification over II might need more preoperative instructions than patients with an ASA I classification.
Randomisation and stratification
The patients were randomly assigned (based on gender, age and the location of the operation-knee or shoulder) to either an experimental group (n=72) that received an internet-based education or to a control group that received face-to-face education taught by nurses (n=77) (Heikkinen et al 2008). Two patients in the control group were excluded from the study because they did not come to the patient education session. Neither the patients nor the study coordinator were aware of the educational assignment until everyone had been randomly assigned to their groups.
Patients in the experimental group participated in the internet-based patient education designed for this study (Heikkinen et al 2010). The website consisted of knowledge about nine surgical topics (i.e. instructions for preparing for the operation, the schedule of events on the operation day, follow-up care, financial aspects and frequently asked questions).We intended that the knowledge be multidimensional and consist of six areas of knowledge (Leino-Kilpi et al 1998, 1999); we did this so that patients would become cognitively empowered and be able to manage their emotions during the ambulatory surgical process (Heikkinen et al 2008).
Patients were asked about their internet usage and the amount of time they spent at the website. Patients visited the website between 1 and 121 days (mean=14, SD 19 1) before the operation. They used the website 4 to 6 times (mean 2.3). The amount of time patients spent at the website ranged from 10 to 300 minutes (mean=81, SD 66.7).
Patients in the control group participated individually in face-to-face patient education with a nurse (in total, eight nurses) in a separate room in the ambulatory surgery unit. The theoretical basis for patient education with a nurse was the same as that for the internet-based education.Patients were given a leaflet explaining the content of the session. Nurses were trained for this study by researcher, they knew the content of the website (internet-based education), and they had a printed version of the website available. The face-to-face education sessions took place, on average, nine days before the surgery occurred (range 1-55 days, SD 7.1) and lasted on average 22 minutes (range 10-40 min, SD 7.0). We derived this information from the documentation records compiled by the nurses.
Instruments and data collection
We collected the data using a structured instrument called the Emotions Questionnaire (E) which we used seven times:
1) before preoperative patient education (baseline)
2) after preoperative patient education
3) on the operation day but before the surgery
4) one day after the operation
5) three days postoperatively
6) two weeks postoperatively and
7) four weeks postoperatively.
Several measurement times were chosen because we wanted to see whether there were changes in the patients' evaluations of their emotions during the ambulatory surgical process.
The Emotions Questionnaire measures seven emotions: fear, nervousness, worry, impatience, depression, anxiety and uncertainty. The emotions were expressed using a vertical visual analogue scale (VAS) of 100mm, where the left side (0) indicated low intensity and the right side (100) indicated an intolerable intensity of emotion. We devised the Emotions Questionnaire based on the existing theoretical literature (e.g. Shuldham 1999, Koivula et al 2002) and statements by an expert panel consisting of three nurses, two physicians and three researchers. The test group for the instrument consisted of 17 ambulatory surgery patients, and no revisions were needed. The VAS has been proven to be a useful and valid measure of preoperative anxiety (Kindler et al 2000).
We tested for the following demographic characteristics gender, age, basic and vocational education, employment status, employment in social and healthcare, long-term illness and the amount of ambulatory surgery operations, to see that the groups were similar.
We analysed the data statistically using SPSS for Windows (version 16.0). The results are shown as frequencies, percentages, means and standard deviations. The Pearson Chi-Square test was used to compare the demographic characteristics of the sample between the groups.
Each patient's estimations of her or his emotions (measured with the Emotions Questionnaire) were divided into three classes: low (0 [less than or equal to] 29.9 mm), moderate (30.0mm [less than or equal to] 69.9 mm) and high (70.0 [less than or equal to] 100mm) We based this division on earlier studies that used the VAS within the context of pain (Collins et al 1997, Kelly 2001).Typically, when researchers see scores of over 30, they interpret them to mean that the patient needs special attention and support from a healthcare professional.
During further analysis, we combined moderate and high scores because very few patients (0-4%) scored high on any of the emotions at any particular point in time. The estimations of emotions were used as dependent variables in a binary logistic regression; we did so using generalised estimating equations, which accounts for the association between repeated measurements. Binary logistic regression included the effect of the method of patient education, the measurement time and the interaction between the method of patient education and the measurement time. In all tests, the level of statistical significance was set at p0.05 (Burns & Grove 2005).
We obtained ethical approval for the study from the ethical research committee of the hospital district and from the organisation concerned. After patients were informed about the study, they agreed to participate in it on a voluntary basis and gave written informed consent.
