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The Effectiveness of three preoperative learning programs on patient recovery and learning Cranstoun, Catherine Jean 1980

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THE EFFECTIVENESS OF THREE PREOPERATIVE LEARNING PROGRAMS ON PATIENT RECOVERY AND LEARNING by CATHERINE JEAN CRANSTOUN B . S c , The U n i v e r s i t y o f T o r o n t o , 1964 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of A d u l t E d u c a t i o n We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t he r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA F e b r u a r y , 1980 0 C a t h e r i n e Jean C r a n s t o u n , 1980 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s unders t o o d t h a t c o p y i n g or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f / n z X o J U i L ^ C L c . C O J ^ i 0~y-^ The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 D A T E A|QAJ a - M ^ f o . i i ABSTRACT The s t u d y r e p o r t e d here was a c o n t r o l l e d experiment i n which t h r e e groups of e l e v e n randomly a s s i g n e d f emale p a t i e n t s u n d e r g o i n g c h o l e c y s t e c -tomy were s t u d i e d f o r the e f f e c t i v e n e s s o f t h r e e d i f f e r e n t t y p e s o f p r e o p e r a t i v e l e a r n i n g programs: 1. a s y s t e m a t i c , p l a n n e d l e a r n i n g program i n which l e a r n i n g o b j e c t i v e s , s t r a t e g i e s and t e s t s were d e s i g n e d t o meet i n d i v i d u a l p a t i e n t p r e o p e r a t i v e l e a r n i n g needs; 2. a p l a nned group l e a r n i n g program which i n v o l v e d a c l a s s of p a t i e n t s and d i s c u s s i o n o f a s l i d e - s o u n d p r e s e n t a t i o n and d e m o n s t r a t i o n o f e x e r c i s e s ; and 3. an unplanned l e a r n i n g program i n which p a t i e n t s e x p e r i e n c e d o n l y i n c i d e n t a l l e a r n i n g o b j e c t i v e s . S i n c e p r e v i o u s r e s e a r c h had not c o n t r o l l e d f o r t y p e o f s u r g e r y , the major q u e s t i o n i n t h i s s t u d y was whether or not the e f f e c t i v e n e s s o f p r e o p e r a t i v e l e a r n i n g programs as measured by p o s t o p e r a t i v e r e c o v e r y measures would be a p e r s i s t e n t f i n d i n g i n a more r i g i d l y c o n t r o l l e d s t u d y . In a d d i t i o n t o t e s t i n g f o r c o g n i t i v e achievement i n a l l t h r e e l e a r n i n g groups, a v a r i e t y o f p h y s i o l o g i c a l measurements of p o s t o p e r a t i v e r e c o v e r y were made and s t u d i e d i n r e l a t i o n t o c o g n i t i v e achievement. The s t u d y a l s o asked p a t i e n t s t o v a l i d a t e a s e r i e s o f 50 p r e o p e r a t i v e l e a r n i n g needs and c o l l e c t e d d a t a about t h e i r c o g n i t i v e l e a r n i n g s t y l e s i n a p o s t o p e r a t i v e p a t i e n t q u e s t i o n n a i r e . i i i C o n t r a r y t o p r e v i o u s r e s e a r c h , i t was found t h a t the t r a d i t i o n a l phy-s i o l o g i c a l measurements o f p o s t o p e r a t i v e r e c o v e r y used t o measure the e f f e c t i v e n e s s o f p r e o p e r a t i v e l e a r n i n g programs c o u l d not be c o n s t r u e d as v a l i d , d i r e c t measurements o f l e a r n i n g . When s t u d i e d i n r e l a t i o n t o c o g n i -t i v e achievement s c o r e s , t h e s e measures d i d not c o r r e l a t e s i g n i f i c a n t l y . Thus, i t was c o n c l u d e d t h a t the measures are not v a l i d , i n d i r e c t measures o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g . There was however, a s u g g e s t i v e f i n d i n g t h a t the use of a n a l g e s i c drugs may be a u s e f u l i n d i r e c t measure o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g . There were no s i g n i f i c a n t d i f f e r e n c e s i n c o g n i t i v e achievement among th e t h r e e groups, but t h e r e was a s i g n i f i c a n t d i f f e r e n c e between the I n d i v i d u a l i z e d and the I n c i d e n t a l L e a r n i n g Group i n r e l a t i o n t o the number o f doses o f p a r e n t e r a l drugs a d m i n i s t e r e d . A n a e s t h e t i c time a l s o c o r r e -l a t e d n e g a t i v e l y and s i g n i f i c a n t l y w i t h the c o g n i t i v e achievement s c o r e and t h e r e were s i g n i f i c a n t d i f f e r e n c e s between a l l t h r e e l e a r n i n g groups i n r e l a t i o n t o a n a e s t h e t i c time. T h i s l a t t e r f i n d i n g i s o f v a l u e i n p r o v i d i n g a p p r o p r i a t e r e i n f o r c e m e n t o f l e a r n i n g p o s t o p e r a t i v e l y . I t may be t h a t p a t i e n t s t h a t have a l o n g a n a e s t h e t i c time w i l l need more r e i n f o r c e m e n t o f l e a r n i n g p o s t o p e r a t i v e l y . i v P a t i e n t v a l i d a t i o n o f 50 p r e o p e r a t i v e l e a r n i n g needs was c o n d u c t e d and 49 o f the needs were r a t e d by a l l p a t i e n t groups as more than f a i r l y impor-t a n t . P a t i e n t s i n the I n d i v i d u a l i z e d L e a r n i n g Group had a g r e a t e r aware-ness of l e a r n i n g needs and r a t e d l e a r n i n g needs h i g h e r than the p a t i e n t s i n t h e o t h e r l e a r n i n g groups. Thus p a t i e n t s do not q u e s t i o n the importance o f p r e o p e r a t i v e l e a r n i n g . The d a t a r e l e v a n t t o t h e p a t i e n t s ' c o g n i t i v e s t y l e s showed t h a t p a t i e n t s tended t o s e l e c t the l e a r n i n g approaches which t h e y had e x p e r i e n c e d and w i t h which th e y were f a m i l i a r . The I n d i v i d u a l i z e d L e a r n i n g Group e x p e r i e n c e d a v a r i e t y o f approaches and p r o b a b l y gave a t r u e r r e p o r t o f t h e i r c o g n i t i v e s t y l e s . The most s i g n i f i c a n t f i n d i n g i s t h a t few p a t i e n t s i n any o f the t h r e e groups e x p r e s s e d a p r e f e r e n c e f o r a c l a s s a l t h o u g h many p r e f e r r e d group d i s c u s s i o n s . The s i t u a t i o n a l v a r i a b l e s f r e q u e n t l y e n c o u n t e r e d i n c l i n i c a l r e s e a r c h were f u r t h e r d e f i n e d i n t h i s s t u d y . The c o n t r o l s f o r type o f s u r g e r y were i n s u f f i c i e n t and i t i s recommended t h a t i n f u t u r e s t u d i e s c o n t r o l s f o r both d o c t o r and nurse i n v o l v e m e n t be p r o v i d e d . T h i s s t u d y s u g g e s t s t h a t f u t u r e r e s e a r c h examine the development, i m p l e m e n t a t i o n and e f f e c t i v e n e s s o f p r e o p e r a t i v e l e a r n i n g d i r e c t l y . The use o f p h y s i o l o g i c a l measurements o f p o s t o p e r a t i v e r e c o v e r y as i n d i r e c t measures o f l e a r n i n g s h o u l d be v a l i d a t e d i n f u t u r e s t u d i e s . V TABLE OF CONTENTS PAGE CHAPTER I. INTRODUCTION 1 A n a l y s i s o f F a c t o r s I n v o l v e d i n S u c c e s s f u l P o s t o p e r a t i v e R ecovery 1 C o r r e l a t i o n o f the E f f e c t s of P r e o p e r a t i v e L e a r n i n g and P o s t o p e r a t i v e Recovery 19 J u s t i f i c a t i o n o f the Problem 21 D e f i n i t i o n of Terms 22 Hypotheses 24 Assumptions and D e l i m i t a t i o n s 25 P l a n o f the Study 27 CHAPTER I I . DEVELOPMENT OF PREOPERATIVE LEARNING PROGRAMS 28 Review of the L i t e r a t u r e 28 Development o f the I n d i v i d u a l i z e d P r e o p e r a t i v e L e a r n i n g Program 30 Development o f the C l a s s P r e o p e r a t i v e L e a r n i n g Program 37 Development o f the I n c i d e n t a l P r e o p e r a t i v e L e a r n i n g Program - 38 Assessment of L e a r n i n g 38 CHAPTER I I I . METHODOLOGY , 40 Sampling P r o c e d u r e s 40 P r e o p e r a t i v e Treatment 42 I n d i v i d u a l i z e d L e a r n i n g Group 42 C l a s s L e a r n i n g Group 50 I n c i d e n t a l L e a r n i n g Group 52 Assignment o f P a t i e n t s t o Treatment Groups 52 v i TABLE OF CONTENTS - Cont'd. PAGE 53 53 55 55 56 58 59 60 CHAPTER IV. FINDINGS 62 C h a r a c t e r i s t i c s o f the Sample 62 C l i n i c a l S e t t i n g V a r i a b l e s 65 T e s t s o f Hypotheses 67 Method o f A n a l y s i s 67 Treatment Group D i f f e r e n c e s 70 D o c t o r - R e l a t e d C e l l Group D i f f e r e n c e s 78 C o r r o b o r a t i o n o f T e s t V a r i a b l e s 83 P a t i e n t P e r c e p t i o n o f P r e o p e r a t i v e L e a r n i n g Needs 95 P a t i e n t P r e f e r e n c e s f o r L e a r n i n g S t y l e 106 D i s c u s s i o n o f T e s t s o f Hypotheses 109 P o s t o p e r a t i v e Treatment Assessment o f C o g n i t i v e L e a r n i n g P o s t o p e r a t i v e l y Assessment o f P r e o p e r a t i v e L e a r n i n g Needs Assessment o f L e a r n i n g S t y l e s C o n t r o l s Data C o l l e c t i o n S t a t i s t i c a l A n a l y s i s L i m i t a t i o n s v i i TABLE OF CONTENTS - Cont'd. PAGE CHAPTER V. SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH 114 Summary 114 C o n c l u s i o n s 118 I m p l i c a t i o n s 119 BIBLIOGRAPHY 122 APPENDICES 128 A - Pamphlet: "You and Your O p e r a t i o n " 128 B - S c r i p t of So u n d - a n d - S l i d e P r e s e n t a t i o n : " O p e r a t i o n To-morrow" 137 C - N u r s i n g H i s t o r y O u t l i n e 147 D - P r e o p e r a t i v e C o g n i t i v e Assessment: Q u e s t i o n G u i d e l i n e s 151 E - P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e 155 F - F a c t o r A n a l y s i s : P r e o p e r a t i v e L e a r n i n g Needs 162 G - P a t i e n t s Comments About P r e o p e r a t i v e L e a r n i n g Programs 166 v i i i LIST OF TABLES PAGE TABLE I OBJECTIVES OF THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM 31 TABLE II LEARNING ACTIVITIES IN THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM 35 TABLE I I I ASSESSMENT STRATEGIES USED IN THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM 39 TABLE IV INDIVIDUALIZED LEARNING PROGRAM: LETTER OF INTRODUCTION ' 43 TABLE V ORIENTATION TO SPECIFIC ANTICIPATED POSTOPERATIVE EVENTS IN THE INDIVIDUALIZED LEARNING PROGRAM 51 TABLE VI APPROACH TO PATIENTS RECEIVING THE POSTOPERATIVE PATIENT QUESTIONNAIRE 54 TABLE VII SUMMARY OF CHARACTERISTICS OF THE SAMPLE 63 TABLE VIII FREQUENCY OF DOCTOR INVOLVEMENT IN THE STUDY 66 TABLE IX CELL DISTRIBUTION OF PATIENTS BY DOCTOR AND TREATMENT GROUP 68 TABLE X TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN THE INDIVIDUALIZED LEARNING GROUP 71 TABLE XI TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN THE INDIVIDUALIZED LEARNING GROUP 72 TABLE XII CELL AND GROUP MEANS FOR TEST VARIABLES IN THE INCIDENTAL LEARNING GROUP (CONTROL) 73 TABLE X I I I RELIABILITY ANALYSIS: COGNITIVE ACHIEVEMENT TEST 79 TABLE XIV TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN DOCTOR RELATED CELL GROUPS 80 TABLE XV FACTOR ANALYSIS: TEST VARIABLES AND CHARACTERISTICS OF THE SAMPLE 84 LIST OF TABLES - Cont'd. TABLE XVI TABLE XVII TABLE XVIII TABLE XIX TABLE XX TABLE XXI TABLE XXII TABLE XXIII TABLE XXIV PAGE TESTS OF SIGNIFICANCE OF THE CHARACTERISTICS OF THE SAMPLE BY TREATMENT GROUP 89 REGRESSION ANALYSIS: TEST VARIABLES AND CHARACTERISTICS OF THE SAMPLE 93 TESTS OF SIGNIFICANCE FOR CHARACTERISTICS OF THE SAMPLE IN DOCTOR RELATED CELL GROUPS 94 MEANS AND STANDARD DEVIATIONS OF PATIENT RATED PREOPERATIVE LEARNING NEEDS ' 96 HIGHEST RATED PREOPERATIVE LEARNING NEEDS 98 LOWEST RATED PREOPERATIVE LEARNING NEEDS 99 ITEMIZED PREOPERATIVE LEARNING NEEDS FACTORS USED IN TESTS OF SIGNIFICANCE 102 TESTS OF SIGNIFICANCE OF PREOPERATIVE LEARNING NEEDS BY TREATMENT GROUP 103 TESTS OF SIGNIFICANCE FOR PREOPERATIVE LEARNING NEEDS BY DOCTOR RELATED CELL GROUPS 105 TABLE XXV PATIENT PREFERENCES FOR LEARNING STYLE 107 - 1 -CHAPTER I INTRODUCTION N u r s i n g and m e d i c i n e have a l o n g h i s t o r y o f r e s e a r c h i n i s o l a t i n g the key f a c t o r s which det e r m i n e how a p a t i e n t may s u c c e s s f u l l y undergo a s u r g i c a l e x p e r i e n c e , both p h y s i c a l l y and p s y c h o s o c i a l l y . In k e e p i n g w i t h t h a t r e s e a r c h , t h i s s t u d y e x p l o r e d the r e l a t i o n s h i p o f p r e o p e r a -t i v e e d u c a t i o n a l p r o c e s s e s t o p o s t o p e r a t i v e r e c o v e r y i n f e m a l e p a t i e n t s undergoing a c h o l e c y s t e c t o m y . In t h i s c h a p t e r , the l i t e r a t u r e w i l l be r e v i e w e d f o r the key f a c -t o r s r e p o r t e d t o be i n v o l v e d i n s u c c e s s f u l p o s t o p e r a t i v e r e c o v e r y . F a c t o r s i s o l a t e d t o d a t e i n c l u d e p h y s i o l o g i c a l and p s y c h o l o g i c a l f a c -t o r s and some d a t a r e l e v a n t t o t o o l s o f measurement f o r t h e s e f a c t o r s have a l s o been r e p o r t e d . T h i s r e v i e w o f the l i t e r a t u r e i s n e c e s s a r y i n o r d e r to u n d e r s t a n d the s i g n i f i c a n c e o f t h i s c u r r e n t s t u d y which i s to examine the r e l a t i o n s h i p o f p r e o p e r a t i v e e d u c a t i o n a l p r o c e s s e s t o p o s t o p e r a t i v e r e c o v e r y . ANALYSIS OF FACTORS INVOLVED IN SUCCESSFUL POSTOPERATIVE RECOVERY Modern s u r g e r y has a s h o r t h i s t o r y o f a p p r o x i m a t e l y 150 y e a r s . D u r i n g the f i r s t phase o f i t s development, the major o b j e c t i v e was t o make s u r g e r y s a f e and humane. B l e e d i n g , i n f e c t i o n and p a i n were the major o b s t a c l e s . Achievements, such as t h e s u c c e s s f u l a n a e s t h e s i a o f a p a t i e n t w i t h e t h e r by Morton i n 1846 marked the advance o f e a r l y s u r g e r y . Once s u r g i c a l t e c h n i q u e s and a n a e s t h e s i a d e v e l o p e d t o the p o i n t where s u r g e r y was s a f e and humane, the second phase o f development began; t h e o b j e c t i v e was t o make t h e p a t i e n t p h y s i o l o g i c a l l y s a f e f o r s u r g e r y . Assessment o f r e s p i r a t o r y and c a r d i o v a s c u l a r f u n c t i o n by means o f c h e s t x - r a y s , pulmonary f u n c t i o n s t u d i e s , e l e c t r o c a r d i o g r a m s , haemoglobin counts and p r o t h r o m b i n times became common i n the e f f o r t to i n s u r e t h a t the p a t i e n t was f i t t o undergo s u r g e r y . The p r e o p e r a -t i v e "work-up" or d i a g n o s t i c i n v e s t i g a t i o n i s now, not j u s t an a c c e p t e d , but an e x p e c t e d p r a c t i c e (American C o l l e g e o f Surgeons, 1971). The surgeon i s e x p e c t e d t o c o r r e c t or c o n t r o l p h y s i o l o g i c a l d e f i c i t s p r e o p e r a t i v e l y as a means o f making the p a t i e n t s a f e f o r s u r g e r y . One o f the more d r a m a t i c changes i n s u r g i c a l c a r e o c c u r r e d i n 1938 when Dr. D.J. L e i t h a u s e r o b s e r v e d a t h i r s t y and a g g r e s s i v e p a t i e n t who had been de n i e d water a f t e r waking from an appendectomy; t h e p a t i e n t got up out o f bed by h i m s e l f and walked t o the bathroom where he drank as much as he wanted. The p a t i e n t s i g n e d h i m s e l f out o f h o s p i t a l the next day and c a r r i e d on a c o m p l e t e l y normal l i f e u n t i l he had h i s s t i t c h e s out i n the d o c t o r ' s o f f i c e some f o u r days l a t e r . T h i s was a s t u n n i n g i n c i d e n t at a time when p a t i e n t s were kept r e s t i n g i n bed p o s t o p e r a t i v e l y f o r at l e a s t two weeks. Subsequent i n v e s t i g a t i o n by L e i t h a u s e r o f 300 appendectomy p a t i e n t s who e x p e r i e n c e d e a r l y ambula-t i o n showed t h a t the p o s t o p e r a t i v e l e n g t h o f s t a y had been red u c e d t o an average o f 2.2 days ( L e i t h a u s e r , 1946). The p r i n c i p a l o f m o b i l i z a -t i o n as a c e n t r a l g u i d e l i n e i n promoting r e h a b i l i t a t i o n o f the s u r g i -c a l p a t i e n t r e v o l u t i o n i z e d s u r g i c a l c a r e and p a t i e n t s began t o - 3 -walk t o r e c o v e r y . " S t i r - u p " , regimens i n c l u d i n g deep b r e a t h i n g e x e r -c i s e s , c o u g h i n g , l e g e x e r c i s e s , t u r n i n g and ambulation were s t u d i e d f o r t h e i r e f f e c t on p o s t o p e r a t i v e r e c o v e r y . A r e d u c t i o n i n the i n c i -dence o f r e s p i r a t o r y and c i r c u l a t o r y p o s t o p e r a t i v e c o m p l i c a t i o n s were ob s e r v e d ( L e i t h a u s e r , 1949; Lindeman & Van Aernam, 1971). S u b s e q u e n t l y , the t e a c h i n g o f p o s t o p e r a t i v e e x e r c i s e s became a p a r t o f p r e o p e r a t i v e p r e p a r a t i o n ; t h e e f f e c t i v e n e s s o f t h i s approach has been w i d e l y r e p o r t e d ( D r i p p s & Waters, 1941; Hanamey, 1965; Healy, 1968; Lindeman & Van Aernam, 1971; Lindeman, 1972; Mezzanote, 1970). P r e o p e r a t i v e p r e p a r a t i o n expanded t o i n c l u d e an i n c r e a s i n g empha-s i s on p s y c h o l o g i c a l as w e l l as p h y s i o l o g i c a l a s p e c t s . The r i s i n g i n t e r e s t i n p s y c h o l o g i c a l p r e p a r a t i o n provoked s t u d i e s o f p a t i e n t s ' f e a r s and p e r c e p t i o n s p r e o p e r a t i v e l y . C a r n e v a l i (1961) and P a r k e r , (1964) compared p a t i e n t s ' and n u r s e s ' p e r c e p t i o n s o f p r e o p e r a t i v e f e a r s . Fear o f p a i n and d i s c o m f o r t were mentioned most f r e q u e n t l y and f e a r o f the unknown or not knowing what t o e x p e c t ranked a c l o s e second. P a r t o f the f e a r o f the unknown was f e a r t h a t t h e y had not been t o l d "the whole t r u t h " about d i a g n o s i s and/or p r o g n o s i s . Other f e a r s r e p o r t e d i n c l u d e d : 1. changes i n body image; 2. s e p a r a t i o n from normal environment, f a m i l y and f r i e n d s ; 3. based on knowledge o f p r e v i o u s s u r g i c a l e x p e r i e n c e s e i t h e r g a i n e d d i r e c t l y or v i c a r i o u s l y through f a m i l y , - 4 -f r i e n d s , t e l e v i s i o n ; 4. death; 5. d i s r u p t i o n o f l i f e p l a n s or s t y l e ; 6. l o s i n g c o n t r o l over one's environment or d e s t i n y p a r t i c u l a r l y i n terms o f the a n a e s t h e t i c ; and 7. f i n a n c i a l d i f f i c u l t i e s . These s t u d i e s were small (10 s u b j e c t s i n the C a r n e v a l i s t u d y and 11 i n the P a r k e r study) and l a r g e l y u n c o n t r o l l e d , p a r t i c u l a r l y f o r t y p e o f s u r g e r y . S u b s e q u e n t l y , M i l l e r (1965) s t u d i e d a l a r g e r group o f p a t i e n t s i n c l u d i n g 30 p a t i e n t s u n d e r g o i n g major s u r g e r y and 30 p a t i e n t s u n d e rgoing minor s u r g e r y . She compared t h e magnitude o f c o n c e r n s e x p r e s s e d i n both groups and f o u n d t h a t f e a r o f p a i n and d i s c o m f o r t , the unknown and f e a r o f d i a g n o s i s were r e p o r t e d most f r e q u e n t l y and i n t h a t o r d e r i n both g roups. T h i s s t u d y a l s o was u n c o n t r o l l e d f o r t y p e of s u r g e r y . Ramsay (1972) conduc t e d a l a r g e s t u d y o f 183 male and 199 f e m a l e p r e - s u r g i c a l p a t i e n t s aged 4-82 y e a r s o f age. He r e p o r t e d t h a t 73% had p r e - o p e r a t i v e f e a r s and 62% had a n a e s t h e t i c f e a r s p r e d o m i n a n t l y ; f e a r o f s u r g e r y (15%) and o t h e r f a c t o r s (23%) were low. He s u g g e s t e d t h a t s i n c e the i n t e r v i e w e r was always i n t r o d u c e d as an a n a e s t h e t i s t t h a t t h i s may have b i a s e d the p a t i e n t s ' r e p o r t i n g o f f e a r s . However, a c l o s e r e x a m i n a t i o n o f the a n a e s t h e t i c f e a r s r e v e a l e d t h a t most o f - 5 -them i n c l u d e d f e a r o f p a i n and the unknown as p r e v i o u s l y r e p o r t e d by C a r n e v a l i , P a r k e r and M i l l e r . These a n e s t h e t i c f e a r s i n c l u d e d : 1. morbid f e a r s , i . e . "I won't wake up" - death; 2. i n d u c t i o n , i . e . masks and n e e d l e s ; 3. waking up under g e n e r a l a n a e s t h e s i a ; 4. p a i n d u r i n g o p e r a t i o n ; 5. p o s t o p e r a t i v e v o m i t i n g ; 6. m i s c e l l a n e o u s f e a r s , i . e . t a l k i n g under a n a e s t h e s i a , and p o s t o p e r a t i v e p a i n . In a d d i t i o n , Ramsay foun d t h a t men and women were e q u a l l y a f f e c t e d by p r e o p e r a t i v e f e a r . Age had a s i g n i f i c a n t i n f l u e n c e i n t h a t both o l d e r (62-82 y e a r s o f age) and younger p a t i e n t s (4-12 y e a r s of age) had a lower i n c i d e n c e o f f e a r s than a d u l t s , p a r t i c u l a r l y the m i d d l e aged a d u l t (42-61 y e a r s o f age). However, Ramsay's f i n d i n g s can o n l y be c o n s i d e r e d s u g g e s t i v e s i n c e t h e r e was no randomized s e l e c t i o n and no c o n t r o l s f o r sex, age or t y p e o f s u r g e r y . W e i l e r (1968) conducted a d e s c r i p t i v e s t u d y o f 100 p a t i e n t s , 60 males and 40 f e m a l e s , over the p e r i o d o f a y e a r ; t h e r e were no c o n t r o l s f o r sex, age or t y p e o f s u r g e r y . The p a t i e n t s p l a c e d f e a r o f the unknown as a h i g h p r i o r i t y i n e v a l u a t i n g t h e i r p r e o p e r a t i v e i n s t r u c t i o n . - 6 -U s i n g a random s t a r t , Graham and C o n l e y (1971) s e l e c t e d 70 p a t i e n t s b e i n g a d m i t t e d f o r major s u r g e r y . T h e i r sample i n c l u d e d 50 women and 20 men and was u n c o n t r o l l e d f o r sex, age or t y p e o f s u r g e r y . They r e p o r t e d t h a t 48.6% o f the p a t i e n t s d e s c r i b e d t hemselves as v e r y a n x i o u s or f r i g h t e n e d the e v e n i n g b e f o r e s u r g e r y . Fear o f the unknown, a n a e s t h e s i a , and what the d o c t o r s would f i n d were t h e major causes o f t h i s f e a r . Palmer (1965) s u b s e q u e n t l y d e v e l o p e d an i n s t r u -ment t o measure p a t i e n t s ' p e r c e p t i o n o f impending s u r g e r y . T h i s i n s t r u m e n t c o n t a i n e d 46 items making up a L i k e r t - t y p e r a t i n g s c a l e . The b a s i c b e l i e f s u n d e r l y i n g p s y c h o l o g i c a l p r e p a r a t i o n o f the p a t i e n t p r e o p e r a t i v e l y were t h a t a n x i e t y and f e a r can l e a d t o sym-p a t h e t i c s t i m u l a t i o n ( S e l y e , 1950; May, 1950) and, i f p r o l o n g e d , can r e d uce the e f f e c t i v e n e s s o f the body d e f e n s e mechanisms i n c o p i n g w i t h t h e subsequent trauma o f s u r g e r y . Elman (1951) s t a t e d t h a t s u r g i c a l p a t i e n t s o f t e n s u f f e r from adverse e m o t i o n a l r e a c t i o n s which t r i g g e r autonomic r e s p o n s e s and, s u b s e q u e n t l y , i n c r e a s e p o s t o p e r a t i v e nausea, v o m i t i n g and u r i n a r y r e t e n t i o n , as w e l l as l o w e r i n g the p a i n t h r e s h o l d . E c k e n o f f (1956) warned t h a t marked a p p r e h e n s i o n i n a p a t i e n t makes him a p o t e n t i a l c a n d i d a t e f o r death i n the o p e r a t i n g room. Ramsay (1972) s t a t e s t h a t "the a r r h y t h m i a s commonly noted i n p a t i e n t s whose c a r d i a c rhythm has been i n f l u e n c e d by e m o t i o n a l o v e r -r e a c t i o n a r e , paroxysmal t a c h y c a r d i a , premature c o n t r a c t i o n s , a t r i a l f i b r i l l a t i o n and f l u t t e r and, o c c a s s i o n a l l y , v e n t r i c u l a r t a c h y c a r d i a " . - 7 -He a l s o r e p o r t e d a wide v a r i e t y o f o t h e r c a r d i a c p a t h o l o g y caused by f e a r and a n x i e t y . F e a r and a n x i e t y p r e o p e r a t i v e l y came t o be viewed as major f a c t o r s which made the p a t i e n t unsafe f o r s u r g e r y , caused p o s t o p e r a t i v e c o m p l i c a t i o n s or c o m p l i c a t e d the p r o g r e s s o f p o s t o p e r a -t i v e r e c o v e r y . A mass o f r e s e a r c h r e l a t i n g p s y c h o l o g i c a l p r e p a r a t i o n t o s u c c e s s -f u l r e c o v e r y p o s t o p e r a t i v e l y i n t r o d u c e d a v a r i e t y o f p h y s i o l o g i c a l and c l i n i c a l parameters o f measurement such as p o s t o p e r a t i v e nausea and v o m i t i n g , u r i n a r y r e t e n t i o n , i n c i d e n c e o f c o m p l i c a t i o n s such as wound i n f e c t i o n , pneumonia and t h r o m b o p h l e b i t i s , amount o f n a r c o t i c s admi-n i s t e r e d , changes i n temperature, p u l s e and r e s p i r a t i o n and l e n g t h o f h o s p i t a l i z a t i o n (Dumas & Leonard, 1963; DeLuca, 1962; E g b e r t , B a t t i t , Welch & B a r t l e t t , 1964; Healy, 1968; S c h m i t t & W o o l r i d g e , 1973; Lindeman & Van Aernam, 1971). These p h y s i o l o g i c a l measurements have c o n t i n u e d t o be used as p o s t o p e r a t i v e dependent measures o f a n x i e t y r e d u c t i o n p r e o p e r a t i v e l y . In e f f e c t , t h e y are used as measures o f p s y c h o l o g i c a l adjustment p o s t o p e r a t i v e l y . However, as W o l f e r p o i n t e d out i n h i s r e v i e w o f the l i t e r a t u r e i n 1973, t h e s e p h y s i o l o g i c a l measurements o f p o s t o p e r a t i v e r e c o v e r y were o n l y assumed t o have a dependent r e l a t i o n s h i p t o a n x i e t y r e d u c t i o n p r e o p e r a t i v e l y . The n a t u r e o f the r e l a t i o n s h i p between a n x i e t y r e d u c t i o n p r e o p e r a t i v e l y and p o s t o p e r a t i v e r e c o v e r y has not been demonstrated s a t i s f a c t o r i l y i n the r e s e a r c h r e p o r t e d t o date; the f i n d i n g s t o date must be c o n s i d e r e d o n l y s u g g e s t i v e . The l a c k o f more d e f i n i t i v e f i n d i n g s may be - 8 -a t t r i b u t e d i n some degree t o r e s e a r c h which has been p r e d o m i n a t e l y p o o r l y c o n t r o l l e d , p a r t i c u l a r l y f o r type o f s u r g e r y . There has been a t e n d e n c y t o make comparisons between e x p e r i m e n t a l groups, when the groups were not com-p a r a b l e . S u b s e q u e n t l y , f o r typ e o f s u r g e r y , g e n e r a l i z a t i o n s from e x p e r i -mental groups t o the p o p u l a t i o n are s i m i l a r l y i n v a l i d . In s t r i v i n g t o e s t a b l i s h the n a t u r e o f p r e o p e r a t i v e a n x i e t y and i t s e f f e c t on p o s t o p e r a t i v e r e c o v e r y , r e s e a r c h i s c o n t i n u i n g t o e x p l o r e t he development o f measuring d e v i c e s , both o f p r e o p e r a t i v e a n x i e t y and o f p s y c h o l o g i c a l adjustment, r a t h e r than p h y s i o l o g i c a l r e c o v e r y p o s t o p e r a t i -v e l y . Few u n o b t r u s i v e , v a l i d , and r e l i a b l e measuring d e v i c e s have been de v e l o p e d t o d a t e . Graham and C o n l e y (1971) sought t o dete r m i n e whether or not some common s i g n s and b e h a v i o r s which are g e n e r a l l y a c c e p t e d as p h y s i o l o g i c a l and p s y c h o l o g i c a l e v i d e n c e s o f a n x i e t y c o u l d be ob s e r v e d p r e o p e r a t i v e l y w i t h any degree o f c o n s i s t e n c y . They found t h a t i n c r e a s e d b l o o d p r e s s u r e and v e r b a l e x p r e s s i o n s o f f e a r were the o n l y s i g n i f i c a n t m a n i f e s t a t i o n s p r e o p e r a t i v e l y . These f i n d i n g s are c o n s i s t e n t w i t h t h o s e o f Schmidt (1966) and w i t h t he p o s i t i o n o f R o l l o May (1950) who wrote t h a t " t he neurophy-s i o l o g i c a l a s p e c t s o f a n x i e t y cannot be u n d e r s t o o d w i t h o u t c o n s t a n t r e f e r e n c e t o the q u e s t i o n : What i s the organism t r y i n g t o f u l f i l l i n i t s s t r u g g l e w i t h i t s environment" (p. 6 6 ) . W o l f e r (1973 s u p p o r t e d t h i s approach as w e l l and s t a t e d t h a t " p h y s i o l o g i c a l i n d i c a t o r s ( o f a n x i e t y ) are b e s t used i n c o n j u n c t i o n w i t h p a t i e n t s ' s e l f - r e p o r t s and no n v e r b a l e x p r e s s i v e b e h a v i o r s " (p. 396). - 9 -Some attempts were made t o dev e l o p n u r s e - o b s e r v e r r a t i n g t o o l s i n measuring a p a t i e n t ' s p s y c h o l o g i c a l s t a t e and p s y c h o l o g i c a l a d j u s t -ment. A y d e l o t t e (1962) and Simon (1961) d e v e l o p e d n u r s e - r a t i n g s o f the p a t i e n t ' s mental a t t i t u d e as p a r t o f a l a r g e b a t t e r y o f n u r s e - r a t i n g s . These r a t i n g s i n d i c a t e d t he degree t o which t he nur s e l a t e r judged t he p a t i e n t as f r i e n d l y , u n d e r s t a n d i n g , q u a r r e l s o m e , despondent, c o o p e r a t i v e , a g r e e a b l e , demanding, i m p a t i e n t and so on. B r o d t and Anderson (1967) adapted t he A y d e l o t t e p a t i e n t w e l f a r e measures and de v e l o p e d n u r s e - r a t i n g s c a l e s which i n c l u d e d t he mental a t t i t u d e c a t e g o r y , d e f i n e d i n terms o f d e n i a l , s u r r e n d e r e d a t t i t u d e , h o s t i l i t y - a n x i e t y , p a r o n o i a and d e p r e s s i o n . They r e p o r t e d t h a t t h e i r s c a l e s r e q u i r e d g r e a t e r p r e c i s i o n , i n c r e a s e d v a l i -d a t i o n , and a d d i t i o n a l t e s t i n g . Other r e s e a r c h e r s have c o n c e n t r a t e d on t h e development o f p a t i e n t s e l f - r e p o r t i n g i n s t r u m e n t s f o r the measurement o f a n x i e t y p r e o p e r a t i v e l y and p o s t - o p e r a t i v e p s y c h o l o g i c a l adjustment. W i l l i a m s , Jones & W i l l i a m s (1969) and B r u e g e l (1971) used C a t t e l l and S c h e i e r ' s I n s t i t u t e f o r P e r s o n a l i t y and A b i l i t y T e s t i n g A n x i e t y S c a l e Q u e s t i o n n a i r e which r e l i a b l y measures the l e v e l o f m a n i f e s t , f r e e - f l o a t i n g a n x i e t y but not the s i t u a t i o n a l or e n v i r o n m e n t a l l y - i n d u c e d a n x i e t y i n v o l v e d i n a s u r g i -c a l e x p e r i e n c e . B r u e g e l recommended a g a i n s t use o f the IPAT A n x i e t y S c a l e i n measuring p r e o p e r a t i v e s i t u a t i o n a l a n x i e t y : C h a r a c t e r i s t i c a n x i e t y l e v e l , as measured by the IPAT A n x i e t y S c a l e which was a d m i n i s t e r e d t o the p a t i e n t s on the e v e n i n g b e f o r e t h e i r s c h e d u l e d s u r g e r y , d i d not i n f l u e n c e p o s t - o p e r a t i v e p a i n p e r c e p -t i o n . The i n v e s t i g a t o r suggests t h a t t h i s l a c k o f r e l a t i o n s h i p i s perhaps r e l a t e d t o d i f f e r e n c e s between c h a r a c t e r i s t i c and s i t u a t i o n a l a n x i e t y , perhaps the a n x i e t y which seems t o i n f l u e n c e p a i n p e r c e p t i o n i s i n d u c e d by the s i t u a t i o n . ( B r u e g e l , 1971, p. 3 0 ) . - 10 -B u r s t e n and Russ (1965) came t o the same c o n c l u s i o n as B r u e g e l (1971) u s i n g a s i m i l a r t y p e o f t e s t c a l l e d the T a y l o r M a n i f e s t A n x i e t y S c a l e . They recommended the use o f a p h y s i o l o g i c a l measure o f p r e o p e r a t i v e s i t u a t i o n a l s t r e s s namely, plasma s t e r o i d l e v e l s . W i l l i a m s e t a l (1969) dev e l o p e d an i n s t r u m e n t c a l l e d the S k i n Conductance A n x i e t y T e s t (SCAT), which t h e y suggest i s a v a l i d , r e l i a b l e and q u a n t i t a t i v e index o f p a t i e n t a n x i e t y p r e o p e r a t i v e l y . The t e c h n i q u e i n v o l v e s the a d m i n i s t r a t i o n o f a 2cc./min. i n f u s i o n o f a g e n e r a l a n a e s t h e t i c (2.5 t h i o p e n t a l sodium) t o reduce and g a l v a n i z e t h e g a l v a n i c s k i n r e s p o n s e (GSR). The q u a n t i t y o f the drug needed t o a c c o m p l i s h t h i s p u r p o r t e d l y g i v e s a measure o f p r e s u r g i c a l a n x i e t y . Thus the more drug n e c e s s a r y t o e l i m i n a t e t h e spontaneous GSR, t h e h i g h e r the l e v e l o f p a t i e n t a n x i e t y . Johnson, Dabbs & L e v e n t h a l (1970) used a measure o f palmar sweat a c t i v i t y as a p o s s i b l e i n d i c a t o r o f emo-t i o n a l changes and the r e s u l t a n t changes i n autonomic nervous system a c t i -v i t y . An index o f serum p o t a s s i u m l e v e l s was d e v e l o p e d by P r i d e (1968) as a measure o f a d r e n a l s t r e s s . However, the use o f p h y s i o l o g i c a l measure-ments o f autonomic nervous system e f f e c t s cannot be viewed as a b s o l u t e measurements o f p r e o p e r a t i v e f e a r and a n x i e t y . Sympathetic s t i m u l a t i o n can be t r i g g e r e d by a v a r i e t y o f emotions, not o n l y f e a r , as w e l l as by changes i n p h y s i c a l c o n d i t i o n and m e d i c a t i o n s . As p r e v i o u s l y i n d i c a t e d , p h y s i o l o -g i c a l measurements are b e s t used i n c o n j u n c t i o n w i t h p a t i e n t s ' s e l f - r e p o r t s and n o n - v e r b a l e x p r e s