Patients' perceptions of preoperative home-based occupational therapy and/or physiotherapy interventions prior to total hip replacement.
Abstract: This study focused on patients' accounts of perceptions and experience of preoperative home-based interventions to increase health professionals' understanding of what is important or not when supporting patients preparing for hip replacements.

Method: A phenomenological approach helped to develop insights into what patients found useful or not about preoperative interventions, thus developing an understanding of the value of the service from patients' perspectives. Data were gathered from 10 participants, using semi-structured interviews. Analysis used a seven-step framework for phenomenological data analysis.

Findings: Five main themes emerged: preoperative equipment use increases independence, progress and confidence; individual needs are better met through timely visits; competent therapist home intervention offers reassurance regarding surgery; knowing one's home environment is suitable increases confidence in planning hospital discharge after surgery; and levels of social support require preoperative assessment.

The participants identified preoperative home visits as valuable in helping to prepare for surgery. Home visits can alleviate preoperative anxiety and may contribute to more streamlined discharge planning. Visits may help to cut the costs of erroneous equipment provision or last-minute equipment deliveries and decrease length of stay.

Conclusion: This research offers clinicians and managers relevant insight into patients' perceptions of home-based services and could work alongside quantitative research findings to inform best practice within National Health Service resource restrictions.

Key words: Occupational therapy/ physiotherapy, home-based intervention, total hip replacement.
Article Type: Report
Subject: Occupational therapists (Practice)
Patient satisfaction (Analysis)
Authors: Orpen, Nicola
Harris, Janet
Pub Date: 10/01/2010
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2010 Source Volume: 73 Source Issue: 10
Topic: Event Code: 200 Management dynamics
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 240098082
Full Text: Introduction

Over 69,000 hip replacement procedures were performed in England and Wales and recorded on the National Joint Registry in 2008. The vast majority (75%) were undertaken within the National Health Service (NHS) (National Joint Registry 2008). Resources devoted to hip replacements in the NHS are considerable, not only for surgical procedures but also for supportive interventions. In some NHS trusts, occupational therapists and physiotherapists provide preoperative interventions.

Preoperative interventions prepare patients for medical or surgical procedures. The service can be provided on an outpatient basis or during a patient-centred preoperative home visit. These interventions vary across NHS trusts, with some offering nurse-led or therapist-led hospital-based services and others offering therapist home-based assessments and interventions. There are no statistics on the number of NHS trusts providing home-based intervention. Services are also being scrutinised as a result of budget constraints, including in response to the Department of Health's spending review and cost-improvement programmes for the NHS from 2004.

Therapy interventions can include an assessment of the patient's home environment and advice offered regarding adaptations, equipment or furniture for postoperative use. The service at the Nuffield Orthopaedic Centre (NOC) offers information, including guidelines regarding total hip replacement (THR), hospital stay and the recommended precautions for performing daily activities after surgery. An assessment is also made of mobility and range of lower limb movement, with the teaching of exercises and use of walking aids.

The home visit provides therapists with valuable information about patients' preoperative function in their daily environment. The intervention facilitates decision making about patients' equipment requirements and discharge planning. Treatment plans are drafted and equipment or adaptations supplied prior to admission in order to facilitate a streamlined inpatient stay and discharge process. Information helps to give patients a sense of control over their pending surgery (Gammon and Mulholland 1996a), and discharge planning is commenced in collaboration with the patient prior to his or her hospital admission.

Occupational therapists and/or physiotherapists can provide this service, assessing the patient's performance of activities of daily living, exercise tolerance and mobility and training in physiotherapy exercises. In the authors' experience, therapists feel that this role is pivotal in aiding the patient's return home as safely as possible within ever-tighter time constraints of the NHS. This study explored patients' perceptions of occupational therapy and /or physiotherapy home visits prior to hip surgery.

Literature review

Studies have investigated whether preoperative education and intervention contribute to better patient outcomes. The outcomes observed through studies include the empowerment of patients (Spalding 2000); a reduced length of hospital stay in patients with complex needs (Wong and Wong 1985, Spalding 2001, Crowe and Henderson 2003); decreased anxiety (Butler et al 1996, Spalding 2001, McDonald et al 2004); less need for occupational therapy and physiotherapy time in hospital (Butler et al 1996, Spalding 2001); a perception of more effective coping and higher sense of self-control (Gammon and Mulholland 1996a); improved physical recovery following surgery (Gammon and Mulholland 1996b); and individual preparation for returning home (Durham 1992, Heaton et al 2000, Spalding 2001).