A total of 147 ambulatory orthopaedic surgery patients were enrolled in the study: 72 in the experimental group and 75 in the control group. We found no statistical differences in the demographic variables (p=0.189-0.976). The average age of participants in the experimental group was 44.2 years (range 18-69, SD=12.73), whereas in the control group it was 43.5 years (range 18-67, SD=12.74).Approximately half of the patients were male (54% in the experimental group and 56% in the control group). More than half of the patients had a shoulder arthroscopy operation (62% in the experimental group and 57% in the control group), and the rest had a knee arthroscopy operation. Most of the patients had had ambulatory surgery previously (58% in the experimental group and 57% in the control group).
Patients' evaluations of their emotions
Ambulatory orthopaedic surgery patients' emotion scores were low. Before the patient education (baseline), most patients in both groups scored their emotions low. In terms of feelings of worry, impatience, and uncertainty, approximately range from 16% to 27% of respondents gave themselves moderate or high scores. After the patient education (2nd measurement), most of the patients still gave themselves low emotion scores. Thus, about 14% of patients in the experimental group and 30% of patients in the control group gave themselves moderate or high scores for nervousness. Also, approximately 27% of the patients in the experimental group and 18% of patients in the control group gave themselves moderate or high scores for impatience. On the operation day, preoperatively (3rd measurement), more than one-third of the patients in both groups gave themselves moderate or high scores for feelings of nervousness, and approximately 16-18% of the patients in both groups gave themselves moderate or high scores for feelings of fear. During the postoperative time (4th to 7th measurements), approximately 90% or more of the patients in both groups gave themselves low emotion scores. However, approximately 7 to 10% of the patients still gave themselves moderate or high scores for feelings of impatience (See Table 1 for more details).
Patients' emotions changed during the surgical process. Their scores for fear, nervousness, worry, impatience, depression, anxiety and uncertainty differed to a statistically significant degree during the surgical process (p [less than or equal to] 0.001-0.001). After the patient education, patient scores for nervousness increased a significant amount statistically (p=0.026). The differences in the scores for the other emotions were not statistically significant. On the operation day, the scores for fear (p=0.031) and nervousness (0.001) increased, whereas the scores for worry (p=0.004) and impatience (p[less than or equal to]0.001) decreased compared to the baseline. Two weeks postoperatively, the emotion scores for all patients had clearly decreased (p[less than or equal to]10.001) (Table 1).
The method of patient education (both for the experimental and the control groups) had no significant effect on the emotion scores (p=0.194-0.794) of the patients. Thus, the emotion scores did not vary for either group. We tested the interaction between the method of patient education and the measurement times for the emotions (logistic regression) and did not find any significant levels of interactions between the two (p=0.255-0.959). Thus, the changes in the patients' emotional scores were similar for both groups throughout the ambulatory surgical process (Table 1).
The purpose of this study was to evaluate changes in ambulatory orthopaedic surgery patients' emotions during the surgical process and to compare the effects of two different patient education methods: internet-based patient education (experimental) and face-to-face education conducted by a nurse (control), on patients' emotions during the ambulatory surgical process.
All patients reported emotion scores that were rather low. The emotion scores for the patients varied during the surgical process, and there were no differences in these variations in either of the education groups.Patients' emotion scores did not change as a result of either form of education (see Johansson et al 2004, 2005, Wofford et al 2005); four weeks postoperatively none or only a few patients scored their emotions as moderate or high. In earlier studies, researchers focused most of their attention on patients' levels of anxiety and depression, and their prevalence preoperatively might have had an effect on the postoperative emotions that patients experienced as well (Gillies & Parry-Jones 1997, Gillies et al 1999, Carr et al 2005, Mitchell 2010). In this study, patient scores for anxiety or depression were rather low: roughly 6 to 16% preoperatively. Four weeks postoperatively patient scores for anxiety or depression ranged from only zero to 3%.
Preoperatively, one-third of patients scored moderate or high on nervousness. The increase in number of patients experiencing nervousness doubled between the measurement period after the education and the operation day. In the control group, this increase in the number of patients experiencing nervousness was already high immediately after they had completed the education. It seems that the discussion with the nurse in the control group, actually Increased patients experience of the nervousness. The reason for that requires research. The increase in the level of nervousness among the experimental group might indicate fear of the operation itself, but it also indicated that fear can be controlled better via internet-based patient education.
The number of patients who expressed moderate or high scores for emotions decreased on the day of the operation, which was most evident in the scores for worry and impatience. The decrease in the emotion scores of the patients on the day of the operation can be explained by the effects of the operation and preoperative issues: when patients are in the hospital, their scores for worry and impatience concerning the upcoming operation decreased because the preoperative waiting period is past and they have been taken care of. Also, the findings of an earlier study suggest that issues other than the education itself are also related to patients' emotions (Carr et al 2005).
In summary, certain emotions are connected with preoperative issues and other emotions with intraoperative issues.Thus, based on this study, no clear conclusion about issues that might have had either an exacerbating or a moderating effect on these emotions can be drawn. In the future, more attention should be given to causal and environmental factors and their potential effects on emotions (Gilmartin & Wright 2008).