s i o n s o f f e a r and a n x i e t y . In a d d i t i o n , t h e s e t y p e s o f p h y s i o l o g i c a l measurements are not u n o b t r u s i v e i n t h a t i t i s d i f f i c u l t t o keep the p a t i e n t unaware t h a t t h e y a r e b e i n g c a r r i e d o u t . They may a l s o be r e a c t i v e i n t h a t the measurements may be d i s t o r t e d due t o a p a t i e n t ' s r e a c t i o n t o b e i n g s t u d i e d . - 11 -Other r e s e a r c h e r s have c o n c e n t r a t e d on d e v e l o p i n g i n s t r u m e n t s which are based on p a t i e n t s ' s e l f - r e p o r t s o f f e a r and a n x i e t y . The Zukerman A f f e c t A d j e c t i v e Check L i s t which g i v e s s c o r e s f o r a n x i e t y , d e p r e s s i o n and h o s t i l i t y was used by Chapman (1970). The Nowlis (1965) Mood A d j e c t i v e Check L i s t was m o d i f i e d by J . E . Johnson e t a l ( 1 9 7 0 ) and used f o r a s s e s s i n g p o s t o p e r a t i v e s t a t e on the o p e r a t i v e day through t o the f o u r t h p o s t o p e r a t i v e day. A d a i l y s c o r e f o r " n e g a t i v e a f f e c t " was o b t a i n e d by summing the s c o r e s o f the f o u r n e g a t i v e moods ( d e p r e s s i o n , f e a r , anger and l e t h a r g y ) and s u b t r a c t i n g t h e s c o r e s f o r a r o u s a l and h a p p i n e s s . T h i s t e s t appeared t o be v a l i d i n t h a t the d i r e c -t i o n o f the d a i l y change i n mood over the h o s p i t a l i z a t i o n p e r i o d was con-s i s t e n t w i t h c l i n i c a l e x p e c t a t i o n s . F e a r was h i g h p r e o p e r a t i v e l y and then g r a d u a l l y d e c r e a s e d . The p o s i t i v e moods o f a r o u s a l and happiness were low i m m e d i a t e l y f o l l o w i n g s u r g e r y and then g r a d u a l l y i n c r e a s e d . These f i n d i n g s must be c o n s i d e r e d s u g g e s t i v e s i n c e J . E . Johnson e t a l (1970) d i d not c o n t r o l f o r t y p e o f s u r g e r y or sample s i z e s , used o n l y f e m a l e s , and d i d not use random s e l e c t i o n or assignment. A Moods and F e e l i n g s I n v e n t o r y was c o n s t r u c t e d by W o l f e r and D a v i s (1970), who p r o v i d e d a s i x - p o i n t s c a l e o f measurement f o r each mood and f e e l i n g d e s c r i b e d by a t o t a l o f 20 a d j e c -t i v e s . The i n s t r u m e n t e l i c i t s a s e p a r a t e f e a r - a n x i e t y " n e g a t i v e a f f e c t " s c o r e and a " p o s i t i v e a f f e c t " s c o r e . The i n v e n t o r y was used p r e o p e r a t i v e l y t o measure f e a r and a n x i e t y and p o s t o p e r a t i v e l y f o r two c o n s e c u t i v e days. No c o n c l u s i v e d a t a were p r o v i d e d as t o the v a l i d i t y or the r e l i a b i l i t y o f - 12 -t h e i n s t r u m e n t . However, Wo l f e r and D a v i s (1970) r e p o r t e d : The most s t r i k i n g f e a t u r e o f t h e s e r e s u l t s was the almost complete absence o f any s i g n i f i c a n t and s u b s t a n t i a l (.50 and above) c o r r e l a t i o n between the pre-and p o s t o p e r a t i v e measures ... The s i g n i f i c a n t c o r r e -l a t i o n s were by and l a r g e too low t o be any v a l u e f o r p r e d i c t i n g p a t i e n t s ' p o s t o p e r a t i v e r e c o v e r y from t h e i r p r e o p e r a t i v e e m o t i o n a l s t a t e s ... The absence o f s u b s t a n t i a l c o r r e l a t i o n s between the pre-and p o s t o p e r a t i v e measures c o u l d be a t t r i b u t e d t o any one or the com-b i n a t i o n o f a l a r g e number o f f a c t o r s i n c l u d i n g the p o s s i b l e unre-l i a b i l i t y and i n v a l i d i t y o f any o f the measures or the i n t e r v e n t i o n o f u n c o n t r o l l e d v a r i a b l e s such as d i f f e r e n t i a l q u a l i t y o f m e d i c a l and n u r s i n g c a r e and i n d i v i d u a l d i f f e r e n c e s i n s t r e s s - c o p i n g a b i l i t y o f t h e p a t i e n t s , (p. 410-411) S i n c e the s t u d y was u n c o n t r o l l e d f o r t y p e o f s u r g e r y , d u r a t i o n o f p r e o p e r a t i v e p e r i o d or e x p e r i m e n t a l t r e a t m e n t methods, and d i d not use random s e l e c t i o n or assignment, t h e y c a u t i o n e d t h a t f u t u r e r e s e a r c h " c o n t r o l f o r s i t u a t i o n a l v a r i a b l e s such as s p e c i f i c t y p e o f s u r g e r y , t y p e and q u a l i t y o f m e d i c a l and n u r s i n g c a r e , both pre-and p o s t o p e r a -t i v e l y , and p a t i e n t s ' c o p i n g a b i l i t y " ( W o l f e r & D a v i s , 1970, p. 4 1 1 ) . Johnson e t a l were a l s o concerned w i t h the r e l a t i o n s h i p o f p r e o p e r a t i v e a n x i e t y t o e f f e c t i v e p o s t o p e r a t i v e r e c o v e r y . They r e p o r t e d : The r e s u l t s s u p p o r t the h y p o t h e s i s t h a t emotional b e h a v i o r appears t o be p a r a l l e l r a t h e r than s e q u e n t i a l l y or c a u s a l l y r e l a t e d t o i n s t r u -mental b e h a v i o r ... The i n s t r u m e n t a l b e h a v i o r s appear t o be a s s o c i a t e d w i t h the b e l i e f t h a t one can e x e r t c o n t r o l over what happens ... The e m o t i o n a l d r i v e t h e o r y advocates t h a t optimum p o s t o p e r a t i v e adjustment w i l l o c c u r when p a t i e n t s are brought t o or m a i n t a i n e d at a medium l e v e l o f p r e o p e r a t i v e f e a r . The f i n d i n g s from t h i s s t u d y demonstrate t h a t i t i s not n e c e s s a r y f o r p a t i e n t s t o be f r i g h t e n e d and, i n f a c t , t h e lower the p o s t o p e r a t i v e f e a r the more l i k e l y t h e r e w i l l be low n e g a t i v e e m o t i o n a l r e a c t i o n s p o s t o p e r a t i v e l y . A l s o , the f i n d i n g s suggest t h a t e m o t i o n a l r e a c t i o n s do not n e c e s s a r i l y i n t e r f e r e w i t h i n s t r u m e n t a l b e h a v i o r s ( J . E . Johnson e t a l , 1970, p. 27-28). - 13 -J a n i s (1958) f i r s t advocated t h e e m o t i o n a l d r i v e t h e o r y , which p o s t u -l a t e d t h a t p a t i e n t s w i t h moderate f e a r p r e o p e r a t i v e l y w i l l be b e t t e r a b l e t o do the "work o f worry" and be b e t t e r p r e p a r e d f o r s u r g e r y than t h o s e w i t h low or h i g h f e a r . T h i s t h e o r y was s u b s e q u e n t l y not o n l y d i s p r o v e d by J . E . Johnson e t al (1970), but a l s o by W o l f e r and D a v i s (1970). The f i n -d i n g s of o t h e r s t u d i e s not o n l y d i s p r o v e the e m o t i o n a l d r i v e t h e o r y but u n d e r l i n e the c o n c l u s i o n t h a t e m o t i o n a l i t y i s i r r e l e v a n t t o t a k i n g a c t i o n ( L e v e n t h a l e t a l , 1966; 1965; 1967). I t was f o u n d t h a t f e a r components o f t h e message about lung c a n c e r and t e t a n u s were a s s o c i a t e d w i t h d e s i r e s t o t a k e p r o t e c t i v e a c t i o n , w h i l e a c o m b i n a t i o n o f f e a r a r o u s a l and s p e c i f i c i n s t r u c t i o n s about how t o o b t a i n t e t a n u s i n n o c u l a t i o n s o r t o r e d u c e smoking were n e c e s s a r y b e f o r e the p r o t e c t i v e a c t i o n o c c u r r e d . J . E . Johnson e t a l a p t l y summarized the f i n d i n g s o f r e s e a r c h t o date: When the amount o f i n f o r m a t i o n on danger exceeds some minimal l e v e l , the i n d i v i d u a l t a k e s p r o t e c t i v e a c t i o n as long as he has c l e a r i n f o r m a t i o n t o g u i d e h i s b e h a v i o r . The amount o f f e a r above and beyond some minimal l e v e l appears t o be i r r e l e v a n t t o t a k i n g a c t i o n (1970, p. 1 9 ) . Thus, r e s e a r c h has demonstrated t h a t not o n l y i s i t d i f f i c u l t t o measure a n x i e t y p r e o p e r a t i v e l y w i t h any degree o f v a l i d i t y , r e l i a b i l i t y or u n o b t r u s i v e n e s s , but the degree o f a n x i e t y i s l a r g e l y i r r e l e v a n t t o t h e t a k i n g o f a c t i o n . In p r a c t i c a l terms, the o n l y u s e f u l f i n d i n g i s t h a t the p a t i e n t s ' v e r b a l e x p r e s s i o n s o f f e a r s p r e o p e r a t i v e l y have been shown t o be a v a l i d , r e a d i l y a v a i l a b l e and u n o b t r u s i v e i n d i c a t o r o f p r e o p e r a t i v e a n x i e t y (Graham & C o n l e y , 1971). - 14 -Closely re lated to the verbal expressions of fears preoperatively i s the method which i s used to deal with these f ears . Recent research by Johnson (1972) has demonstrated that "cogni t ive s t ructur ing" r e s u l t i n g in accurate expectations about sensations reduces s t ress . In addi t ion , information leading to accurate expectations has proven more e f fec t ive than the usual nursing pract ice of describing procedures and the usual explanations given by physic ians . Distress was reduced during actual confrontation with the threatening event only when accurate explanations about the sensations experienced were available©(Johnson, 1972, p. 502). Johnson used a laboratory experimental s i tua t ion i n which the threatening event was the appl icat ion of a blood pressure cuff which was pumped up to 250 mm Hg. pressure and l e f t i n f l a t e d for a s p e c i f i c period of time. A c l i n i c a l experimental s i tua t ion was also used and the threatening event was a gas t ro intes t ina l endoscopy, a diagnostic procedure. Johnson's study was based on the psychological theories relevant to the ro le of cognit ive pro-cesses in guiding behavior (Chomsky, 1965; Fest inger, 1957; Kohlberg, 1969; M i l l e r et a l , 1960). Johnson advocated: Patients should not be to ld of sensations that are only r a r e l y experienced because, such information would, for most pat ients , contribute to incongruency between expected and experienced sen-sat ions . On the other hand, i f patients are informed of often experienced sensations, incongruency i s minimized, (1972, p. 503). Other studies of preoperative preparation are consistent with that of Johnson (1972) and adovcate that a patient must be informed about his surgical experience (Jam's, 1958; Egbert, B a t t i t , Turndorf & Beecher, 1963; Egbert et a l , 1964; N o r r i s , 1964; Healy, 1965; Levine & F i e d l e r , 1970). I t i s implied that i f the patient has a r e a l i s t i c view of the surgical experience he i s about to face, he w i l l be less frightened and - 15 -a n x i o u s and more a b l e t o c o o p e r a t e e f f e c t i v e l y i n h i s p o s t o p e r a t i v e r e c o -v e r y . Dodge, i n a s t u d y o f m e d i c a l and s u r g i c a l p a t i e n t s p e r c e p t i o n s o f t h e i r c o g n i t i v e needs r e p o r t e d : The more a p a t i e n t knows about h i s c o n d i t i o n , the more l i k e l y he i s t o c o o p e r a t e s u c c e s s f u l l y i n h i s t r e a t m e n t ... U n d e r s t a n d i n g i s f a c i l i t a t e d when an i n d i v i d u a l r e c e i v e s the k i n d o f i n f o r m a t i o n t h a t he f e e l s he needs i n a p a r t i c u l a r s i t u a t i o n . C o n v e r s e l y , com-m u n i c a t i o n i s i m p a i r e d when an i n d i v i d u a l r e g a r d s a p a r t i c u l a r message as not s u f f i c i e n t l y i m p o r t a n t t o a t t e n d t o , or even worse, when he r e j e c t s i t (1969, p. 502). Meyer e x p l o r e d the e f f e c t s of s t r u c t u r e d communications, no c o m u n i c a t i o n and i r r e l e v a n t communication i n 72 m e d i c a l and s u r g i c a l p a t i e n t s . She c o n c l u d e d : Less t e n s i o n i s c r e a t e d when the p a t i e n t i s g i v e n s p e c i f i c i n f o r -m ation upon which he can s t r u c t u r e the event o f impending s t r e s s . I t i s e s s e n t i a l t o keep i n mind t h a t how he has l e a r n e d t o cope w i t h s t r e s s from p a s t e x p e r i e n c e w i l l i n f l u e n c e t o a l a r g e e x t e n t the way he handles the s t r e s s ; but r e g a r d l e s s o f the f a c t t h a t he may be over-f e a r f u l or denying as a r e s u l t o f h i s p e r s o n a l i t y , communication i s i m p o r t a n t . S i n c e t e n s i o n i s produced by d i s t r a c t i n g communication, t h i s type o f approach i s the l e a s t d e s i r a b l e and i n terms o f t e n s i o n r e d u c t i o n , i t would be b e t t e r t o say n o t h i n g at a l l . To t e l l t h e p a t i e n t e x a c t l y what i s g o i n g t o happen t o him (by s t r u c t u r i n g the communication) i s most d e s i r a b l e (1964, p. 131). In another study, S c h m i t t and W o o l r i d g e h y p o t h e s i z e d t h a t " e x t r a p r e p a r a t i o n g i v e n t o e x p e r i e m e n t a l p a t i e n t s would i n c r e a s e t h e i r p ar-t i c i p a t i o n i n t h e i r t r e a t m e n t , d e c r e a s e s t r e s s caused by t e n s i o n and a n x i e t y , and l e a d t o a more r a p i d p o s t o p e r a t i v e r e c o v e r y " (1973, p. 109). T h e r e were 50 male p a t i e n t s i n the s t u d y who were matched f o r t y p e o f s u r g e r y and then randomly a s s i g n e d i n t o e x p e r i m e n t a l or c o n t r o l groups. E x p e r i m e n t a l p a t i e n t s p a r t i c i p a t e d i n a group d i s c u s s i o n d u r i n g the e v e n i n g p r e o p e r a t i v e l y and were p r o v i d e d w i t h f o u r t y p e s o f i n f o r m a t i o n : - 16 -1. o r i e n t a t i o n ( e . g . time o f s u r g e r y or how long they would be i n the r e c o v e r y room; 2. new knowledge; 3. f e e l i n g s about s u r g e r y ; and 4. s p e c i f i c a c t i v i t i e s t h e y c o u l d p e r f o r m t o speed up t h e i r r e c o v e r y ( e . g . l e g e x e r c i s e s ) . C o n t r o l p a t i e n t s r e c e i v e d the r o u t i n e c a r e u s u a l l y p r o v i d e d by h o s p i t a l s t a f f which was d e s c r i b e d as t a s k - o r i e n t e d . A v a r i e t y o f p h y s i o l o g i c a l i n d i c a t o r s o f p o s t o p e r a t i v e recovery were used as w e l l as p a t i e n t s ' s e l f - r e p o r t s c o l l e c t e d i n the form o f a q u e s t i o n n a i r e at the time o f d i s c h a r g e . E x p e r i m e n t a l p a t i e n t s demonstrated a more une-v e n t f u l and r a p i d r e c o v e r y than c o n t r o l p a t i e n t s . S c h m i t t and W ooldridge c o n c l u d e t h a t " g i v i n g the p a t i e n t i n i t i a l s u p p o r t and some s k i l l s t o work w i t h made him b e t t e r a b l e t o cope e f f e c t i v e l y w i t h the c r i s i s o f s u r g e r y " (1973, p. 115). The f i n d i n g s must be viewed as s u g g e s t i v e s i n c e o n l y men were s t u d i e d , random s e l e c t i o n was not used, the sample s i z e s were small f o r each ty p e o f s u r g e r y (one e x p e r i m e n t a l p a t i e n t and one c o n t r o l p a t i e n t ) and t h e r e were no c o n t r o l s f o r t y p e o f s u r g e r y . As p s y c h o l o g i c a l p r e p a r a t i o n o f the p a t i e n t p r e o p e r a t i v e l y moved c l o s e r towards " c o g n i t i v e s t r u c t u r i n g " and s h a p i n g o f a p a t i e n t s e x p e c t a t i o n s , t e a c h i n g the p a t i e n t was r e f e r r e d t o more f r e q u e n t l y . I t was e i t h e r d i r e c t l y s t a t e d ( D e l u c a , 1962; E g b e r t et a l , 1964; Hanamey, 1965; Healy, 1968; W e i l e r , 1968; Mezzanote, 1970; Lindeman & Van Hernam, 1971; Lindeman, 1972) or s t r o n g l y i m p l i e d t h a t p r e o p e r a t i v e i n s t r u c t i o n improved p o s t o p e r a t i v e r e c o v e r y . Dumas - 17 -(1964) s t a t e d t h a t p a t i e n t s need i n f o r m a t i o n i n o r d e r t o u n d e r s t a n d what i s happening t o them or about t o happen t o them. I f t h e y have u n d e r s t a n d i n g , t h e y w i l l be p s y c h o l o g i c a l l y p r e p a r e d and have a more u n e v e n t f u l p o s t o p e r a t i v e r e c o v e r y as measured by i n c i d e n c e o f p o s t o -p e r a t i v e v o m i t i n g . N o r r i s r e p o r t e d t h a t " i f on her rounds a nurse can f i n d time t o answer her p a t i e n t s q u e s t i o n s s i m p l y and q u i e t l y and e x p l a i n some o f what l i e s ahead, she w i l l save many a g r e a t d e a l o f n e e d l e s s s u f f e r i n g and w i l l have a c h i e v e d almost as much as the drug p r e m e d i c a t i o n - and w i t h o u t any o f the s i d e e f f e c t s a s s o c i a t e d w i t h t h e l a t t e r " (1964, p. v ) . N u r s i n g i n t e r v e n t i o n i n v o l v i n g i n f o r m a t i o n -g i v i n g about p a i n p a t i e n t s are e x p e r i e n c i n g and how t h a t p a i n might be r e l i e v e d i n a v a r i e t y of ways, was d e s c r i b e d as s u c c e s s f u l i n c h a n g i n g p a t i e n t s ' a t t i t u d e s (Moss & Meyer, 1966). L e v i n e and F i e d l e r (1970) s t r e s s e d t h a t f e a r o f the unknown i s the g r e a t e s t f e a r o f the p r e o p e r a t i v e p a t i e n t . They d e s c r i b e d a p r e o p e r a t i v e i n f o r m a t i o n program d e s i g n e d t o r e d u c e t h i s f e a r . A group d i s c u s s i o n geared t o d e a l w i t h a wide range o f i d e n t i f i e d c o g n i t i v e and psychomotor l e a r n i n g needs was p r o v i d e d f o r e x p e r i m e n t a l p a t i e n t s by S c h m i t t and W o o l r i d g e (1973). T h i s r e v i e w of the l i t e r a t u r e has i s o l a t e d a number o f f a c t o r s p o s t u l a t e d as s i g n i f i c a n t i n i n f l u e n c i n g s u c c e s s f u l p o s t o p e r a t i v e r e c o v e r y . F e a r and a n x i e t y were b e l i e v e d t o be key f a c t o r s i n e f f e c t i v e p s y c h o l o g i c a l p r e p a r a t i o n and p s y c h o l o g i c a l p r e o p e r a t i v e p r e p a r a t i o n has come t o be equated w i t h p r e o p e r a t i v e t e a c h i n g . However, the e m o t i o n a l i t y o f a p a t i e n t was demonstrated t o be i r r e l e v a n t t o h i s t a k i n g a c t i o n or b e i n g i n s t r u m e n t a l i n h i s own r e c o v e r y . R a t h e r , the drawing out o f c l e a r e x p e c a t i o n s , not o n l y about the p r o c e d u r e s t o be e x p e c t e d , but the - 18 -s e n s a t i o n s t o be e x p e c t e d i n a s u r g i c a l e x p e r i e n c e , was the major f a c t o r i n h e l p i n g a p a t i e n t t o become i n s t r u m e n t a l i n h i s own r e c o v e r y . The degree of a n x i e t y m a n i f e s t e d p r e o p e r a t i v e l y was not shown t o be s i g n i f i c a n t and t h e o n l y p r a c t i c a l , v a l i d and u n o b t r u s i v e measure o f p r e o p e r a t i v e a n x i e t y was the p a t i e n t s ' v e r b a l e x p r e s s i o n s of h i s f e a r s . Data r e l e v a n t t o the development of v a l i d and r e l i a b l e measures o f p s y c h o l o g i c a l adjustment p o s t o p e r a t i v e l y are i n c o n c l u s i v e . P h y s i o l o g i c a l measures o f p a t i e n t r e c o -v e r y p o s t o p e r a t i v e l y were c o n s i s t e n t l y used t o measure the e f f e c t s o f n u r s i n g i n t e r v e n t i o n p r e o p e r a t i v e l y whether d e s c r i b e d as p s y c h o l o g i c a l p r e -p a r a t i o n or i n s t r u c t i o n . No d i r e c t measures o f p a t i e n t s ' l e a r n i n g sub-sequent t o p r e o p e r a t i v e i n s t r u c t i o n have been r e p o r t e d . A l l f i n d i n g s t o date are s u g g e s t i v e r a t h e r than c o n c l u s i v e i n c o m p a r a t i v e s t u d i e s o f the e f f e c t s o f p r e o p e r a t i v e p r e p a r a t i o n or i n s t r u c t i o n i n t h a t no s t u d i e s c o n t r o l l e d f o r t y p e o f s u r g e r y . - 19 -CORRELATION OF THE EFFECTS OF PREOPERATIVE LEARNING AND POSTOPERATIVE RECOVERY L e a r n i n g may be d e f i n e d as a r e l a t i v e l y permanent change i n human b e h a v i o r which cannot be s i m p l y d e s c r i b e d t o the p a t t e r n o f growth (Gagne, 1970, p. 3 ) . L e a r n i n g as such i s an i n t e r n a l p r o c e s s and i s s i m i l a r t o a n x i e t y which can be measured o n l y i n d i r e c t l y by measuring the p r o d u c t o f l e a r n i n g m a n i f e s t e d i n c o g n i t i v e , a f f e c t i v e or psychomotor b e h a v i o r s . The l i t e r a t u r e has p r o v i d e d a c o n s i d e r a b l e amount o f i n f o r m a t i o n about a p a t i e n t ' s l e a r n i n g needs p r e o p e r a t i v e l y r e l e v a n t t o the t h r e e domains o f l e a r n i n g - c o g n i t i v e , a f f e c t i v e and psychomotor. C o g n i t i v e needs have c e n t e r e d around knowledge t o a l l e v i a t e the f e a r o f the unknown; a f f e c t i v e needs have f o c u s e d on the development o f a p o s i t i v e a t t i t u d e toward impending s u r g e r y and a d e s i r e t o p a r t i c i p a t e i n p o s t o p e r a t i v e e x e r c i s e s ; psychomotor needs have p r i m a r i l y i n v o l v e d p o s t o p e r a t i v e e x e r c i s e s . There i s l i t t l e r e p o r t e d e v i d e n c e p e r t a i n i n g t o s y s t e m a t i c educa-t i o n a l approaches t o p r e o p e r a t i v e l e a r n i n g i n which l e a r n i n g o b j e c -t i v e s were s e t , r e l e v a n t l e a r n i n g a c t i v i t i e s o u t l i n e d and measurement o f l e a r n i n g achievement conducted. There were no d i r e c t l y s t a t e d l e a r n i n g o b j e c t i v e s r e p o r t e d . O n l y a few s t u d i e s even r e f e r r e d t o p r e o p e r a t i v e p r e p a r a t i o n as e d u c a t i o n , i n s t r u c t i o n or t e a c h i n g ( E g b e r t e t a l , 1964; Hanamey, 1965; Healy, 1968; L e v i n e & F i e d l e r , 1970; Mezzanote, 1970; Lindeman & Van Aernam, 1971). - 2 0 -S e v e r a l s t u d i e s have o u t l i n e d l e a r n i n g a c t i v i t i e s , but none r e p o r t e d t e s t i n g f o r l e a r n i n g a c h i e v e d . R a t h e r , s t u d i e s t o d a t e have tended t o use a v a r i e t y o f p h y s i o l o g i c a l w e l f a r e measures as measures o f suc-c e s s f u l p r e o p e r a t i v e t e a c h i n g or l e a r n i n g . These measurements, w h i l e t h e y may c o r r e l a t e w i t h e f f e c t i v e p r e o p e r a t i v e i n s t r u c t i o n and l e a r n i n g , cannot be c o n s i d e r e d as v a l i d measurements o f l e a r n i n g s i n c e t h e y do not measure l e a r n i n g d i r e c t l y . In a d d i t i o n , s i n c e a l l p r e v i o u s s t u d i e s d i d not c o n t r o l f o r t y p e o f s u r g e r y , the v a l i d i t y o f the p h y s i o l o g i c a l w e l f a r e measures as s i g n i f i c a n t c o r r e l a t e s o f e f f e c t i v e p r e o p e r a t i v e i n s t r u c t i o n as r e p o r t e d i n t h o s e s t u d i e s must be q u e s t i o n e d s i n c e f i n d i n g s d e r i v e d i n t h o s e i n s t a n c e s are not comparable. T h e r e f o r e i t was the purpose o f t h i s s t u d y t o use a randomized e x p e r i m e n t a l d e s i g n i n which ty p e o f s u r g e r y was c o n t r o l l e d and t o s t u d y t h e e f f e c t i v e n e s s o f t h r e e d i f f e r e n t types o f p r e o p e r a t i v e l e a r n i n g programs by measuring c o g n i t i v e achievement, as w e l l as t o s t u d y t h e c o r r e l a t i o n between the e f f e c t i v e n e s s o f the l e a r n i n g programs and p o s t o p e r a t i v e r e c o v e r y as measured by a v a r i e t y o f phy-s i o l o g i c a l measurements. A n x i e t y was not i d e n t i f i e d as a s i n g l e i n d e -pendent v a r i a b l e p r e o p e r a t i v e l y which a f f e c t s p o s t o p e r a t i v e r e c o v e r y . R a t h e r , a n x i e t y and f e a r were c o n s i d e r e d as the e f f e c t s o f m u l t i p l e c auses i n v o l v e d i n the p r e o p e r a t i v e p r e p a r a t i o n and p o s t o p e r a t i v e r e c o v e r y o f a p a t i e n t . A n x i e t y and f e a r i n the e d u c a t i o n a l model used i n t h i s s t u d y were t r e a t e d as p r e c o n d i t i o n s o f l e a r n i n g which must be i d e n t i f i e d and d e a l t w i t h i n s e t t i n g the s t a g e f o r p r e o p e r a t i v e l e a r n i n g . - 21 -JUSTIFICATION OF THE PROBLEM The t h r e e types of p r e o p e r a t i v e l e a r n i n g programs i n c l u d e d i n t h i s s t u d y were: 1. an i n d i v i d u a l i z e d l e a r n i n g program d e f i n e d as a planned program d e s i g n e d t o meet the s p e c i f i c p r e o p e r a t i v e l e a r n i n g needs o f an i n d i v i d u a l u s i n g a v a r i e t y o f l e a r n i n g a c t i v i t i e s ; 2. a c l a s s l e a r n i n g program d e f i n e d as a planned program de s i g n e d t o meet p r e o p e r a t i v e l e a r n i n g needs u s i n g a group or c l a s s method; and 3 . an i n c i d e n t a l l e a r n i n g program d e f i n e d as an unplanned program i n which p a t i e n t s meet l e a r n i n g needs i n an i n c i d e n -t a l way thro u g h the i n t e r a c t i o n and i n f o r m a l t e a c h i n g p r o -v i d e d by h e a l t h c a r e p e r s o n n e l i n v o l v e d i n t h e i r c a r e p r e o p e r a t i v e l y . Comparison o f the e f f e c t i v e n e s s of d i f f e r e n t p r e o p e r a t i v e l e a r n i n g programs i s p o t e n t i a l l y s i g n i f i c a n t t o n u r s i n g c l i n i c i a n s and n u r s i n g r e s e a r c h e r s as w e l l as to h o s p i t a l a d m i n i s t r a t o r s . A s t u d y o f the e f f e c -t i v e n e s s o f a p l a n n e d p r e o p e r a t i v e l e a r n i n g program as compared t o an unplanned program can be used as a model f o r c l i n i c a l p r a c t i t i o n e r s c o n c e r n e d w i t h d e v e l o p i n g s u c c e s s f u l p r e o p e r a t i v e l e a r n i n g programs. P r e o p e r a t i v e p s y c h o l o g i c a l p r e p a r a t i o n can be d e f i n e d as p a r t of a t e a c h i n g - l e a r n i n g p r o c e s s which r e d u c e s a n x i e t y as a p r e c o n d i t i o n f o r l e a r n i n g , i n s u r i n g t h a t a p a t i e n t l e a r n s the s k i l l s needed t o cope e f f e c t i v e l y w i t h the s u r g i c a l e x p e r i e n c e . Once the emphasis i n a - 22 -p r e o p e r a t i v e l e a r n i n g program i s p l a c e d on 1) assessment o f the p a t i e n t ' s l e a r n i n g needs, 2) p r o v i s i o n f o r c o n t r o l of the p r e -c o n d i t i o n s and c o n d i t i o n s o f l e a r n i n g , 3) the i m p l e m e n t a t i o n o f e f f e c -t i v e t e a c h i n g - l e a r n i n g p r o c e s s e s and 4) the measurement o f a p a t i e n t ' s l e a r n i n g , then, a u s e f u l body o f knowledge about p r e o p e r a t i v e l e a r n i n g programs can b e g i n t o d e v e l o p . T h i s knowledge i s o f v a l u e not o n l y t o the n u r s i n g c l i n i c i a n , but a l s o t o the n u r s i n g r e s e a r c h e r concerned w i t h c o n t r i b u t i n g t o the growing body o f n u r s i n g t h e o r y . H o s p i t a l a d m i n i s t r a t o r s s h o u l d f i n d the s t u d y o f p r e o p e r a t i v e l e a r n i n g programs t o be o f v a l u e e c o n o m i c a l l y . There are p o t e n t i a l c o s t bene-f i t s a c c r u i n g from the e f f i c i e n t use o f s t a f f and f a c i l i t i e s i f a p l a n n e d , p r e o p e r a t i v e l e a r n i n g program i s s u c c e s s f u l i n promoting r a p i d and u n e v e n t f u l p o s t o p e r a t i v e r e c o v e r y . In a d d i t i o n , o p e r a -t i o n a l d e f i n i t i o n s o f e x p e c t e d p a t i e n t b e h a v i o r s p o s t o p e r a t i v e l y a f f o r d a c o n c r e t e b a s i s f o r the development o f c a r e s t a n d a r d s and i n a c c o u n t i n g f o r the e f f e c t i v e n e s s o f c a r e p r o v i d e d . The a b i l i t y t o account f o r s e r v i c e s r e n d e r e d as w e l l as f o r the economy o f t h o s e s e r -v i c e s i n a measureable way i s o f i n c r e a s i n g i n t e r e s t t o h o s p i t a l admin-i s t r a t o r s , e s p e c i a l l y i n t h i s e r a o f economic r e s t r a i n t . DEFINITION OF TERMS A number o f terms which are c e n t r a l t o an u n d e r s t a n d i n g o f t h i s s t u d y are d e f i n e d below: - 2 3 -A d u l t s u r g i c a l p a t i e n t i s any p a t i e n t 15 y e a r s o f age or o l d e r who has been admitted f o r e l e c t i v e s u r g e r y . A n a l g e s i c i s any p a i n - r e l i e v i n g m e d i c a t i o n o r d e r e d by the p h y s i c i a n . A n a l g e s i c s may be a d m i n i s t e r e d e i t h e r o r a l l y or p a r e n t e r a l l y by i n j e c t i o n i n t o t he t i s s u e s . B e l i e f s are the r e c o r d e d v e r b a l r e p o r t s o f a p a t i e n t s ' b e l i e f s about h i s i l l n e s s , h o s p i t a l i z a t i o n , and tre a t m e n t as determined i n the p r e o p e r a t i v e i n t e r v i e w . These b e l i e f s i n c l u d e t he f a c t s about t h e s e e v e nts as the p a t i e n t b e l i e v e s them t o be and a l s o i n c l u d e s f e a r s caused by r e a l dangers and a n x i e t i e s provoked by unknown and u n i d e n -t i f i e d f a c t o r s . C h o l e c y s t e c t o m y i s the e x c i s i o n o f the g a l l b l a d d e r and c y s t i c d u c t . F l o a t Nurse i s a nurse who i s not s p e c i f i c a l l y a s s i g n e d t o a g i v e n ward u n i t but moves as d i r e c t e d from ward t o ward d u r i n g a s h i f t a c c o r d i n g t o the v a r y i n g ward needs f o r s t a f f . I n s t r u c t i o n i s the p r o c e s s o f m a n i p u l a t i n g t he c o n d i t i o n s o f l e a r n i n g r e q u i r e d t o a l l o w a p e r s o n t o r e a c h l e a r n i n g o b j e c t i v e s . L e a r n i n g i s a r e l a t i v e l y permanent change i n human b e h a v i o r which cannot be s i m p l y a s c r i b e d t o the p r o c e s s o f growth. - 24 -Length o f P o s t o p e r a t i v e S t a y i s the number o f days the p a t i e n t i s h o s p i t a l i z e d p o s t o p e r a t i v e l y commencing from the f i r s t day f o l l o w i n g the o p e r a t i o n day and i n c l u d i n g the day o f d i s c h a r g e . Number o f A n a l g e s i c s A d m i n i s t e r e d P r e o p e r a t i v e l y i s the t o t a l number o f doses o f pro r e n a t a ( p . r . n . - whenever n e c e s s a r y ) o r a l and p a r e n t e r a l a n a l g e s i c s a d m i n i s t e r e d p o s t o p e r a t i v e l y . P o s t o p e r a t i v e R e c o v e r y i s t h e r e t u r n o f a p a t i e n t t o normal f u n c -t i o n as measured by a v a r i e t y o f p h y s i o l o g i c a l i n d i c a t o r s i n c l u d i n g t emperature r e a d i n g s , i n c i d e n c e o f u r i n a r y r e t e n t i o n , pulmonary and c a r d i o v a s c u l a r c o m p l i c a t i o n s , wound c o m p l i c a t i o n s , nausea, v o m i t i n g and gaseous d i s t e n s i o n , l e n g t h o f p o s t o p e r a t i v e s t a y and the numbers of doses o f a n a l g e s i c s a d m i n i s t e r e d p o s t o p e r a t i v e l y . HYPOTHESES The f o l l o w i n g major hypotheses were f o r m u l a t e d and t e s t e d : 1. That the I n d i v i d u a l i z e d L e a r n i n g Group and the C l a s s L e a r n i n g Group w i l l demonstrate a more s u c c e s s f u l p o s t o p e r a t i v e r e c o -v e r y than the I n c i d e n t a l L e a r n i n g Group as measured by each o f the f o l l o w i n g n i n e measures: 1.1 fewer doses o f o r a l a n a l g e s i c s ; 1.2 fewer doses o f p a r e n t e r a l a n a l g e s i c s ; 1.3 more r a p i d p r o g r e s s t o the use o f o r a l a n a l g e s i c s ; 1.4 fewer days o f use o f o r a l a n a l g e s i c s ; 1.5 fewer days of use o f p a r e n t e r a l a n a l g e s i c s ; - 25 -1.6 l e s s f e v e r ; 1.7 lower i n c i d e n c e o f g a s t r o i n t e s t i n a l d y s f u n c t i o n ; 1.8 lower i n c i d e n c e of c o m p l i c a t i o n s ; and 1.9 s h o r t e r p o s t o p e r a t i v e s t a y . 2. That t h e I n d i v i d u a l i z e d L e a r n i n g Group and the C l a s s L e a r n i n g Group w i l l a c h i e v e a h i g h e r s c o r e on t h e p o s t o p e r a t i v e c o g n i t i v e achievement t e s t than t he I n c i d e n t a l L e a r n i n g Group. The purpose o f t e s t i n g t he group d i f f e r e n c e s i n terms o f p h y s i o l o -g i c a l i n d i c a t o r s was t o determine whether or not t h e r e i s any c o r r e l a -t i o n between t h e s e i n d i c a t o r s and the e f f e c t i v e n e s s o f d i f f e r e n t k i n d s o f p r e o p e r a t i v e l e a r n i n g programs as measured by c o g n i t i v e achievement s c o r e s . In a d d i t i o n , t he p a t i e n t s ' p e r c e p t i o n s o f the v a l i d i t y o f p r e o p e r a t i v e l e a r n i n g o b j e c t i v e s was a s s e s s e d through t he use o f a p a t i e n t q u e s t i o n n a i r e a d m i n i s t e r e d t o a l l p a t i e n t s on the f i f t h p o s t o p e r a t i v e day. ASSUMPTIONS AND DELIMITATIONS Four major assumptions u n d e r l a i d t he d e s i g n o f t h i s study: 1. The t e a c h i n g - l e a r n i n g p r o c e s s e s i n v o l v e d i n each o f the t h r e e p r e o p e r a t i v e l e a r n i n g programs were c l a s s i f i e d as independent v a r i a b l e s . - 26 -2. T e a c h i n g - l e a r n i n g p r o c e s s e s were ways o f c r e a t i n g l e a r n i n g con-d i t i o n s i n which the p a t i e n t can l e a r n how t o cope s u c c e s s f u l l y w i t h the s u r g i c a l e x p e r i e n c e . 