A Cochrane review (McDonald et al 2004) investigating preoperative education for total hip and knee replacements found conflicting evidence regarding the impact of education on length of stay. The review noted that its findings differed from a review of preoperative education across a variety of surgical procedures by Shuldham (1999), who found a significant reduction in length of stay in patients who had preoperative education. McDonald et al (2004) found a decrease in preoperative anxiety, which could help people to assimilate new information better; however, they argued that the effect was small and therefore required cautious interpretation. They also concluded that although there is insufficient evidence to support or deny the role of preoperative education in managing postoperative outcomes, there might be benefits when it is tailored according to anxiety and focused on those most in need.

Although these studies have all addressed preoperative education, suggesting that it might have an impact on postoperative outcomes, they assessed hospital-based preoperative interventions rather than home-based therapy services.

Home-based preoperative intervention

Two quantitative studies (Williams 1986, Rivard et al 2003) analysed the provision of preoperative intervention in the home and one qualitative study (Heaton et al 2000) investigated patients' perceptions of a preoperative home-based therapy intervention. All involved patients undergoing THR surgery.

Heaton et al (2000) reported an analysis of patients' perceptions of the rehabilitation they received before and after THR surgery, including some patients who received home-based interventions. Although the study focused on more than the home-based interventions, the conclusions drawn about the latter were that patients who had these interventions found them to be of limited value. For the present study, it was intended to explore this further, using participants' stories to ascertain what patients' perceptions currently are of the specific preoperative home-based interventions they received.

Studies have reported that preoperative home visits reduce length of stay (Rivard et al 2003); aid postoperative recovery (Williams 1986); provide a qualitative dimension of care (for example, accommodating patients' comfort and level of anxiety) (Williams 1986, Rivard et al 2003); provide opportunities for assessing safety prior to discharge (Welch and Lowes 2005); and relieve pressure on acute beds (Shepperd and Iliffe 2005). Three qualitative studies (Spalding 2000, 2001, Heaton et al 2000), one literature review (Welch and Lowes 2005), two systematic reviews (McDonald et al 2004, Shepperd and Iliffe 2005) and one quantitative study (Gammon and Mulholland 1996a) were conducted in the United Kingdom, although the systematic reviews included international papers in the analysis.

The remainder were completed in other countries (Williams 1986, Durham 1992, Butler et al 1996, Crowe and Henderson 2003, Rivard et al 2003). The findings may not, therefore, be transferable, in the light of differences between the national and private sector health care health systems and the social contexts in different countries.

Qualitative studies into preoperative interventions indicate that patients value early equipment provision (Heaton et al 2000) and individualised patient preparation for returning home (Durham 1992).

Research gap

Although all the studies above have addressed preoperative education with varying conclusions, suggesting that it might have an impact on postoperative outcomes, a research gap exists regarding in-depth reporting of patients' perceptions of receiving preoperative education and intervention through home-based therapy services prior to hip replacement surgery within the NHS.

In 2005, the NOC performed approximately 450 home visits to patients awaiting a THR. At the time, the services represented a significant staffing resource to visit patients across Oxfordshire. With the culture of constant change and the strive for cost-effectiveness in the NHS, as well as the dearth of patient-based evidence, research was needed to identify the benefits of preoperative home visits to patients. Because little evidence could be found at the time regarding the true value of home visits to patients awaiting a THR within the NHS, this study aimed to obtain and report the stories of patients' experiences of home visits. The study formed part of an MSc degree.

Sharing findings with the broader research community should encourage further debate about the true value of community-based hospital services and inform quantitative studies into the clinical effectiveness and cost-effectiveness of home-based services.

Method

The research question for this study was:

* What are patients' perceptions of preoperative home-based occupational therapy and/or physiotherapy interventions prior to total hip replacement?

The study aimed to focus on patients' accounts of their own perceptions and experience of the intervention in order to increase health professionals' understanding of what is important or not important in supporting patients preparing for hip replacement surgery.

A phenomenological approach was used to obtain insights into what patients found useful or not about preoperative education and intervention, thus helping to develop an understanding of the value of the service from a patient's perspective (Carpenter 2000).

Phenomenology is used in health care research to explore how people experience illness subjectively and the process of receiving services. It can provide insight into the meaning of an experience for an individual and allow the researcher to situate the experience of the service in the context of the everyday concerns of the patient. The findings have the potential to increase empathic understanding of the patient experience and to use insight to make more appropriate decisions about treatment (Benner 1994).

Ethical approval was obtained from the Milton Keynes Research Ethics Committee and the NOC Research Group prior to commencing the study.

Sampling

The study was based at the NOC NHS Trust, Oxford, enabling access to a large number of potential participants undergoing THR surgery. The sample was drawn from all patients who had received a home visit from the NOC home-based services and undergone surgery between February and June 2006 (n = 201). Patients over age 16 years, who had had a preoperative home visit from the NOC and had undergone THR surgery in the NHS, were considered for inclusion in the study (Table 1).