The method of patient education was not associated with the emotion scores.Whereas earlier studies have produced findings that are in line with the results of this study, there have also been contradictory results (Johansson et al 2004, 2005, Wofford et al 2005). The content of patient education in this study consisted of six dimensions of knowledge measured during the entire ambulatory surgical process, and this multidimensional approach proved to be a viable method. It is also clinically relevant because it is more effective to share and examine knowledge about the entire surgical process than to focus on just a part of it. Thus, there are also studies that have focused on only one particular issue or one area of knowledge, such as anaesthesia issues (Lee et al 2003, Hering et al 2005).
One advantage of using the internet is the possibility to offer a wider base of knowledge to patients, which they study in their own time and in a place of their choosing. Healthcare services should also be aware of the benefits of the internet in terms of learning. In the future, more and more patients will use the internet. People are already now using the internet in their daily lives, for example when handling their financial issues. Also the number of people who use the internet when searching health-related issues is remarkable (Beall et al 2002, Jariwala et al 2005). However, we could increase how much the internet is used in patient education and make the learning more systematic. With regulated and evaluated web pages we can help patients to find and use reliable knowledge.
Still, the need for different education methods remains because patients and situations differ; the Internet cannot always replace face-to-face education.
Some limitations to this study concern the type of instrument, the measurement times, the method of data analysis and the sample that we used. The content of the Emotions Questionnaire was broad, encompassing many different emotions, and it was based on patients' own evaluations and perceptions. In earlier studies, researchers most commonly only evaluated anxiety or fear (e.g. Shuldham 1999, Lee et al 2003, Johansson et al 2005). It might be difficult for patients to distinguish between certain emotions, such as anxiety or fear. Also, different people score themselves in different ways. However, it was essential to evaluate several emotions to see which emotions patients experience the most. On the other hand, we could also see that the trends in the emotions and the scores for several emotions were parallel to one another.
We used seven different measurement times to see whether some of the measurement times would be of particular importance. We encourage using several evaluations of the patients' emotion scores, especially preoperatively, to measure the effects of the education. However, postoperative evaluations might need less of a measurement time because there were not many changes in patients' scores postoperatively. Test-retest bias did not seem to be a problem because the patients' evaluations of their emotions varied at different measurement times.
In data analysis, we defined the range of scores for patient emotions based on a pain instrument (e.g. Collins et al 1997, Kelly 2001). We selected this method because there was no available means for classifying the emotion scores. As a result, the classification system that we used may not be suitable for every purpose. However, the classification system was useful for our purposes and it provided information about the number of patients having higher scores. For example, we did not include the means for emotion scores because they were so low. In addition, it is difficult to compare the results to earlier studies because of the variety of instruments used in the other studies. The study sample was drawn from one university hospital in Finland. This was based on the fact that there is little variation in surgical procedures in Finland. These results could be generalised to represent the nature of hospital procedures throughout Finland, but they may also be useful in other countries due to the similarity of surgical procedures worldwide.
We found that ambulatory orthopaedic surgery patients did not report high scores for their emotions. Patients' evaluations of their emotional scores varied during the surgical process and were not impacted by the education they received. Our findings suggest that internet-based patient education and face-to-face education are relevant methods in ambulatory orthopaedic surgery patients' education.