3. The p h y s i o l o g i c a l i n d i c a t o r s were measures o f p o s t o p e r a t i v e r e c o v e r y , not l e a r n i n g . 4. The c o g n i t i v e p o s t - t e s t was a measure o f knowledge and was c l a s s i f i e d as a dependent v a r i a b l e or an e f f e c t o f the c o g n i t i v e t e a c h i n g - l e a r n i n g p r o c e s s e s . S u b j e c t s 15 y e a r s o f age or o l d e r and e l i g i b l e f o r a d m i s s i o n t o an a d u l t acute c a r e s u r g i c a l u n i t were i n c l u d e d i n t h i s s t u d y . The s t u d y was l i m i t e d t o f e m a l e s i n t h a t the m a j o r i t y o f p a t i e n t s u n d ergoing a c h o l e -c y s t e c t o m y are f e m a l e , ( S l e i s e n g e r & F o r d t r a n , 1978, p. 1284). In o r d e r t o i n s u r e t h a t the s u r g i c a l trauma was r e l a t i v e l y e q u i v a l e n t f o r a l l p a t i e n t s i n the s t u d y , s u b j e c t s a d m i t t e d f o r an e l e c t i v e c h o l e c y s t e c t o m y under non-emergency c o n d i t i o n s were s e l e c t e d . A p r e r e q u i s i t e s k i l l was the a b i l i t y t o u n d e r s t a n d o r a l and w r i t t e n E n g l i s h . P a t i e n t s who d i d not have t h i s p r e - r e q u i s i t e l e a r n i n g would be unable t o r e a c h the l e a r n i n g o b j e c t i v e s i n the p r e o p e r a t i v e t e a c h i n g programs used i n the s t u d y and t h e r e f o r e were e x c l u d e d . P a t i e n t s d i a g n o s e d as p s y c h i a t r i c would tend t o skew the r e s u l t s o f the s t u d y s i n c e t h e i r l e v e l o f f e a r and a n x i e t y u s u a l l y would demand i n t e r v e n t i o n beyond the l e v e l o f the e d u c a t i o n a l p r o c e s s used i n t h i s study, so such p a t i e n t s were e x c l u d e d . - 2 7 -PLAN OF THE STUDY The p l a n o f t h i s s t u d y i n c l u d e d t he development o f t h r e e d i f f e r e n t p r e o p e r a t i v e l e a r n i n g programs and t e s t i n g t h e e f f e c t i v e n e s s o f t h o s e programs by a c o g n i t i v e p o s t - t e s t on t h e f i f t h p o s t o p e r a t i v e day. C o r r e l a t i o n o f the e f f e c t i v e n e s s o f t h e s e t h r e e l e a r n i n g programs w i t h a v a r i e t y o f the t r a d i t i o n a l p h y s i o l o g i c a l measures o f p o s t o p e r a t i v e r e c o v e r y was a l s o done as a means o f d e t e r m i n i n g whether or not the p h y s i o l o g i c a l measures were v a l i d measures o f s u c c e s s f u l p r e o p e r a t i v e l e a r n i n g as i n d i c a t e d i n p r e v i o u s r e s e a r c h . In a d d i t i o n , t he p a t i e n t s were asked t o v a l i d a t e a s e r i e s o f s p e c i f i c p r e o p e r a t i v e l e a r n i n g o b j e c t i v e s i n v o l v e d i n a p r e o p e r a t i v e l e a r n i n g program f o r a p a t i e n t undergoing a c h o l e c y s t e c t o m y . The p a t i e n t s ' v a l i d a t i o n was conducte d on t h e f i f t h p o s t o p e r a t i v e day and was used as a s e p a r a t e assessment o f the t h r e e p r e o p e r a t i v e l e a r n i n g programs. The r a t i o n a l e u n d e r l y i n g the s e l e c t i o n o f the t h r e e l e a r n i n g programs i s r e p o r t e d i n Chapte r I I . Chapter I I I r e p o r t s t he methodology used i n the s t u d y and f i n d i n g s a re p r e s e n t e d i n Ch a p t e r IV. The f i n a l c h a p t e r c o n t a i n s a summary o f the st u d y t o g e t h e r w i t h c o n c l u s i o n s . - 2 8 -CHAPTER II DEVELOPMENT OF PREOPERATIVE LEARNING PROGRAMS The development o f the t h r e e p r e o p e r a t i v e l e a r n i n g programs i n t h i s s t u d y was a c r i t i c a l s t e p . The r a t i o n a l e u n d e r l y i n g t h e i r s e l e c t i o n and development i s d e s c r i b e d i n t h i s c h a p t e r . REVIEW OF THE LITERATURE P u b l i s h e d d e s c r i p t i o n s o f p r e o p e r a t i v e t e a c h i n g programs have been of l i m i t e d v a l u e i n p r o v i d i n g f o r the development of p r e o p e r a t i v e l e a r n i n g programs. Dumas and Anderson (1964) i n c l u d e d a t o t a l p r e o p e r a t i v e p r e -p a r a t i o n i n t h e i r s t u d y , but d i d not i d e n t i f y t h i s p r o c e s s as e d u c a t i o n a l , a l t h o u g h i t was s t r o n g l y i m p l i e d . S e v e r a l r e s e a r c h e r s d i d some i n t e r e s t i n g non-experimental s t u d i e s o f p r e o p e r a t i v e t e a c h i n g programs (Hanamey, 1965; L e v i n e & F i e d l e r , 1970; Mezzanote, 1970) In a d d i t i o n t o the l a c k o f g e n e r a l i z a b i l i t y o f such s t u d i e s , the l e a r n i n g o b j e c t i v e s were not d e f i n e d i n b e h a v i o r a l terms. T e a c h i n g t e c h n i q u e s were not c l e a r l y i d e n -t i f i e d , but c o n s i s t e d m a i n l y o f g e n e r a l o u t l i n e s o f what p a t i e n t s were t o l d . Lindeman and Van Aernam (1971), i n a c o n t r o l l e d s t u d y o f group and i n d i v i d u a l t e a c h i n g methods, used a " s t i r - u p " regimen p r e o p e r a t i v e l y i n which deep b r e a t h i n g , c o u g h i n g , l e g e x e r c i s e s and e a r l y a m b u l a t i o n t e c h -n i q u e s were t a u g h t . They c o n c l u d e d t h a t group t e a c h i n g was s u p e r i o r t o i n d i v i d u a l t e a c h i n g , but t h i s a p p l i e s o n l y t o p a t i e n t s b e i n g t a u g h t " s t i r -up" regimens. In a d d i t i o n , the v a l i d i t y o f the comparison i s q u e s t i o n a b l e s i n c e the group method was v e r y i n d i v i d u a l i z e d . P a t i e n t s were brought - 29 -t o g e t h e r i n a group s e t t i n g and s t i r - u p e x e r c i s e s were demonstrated u s i n g a s l i d e - s o u n d p r e s e n t a t i o n f o r the group. However, each p a t i e n t i n the group s e t t i n g was i n d i v i d u a l l y g i v e n s u p e r v i s e d p r a c t i c e o f the e x e r c i s e s and t e s t e d f o r achievement. The i n d i v i d u a l group o f p a t i e n t s viewed the same s l i d e - s o u n d p r e s e n t a t i o n on an i n d i v i d u a l b a s i s i n t h e i r rooms and were g i v e n s u p e r v i s e d p r a c t i c e as w e l l . There was no c o n t r o l o f time i n the s t u d y f o r the p a t i e n t s e x p e r i e n c i n g the i n d i v i d u a l method. The p r e s e n -t a t i o n was made a v a i l a b l e t o i n d i v i d u a l p a t i e n t s sometime d u r i n g the e v e n i n g p r e o p e r a t i v e l y , depending on the a v a i l a b i l i t y o f the p r o j e c t i o n equipment and s t a f f n u r s e s . The l e a r n i n g c o n d i t i o n s f o r the i n d i v i d u a l t e a c h i n g - l e a r n i n g p r o v i d e d i n the group s e t t i n g may w e l l have been more i n d i v i d u a l and c o n d u c i v e t o l e a r n i n g than t h a t p r o v i d e d f o r i n d i v i d u a l s i n t h e c l i n i c a l u n i t s e t t i n g where needs o f o t h e r p a t i e n t s and v a r i o u s c l i n i -c a l demands were i n c o m p e t i t i o n . Thus, the d i f f e r e n c e i n l e a r n i n g con-d i t i o n s may be the d e c i s i v e f a c t o r f o r the o b s e r v e d d i f f e r e n c e s r a t h e r than t h e methods used, which i n a c t u a l i t y , both appeared t o be i n d i v i d u a l i z e d . The group d i s c u s s i o n t e c h n i q u e was used by a v a r i e t y o f r e s e a r c h e r s (Lindeman, 1972; Lindeman & Van Aernam, 1971; Mezzanote, 1970; Schmidt & W o o l r i d g e , " 1 9 7 3 ) , as a means o f a l l o w i n g p a t i e n t s t o e x p r e s s t h e i r f e a r s and meet some o f t h e i r c o g n i t i v e and a f f e c t i v e l e a r n i n g needs i n a f r e e - f l o w i n g s t y l e . T h i s r e v i e w o f the l i t e r a t u r e was not a b l e t o i d e n t i f y a complete p l a n o f a p r e o p e r a t i v e l e a r n i n g program i n c l u d i n g l e a r n i n g o b j e c t i v e s , t e a c h i n g -l e a r n i n g s t r a t e g i e s , r e s o u r c e s r e q u i r e d , and t e s t i n g t e c h n i q u e s . - 30 -DEVELOPMENT OF THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM Gagne (1970) m a i n t a i n e d t h a t no one t e a c h i n g approach i s c o n s i s t e n t l y s u p e r i o r t o a n o t h e r . Rather i t i s the j o b o f an i n s t r u c t o r t o i d e n t i f y l e a r n i n g needs, d e v e l o p b e h a v i o r a l l e a r n i n g o b j e c t i v e s based on t h o s e needs, p r o v i d e a p p r o p r i a t e c o n d i t i o n s f o r l e a r n i n g and l e a r n i n g a c t i v i t i e s which maximize l e a r n i n g , and t e s t t o determine whether the d e s i r e d l e a r n i n g was a c h i e v e d . T h i s r a t i o n a l e was used p r i m a r i l y i n the d e v e l o p -ment of the I n d i v i d u a l i z e d P r e o p e r a t i v e L e a r n i n g Program. Development o f L e a r n i n g O b j e c t i v e s The needs o f a l e a r n e r must be t r a n s l a t e d i n t o b e h a v i o r a l o b j e c t i v e s which d e s c r i b e t he e x p e c t e d b e h a v i o r a l e a r n e r w i l l demonstrate t o show t h a t he has met a g i v e n l e a r n i n g need. L e a r n i n g needs may be c a t e g o r i z e d i n t o t h r e e groups o f b e h a v i o r s ( K i b l e r , 1970): c o g n i t i v e (knowledge s k i l l s ) , a f f e c t i v e ( a t t i t u d e s ) , and psychomotor (motor s k i l l s ) . S i n c e l e a r n i n g o b j e c t i v e s are the major g u i d e l i n e i n the development o f an i n d i v i d u a l i z e d l e a r n i n g p l a n , t he f i r s t s t e p i n the development o f the I n d i v i d u a l i z e d P r e o p e r a t i v e L e a r n i n g Program was the d e f i n i t i o n o f o b j e c -t i v e s . These o b j e c t i v e s are l i s t e d i n TABLE I. These o b j e c t i v e s r e f l e c t t he p a t i e n t ' s c o g n i t i v e , a f f e c t i v e and psychomotor l e a r n i n g needs. P r e v i o u s n u r s i n g r e s e a r c h i n d i c a t e d t h a t t he most e f f e c t i v e way o f r e l i e v i n g a n x i e t y p r e o p e r a t i v e l y i n v o l v e s i n t e r a c t i o n between t h e h e a l t h p r o f e s s i o n a l s and the p a t i e n t , i n which c o g n i t i v e s t r u c t u r e f o r expec-t a t i o n s was p r o v i d e d (Dumas & Anderson, 1964; E g b e r t e t a l , 1964; Hanamey, 1965; J a n i s , 1958; Johnson, 1972; Moss & Meyer, 1966; Schmidt, 1966). - 31 -TABLE I OBJECTIVES OF THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM A t the t e r m i n a t i o n o f an i n d i v i d u a l i z e d p r e o p e r a t i v e l e a r n i n g program, a p a t i e n t undergoing an e l e c t i v e c h o l e c y s t e c t o m y w i l l be a b l e t o : 1. i d e n t i f y the r o l e s o f major h e a l t h p e r s o n n e l i n v o l v e d i n her c a r e ; 2. i d e n t i f y t h e purposes o f t h e p r e o p e r a t i v e p r e p a r a t i o n s p l a n n e d f o r her; 3. i d e n t i f y how soon she e x p e c t s t o resume normal f u n c t i o n o f a l l major body systems p o s t o p e r a t i v e l y ; 4. i d e n t i f y the s e n s a t i o n s she can e x p e c t t o f e e l as a r e s u l t o f the major p r o c e d u r e s she w i l l undergo p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y ; 5. demonstrate s k i l l i n l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g , t u r n i n g and a m b u l a t i n g ; 6. f e e l adequate t o cope w i t h her s u r g i c a l e x p e r i e n c e ; 7. a c c e p t her r o l e i n f a c i l i t a t i n g her own r e c o v e r y ; 7.1 o p e n l y e x p r e s s her needs t o the m e d i c a l and n u r s i n g s t a f f ; 7.2 perform her own l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g , t u r n i n g and a m b u l a t i n g e x e r c i s e s w i t h minimal prompting. - 32 -K a t z , a p s y c h o l o g i s t , a l s o p r o v i d e d s u p p o r t f o r t h i s c o g n i t i v e s t r u c t u r i n g . He p o s t u l a t e d a t h e o r y c o n c e r n i n g the f u n c t i o n s o f a t t i t u d e s and sought t o r e c o n c i l e the i r r a t i o n a l v e r s u s the r a t i o n a l model o f man. He s t a t e d t h a t i r r a t i o n a l , u n t h i n k i n g r e s p o n s e s t o a t t i t u d e cues are more l i k e l y i n r e s t r i c t e d s i t u a t i o n s where a p e r s o n has l i t t l e o p p o r t u n i t y t o e x p l o r e or s o l v e problems. G i v e n more communication or i n v o l v e m e n t i n h i s e n v i r o n -ment, a p e r s o n tends t o seek m e a n i n g f u l n e s s or t o make sense o f s t i m u l i and r e s p o n d s i n a r a t i o n a l way ( K a t z , 1967, pp. 457-458). Thus, p r e o p e r a t i v e a n x i e t y a r i s i n g from f e a r o f the unknown i s c a t e g o r i z e d as a c o g n i t i v e need r e f l e c t e d i n c o g n i t i v e l e a r n i n g o b j e c t i v e s , a l t h o u g h a t t i t u d e s may seem t o be p r i m a r i l y i n v o l v e d . These c o g n i t i v e l e a r n i n g o b j e c t i v e s a r e l i s t e d i n TABLE I : 1. i d e n t i f y the r o l e s o f major h e a l t h p e r s o n n e l i n v o l v e d i n her c a r e ; 2. i d e n t i f y the purposes o f p r e o p e r a t i v e p r e p a r a t i o n s p l a nned f o r her; 3. i d e n t i f y how soon she e x p e c t s t o resume normal f u n c t i o n o f a l l major body systems p o s t o p e r a t i v e l y ; 4. i d e n t i f y the s e n s a t i o n s she can e x p e c t t o f e e l as a r e s u l t o f the major p r o c e d u r e s she w i l l undergo p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y . The f e e l i n g o f h e l p l e s s n e s s and inadequacy which a p a t i e n t can e x p e r i e n c e upon a d m i s s i o n t o h o s p i t a l ( D i c h t e r , 1954; L e d e r e r , 1958) r e f l e c t s both an a f f e c t i v e ( a t t i t u d i n a l ) s t a t e and an a f f e c t i v e l e a r n i n g need. The p a t i e n t needs t o l e a r n not o n l y how t o cope w i t h a s u r g i c a l e x p e r i e n c e , but must f e e l a b l e t o cope i f she i s t o be m o t i v a t e d - 3 3 -t o p a r t i c i p a t e e f f e c t i v e l y i n her own p o s t o p e r a t i v e r e c o v e r y . A f f e c t i v e l e a r n i n g o b j e c t i v e s i d e n t i f i e d i n the I n d i v i d u a l i z e d P r e o p e r a t i v e L e a r n i n g Program are: 6. f e e l adequate t o cope w i t h her s u r g i c a l e x p e r i e n c e ; 7. a c c e p t her r o l e i n f a c i l i t a t i n g her own r e c o v e r y : 7.1 o p e n l y e x p r e s s her needs t o the m e d i c a l and n u r s i n g s t a f f ; and 7.2 p e r f o r m her own l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g t u r n i n g and ambulating w i t h minimal prompting. Leg e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g , t u r n i n g and a m b u l a t i n g r e q u i r e d p o s t - o p e r a t i v e l y a r e psychomotor s k i l l s . These a r e r e l e c t e d i n a psychomotor l e a r n i n g o b j e c t i v e : demonstrate s k i l l i n l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g , t u r n i n g and a mbulating ( O b j e c t i v e 5 ) . The v a l i d i t y o f t h e s e psychomotor l e a r n i n g needs was s u p p o r t e d i n the l i t e r a t u r e ( D r i p p s & Waters, 1941; L e i t h a u s e r , 1946; L e i t h a u s e r , 1949). I n d i v i d u a l i z e d T e a c h i n g - L e a r n i n g S t r a t e g i e s Methods t o p r o v i d e i n d i v i d u a l i z a t i o n i n e d u c a t i o n a l programming have become more p r e v a l e n t i n the p a s t t e n y e a r s , (Diamond, 1975; Gagne & B r i g g s , 1974; Kemp, 1977; Nunney & H i l l , 1972; P o s t l e w a i t e t a l , 1972), and t h i s r e s e a r c h was c o n s i d e r e d i n p l a n n i n g the I n d i v i d u a l i z e d P r e o p e r a t i v e L e a r n i n g Program. I n d i v i d u a l i z e d l e a r n i n g programs are d e s i g n e d t o meet the needs o f an i n d i v i d u a l l e a r n e r . The s t r a t e g i e s may be v a r i e d and are s e l e c t e d on the b a s i s o f t h e i r e f f e c t i v e n e s s i n a s s i s t i n g a g i v e n i n d i v i d u a l t o r e a c h the d e f i n e d l e a r n i n g o b j e c t i v e s . The l e a r n i n g program i s o p t i m a l l y s e l f - p a c e d and the l e a r n e r proceeds at h i s own r a t e o f l e a r n i n g . Complete s e l f - p a c i n g by the l e a r n e r i n the I n d i v i d u a l i z e d L e a r n i n g Program was not p o s s i b l e , but g i v e n the time l i m i t a t i o n o f the - 34 -p r e o p e r a t i v e p r e p a r a t i o n p e r i o d , t he l e a r n i n g a c t i v i t i e s were v a r i e d and spaced out over the e n t i r e p e r i o d o f time t o a l l o w a range o f i n d i v i d u a l l e a r n i n g r e s p o n s e s (See TABLE I I ) . The f i n a l l e a r n i n g a c t i v i t y s c h e d u l e d was an i n t e r p e r s o n a l i n t e r a c t i o n between the p a t i e n t and the n u r s e - r e s e a r c h e r i n which p r e v i o u s l e a r n i n g was a s s e s s e d . Based on t h i s f eedback, the l e a r n e r was p r o v i d e d w i t h a d d i -t i o n a l l e a r n i n g e x p e r i e n c e s d e s i g n e d t o i n s u r e t h a t she r e a c h e d the d e f i n e d l e a r n i n g o b j e c t i v e s . The p a t i e n t had the o p p o r t u n i t y t o pace t h i s a c t i v i t y and no time l i m i t was s e t . The p e r s o n a l i n t e r v i e w was used not o n l y t o a s s e s s l e a r n i n g and t o p r o v i d e a d d i t i o n a l l e a r n i n g e x p e r i e n c e s , but a l s o t o dea l w i t h major p r e -c o n d i t i o n s of l e a r n i n g , such as the a l l e v i a t i o n o f f e a r and a n x i e t y . S e v e r a l n u r s i n g s t u d i e s have recommended t h a t t he b e s t i n d i c a t o r o f f e a r and a n x i e t y i n the p r e o p e r a t i v e p a t i e n t was s u b j e c t i v e e x p r e s s i o n ( C a r n e v a l l i , 1961; Dumas & Anderson, 1964; Graham & C o n l e y , 1971; P a r k e r , 1964; S c h m i t t & W o o l r i d g e , 1973). The p a t i e n t was encouraged t o f e e l f r e e t o e x p r e s s f e a r and a n x i e t y through the use o f n o n - d i r e c t i v e i n t e r v i e w i n g t e c h n i q u e s used i n the i n t e r p e r s o n a l i n t e r a c t i o n . A l t h o u g h a N u r s i n g H i s t o r y O u t l i n e ( s e e Appendix A) was used, the q u e s t i o n s were used o n l y t o encourage the p a t i e n t t o p r o v i d e i n f o r m a t i o n which she d i d not do spon-t a n e o u s l y i n the c o u r s e o f a r a m b l i n g c o n v e r s a t i o n . F or example, the q u e s t i o n "What caused you t o come t o the h o s p i t a l " may be the o n l y q u e s t i o n o u t of the n i n e q u e s t i o n s r e l e v a n t t o " P e r c e p t i o n s Re I l l n e s s " t h a t the n u r s e - r e s e a r c h e r might pose. The p a t i e n t was encouraged t o t a l k f r e e l y at her own r a t e and t o take the l e a d i n the i n t e r v i e w . TABLE II LEARNING ACTIVITIES IN THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM OBJECTIVES 1. I d e n t i f y the r o l e s o f major h e a l t h p e r s o n n e l i n v o l v e d i n a s u r g i c a l e x p e r i e n c e . 2. I d e n t i f y the purposes of the p r e -o p e r a t i v e p r e p a r a t i o n s planned f o r her. 3. I d e n t i f y how soon she e x p e c t s t o resume normal f u n c t i o n o f a l l major body systems p o s t o p e r a t i v e l y . 4. I d e n t i f y the s e n s a t i o n s she can e x p e c t t o f e e l as a r e s u l t o f the major p r o c e d u r e s she w i l l undergo p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y . LEARNING ACTIVITIES (Admission t o h o s p i t a l 3:00 - 4:00 P.M.) W r i t t e n o r i e n t a t i o n t o r o l e s i n pamphlet "You and Your O p e r a t i o n " . These r o l e s were r e i n f o r c e d i n the s o u n d - a n d - s l i d e p r e s e n t a t i o n and reviewed and/or r e i n f o r c e d i n the p r e o p e r a t i v e i n t e r v i e w . Same as f o r O b j e c t i v e #1 I n t r o d u c e d i n a s l i d e - s o u n d p r e s e n t a t i o n e n t i t l e d " O p e r a t i o n Tomorrow" and expanded upon and r e i n f o r c e d i n the p r e o p e r a t i v e i n t e r v i e w . P r e o p e r a t i v e s e n s a t i o n s are o u t l i n e d p r i m a r i l y i n the pamphlet "You and Your O p e r a t i o n " . General p o s t o p e r a t i v e e x p e c t a t i o n s are p r e s e n t e d i n " O p e r a t i o n Tomorrow" and expanded upon and r e i n f o r c e d i n the p r e o p e r a t i v e i n t e r v i e w . TABLE II - Cont'd. OBJECTIVES 5. Demonstrate s k i l l i n deep b r e a t h i n g , c o u g h i n g , t u r n i n g and am b u l a t i n g . 6. F e e l adequate t o cope w i t h her s u r g i c a l e x p e r i e n c e . A c c e p t her r o l e i n f a c i l i t a t i n g her own r e c o v e r y : 7.1 op e n l y e x p r e s s her needs t o the me d i c a l s t a f f ; 7.2 p e r f o r m her own " s t i r - u p " e x e r c i s e s w i t h minimal prompting. LEARNING ACTIVITIES In t r o d u c e d i n " O p e r a t i o n Tommorrow" and by the p h y s i o t h e r a p i s t . A s s e s s e d i n t h e p r e o p e r a t i v e i n t e r v i e w . R e i n f o r c e d by a l l the l e a r n i n g a c t i v i t i e s and p a r t i c u l a r l y i n the p r e o p e r a t i v e i n t e r v i e w . Same as thos e o u t l i n e d f o r O b j e c t i v e #6. - 3 7 -The p a t i e n t was not h e l d t o the o r d e r o f q u e s t i o n s i n the N u r s i n g H i s t o r y O u t l i n e but a l l o w e d t o choose her own o r d e r i n a n a t u r a l c o n v e r s a t i o n a l s t y l e . When f e a r and a n x i e t y were v o i c e d by a p a t i e n t , t he nur s e -r e s e a r c h e r attempted t o reduce i t d i r e c t l y through t he use o f c o n c r e t e i n f o r m a t i o n d e s i g n e d t o deal w i t h f e a r s o f the unknown s u r g i c a l e x p e r i e n c e s . DEVELOPMENT OF THE CLASS PREOPERATIVE LEARNING PROGRAM The i n d i v i d u a l n a t u r e o f a d u l t l e a r n i n g g e n e r a l l y has not been r e f l e c t e d i n p r e v i o u s p r e o p e r a t i v e l e a r n i n g programs r e p o r t e d i n the l i t e r a t u r e . The c o n v e n t i o n a l approach has been t o t e a c h p e o p l e i n a group c l a s s r o o m s e t t i n g , an approach which does not u s u a l l y a l l o w f o r i n d i v i -d u a l i z a t i o n . T h i s group method was c o n s i d e r e d i n d e s i g n i n g t h e C l a s s P r e o p e r a t i v e L e a r n i n g Program. I t was s e l e c t e d because i t i s f a m i -l i a r t o the m a j o r i t y o f a d u l t s as a r e s u l t o f t h e i r own s c h o o l e x p e r i e n c e s . P a t i e n t s i n t h i s s t u d y group r e c e i v e d f o r m a l i z e d i n s t r u c t i o n as a group i n a c l a s s r o o m s e t t i n g . They viewed t he s l i d e - s o u n d p r e s e n t a t i o n "You and Your O p e r a t i o n " which was the same program p r o v i d e d f o r l e a r n e r s i n the I n d i v i d u a l i z e d L e a r n i n g Group. O p p o r t u n i t y t o ask q u e s t i o n s and t o view a l i v e d e m o n s t r a t i o n o f l e g e x e r c i s e s , deep b r e a t h i n g and coug h i n g were p r o -v i d e d . There were no r e t u r n d e m o n s t r a t i o n s or s u p e r v i s e d p r a c t i s e o f t h e s e psychomotor s k i l l s and no t e s t i n g o f l e a r n i n g a c h i e v e d . The group e x p e r i e n c e was t h e p r i m a r y l e a r n i n g a c t i v i t y i n t h e C l a s s L e a r n i n g Program. - 3 8 -DEVELOPMENT OF THE INCIDENTAL PREOPERATIVE LEARNING PROGRAM F o r m a l i z e d , p l a n n e d p r e o p e r a t i v e i n s t r u c t i o n has not been implemented w i d e l y i n c l i n i c a l p r a c t i s e . More commonly, p r e o p e r a t i v e l e a r n i n g o c c u r s i n an unplanned, i n c i d e n t a l f a s h i o n . A p a t i e n t may or may not be under the c a r e o f a nurse or d o c t o r who has both the time and the m o t i v a t i o n t o p r o -v i d e some p r e o p e r a t i v e i n s t r u c t i o n d u r i n g the c o u r s e o f c a r e . T h i s k i n d o f i n s t r u c t i o n i s not d e f i n e d or f o r m a l i z e d i n any way and v a r i e s a c c o r d i n g t o t h e penchant o f an i n d i v i d u a l c a r e g i v e r . T h i s type o f l e a r n i n g program was i n c l u d e d i n t h i s study and d e s i g n a t e d as the I n c i d e n t a l L e a r n i n g Program. ASSESSMENT OF LEARNING The e d u c a t i o n a l model would not be complete w i t h o u t an assessment o f l e a r n i n g . The t e c h n i q u e s used f o r p r e o p e r a t i v e assessment o f l e a r n i n g d e f i n e d f o r the p a t i e n t s i n the I n d i v i d u a l i z e d L e a r n i n g Group are o u t l i n e d i n TABLE I I I . There was no planned p r e o p e r a t i v e assessment of l e a r n i n g a c h i e v e d by the p a t i e n t s i n e i t h e r the C l a s s or I n c i d e n t a l L e a r n i n g Groups. P a t i e n t s i n a l l t h r e e l e a r n i n g groups were g i v e n a c o g n i t i v e p o s t - t e s t on t h e f i f t h p o s t o p e r a t i v e day t o t e s t c o g n i t i v e achievement. No c o g n i t i v e p r e - t e s t was g i v e n . - 3 9 -TABLE I I I ASSESSMENT STRATEGIES USED IN THE INDIVIDUALIZED PREOPERATIVE LEARNING PROGRAM OBJECTIVES ASSESSMENT 6, 7, I d e n t i f y the r o l e s o f major h e a l t h p e r s o n n e l i n v o l v e d i n a s u r g i c a l e x p e r i e n c e . I d e n t i f y the purposes o f the p r e o p e r a t i v e p r e p a r a t i o n s planned f o r her. I d e n t i f y how soon she e x p e c t s t o resume normal f u n c t i o n o f a l l major body systems p o s t o p e r a t i v e l y . I d e n t i f y the s e n s a t i o n s she can expect to f e e l as a r e s u l t o f the major p r o c e d u r e s she w i l l undergo p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y . Demonstrate s k i l l i n deep b r e a t h i n g , c o u g h i n g , t u r n i n g and a m b u l a t i n g . F e e l adequate t o cope w i t h s u r g i c a l e x p e r i e n c e . A c c e p t her r o l e i n f a c i l i t a t i n g her own r e c o v e r y : 7.1 o p e n l y e x p r e s s her needs t o the m e d i c a l and n u r s i n g s t a f f ; 7.2 perform her own " s t i r - u p " e x e r c i s e s w i t h minimal prompting. C o g n i t i v e Q u e s t i o n n i n g C o g n i t i v e Q u e s t i o n n i n g C o g n i t i v e Q u e s t i o n n i n g C o g n i t i v e Q u e s t i o n n i n g C o g n i t i v e Q u e s t i o n n i n g R e t u r n D e m o n s t r a t i o n I n t e r v i e w i n g w i t h the Use o f the N u r s i n g H i s t o r y O u t l i n e Not A s s e s s e d - 40 -CHAPTER I I I METHODOLOGY The p r o c e d u r e s i n v o l v e d i n d e v e l o p i n g and implementing t he s t u d y are d e s c r i b e d i n t h i s c h a p t e r . They i n c l u d e d e s c r i p t i o n s of the sampling s t r a -t e g i e s , i m p l e m e n t a t i o n o f tre a t m e n t m e t h o d o l o g i e s f o r each o f the t h r e e l e a r n i n g groups, c o n t r o l measures, assessment t o o l s and d a t a c o l l e c t i o n p r o c e d u r e s . SAMPLING PROCEDURES The p o t e n t i a l p o p u l a t i o n i n c l u d e d a l l female p r e o p e r a t i v e p a t i e n t s who met the s t a t e d c r i t e r i a . The sample was randomly s e l e c t e d from a s u b s e t o f p a t i e n t s admitted f o r e l e c t i v e c h o l e c y s t e c t o m y at a l a r g e , m e t r o p o l i t a n , a c u t e c a r e h o s p i t a l d u r i n g a 20-week p e r i o d . The p o t e n t i a l number of sub-j e c t s i n a 10-week p e r i o d was 100, which was c a l c u l a t e d by r e v i e w i n g t he me d i c a l r e c o r d s and the d a i l y O p e r a t i n g Room s l a t e s f o r the p r e v i o u s y e a r . Random s e l e c t i o n o f 33 p a t i e n t s f o r t h i s s t u d y was conduct e d u s i n g t h e c o n f i r m e d l i s t o f a d m i s s i o n s to h o s p i t a l a v a i l a b l e one week p r i o r t o the planned a d m i s s i o n d a t e . Three p a t i e n t s were randomly s e l e c t e d weekly from t h i s l i s t . A t t e n d i n g p h y s i c i a n s were c o n t a c t e d a f t e r s e l e c t i o n o f the p a t i e n t s i n o r d e r t o s e c u r e m e d i c a l p e r m i s s i o n t o i n c l u d e the p a t i e n t s i n the s t u d y . A t t h a t time, the p h y s i c i a n s were asked f o r a me d i c a l assessment of the s u b j e c t s s e l e c t e d r e g a r d i n g t he e x i s t e n c e o f any d e l i m i t i n g f a c t o r s , p a r -t i c u l a r l y the a b i l i t y t o u n d e r s t a n d o r a l and w r i t t e n E n g l i s h and - 41 -p s y c h i a t r i c d i a g n o s e s . Random assignment t o one o f each o f the t h r e e t r e a t m e n t groups was done f o l l o w i n g the s e c u r i n g o f m e d i c a l p e r m i s s i o n and assessment. The s t u d y commenced w i t h the a d m i s s i o n o f t h e f i r s t p a r t i c i p a n t on Sunday, F e b r u a r y 17, 1974. P e r m i s s i o n t o conduct a s t u d y i n v o l v i n g the use of l i v e s u b j e c t s had been g r a n t e d by the U n i v e r s i t y o f B r i t i s h Columbia. P a r t i c i p a n t s were randomly s e l e c t e d and a s s i g n e d t o the t h r e e t r e a t m e n t groups d u r i n g t h i s f i r s t week. I t q u i c k l y became e v i d e n t t h a t the a t t r i -t i o n r a t e among p a r t i c i p a n t s tended t o be h i g h , and subsequent p a r t i c i p a n t s were randomly a s s i g n e d from the e n t i r e p o p u l a t i o n o f females a d m i t t e d f o r e l e c t i v e c h o l e c y s e c t o m y . The s t u d y was conducted over a p e r i o d o f twenty weeks r a t h e r than the a n t i c i p a t e d e l e v e n weeks. The extended time p e r i o d was caused p r i m a r i l y by a h i g h a t t r i t i o n r a t e among s u b j e c t s , as w e l l as t h e l a c k o f s u b j e c t s d u r i n g one week o f t h e s t u d y and i l l n e s s o f the n u r s e -r e s e a r c h e r f o r another week. A t o t a l o f 74 s u b j e c t s made up the p o p u l a t i o n pool f o r p o t e n t i a l sub-j e c t s a v a i l a b l e d u r i n g t h i s twenty week p e r i o d . Of t h e s e , f i v e were e l i m i -nated p r i o r t o random assignment, f o u r were e l i m i n a t e d because o f p s y c h i a t r i c problems, and one because o f a language problem. Of the r e m a i n i n g 64, 31 were e l i m i n a t e d d u r i n g the c o u r s e o f the s t u d y : e i g h t due t o the performance o f a d d i t i o n a l s u r g e r y o t h e r than the c h o l e c y s t e c t o m y and seventeen due t o i n f r a c t i o n s o f the e x p e r i m e n t a l method. Common i n f r a c t i o n s o f the e x p e r i m e n t a l method i n c l u d e d f a i l u r e t o r e c e i v e t he pamphlet "You and Your O p e r a t i o n " on a d m i s s i o n , f a i l u r e t o a t t e n d t he s o u n d - a n d - s l i d e p r e s e n t a t i o n , or a t t e n d a n c e at t h e - 4 2 -s o u n d - a n d - s l i d e p r e s e n t a t i o n when not s t i p u l a t e d . S i x were e l i m i n a t e d due t o f a c t o r s such as language b a r r i e r s , d e a f n e s s , or e x i s t i n g i l l n e s s e s which were not made e v i d e n t p r i o r t o random assignment. More time than e x p e c t e d was g i v e n t o p r e o p e r a t i v e i n t e r v i e w s , p a r t i c u l a r l y because s e v e n t e e n o f the e l i m i n a t e d s u b j e c t s were a s s i g n e d t o the I n d i v i d u a l i z e d L e a r n i n g Group and were not e l i m i n a t e d u n t i l a f t e r t h e p r e o p e r a t i v e p e r i o d . PREOPERATIVE TREATMENT The d e s i g n o f the s t u d y was a randomized c o n t r o l group p o s t - t e s t d e s i g n . Three groups o f p a t i e n t s were i n v o l v e d . The I n d i v i d u a l i z e d L e a r n i n g Group and the C l a s s L e a r n i n g Group were d e s i g n a t e d as the e x p e r i -mental groups and the I n c i d e n t a l L e a r n i n g Group as the c o n t r o l group. I n d i v i d u a l i z e d L e a r n i n g Group The program f o r the I n d i v i d u a l i z e d L e a r n i n g Group was s y s t e m a t i c a l l y p l a n n e d and l e a r n i n g a c t i v i t i e s and r e s o u r c e s were c a r e f u l l y matched t o the l e a r n i n g o b j e c t i v e s . The s c h e d u l e d l e a r n i n g a c t i v i t i e s extended from t he time o f a d m i s s i o n through t o the ev e n i n g o f the a d m i s s i o n / p r e o p e r a t i v e day. Upon a d m i s s i o n t o h o s p i t a l i n t h e A d m i t t i n g Department, a p a t i e n t i n the I n d i v i d u a l i z e d L e a r n i n g Group r e c e i v e d a l e t t e r o f i n t r o d u c t i o n from the n u r s e - r e s e a r c h e r which i s shown i n TABLE IV. The T e t t e r s e r v e d t he f o l l o w i n g p u r p o s e s : - 43 -TABLE IV INDIVIDUALIZED LEARNING PROGRAM: LETTER OF INTRODUCTION Dear Welcome t o S t . P a u l ' s H o s p i t a l . The a d m i n i s t r a t i o n and s t a f f at S t . P a u l ' s a re anxious t o h e l p you t o r e c o v e r from y o u r o p e r a t i o n