Patients were excluded if they were undergoing non-THR surgery or had had two or more home visits within the study period. The researcher had intended to meet with participants 3-5 weeks following their discharge. However, service restructuring created a variation in the number of procedures performed during the study timeframe and interviews therefore took place 5 weeks to 6 months after surgery.

Attempts were made to ensure variability in terms of the following factors:

* People living alone and with family/friends

* Age

* Comorbidities affecting their ability to make changes actively within their homes prior to admission (for example, history of cerebral vascular accident, heart disease or hypertension)

* Socioeconomic backgrounds in terms of ability to make changes to their home environment in preparation for surgery

* First-time versus previous hip surgery.

Procedure

Occupational therapists who had performed the visits received a template of the inclusion and exclusion criteria to guide their identification of patients. The occupational therapy secretary received instructions on responding to patient queries about the study and was given a participant information sheet for reference. The secretary posted invitation letters, participant information sheets, reply slips and prepaid envelopes to eligible patients.

The information sheet included assurances that the decision to participate would not affect ongoing treatment and care at the NOC and that patients were free to withdraw from the study at any time without consequence to their treatment. Confidentiality and anonymity were explained and assurances given that participant names would not appear in reports shared with health care professionals or published in therapy journals. Information was given regarding validation, that is, asking participants to check if transcripts reflected accurately what they said during an interview or that the themes emerging during the analysis phase were sensible and reliable (Colaizzi 1978). Participants were informed that the researcher might contact them a second time to validate findings.

A reply slip was included in the information pack and a signed copy of this was required from the patient before the researcher sent the consent form.

Participants

Of the 19 patients eligible to participate, 14 replied: 4 declined to participate and 10 agreed to participate in the study (Table 2).

An occupational therapist and /or a physiotherapist carried out routine preoperative home visits in participants' homes prior to the study. The researcher interviewed the participants following discharge. Interviews were carried out in the same setting as the preoperative home visit to aid recall. At the start of each interview, the consent form was again discussed and a signed copy was given to the participant.

Data collection

The researcher used a technique called 'bracketing' before commencing data collection to identify personal assumptions about the lived experience of a home-based therapy regime (Carpenter 2000).

Semi-structured interviews were used to gather the data. A topic guide was developed based on the intended outcomes of the home-based therapy intervention service. These included reducing preoperative and discharge-related anxiety, facilitating streamlined hospital discharges, reducing length of stay, facilitating improved coping mechanisms and having a positive impact on surgery by preparing patients preoperatively. Broad lines of enquiry were used and leading questions were avoided to ensure that participants were free to offer personal views and not be led by the researcher during the interviews.

A pilot interview (participant A1) was completed to develop the topic guide further and prepare for the study. This topic guide was revised twice during the study to aid the researcher in gathering the required information and avoid closed questions (Appendix 1).

Permission was again sought from participants, at the start of the interview, for the interview to be recorded. The interviews lasted between 40 and 90 minutes, as determined by the detail offered by each participant. At the start of each interview, participants were informed that they could stop the interview at any time. The interviewer also asked participants at regular intervals during each interview if they were all right to continue. None expressed signs of fatigue and interviews were continued for a time deemed appropriate for each participant. All stated that they appreciated the opportunity to talk about their experience of the services they had received. A typed verbatim transcript was made of each recording to preserve the language of the participants (Schutz 1970).

No new themes seemed to be emerging after the tenth interview. This suggested data saturation (Strauss and Corbin 1998) with regard to patients' perceptions of the preoperative home-based intervention they received. Given the broad nature of the sample (Table 1) and time constraints of the MSc, the researcher decided that no further participants would be approached.

Data analysis

Data extraction and analysis took place in a secure room. All data and records were locked away to maintain confidentiality. Analysis occurred following each interview and was ongoing throughout the study, including after all interviews were completed.

The analysis used Colaizzi's (1978) seven-step framework for phenomenological data analysis. Participant descriptions were read, significant statements were extracted, first level coding was developed, theme clusters were created and an exhaustive description was developed as the statement of fundamental essence of the experience of the intervention. Finally, participant validation took place.

Colaizzi's (1978) approach was used because it enables in-depth analysis of individual subjective experiences of the phenomenon and provides a useful framework for comparing statements of experience across accounts. The comparison of accounts produces common themes that can be used to reflect upon current service provision and make decisions regarding service improvement (Ayres et al 2003).

The researcher referred back to bracketing notes made prior to the study to check if personal opinions and /or bias were potentially influencing the conclusions from the findings. A reflective diary was maintained throughout the study.

The final statement identifying the fundamental structure of the experience was drawn from all 10 exhaustive statements and from the researcher's reflective diary.

Copies of transcripts were sent in the post to the first three participants, with a stamped addressed envelope to return comments. A minimum of 10 days was given for participants to respond. All were returned within the timeframe. A follow-up meeting was offered if the participants preferred to discuss their queries or to feed back face to face, but this was not requested. The participants did not request any significant changes or data omissions.