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by Katja Heikkinen, Sanna Salantera, Tiina Leppanen, Tero Vahlberg and Helena Leino-Kilpi
Correspondence address: Katja Heikkinen, University of Turku, Department of Nursing Science, FIN-20014 Turku, Finland. Email: firstname.lastname@example.org
About the authors
University of Turku, Department of Nursing Science, Finland
Professor/Nurse Manager, University of Turku, Department of Nursing Science, Finland
Head of Ward, Turku University Hospital, Finland
Biostatistician, University of Turku, Finland
Professor and Head of Department/Nurse Manager, University of Turku, Department of Nursing Science, Finland
No competing interests declared
Emotion Before the After the Operation day scores patient patient preoperatively education* education ** 3rd measurement Baseline 2nd exp/control exp/control measurement N=72/ N=74 N=72/ N=75 exp/control N=71/ N=73 Fear moderate 11.3 / 10.8 14.3 / 16.9 18.1 / 16.2 or high OR (95% C1) 1 1.49 1.67 (1.05-2.65) p-value (0.87-2.54) 0.031 0.143 Nervousness 11.3 / 17.6 14.3 / 29.6 31.0 / 36.5 moderate or high OR (95% C1) 1 1.67 3.04 (1.93-4.77) p-value (1.06-2.64) [less than or 0.026 equal to 0.001 Worry moderate 23.9 / 27.0 15.7 / 22.5 12.7 / 15.1 or high OR (95% C1) 1 0.69 0.47 (0.28-0.79) p-value (0.44-1.08) 0.004 0.106 Impatience 22.5 / 21.6 27.1 / 18.3 12.5 / 8.1 moderate or high OR (95% C1) 1 1.04 0.40 (0.23-0.70) p-value (0.67-1.61) [less than or 0.876 equal to 0.001 Depression 9.9 / 9.5 15.7 / 8.5 5.6 / 4.1 moderate or high OR (95% C1) 1 1.28 0.47 (0.22-1.01) p-value (0.77-2.14) 0.052 0.346 Anxiety 5.6 / 6.8 10.0 / 7.0 5.6 / 4.1 moderate or high OR (95% C1) 1 1.40 0.77 (0.31-1.91) p-value (0.76-2.58) 0.577 0.274 Uncertainty 16.2 / 16.2 13.2 / 17.1 7.0 / 12.3 moderate or high OR (95% C1) 1 0.93 0.56 (0.30-1.04) p-value (0.57-1.54) 0.067 0.786 Emotion First Third Two weeks scores postoperative postoperative postoperatively day 4th day 5th 6th measurement measurement measurement exp/control N=71/ exp/control exp/control N=73 N=71/ N=74 N=71/ N=74 Fear moderate 4.4 / 2.9 2.8 / - - / 1.4 or high OR (95% C1) 0.30 0.11 0.06 (0.01-0.44) p-value (0.11-0.83) (0.3-0.42) 0.006 0.021 [less than or equal to 0.001 Nervousness 4.4 / 4.3 4.2 / 1.4 1.4 / 4.1 moderate or high OR (95% C1) 0.27 0.17 0.17 (0.06-0.47) p-value (0.11-0.66) (0.06-0.47) [less than or 0.004 [less than or equal to 0.001 equal to 0.001 Worry moderate 10.3 / 10.0 9.8 / 5.5 2.8 / 8.2 or high OR (95% C1) 0.33 0.24 0.17 (0.08-0.38) p-value (0.17-0.62) (0.13-0.45) [less than or [less than or [less than or equal to 0.001 equal to equal to 0.001 0.001 Impatience 14.7 / 14.3 11.3 / 11.0 11.3 / 15.1 moderate or high OR (95% C1) 0.60 0.44 0.50 (0.29-0.87) p-value (0.34-1.07) (0.25-0.78) 0.015 0.082 0.005 Depression 5.9 / 1.4 1.4 / 2.7 2.8 / 4.1 moderate or high OR (95% C1) 0.35 0.20 0.34 (0.13-0.87) p-value (0.15-0.85) (0.07-0.61) 0.025 0.020 0.005 Anxiety 4.4 / 4.3 1.4 / 1.4 1.4 / 1.4 moderate or high OR (95% C1) 0.69 0.21 0.21 (0.06-0.74) p-value (0.25-1.88) (0.04-1.02) 0.014 0.465 0.053 Uncertainty 7.4 / 11.8 8.5 / 8.3 2.8 / 9.7 moderate or high OR (95% C1) 0.55 0.48 0.35 (0.17-0.73) p-value (0.29-1.04) (0.25-0.93) 0.005 0.064 0.028 Emotion Four weeks scores postoperatively 7th measurement exp/control N=71/ N=72 Fear moderate 1.4 / - or high OR (95% C1) 0.06 (0.01-0.45) p-value 0.006 Nervousness 1.4 / - moderate or high OR (95% C1) 0.04 (0.01-0.32) p-value 0.002 Worry moderate 2.9 / 2.8 or high OR (95% C1) 0.08 (0.03-0.25) p-value [less than or equal to 0.001 Impatience 10.0 / 7.0 moderate or high OR (95% C1) 0.33 (0.17-0.64) p-value [less than or equal to 0.001 Depression 2.9 / 2.8 moderate or high OR (95% C1) 0.27 (0.08-0.87) p-value 0.028 Anxiety 1.4 / - moderate or high OR (95% C1) 0.11 (0.01-0.87) p-value 0.037 Uncertainty 2.9 / 2.8 moderate or high OR (95% C1) 0.15 (0.05-0.44) p-value [less than or equal to]0.001 Binary logistic regression with generalized estimating equations OR= odds ratio, adjusted for group; OR > 1 indicates an increase in emotion scores (moderate or high scores versus low scores) CI= confidence interval * = on average 37 days before the operation; **= on average 9 (control) -14 (experiment) days before the operation Table 1 Patients' emotion scores grouped into two classes (1) low score and (2) moderate or high score, during seven different measurement times for the experiment group and the control group (patient education method), measured in percentages (%). The effects of the patient education method, the measurement time and the interaction between the patient education method and measurement time were tested
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