as f a s t as p o s s i b l e . One way o f d o i n g t h i s i s t o t e a c h you how you can h e l p y o u r s e l f t o get b e t t e r . Because o f t h i s , I have been g i v e n p e r m i s s i o n t o s t u d y how we can put on b e t t e r t e a c h i n g programs f o r p a t i e n t s . I am a g r a d u a t e s t u -dent at the U n i v e r s i t y of B.C. and w i t h t h e p e r m i s s i o n o f t h e h o s p i t a l and you r d o c t o r I have s e l e c t e d you t o h e l p us get some answers. I hope you w i l l agree t o take p a r t . B e f o r e you make a d e c i s i o n , I would l i k e you t o read t he a t t a c h e d pamphlet - "You and Your O p e r a t i o n " . T h i s w i l l p r o b a b l y answer some o f the q u e s t i o n s you might have. A f t e r you have r e a c h e d your ward and s e t t l e d i n , I have ar r a n g e d f o r you t o a t t e n d a S o u n d - a n d - S l i d e P r e s e n t a t i o n which i s h e l d i n t h e 4 E a s t C l i n i c Room at 6:30 p.m. t h i s e v e n i n g . T h i s p r e s e n t a t i o n i s put on e v e r y e v e n i n g by the h o s p i t a l and a l l p a t i e n t s h a v i n g an o p e r a t i o n a r e welcome t o come. You w i l l f i n d t h i s v e r y h e l p f u l i n u n d e r s t a n d i n g even more about y o u r o p e r a t i o n . I w i l l be up t o v i s i t you d u r i n g t he e v e n i n g t o meet you and t o answer any more q u e s t i o n s you might have. By t h a t t i m e , perhaps you w i l l have made your d e c i s i o n about h e l p i n g us i n t h i s s t u d y . Yours s i n c e r e l y , (Ms.) Jean C r a n s t o u n , R.N.,B.ScN. - 44 -1. i n t r o d u c e d the n u r s e - r e s e a r c h e r ; 2. o r i e n t e d the p a t i e n t t o the purpose o f the study; 3. r e q u e s t e d the p a t i e n t t o p a r t i c i p a t e i n the study; 4. m o t i v a t e d the p a t i e n t t o be w i l l i n g t o p a r t i c i p a t e i n the study; 5. r e q u e s t e d the p a t i e n t t o r e a d the pamphlet e n t i t l e d "You and Your O p e r a t i o n " ; 6. r e q u e s t e d the p a t i e n t t o a t t e n d the S o u n d - a n d - S l i d e P r e s e n t a t i o n e n t i t l e d " O p e r a t i o n Tomorrow" Sch e d u l e d f o r 6:30 P.M. the e v e n i n g o f a d m i s s i o n ; 7. i n f o r m e d the p a t i e n t t h a t the n u r s e - r e s e a r c h e r would be v i s i t i n g her t h a t e v e n i n g t o answer q u e s t i o n s and s e c u r e her p e r m i s s i o n t o p a r t i c i p a t e i n the s t u d y . The pamphlet "You and Your O p e r a t i o n " was g i v e n t o the p a t i e n t on a d m i s s i o n (See Appendix A ) . I t d e s c r i b e d some common and r e l a t i v e l y n o n - t h r e a t e n i n g a s p e c t s o f the p r e o p e r a t i v e p r e p a r a t i o n p r o c e s s p l a n n e d f o r t h e p a t i e n t u n d e r g o i n g a c h o l e c y s t e c t o m y . The p a t i e n t r e a d t h i s i n f o r -mation i n the a d m i t t i n g o f f i c e a f t e r a d m i s s i o n d u r i n g the a f t e r n o o n and w h i l e w a i t i n g t o be taken up t o the ward. Thus, i t was i m p o r t a n t t h a t the i n f o r m a t i o n be c l e a r , s i m p l e and not p r o v o c a t i v e o f a s t r e s s r e s p o n s e which r e q u i r e d feedback or s u p p o r t from n u r s i n g s t a f f . The pamphlet i n t r o -duced the f o l l o w i n g a s p e c t s of p r e o p e r a t i v e p r e p a r a t i o n : - 45 -1. a s k i n g q u e s t i o n s i s encouraged and e x p e c t e d ; 2. o u t l i n e o f the r o l e s o f s t a f f i n v o l v e d i n her c a r e ; 3. s e l f - o r i e n t a t i o n t o ward u n i t i n c l u d i n g : 3.1 i n t r o d u c t i o n t o roommate(s) 3.2 use of c a l l - b e l l 3.3 l o c a t i o n o f bathrooms 3.4 supper time 3.5 time o f the a f t e r n o o n and n i g h t s h i f t change 3.6 bedtime 4. r a t i o n a l e u n d e r l y i n g p r o c e d u r e s i n v o l v e d i n p h y s i c a l p r e o p e r a t i v e p r e p a r a t i o n ; 5. i n f o r m a t i o n about d r e s s and t r a n s p o r t a t i o n t o the o p e r a t i n g room; 6. s e n s a t i o n s e x p e c t e d a f t e r r e c e i v i n g the p r e o p e r a t i v e m e d i c a t i o n . At 6:30 p.m. i n the e v e n i n g , the p a t i e n t viewed the s o u n d - a n d - s l i d e p r e s e n t a t i o n e n t i t l e d "You and Your O p e r a t i o n " . T h i s p r e s e n t a t i o n was planned (see Appendix B) and d e v e l o p e d by the s t a f f o f the h o s p i t a l i n which the s t u d y was c o n d u c t e d . I t was made a v a i l a b l e t o a l l p r e o p e r a t i v e p a t i e n t s e v e r y e v e n i n g , e x c e p t S a t u r d a y , at 6:30 p.m. The program was a g e n e r a l i z e d one d e s i g n e d t o meet a v a r i e t y o f group c o g n i t i v e needs. The t o p i c s d e a l t w i t h i n the s o u n d - a n d - s l i d e p r e s e n t a t i o n i n c l u d e d : - 46 -r e c o g n i t i o n and d e s c r i p t i o n s of the r o l e s p l a y e d by the f o l l o w i n g s t a f f members: 1.1 r e g i s t e r e d nurse 1.2 i n t e r n 1.3 p r a c t i c a l nurse 1.4 housekeeping a i d e 1.5 o r d e r l y 1.6 d i e t a r y a i d e 1.7 p h y s i o t h e r a p i s t 1.8 head nurse 1.9 v o l u n t e e r 1.10 u n i t c l e r k (ward c l e r k ) 1.11 a n a e t h e t i s t r a t i o n a l e u n d e r l y i n g p r o c e d u r e s i n v o l v e d i n p h y s i c a l p r e o p e r a t i v e p r e p a r a t i o n : 2.1 s k i n p r e p a r a t i o n (shave) 2.2 bath t he e v e n i n g or morning o f s u r g e r y 2.3 enema 2.4 h i s t o r y 2.5 co n s e n t form 2.6 n i g h t s e d a t i o n 2.7 f a s t i n g from m i d n i g h t the n i g h t b e f o r e s u r g e r y 2.8 removal o f makeup, n a i l p o l i s h and h a i r p i n s , e y e g l a s s e s , j e w e l r y , d e n t u r e s , e t c . the morning o f s u r g e r y 2.9 p r e o p e r a t i v e m e d i c a t i o n t he morning o f s u r g e r y - 47 -i n f o r m a t i o n about d r e s s and t r a n s p o r t a t i o n t o the o p e r a t i n g room; v i s u a l o r i e n t a t i o n t o an o p e r a t i n g room; o r i e n t a t i o n t o the p r o c e d u r e s i n v o l v e d i n the p o s t - a n e t h e t i c room ( r e c o v e r y room); d e s c r i p t i o n o f t h r e e t y p e s o f a n a e s t h e s i a and the s e n s a t i o n s a f f e c t e d : 6.1 g e n e r a l 6.2 s p i n a l 6.3 l o c a l r a t i o n a l e u n d e r l y i n g common p o s t o p e r a t i v e t r e a t m e n t s or p r o c e d u r e s : 7.1 use o f the oxygen mask a f t e r a g e n e r a l a n a e s t h e t i c 7.2 f r e q u e n t c h e c k i n g o f b l o o d p r e s s u r e and p u l s e 7.3 deep b r e a t h i n g , c o u g h i n g , l e g e x e r c i s e s , t u r n i n g and ambul a t i n g 7.4 s e l f - s u p p o r t i n g o f i n c i s i o n d u r i n g coughing 7.5 use o f an i n t r a v e n o u s i n f u s i o n 7.6 wound d r a i n a g e tubes p r e o p e r a t i v e l y d i e t changes e x p e c t e d as bowel f u n c t i o n r e t u r n s t o normal f e a r o f t a l k i n g under a n a e s t h e t i c types o f wound d r e s s i n g s and d r a i n a g e c o n t r o l o f wound p a i n - 48 -In a d d i t i o n t o the s o u n d - a n d - s l i d e p r e s e n t a t i o n , a d e m o n s t r a t i o n o f " s t i r - u p " e x e r c i s e s i n c l u d i n g deep b r e a t h i n g , coughing and l e g e x e r c i s e s was p r o v i d e d by a p h y s i o t h e r a p i s t . P a t i e n t s were encouraged t o p r a c t i c e t h e " s t i r - u p " e x e r c i s e s as a group, but i n d i v i d u a l p r a c t i c e was not super-v i s e d or l e a r n i n g achievement a s s e s s e d . A " F l o a t " r e g i s t e r e d nurse, was a s s i g n e d t o i n t r o d u c e t h e s o u n d - a n d - s l i d e p r e s e n t a t i o n and answer any g e n e r a l q u e s t i o n s which a r o s e . I n d i v i d u a l l e a r n i n g needs r e l a t i v e t o p r e o p e r a t i v e p r e p a r a t i o n and p o s t o p e r a t i v e r e c o v e r y o f a s p e c i f i c n a t u r e were not d e a l t w i t h at t h i s time. F o l l o w i n g the s o u n d - a n d - s l i d e p r e s e n t a t i o n , the n u r s e - r e s e a r c h e r v i s i t e d the p a t i e n t and s e c u r e d a w r i t t e n consent t o p a r t i c i p a t e i n the s t u d y . S u b s e q u e n t l y , a p r e o p e r a t i v e i n t e r v i e w was c a r r i e d o u t t o a c h i e v e t h e f o l l o w i n g p u r p o s e s : 1. t o encourage the p a t i e n t t o v e r b a l i z e f e a r and a n x i e t y ; 2. t o m i n i m i z e f e a r and a n x i e t y t h r o u g h c o n c r e t e e x p l a n a t i o n s o f e x p e r i e n c e s t o be e x p e c t e d and how t o cope w i t h them as w e l l as o t h e r n u r s i n g s t r a t e g i e s as r e q u i r e d t o d e a l w i t h i n d i v i d u a l f e a r s ; 3. t o a s s e s s l e a r n i n g a c h i e v e d i n r e l a t i o n t o o b s e r v e d needs and d e f i n e d p r e o p e r a t i v e l e a r n i n g o b j e c t i v e s ; 4. t o p r o v i d e a d d i t i o n a l l e a r n i n g e x p e r i e n c e s r e q u i r e d t o meet l e a r n i n g needs a s s e s s e d and the d e f i n e d c o g n i t i v e , a f f e c t i v e and psychomotor l e a r n i n g o b j e c t i v e s . - 4 9 -D u r i n g t he f i r s t p a r t o f the p r e o p e r a t i v e i n t e r v i e w the nu r s e -r e s e a r c h e r completed a n u r s i n g h i s t o r y as a means o f g e t t i n g t o know the p a t i e n t and e n c o u r a g i n g her to exp r e s s her f e a r s and a n x i e t i e s . The n u r s i n g h i s t o r y o u t l i n e used as a g u i d e l i n e f o r a n o n - d i r e c t i v e t y p e o f i n t e r v i e w i s i n c l u d e d i n Appendix C. A r e l a x e d , c o n v e r s a t i o n a l approach was used t o g a i n i n f o r m a t i o n about the p a t i e n t s p e r c e p t i o n s of her i l l n e s s , h o s p i t a l i z a t i o n , and t r e a t m e n t , as w e l l as f a m i l y and home l i f e , and l i f e s t y l e . The n u r s i n g h i s t o r y was completed i n a w r i t t e n form and a l s o i n c l u d e d g e n e r a l o b s e r v a t i o n s about the p a t i e n t ' s appearance, f a c i a l e x p r e s s i o n s , communicativeness and g e n e r a l b e h a v i o r d u r i n g t h e i n t e r v i e w . T h i s w r i t t e n n u r s i n g h i s t o r y was l e f t on the p a t i e n t ' s c h a r t a c c o r d i n g t o e s t a b l i s h e d h o s p i t a l r o u t i n e . During the second p a r t o f the p r e o p e r a t i v e i n t e r v i e w t he nu r s e -r e s e a r c h e r a s s e s s e d p r e v i o u s l e a r n i n g a c h i e v e d and p r o v i d e d a d d i t i o n a l l e a r n i n g e x p e r i e n c e s as r e q u i r e d . P r e v i o u s c o g n i t i v e achievement was a s s e s s e d t h r o u g h t he use o f q u e s t i o n i n g and t h e q u e s t i o n g u i d e l i n e s deve-l o p e d f o r t h i s use are i n c l u d e d i n Appendix D. The q u e s t i o n g u i d e l i n e s were d i v i d e d i n t o two s e c t i o n s . P a r t A i n c l u d e d q u e s t i o n s d e s i g n e d t o t e s t l e a r n i n g i n v o l v e d i n r e a d i n g t he pamphlet, "You and Your O p e r a t i o n " as w e l l as d e t e r m i n i n g the i n f o r m a t i o n which had been p r o v i d e d by the anaethe-t i s t , p h y s i o t h e r a p i s t and ward n u r s e . P a r t B o f the q u e s t i o n g u i d e l i n e s a s s e s s e d knowledge a c h i e v e d about the g e n e r a l a n a e s t h e t i c , p r e o p e r a t i v e m e d i c a t i o n , i n t r a v e n o u s i n f u s i o n , a n t i c i p a t e d r e t u r n o f normal e a t i n g h a b i t s and bowel f u n c t i o n p o s t o p e r a t i v e l y , l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g , t u r n i n g and amb u l a t i o n and wound s p l i n t i n g . The p a t i e n t was a l s o encouraged t o v o i c e s p e c i f i c f e a r s about the a n a e s t h e t i c , i n t r a v e n o u s i n f u -s i o n and any o t h e r f e a r s c a u s i n g s t r e s s at t h a t time. S k i l l i n p e r f o r m i n g - 5 0 -l e g e x e r c i s e s , deep b r e a t h i n g , c o u g h i n g t u r n i n g and ambulating was a s s e s s e d by a s k i n g the p a t i e n t t o demonstrate them. D u r i n g t h e f i n a l p a r t o f t h e p r e o p e r a t i v e i n t e r v i e w , t h e n u r s e -r e s e a r c h e r f o c u s e d on the more t h r e a t e n i n g a s p e c t s o f the p o s t o p e r a t i v e r e c o v e r y p e r i o d . I t was a n t i c i p a t e d t h a t at t h i s stage o f the i n t e r v i e w a r a p p o r t would have been e s t a b l i s h e d and the p a t i e n t would f e e l more w i l l i n g t o deal w i t h such t h r e a t e n i n g e x p e r i e n c e s as wound p a i n and the g a s t r i c tube and s u c t i o n . The s p e c i f i c p o s t o p e r a t i v e e x p e r i e n c e s a n t i c i p a t e d which were d i s c u s s e d at t h i s s t a g e are l i s t e d i n TABLE V. Em o t i o n a l s u p p o r t ' b y a nurse i n e x p l o r i n g the i m p l i c a t i o n s of p o s t o p e r a t i v e events and how t o cope w i t h them was viewed as a c r i t i c a l f a c t o r i n p r o v i d i n g e f f e c t i v e c o n d i t i o n s f o r l e a r n i n g p r e o p e r a t i v e l y . The n u r s e - r e s e a r c h e r was c o n s i d e r e d the manager o f the l e a r n i n g program used f o r the I n d i v i d u a l i z e d L e a r n i n g Group and was r e s p o n s i b l e f o r p l a n n i n g t h e t e a c h i n g program and a s s e s s i n g l e a r n i n g . Some i n s t r u c t i o n was p r o v i d e d d i r e c t l y by the n u r s e - r e s e a r c h e r , but not a l l i n s t r u c t i o n r e q u i r e d by t h e I n d i v i d u a l i z e d L e a r n i n g Group was p r o v i d e d d i r e c t l y by the n u r s e - r e s e a r c h e r . C l a s s L e a r n i n g Group T h i s e x p e r i m e n t a l group e x p e r i e n c e d a p r e o p e r a t i v e l e a r n i n g program which used a f o r m a l i z e d c l a s s method. T h i s group viewed the sound-and-s l i d e p r e s e n t a t i o n e n t i t l e d " O p e r a t i o n To-Morrow" which was p r e v i o u s l y d e s c r i b e d . The l e a r n i n g a c t i v i t i e s i n c l u d e d the s o u n d - a n d - s l i d e p r e s e n t a t i o n , answering o f g e n e r a l q u e s t i o n s by a nurse, and d e m o n s t r a t i o n of l e g e x e r c i s e s , deep b r e a t h i n g and coughing by a p h y s i o t h e r a p i s t . - 51 -TABLE V ORIENTATION TO SPECIFIC ANTICIPATED POSTOPERATIVE EVENTS IN THE INDIVIDUALIZED LEARNING PROGRAM 1. Simple e x p l a n a t i o n o f the o p e r a t i v e p r o c e d u r e and the changes i n phy-s i o l o g y e x p e c t e d . 2. Type o f i n c i s i o n i n c l u d i n g : 2.1 l o c a t i o n 2.2 the p o s s i b i l i t y o f wound d r a i n a g e tube and the r e a s o n s u n d e r l y i n g 2.3 t y p e o f wound d i s c h a r g e e x p e c t e d 2.4 t y p e o f d r e s s i n g s e x p e c t e d 2.5 how o f t e n t h e d r e s s i n g s would be changed 2.6 when the wound d r a i n would be removed and how 2.7 when the s t i t c h e s would be removed 2.8 how l o n g b e f o r e t o t a l wound h e a l i n g o c c u r s 2.9 how much wound h e a l i n g has t o o c c u r b e f o r e d i s c h a r g e home i s e x p e c t e d 2.10 i m p l i c a t i o n s o f ambulation and e x e r c i s e i n r e l a t i o n t o wound h e a l i n g 3. E x p e r i e n c e s a n t i c i p a t e d i n the o p e r a t i n g room and the r e c o v e r y room and u n d e r l y i n g r a t i o n a l e : 3.1 t y p e o f a n a e s t h e t i c t o be g i v e n , how and where 3.2 e x p e r i e n c e s i n the r e c o v e r y room i n c l u d i n g f r e q u e n t m o n i t o r i n g o f v i t a l s i g n s and t h e p o s s i b l e a d m i n i s t r a t i o n o f oxygen by mask 4. Immediate p o s t o p e r a t i v e p i c t u r e and u n d e r l y i n g r a t i o n a l e i n v o l v e d : 4.1 g a s t r i c tube and g a s t r i c s u c t i o n 4.2 i n t r a v e n o u s i n f u s i o n 4.3 n o t h i n g t o e a t by mouth (NPO) 4.4 t y p e o f p a i n e x p e c t e d , a n a l g e s i c s a v a i l a b l e , how t o s e c u r e p a i n r e l i e f and how l o n g s e v e r e p a i n l a s t s p o s t o p e r a t i v e l y 4.5 a c t i v i t y and ambulation e x p e c t e d 4.6 how t o t u r n , deep b r e a t h e and cough w i t h minimal p a i n 4.7 b a t h i n g p r o c e d u r e s t o be e x p e c t e d w i t h an i n c i s i o n 5. A n t i c i p a t e d r e t u r n o f normal f u n c t i o n w i t h i n a t e n t a t i v e time frame: 5.1 e a t i n g - p r o g r e s s from n o t h i n g by mouth t o f l u i d s , s o f t d i e t and normal d i e t 5.2 d e f e c a t i n g and r e l a t i o n s h i p s t o d i e t , f l u i d i n t a k e and a c t i v i t y 5.3 u r i n a t i n g - how t o use a bed pan c o m f o r t a b l y and e f f e c t i v e l y 5.4 s l e e p i n g and r e s t i n g - the p o s s i b i l i t y o f p o s t o p e r a t i v e " b l u e s " and the use of s l e e p i n g p i l l s 5.5 ambulation - when t o e x p e c t and how t o move with ease 5.6 a n t i c i p a t e d date o f d i s c h a r g e home and r e t u r n t o work or normal home and community a c t i v i t y - 5 2 -More s p e c i f i c l e a r n i n g needs r e l a t e d t o t h e p a t i e n t ' s c h o l e c y s t e c t o m y e x p e r i e n c e were e x p e c t e d t o be met by t h e ward s t a f f and o t h e r h o s p i t a l s t a f f i n v o l v e d i n the c a r e o f the p a t i e n t . These s p e c i f i c l e a r n i n g needs were not planned f o r but were met i n an i n c i d e n t a l f a s h i o n depending on the s t a f f i n v o l v e d . No f o r m a l assessment o f p r e o p e r a t i v e l e a r n i n g was pl a n n e d or c a r r i e d out d u r i n g t he p r e o p e r a t i v e p e r i o d . I n c i d e n t a l assessment o f p r e o p e r a t i v e l e a r n i n g may have o c c u r r e d but was not r e p o r t e d . I n c i d e n t a l L e a r n i n g Group The I n c i d e n t a l L e a r n i n g Group e x p e r i e n c e d an unplanned t e a c h i n g program i n which t e a c h i n g was c a r r i e d out on an i n d i v i d u a l b a s i s , i n t h a t i t was p r o v i d e d by one h e a l t h p r o f e s s i o n a l at a time t o one p a t i e n t at a ti m e . The h e a l t h p r o f e s s i o n a l s p o t e n t i a l l y i n v o l v e d i n t h i s t e a c h i n g program i n c l u d e d s urgeons, a n a e t h e t i s t s , nurses and p h y s i o t h e r a p i s t s . These h e a l t h p r o f e s s i o n a l s were a l s o p o t e n t i a l l y i n v o l v e d i n the o t h e r two tr e a t m e n t groups to the same e x t e n t as th e y were i n v o l v e d with p a t i e n t s i n t h e I n c i d e n t a l L e a r n i n g Group. E s s e n t i a l l y , t h e needs o f p a t i e n t s i n t h i s group were not s y s t e m a t i c a l l y a s s e s s e d , nor were t h e t e a c h i n g - l e a r n i n g a c t i v i t i e s documented or s t a n d a r d i z e d i n any way. Assignment o f P a t i e n t s t o Treatment Groups One p a t i e n t per week was randomly a s s i g n e d t o each o f the t h r e e t r e a t -ment groups. A s t a n d a r d i z e d w r i t t e n form was used t o communicate w i t h t h e Head Nurse on the ward u n i t t o which a p a t i e n t was a d m i t t e d . T h i s form was a t t a c h e d t o the p a t i e n t ' s c h a r t i n A d m i t t i n g . The Head Nurse was r e q u e s t e d t o send or not t o send a p a t i e n t t o t h e s o u n d - a n d - s l i d e p r e s e n t a t i o n as r e q u i r e d by the t r e a t m e n t method. - 5 3 -POSTOPERATIVE TREATMENT P a t i e n t s i n a l l t h r e e t r e a t m e n t groups were t e s t e d f o r c o g n i t i v e achievement, asked t o v a l i d a t e p r e o p e r a t i v e l e a r n i n g needs o f a c h o l e -c y s t e c t o m y p a t i e n t , and i d e n t i f y p e r s o n a l l e a r n i n g s t y l e s on the f i f t h p o s t o p e r a t i v e day. The t r e a t m e n t ended f o r a l l t h r e e groups on t h e f i f t h p o s t o p e r a t i v e day. Each p a t i e n t was r e q u e s t e d by the n u r s e - r e s e a r c h e r d u r i n g t he f i f t h p o s t o p e r a t i v e day t o complete a P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e . A s t a n d a r d i z e d approach was used t o i n t r o d u c e t h e p a t i e n t s i n the C l a s s and I n c i d e n t a l L e a r n i n g Groups t o the n u r s e - r e s e a r c h e r and s e c u r e t h e i r w r i t t e n c o n s e n t t o p a r t i c i p a t e i n the s t u d y . An o u t l i n e o f t h i s approach i s i n c l u d e d i n TABLE V I . A l l p a t i e n t s i n each o f the t h r e e l e a r n i n g groups were g i v e n a s t a n d a r d i z e d e x p l a n a t i o n o f how t o complete the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e (see TABLE V I ) . Assessment o f C o g n i t i v e L e a r n i n g P o s t o p e r a t i v e l y Assessment o f c o g n i t i v e l e a r n i n g p o s t o p e r a t i v e l y was measured by a c o g n i t i v e p o s t - t e s t a d m i n i s t e r e d t o a l l p a t i e n t s i n each t r e a t m e n t group on the f i f t h p o s t o p e r a t i v e day. T h i s t e s t was i n c l u d e d as p a r t o f the P o s t o -p e r a t i v e P a t i e n t Q u e s t i o n n a i r e ( s e e APPENDIX E) t o a v o i d c r e a t i n g any a p p r e h e n s i o n about t e s t i n g and t h e r e b y b i a s i n g t he r e s u l t s . Ten m u l t i p l e c h o i c e items were i n c l u d e d i n t h i s p o s t - t e s t . T h i s i n s t r u m e n t was reviewed f o r c o n t e n t and c o n s t r u c t v a l i d i t y by a panel o f nu r s e -e d u c a t o r s . Minor changes i n wording were made on the s u g g e s t i o n s o f the j u d g e s . - 5 4 -TABLE VI APPROACH TO PATIENTS RECEIVING THE POSTOPERATIVE PATIENT QUESTIONNAIRE H e l l o , , my name i s . I am a nurse and a s t u d e n t at U.B.C. who i s i n t e r e s t e d i n f i n d i n g out what p a t i e n t s need and want t o know about t h e i r o p e r a t i o n and h o s p i t a l i z a t i o n b e f o r e s u r g e r y . I have been g i v e n p e r m i s s i o n by your d o c t o r and the h o s p i -t a l to do t h i s . We would l i k e t o have your o p i n i o n s and I have a q u e s t i o n -n a i r e which we hope you w i l l f i l l o u t. Your answers are c o n f i d e n t i a l and are seen o n l y by me. The r e s u l t s o f t h i s s t u d y can be used by the h o s p i t a l to p l a n b e t t e r c a r e f o r p a t i e n t s i n the f u t u r e . Would you l i k e t o h e l p us in t h i s study and g i v e us p e r m i s s i o n t o i n c l u d e you. ( P r e s e n t consent form) T h i s q u e s t i o n n a i r e has 3 p a r t s . The f i r s t p a r t , S e c t i o n A, asks you t o mark how important c e r t a i n p e o p l e and p r o c e d u r e s are t o know about. Don't worry over each q u e s t i o n , but g i v e us the f i r s t i m p r e s s i o n you g e t . The second p a r t , S e c t i o n B, shows what you have l e a r n e d about y o u r o p e r a t i o n . T h i n k out your answers t o t h e s e q u e s t i o n s and take your time w i t h t h i s s e c -t i o n . S e c t i o n C, the t h i r d s e c t i o n i s a s e c t i o n i n which you can w r i t e any comments or s u g g e s t i o n s you c a r e t o make. Thank you f o r g i v i n g us yo u r time and h e l p i n g us i n t h i s s t u d y . - 55 -Assessment o f P r e o p e r a t i v e L e a r n i n g Needs Assessment o f the v a l i d i t y o f the i n s t r u c t i o n a l c o n t e n t i n a l l t h r e e t r e a t m e n t groups was done by means o f a s c a l e d q u e s t i o n n a i r e i n c l u d e d as p a r t o f the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e (APPENDIX E) on the f i f t h p o s t o p e r a t i v e day. A f i v e - p o i n t s c a l e was used. T h i s i n s t r u m e n t was r e v i e w e d by the same panel o f n u r s e - e d u c a t o r s used t o v a l i d a t e the c o g n i -t i v e p o s t - t e s t . No changes were recommended. The r e were f i f t y items i n t h e p o s t o p e r a t i v e l e a r n i n g needs s e c t i o n o f the q u e s t i o n n a i r e . These items r e f l e c t e d t h e p o t e n t i a l c o g n i t i v e , a f f e c t i v e and psychomotor l e a r n i n g needs of a p a t i e n t u n d e r g o i n g a c h o l e c y s e c t o m y . Examples o f some o f the items a r e : DON'T KNOW 10. Why you may have an enema b e f o r e s u r g e r y 5 4 3 2 1 32. How much p a i n you w i l l have 5 4 3 2 1 33. Why you might have a stomach tube a f t e r s u r g e r y 5 4 3 2 1 Assessment o f L e a r n i n g S t y l e s The t h i r d p a r t o f the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e d e a l t w i t h l e a r n i n g s t y l e . The p a t i e n t s were asked t o i d e n t i f y how t h e y b e s t l i k e d t o l e a r n and t o g i v e the r e a s o n s f o r t h e i r c h o i c e . The c h o i c e s i n c l u d e d a p r i v a t e s e s s i o n w i t h a n u r s e , a group s e s s i o n where f e e l i n g s c o u l d be s h a r e d w i t h o t h e r p a t i e n t s , a c l a s s , a c o m b i n a t i o n o f any o f the t h r e e p r e -c e d i n g c h o i c e s or any o t h e r method th e y chose t o name. They were a l s o asked t o p r o v i d e s u g g e s t i o n s which would be h e l p f u l i n p l a n n i n g t o p r o v i d e o t h e r p a t i e n t s w i t h i n f o r m a t i o n t h e y f e l t was i m p o r t a n t . - 56 -CONTROLS S i n c e the r a t i o o f women t o men un d e r g o i n g c h o l e c y s t e c t o m y i s 4:1 ( S l e i s e n g e r & F o r d t r a n , 1978, p. 1284), p o s s i b l e sex d i f f e r e n c e s were i g n o r e d by i n c l u d i n g o n l y f e m a l e s i n the st u d y . A l l o t h e r causes o f s y s t e -m a t i c v a r i a n c e , p a r t i c u l a r l y q u a l i t y and t y p e s o f n u r s i n g i n t e r v e n t i o n , were c o n t r o l l e d by the randomized d e s i g n . V a r i a n c e due t o d o c t o r i n t e r v e n t i o n was not c o n t r o l l e d and t h i s i s a weakness i n the study. B i a s i n g o f the ward n u r s i n g s t a f f by the n u r s e - r e s e a r c h e r c o u l d o c c u r i n the communication o f the summary d a t a o f the p r e o p e r a t i v e i n t e r v i e w w i t h p a t i e n t s i n the I n d i v i d u a l i z e d L e a r n i n g Group. S i n c e the s t a f f was f a m i -l i a r w i t h n u r s i n g s t u d e n t s c a r r y i n g out n u r s i n g h i s t o r i e s and l e a v i n g t h i s d a t a on the c h a r t f o r s t a f f use as d e s i r e d , t h i s approach s h o u l d be a c c e p t e d as r o u t i n e by the ward s t a f f and a b i a s e d r e s p o n s e a v o i d e d . In a d d i t i o n , the c o - o p e r a t i o n o f the s e n i o r n u r s i n g a d m i n i s t r a t o r s , who were aware o f the st u d y , was s e c u r e d i n p r e v e n t i n g ward s t a f f awareness o f t h e s t u d y , s h o u l d t h e ward s t a f f q u e s t i o n them about t h e p r e s e n c e o f t h e n u r s e -r e s e a r c h e r on t h e ward or t h e r e a s o n s why a p a t i e n t was or was not b e i n g s e n t t o t h e s o u n d - a n d - s l i d e p r e s e n t a t i o n . The c o n f o u n d i n g e f f e c t s o f time i n the p r e o p e r a t i v e i n t e r v i e w were c o n t r o l l e d by c o n d u c t i n g t h i s a c t i v i t y at .the same time f o r a l l p a t i e n t s d u r i n g the e v e n i n g o f the p r e o p e r a t i v e day. The c o n f o u n d i n g e f f e c t s o f tim e and p l a c e r e g a r d i n g the p r e s e n t a t i o n o f " O p e r a t i o n To-morrow" were c o n t r o l l e d i n t h a t i t was always c a r r i e d at t h e same tim e (6:30 P.M.) and i n t h e same p l a c e d u r i n g t h e e v e n i n g o f the p r e o p e r a t i v e day. - 57 -The n u r s e - r e s e a r c h e r conducted a l l o f the p r e o p e r a t i v e i n t e r v i e w s i n t h e I n d i v i d u a l i z e d L e a r n i n g Group. S i n c e an i n t e r v i e w e r tends t o adopt a r e l a t i v e l y c o n s i s t e n t s t y l e , t h i s s h o u l d p r e v e n t t h i s cause o f t r e a t m e n t v a r i a n c e . Other v a r i a t i o n s i n t r e a t m e n t f o r the I n d i v i d u a l i z e d L e a r n i n g Group were c o n t r o l l e d by the use o f s t a n d a r d i z e d d e v i c e s and i n t e r v i e w i n g g u i d e s p r e v i o u s l y d e s c r i b e d . The a t t r i t i o n r a t e was e x p e c t e d t o be minimal due t o t h e use o f t h e d e l i m i t i n g c r i t e r i a f o r s e l e c t i o n o f p a t i e n t s and the low m o r t a l i t y r a t e f o r c h o l e c y s t e c t o m y i t s e l f which i s e s t i m a t e d t o be 0.05 p e r c e n t ( S l e i s e n g e r & F o r d t r a n , 1978, p. 1294). I n t e r a c t i o n e f f e c t s between the n u r s e - r e s e a r c h e r and the t r e a t m e n t sub-j e c t s , as w e l l as a time b i a s i n g f a c t o r were p o t e n t i a l l y i n v o l v e d i n the use o f the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e . These f a c t o r s were c o n t r o l l e d by g i v i n g the q u e s t i o n n a i r e t o a l l p a t i e n t s on the f i f t h p o s t o -p e r a t i v e day and by u s i n g a s t a n d a r d i z e d approach when p r e s e n t i n g the q u e s t i o n n a i r e t o each p a t i e n t . The p a t i e n t was a s s u r e d o f c o n f i d e n t i a l i t y and no s i g n a t u r e was r e q u i r e d on the q u e s t i o n n a i r e . P a t i e n t s were encouraged t o a s s e s s f r a n k l y the u s e f u l n e s s o f the i n s t r u c t i o n a l c o n t e n t , whether i t was g i v e n by the n u r s e - r e s e a r c h e r or n o t . I t was s t r e s s e d t h a t i n d i v i d u a l comments o f p a t i e n t s would not be r e v e a l e d t o anyone but the n u r s e - r e s e a r c h e r . - 5 8 -DATA COLLECTION Assessment of l e a r n i n g i n the I n d i v i d u a l i z e d L e a r n i n g Group was a s s e s s e d d u r i n g the p r e o p e r a t i v e i n t e r v i e w . C o g n i t i v e l e a r n i n g was t e s t e d by t h e use o f a d i r e c t e d q u e s t i o n and answer t e c h n i q u e , a f f e c t i v e l e a r n i n g s u b j e c t i v e l y by o b s e r v a t i o n o f p a t i e n t s v e r b a l r e p o r t s and n o n v e r b a l beha-v i o r , and psychomotor l e a r n i n g by the use o f p a t i e n t d e m o n s t r a t i o n . P r e o p e r a t i v e l e a r n i n g was a l s o a s s e s s e d p o s t o p e r a t i v e l y by a c o g n i t i v e p o s t - t e s t g i v e n on t h e f i f t h p o s t o p e r a t i v e day t o p a t i e n t s i n a l l t h r e e t r e a t m e n t groups. Assessment o f p o s t o p e r a t i v e r e c o v e r y was measured by a number o f phy-s i o l o g i c a l and c l i n i c a l i n d i c a t o r s o b s e r v e d and r e c o r d e d by the m e d i c a l and n u r s i n g s t a f f . Those d a t a were c o l l e c t e d from the m e d i c a l r e c o r d s as f o l l o w s : 1. measurements o f the p h y s i o l o g i c a l v a r i a b l e s such as nausea, v o m i t i n g , gaseous d i s t e n s i o n and u r i n a r y r e t e n t i o n were r e c o r d e d as e i t h e r p r e s e n t , s i g n i f i e d by 1, or absent, s i g n i f i e d by 0; 2. temperature r e a d i n g s above 37*C were c o n s i d e r e d as f e v e r and r e c o r d e d t o the t e n t h o f a degree C e n t i g r a d e ; 3. u n i t measurements f o r a n a l g e s i c s , o r a l and p a r e n t e r a l were r e c o r d e d i n terms o f the numbers of dosages a d m i n i s t e r e d and t h e number o f days d u r i n g which a n a l g e s i c s were a d m i n i s t e r e d p o s t o p e r a t i v e l y ; - 59 -No attempt was made to r e f i n e t h e s e u n i t measurements o f a n a l g e s i c s any f u r t h e r such as S c h m i t t and W o o l r i d g e (1973) have done. I t was assumed t h a t a d o c t o r would o r d e r an a p p r o p r i a t e dosage f o r each p a t i e n t a c c o r d i n g t o i n d i v i d u a l h e i g h t , weight and o t h e r i n d i v i d u a l c r i t e r i a . The v a r i a n c e i n t h e q u a n t i t i e s a d m i n i s t e r e d per dose would ten d t o be c o n t r o l l e d by t h e randomized d e s i g n . 