The MSc supervisor (JH), who was not familiar with the patients or the service, reviewed the data analysis tables and identified potential sources of bias. Copies of the exhaustive statements were sent to all 10 participants for validation. All 10 were returned and participant suggestions were incorporated into the analysis.

Findings

Five main themes were generated: preoperative equipment use increases independence, progress and confidence; individual needs are better met through timely visits; competent therapist home intervention offers reassurance regarding surgery; knowing one's home environment is suitable increases confidence in planning hospital discharge after surgery; and levels of social support require preoperative assessment.

Preoperative equipment use increases independence, progress and confidence

Seven of the participants felt that the equipment (for example, toileting, bathing and dressing aids) supplied during the visit helped them to manage daily activities more easily while they waited for surgery:

Seven participants used aids daily to increase their independence and /or to help them to manage activities of daily living while they waited for surgery. The other three participants practised using aids and believed that having got used to the aids beforehand helped them to exert some influence over their length of stay postoperatively.

Individual needs are better met through timely visits

The importance of the timing of the visit was evident in each interview for different reasons. Two participants felt that they could have benefited from having the intervention and aids much earlier:

Four participants felt more competent doing things properly and safely when they had more time to assimilate the information and to practise the techniques. Another five participants wanted the preoperative visit closer to admission to help them to recall what they had been told and shown:

Competent therapist home intervention offers reassurance regarding surgery

Reassurance was a repetitive theme in all 10 interviews:

The participants found that the home visit helped them to feel more confident about the surgery and returning home afterwards:

The therapists allayed anxieties and helped patients to cope better with the prospect of preparing for surgery by showing them how to use the aids and discussing what to expect:

Knowing one's home environment is suitable increases confidence in planning hospital discharge after surgery

Eight participants felt that it was helpful to have home-based rather than hospital intervention:

Other participants confirmed the potential for home visits to provide more accurate information than hospital-based assessment:

All but one participant felt that having the assessment in the home helped to give a more accurate picture of the environment and its potential shortcomings following hip surgery.

Home intervention helped the participants to apply the information immediately and to visualise how they might manage following surgery:

Levels of social support require preoperative assessment

The participants stated that social support networks played an important role in their preoperative preparation for surgery and in their ultimate discharge planning following surgery. All the participants commented on this dimension of their lives. Nine of the participants felt that friends and family were a very important part of their rehabilitation on leaving hospital and in their transition home:

People who had social support found it difficult to imagine how they would cope without it.

Of the six patients (aged 60 years and over) who lived alone, four expressed concerns about coping and said that they relied heavily on their extended family and friends:

One participant reflected that her lack of family support was a big problem for her during her recovery and she therefore relied heavily on the support from clinicians to help her transition from the convalescent home to her own home:

Discussion

Equipment use

The study participants all commented that using equipment before the operation increased independence, confidence and progress after the operation. They found having adaptive aids prior to surgery very important in their successful transition home. Other authors have found that although patients are taught how to use equipment or are assessed carrying out tasks within the hospital setting, translating this into functioning at home on discharge can be difficult for people to achieve without some form of home-based intervention (Gage et al 1996, Welch and Lowes 2005).

Length of stay

Three participants in the study related the home visit to a shorter length of stay. This contrasts with earlier quantitative studies that debate the influence of preoperative education at home on length of stay (Williams 1986, Welch and Lowes 2005, McDonald et al 2004), while concurring with Crowe's and Henderson's (2003) findings that patients who received a full rehabilitation intervention preoperatively had shorter hospital stays. Length of stay as an outcome should be treated cautiously, however, as many variables can influence this. McDonald et al (2004) argued that length of stay is closely related to the procedures and protocols within individual hospitals. The present study helps to demonstrate that some patients perceive that the preoperative home-based intervention helps them to feel less anxious about coping at home and hence more ready to return home at the earliest opportunity. It could be argued that without the preoperative preparation, these patients may have been reluctant to return home early and hence remained an extra day in hospital if given the choice.

Home versus hospital interventions

Some research has been unable to prove that home is the best location for preoperative education (Rivard et al 2003), while others found that preoperative anxiety was significantly reduced in groups receiving their education at home versus those receiving hospital-based interventions (Williams 1986). The participants in the present study stated that therapists can get only a limited understanding of the home environment from talking to a patient in the hospital setting. They also concurred that the home setting was well suited to a more accurate assessment and gave the opportunity for patients and therapists to address individual needs and environments.

Managing anxiety

It is well recognised that hospitalisation for surgical or medical care evokes significant anxiety and stress in people, as does discharge (Johnson et al 1978, Hathaway 1986, Teasdale 1995, Gammon and Mulholland 1996a, Gage et al 1996, Doering et al 2000). The present study found that the participants experienced psychological and emotional adjustment when returning home following hospitalisation. The participants were reassured when the visit from the therapist affirmed that the home environment was suitable. This increased confidence in planning for life after hospital discharge.

Information provision

Some researchers found that videos or written material given to patients prior to hip replacement surgery can be effective in alleviating preoperative and postoperative anxiety (Butler et al 1996, Gammon and Mulholland 1996a), perioperative blood pressure problems and postoperative need for excessive analgesia (Doering et al 2000). The present study found that written information might be used as a reference, but that information in a book was not as useful as personal contact, explanations and demonstrations. The findings from a recent systematic review reinforce that patients do not perceive written information to be useful unless it is tailored to individual concerns and needs (Raynor et al 2007).

Raynor et al (2007) took research findings back to patients, including users' views, in order to link experiences of using written information to the research findings. Although this review focused on the utility of written information on medications, it is believed that it strongly supports the present research on the need to situate written information about using adaptive devices after surgery in the context of everyday life.

Social support

Some research has identified the need for the assessment of social support from family and /or friends (Williams 1986, Heaton et al 2000), but little research was found regarding the specific needs and anxieties of patients who live alone. In this study, participants who lived alone described strong feelings about the benefit of having the preoperative home-based intervention. Those who had support from family and friends identified this as a key element in supporting their recovery. This finding suggests that health professionals should be aware that people living alone should be offered a greater level of preoperative and postoperative support and intervention to ensure that they feel confident and ready to return home alone on discharge from hospital. Given the tendency within the NHS to focus on older patients, it was interesting to learn how younger patients experience similar anxieties and benefit from a similar intensity of services, especially if they have little or no social support. In an ideal world, both the preoperative and the postoperative home-based support would be supplied; however, with the ever-increasing constraints on NHS resources, a difficult decision must be made about how best to use valuable resources, weighing up the needs of patients and therapists.

Critical evaluation

This study aimed to investigate patients' experiences of the preoperative home-based therapy interventions prior to hip surgery.

The sample size of 10 may be considered small, but similar themes were starting to emerge during interviews, implying that data saturation may have been achieved. Opportunistic sampling can introduce an element of bias but the sample included a wide demographic variation, which maximises the chances of obtaining a range of experiences on the same phenomenon. Recall bias may have influenced the participants' responses. However, different participants provided similar information at different points in time between surgery and interviews.

Two participants suffered complications following surgery, which may have affected their opinion of the services they had received, but stated that they felt they could separate the preoperative home visit from the surgical complications. Further research may be needed to investigate whether negative experiences influence views of the utility of the preoperative home visit.

The MSc supervisor independently reviewed the transcripts and checked emerging themes for consistency. Owing to time constraints, a written statement requesting participant validation was sent rather than conducting further interviews.

Conclusion and recommendations

The participants in this study identified the preoperative home visit as valuable in helping them to prepare for surgery. Home visits can alleviate preoperative anxiety and may contribute to more streamlined discharge planning. Visits may also help to cut the costs of erroneous equipment provision or last-minute (more expensive) equipment deliveries and decrease length of stay.

The role of family and friends was seen as an essential part of safe discharge planning. This is something for clinicians to consider at all stages of intervention for patients undergoing hip replacements. With the trend towards shorter hospital stays and the increasingly limited community-based support for people after discharge, the safety and sensibility of discharging socially isolated patients home alone needs careful consideration before these patients are considered safe for discharge. The preoperative home visit offers an opportunity for the clinician to identify the expected ability of the individual to cope alone at home and to clarify the support he or she might have available from family and friends. Where coping ability is limited, it offers time to make the necessary arrangements so that postoperative referrals can be timely and avoid unnecessary delayed discharges.

This research offers clinicians and managers some relevant insight into how patients perceive the services on offer. These insights should be used alongside the data and findings from quantitative research to inform best practice within the resource restrictions in each given area. At the NOC, the preoperative home-based service has continued within occupational therapy although, for budgetary reasons, the physiotherapy input was withdrawn. Patients continue to benefit from full occupational therapy intervention at home in order to assess their preoperative functional status and home environment and to offer education and guidance on how best to prepare for their pending hospital stay and to cope following discharge. The findings have helped to confirm for staff that this service is worthy of maintenance and development so that patients may take advantage of what occupational therapists can offer at all stages of the clinical pathway related to total hip replacements.

Trusts may wish to use the findings to inform the design of future services or to inform the design of a clinical trial into the cost-effectiveness of different types of home-based services. It seems unnecessary to conduct further research comparing home-based services with hospital-based services owing to the differing nature of these services. However, the findings from this study may be useful for further research into patient satisfaction on a larger scale, through a survey focusing on home-based services. Future research could also compare systematically the effectiveness of different models of home-based interventions before and after hip or knee surgery. The findings from the current study could contribute to the design of a clinical trial intervention and the assessment of client-based outcomes.