4. u n i t s o f measurement o f l e n g t h o f p o s t o p e r a t i v e s t a y were r e c o r d e d i n days i n c l u d i n g o p e r a t i v e day and day o f d i s c h a r g e ; 5. measurement o f the time p o s t o p e r a t i v e l y when a p a t i e n t commenced use o f o r a l a n a l g e s i c s was r e c o r d e d i n terms of the number o f the p o s t o p e r a t i v e day. Assessment o f the 50 p r e o p e r a t i v e l e a r n i n g needs was s c o r e d on a f i v e -p o i n t s c a l e which ranged from a s c o r e o f f i v e , s i g n i f y i n g v e r y i m p o r t a n t , to one, s i g n i f y i n g not i m p o r t a n t at a l l . "Don't Know" was r e c o r d e d as z e r o . These d a t a were c o l l e c t e d i n t h e P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e on the f i f t h p o s t o p e r a t i v e day. P r e f e r e n c e s f o r l e a r n i n g s t y l e were i n d i c a t e d on a check l i s t or l i s t e d by the p a t i e n t . These d a t a were a l s o c o l l e c t e d as p a r t o f the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e on the f i f t h p o s t o p e r a t i v e day. STATISTICAL ANALYSIS The s p e c i f i c hypotheses were t e s t e d f o r s i g n i f i c a n c e at the .05 l e v e l . One-way a n a l y s i s o f v a r i a n c e o f the demographic v a r i a b l e s was done t o determine a p r i o r e q u a l i t y among t h e t h r e e sample groups. Data - 60 -r e g a r d i n g age, m a r i t a l s t a t u s , s u r g i c a l r i s k c l a s s i f i c a t i o n , a n a e s t h e t i c t i m e , number o f dependents e i g h t e e n y e a r s of age and under, y e a r s o f s c h o o l i n g and d o c t o r was t e s t e d f o r i n t e r g r o u p e q u i v a l e n c y . The s t u d y d i d not c o n t r o l f o r d o c t o r i n t e r v e n t i o n as p a t i e n t s were randomly a s s i g n e d o n l y t o treatment groups. S t r a t i f i e d r a n d o m i z a t i o n t o c o n t r o l f o r d o c t o r p a r -t i c i p a t i o n was not used, but t h i s f a c t o r was c o n s i d e r e d i n the s e l e c t i o n o f methods o f s t a t i s t i c a l a n a l y s i s . The hypotheses were t e s t e d by a n a l y z i n g the ten t e s t v a r i a b l e s i n a n e s t e d d e s i g n w i t h the e f f e c t s o f the t h r e e l e a r n i n g groups ne s t e d w i t h i n d o c t o r e f f e c t s . F a c t o r a n a l y s i s of the p a t i e n t q u e s t i o n n a i r e items was conducted t o determine p a t i e n t s ' i m p r e s s i o n s of the s i g n i f i c a n c e o f the l e a r n i n g o b j e c t i v e s i n a p r e o p e r a -t i v e l e a r n i n g program. LIMITATIONS The major weaknesses o f t h i s s t u d y e x i s t i n e v a l u a t i o n o f the i n s t r u c -t i o n i t s e l f and the assessment o f p a t i e n t l e a r n i n g . Content v a l i d i t y was a s s e s s e d by both p a t i e n t s and n u r s e - e d u c a t o r s , but i n s t r u c t i o n a l s t r a t e g i e s were not a s s e s s e d f o r e f f e c t i v e n e s s o f use. Both would p r o v i d e a more complete assessment o f the t e a c h i n g - l e a r n i n g p r o c e s s , but assessment of the e f f e c t i v e n e s s of i n s t r u c t i o n a l s t r a t e g i e s i s d i f f i c u l t t o implement i n u n o b t r u s i v e ways and was beyond the r e s o u r c e s a v a i l a b l e t o implement t h i s s t u d y . - 61 -The methods o f e v a l u a t i n g l e a r n i n g i n the I n d i v d u a l i z e d L e a r n i n g Group were complete i n r e l a t i o n t o the t h r e e domains o f l e a r n i n g i n v o l v e d . The c o g n i t i v e and psychomotor assessments used were v a l i d , but t h e assessment o f a t t i t u d e l e a r n i n g was d e f i c i e n t i n t h a t a v a l i d a t e d , r e l i a b l e t o o l was not used. The c o g n i t i v e p o s t - t e s t c o u l d be used t o g i v e a measure o f l e a r n i n g i n t h i s s t u d y i n t h a t i t was used i n the same way f o r a l l s u b j e c t s . However, the r e l i a b i l i t y o f t h i s t o o l was not determined p r i o r to the a d m i n i s t r a t i o n o f t h e t e s t and the l a c k o f a p r e - t e s t l e f t i n q u e s t i o n whether the l e a r n i n g measured was an outcome o f the p r e o p e r a t i v e l e a r n i n g program or had o c c u r r e d p r i o r t o a d m i s s i o n t o h o s p i t a l . - 62 -CHAPTER IV FINDINGS The major hypotheses were t e s t e d and the f i n d i n g s r e p o r t e d i n t h i s c h a p t e r . S e l f - r e p o r t e d l e a r n i n g needs o f p a t i e n t s u n d e r g o i n g c h o l e c y s t e c -tomy and summary d a t a r e l e v a n t t o p a t i e n t s ' l e a r n i n g s t y l e s were a n a l y z e d and r e p o r t e d as w e l l . CHARACTERISTICS OF THE SAMPLE S t a t i s t i c s r e g a r d i n g age, y e a r s o f s c h o o l i n g , s t a t u s o f s u r g i c a l r i s k , a n a e s t h e t i c time, m a r i t a l s t a t u s , and number o f c h i l d r e n e i g h t e e n y e a r s o f age and under are summarized i n T a b l e V I I . The C l a s s L e a r n i n g Group had t h e o l d e s t p a r t i c i p a n t s w i t h t h e h i g h e s t s u r g i c a l r i s k r a t i n g s , the l o n g e s t a n a e s t h e t i c time and t h e lowest number o f y e a r s o f s c h o o l i n g . The I n d i v i d u a l i z e d L e a r n i n g Group and the I n c i d e n t a l L e a r n i n g Group were r e l a -t i v e l y s i m i l a r i n terms o f age, y e a r s o f s c h o o l i n g and s t a t u s o f s u r g i c a l r i s k , but the I n d i v i d u a l i z e d L e a r n i n g Group had a somewhat l o n g e r anaesthe-t i c time than the I n c i d e n t a l L e a r n i n g Group. The I n d i v i d u a l i z e d L e a r n i n g Group and the I n c i d e n t a l l e a r n i n g Group had the same number o f m a r r i e d and u n married p a r t i c i p a n t s i n a r a t i o o f a p p r o x i m a t e l y 3:1. Unmarried p a r -t i c i p a n t s i n c l u d e d a l l t h o s e i d e n t i f i e d as s i n g l e , d i v o r c e d , s e p a r a t e d or widowed. The C l a s s L e a r n i n g Group had an almost even number o f m a r r i e d and nonmarried p a r t i c i p a n t s . The major d i f f e r e n c e among the t h r e e t r e a t m e n t groups o c c u r r e d i n the I n d i v i d u a l i z e d L e a r n i n g Group which had the l a r g e s t mean number o f c h i l d r e n e i g h t e e n y e a r s o f age and under, and the l a r g e s t number o f p a t i e n t s w i t h c h i l d r e n . The a n a l y s i s o f the t h r e e t r e a t m e n t TABLE VII SUMMARY OF CHARACTERISTICS OF THE SAMPLE VARIABLE INDIVIDUALIZED LEARNING GROUP CLASS LEARNING GROUP INCIDENTAL LEARNING GROUP OVERALL F RATIO CRITICAL VALUE OF F SIGNIFICANCE AGE Mean S.D. 43.455 15.719 56.636 10.102 46.727 15.206 48.939 14.620 2.676 3.32 (.05) N.S. YEARS OF  SCHOOLING Mean S.D. 11.545 1.9679 10.455 3.7246 11.273 1.4894 11.091 2.5417 .509 3.32 (.05) N.S. STATUS OF SURGICAL RISK Mean S.D. 1.1818 0.40452 1.6364 0.80904 1.2727 0.46710 1.3636 0.60302 2.2796 3.32 (.05) I.S. ANAESTHETIC  TIME Mean S.D. 88.182 25.522 102.73 25.919 81.818 22.391 90.909 25.478 2.077 3.32 (.05) N.S. MARITAL  STATUS M a r r i e d Other 72.7% 27.3% 54.5% 45.4% 72.7% 27.3% 66.6% 33.33% 0.527 3.32 (.05) N.S. TABLE VII - Cont'd. VARIABLE INDIVIDUALIZED CLASS LEARNING GROUP LEARNING ' GROUP DEPENDENT  CHILDREN 18  AND UNDER Mean 1.82 0.36 S.D. 2.40 0.81 NUMBER OF PATIENTS WITH DEPENDENT CHILDREN 54.54% 18.18% INCIDENTAL OVERALL F RATIO C R I T I C A L S I G N I F I C A N C E LEARNING VALUE GROUP OF F  0.36 0.81 0.85 2.9 3.38 3.32 (0.05) S i g n i f i c a n t 27.27% 33.33% 3.3.2 (.05) c n -F=> - 65 -groups demonstrated t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between the groups w i t h the e x c e p t i o n o f one v a r i a b l e - number o f p a t i e n t s w i t h depen-dent c h i l d r e n . In t h a t r e g a r d , t h e r e was a s i g n i f i c a n t d i f f e r e n c e among the groups at the 0.05 l e v e l a t t r i b u t e d t o the l a r g e number o f c h i l d r e n under e i g h t e e n y e a r s o f age i n t h e I n d i v i d u a l i z e d L e a r n i n g Group. CLINICAL SETTING VARIABLES E l e v e n d o c t o r s were i n v o l v e d i n the s t u d y and the f r e q u e n c y o f t h e i r involvement i n each t r e a t m e n t group i s o u t l i n e d i n T a b l e V I I I . The d a t a on d o c t o r involvement i n the s t u d y was skewed by f o u r d o c t o r s who were i n v o l v e d o n l y once; two o f t h e s e d o c t o r s were i n v o l v e d i n the I n d i v i d u a l i z e d L e a r n i n g Group and two i n t h e C l a s s L e a r n i n g Group. F u r t h e r skewing was caused by Doctor #10 who was i n v o l v e d t w i c e as o f t e n the second h i g h e s t r a n k i n g d o c t o r p a r t i c i p a n t . T h i s skewing o f d o c t o r i n v o l v e m e n t may have o c c u r r e d because o f the sample s e l e c t i o n s t r a t e g i e s . Samples o f p a t i e n t s drawn f o r t h i s s t u d y i n v o l v e d almost the e n t i r e p o p u l a t i o n o f p a t i e n t s a v a i l a b l e at the h o s p i t a l under s t u d y , r a t h e r than randomly s e l e c t e d samples of p a t i e n t s undergoing c h o l e c y s t e c t o m y . The p a t i e n t s may be c o n s i d e r e d d o c t o r - s e l e c t e d and as such, the s e l e c t i o n c o u l d be c o r r e l a t e d w i t h the f r e q u e n c y o f c h o l e c y s t e c t o m i e s performed by the surgeons p r a c t i s i n g a t t h i s h o s p i t a l . T h i s f a c t o r i s one which commonly o p e r a t e s i n c l i n i c a l e x p e r i e m e n t a l r e s e a r c h and was c o n s i d e r e d i n subsequent a n a l y s i s o f d a t a . T h i s f a c t o r might have been c o n t r o l l e d by u s i n g a s t r a t i f i e d random a s s i g n -ment o f p a t i e n t s a c c o r d i n g t o d o c t o r s . TABLE VIII FREQUENCY OF DOCTOR INVOLVEMENT IN THE STUDY TJTJCTOR INDIVIDUALIZED CLASS INCIDENTAL OVERALL PERCENTAGE OF LEARNING GROUP LEARNING LEARNING PATIENTS GROUP GROUP TREATED BY EACH DOCTOR 1 3 2 2 2 0 3 0 1 4 0 1 5 0 1 6 1 0 7 1 2 8 0 2 9 1 0 10 2 2 11 1 0 TOTAL 7 7 NUMBER OF DOCTORS INVOLVED IN EACH OF THE THREE TREATMENT GROUPS 0 5 15.2 2 4 12.1 1 2 6.1 0 1 3.0 0 1 3.0 0 1 3.0 0 3 9.1 1 3 9.1 1 2 6.1 6 10 30.3 0 1 3.0 5 33 100 - 67 -The problem o f c o n t r o l l i n g f o r u n a v o i d a b l e e x t r a n e o u s v a r i a b l e s which may l e a d t o c o n f o u n d i n g o f a s t u d y i s a p e r e n n i a l problem i n n u r s i n g r e s e a r c h (B.A. Johnson, 1970; W o l f e r , 1973). U n l i k e p r e v i o u s s t u d i e s , t h i s s t u d y c o n t r o l l e d f o r the typ e o f s u r g e r y , but d i d not c o n t r o l f o r d o c t o r i n v o l v e m e n t . Other s i t u a t i o n a l v a r i a b l e s which may confound t h e s t u d y i n c l u d e the q u a l i t y and typ e o f n u r s i n g c a r e a v a i l a b l e t o p a t i e n t s which might f l u c t u a t e f r o m ward t o ward, day t o day and s h i f t t o s h i f t . L a r g e sample s i z e s can mediate t he c o n f o u n d i n g e f f e c t s o f such v a r i a b l e s . T h i s s t u d y used a r e l a t i v e l y l a r g e sample s i z e , b u t f u t u r e r e s e a r c h c o u l d use even l a r g e r samples and c o n t r o l f o r both d o c t o r involvement and ward u n i t i n volvement through s t r a t i f i e d random assignment t o reduce t he c o n f o u n d i n g e f f e c t s o f t h e s e c l i n i c a l s e t t i n g v a r i a b l e s t o a g r e a t e r degree. TESTS OF HYPOTHESES Methods o f A n a l y s i s To d e a l with t he skewing caused by d o c t o r involvement i n the s t u d y , an a n a l y s i s o f group d i f f e r e n c e s n e s t e d w i t h i n d o c t o r s was chosen. The U n i v e r s i t y o f B r i t i s h Columbia v e r s i o n o f the MULTIVAR program was used ( U n i v e r s i t y o f B r i t i s h Columbia, 1972). The two major elements i n t h i s n e s t e d d e s i g n a r e : (1) t he t h r e e e x p e r i m e n t a l groups o f t h i r t y - t h r e e p a t i e n t s ; and (2) the e l e v e n d o c t o r s . The f o u r d o c t o r s who p a r t i c i p a t e d o n l y once were combined and a n a l y z e d as though t h e y were one d o c t o r ( D o c t o r #8). T h i s n e s t i n g o f p a t i e n t s w i t h i n d o c t o r s r e s u l t s i n seventeen f u l l c e l l s ( s e e T a b l e I X ) . Observed means TABLE IX CELL DISTRIBUTION OF PATIENTS BY DOCTOR AND TREATMENT GROUP DOCTOR 1 2 3 4 5 6 7 8 CELL n ; GROUP N INDIVIDUALIZED 1 0 9 11 LEARNING GROUP 3 2 - 1 - 1 ^ ^ CLASS LEARNING , 0 0 0 0 11 GROUP 2 - 1 2 2 - 2 2 11 INCIDENTAL LEARNING GROUP TOTAL NUMBER OF PATIENTS PER DOCTOR DOCTOR 5 4 2 3 3 2 10 4 1 2 3 4 5 6 7 8 11 CO - 69 -of each o f the ten t e s t v a r i a b l e s were a n a l y z e d c e l l by c e l l . The t r e a t -ment group means r e p o r t e d f o r each t e s t v a r i a b l e were combined e s t i m a t e d means a d j u s t e d t o accommodate e s t i m a t e d e r r o r e f f e c t s . The s i g n i f i c a n c e the group e f f e c t s i s r e p o r t e d i n terms o f p v a l u e s . S i n c e The I n c i d e n t a l L e a r n i n g Group was c o n s i d e r e d t h e c o n t r o l group, d i f f e r e n c e s between t h e I n d i v i d u a l i z e d L e a r n i n g Group and t h e I n c i d e n t a l L e a r n i n g Group, and b e t -ween the C l a s s L e a r n i n g and The I n c i d e n t a l L e a r n i n g Group o n l y , were r e p o r t e d . D o c t o r - r e l a t e d c e l l group d i f f e r e n c e s were a l s o a n a l y z e d and r e p o r t e d i n terms o f p v a l u e s . S i n c e d o c t o r #7 p a r t i c i p a t e d i n a l l t h r e e t r e a t m e n t groups, he had two p v a l u e s , showing h i s r e l a t i o n s h i p s t o p a t i e n t s i n c e l l groups i n v o l v i n g : (1) t h e I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups; and (2) the C l a s s and I n c i d e n t a l L e a r n i n g Groups. The nin e p o s t o p e r a t i v e r e c o v e r y v a r i a b l e s used i n t e s t i n g the hypothe s i s t h a t the I n d i v i d u a l i z e d and C l a s s L e a r n i n g Groups would demonstrate a more s u c c e s s f u l r e c o v e r y than t h e I n c i d e n t a l L e a r n i n g Group i n c l u d e d : 1. doses o f o r a l a n a l g e s i c s ; 2. doses o f p a r e n t e r a l a n a l g e s i c s ; 3. s t a r t o f the use o f o r a l a n a l g e s i c s ; 4. days o f o r a l a n a l g e s i c s ; 5. days o f p a r e n t e r a l a n a l g e s i c s ; 6. i n c i d e n c e o f f e v e r ; 7. i n c i d e n c e o f g a s t r o i n t e s t i n a l d y s f u n c t i o n ; 8. i n c i d e n c e o f p o s t o p e r a t i v e c o m p l i c a t i o n s ; 9. l e n g t h o f p o s t o p e r a t i v e s t a y . - 70 -S c o r e s on the p o s t o p e r a t i v e c o g n i t i v e p o s t - t e s t were used i n t e s t i n g the h y p o t h e s i s t h a t t h e I n d i v i d u a l i z e d and C l a s s L e a r n i n g Groups would s c o r e h i g h e r than the I n c i d e n t a l L e a r n i n g Group. Treatment Group D i f f e r e n c e s A l l o f the n i n e p o s t o p e r a t i v e r e c o v e r y v a r i a b l e s and the c o g n i t i v e achievement v a r i a b l e were f i r s t a n a l y z e d f o r the s i g n i f i c a n c e o f t r e a t m e n t group d i f f e r e n c e s . These d i f f e r e n c e s are r e p o r t e d i n terms o f group p v a l u e s f o r the I n d i v i d u a l i z e d and C l a s s L e a r n i n g Groups showing the s i g n i -f i c a n c e o f d i f f e r e n c e s between each o f t h e s e two treatment groups and t h e I n c i d e n t a l L e a r n i n g Group which s e r v e d as t h e c o n t r o l group. Observed c e l l means were r e p o r t e d f o r each o f the seventeen c e l l groups as w e l l as t h e combined treatment group means f o r each o f the t h r e e t r e a t m e n t groups r e l e -vant t o each o f the t e n t e s t v a r i a b l e s . These f i n d i n g s are o u t l i n e d i n TABLES X, XI and X I I . The s c o r e f o r g a s t r o i n t e s t i n a l f u n c t i o n i s an aggregate s c o r e c o m p i l e d by g i v i n g each p a t i e n t one p o i n t f o r each time nausea and v o m i t i n g and gaseous d i s t e n t i o n are r e p o r t e d , each time an a n t i e m e t i c , l a x a t i v e or enema i s g i v e n and f o r the number o f days a n a s o g a s t r i c tube was " i n s i t u " . The I n c i d e n t a l L e a r n i n g Group had the lowest i n c i d e n c e o f g a s t r o i n t e s t i n a l dys-f u n c t i o n w i t h a combined group mean o f 2.25. The I n d i v i d u a l i z e d L e a r n i n g Group ranked second w i t h a mean o f 4.25 and the C l a s s L e a r n i n g Group t h i r d w i t h a mean o f 4.40. The p v a l u e f o r the I n d i v i d u a l i z e d L e a r n i n g Group was 0.89 and 0.31 f o r t h e C l a s s L e a r n i n g Group. T h e r e were no s i g n i f i c a n t group d i f f e r e n c e s . TABLE X TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN THE INDIVIDUALIZED LEARNING GROUP INDIVIDUALIZED LEARNING GROUP CELL n 3 2 X 1 X 1 2 2 COMBINED GROUP MEAN GROUP P VALUE SIGNIFICANCE OBSERVED CELL MEANS G.I. F u n c t i o n 3.33 7.0 - 2.0 - 6.0 53.5 5.0 4.25 0.89 N.S. Fev e r 3.967 3.85 - 2.7 - 2.1 3.5 4.2 3.43 0.76 N.S. C o m p l i c a t i o n s 0.33 0.5 - 0.0 - 1.0 0.0 1.0 0.497 0.91 N.S. Doses o f O r a l A n a l g e s i c s 10.33 4.5 - 3.0 - 1.0 2.0 2.0 2.57 0.12 N.S. Does o f P a r e n t e r a l A n a l g e s i c s 15.0 9.5 - 14.0 - 14.0 10.0 10.0 9.87 0.006 0.006 S t a r t o f O r a l A n a l g e s i c s 3.67 3.5 - 3.0 - 4.0 3.0 2.0 2.352 0.13 N.S. Days o f O r a l A n a l g e s i c s 5.33 2.0 - 3.0 - 1.0 1.5 1.5 1.85 0.28 N.S. Days o f P a r e n t a l A n a l g e s i cs 4.0 3.5 - 4.0 - 5.0 3.5 5.0 3.77 0.25 N.S. P o s t o p e r a t i v e S t a y 11.0 11.5 - 7.0 - 8.0 6.5 8.0 8.48 0.89 N.S. C o g n i t i v e T e s t S c o r e 5.33 4.0 - 6.0 - 7.0 6.5 4.0 5.47 0.83 N.S. TABLE XI TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN THE CLASS LEARNING GROUP CLASS LEARNING GROUP CELL n 2 X 1 2 2 X 2 2 COMBINED GROUP MEAN GROUP P VALUE SIGNIFICANCE OBSERVED CELL MEANS G.I. F u n c t i o n 10.0 - 5.0 3.0 4.0 - 1.0 4.0 4.40 0.31 N.S. Fev e r 3.7 - 3.3 4.3 5.1 - 3.2 3.55 3.95 0.56 N.S. C o m p l i c a t i o n s 0.5 - 1.0 1.5 1.0 - 0.5 1.5 0.96 0.81 N.S. Doses o f O r a l A n a l g e s i c s 5.5 - 6.0 6.5 1.0 - 0.0 6.0 4.79 0.11 N.S. Doses o f P a r e n t a l A n a l g e s i c s 12.5 - 12.0 9.5 12.0 - 10.5 14.5 12.07 0.96 N.S. S t a r t o f O r a l A n a l g e s i c s 2.0 - 4.0 3.0 2.0 - 0.0 3.5 2.355 0.52 N.S. Days o f O r a l A n a l g e s i c s 4.0 - 4.0 3.0 1.0 - 0.0 2.5 2.75 0.07 N.S. Days o f P a r e n t a l A n a l g e s i c s 4.0 - 6.0 4.0 4.0 - 4.0 4.5 4.33 0.15 N.S. P o s t o p e r a t i v e S t a y 9.5 - 10.0 8.5 8.5 - 7.5 9.0 8.62 0.47 N.S. C o g n i t i v e T e s t S c o r e 4.5 - 7.0 5.5 2.5 - 6.0 5.0 5.05 0.60 N.S. TABLE XII CELL AND GROUP MEANS FOR TEST VARIABLES IN THE INCIDENTAL LEARNING GROUP (CONTROL) INCIDENTAL LEARNING GROUP CELL n X 2 1 X 1 1 6 X COMBINED GROUP MEAN G.I. F u n c t i o n 3.0 1.0 6.0 0.0 2.5 - 2.25 Fever 3.1 2.9 3.0 4.3 3.9 - 3.37 C o m p l i c a t i o n s 1.0 1.0 0.0 1.0 0.67 - 0.705 Doses o f O r a l A n a l g e s i c s 1.5 9.0 8.0 7.0 4.0 - 3.596 Doses o f P a r e n t a l A n a l g e s i c s 11.0 14.0 20.0 9.0 7.5 - 10.38 S t a r t of O r a l A n a l g e s i c s 1.5 4.0 4.0 3.0 2.17 - 2.354 Days o f O r a l A n a l g e s i c s 1.0 4.0 3.0 4.0 2.0 - 1.6 Days o f P a r e n t a l A n a l g e s i c s 4.0 4.0 4.0 3.0 3.17 - 3.44 P o s t o p e r a t i v e S t a y 8.0 9.0 7.0 7.0 7.67 - 7.55 C o g n i t i v e T e s t S c o r e 3.0 6.0 4.0 5.0 5.67 - 4.72 - 74 -The s c o r e f o r f e v e r i s a combined mean of the d a i l y mean temperature r e a d i n g s above 37 degrees C e n t i g r a d e and was c a l c u l a t e d t o the t e n t h o f a degree. There was v e r y l i t t l e d i f f e r e n c e between group means, a l t h o u g h t h e I n c i d e n t a l L e a r n i n g Group had t h e lowest s c o r e w i t h a mean o f 3.37. The I n d i v i d u a l i z e d L e a r n i n g Group ranked second w i t h a mean o f 3.43 and t h e C l a s s L e a r n i n g Group t h i r d w i t h a mean o f 3.95. These group d i f f e r e n c e s are not s t a t i s t i c a l l y s i g n i f i c a n t . S c o r e s f o r o t h e r c o m p l i c a t i o n s are s i g n i f i e d by a 1 i f p r e s e n t and a z e r o i f absent. The I n d i v i d u a l i z e d L e a r n i n g Group had the fe w e s t number o f c o m p l i c a t i o n s w i t h a s c o r e o f s i x , t h e C l a s s L e a r n i n g Group had a s c o r e o f e l e v e n , and the I n c i d e n t a l L e a r n i n g Group had a s c o r e o f e i g h t . The t y p e s of c o m p l i c a t i o n s r e p o r t e d f o r t h i s t e s t v a r i a b l e and the i n c i d e n c e i n each of the t h r e e t r e a t m e n t s groups i s as f o l l o w s : I n d i v i d u a l i z e d L e a r n i n g Group (6 C o m p l i c a t i o n s ) : 1. r i g h t and l e f t lower l o b e pneumonia ( 1 ) ; 2. a t e l e c t a s i s w i t h r i g h t p l e u r a l e f f u s i o n ( 1 ) ; 3. muscle spasm i n r i g h t s h o u l d e r ( 1 ) ; 4. s k i n r a s h ( 1 ) ; 5. d i f f i c u l t y v o i d i n g and c a t h e t e r i z e d ( 2 ) ; - 75 -C l a s s L e a r n i n g Group (11 C o m p l i c a t i o n s ) : 1. i n f e c t i o n as e v i d e n c e d by f e v e r and t r e a t e d w i t h a n t i b i o t i c s but u n c o n f i r m e d as t o s o u r c e ( 2 ) ; 2. d i f f i c u l t y v o i d i n g and c a t h e t e r i z e d ( 4 ) ; 3. wound i n f l a m m a t i o n w i t h s e r o p u r u l e n t d i s c h a r g e ( 1 ) ; 4. u r i n a r y t r a c t i n f e c t i o n ( 2 ) ; 5. upper r e s p i r a t o r y t r a c t i n f e c t i o n ( 1 ) ; 6. m i g r a i n e hedache ( 1 ) . I n c i d e n t a l L e a r n i n g Group (8 C o m p l i c a t i o n s ) : 1. b r a d y c a r d i a ( 1 ) ; 2. h y p o v o l e m i a ( 1 ) ; 3. f e v e r d i a g n o s e d as due t o e i t h e r upper r e s p i r a t o r y or u r i n a r y t r a c t i n f e c t i o n but u n c o n f i r m e d ( 1 ) ; 4. r e s p i r a t o r y i n f e c t i o n ; 5. anemi a ( 1 ) ; 6. d i f f i c u l t y v o i d i n g and c a t h e t e r i z e d ( 1 ) ; 7. segmental a t e l e c t a s i s i n the l e f t lower l o b e ( 1 ) ; 8. u r i n a r y t r a c t i n f e c t i o n ( 1 ) . The group means were c o n s i s t e n t w i t h t h e i n c i d e n c e o f c o m p l i c a t i o n s . The I n d i v i d u a l i z e d L e a r n i n g Group had a mean of 0.497, t h e I n c i d e n t a l L e a r n i n g Group 0.70 and t h e C l a s s L e a r n i n g Group 0.96. These d i f f e r e n c e s were not s t a t i s t i c a l l y s i g n i f i c a n t . - 76 -The I n d i v i d u a l i z e d L e a r n i n g Group had the f e w e s t number o f doses o f  o r a l a n a l g e s i c s even though t h r e e p a t i e n t s i n c e l l one had the h i g h e s t mean o f 10.33 d o s e s . The combined group mean f o r the I n d i v i d u a l i z e d L e a r n i n g Group was 3.596. The group mean f o r the I n c i d e n t a l L e a r n i n g Group was 4.0 and 4.79 f o r the C l a s s L e a r n i n g Group. The group d i f f e r e n c e s were not s t a -t i s t i c a l l y s i g n i f i c a n t , but r e f l e c t o n l y s u g g e s t i v e d i f f e r e n c e s w i t h a p v a l u e of 0.12 f o r the I n d i v i d u a l i z e d L e a r n i n g Group and 0.11 f o r the C l a s s L e a r n i n g Group. The I n d i v i d u a l i z e d L e a r n i n g Group had the fewest doses o f p a r e n t e r a l  a n a l g e s i c s , and a mean o f 9.87. The I n c i d e n t a l L e a r n i n g Group ranked second w i t h a mean o f 10.38 and the C l a s s L e a r n i n g Group was t h i r d w i t h a mean o f 12.07. T h e r e were s i g n i f i c a n t group d i f f e r e n c e s between t h e I n d i v i d u a l i z e d L e a r n i n g Group and the I n c i d e n t a l L e a r n i n g Group at the 0.006 l e v e l o f s i g n i f i c a n c e . T h e r e were d i f f e r e n c e s a p p r o a c h i n g s i g n i f i -cance between the C l a s s L e a r n i n g Group and the I n c i d e n t a l L e a r n i n g Group at a p o f 0.096. A l l t h r e e groups had almost i d e n t i c a l group means f o r t h e number o f  p o s t o p e r a t i v e days a p a t i e n t commenced u s i n g o r a l a n a l g e s i c s . The I n d i v i d u a l i z e d L e a r n i n g Group r e p o r t e d a mean o f 2.352, the I n c i d e n t a l L e a r n i n g Group 2.354, and the C l a s s L e a r n i n g Group 2.355. T h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t group d i f f e r e n c e s . - 77 -The I n c i d e n t a l L e a r n i n g Group used o r a l a n a l g e s i c s f o r the fe w e s t number o f days and r e p o r t e d a mean o f 1.6 days. The I n d i v i d u a l i z e d L e a r n i n g Group ranked second w i t h a mean o f 1.85 days, and the C l a s s L e a r n i n g Group t h i r d w i t h a mean o f 2.75 days. There were no s t a t i s t i c a l l y s i g n i f i c a n t group d i f f e r e n c e s , a l t h o u g h t he d i f f e r e n c e s between the C l a s s and I n c i d e n t a l L e a r n i n g Group at t h e 0.07 l e v e l approached s i g n i f i c a n c e . The I n c i d e n t a l L e a r n i n g Group a l s o was r e p o r t e d as u s i n g p a r e n t e r a l  a n a l g e s i c s f o r the fewest number o f days and had a group mean o f 3.44 days. The I n d i v i d u a l i z e d L e a r n i n g Group ranked second w i t h a mean o f 3.77 days and the C l a s s L e a r n i n g Group was t h i r d w i t h a mean o f 4.33 days. There were no s i g n i f i c a n t group d i f f e r e n c e s . The I n c i d e n t a l L e a r n i n g Group had the s h o r t e s t p o s t o p e r a t i v e s t a y w i t h a mean o f 7.55 days. The I n d i v i d u a l i z e d L e a r n i n g Group ranked second w i t h a mean o f 8.48 days and the C l a s s L e a r n i n g Group t h i r d w i t h a mean o f 8.62 days. There were no s i g n i f i c a n t d i f f e r e n c e s between groups. There were t e n items on t h e c o g n i t i v e p o s t - t e s t and t h e maximum s c o r e p o s s i b l e was 10. P a t i e n t s were g i v e n a s c o r e o f 0 f o r each wrong answer. The I n d i v i d u a l i z e d L e a r n i n g Group had the h i g h e s t c o g n i t i v e achievement s c o r e was a mean o f 5.47. The C l a s s L e a r n i n g Group ranked second w i t h a mean o f 5.05 and the I n c i d e n t a l L e a r n i n g Group t h i r d w i t h a mean o f 4.72. There were no s i g n i f i c a n t group d i f f e r e n c e s . - 78 -A l t h o u g h t h i s c o g n i t i v e p o s t - t e s t had been reviewed by a panel o f n u r s e - e d u c a t o r s f o r c o n t e n t and c o n s t r u c t v a l i d i t y p r i o r t o i t s a d m i n i s t r a t i o n , i t had not been t e s t e d f o r r e l i a b i l i t y . A f t e r a d m i n i s t r a t i o n o f the t e s t , i t was a n a l y z e d f o r r e l i a b i l i t y . The average i n t e r c o r r e l a t i o n among the t e n items was s u f f i c i e n t l y l a r g e t o j u s t i f y the t o t a l c o g n i t i v e s c o r e as a measure o f c o g n i t i v e achievement. The d a t a r e p o r t e d i n T a b l e s IX, X and XI were based on the t o t a l c o g n i t i v e achievement s c o r e s f o r each o f the 33 s u b j e c t s . The a l p h a r e l i a b i l i t y o f the o v e r a l l t e s t i s 0.63. The f i n d i n g s f o r t he r e l i a b i l i t y a n a l y s i s of each o f the t e n items i n the c o g n i t i v e achievement t e s t are o u t l i n e d i n TABLE X I I I . D o c t o r - R e l a t e d C e l l Group D i f f e r e n c e s Subsequent t o t e s t i n g f o r t r e a t m e n t group d i f f e r e n c e s , a l l o f t h e n i n e p o s t o p e r a t i v e r e c o v e r y v a r i a b l e s and the c o g n i t i v e achievement v a r i a b l e were a n a l y z e d f o r d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s . The c e l l groups o f p a t i e n t s t r e a t e d by each d o c t o r i n v o l v e d i n the s t u d y were a n a l y z e d f o r s i g n i f i c a n t between-group d i f f e r e n c e s . These f i n d i n g s were r e p o r t e d i n terms of p v a l u e s f o r each d o c t o r and are l i s t e d i n TABLE XIV. S i n c e D octor #7 t r e a t e d p a t i e n t s i n a l l t h r e e t r e a t m e n t groups, he had two p v a l u e s r e p o r t e d which showed two k i n d s o f between-group c e l l d i f f e r e n c e s : between the c e l l s i n the I n d i v i d u a l i z e d L e a r n i n g Group and the I n c i d e n t a l L e a r n i n g Group, and between the c e l l s i n the C l a s s L e a r n i n g Group and the I n d i v i d u a l i z e d L e a r n i n g Group. A l l o t h e r d o c t o r s had c e l l groups o f p a t i e n t s i n o n l y two of the t h r e e t r e a t m e n t groups. The p v a l u e s f o r a l l t h e o t h e r d o c t o r s , t h e n , showed the o t h e r c e l l group d i f f e r e n c e s between t h e two t r e a t m e n t groups i n v o l v e d f o r each d o c t o r as i d e n t i f i e d at t h e top of TABLE X I I I . There were no s i g n i f i c a n t d o c t o r - r e l a t e d c e l l group TABLE XIII RELIABILITY ANALYSIS: COGNITIVE ACHIEVEMENT TEST ITEM NUMBER AND STEM MEAN S.D. ALPHA IF ITEM DELETED 1. Leg e x e r c i s e s are i m p o r t a n t a f t e r s u r g e r y because they 0.45 0.51 0.60 2. A s l e e p i n g p i l l the n i g h t b e f o r e s u r g e r y 0.33 0.49 0.64 3. You are asked t o s u p p o r t or " s p l i n t " y o u r i n c i s i o n when coughing because 0.73 0.45 0.60 4. In o r d e r f o r the a n a e t h e t i s t t o be a b l e t o check your c i r c u l a t i o n d u r i n g the a n a e s t h e t i c you are asked t o remove your 0.60 0.496 0.59 5. A stomach tube a t t a c h e d t o s u c t i o n may be put i n p l a c e through your nose because 0.79 0.41 0.63 6. Your i n t r a v e n o u s w i l l be stopped 0.58 0.50 0.63 7. You have a d r a i n i n your i n c i s i o n because 0.45 0.51 0.62 8. A g e n e r a l a n a e s t h e t i c i s when you are 0.27 0.45 0.61 9. You can expect t o go home a f t e r y o u r o p e r a t i o n 0.51 0.51 0.59 10. A f t e r your o p e r a t i o n you can e x p e c t t o e a t 0.33 0.48 0.59 Mean I n t e r - i t e m c o r r e l a t i o n = .101 O v e r a l l a l p h a = .63 TABLE XIV TESTS OF SIGNIFICANCE FOR TEST VARIABLES IN DOCTOR RELATED CELL GROUPS CELL n I n d i v i d u a l i z e d L e a r n i n g Group 3 2 - 1 - 1 2 2 C l a s s L e a r n i n g Group 2 - 1 2 2 - 2 2 I n c i d e n t a l L e a r n i n g Group - 2 1 - 1 1 6 6 -Doctor 1 2 3 4 5 6 7 7 8 TEST VARIABLES DOCTOR P VALUES G.I. F u n c t i o n 0.99 0.44 0.99 0.74 0.49 0.44 0.66 0.43 0.56 S i g n i f i c a n c e N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. Fever 0.92 0.96 0.85 0.54 0.26 0.31 0.66 0.56 0.81 S i g n i f i c a n c e N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. Compli c a t i o n s 0.83 0.77 0.99 0.53 0.74 0.99 0.75 0.94 0.93 S i g n i f i c a n c e N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. Doses o f O r a l A n a l g e s i c s 0.009 0.08 0.23 0.21 0.01 0.52 0.17 0.09 0.21 S i g n i f i c a n c e 0.01 N.S. N.S. N.S. 0.01 N.S. N.S. N.S. N.S. ' Doses o f P r e n t e r a l A n a l g e s i c s 0.001 0.03 0.12 0.002 0.016 0.004 0.001 0.87 0.03 S i g n i f i cance 0.01 0.03 N.S. 0.01 0.02 0.01 0.01 N.S. 0.03 S t a r t o f O r a l A n a l g e s i c s 0.05 0.06 0.82 0.18 0.15 0.09 0.06 0.17 0.296 S i g n i f i c a n c e 0.05 N.S. N.S. N.S. N.S. N.S. N.S. N.S. N.S. TABLE XIV - Cont'd. TEST VARIABLES Days o f P a r e n t e r a l A n a l g e s i c s 0.16 0.46 S i g n i f i c a n c e N.S. N.S. Days o f O r a l A n a l g e s i c s 0.03 0.22 S i g n i f i c a n c e 0.03 N.S. P o s t o p e r a t i v e S t a y 0.31 0.24 S i g n i f i c a n c e N.S. N.S. C o g n i t i v e T e s t S c o r e 0.91 0.88 S i g n i f i c a n c e N.S. N.S. DOCTOR P VALUES 0.24 0.18 0.26 0.04 0.13 0.76 0.06 N.S. N.S. N.S. 0.04 N.S. N.S. N.S. 0.47 0.15 0.03 0.75 0.26 0.06 0.25 N.S. N.S. 0.03 N.S. N.S. N.S. N.S. 0.88 0.99 0.85 0.79 0.97 0.84 0.88 N.S. N.S. N.S. N.S. N.S. N.S. N.S. 0.73 0.89 0.19 0.69 0.84 0.56 0.76 N.S. N.S. N.S. N.S. N.S. N.S. N.S. - 82 -d i f f e r e n c e s c o r r e l a t e d w i t h g a s t r o i n t e s t i n a l f u n c t i o n , f e v e r , c o m p l i c a -t i o n s , p o s t o p e r a t i v e s t a y or c o g n i t i v e t e s t s c o r e s . However, t h e r e were s i g n i f i c a n t d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s w i t h r e s p e c t t o each o f th e f i v e a n a l g e s i c drug v a r i a b l e s . The l a r g e s t number o f d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s were f o r the numbers o f doses o f p a r e n t e r a l a n a l g e -s i c s . In t h i s i n s t a n c e t h e r e were seven s i g n i f i c a n t d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s r e p o r t e d out o f a p o s s i b l e maximum of n i n e . These c e l l group d i f f e r e n c e s were s i g n i f i c a n t at a l e v e l of 0.01 f o r f o u r c e l l g r o u p s , 0.02 f o r one group and 0.03 f o r 2 groups. T h e r e i s some q u e s t i o n o f v a l i d i t y i n c l a s s i f y i n g t h e s e c e l l group d i f f e r e n c e s as d o c t o r - r e l a t e d . A l l the a n a l g e s i c s p r e s c r i b e d f o r the p a t i e n t s i n t h i s study were o r d e r e d t o be a d m i n i s t e r e d whenever n e c e s s a r y at the d i s c r e t i o n of the nurse. T h e r e f o r e , t he a d m i n i s t r a t i o n o f a n a l g e -s i c s was nurse c o n t r o l l e d . C e l l group d i f f e r e n c e s r e l e v a n t t o use o f a n a l g e s i c s are more a p p r o p r i a t e l y i d e n t i f i e d as n u r s e - r e l a t e d . C e l l groups r e l a t i n g t o Nurse #1 c o n s i s t e n t l y showed the l a r g e s t number o f s i g n i f i c a n t c e l l group d i f f e r e n c e s w i t h a t o t a l of f o u r c e l l group d i f f e r e n c e s , at a l e v e l of 0.01 i n two i n s t a n c e s , 0.03 i n one and 0.5 i n another i n s t a n c e . Nurse #5 ranked second as t h r e e s i g n i f i c a n t c e l l group d i f f e r e n c e s r e l a t i n g t o her were r e p o r t e d at l e v e l s o f 0.01, 0.02 and 0.03. Nurse #6 had two s i g n i f i c a n t c e l l group d i f f e r e n c e s at l e v e l s of 0.01 and 0.04. A l l o f t h e s e s i g n i f i c a n t n u r s e - r e l a t e d c e l l group d i f f e r e n c e s were c o r r e l a t e d w i t h one or more of the f i v e a n a l g e s i c drug v a r i a b l e s . These f i n d i n g s showed t h a t t h e r e was a nurse b i a s f a c t o r o p e r a t i n g w i t h i n a number o f c e l l groups c o r r e l a t e d w i t h the use o f a n a l g e s i c drugs. The a n a l y s i s d i d not demonstrate the s i g n i f i c a n c e o f the d i r e c t i o n o f the b i a s among the t h r e e - 83 -t r e a t m e n t groups. Only t he e x i s t e n c e o f the nurse b i a s i n r e l a t i o n t o n i n e c e l l groups was demonstrated. Four o f t h e s e c e l l groups i n v o l v e d d i f f e r e n -ces between c e l l groups from t he I n d i v i d u a l i z e d and the C l a s s L e a r n i n g Groups; t h r e e were between c e l l groups from t he C l a s s and the I n c i d e n t a l L e a r n i n g Groups; and two were between c e l l groups from the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups. The C l a s s L e a r n i n g Group was more f r e -q u e n t l y i n v o l v e d w i t h c e l l group d i f f e r e n c e s than any o f the o t h e r l e a r n i n g g r o u p s . CORROBORATION OF TEST VARIABLES A f a c t o r a n a l y s i s o f the t e n t e s t v a r i a b l e s and the s i x c h a r a c t e r i s t i c s o f t he sample was c a r r i e d out t o dete r m i n e t he r e l a t i o n s h i p among t h e s e v a r i a b l e s . The f i n d i n g s are r e p o r t e d i n TABLE XV. The BMD P4M f a c t o r ana-l y s i s program ( U n i v e r s i t y o f C a l i f o r n i a , 1977) was used. The p r i n c i p a l f a c t o r s method was i n v o l v e d i n the a n a l y s i s o f the c o r r e l a t i o n m a t r i x o f s i x t e e n v a r i a b l e s and t h e s i x f a c t o r s e l i c i t e d were r o t a t e d by the varimax method ( o r t h o g o n a l ) . The f a c t o r l o a d i n g s r e p o r t e d i n TABLE XV a r e s o r t e d , r o t a t e d f a c t o r l o a d i n g s . T e s t v a r i a b l e s . i n c l u d e d : 1. doses o f o r a l anal a n a l g e s i c s ; 2. doses o f p a r e n t e r a l a n a l g e s i c s ; 3. s t a r t o f the use o f o r a l a n a l g e s i c s ; 4. days o f o r a l a n a l g e s i c s ; 5. days o f p a r e n t e r a l a n a l g e s i c s ; 6. i n c i d e n c e o f f e v e r ; TABLE XV FACTOR ANALYSIS: TEST VARIABLES AND CHARACTERISTICS OF THE SAMPLE • FACTOR FACTOR FACTOR FACTOR FACTOR FACTOR 2 VARIABLE 1 2 3 4 5 6 h Number o f doses o f P a r e n t e r a l A n a l g e s i c s (T) 0.898* O.B^bb Number o f days o f Q 1 Q 7 O r a l A n a l g e s i c s (T) 0.888* ° - 8 1 8 7 Number of doses o f . O r a l A n a l g e s i c s (T) 0.802* V./iU Age (C) 0.750* 0.411 0.7929 Length o f _ n o n , . P o s t o p e r a t i v e S t a y (T) 0.460* 0.740* 0.7841 C o m p l i c a t i o n s (T) 0.727* 0.593 S t a t u s o f _ S u r g i c a l R i s k (C) 0.578* 0.421* 0.270* 0.6122 A n a e s t h e t i c Time (C) 0.733* -0.346* 0.7731 S t a r t o f Use of „ n i 1 n , O r a l A n a l g e s i c s (T) 0.310* 0.704* 0.291* 0.7104 Number o f days _ -7/lo1 o f P a r e n t e r a l A n a l g e s i c s (T) 0.542* 0.632* 0.7431 C o g n i t i v e Achievement (T) 0.845* 0.8297 TABLE XV - Cont'd. VARIABLE FACTOR 1 FACTOR 2 FACTOR 3 FACTOR 4 FACTOR 5 FACTOR 6 2 h Fever (T) -0.266* 0.658* 0.454 0.7385 Years o f S c h o o l i n g (C) -0.257 0.791* 0.7742 M a r i t a l S t a t u s (C) -0.324 -0.760* 0.7627 G.I. F u n c t i o n (T) 0.839* 0.7351 Number o f Dependent C h i l d r e n (C) 0.481 -0.252* -0.468 0.5449 VARIANCE 22.72% 15.22% 11.65% 9.12% 8.45% 6.41% TOTAL VARIANCE EXPLAINED = 73.55% T = T e s t C = C h a r a c t e r i s t i c s o f the Sample * = s i g n i f i c a n t v a r i a b l e s - 8 6 -7 . i n c i d e n c e o f g a s t r o i n t e s t i n a l d y s f u n c t i o n ; 8 . i n c i d e n c e o f p o s t o p e r a t i v e c o m p l i c a t i o n s ; 9 . l e n g t h o f p o s t o p e r a t i v e s t a y ; 10. c o g n i t i v e achievement s c o r e . C h a r a c t e r i s t i c s o f the sample i n c l u d e d : 1. age; 2 . y e a r s o f s c h o o l i n g ; 3 . s t a t u s o f s u r g i c a l r i s k ; 4 . a n a e s t h e t i c time; 5 . m a r i t a l s t a t u s ; 6 . number o f c h i l d r e n e i g h t e e n y e a r s o f age and under. A l l s i x t e e n v a r i a b l e s were i n c l u d e d w i t h i n the s i x f a c t o r s which e x p l a i n e d 7 3 . 