DOI: 10.4276/030802210X12865330218267

Appendix 1. Example of topic guide (interview questions)

* Tell me what it was like having somebody come into your home from the hospital?

* How long had you been waiting at this stage?

* What did you know about these sorts of services before the visit?

* What were your concerns, if any, about managing following your surgery?

* How were these addressed on the home visit?

* What had been your plans in terms of coping at home afterwards?

* What are your views on the timing of the preoperative home visit?

* What equipment was provided? What guidance was given in using it?

* How much use did you make of it before you came into hospital?

* What would you think if we had done the visit but not supplied the equipment, just talked about what you would need afterwards and said we will give that to you when you come into hospital?

* We have an occupational therapist at the preadmission clinic. What would you think about the comparison of being seen there versus the visit you had?

* If you could change anything about the home visit, what would it be?

* What might your family have liked to have known or been involved in before you came in?

* What do you think of the written information booklets you were given?

* What do you think of the amount of information given in general?

* We are looking at trying to intervene earlier, when people are first put on the waiting list for their hip replacement. What are your views on that plan?

* Is there anything you would like to mention about your ongoing recovery?

Acknowledgements

The authors gratefully acknowledge the support of colleagues, including Claire Ireson, Sonia Moses, Isobel Dodsworth, Clare McKenzie, Lynden Guiver and the Milton Keynes Research Ethics Committee. The research and MSc degree were partly funded by the Elizabeth Casson Memorial Trust, Hip Walk for Life and Thames Valley Health Authority, whose contributions are gratefully acknowledged. A special thanks also to all study participants.

Conflict of interest: None.

Key findings

* Participants found that home-based preoperative interventions and use of equipment in their own environment prior to surgery helped them to prepare better for surgery and hospital discharge.

* This may have contributed to a decreased length of stay.

What this study adds

Hospital-based education can be enhanced by providing opportunities to practise and apply guidance during home-based intervention. Social support structures should be assessed prior to surgery to ensure adequate planning for timely discharges from hospital to the most suitable destination for that individual.

References

Ayres L, Kavanaugh K, Knafl K (2003) Within-case and across-case approaches to qualitative data analysis. Qualitative Health Research, 13(6), 871-83.

Benner PE, ed (1994) The tradition and skill of interpretive phenomenology in studying health, illness and caring practices. Interpretive phenomenology. Embodiment, caring and ethics in health and illness. London: Sage.

Butler GS, Hurley CAM, Buchanan KL, Smith-VanHorne J (1996) Prehospital education: effectiveness with total hip surgery patients. Journal of Patient Education and Counselling, 29(2), 189-97.

Carpenter C (2000) Exploring the lived experience of disability. In: KW Hammell, C Carpenter, I Dyck, eds. Using qualitative research. London: Churchill Livingstone.

Colaizzi PF (1978) Psychological research as the phenomenologist views it. In: RS Valle, M King, eds. Existential-phenomenological alternatives for psychology. New York: Oxford University Press.

Crowe J, Henderson J (2003) Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Canadian Journal of Occupational Therapy, 70(2), 88-96.

Doering S, Katzlberger F, Rumpold G, Roessler S, Hofstoetter B, Schatz DD, Behensky H, Krismer M, Luz G, Innerhofer P, Benzer H, Sara A, Schuessler G (2000) Videotape preparation of clients before hip replacement reduces stress. Psychosomatic Medicine, 62(3), 365-73.

Durham DP (1992) Occupational and physical therapists' perspective of the perceived benefits of a therapeutic home visit programme. Physical and Occupational Therapy in Geriatrics, 10(3), 15-33.

Gage M, Valiant Cook J, Fryday-Field K (1996) Understanding the transition to community living after discharge from an acute hospital: an exploratory study. American Journal of Occupational Therapy, 51(6), 103.

Gammon J, Mulholland CW (1996a) Effect of preparatory information prior to elective total hip replacement on psychological coping outcomes. Journal of Advanced Nursing, 24(2), 303-08.

Gammon J, Mulholland CW (1996b) Effect of preparatory information prior to elective total hip replacement on post-operative physical coping outcomes. International Journal of Nursing Studies, 33(6), 589-604.

Hathaway D (1986) Effect of preoperative instruction on post-operative outcomes: a meta-analysis. Nursing Research, 35(5), 269-75.

Heaton J, McMurray R, Sloper P, Nettleton S (2000) Rehabilitation and total hip replacement: patients' perspectives on provision. International Journal of Rehabilitation Research, 23(4), 253-59.