5 5 % o f the t o t a l v a r i a n c e . Not o n l y the t e n t e s t v a r i a b l e s , but a l s o t h e s i x c h a r a c t e r i s t i c s o f the sample were d e t e r m i n a n t s o f v a r i a n c e . The t e n t e s t v a r i a b l e s were c o r r o b o r a t e d as d e t e r m i n a n t s o f v a r i a n c e but were not the o n l y v a r i a b l e s i n t h i s s t u d y which determined v a r i a n c e . A l l of the a n a l g e s i c drug measures c l u s t e r e d i n F a c t o r 1 measured s i m i -l a r t h i n g s and were e s t i m a t e d t o be a f u n c t i o n o f the l e n g t h o f the p o s t o -p e r a t i v e s t a y . T h i s f a c t o r was d e s i g n a t e d as an a n a l g e s i c drug use f a c -t o r . Age, c o m p l i c a t i o n s and s t a t u s o f s u r g i c a l r i s k c l u s t e r e d i n F a c t o r 2 and were a l s o e s t i m a t e d t o be a f u n c t i o n o f l e n g t h o f p o s t o p e r a t i v e s t a y . T h e r e was a l s o a n e g a t i v e f a c t o r l o a d i n g f o r f e v e r i n F a c t o r 2 . I t i s c h a r a c t e r i s t i c f o r an e l d e r l y p e r s o n t o have a low metabolism and - 87 -a t e n dency towards a low normal body t e m p e r a t u r e . In a d d i t i o n , the p o s s i -b i l i t y o f h y p o t h e r m i a w i t h a c o n s i s t e n t l y low body t e m p e r a t u r e i s b e i n g r e p o r t e d more f r e q u e n t l y among the e l d e r l y . B r o c k l e h u r s t (1978) d e s c r i b e d t h i s phenomenon o f i m p a i r e d t h e r m o r e g u l a t o r y r e f l e x e s among the e l d e r l y . E x i s t i n g knowledge o f g e r o n t o l o g y appears t o s u p p o r t t h i s n e g a t i v e r e l a t i o n s h i p between low f e v e r and advanced age. F a c t o r 2 was t h e r e f o r e d e s i g n a t e d as an a g e - r i s k f a c t o r . A n a e s t h e t i c t i m e , t h e number o f days o f use o f p a r e n t e r a l a n a l g e s i c s and the s t a r t o f use o f o r a l a n a l g e s i c s c l u s t e r e d t o g e t h e r i n F a c t o r 3. T h e r e i s a l o g i c a l r e l a t i o n s h i p among t h e s e t h r e e v a r i a b l e s . I f a p a t i e n t had e x t e n s i v e s u r g i c a l trauma as e v i d e n c e d by a l e n g t h y a n a e s t h e t i c time, i t i s e x p e c t e d t h a t she would have more p a i n p o s t o p e r a t i v e l y and need the use o f the more p o t e n t p a r e n t e r a l a n a l g e s i c s f o r a l o n g e r time. C o n s e q u e n t l y , she would a l s o b e g i n the use o f the l e s s p o t e n t o r a l a n a l g e s i c s l a t e r i n the p o s t o p e r a t i v e p e r i o d . T h i s f a c t o r was d e s i g n a t e d as a s u r g i c a l trauma f a c t o r . A n a e s t h e t i c t i m e , s t a t u s o f s u r g i c a l r i s k , f e v e r , s t a r t o f use o f o r a l a n a l g e s i c s and c o g n i t i v e achievement s c o r e c l u s t e r e d i n F a c t o r 4. I t would be a n t i c i p a t e d t h a t l e a r n i n g and the measurement o f c o g n i t i v e achievement would be a f f e c t e d by the s e v e r i t y o f the p a t i e n t ' s s t a t e o f i l l n e s s . The more s e v e r e l y i l l a p a t i e n t i s , the l e s s l i k e l y she i s t o be a b l e t o r e c a l l p r e o p e r a t i v e l e a r n i n g and use i t t o f a c i l i t a t e her own r e c o v e r y . She would tend t o be p r e o c c u p i e d w i t h the d i s t r e s s o f her i l l n e s s and d i s t u r b i n g symptoms such as s e v e r e p a i n , p r o s t r a t i o n o f f e v e r , and t h e s t u p o r enduced by a l o n g a n a e s t h e t i c time. The n e g a t i v e f a c t o r l o a d i n g f o r a n a e s t h e t i c - 88 -time i s p a r t i c u l a r l y s i g n i f i c a n t when i t i s c o r r e l a t e d w i t h the p o s i t i v e l o a d i n g f o r c o g n i t i v e achievement. T h i s f i n d i n g would i n d i c a t e t h a t a p e r -son w i t h a h i g h c o g n i t i v e achievement s c o r e would a l s o have a low anaesthe-t i c t ime. T h i s i s a l o g i c a l r e l a t i o n s h i p i n t h a t a p a t i e n t w i t h a low a n a e s t h e t i c time c o u l d be e x p e c t e d t o be l e s s s t u p o r o u s p o s t o p e r a t i v e l y and p e r f o r m b e t t e r on a c o g n i t i v e achievement t e s t i n which c o r t i c a l f u n c t i o n s p redominate. T h i s f a c t o r was d e s i g n a t e d as a c o g n i t i v e achievement f a c t o r as r e l a t e d t o s t a t u s of i l l n e s s . Many o f the v a r i a b l e s c l a s s i f i e d as c h a r a c t e r i s t i c s of the sample c l u s t e r e d i n F a c t o r 5. These i n c l u d e d number o f dependent c h i l d r e n 18 y e a r s o f age and under, m a r i t a l s t a t u s , y e a r s o f s c h o o l i n g and s t a t u s of s u r g i c a l r i s k . The communality s c o r e s and the h i g h f a c t o r l o a d i n g s f o r y e a r s of s c h o o l i n g and m a r i t a l s t a t u s s t r o n g l y s u g g e s t t h a t t h e s e two v a r i a b l e s f i g u r e p r e d o m i n a t e l y i n F a c t o r 5. T h i s f a c t o r was d e s i g n a t e d as a demographic f a c t o r . I n t e r p r e t a t i o n o f F a c t o r 6 i s based on the h i g h communality s c o r e f o r g a s t r o i n t e s t i n a l f u n c t i o n and the f a c t t h a t i t appears o n l y i n F a c t o r 6. T h i s f a c t o r was d e s i g n a t e d a g a s t r o i n t e s t i n a l d y s f u n c t i o n f a c t o r . The s i x c h a r a c t e r i s t i c s of the sample were c o r r o b o r a t e d i n the f a c t o r a n a l y s i s as d e t e r m i n a n t s o f v a r i a n c e as w e l l as the t e n t e s t v a r i a b l e s . Thus, they were a n a l y z e d f o r t r e a t m e n t group d i f f e r e n c e s and d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s u s i n g the same methods o f a n a l y s i s a p p l i e d t o the t e s t v a r i a b l e s . I t would a l s o be p o s s i b l e t o a n a l y z e the s i x f a c t o r s e l i -c i t e d i n the f a c t o r a n a l y s i s s i m i l a r l y , but t h i s d i r e c t i o n was not pursued i n t h i s s t u d y . TABLE XVI TESTS OF SIGNIFICANCE OF THE CHARACTERISTICS OF THE SAMPLE BY TREATMENT GROUP INDIVIDUALIZED LEARNING GROUP CELL n 3 2 X 1 X 1 2 2 COMBINED GROUP MEAN GROUP P VALUE SIGNIFICANCE OBSERVED CELL MEANS Age 41.0 71.5 - 27.0 - 32.0 39.0 37.5 41.29 0.84 N.S. M a r i t a l S t a t u s 2.0 1.5 1.0 - 2.0 2.0 1.5 1.992 0.10 N.S. Years o f S c h o o l i n g 11.67 10.0 - 13.0 - 13.0 12.0 11.0 10.979 0.84 N.S. S t a t u s o f S u r g i c a l R i s k 1.0 1.5 1.0 - 1.0 1.5 1.0 1.08 0.91 N.S. A n a e s t h e t i c Time 98.33 75.0 - 110.0 - 50.0 72.5 110.0 67.87 0.009 N.S. Number o f Dependent C h i l d r e n 2.67 0.0 0.0 2.0 1.5 1.5 1.38 0.61 N.S. TABLE XVI - Cont'd. CLASS LEARNING GROUP CELL n 2 X 1 2 2 X 2 2 COMBINED GROUP MEAN GROUP P VALUE SIGNIFICANCE OBSERVED CELL MEANS Age 50.5 - 74.0 63.5 53.0 46.5 61.0 55.09 0.72 N.S. M a r i t a l S t a t u s 1.5 1.0 1.5 1.0 2.0 2.0 1.514 0.66 N.S. Years o f S c h o o l i n g 8.5' - 11.0 10.5 14.5 10.0 8.5 10.34 0.49 N.S. S t a t u s o f S u r g i c a l R i s k 1.0 3.0 2.0 1.5 1.5 1.5 1.64 0.86 N.S. A n a e s t h e t i c Time 107.5 - 150.0 90.0 107.5 77.5 107.5 109.85 0.009 0.01 Number o f Dependent C h i l d r e n 1.0 0.0 0.0 0.0 1.0 0.0 0.45 0.49 N.S. TABLE XVI - Cont'd. INCIDENTAL LEARNING GROUP CELL n X 2 1 X 1 1 6 X COMBINED GROUP SIGNIFICANCE GROUP P VALUE MEAN OBSERVED CELL MEANS Age - 57.0 45.0 - 41.0 19.0 49.17 - 47.73 M a r i t a l S t a t u s * 2.0 2.0 1.0 1.0 1.83 - 1.75 Years o f S c h o o l i n g - 10.0 8.0 - 12.0 12.0 12.0 10.83 S t a t u s o f S u r g i c a l R i s k 1.5 1.0 1.0 1.0 1.3 1.37 A n a e s t h e t i c Time - 85.0 105.0 - 120.0 70.0 72.5 74.71 Number o f Dependent C h i l d r e n 0.0 0.0 1.0 0.0 0.5 0.16 2 = M a r r i e d 1 = Other ( S i n g l e , D i v o r c e d , S e p a r a t e d , Widowed) - 92 -The t e s t s o f s i g n i f i c a n c e f o r t r e a t m e n t group d i f f e r e n c e s c o r r e l a t e d w i t h the s i x c h a r a c t e r i s t i c s of the sample are o u t l i n e d i n TABLE XVI. The o n l y s i g n i f i c a n t f i n d i n g i s i n r e l a t i o n t o a n a e s t h e t i c t i m e . The I n d i v i d u a l i z e d L e a r n i n g Group had the lowest mean a n a e s t h e t i c time at 67.87 mi n u t e s . The I n c i d e n t a l L e a r n i n g Group ranked second w i t h a mean of 74.71 minutes and the C l a s s L e a r n i n g Group was t h i r d w i t h a mean of 109.85 mi n u t e s . The d i f f e r e n c e s between the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Group, and t h o s e between the C l a s s and I n c i d e n t a l L e a r n i n g Group were both s i g n i f i c a n t at the 0.009 l e v e l . F i n d i n g s o f the r e g r e s s i o n ana-l y s i s ( s e e TABLE XVII) o f both t e s t v a r i a b l e s and c h a r a c t e r i s t i c s of the sample l e n d s u p p o r t t o the s i g n i f i c a n c e o f a n a e s t h e t i c time. In t h a t ana-l y s i s , a n a e s t h e t i c time was s i g n i f i c a n t l y and n e g a t i v e l y c o r r e l a t e d w i t h t h e c o g n i t i v e t e s t s c o r e (r=-.59) a t the 0.02 l e v e l . I t i s not s u r p r i s i n g t h a t a low c o g n i t i v e t e s t s c o r e would be r e l a t e d t o a h i g h a n a e s t h e t i c t i m e . C l o u d i n g of the sensorium and i m p a i r e d c e n t r a l nervous system f u n c -t i o n i s known t o a f f e c t c o r t i c a l f u n c t i o n and c o g n i t i v e a b i l i t y . F u r t h e r a n a l y s i s of d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s was con-d u c t e d . These f i n d i n g s are l i s t e d i n TABLE X V I I I . There was one s i g n i f i -c a n t c e l l group d i f f e r e n c e f o r D o c t o r 3 r e l a t e d t o s t a t u s o f s u r g i c a l r i s k at the 0.03 l e v e l . The g r e a t e s t number o f s i g n i f i c a n t f i n d i n g s were r e l a t e d t o a n a e s t h e t i c time, which c o n t i n u e d t o be a s i g n i f i c a n t v a r i a b l e t h r o u g h o u t the t e s t s of s i g n i f i c a n c e . There were s i x s i g n i f i c a n t c e l l group d i f f e r e n c e s at the 0.04 l e v e l or lower out of a p o s s i b l e n i n e . S i n c e a n a e s t h e t i c time i s a d o c t o r - c o n t r o l l e d f u n c t i o n , t h e s e f i n d i n g s demonstrate a d o c t o r - b i a s f a c t o r r e l a t e d t o a n a e s t h e t i c time s i m i l a r t o the REGRESSION ANALYSIS: TABLE XVII TEST VARIABLES AND CHARACTERISTICS OF THE SAMPLE * S i g n i f i c a n t P Value CO-VARIABLES DOSES OF ORAL ANAL. M a r i t a l  S t a t u s Reg. Coef. P Value 0.027 0.92 DOSES OF PARENT ANAL. START OF ORAL ANAL. -0.260 0.36 0.100 0.74 DAYS OF ORAL ANAL. 0.076 0.79 DAYS OF PARENT ANAL. ' 0.009 0.97 LENGTH OF P.O. STAY G.I. FUNCTION FEVER -0.461 0.068 OTHER COMPLI-CATIONS -0.166 0.58 -0.0913 0.73 -0.142 0.62 COGNI-TIVE ACHIEV. 0.043 0.85 Age Reg. Coef. P Value -0.299 0.36 -0.005 0.98 -0.115 0.74 -0.298 0.53 0.106 0.75 0.409 0.15 0.313 0.37 -0.413 0.18 0.260 0.42 0.069 0.79 S u r g i c a l "RTs Reg. Coef. P Value -0.128 0.65 -.140 0.61 0.029 0.92 -0.111 0.71 0.106 0.71 0.109 0.63 -0.144 0.6 0.091 0.73 0.015 0.96 0.053 0.82 A n a e s t h e t i c  Time Reg. Coef. P Value -0.222 0.41 0.015 0.95 -0.039 0.89 -0.046 0.87 -0.037 0.89 -0.002 0.99--0.038 0.89 0.296 0.25 -0.004 0.99 -0.587 0.02 * Y r s . o f  S c h o o l i n g Reg. Coef. P Value -0.376 0.19 -0.425 0.14 -0.011 0.97 -0.133 0.66 0.324 0.27 -0.410 0.10 0.107 0.72 0.159 0.54 -0.187 0.51 0.193 0.41 Dependent  C h i l d r e n Reg. Coef. P Value 0.215 0.59 0.177 0.57 0.095 0.78 -0.045 0.89 0.020 0.95 0.224 0.41 0.217 0.53 0.125 0.68 -0.157 0.63 -0.198 0.45 - 94 -TABLE XVIII TESTS OF SIGNIFICANCE FOR CHARACTERISTICS OF THE SAMPLE IN DOCTOR-RELATED CELL GROUPS CELL n INDIVIDUALIZED GROUP 3 2 - 1 - 1 2 2 CLASS GROUP 2 - 1 2 2 - 2 2 INCIDENTAL GROUP - 2 1 - 1 1 6 6 -DOCTOR 1 2 3 4 5 6 7 7 8 CHARACTERISTICS DOCTOR P VALUES Age S i g n i f i c a n c e 0.92 N.S. 0.31 N.S. 0.21 N.S. 0.38 N.S. 0.85 N.S. 0.91 N.S. 0.91 N.S. 0.81 N.S. 0.67 N.S. M a r i t a l S t a t u s S i g n i f i c a n c e 0.30 N.Sr 0.06 N.S. 0.39 N.S. 0.07 N.S. 0.80 N.S. 0.56 N.S. 0.12 N.S. 0.76 N.S. 0.56 N.S. Years o f S c h o o l i n g S i g n i f i c a n c e 0.72 N.S. 0.97 N.S. 0.45 N.S. 0.76 N.S. 0.13 N.S. 0.67 N.S. 0.-94 N.S. 0.74 N.S. 0.81 N.S. S t a t u s o f S u r g i c a l R i s k S i g n i f i c a n c e 0.84 N.S. 0.87 N.S. 0.03 N.S. 0.49 N.S. 0.68 N.S. 0.93 N.S. 0.84 N.S. 0.79 N.S. 0.72 N.S. A n a e s t h e t i c Time S i g n i f i c a n c e 0.003 0.01 0.03 0.03 0.98 N.S. 0.002 0.01 0.04 0.04 0.12 N.S. 0.008 0.01 0.18 N.S. 0.002 0.01 Number o f Depen-dent C h i l d r e n S i g n i f i c a n c e 0.41 N.S. 0.59 N.S. 0.64 N.S. 0.89 N.S. 0.40 N.S. 0.63 N.S. 0.91 N.S. 0.75 N.S. 0.69 N.S. - 95 -n u r s e - b i a s o p e r a t i n g i n the a d m i n i s t r a t i o n o f a n a l g e s i c d r u g s , and the e x i s t e n c e o f t h i s d o c t o r b i a s was demonstrated i n s i x c e l l g r oups. In g e n e r a l the I n d i v i d u a l i z e d L e a r n i n g Group was more f r e q u e n t l y i n v o l v e d w i t h c e l l group d i f f e r e n c e s than any o f the o t h e r l e a r n i n g groups. PATIENT PERCEPTION OF PREOPERATIVE LEARNING NEEDS Each p a t i e n t i n the t h r e e t r e a t m e n t groups was asked t o complete a p a t i e n t q u e s t i o n n a i r e on the f i f t h p o s t o p e r a t i v e day. There were 50 items r e p r e s e n t a t i v e o f l e a r n i n g needs i n a p r e o p e r a t i v e l e a r n i n g program f o r c h o l e c t y s t e c t o m y p a t i e n t s . The p a t i e n t s were asked t o rank each i t e m i n terms o f how i m p o r t a n t i t was t o know about the i t e m b e f o r e h a v i n g a c h o l e c y s t e c t o m y . A p a t i e n t responded by u s i n g a 5 - p o i n t s c a l e o f impor-t a n c e w i t h 5 r e f l e c t i n g " v e r y i m p o r t a n t " , 4, " q u i t e i m p o r t a n t " , 3, " f a i r l y i m p o r t a n t " , 2, "not v e r y i m p o r t a n t " and 1, "not i m p o r t a n t at a l l " , or i n d i -c a t i n g t h a t she d i d n ' t know and c o u l d n ' t respond t o the i t e m . The means and s t a n d a r d d e v i a t i o n s f o r each item are l i s t e d i n TABLE XIX. The p a t i e n t s ranked a l l 50 items as more than f a i r l y i m p o r t a n t w i t h the excep-t i o n o f item 18 (What the r e c o v e r y room l o o k s l i k e ) which had a mean s c o r e o f 2.97. A d e s c r i p t i o n o f the f i f t e e n items ranked h i g h e s t and lowest by the p a t i e n t s i s i n c l u d e d i n TABLES XX AND XXI. Those i n the h i g h e s t c a t e g o r y were l e s s d i s p e r s e d than t h o s e i n t h e lowest c a t e g o r y . In t h e h i g h e s t c a t e g o r y , the means ranged from 4.39 t o 4.64, and i n t h e lowest c a t e g o r y from 2.97 t o 3.97. - 96 -TABLE XIX MEANS AND STANDARD DEVIATIONS OF PATIENT RATED PREOPERATIVE LEARNING NEEDS QUESTIONNAIRE ITEM MEAN STANDARD DEVIATION 1 3.27 1.48 2 4.06 1.14 3 4.48 0.83 4 4.54 0.94 5 4.61 0.79 6 4.36 0.99 7 4.42 0.97 8 4.21 1.29 9 4.51 1.00 10 4.30 1.16 11 4.45 0.97 12 3.97 1.36 13 4.27 1.30 14 4.27 1.04 15 4.27 1.01 16 3.42 1.35 17 3.48 1.35 18 2.97 1.55 19 3.45 1.23 20 4.48 0.91 21 4.48 0.87 22 4.39 0.99 23 4.36 0.93 24 3.97 1.04 25 3.94 1.14 26 3.94 1.34 27 3.73 1.31 28 4.21 1.24 29 3.45 1.44 30 4.21 1.02 31 4.12 1.24 32 4.06 1.09 33 4.42 1.09 34 4.03 1.07 35 4.12 1.23 36 4.64 0.60 37 4.45 0.87 38 4.39 1.25 39 4.48 0.91 40 4.21 0.96 TABLE XIX - Cont'd. - 97 -QUESTIONNAIRE ITEM MEAN STANDARD DEVIATION 41 4.09 1.07 42 3.54 1.20 43 3.91 1.23 44 4.12 0.99 45 4.18 0.92 46 4.18 1.01 47 4.42 0.97 48 3.82 1.31 49 3.94 0.97 50 4.12 1.14 - 98 -TABLE XX HIGHEST RATED PREOPERATIVE LEARNING NEEDS 7 4.42 47 4.42 38 4.39 ITEM NO. MEAN DESCRIPTION OF ITEM  H i g h e s t R a t i n g s N=13 36 4.64 How you do p o s t o p e r a t i v e e x e r c i s e s 5 4.61 How the a n a e t h e t i s t h e l p s you 4 4.54 Why you have a m e d i c a l h i s t o r y and p h y s i c a l e x a m i n a t i o n b e f o r e y o u r o p e r a t i o n 9 4.51 Why you s i g n a consent b e f o r e s u r g e r y 3 4.48 What the p h y s i o t h e r a p i s t does f o r you 20 4.48 Why you a r e checked so o f t e n i n t h e r e c o v e r y room 21 4.48 Why you might r e c e i v e oxygen by mask i n the r e c o v e r y room 39 4.48 Why you might have a stomach tube a f t e r s u r g e r y 11 4.45 Why you c a n ' t e a t or d r i n k the n i g h t b e f o r e s u r g e r y 37 4.45 Why you do p o s t o p e r a t i v e e x e r c i s e s Why you get a n e e d l e the morning o f s u r g e r y 3 3 4 « 4 2 How y o u r p a i n i s c o n t r o l l e d When you can expect t o go back t o work or c a r r y on your normal a c t i v i t i e s 2 2 4 - 3 9 What an i n t r a v e n o u s i s Why the nurses keep p e s t e r i n g you t o get out o f bed and e x e r c i s e when you don't f e e l l i k e i t - 99 -TABLE XXI LOWEST RATED PREOPERATIVE LEARNING NEEDS ITEM NO MEAN DESCRIPTION OF ITEM  Lowest R a t i n g s N=15 18 2.97 What the r e c o v e r y room l o o k s l i k e 1 3.27 Who the head nurse i s 16 3.42 What the o p e r a t i n g room l o o k s l i k e 19 3.45 How you are taken t o the o p e r a t i n g room 29 3.45 What the d i s c h a r g e from y o u r i n c i s i o n l o o k s l i k e 17 3.48 What the O p e r a t i n g Room Nurse Does f o r You 42 3.54 When you can s t a r t e a t i n g a f t e r your o p e r a t i o n 27 3.73 What yo u r d r e s s i n g s w i l l be l i k e 48 3.82 Why you sometimes f e e l " b l u e " a few days a f t e r your o p e r a t i o n 43 3.91 What k i n d s o f f o o d you can e a t a f t e r s u r g e r y 25 3.94 How you f e e l when you have an i n t r a v e n o u s 26 3.94 Where yo u r i n c i s i o n w i l l be 49 3.94 The i n f o r m a t i o n g i v e n t o you i n the pamphlet "You and Your O p e r a t i o n " 22 3.97 Why yo u r v a l u a b l e s are l o c k e d away 24 3.97 How l o n g you w i l l have an i n t r a v e n o u s - 100 -F o u r t e e n out o f the f i f t e e n h i g h e s t r a t e d l e a r n i n g needs were c o g n i -t i v e . O n l y one o f the items was psychomotor - how t o do p o s t o p e r a t i v e e x e r c i s e s -and i t was the h i g h e s t r a t e d i t e m . The p a t i e n t s demonstrated a keen i n t e r e s t i n knowing what e x p e r i e n c e s t h e y would have p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y , t he re a s o n s u n d e r l y i n g n u r s i n g and m e d i c a l p r o c e d u r e s , and how th e y c o u l d p a r t i c i p a t e i n t h e i r own r e c o v e r y . The lowest r a t e d l e a r n i n g needs were a l l c o g n i t i v e . P a t i e n t s d i d n ' t e s p e c i a l l y want t o have a p h y s i c a l o r i e n t a t i o n t o t h e o p e r a t i n g and r e c o -v e r y rooms and were not v e r y i n t e r e s t e d i n i d e n t i f y i n g t he Head Nurse or what the O p e r a t i n g Room Nurse d i d f o r them. Two o f the items r e l a t e d t o th e p r e o p e r a t i v e l e a r n i n g p e r i o d and i n c l u d e d t he i n f o r m a t i o n i n the pamph-l e t "You and Your O p e r a t i o n " and why v a l u a b l e s a re l o c k e d away p r e o p e r a -t i v e l y . However, even though t h e s e items a r e among t h e f i f t e e n l o w e s t r a t e d , t h e y had means of 3.94 and 3.97 which c l a s s i f i e s them as q u i t e i m p o r t a n t . S i x o f the o t h e r lowest r a t e d items r e l a t e d t o knowledge about p o s t o p e r a t i v e e x p e r i e n c e s and had means r a n g i n g from 3.73 t o 3.97, which a l s o c l a s s i f i e s them as q u i t e i m p o r t a n t . Two o f t h e s e items r e l a t e d t o knowledge about f e e l i n g s , i n c l u d i n g how an i n t r a v e n o u s f e e l s and why the " b l u e s " sometimes o c c u r a few days p o s t o p e r a t i v e l y . A f a c t o r a n a l y s i s o f the 50 p r e o p e r a t i v e l e a r n i n g needs was done. S i x major f a c t o r s r e p r e s e n t a t i v e o f s i x s e t s o f l e a r n i n g needs emerged. The BMD P4M f a c t o r a n a l y s i s program ( U n i v e r s i t y o f C a l i f o r n i a , 1977) was used. The p r i n c i p a l f a c t o r s method was i n v o l v e d i n the a n a l y s i s o f the c o r r e l a -t i o n m a t r i x o f 50 v a r i a b l e s and the s i x f a c t o r s e l i c i t e d were r o t a t e d by th e varimax method ( o r t h o g o n a l ) . The f a c t o r l o a d i n g s a re l i s t e d i n - 101 -APPENDIX F and are s o r t e d , r o t a t e d f a c t o r l o a d i n g s . The f a c t o r s were d e s i g n a t e d : F a c t o r 1: E x p e r i e n c e s E x p e c t e d Immediately P o s t o p e r a t i v e F a c t o r 2: Reasons U n d e r l y i n g P r o c e d u r e s C a r r i e d Out i n the P r e o p e r a t i v e P r e p a r a t i o n P e r i o d F a c t o r 3: How t o Combat the E f f e c t s o f a G e n e r a l A n a e s t h e t i c F a c t o r 4: O r i e n t a t i o n t o P e o p l e and P l a c e s F a c t o r 5: P a i n E x p e c t e d Immediately P o s t o p e r a t i v e F a c t o r 6: Landmarks o f Recovery i n the L a t e P o s t o p e r a t i v e P e r i o d ( B e f o r e Going Home) A l l o f the 50 l e a r n i n g needs were c l u s t e r e d among t h e s e s i x f a c t o r s w i t h t h e e x c e p t i o n o f items 10, 35, 36, 38, 47 and 48. These s i x f a c t o r s e x p l a i n e d 74.16% o f the v a r i a n c e thus i n d i c a t i n g t h a t the 45 l e a r n i n g needs i n v o l v e d were s i g n i f i c a n t d e t e r m i n a n t s o f v a r i a n c e . S u b s e q u e n t l y , t he s i x p r e o p e r a t i v e l e a r n i n g need f a c t o r s were a n a l y z e d f o r t r e a t m e n t group d i f f e r e n c e s and d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s , u s i n g t he same methods of a n a l y s i s a p p l i e d t o the t e s t v a r i a b l e s and the c h a r a c t e r i s t i c s o f the sample. The items i n c l u d e d w i t h i n each o f the s i x p r e o p e r a t i v e l e a r n i n g need f a c t o r s f o r the t e s t s of s i g n i f i c a n c e a re l i s t e d i n TABLE XXII and the f i n d i n g s o f the t e s t s o f s i g n i f i c a n c e a re l i s t e d i n TABLE X X I I I . T h e r e were s i g n i f i c a n t t r e a t m e n t group d i f f e r e n c e s . The I n d i v i d u a l i z e d L e a r n i n g Group had a h i g h e r group mean than the C l a s s and I n c i d e n t a l L e a r n i n g Groups f o r a l l s i x p r e o p e r a t i v e l e a r n i n g need f a c t o r s . - 102 -TABLE XXII ITEMIZED PREOPERATIVE LEARNING NEEDS FACTORS USED IN TESTS OF SIGNIFICANCE FACTOR 1: EXPERIENCES EXPECTED IMMEDIATELY POSTOPERATIVE 31. How s t r o n g the s t i t c h e s are 30. How f a s t y o u r i n c i s i o n h e a l s 24. How l o n g you w i l l have an i n t r a v e n o u s 27. What yo u r d r e s s i n g s w i l l be l i k e 33. How your p a i n i s c o n t r o l l e d 34. How l o n g your p a i n w i l l l a s t 45. When you f i r s t get out o f bed FACTOR 2: REASONS UNDERLYING PROCEDURES CARRIED OUT IN THE PREOPERATIVE PREPARATION PERIOD 13. Why you remove your make-up b e f o r e s u r g e r y 8. Why yo u r s k i n i s shaved b e f o r e s u r g e r y 12. Why your v a l u a b l e s are l o c k e d away 4. Why you have a m e d i c a l h i s t o r y and a p h y s i c a l e x a m i n a t i o n b e f o r e your o p e r a t i o n 9. Why you s i g n a consent b e f o r e s u r g e r y FACTOR 3: HOW TO COMBAT THE EFFECTS OF A GENERAL ANAESTHETIC 3. What the p h y s i o t h e r a p i s t does f o r you 5. How the a n a e t h e t i s t h e l p s you 15. How i t f e e l s t o have a g e n e r a l a n a e s t h e t i c 37. Why you do p o s t o p e r a t i v e e x e r c i s e s 45. When you f i r s t get out o f bed 39. Why you might.have a stomach tube a f t e r s u r g e r y FACTOR 4: ORIENTATION TO PEOPLE AND PLACES 1. Who the head nurse i s 18. What the r e c o v e r y room l o o k s l i k e 2. What the i n t e r n or r e s i d e n t does 19. How you are taken t o the r e c o v e r y room FACTOR 5: PAIN EXPECTED IMMEDIATELY POSTOPERATIVE 32. How much p a i n you w i l l have 25. How you f e e l when you have an i n t r a v e n o u s 39. Why you might have a stomach tube a f t e r s u r g e r y FACTOR 6: LANDMARKS OF RECOVERY IN THE LATE POSTOPERATIVE PERIOD (BEFORE GOING HOME) 46. When you can ex p e c t t o go home 42. When you s t a r t e a t i n g a f t e r your o p e r a t i o n 43. What k i n d s of f o o d you can e a t a f t e r s u r g e r y TABLE XXIII TESTS OF SIGNIFICANCE FOR PREOPERATIVE LEARNING NEEDS BY TREATMENT GROUP GROUP MEANS p VALUES INDIVIDUALIZED CLASS LEARNING INCIDENTAL OVERALL LEARNING GROUP GROUP LEARNING MEAN A-C B-C FACTOR 6. Landmarks of Recovery 4.05 GROUP 1. E x p e c t a t i o n s Immediately 4 < 2 9 Q 0 2 0 . 0 4 P o s t o p e r a t i v e 4.bY ^••L± 2. Reasons f o r P r e o p e r a t i v e 4 4 6 0 . 0 0 1 0.72 P r e p a r a t i o n s 5.26 4.3/ 3. How to'Combat a Gene r a l 4 „ 0 > 0 0 4 0. 4 1 A n a e s t h e t i c 5.06 ^.Jo 4. O r i e n t a t i o n t o P e o p l e « 3 > 4 2 0 > 1 2 0 . 