Johnson J, Rice VH, Fuller SS, Endress MP (1978) Sensory information, instruction in a coping strategy and recovery from surgery. Gastrointestinal Endoscopy, 19, 180-82.

McDonald S, Green SE, Hetrick S (2004) Pre-operative education for hip or knee replacement. The Cochrane Database of Systematic Reviews, Issue 1. Art. No: CD003526. DOI: 10.1002/14651858.CD003526.pub2. http://www.cochrane.org/reviews/en/ab003526.html

National Joint Registry (2007-2008) 5th annual report. Available at: http:// www.njrcentre.org.uk/Public/prev_annual_reports.htm Accessed on 23.04.09.

Raynor DK, Blenkinsopp A, Knapp P, Grime J, Nicolson DJ, Pollock K, Dorer G, Gilbody S, Dickinson D, Maule AJ, Spoor P (2007) A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technology Assessment, 11(5), 1-178.

Rivard A, Warren S, Voaklander D, Jones A (2003) The efficacy of pre-operative home visits for total hip replacement clients. Canadian Journal of Occupational Therapy, 70(4), 226-32.

Schutz A (1970) Alfred Schutz on phenomenology and social relations. Chicago: University of Chicago Press. Cited in: C Edwards, A Titchen (2003) Research into patients' perspectives: relevance and usefulness of phenomenological sociology. Journal of Advanced Nursing, 44(5), 450-60.

Shepperd S, Iliffe S (2005) Hospital at home versus in-patient hospital care. The Cochrane Database of Systematic Reviews, Issue 3. Art. No: CD000356. DOI: 10.1002/14651858.CD000356.pub2. http://www.cochrane.org/ reviews/en/ab000356.html

Shuldham C (1999) A review of the impact of preoperative education on recovery from surgery. International Journal of Nursing Studies, 36(2), 171-77.

Spalding N (2000) The empowerment of clients through preoperative education. British Journal of Occupational Therapy, 63(4), 148-54.

Spalding N (2001) Clients' views of preoperative education before hip replacement: symposium on patient education. British Journal of Therapy and Rehabilitation, 8(4), 130-35.

Spending Review (2004) Stability, security and opportunity for all: investing for Britain's long-term future. New Public Spending Plans 2005-2008. Available at: http://www.hm-treasury.gov.uk/spend_sr04_repindex.htm Accessed on 17.07.08.

Strauss A, Corbin J (1998) Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage.

Teasdale K (1995) The nurse's role in anxiety management. Professional Nurse, 10(8), 509-12.

Welch A, Lowes S (2005) Home assessment visits within the acute setting: a discussion and literature review. British Journal of Occupational Therapy, 68(4), 158-64.

Williams D (1986) Preoperative patient education: in the home or in the hospital. Orthopaedic Nursing, 5(1), 34-41.

Wong J, Wong S (1985) A randomised controlled trial of a new approach to pre-operative teaching and patient compliance. International Journal of Nursing Studies, 22(2), 105-15.

Focus on research

Theses donated to the COT Library are available for loan, but are not downloadable. Please contact the Library for details.

Gemma Dorer

Community occupations of mental health service users: a quantitative study of engagement and social inclusion. Brunel University, 2005. MSc in Occupational Therapy.

There has been increasing evidence over the past years that people with mental health problems are frequently socially excluded and have decreased levels of occupational engagement (Shimitras et al 2003). This study aimed to identify service users' current level of social inclusion through their engagement in community occupations.

A quantitative cross-sectional survey was undertaken with a purposive sample of all the users (n = 199) of a mental health rehabilitation service within an inner-city NHS trust. Data were collected from staff on the community occupations of their service users across nine occupational domains over the previous week. Information was gathered on the frequency and time spent in community occupations as well as the level of social inclusion experienced in those activities.

It was found that over half of the service users engaged in only two community occupation domains, or less, over the week. These were, most commonly, use of local facilities and contact with family and friends. Few service users were engaged in the community occupations of education, employment, sports, faith, arts and day centres. The domains providing high levels of social inclusion were faith activities, use of local facilities, sports, and seeing family and friends. The lowest levels of social inclusion were found in occupations relating to day centre attendance, art activities, employment and education. Statistical analyses revealed that service users' accommodation type, level of staff support, age and gender had a bearing on the type of occupational engagement, but ethnicity did not.

These findings indicate that many people with mental health problems may not be engaging in community occupations that support their social inclusion and suggest evidence of occupational imbalance and deprivation. The study has implications for occupational therapists, who have the skills to promote social inclusion and health through occupational engagement.

Nicola Orpen (1) and Janet Harris (2)

(1) Occupational Therapy Professional Lead, Nuffield Orthopaedic Centre, Headington, Oxford.

(2) Lecturer, Bergen University College, Bergen, Norway, and School of Health and Related Research, University of Sheffield, Sheffield.