7 0 ^ and P l a c e s ^.ov t 5- Sedi^l^stoperative 5.12 4.23 3.68 4.35 0.007 0.75 O OJ I 3.79 3.94 3.93 0.27 0.12 * A-C = I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups ** B-C = C l a s s and I n c i d e n t a l L e a r n i n g Groups - 104 -The d i f f e r e n c e s between the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups were h i g h l y s i g n i f i c a n t at 0.02 o r lower f o r F a c t o r s 1, 2, 3 and 5. The C l a s s L e a r n i n g Group had a h i g h e r group mean than t he I n c i d e n t a l L e a r n i n g Group f o r f a c t o r s 2, 3, 4 and 5, and a lower mean than t he I n c i d e n t a l L e a r n i n g Group f o r F a c t o r s 1 and 6. The o n l y s i g n i f i c a n t d i f -f e r e n c e between the C l a s s and I n c i d e n t a l L e a r n i n g Groups was i n r e l a t i o n t o F a c t o r 1 a t the 0.04 l e v e l . The I n d i v i d u a l i z e d L e a r n i n g Group had a g r e a t e r awareness o f p r e o p e r a t i v e l e a r n i n g needs and ranked needs h i g h e r than t he o t h e r l e a r n i n g groups because o f t h i s awareness. A n a l y s i s o f d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s showed some s i g n i f i -c a n t d i f f e r e n c e s (TABLE XXIV). S i g n i f i c a n t c e l l group d i f f e r e n c e s were ob s e r v e d f o r each o f the s i x f a c t o r s . The l a r g e s t numbers o f c e l l group d i f f e r e n c e s o c c u r r e d i n r e l a t i o n t o F a c t o r s 1, 2 and 3. T h e r e were f i v e s i g n i f i c a n t c e l l group d i f f e r e n c e s f o r F a c t o r 1 a t the 0.03 l e v e l or lower, seven f o r F a c t o r 2 a t the 0.01 l e v e l or lower, and f i v e f o r F a c t o r 3 a t 0.03 l e v e l or lower. I t was e v i d e n t t h a t t h e r e was some b i a s f a c t o r o p e r a t e d i n o r d e r t o b r i n g about t h e s e c e l l group d i f f e r e n c e s , b ut the n a t u r e o f t h a t b i a s i s d i f f i c u l t t o i d e n t i f y . A g r e a t v a r i e t y o f d o c t o r s and nurses o f v a r i o u s c a t e g o r i e s were i n v o l v e d w i t h i n s t r u c t i o n o f p a t i e n t s about t he items i n v o l v e d i n the s i x f a c t o r s . I t i s p r o b a b l y a c c u r a t e t o c o n c l u d e t h a t a d o c t o r - n u r s e b i a s was o p e r a t i n g i n r e l a t i o n t o c e l l group d i f f e r e n c e s c o r r e l a t e d w i t h p r e o p e r a t i v e l e a r n i n g needs. TABLE XXIV TESTS OF SIGNIFICANCE FOR PREOPERATIVE LEARNING NEEDS BY DOCTOR RELATED CELL GROUPS CELL INDIVIDUALIZED LEARNING GROUP 3 2 1 1 2 2 CLASS LEARNING GROUP 2 _ 1 2 2 _ 2 2 INCIDENTAL LEARNING GROUP - 2 1 _ 1 1 6 6 DOCTOR 1 2 3 4 5 6 7 7 8 FACTORS DOCTOR P VALUES 1. E x p e c t a t i o n s Immediately P o s t o p e r a t i v e 0.12 0.03 0.008 0.49 0.01 0.096 0.10 0.007 0.005 S i g n i f i c a n c e N.S. 0.03 0.008 N.S. 0.01 N.S. N.S. 0.007 0.005 2. Reasons f o r P r e o p e r a t i v e P r e p a r a t i o n s 0.01 0.005 0.005 0.29 0.01 0.008 0.01 0.926 0.01 S i g n i f i c a n c e 0.01 0.005 0.005 N.S. 0.01 0.008 0.01 N.S. 0.01 3. How to Combat a General A n a e s t h e t i c 0.03 0.12 0.008 0.26 0.08 0.03 0.02 0.63 0.009 S i g n i f i c a n c e 0.03 N.S. 0.008 N.S. N.S. 0.03 0.02 N.S. 0.009 4. O r i e n t a t i o n t o P e o p l e and P l a c e s 0.42 0.05 0.08 0.13 0.03 0.25 0.16 0.82 0.31 S i g n i f i c a n c e N.S. 0.05 N.S. N.S. 0.03 N.S. N.S. N.S. N.S. 5. P a i n E x p e c t e d Immediately 0.09 0.01 0.299 0.07 0.37 0.16 0.06 0.73 0.02 S i g n i f i c a n c e N.S. 0.01 N.S. N.S. N.S. N.S. N.S. N.S. 0.02 6. Landmarks o f Recovery 0.63 0.03 0.39 0.86 0.01 0.17 0.31 0.19 0.17 S i g n i f i c a n c e N.S. 0.03 N.S. N.S. 0.01 N.S. N.S. N.S. N.S. - 106 -PATIENT PREFERENCES FOR LEARNING STYLE The p a t i e n t s p r e f e r e n c e s f o r l e a r n i n g s t y l e s were a l s o e l i c i t e d i n the P o s t o p e r a t i v e P a t i e n t Q u e s t i o n n a i r e . P a t i e n t s were asked t o i d e n t i f y how t h e y l i k e d t o L e a r n : i n a p r i v a t e s e s s i o n w i t h t h e i r n u r s e , a group s e s s i o n where t h e y c o u l d s h a r e t h e i r f e e l i n g s w i t h o t h e r p a t i e n t s , a c l a s s , a c o m b i n a t i o n o f one or more o f the p r e c e d i n g s t r a t e g i e s or through some o t h e r means. The f i n d i n g s are summarized i n TABLE XXV. The t h r e e groups o f p a t i e n t s tended t o show p r e f e r e n c e s f o r p r e o p e r a -t i v e l e a r n i n g e x p e r i e n c e s based on t h e i r c u r r e n t l e a r n i n g program e x p e r i e n c e . The I n c i d e n t a l L e a r n i n g Group p r i m a r i l y e x p e r i e n c e d i n c i d e n t a l t e a c h i n g on the p a r t o f t h e i r nurse and d o c t o r . They showed a s t r o n g p r e -f e r e n c e f o r a p r i v a t e t a l k w i t h t h e i r n u r s e and i n d i c a t e d t h a t t h e y wanted more i n f o r m a t i o n from the d o c t o r s . The C l a s s L e a r n i n g Group showed a s t r o n g p r e f e r e n c e f o r a group s e s s i o n which c o r r e s p o n d e d w i t h t h e i r p r e o p e r a t i v e l e a r n i n g e x p e r i e n c e . The I n d i v i d u a l i z e d L e a r n i n g Group had a v a r i e t y o f l e a r n i n g e x p e r i e n c e s i n t h e i r l e a r n i n g program and t h e i r r e s p o n -ses p r o b a b l y r e f l e c t p e r s o n a l c o g n i t i v e s t y l e r a t h e r than a tendency t o choose l e a r n i n g e x p e r i e n c e s t h e y were f a m i l i a r w i t h . They tended t o f a v o u r a group s e s s i o n and a p r i v a t e t a l k w i t h the nurse e q u a l l y , w h i l e two TABLE XXV PATIENT PREFERENCES FOR LEARNING STYLE LEARNING STYLE INDIVIDUALIZED LEARNING GROUP CLASS LEARNING GROUP INCIDENTAL LEARNING GROUP 1. A p r i v a t e s e s s i o n w i t h y o u r nurse 2 . A group s e s s i o n where you can sh a r e your f e e l i n g s w i t h o t h e r p a t i e n t s 3 . A c l a s s 4 2 6 1 4 . A c o m b i n a t i o n o f one or more o f the above Sli d e - a n d - S o u n d P r e s e n t a t i o n and p r i v a t e t a l k with nurse Slide-and-Sound P r e s e n t a t i o n and p r i v a t e t a l k w i t h nurse Other P e r s o n a l explana-t i o n from the d o c t o r 4 More informa-from t h e d o c t o r s - 108 -p a t i e n t s l i k e d a c o m b i n a t i o n o f b o t h . None o f the t h r e e groups s t r o n g l y f a v o u r e d t h e c l a s s approach, i n c l u d i n g t h e C l a s s L e a r n i n g Group which e x p e r i e n c e d t h i s t y p e o f l e a r n i n g s i t u a t i o n . Awareness o f the k i n d s o f l e a r n i n g o p p o r t u n i t i e s a v a i l a b l e i n a p r e o p e r a t i v e t e a c h i n g program appeared to be a major f a c t o r i n d e t e r m i n i n g p r e f e r e n c e s f o r l e a r n i n g s t y l e . The p a t i e n t s were a l s o asked f o r a d d i t i o n a l comments which t h e y thought would be h e l p f u l i n p l a n n i n g t o g i v e o t h e r p a t i e n t s l i k e t h e m s e l v e s , t h e i n f o r m a t i o n t h a t t h e y f e e l i s i m p o r t a n t . These comments are l i s t e d i n APPENDIX G and were grouped i n t o f i v e c a t e g o r i e s : 1. need f o r knowledge; 2. p r i v a t e t a l k w i t h nurse; 3. group s e s s i o n s ; 4. i n d i v i d u a l i z e d l e a r n i n g program; 5. e x p l a n a t i o n s from the d o c t o r ; These comments o f the p a t i e n t s were an e x p r e s s i o n o f t h e i r d i r e c t views o f p r e o p e r a t i v e l e a r n i n g e x p e r i e n c e s . They document the need f o r i n f o r m a t i o n i n o r d e r t o a l l e v i a t e f e a r and a n x i e t y . Perhaps t h e most cogent comment was made by the p a t i e n t who s t a t e d : " P a t i e n t s s h o u l d be i n f o r m e d ; i g n o r a n c e i s not b l i s s " . - 109 -The h y p o t h e s i s t h a t p a t i e n t s ' views about l e a r n i n g s t y l e are i n f l u e n c e d by t h e i r p r e v i o u s p r e o p e r a t i v e l e a r n i n g e x p e r i e n c e was s u p p o r t e d by t h e i r d i r e c t comments about p r e o p e r a t i v e l e a r n i n g . For example, t h e I n d i v i d u a l i z e d L e a r n i n g and the I n c i d e n t a l L e a r n i n g Group e x p e r i e n c e d a p r i v a t e t a l k w i t h a nurse p r e o p e r a t i v e l y and tended t o make the most f a v o u r a b l e comments about t h i s k i n d o f e x p e r i e n c e . S i m i l a r l y , the p a t i e n t s who comnented on the I n d i v i d u a l i z e d L e a r n i n g Program d e s c r i b e d t h e impor-t a n c e of the v a r i o u s l e a r n i n g e x p e r i e n c e s p r o v i d e d i n t h a t program. A l l the p a t i e n t s who commented about e x p l a n a t i o n s from the d o c t o r were p a t i e n t s i n t h e I n c i d e n t a l L e a r n i n g Program i n which t h i s e x p e r i e n c e was one o f t h e main l e a r n i n g e x p e r i e n c e s p r o v i d e d . DISCUSSION OF TESTS OF HYPOTHESES The f i n d i n g s p r o v i d e d s u g g e s t i v e e v i d e n c e o n l y of group d i f f e r e n c e s w i t h the e x c e p t i o n o f one p h y s i o l o g i c a l v a r i a b l e - doses o f p a r e n t e r a l ana-l y s i s . The I n d i v i d u a l i z e d L e a r n i n g Group used fewer doses o f p a r e n t e r a l a n a l g e s i c s and was s i g n i f i c a n t l y d i f f e r e n t from t h e I n c i d e n t a l L e a r n i n g Group i n t h i s r e g a r d . The s u g g e s t i v e e v i d e n c e demonstrates t h a t the major d i f f e r e n c e s o c c u r r e d between t h e I n d i v i d u a l i z e d and the I n c i d e n t a l L e a r n i n g Groups. Both the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups ranked e i t h e r f i r s t or second i n r e l a t i o n t o a l l t e n t e s t v a r i a b l e s . The C l a s s L e a r n i n g Group ranked t h i r d on a l l ten t e s t v a r i a b l e s and i n t h a t , was con-s i s t e n t l y d i f f e r e n t from t h e o t h e r two g r o u p s . Both t h e I n d i v i d u a l i z e d and the I n c i d e n t a l L e a r n i n g Groups each ranked f i r s t on an equal number of the - 110 -t e s t v a r i a b l e s . The I n d i v i d u a l i z e d L e a r n i n g Group ranked f i r s t i n r e l a t i o n t o c o m p l i c a t i o n s , doses o f o r a l and p a r e n t e r a l a n a l g e s i c s , t h e s t a r t o f o r a l a n a l g e s i c s and achievement on the c o g n i t i v e p o s t - t e s t s . The I n c i d e n t a l L e a r n i n g Group ranked f i r s t i n r e l a t i o n t o g a s t r o i n t e s t i n a l dys-f u n c t i o n , f e v e r , days o f o r a l and p a r e n t e r a l a n a l g e s i c s and p o s t o p e r a t i v e s t a y . S i n c e i t was demonstrated t h a t one d o c t o r tended t o skew t h e d a t a i n the I n c i d e n t a l L e a r n i n g Group, the d i f f e r e n c e s between the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups may have become more pronounced i f d o c t o r i n v o l v e m e n t had been c o n t r o l l e d by the s t u d y d e s i g n . A l s o , t h e c o g n i t i v e p o s t - t e s t may not have been a s u f f i c i e n t l y p o w e r f u l t e s t o f l e a r n i n g t o d i s t i n g u i s h group d i f f e r e n c e s . The use o f a s e r i e s o f achievement p o s t -t e s t s both p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y would have been b e t t e r i n d i -c a t o r s o f l e a r n i n g t r e n d s . However, t h e f i n d i n g s s u g g e s t t h a t t h e I n d i v i d u a l i z e d L e a r n i n g Group had the g r e a t e s t l e v e l o f achievement and t h i s v a r i a b l e c o r r e l a t e d w i t h f o u r o f the p h y s i o l o g i c a l measurements o f p o s t o p e r a t i v e r e c o v e r y . T h r e e o f t h e s e p o s t o p e r a t i v e r e c o v e r y measurements r e l a t e d t o measurements o f a n a l g e s i c drug usage, i n c l u d i n g numbers o f doses o f p a r e n t e r a l a n a l g e s i c s . S i n c e the f a c t o r a n a l y s i s i n d i c a t e d t h a t a l l f i v e a n a l g e s i c drug v a r i a b l e s measured the same t h i n g , the t h r e e a n a l g e s i c drug measures, i f viewed i n a g g r e g a t e , may be seen as a s i g n i f i c a n t v a r i a b l e i n which t h e r e were d i f f e r e n c e s between t h e I n d i v i d u a l i z e d L e a r n i n g Group and t h e I n c i d e n t a l L e a r n i n g Group. In c o n c l u s i o n , the f i n -d i n g s are o f s u g g e s t i v e importance and are i n d i c a t i v e o f d i f f e r e n c e s b e t -ween the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups on measures o f l e a r n i n g achievement and p o s t o p e r a t i v e r e c o v e r y as measured by use o f - I l l -a n a l g e s i c drugs. Of a l l the p o s t o p e r a t i v e r e c o v e r y measures o n l y the use o f a n a l g e s i c drugs c o r r e l a t e d w i t h l e a r n i n g achievement and may be u s e f u l as a c o r r e l a t i n g measure o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g . The v a l i d i t y o f t h e s e s u g g e s t i v e f i n d i n g s must be t e s t e d i n f u t u r e r e p l i c a t e d s t u d i e s . The u s e f u l n e s s o f p h y s i o l o g i c a l measures o f p o s t o p e r a t i v e r e c o v e r y as c o r r e l a t i n g measures o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g was not s u p p o r t e d by the f i n d i n g s o f t h i s s t u d y . With the e x c e p t i o n of use o f a n a l g e s i c s d r u g s , which showed s u g g e s t i v e u s e f u l n e s s o n l y , a l l o t h e r p o s t o p e r a t i v e r e c o v e r y measures were not d i s c r i m i n a t i n g measures of group d i f f e r e n c e s r e s u l t i n g from p r e o p e r a t i v e l e a r n i n g programs. T h i s i s c o n t r a r y t o the f i n d i n g s o f p r e v i o u s r e s e a r c h e r s who r e p o r t e d c o n s i s t e n t p o s t o p e r a t i v e r e c o v e r y d i f f e r e n c e s t o be h i g h l y c o r r e l a t e d w i t h p r e o p e r a t i v e l e a r n i n g . I t may be t h a t w i t h the advance o f p r e o p e r a t i v e p r e p a r a t i o n , i n c l u d i n g phy-s i o l o g i c a l and e d u c a t i o n a l e l e m e n t s , t h a t a l l p r e o p e r a t i v e p a t i e n t s are b e t t e r p r e p a r e d , whether or not a f o r m a l i z e d l e a r n i n g program i s p r o v i d e d and t h a t group d i f f e r e n c e s have become too small t o be s i g n i f i c a n t . The p h y s i o l o g i c a l p r e p a r a t i o n may a l s o be so advanced t h a t the t r a d i t i o n a l phy-s i o l o g i c a l measures o f p o s t o p e r a t i v e r e c o v e r y are no l o n g e r d i s c r i m i n a t i n g o f the minor d i f f e r e n c e s which o c c u r . F o r example, g a s t r o i n t e s t i n a l dys-f u n c t i o n and p o s t o p e r a t i v e c o m p l i c a t i o n s may be o c c u r r i n g so i n f r e q u e n t l y t h a t the measurements used i n t h i s s t u d y are not d i s c r i m i n a t i n g enough t o d e t e c t group d i f f e r e n c e s . I t may be t h a t w i t h small group d i f f e r e n c e s even more powerful t e s t s o f s i g n i f i c a n c e than t h o s e used i n t h i s s t u d y are r e q u i r e d . - 1 1 2 -Some o f the t r a d i t i o n a l measures o f p o s t o p e r a t i v e r e c o v e r y need much more i n v e s t i g a t i o n as t o t h e i r v a l i d i t y as p o s t o p e r a t i v e r e c o v e r y measures b e f o r e they are used i n any f u t u r e s t u d i e s as c o r r e l a t i n g measures o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g . Fever i s one o f t h e s e measures whose v a l i d i t y i s q u e s t i o n a b l e . S i n c e an e l d e r l y p e r s o n tends t o have a low nor-mal body temperature, even i n the p r e s e n c e of i n f e c t i o n , a s t u d y group which has a s u f f i c i e n t number o f e l d e r l y p e o p l e w i l l tend t o s h i f t towards the mean, which may w e l l be a normal body temperature. Length o f s t a y f a c -t o r e d w i t h both t h e a n a l g e s i c drug use measures i n one f a c t o r and the age-r i s k v a r i a b l e s i n another f a c t o r . I t s v a l i d i t y as a measure o f p o s t o p e r a -t i v e r e c o v e r y i s a l s o q u e s t i o n a b l e . Even t h e d i r e c t measurements o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g w a r r a n t f u t u r e i n v e s t i g a t i o n o f t h e i r v a l i d i t y . C o g n i t i v e achievement t e s t s must be a s s e s s e d f o r v a l i d i t y as a measure o f p r e o p e r a t i v e l e a r n i n g i n t h e con-t e x t o f t h a t s i t u a t i o n . In t h i s s t u d y , a n a e s t h e t i c time s i g n i f i c a n t l y i n f l u e n c e d c o g n i t i v e achievement s c o r e s . In f u t u r e s t u d i e s , c o n t r o l s f o r a n a e s t h e t i c time would be r e q u i r e d t o d e a l w i t h t h i s i n t e r a c t i o n . The common f i n d i n g i n c l i n i c a l e x p e r i m e n t a l r e s e a r c h o f b i a s due t o the i n t e r v e n t i o n o f d o c t o r s and n u r s e s was documented i n t h i s s t u d y , but docu-m e n t a t i o n o f the i n f l u e n c e o f t h a t b i a s i n a f f e c t i n g p o s t o p e r a t i v e r e c o v e r y was not p o s s i b l e w i t h i n the l i m i t s o f t h i s s t u d y . A l l o f t h e s e f i n d i n g s as t o t h e v a l i d i t y o f p o s t o p e r a t i v e r e c o v e r y and l e a r n i n g achievement measures i n d i s c r i m i n a t i n g group d i f f e r e n c e s o f p o s t o p e r a t i v e r e c o v e r y p o i n t out the need f o r c o n t i n u i n g r e s e a r c h f o r d i s c r i m i n a t i n g measures. T h i s s t u d y has - 113 -c o n t r i b u t e d somewhat i n t h a t d i r e c t i o n through the use o f the MULTIVAR program o f s t a t i s t i c a l a n a l y s i s which was e f f e c t i v e i n e l i c i t i n g some s i g n i f i c a n t group d i f f e r e n c e s i n s p i t e of a skewed d o c t o r p a r t i c i p a t i o n and t r e a t m e n t groups t h a t d i d not demonstrate a t r u l y random d i s t r i b u t i o n . F u t u r e r e s e a r c h must f o c u s on g r e a t e r c o n t r o l s u s i n g s t r a t i f i e d random sampling and l a r g e r samples i f t r u e group d i f f e r e n c e s are t o be i s o l a t e d . - 114 -CHAPTER V SUMMARY, CONCLUSIONS AND IMPLICATIONS SUMMARY The s t u d y i n c l u d e d t h e development o f t h r e e d i f f e r e n t p r e o p e r a t i v e l e a r n i n g programs, t e s t i n g o f the e f f e c t i v e n e s s o f t h e s e programs by a c o g n i t i v e p o s t - t e s t on the f i f t h p o s t o p e r a t i v e day. C o r r e l a t i o n o f the e f f e c t i v e n e s s o f the t h r e e l e a r n i n g programs w i t h a v a r i e t y o f t r a d i t i o n a l p h y s i o l o g i c a l measures o f p o s t o p e r a t i v e r e c o v e r y was a l s o done as a means o f d e t e r m i n i n g whether or not the p h y s i o l o g i c a l measures were v a l i d c o r r e -l a t i n g measures o f s u c c e s s f u l p r e o p e r a t i v e l e a r n i n g . T h i s l a t t e r p o i n t was a s i g n i f i c a n t p a r t o f t h i s s t u d y i n t h a t p r e v i o u s r e s e a r c h assumed t h a t the t r a d i t i o n a l p h y s i o l o g i c a l measures were measures o f e f f e c t i v e p r e o p e r a t i v e i n s t r u c t i o n w i t h o u t p r o v i d i n g any e v i d e n c e t o s u p p o r t t h i s assumption. L a s t l y , the s t u d y i n c l u d e d p a t i e n t v a l i d a t i o n o f a s e r i e s o f s p e c i f i c p r e o p e r a t i v e l e a r n i n g needs i n v o l v e d i n a p r e o p e r a t i v e l e a r n i n g program f o r a p a t i e n t u n d e r g o i n g c h o l e c y s t e c t o m y . Summary d a t a r e l e v a n t t o t h e p a t i e n t s ' p r e f e r r e d l e a r n i n g s t y l e s were a l s o c o l l e c t e d . T h r e e t r e a t m e n t groups t o t a l l i n g 3 3 f e m a l e p a t i e n t s u n d e r g o i n g e l e c t i v e c h o l e c y s t e c t o m y were randomly a s s i g n e d . The I n d i v i d u a l i z e d L e a r n i n g Group e x p e r i e n c e d a p r e o p e r a t i v e l e a r n i n g program which was based on p e r c e p t i o n o f i n d i v i d u a l l e a r n i n g needs and i n c l u d e d a v a r i e t y o f l e a r n i n g e x p e r i e n c e s d e s i g n e d t o meet t h o s e needs, such as p r i n t e d l e a r n i n g m a t e r i a l , a s l i d e -sound p r e s e n t a t i o n , an i n d i v i d u a l i n t e r v i e w / l e a r n i n g s e s s i o n w i t h a n u r s e . The C l a s s L e a r n i n g Group e x p e r i e n c e d a s l i d e - s o u n d p r e s e n t a t i o n which was p r i m a r i l y a c l a s s s e s s i o n . I n c i d e n t a l t e a c h i n g from d o c t o r s and - 115 -n u r s e s may have supplemented the C l a s s Group e x p e r i e n c e . The I n c i d e n t a l L e a r n i n g Group e x p e r i e n c e d i n c i d e n t a l t e a c h i n g from d o c t o r s , n u r s e s and p h y s i o t h e r a p i s t s , e t c . and was c o n s i d e r e d the c o n t r o l group. A l l p a t i e n t s were asked t o respond t o a p a t i e n t q u e s t i o n n a i r e on the f i f t h p o s t o p e r a t i v e day, i n which th e y completed a t e n - i t e m c o g n i t i v e t e s t , ranked 50 items r e p r e s e n t a t i v e o f p r e o p e r a t i v e l e a r n i n g needs and i d e n -t i f i e d t h e i r p r e f e r r e d l e a r n i n g s t y l e . Data r e l e v a n t t o t e n t e s t v a r i a b l e s (number o f doses o f o r a l a n a l g e s i c s , number o f doses o f p a r e n t e r a l a n a l g e s i c s , number o f days o f o r a l a n a l g e s i c s , number o f days o f p a r e n t e r a l a n a l g e s i c s , p o s t o p e r a t i v e day on which o r a l a n a l g e s i c s commenced, g a s t r o i n -t e s t i n a l f u n c t i o n , f e v e r , c o m p l i c a t i o n s , l e n g t h o f p o s t o p e r a t i v e s t a y and c o g n i t i v e t e s t s c o r e ) and s i x demographic v a r i a b l e s (age, m a r i t a l s t a t u s , s t a t u s o f s u r g i c a l r i s k , a n a e s t h e t i c time, number o f dependent c h i l d r e n 18 y e a r s and under and y e a r s o f s c h o o l i n g ) were c o l l e c t e d and a n a l y z e d f o r s i g n i f i c a n t t r e a t m e n t group d i f f e r e n c e s and d o c t o r - r e l a t e d c e l l group d i f -f e r e n c e s . The e x p e r i m e n t a l c o n t r o l s were not adequate t o c o n t r o l f o r doc-t o r e f f e c t s . The d o c t o r i n f l u e n c e s were taken i n t o c o n s i d e r a t i o n by a n a l -y z i n g group d i f f e r e n c e s n e s t e d w i t h i n d o c t o r and the r e s u l t s were d a t a r e p o r t e d as c e l l group d i f f e r e n c e s . F a c t o r a n a l y s i s o f a l l t e n t e s t v a r i a b l e s , s i x demographic v a r i a b l e s and the 50 l e a r n i n g need items was c a r r i e d out u s i n g the p r i n c i p a l f a c t o r s approach and the varimax method o f r o t a t i o n ( o r t h o g o n a l ) . - 116 -T h e r e were no s i g n i f i c a n t t r e a t m e n t group d i f f e r e n c e s i n r e l a t i o n t o t h e t e n dependent t e s t v a r i a b l e s , w i t h the e x c e p t i o n o f number o f doses o f p a r e n t e r a l a n a l g e s i c s . The I n d i v i d u a l i z e d L e a r n i n g Group use the f e w e s t number of doses o f p a r e n t e r a l a n a l g e s i c s and d i f f e r e d s i g n i f i c a n t l y from t h e I n c i d e n t a l L e a r n i n g Group at a l e v e l o f 0.006. However, t h e r e are o t h e r f i n d i n g s o f s u g g e s t i v e importance i n d i c a t i n g d i f f e r e n c e s between the I n d i v i d u a l i z e d and I n c i d e n t a l L e a r n i n g Groups on measures o f l e a r n i n g achievement and p o s t o p e r a t i v e r e c o v e r y as measured by t h e use o f a n a l g e s i c d r u g s . Of a l l o f the p o s t o p e r a t i v e r e c o v e r y measures, o n l y the use o f a n a l g e s i c drugs c o r r e l a t e d s u g g e s t i v e l y w i t h l e a r n i n g achievement and may be u s e f u l as a c o r r e l a t i n g measure o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g . The v a l i d i t y o f t h e s e s u g g e s t i v e f i n d i n g s must be t e s t e d i n f u t u r e r e p l i c a t e d s t u d i e s . S i g n i f i c a n t n u r s e - r e l a t e d c e l l group d i f f e r e n c e s were noted i n r e l a t i o n t o a l l o f the f i v e a n a l g e s i c drug measures, p a r t i c u l a r l y , number o f doses o f p a r e n t e r a l d r u g s . S i g n i f i c a n t d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s were noted i n r e l a t i o n t o a n a e s t h e t i c time and a n a e s t h e t i c time c o r r e l a t e d s i g n i f i c a n t l y and n e g a t i v e l y at the 0.02 l e v e l w i t h the c o g n i t i v e t e s t s c o r e . Thus p a t i e n t s w i t h a long a n a e s t h e t i c time were l i k e l y t o have a low c o g n i t i v e t e s t s c o r e and v i c e v e r s a . T h e r e were a l s o s i g n i f i c a n t t r e a t m e n t group d i f f e r e n c e s between t h e I n d i v i d u a l i z e d , C l a s s and I n c i d e n t a l L e a r n i n g Groups i n r e l a t i o n t o a n a e s t h e t i c time at t h e 0.009 l e v e l . - 117 -P a t i e n t s from a l l t h r e e t r e a t m e n t groups r a t e d the 50 p r e o p e r a t i v e l e a r n i n g needs as more than f a i r l y i m p o r t a n t , w i t h t h e e x c e p t i o n o f one i t e m . P a t i e n t s i n the I n d i v i d u a l i z e d L e a r n i n g Group had a g r e a t e r aware-ness of l e a r n i n g needs and r a t e d l e a r n i n g needs h i g h e r than t h e o t h e r t r e a t m e n t groups. H i g h l y s i g n i f i c a n t t r e a t m e n t group d i f f e r e n c e s a t t h e 0.02 l e v e l or lower were r e p o r t e d f o r the I n d i v i d u a l i z e d L e a r n i n g Group i n r e l a t i o n t o f o u r o f the s i x groups o f l e a r n i n g needs e l i c i t e d through f a c -t o r a n a l y s i s . P a t i e n t s demonstrated a keen i n t e r e s t i n knowing what e x p e r i e n c e s t h e y would have p r e o p e r a t i v e l y and p o s t o p e r a t i v e l y , the r e a s o n s u n d e r l y i n g n u r s i n g and m e d i c a l p r o c e d u r e s and how t h e y c o u l d p a r t i c i p a t e i n t h e i r own r e c o v e r y . F o r t y - f i v e o f the f i f t y l e a r n i n g needs were i n c l u d e d among the s i x f a c t o r s e l i c i t e d i n the f a c t o r a n a l y s i s and t h e s e f a c t o r s e x p l a i n e d 74.16% o f the v a r i a n c e . Thus, not o n l y d i d p a t i e n t s p e r c e i v e p r e o p e r a t i v e l e a r n i n g needs as i m p o r t a n t , but the s i g n i f i c a n c e o f t h o s e l e a r n i n g needs as d e t e r m i n a n t s o f v a r i a n c e was s u p p o r t e d by t h e f a c t o r a n a l y s i s . A n a l y s i s o f p r e o p e r a t i v e l e a r n i n g needs f o r d o c t o r - r e l a t e d c e l l group d i f f e r e n c e s showed s i g n i f i c a n t d i f f e r e n c e s f o r each o f the s i x f a c t o r s . The l a r g e s t numbers o f c e l l group d i f f e r e n c e s o c c u r r e d i n r e l a t i o n t o F a c t o r s 1, 2 and 3 namely: e x p e r i e n c e s e x p e c t e d i m m e d i a t e l y p o s t o p e r a t i v e , r e a s o n s u n d e r l y i n g p r e o p e r a t i v e p r e p a r a t i o n p r o c e d u r e s and how t o combat a g e n e r a l a n a e s t h e t i c . I t was e s t i m a t e d t h a t a d o c t o r - n u r s e b i a s was o p e r a t i n g i n r e l a t i o n t o c e l l group d i f f e r e n c e s a s s o c i a t e d w i t h p r e o p e r a -t i v e l e a r n i n g needs. - 118 -P a t i e n t p r e f e r e n c e s f o r l e a r n i n g s t y l e s tended t o r e f l e c t t h e i r c u r r e n t e x p e r i e n c e i n a t r e a t m e n t group r a t h e r than p e r s o n a l c o g n i t i v e s t y l e , w i t h t h e e x c e p t i o n o f the I n d i v i d u a l i z e d L e a r n i n g Group. The I n d i v i d u a l i z e d L e a r n i n g Group e x p e r i e n c e d a wide v a r i e t y o f l e a r n i n g e x p e r i e n c e s and thus were more l i k e l y t o choose l e a r n i n g s t y l e which b e s t matched t h e i r own c o g n i t i v e s t y l e , r a t h e r than o n l y t h a t s t y l e which had been p r o v i d e d i n t h e i r p r e o p e r a t i v e l e a r n i n g program. CONCLUSIONS The hypotheses t h a t the I n d i v i d u a l i z e d and the C l a s s L e a r n i n g Groups would demonstrate a more s u c c e s s f u l p o s t o p e r a t i v e r e c o v e r y than the I n c i d e n t a l L e a r n i n g Group based on measurements o f t h e n i n e t e s t v a r i a b l e s were r e j e c t e d f o r e i g h t o f the v a r i a b l e s and a c c e p t e d f o r one: The I n d i v i d u a l i z e d L e a r n i n g Group used fewer doses o f p a r e n t e r a l a n a l g e s i c s than t h e I n c i d e n t a l L e a r n i n g Group ( o r c o n t r o l g r o u p ) . The h y p o t h e s i s t h a t the I n d i v i d u a l i z e d and the C l a s s L e a r n i n g Groups would s c o r e h i g h e r on the p o s t o p e r a t i v e c o g n i t i v e achievement t e s t than the I n c i d e n t a l L e a r n i n g Group was r e j e c t e d . The u s e f u l n e s s o f p h y s i o l o g i c a l measures o f p o s t o p e r a t i v e r e c o v e r y as c o r r e l a t i n g measures o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g was not s u p p o r t e d by the f i n d i n g s o f t h i s s t u d y . With the e x c e p t i o n o f the use o f a n a l g e s i c d r u g s , which showed s u g g e s t i v e u s e f u l n e s s o n l y , a l l o t h e r p o s t o p e r a t i v e r e c o v e r y measures were not d i s c r i m i n a t i n g measures o f group d i f f e r e n c e s r e s u l t i n g from p r e o p e r a t i v e l e a r n i n g programs. T h i s i s c o n t r a r y t o the f i n d i n g s o f p r e v i o u s r e s e a r c h e r s who r e p o r t e d c o n s i s t e n t p r e o p e r a t i v e r e c o -v e r y d i f f e r e n c e s t o be h i g h l y c o r r e l a t e d w i t h p r e o p e r a t i v e l e a r n i n g . - 119 -P a t i e n t s v a l i d a t e d 49 out o f the 50 p r e o p e r a t i v e l e a r n i n g needs o f a c h o l e c y s t e c t o m y p a t i e n t . Data from the f a c t o r a n a l y s i s of p r e o p e r a t i v e l e a r n i n g needs s u p p o r t e d the p a t i e n t s views. IMPLICATIONS D e s p i t e the d i f f i c u l t i e s o f a t r u l y randomized e x p e r i m e n t a l d e s i g n , c o n t i n u i n g e x p e r i m e n t a l r e s e a r c h r e l e v a n t t o the e f f e c t i v e n e s s o f p r e o p e r a -t i v e l e a r n i n g programs i s w a rranted. There has been ample r e s e a r c h docu-menting and v a l i d a t i n g p a t i e n t s ' l e a r n i n g needs p r e o p e r a t i v e l y and v a l i -d a t i n g l e a r n i n g needs based on p a t i e n t p e r c e p t i o n s . The major emphasis i n f u t u r e r e s e a r c h s h o u l d be on the development and i m p l e m e n t a t i o n o f p r e o p e r a t i v e l e a r n i n g programs d e s i g n e d t o meet v a l i d a t e d needs i n v a r i o u s ways and i n c l u d i n g a v a r i e t y o f l e a r n i n g e x p e r i e n c e s d e s i g n e d t o appeal t o a v a r i e t y of i n d i v i d u a l c o g n i t i v e l e a r n i n g s t y l e s . Comparison o f the e f f e c -t i v e n e s s o f l e a r n i n g programs i n c l u d i n g p r e - h o s p i t a l a d m i s s i o n e x p e r i e n c e s w i t h t r a d i t i o n a l p o s t - a d m i s s i o n l e a r n i n g e x p e r i e n c e s are w arranted as w e l l as i n v e s t i g a t i o n of the c o g n i t i v e l e a r n i n g s t y l e s (Nunney & H i l l , 1972) o f p a t i e n t s i n p r e o p e r a t i v e l e a r n i n g programs. The need f o r the d e v e l o p -ment o f d e f i n i t i v e p r e o p e r a t i v e l e a r n i n g programs i s becoming even more c r u c i a l w i t h the advance of q u a l i t y a s s u r a n c e programs such as the W i s c o n s i n System (Hover & Zimmer, 1978) i n which f o u r o f the f i v e c r i t i -c a l c r i t e r i a are r e l a t e d t o l e a r n i n g programs: C r i t e r i o n I Knowledge of i l l n e s s and i t s t r e a t m e n t C r i t e r i o n II S k i l l s C r i t e r i o n I I I Knowledge of m e d i c a t i o n s C r i t e r i o n IV A d a p t i v e b e h a v i o r s C r i t e r i o n V H e a l t h and p h y s i o l o g i c a l s t a t u s - 120 -C o s t a n a l y s i s o f d i f f e r e n t t y p e s o f p r e o p e r a t i v e l e a r n i n g programs i s a l s o o f importance i n f u t u r e r e s e a r c h . P r e s c r o t t and Sorensen s t a t e : As the c o s t s o f h e a l t h c a r e c o n t i n u e t o i n c r e a s e at an a l a r m i n g r a t e , h e a l t h c a r e f u n d e r s are concerned t h a t programs be both e f f e c t i v e i n a c h i e v i n g d e s i r e d r e s u l t s and e f f i c i e n t i n u s i n g r e s o u r c e s t o o b t a i n t h o s e r e s u l t s . Program e v a l u a t o r s can no l o n g e r s i m p l y l i m i t t h e i r s t u d i e s t o program outcomes. Now e v a l u a t i o n must r e l a t e program out-comes t o program c o s t s . T h i s type o f a n a l y s i s , c a l l e d cost-outcome and c o s t - e f f e c t i v e n e s s a n a l y s i s , answers e v a l u a t i o n q u e s t i o n s such as "What r e s o u r c e s were consumed t o produce the r e s u l t s o f Program A?' o r 'Is program A more e f f e c t i v e r e l a t i v e t o r e s o u r c e s consumed than Program B'? (1978, p. 1 7 ) . The c o s t - e f f e c t i v e n e s s o f d i f f e r e n t l e a r n i n g e x p e r i e n c e s s h o u l d i n c l u d e an assessment o f the c o s t - e f f e c t i v e n e s s o f the a c t i v i t i e s o f a v a r i e t y o f h e a l t h c a r e p e r s o n n e l who may be i n v o l v e d i n a p r e o p e r a t i v e l e a r n i n g program, such a surgeons, a n a e s t h e t i s t s , f a m i l y d o c t o r s , d o c t o r s ' o f f i c e n u r s e s , ward u n i t s t a f f , o p e r a t i n g room n u r s e s , p h y s i o t h e r a p i s t s and d i e t i -c i a n s , as w e l l as s p e c i a l i z e d p a t i e n t t e a c h i n g s t a f f . In c o n c l u s i o n , p r e v i o u s r e s e a r c h i n p r e o p e r a t i v e l e a r n i n g programs has f o c u s e d p r i m a r i l y on i d e n t i f y i n g p a t i e n t l e a r n i n g needs based on p a t i e n t p e r c e p t i o n . In the f u t u r e , r e s e a r c h emphasis s h o u l d be p l a c e d on g e n e r a l i -z a b l e e x p e r i m e n t a l r e s e a r c h , c o n cerned w i t h p a t i e n t s ' c o g n i t i v e l e a r n i n g s t y l e s , t e a c h i n g - l e a r n i n g s t r a t e g i e s , use o f a wide v a r i e t y o f h e a l t h p e r -sonnel i n t e a c h i n g r o l e s and v a l i d e v a l u a t i o n o f l e a r n i n g outcomes w i t h i n a c o s t - e f f e c t i v e n e s s framework. - 121 -T h i s s t u d y s e r v e d t o p o i n t out the u s e f u l n e s s o f s p e c i f i c d i r e c t i o n s f o r f u t u r e r e s e a r c h , p r i m a r i l y r e s e a r c h geared t o p r o v i d e the c l i n i c a l p r a c t i t i o n e r s who are i n v o l v e d i n p r e o p e r a t i v e l e a r n i n g programs w i t h e f f e c t i v e t o o l s f o r e f f e c t i n g p r e o p e r a t i v e l e a r n i n g and measuring the out-comes o f l e a r n i n g a g a i n s t s p e c i f i c b e h a v i o r i a l l e a r n i n g c r i t e r i a . T h i s s t u d y p r o v i d e d a model o f a planned p r e o p e r a t i v e l e a r n i n g program which can be used by p r a c t i c i o n e r s i n c a r r y i n g out p r e o p e r a t i v e i n s t r u c t i o n . L a s t l y , t h e study c o n f i r m e d t h a t t h e r e i s no v a l i d i t y i n c o n t i n u i n g t o use phy-s i o l o g i c a l measures of p o s t o p e r a t i v e r e c o v e r y as c o r r e l a t i n g measures o f e f f e c t i v e p r e o p e r a t i v e l e a r n i n g u n t i l f u r t h e r r e s e a r c h has been c a r r i e d out t o v a l i d a t e t h e s e measures. - 122 -BIBLIOGRAPHY American C o l l e g e o f Surgeons, Committee on P r e - and P o s t o p e r a t i v e Care; Manual o f P r e o p e r a t i v e and P o s t o p e r a t i v e C a r e , 2nd ed., P h i l a d e l p h i a : W. B. Saunders Co., 1971. A y d e l o t t e , M y r t l e M., "The Use of P a t i e n t W e l f a r e As a C r i t e r i o n Measure", N u r s i n g R e s e a r c h , V o l . I I , No. 1, W i n t e r , 1962, pp. 10-14. BMD P4M - F a c t o r A n a l y s i s , Los A n g e l o s , C a l i f o r n i a : H e a l t h S c i e n c e and Computing F a c i l i t y , U n i v e r s i t y of C a l i f o r n i a , 1977. B r o c k l e h u r s t , J.C. ( e d . ) , Textbook o f g e r i a t r i c M e d i c i n e and G e r o n t o l o g y , 2nd ed., London: C h u r c h i l l L i v i n s t o n e , 1978. B r o d t , Dagmar E. and Anderson, E l l e n H. " V a l i d a t i o n o f a P a t i e n t W e l f a r e E v a l u a t i o n Instrument", N u r s i n g R e s e a r c h , V o l . 16, No. 2, S p r i n g , 1967, pp. 167-169. B r u e g e l , Mary A. " R e l a t i o n s h i p o f P r e o p e r a t i v e A n x i e t y t o P e r c e p t i o n o f P o s t o p e r a t i v e P a i n " , N u r s i n g R e s e a r c h , V o l . 