Corresponding author: Nicola Orpen, Occupational Therapy Professional Lead, Occupational Therapy Department, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD. Email: norpen@rocketmail.com

Reference: Orpen N, Harris J (2010) Patients' perceptions of preoperative home-based occupational therapy and/or physiotherapy interventions prior to total hip replacement. British Journal of Occupational Therapy, 73(10), 461-469.

[C] The College of Occupational Therapists Ltd. Submitted: 17 July 2008.

Accepted: 14 June 2010.
... because my condition was deteriorating, the aids that she gave
   me at that stage made all the difference between just existing and
   actually being able to do a bit of living (B1). [Having the
   equipment beforehand] obviously prepares you and it gives you more
   confidence that you can cope on your own (B4).


[At] the hospital appointment in November ... they said it would be
   6 months [until surgery]. If [the occupational therapist] had come
   in the January, that would have helped. I think it was more like
   March (B1).


I am glad mine was when it was because I remembered [what I was
   told] (B6).


Well you see you can read this in the book but then when you have
   this personal contact and they come with you and do the practical
   side of it, it is a great help, absolutely great help (B2).


I was confident about coming out of hospital because I had actually
   walked through in my mind at the home visit, those issues of
   cleanliness, going to the toilet, getting up and downstairs, which
   bed to sleep in, which chair to sit in, issues that hadn't been in
   my mind at all before the visit and wouldn't have come to my mind
   until 3 days after the op (B8).


If [the occupational therapist] hadn't have come I would have said
   no [to having surgery] ... because I couldn't face it. And somehow,
   she was a very nice girl and I asked her different questions and
   ... she reassured me anyway (B7).


I think the home for me was invaluable, because it was so
   affirming. [The occupational therapist] said your house is so well
   set up, which is really nice to know and they wouldn't ever have
   been able to say that in a hospital. You could make up anything
   couldn't you, if you are a patient ... I think for occupational
   therapist it has to be in the home because this is the environment
   in which you've got to cope (B1).


They wouldn't have realised the problems of this flat [if they
   hadn't visited me at home] ... in particular you see the distance
   between my bed and the loo, if you go to the loo in the night (B6).


Yes, it's difficult for you as a patient to translate anything
   that's said [in hospital] into your home environment. Well it is
   for me anyway. I wouldn't be able to imagine everything that I
   would need at home while I was sitting in hospital with somebody
   just talking about it (B1).


I went to my mother's first actually. She's got a high seat and
   stuff anyway so she put me in her high seat and then I gradually
   got adjusted to doing my exercises and then after a few weeks
   really acclimatised, I had no problems at all (B3).


I think probably then I would have thought, 'Well yeah I do need to
   go into [a Community Hospital] or somewhere'. But I knew I had got
   plenty of support around me (B10).


I've got no-one else, no-one. My friends have died, all my friends
   are gone. I had some lovely friends but they're all gone. That's
   the trouble isn't it and my brother has gone who would have helped
   (B7).


Table 1. Criteria for participation

Inclusion criteria

* Therapy home visit prior to
admission for THR surgery

* Discharged between February
and June 2006

* Underwent THR or revision THR

* Aged 16 years and over

* Free from psychiatric history

* Physically able to comply with
study requirements

Exclusion criteria

* Inability to communicate
opinions about service they
received (that is, secondary
to dementia or mental illness
precluding active consent
and participation in study)

* Patients not consenting to
audiotape-recording of
interviews

* Non-English speaking patients

* Patients seen at home by
researcher in her role as a
therapist

* Nursing or residential home
residents

THR = total hip replacement.

Table 2. Summary of participants

                                            Occupational
                                             therapist-
                 Age     Gender   Living      only or
Participant    (years)            alone    combined visit

A1 (pilot)       64        F        No        OT-only

B1               59        F       Yes        OT-only

B2               85        M        No         OT/PT

B3               54        M       Yes        OT-only

B4               73        M       Yes         OT/PT

B5               53        F        No         OT/PT

B6               79        F       Yes         OT/PT

B7               77        F       Yes        OT-only

B8               54        M        No         OT/PT

B9               78        F        No         OT/PT

B10              69        F       Yes     OT-only, PT at
                                             preadmission
                                                clinic

                  Primary or       Time since
Participant      secondary hip     discharge

A1 (pilot)            N/A             N/A

B1                  Primary         1 month

B2                  Primary         4 months

B3                  Primary         2 months

B4             Primary, previous    3 months
                 THR other side

B5                  Primary         3 months

B6                  Primary         5 months

B7               Secondary and      4 months
                  previous THR
                   other side

B8                  Primary         6 months

B9                  Primary         6 months

B10                Secondary        4 Months

OT = occupational therapist; PT = physiotherapist;
THR = total hip replacement
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.