20, No. 1, J a n u a r y -F e b r u a r y , 1971, pp. 26-30. B u r s t e n , Ben and Russ, J . J . , " P r e o p e r a t i v e p s y c h o l o g i c a l s t a t e and c o r t i c o s t e r o i d l e v e l s of s u r g i c a l p a t i e n t s , " P s y c h s o m a t i c M e d i c i n e , 27:309-316, J u l y - A u g u s t , 1965. C a r n i v a l l i , D o r i s , A Study t o Compare P a t i e n t s and Nurses P e r c e p t i o n s o f  A n x i e t y - P r o d u c i n g F a c t o r s and S u p p o r t i v e A s p e c t s o f N u r s i n g Care i n  the P r e o p e r a t i v e p e r i o d , S e a t t l e , Wash.: U n i v e r s i t y o f Washington, 1961 ( U n p u b l i s h e d master's t h e s i s ) . Chapman, J . E . , " E f f e c t s o f d i f f e r e n t n u r s i n g approaches on p s y c h o l o g i c a l and p h y s i o l o g i c a l r e s p o n s e s " , N u r s i n g Research R e p o r t 5 : l f f , March, 1970. Chomsky, Noam, A s p e c t s o f Theory o f Syntax, Cambridge, Mass: M.I.T. P r e s s , 1965. DeCecco, John P. and Crawford, Wm. R., The P s y c h o l o g y o f L e a r n i n g and  I n s t r u c t i o n , 2nd ed., Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l Inc., 1974. - 123 -De L u c a , V i r g i n i a M., Some O b s e r v a t i o n s on the Use o f a D e l i b e r a t i v e  N u r s i n g P r o c e s s and the I n c i d e n c e o f U r i n a r y R e t e n t i o n F o l l o w i n g  S u r g e r y , New Haven, Conn.: Y a l e U n i v e r s i t y S c h o o l o f N u r s i n g , 1962. (M.S. t h e -s i s m i c r o f i l m ) ( A b s t r a c t e d i n N u r s i n g R e s e a r c h , V o l . 13, No. 275, Summer, 1964, p. 139. Diamond, Robert M. e t al I n s t r u c t i o n a l Development f o r I n d i v i d u a l i z e d  L e a r n i n g i n H i g h e r E d u c a t i o n , Englewood C l i f f s , New J e r s e y : E d u c a t i o n a l T e c h n o l o g y P u b l i c a t i o n s , 1975. D i c h t e r , E r n e s t , "A p s y c h o l o g i c a l s t u d y o f the h o s p i t a l p a t i e n t r e l a t i o n s h i p ; what the p a t i e n t r e a l l y wants from the h o s p i t a l . " Modern H o s p i t a l , V o l . 83, No. 136, September 1954, pp. 51-54. Dodge, Joan S., " F a c t o r s R e l a t e d t o P a t i e n t s ' P e r c e p t i o n s o f t h e i r C o g n i t i v e Needs," N u r s i n g R e s e a r c h , V o l . 18, No. 6, November -December, 1969, pp. 502-513. D r i p p s , R.D. and Waters, R.N., " N u r s i n g C a r e o f S u r g i c a l P a t i e n t s : P a r t 1. The S t i r - u p " , American J o u r n a l o f N u r s i n g , V o l . 4, May, 1941, pp. 530-534. Dumas, Rhetaugh G. and Leonard, Robert C , "The E f f e c t o f N u r s i n g on the I n c i d e n c e o f P o s t o p e r a t i v e V o m i t i n g " , N u r s i n g R e s e a r c h , V o l . 12, W i n t e r , 1963, pp. 12-15. Dumas, Rhetaugh G. and Anderson, B a r b a r a J . , " P s y c h o l o g i c a l P r e p a r a t i o n B e n e f i c i a l I f Based on I n d i v i d u a l ' s Needs, H o s p i t a l T o p i c s , V o l . 42, May, 1964, p. 79. E c k e n o f f , J . E . , "Some p r e o p e r a t i v e warning o f p o t e n t i a l o p e r a t i n g - r o o m d e a t h s " , New England J o u r n a l o f M e d i c i n e , V o l . 255, December 6, 1956, pp. 1075-1079. E g b e r t , Lawrence D., B a t t i t , George E., T u r n d o r f , Herman and Beecher, Henry K., "The V a l u e o f the p r e o p e r a t i v e V i s i t by an A n a e t h e t i s t , " J o u r n a l o f t h e American M e d i c a l A s s o c i a t i o n , V o l . 185, No. 7, August 17, 1963, pp. 553-555. E g b e r t , Lawrence D., B a t t i t , George E., T u r n d o r f , Herman and Beecher, Henry K. " R e d u c t i o n o f P o s t o p e r a t i v e P a i n by Encouragement and I n s t r u c t i o n o f P a t i e n t s " , New England J o u r n a l o f M e d i c i n e , V o l . 270, A p r i l 16, 1964, pp. 825-827. Elman, R o b e r t , S u r g i c a l C a r e : A P r a c t i c a l P h y s i o l o g i c a l Guide, New York: A p p l e t o n - C e n t u r y C r o f t s , 1951, pp. 42-46. F e s t i n g e r , Leon, Theory o f C o g n i t i v e D i s s o n a n c e , E v a n s t o n , I l l i n o i s : Row, P e t e r s o n , 1957. - 124 -Gagne, Robert M., The C o n d i t i o n s o f L e a r n i n g , 2nd ed., New York: H o l t , R i n e h a r t and Winston, I n c . , 1970. Gagne, Robert M. and B r i g g s , L e s l i e J . , P r i n c i p l e s o f I n s t r u c t i o n a l  D e s i g n , T o r o n t o : H o l t , R i n e h a r t and Winston, I n c . , 1974. G i l l e r , D.W., Some p y s c h o l o g i c a l c o r r e l a t e s o f r e c o v e r y from s u r g e r y Tex Rep B i o l o g y Med., V o l . 20, F a l l , 1962, p. 366-376. Graham, L o i s E. and C o n l e y , E l i z a b e t h M., " E v a l u a t i o n o f A n x i e t y and F e a r i n A d u l t S u r g i c a l P a t i e n t s , " N u r s i n g R e s e a r c h , V o l . 20, March-A p r i l , 1971, pp. 113-122. Hanamey, Rosemary, " T e a c h i n g P a t i e n t s B r e a t h i n g and Coughing T e c h n i q u e s , N u r s i n g O u t l o o k , August, 1965, pp. 58-59. Healy, K a t h r y n M., "Does P r e o p e r a t i v e I n s t r u c t i o n Make a D i f f e r e n c e ? " American J o u r n a l o f N u r s i n g , V o l . 68, J a n u a r y , 1968, p. 62-67. Houle, C y r i l 0., The Design o f E d u c a t i o n , San F r a n c i s c o : J o s s e y - B a s s , I n c . , P u b l i s h e r s , 1972. Hover, J u l i e and Zimmer, M a r i e J . , " N u r s i n g Q u a l i t y A s s u r a n c e : The W i s c o n s i n System," N u r s i n g O u t l o o k , A p r i l , 1978, pp. 242-248. Jam's, I.L., P s y c h o l o g i c a l S t r e s s : P s y c h o a n a l y t i c and B e h a v i o r a l S t u d i e s  o f S u r g i c a l P a t i e n t s , New York: John W i l e y and Sons, 1958. Johnson, B.A. e t a l , "Research i n n u r s i n g p r a c t i c e , t he problems o f u n c o n t r o l l e d s i t u a t i o n a l v a r i a b l e s , " N u r s i n g R e s e a r c h , V o l . 19, J u l y - A u g u s t , 1970, pp. 337-340. Johnson, Jean E., " E f f e c t s of S t r u c t u r i n g P a t i e n t s ' E x p e c t a t i o n o f T h e i r R e a c t i o n s t o T h r e a t e n i n g E v e n t s , " N u r s i n g R e s e a r c h , V o l . 2, November-December, 1972, pp. 499-504. Johnson, Jean E., Dabbs, James M. and L e v a n t h a l , Howard, " P s y c h o l o g i c a l F a c t o r s i n the W e l f a r e o f S u r g i c a l P a t i e n t s ' " , N u r s i n g R e s e a r c h , V o l . 19, No. 1, J a n u a r y - F e b r u a r y , 1970, pp. 18-29. K a t z , D a n i e l , "The F u n c t i o n a l Approach t o the Study o f A t t i t u d e s " , i n M a r t i n F i s h b e i n (ed.) Readings i n A t t i t u d e Theory and Measurement, New York: John W i l e y and Sons, I n c . , 1967, pp. 457-458. Kemp, J e r r o l d , E., I n s t r u c t i o n a l D e s i g n , 2nd ed., Belmond, C a l i f o r n i a : Fearon P u b l i s h e r s , I n c . , 1977. K i b l e r , Robert J . e t a l , B e h a v i o r a l O b j e c t i v e s and I n s t r u c t i o n , B o s t o n : A l l y n and Bacon, Inc., 1970. - 125 -K o h l b e r g , L., "Stage and sequence: the c o g n i t i v e - d e v e l o p m e n t a l approach t o s o c i a l i z a t i o n " i n D. A. G o s l i n (ed.) Handbook o f  S o c i a l i z a t i o n T h e o ry and R e s e a r c h , C h i c a g o : Rand M c N a l l y and Co., 1969, pp. 347-480. I.ederer, Henry, "How p a t i e n t s view t h e i r w o r l d , " i n E.C. J a c o , ( e d . ) , P a t i e n t s , P h y s i c i a n s and I l l n e s s , G l e n c o e , 111: F r e e P r e s s , 1958, p. 249. L e i t h a u s e r , D.J., E a r l y A m b u l a t i o n and R e l a t e d P r o c e d u r e s i n S u r g i c a l  Management, S p r i n g f i e l d , 111.: C h a r l e s C. Thomas, 1946, p. 175. L e v a n t h a l , Howard e t a l , "Sex d i f f e r e n c e i n a t t i t u d e and b e h a v i o r change under c o n d i t i o n s of f e a r and s p e c i f i c i n s t r u c t i o n s , " Exp. Soc.  P s y c h o l ; V o l . 2 ( 4 ) , 1966, pp. 381-399. L e v a n t h a l , Howard, " E f f e c t s o f f e a r and i n s t r u c t i o n s on how t o cope w i t h danger," J . P e r s o n a l i t y Soc. P s y c h . , V o l . 6, J u l y , 1967, pp. 313-321. L e v i n e , Dale C. and F i e d l e r , June P., " F e a r , F a c t s and F a n t a s i e s About P r e - and P o s t o p e r a t i v e C a r e , " N u r s i n g O u t l o o k , V o l . 70, F e b r u a r y , 1970, pp. 26-27. Lindeman, C a r o l A. and Van Aernam, B e t t y , " N u r s i n g I n t e r v e n t i o n w i t h the P r e s u r g i c a l P a t i e n t - The E f f e c t s o f S t r u c t u r e d and U n s t r u c t u r e d P r e o p e r a t i v e T e a c h i n g , " N u r s i n g R e s e a r c h , V o l . 20, J u l y - A u g u s t , 1971, pp. 319-332. Lindeman, C a r o l A., " N u r s i n g I n t e r v e n t i o n w i t h the P r e s u r g i c a l P a t i e n t , " N u r s i n g R e s e a r c h , V o l . 21, May-June 1972, pp. 196-209. Mager, Robert F., P r e p a r i n g I n s t r u c t i o n a l O b j e c t i v e s , P a l o A l t o , C a l i f o r n i a : Fearon P u b l i s h e r s , 1962. May, R o l l o , The Meaning o f A n x i e t y , New York: The Ronald P r e s s Co., 1950. Meyers, Mary E., "The E f f e c t o f Types o f Communication on P a t i e n t s ' R e a c t i o n t o S t r e s s " , N u r s i n g R e s e a r c h , V o l . 13, No. 2, S p r i n g , 1964, pp. 126-131. Mezzanote, E l i z a b e t h J . , "Group I n s t r u c t i o n i n P r e p a r a t i o n f o r Surgery", American J o u r n a l o f N u r s i n g , V o l . 70, J a n u a r y 1970, pp. 89-91. M i l l e r , G.A. e t a l , P l a n s and the S t r u c t u r e o f B e h a v i o r , New York: R i n e h a r t & Winston, 1960. M i l l e r , P a t r i c i a , A D e s c r i p t i v e Survey t o I d e n t i f y and Compare t h e  Concerns o f P r e o p e r a t i v e P a t i e n t s , S e a t t l e , Wash.: U n i v e r s i t y o f Washington, 1965 ( u n p u b l i s h e d master's t h e s i s ) . - 126 -Moss, Fay T. and Meyer, B u r t o n , "The E f f e c t s o f N u r s i n g I n t e r a c t i o n Upon P a i n R e l i e f i n P a t i e n t s , " N u r s i n g R e s e a r c h , V o l . 15, F a l l , 1966, pp. 303-306. N o r r i s , W a l t e r , " P r e - a n a e s t h e t i c M e d i c a t i o n " , N u r s i n g M i r r o r , V o l . 18, September, 1964, p. i i i - v . N o w l i s , V., "Research w i t h the mood a d j e c t i v e c h e c k l i s t , " i n S. Tomskin & E. I z a r d (eds.) A f f e c t , C o g n i t i o n and P e r s o n a l i t y , New York: S p r i n g , 1965, pp. 352-389. Nunney, Derek N., and H i l l , Joseph E., " P e r s o n a l i z e d E d u c a t i o n a l Programs," A u d i o v i s u a l I n s t r u c t i o n , F e b r u a r y , 1972, pp. 10-15. Palmer, I r e n e S., "The Development o f a Measuring D e v i c e , " N u r s i n g  R e s e a r c h , V o l . 14, No. 2, S p r i n g , 1965, pp. 100-105. P a r k e r , Dorothy, A Study t o Compare P a t i e n t s ' and Nurses' P e r c e p t i o n o f  A n x i e t y - P r o d u c i n g F a c t o r s and S u p p o r t i v e A s p e c t s o f N u r s i n g Care i n  the P r e o p e r a t i v e P e r i o d , and o f N u r s i n g which was P e r c e i v e d as B e i n g  S u p p o r t i v e , S e a t t l e , Wash.: U n i v e r s i t y o f Washington, 1964 ( u n p u b l i s h e d m a s t e r ' s t h e s i s ) . Popham, W. James and Baker, Eva L., P l a n n i n g I n s t r u c t i o n a l Sequence, Englewood C l i f f s , New J e r s e y : P r e n t i c e - H a l l , Ince., 1970. P o s t l e t h w a i t , Samuel N., Novak, J . and Murray, H., The A u d i o - T u t o r i a l  Approach t o L e a r n i n g , M i n n e a p o l i s : Burgess P u b l i s h i n g Co., 1972. P r e s c o t t , P.A. and Sorensen, James E., " C o s t - e f f e c t i v e n e s s A n a l y s i s : An Approach t o E v a l u a t i n g N u r s i n g Programs," N u r s i n g A d m i n i s t r a t i o n  Q u a r t e r l y , V o l . 4, No. 4, 1978, pp. 17-40. P r i d e , L.F., "An A d r e n a l s t r e s s index as a c r i t e r i o n measure f o r n u r s i n g , " N u r s i n g R e s e a r c h , V o l . 17, J u l y - A u g u s t , 1968, pp. 292-303. Ramsay, M.A.F., "A Survey o f P r e o p e r a t i v e F e a r " , A n a e s t h e s i a , V o l . 27, O c t o b e r , 1972, pp. 396-402. S a y l o r , Dennis E., " U n d e r s t a n d i n g P r e s u r g i c a l A n x i e t y , " AORN J o u r n a l , V o l . 22, No. 4, O c t o b e r , 1975, pp. 624-636. Schmidt, Ruth L., An E x p l o r a t o r y Study o f N u r s i n g and P a t i e n t R e a d i n e s s  f o r S u r v e r y , New Haven, Conn: Y a l e U n i v e r s i t y , S c h o o l o f N u r s i n g , 1966 ( u n p u b l i s h e d master's t h e s i s ) . Schmidt, F l o r e n c e E. and W o o l r i d g e , Powhatan J . , " P s y c h o l o g i c a l P r e p a r a t i o n o f S u r g i c a l P a t i e n t s " , N u r s i n g R e s e a r c h , V o l . 73, M a r c h - A p r i l , 1973, pp. 108-116. - 127 -S e l y e , Hans S t r e s s : The P h y s i o l o g y and P a t h o l o g y o f Exposure t o S t r e s s , M o n t r e a l : A c t a , I n c . , 1950. Simon, J.R., "Nurses' R a t i n g s o f P a t i e n t W e l f a r e as C r i t e r i o n Measures i n t h e H e a l t h S c i e n c e s , " ,0ccup. P s y c h . , V o l . 35 ( 1 - 2 ) , 1961, pp. 10-22. S l e i s e n g e r , M a r v i n H. and F o r d t r a n , John S., G a s t r o i n t e s t i n a l D i s e a s e , . 2nd ed., T o r o n t o : W.B. Saunders, 1978, p. 1284. S n e l b e c k e r , Glenn E., L e a r n i n g Theory, I n s t r u c t i o n a l Theory and  P s y c h o e d u c a t i o n a l D e s i g n , T o r o n t o : McGraw-Hill Book Co., 1974. Tanasuk, M.B., e t a l , "An e x p e r i m e n t a l t e s t o f the importance o f communication s k i l l s f o r e f f e c t i v e n u r s i n g " i n J.K. S k i p p e r , J r . & R.C. L e o n a r d , (eds.) S o c i a l I n t e r a c t i o n and P a t i e n t C a r e , P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 1965, pp'. 110-120. T i t c h e n e r , James L. and L e v i n e , M a u r i c e , S u r g e r y As a Human E x p e r i e n c e , New York: O x f o r d U n i v e r s i t y P r e s s , 1960, p. 52. U n i v e r s i t y o f B r i t i s h Columbia v e r s i o n o f MULTIVAR ( M u l t i v a r i a n t A n a l y s i s and C o - v a r i a n c e , 6.1, I n t e r n a t i o n a l E d u c a t i o n a l S e r v i c e s ) , 1972. W a i l i s , Ruth M., " P r e o p e r a t i v e v i s i t s - A C h a l l e n g e f o r OR Nurses", AORN J o u r n a l , December, 1971, pp. 53-56. WeiIer S i s t e r M. C a s h e l , " P o s t o p e r a t i v e P a t i e n t s E v a l u a t e I n s t r u c t i o n " , American J o u r n a l o f N u r s i n g , J u l y , 1968, pp. 1465-1467. W i l l i a m s , James, J o n e s , John R., and W i l l i a m s , B a r b a r a , A p h y s i o l o g i c a l measure o f p r e o p e r a t i v e a n x i e t y P s y c h o s o m a t i c M e d i c i n e , V o l . XXXI, 1969, pp. 522-527. W o l f e r , John A. and D a v i s , C a r o l E., "Assessment of S u r g i c a l P a t i e n t s ' P r e o p e r a t i v e E m o t i o n a l C o n d i t i o n and P o s t o p e r a t i v e W e l f a r e " , N u r s i n g R e s e a r c h , V o l . 19, September-October, 1970, pp. 402-414. W o l f e r , John A., " D e f i n i t i o n and Assessment o f S u r g i c a l P a t i e n t s ' W e l f a r e and Recovery", ( S e l e c t e d Review o f the L i t e r a t u r e ) , N u r s i n g R e s e a r c h , V o l . 22, September-October, 1973, pp. 394-401. - 128 -APPENDIX A PAMPHLET: "YOU AND YOUR OPERATION - 129 -•YOU AND YOUR OPERATION' - 130 -ARRIVING AT HOSPITAL You probably felt sort of strange and lonely as you sat waiting for the AdmittingLClerk to take your infor-mation. TEverybody seems to be so busy and rushing about. You feel that you shouldn't really bother them to ask that nagging little question you have. STOP! The first lesson for a new patient to learn is that people usually have a minute to spare. If you have a problem or a question, tell somebody about it. If they can't nelp you they will tell you who can. Remember nobody can guess what you are thinking so ask away. We really want to know now we can help you even if we look tied-up. ON THE WARD From the Admitting Office you will be taken up to /our ward, probably by a Volunteer (a member of the Women's Auxiliary) who will be wearing a red smock. Ask her where your ward is and what your room number is. You will want this information to give your family and friends. On the ward, you will be greeted by the Ward Clerk, who is like a sort of secre-tary for the Ward. She works under the direction of the Head Nurse. She takes most of the telephone messages and is a good person to know if you nave a message to be delivered. She is at the Nurses' Station most of the time so she catches the nurses and doctors as they come and go. Don't be upset if the nurses seem quite frantic when you arrive. The change of shift is 3.30 p.m. so the day nurses are rushing to finish and, then the after -noon nurses are rushing to get orga-nized. Things will settle down by supper-time and your nurse will have a little more time. Supper comes between 5:00 and 6:00 p.m. - 131 -In the meantime, take a look around your room, meet your room-mates, find out how your call-bell works, look for bathrooms and generally get feeling a little more familiar with your new home. Also, remember Rule No. I - ASK QUESTIONS. Your room-mate probably has lots of answers if she has been in hospital a few days. SPECIAL HAPPENINGS! SPECIAL VISITORS! ON THE EVENING BEFORE YOUR OPERATION You are a very busy person this evening and you will be having a number of special visitors. Each one of them will be helping you to prepare for your operation in a spe-cial way. THE SURGICAL RESIDENT OR INTERN This person is what is known as a "house doctor" in the movies. He is a graduate of a medical school and is learning special skills in the hospital under the direction of your doctor and other surgeons. He will be visiting you and will be asking you questions about your medicaT history as well as doing a physical examination. This is requested by your doctor just to be sure that you are in tip-top shape for surgery. He will also order some routine blood and urine tests to be done. - 132 -THE ANAESTHETIST Your anaesthetist is a specialist in giving anaesthetics of al l kinds. He is also concerned about preparing you for your surgery. He wi l l usually ask you a few questions and perhaps, listen to your chest. You wi l l be having a "general anaesthetic" which means you wi l l be completely asleep for your operation. Your anaesthetist is a good person to ask questions. He can tel l you when your operation is, how long it wi l l be ana how long you wi l l be in the Recovery Room (where you go to wake up before coming back to the Ward). If you have any concerns about your anaesthetic or sleeping ask your anaesthetist. Usually your anaesthetist orders some medications for you before the operation. THE FIRST MEDICATION is a sleeping pi l l which you may have if you prefer ana you do not have to take if you nave any objection. This medication is quite mild and certainly not addict ive when taken under these circumstances. Many patients find it a help to settle to sleep when they are bothered by the strange bed, the noise at night or the worry you feel before an operation. THE NEXT MEDICATION he has ordered for you wi l l be given to you one hour before your operation in the morning. This medication, sometimes called the Ereoperative medication or "preop. med." y the nurses, is quite strong ana is given by needle. You wi l l start to feel very drowsy in about 15 minutes and your tongue might feel dry. Be sure that you have passed your water just before this and are ready to settle down to sleep before it's time to go to the operating room. 133 THE PHYSIOTHERAPIST This lady is concerned about helping you get better faster. She will explain the "stir-up" exer-cises and help you to learn how to do them. You will be getting another chance to practice after the "Operation Tomorrow" presen-tation this evening. We all know how important these exercises are for you to learn. How well you do your exercises after the operation has a lot to do with how fast you get better. Your physiotherapist will be visiting you after your operation to see how you get along and help you to do your exercises. THE "PREP NURSE" This nurse will be giving you what is known as a preoperative skin pre-paration and called a "prep" by the nurses and a shave by you. It is routine to shave a wide space all around the area where your incision will be and to clean the skin with a special disinfecting soap. Hair can't be disinfected so it is removed by shaving. We don't want you to have any infection after your operation. YOUR NURSE Your nurse will be popping in and out during the evening, but she has some special things to do in helping you to prepare: THE CONSENT FORM Your nurse will be asking you to sign a consent-for-surgery form. This is a standard practice in hospitals to make sure that a person knows he is having an operation and what kind. This also gives your doctor permission to do your surgery. - 134 -THE ENEMA Your doctor will order an enema for you if he thinks it is necessary. In an operation like yours, your bowel is quite slow afterwards. If you haven't had an enema before the operation you can get quite consti-pated and that is no fun when you have an abdominal incision. o a V THE BATH Your nurse will encourage you to have a bath at bedtime with a spe-cial hospital soap. This is also part of the preparation of your skin to prevent infection. Ask her where the tubs or showers are and tell her which you prefer. Remember that your nurses are with you 24 hours of every day and the reason they are is to be able to help. Let them know what your problems are and what kind of help you need. AT BEDTIME Your nurse will be coming around with the sleeping pills about 10:00 p.m. If you want to stay up and read or watch T.V. let her know. The shift changes at 1 1:30 p.m. and she could ask the night nurse to give you a sleeping pill if you prefer. After midnight your food and water supply is C U T off. We aren't trying to be mean. This is a very important precaution before a qeneral anaesthetic. Please do not eat or drink ANYTHING after mid-night. If you do this can be a serious danger during the opera-tion, and the anaesthetic will have to be delayed or cancelled depending on what you ate. Your water iyg will be removed and a FASTING sign will be put on your bed to remind you and the nurses. DO rooT - 135 -THE MORNING OF YOUR OPERATION When you first wake up in the morning don't forget to leave a sample of urine for the nurse when you go to the bathroom. A routine test of your urine is expected by your doctor. Your nurse will be reminding you about other special preparations which are done for your safety: VALUABLES? Al l personal valuables such as watches, rings and money are listed and locked away while you are in the operating room. You can ask to have them back as soon as you return. MAKE-UP? Al l make-up and nail polish is removed so that the anaesthetist can look at the colour of your skin and nails during the operation. - 136 -REMOVABLES ? Other removable objects such as hairpins, glasses, contact lenses, dentures, wigs, hearing aids, pierced earrings, etc., should be removed and stored away. We ask you to do this because loose objects can injure you when you are asleep as well as being lost or broken. Y O U R N E E D L E Remember to pass your water just before your needle is due and settle into bed to wait for your nurse. GOING TO THE O.R. Final ly the big moment arr ives. A nurse from the O.R. wi l l come to take you to the operating room on a stretcher. She wi l l cover your hair with a l i t t le cap and wi l l take you up to the operating room on the 6th Floor. There, she wi l l introduce you to the nurse who wi l l stay with you during your operation. Don't forget your date with "Operation Tomorrow" at 6:30 p.m.! - 137 -APPENDIX B SCRIPT OF SOUND-AND-SLIDE PRESENTATION: "OPERATION TO-MORROW" - 138 -OPERATION TOMORROW Welcome t o S t . P a u l ' s H o s p i t a l . I am here t o h e l p make you f a m i l i a r w i t h t he events which w i l l o c c u r b e f o r e and a f t e r y o u r o p e r a t i o n . I w i l l t r y t o answer any q u e s t i o n s you have, so remember them and ask me a f t e r the s l i d e s a r e ov e r . F i r s t , l e t me i n t r o d u c e you t o some o f the members o f the h e a l t h team t h a t w i l l be l o o k i n g a f t e r you. I t t a k e s many d i f f e r e n t p e o p l e w i t h d i f f e r e n t s k i l l s t o t o t a l l y look a f t e r any one p a t i e n t . I t i s s o m e t i -mes d i f f i c u l t t o i d e n t i f y who you are t a l k i n g t o by h i s or her u n i f o r m , but he w i l l u s u a l l y have a name t a g on, or you can s i m p l y ask him. In t h e back row on the f a r l e f t i s a 1. R e g i s t e r e d Nurse, s t a n d i n g h o l d i n g a t r a y o f m e d i c i n e s , she may be a s s i g n e d t o g i v e you c a r e or t o s u p e r v i s e t h o s e g i v i n g y o u r c a r e . 2. S t a n d i n g b e s i d e t he nurse w i t h a wh i t e j a c k e t on and a s t e t h o s c o p e around h i s neck, i s an i n t e r n e . R e s i d e n t s and I n t e r n e s are doc-t o r s who are g a i n i n g e x p e r i e n c e by working i n the h o s p i t a l under t h e s u p e r v i s i o n o f more s e n i o r d o c t o r s . 3. Next t o the I n t e r n e i s the P r a c t i c a l Nurse who i n t h i s p i c t u r e has a green c r o s s on her cap. She g i v e s n u r s i n g c a r e under the super-v i s i o n o f a R e g i s t e r e d Nurse. 4. Next i s a member o f the housekeeping s t a f f wearing a g o l d u n i f o r m . Members o f t h i s department are r e s p o n s i b l e f o r k e e p i n g t he h o s p i -t a l c l e a n . - 139 -5. The O r d e r l y i s on the f a r r i g h t h o l d i n g a t r e a t m e n t t r a y . He i s t r a i n e d t o a s s i s t nurses i n c a r i n g f o r male p a t i e n t s and i s i d e n -t i f i a b l e by the b l u e t r i m on h i s c o l l a r . 6. In the f r o n t row on the f a r l e f t i s a l a d y wearing a pink d r e s s and h o l d i n g a meal t r a y . She i s one o f the members o f the d i e t a r y department and you w i l l see them on your ward. 7 . The g i r l s i t t i n g i n the m i d d l e wearing a b l u e s h i r t and w h i t e b l o u s e i s a p h y s i o t h e r a p i s t . L a t e r she w i l l be t e a c h i n g you the e x e r c i s e s you must do a f t e r your o p e r a t i o n and w i l l be h e l p i n g you do them on the ward. 8 . The Head Nurse, s e a t e d on the r i g h t h o l d i n g a c h a r t , i s an e x p e r i e n c e d R e g i s t e r e d Nurse who i s r e s p o n s i b l e f o r a l l the n u r s i n g c a r e g i v e n on her ward. On a d m i s s i o n t o h o s p i t a l you gave the A d m i t t i n g C l e r k i n f o r m a t i o n . The A d m i t t i n g p r o c e d u r e may or may not have i n c l u d e d the t a k i n g o f b l o o d sample from y o u r arm. You were then t a k e n t o the ward. I f the l a d y had a r e d smock on, she was a v o l u n t e e r member o f the Women's A u x i l l i a r y and t h i s i s one o f t h e i r s e r v i c e s . On the ward you were g r e e t e d by a U n i t C l e r k or by a n u r s e . The e v e n i n g b e f o r e y o u r s u r g e r y you w i l l r e c e i v e what we c a l l P r e - o p e r a t i v e P r e p a r a t i o n or "Preop-Prep". - 140 -For most o f you a s k i n shave i s r e q u i r e d . As s k i n h a i r i s a p o s s i b l e s o u r c e o f i n f e c t i o n , i t i s removed. Your i n c i s i o n w i l l not be as l a r g e as t he a r e a shaved. I t i s a good i d e a t o t a k e a tub bath or shower ( i f p o s s i b l e ) t h e n i g h t b e f o r e or the morning o f y o u r s u r g e r y w i t h s p e c i a l h o s p i t a l soap. An enema or c l e a n s i n g o f the bowel i s n e c e s s a r y f o r abdominal s u r g e r y and some o t h e r t y p e s o f s u r g e r y as w e l l . The enema p r e v e n t s you from h a v i n g a bowel movement imme d i a t e l y a f t e r s u r g e r y . The nurse on yo u r ward w i l l i n f o r m you i f you are t o have an enema. . The A n a e s t h e t i s t i s a d o c t o r w i t h s p e c i a l t r a i n i n g i n p u t t i n g p a t i e n t s t o s l e e p or making a c e r t a i n a r e a numb. He may v i s i t you or j u s t r e v i e w y o u r c h a r t t o o b t a i n t he i n f o r m a t i o n he r e q u i r e s . I f he v i s i t s he w i l l ask you q u e s t i o n s and p l e a s e f e e l f r e e t o ask him q u e s t i o n s . T h e r e are t h r e e t y p e s o f a n a e s t h e s i a : a) With a g e n e r a l a n e s t h e t i c you go c o m p l e t e l y t o s l e e p i n a few seconds. T h i s a n e s t h e t i c i s i n j e c t e d by a n e e d l e i n t o y o u r arm. b) With a s p i n a l a n e s t h e t i c you have no c e n s a t i o n from t he w a i s t downwards. c) With a l o c a l a n e s t h e t i c o n l y a s p e c i f i c a r e a has no s e n s a t i o n . The c h o i c e o f a n e s t h e s i a i s made by your d o c t o r and your a n e s t h e t i s t . - 141 -11. As t h i s i s a t e a c h i n g h o s p i t a l , an i n t e r n e may t a k e y o u r h i s t o r y on b e h a l f o f y o u r surgeon. I t i s n e c e s s a r y t h a t you c o o p e r a t e and answer h i s or her q u e s t i o n s . 12. You w i l l s i g n a s u r g e r y consent form. T h i s g r a n t s t he d o c t o r p e r -m i s s i o n t o p e r f o r m the s u r g e r y and a l s o i n d i c a t e s t h a t you have had the s u r g e r y e x p l a i n e d t o you. I f you do not s i g n t h i s form the s u r g e r y cannot be done. 13. As everyone i s a b i t nervous b e f o r e s u r g e r y , t he d o c t o r e n s u r e s you a good n i g h t ' s s l e e p by g i v i n g you a s l e e p i n g m e d i c a t i o n . 14. A f t e r 12 m i d n i g h t t o n i g h t you w i l l not be a l l o w e d t o e a t or d r i n k a n y t h i n g because y o u r stomach must be empty t o ensure y o u r s a f e t y . Even y o u r water j u g i s taken away so p l e a s e do not t a k e a d r i n k from the tap i n the bathroom, or e a t a n y t h i n g . T h i s i s a r e q u e s t on b e h a l f o f y o u r a n e s t h e t i s t . I f yo u r s u g e r y i s v e r y l a t e or you are h a v i n g a l o c a l a n e s t h e t i c , s p e c i a l i n s t r u c t i o n s r e g a r d i n g f o o d w i l l be made. 15. The morning o f s u r g e r y . On the morning o f s u r g e r y s p e c i a l p r e p a r a t i o n s may be n e c e s s a r y depending on the typ e o f s u r g e r y t o be done. I cannot t e l l you what t h e s e w i l l be as each s u r g e r y d i f f e r s . Your ward nu r s e w i l l e x p l a i n what has t o be done. 16. A u r i n e sample w i l l be taken your f i r s t morning i n h o s p i t a l . When you wake up and want t o go t o the bathroom, p l e a s e use yo u r bedpan or u r i -n a l and s e t i t a s i d e f o r the nu r s e . - 142 -A s p e c i a l note: L a d i e s - we r e q u e s t t h a t you remove a l l t r a c e s o f makeup and n a i l p o l i s h b e f o r e g o i n g t o the O p e r a t i n g Room. I t i s e s s e n t i a l t h a t the A n e s t h e t i s t be a b l e t o o b s e r v e t h e c o l o u r o f y o u r l i p s and n a i l s . Do not a p p l y makeup o f any k i n d i n the morning. I f y o u r h a i r i s l o n g i t s h o u l d be b r a i d e d and a l l h a i r p i n s , e t c . be removed. Your h a i r w i l l be c o v e r e d d u r i n g s u r g e r y . Men - i t i s a d v i s a b l e t h a t you shave i n the morning. To a l l o f you - remove your f a l s e e y e l a s h e s , eye g l a s s e s , c o n t a c t l e n -s e s , wigs, h a i r p i e c e s , h e a r i n g a i d s , p i e r c e d e a r r i n g s and a l l o t h e r j e w e l l r y . For d e n t u r e wearers a s p e c i a l cup i s p r o v i d e d f o r y o u r t e e t h and l e f t at the b e d s i d e u n t i l y o u r r e t u r n t o the ward. Wearing a p p a r e l t o the O p e r a t i n g Room i s a h o s p i t a l gown o n l y . P l e a s e do not wear underwear. The time of y o u r s u r g e r y may be moved up or d e l a y e d a c c o r d i n g t o the O p e r a t i n g Room s c h e d u l i n g . Sometimes a s u r g e r y t a k e s more time and sometimes l e s s time, then s c h e d u l e d . Don't be s u r p r i s e d i f y o u r s u r g e r y i s e a r l i e r or l a t e r than you had e x p e c t e d . . About an hour b e f o r e your s u r g e r y time you w i l l r e c e i v e a "preop-m e d i c a t i o n " . T h i s may be a p i l l o r an i n j e c t i o n . The m e d i c a t i o n w i l l make you drowsy and r e l a x e d . Do not be alarmed i f y o u r mouth gets v e r y d r y . T h i s i s an e f f e c t some drugs have. P l e a s e s t a y i n bed a f t e r you have had t h i s m e d i c a t i o n . - 143 -19. The next p e r s o n you w i l l n o t i c e i s from the O p e r a t i n g Room. T h i s p e r -son w i l l t r a n s f e r you t o a s t r e t c h e r and put a c o v e r over y o u r h a i r t o keep i t out o f the way and from g e t t i n g t a n g l e d . Then you w i l l be taken up t o the 6 t h f l o o r where the O p e r a t i n g Room i s l o c a t e d . 20. What the e l e v a t o r l o o k s l i k e from the s t r e t c h e r . 21. In the O p e r a t i n g Room you w i l l be g r e e t e d by a nurse who w i l l remain w i t h you d u r i n g your s u r g e r y . 22. A scene i n the O p e r a t i n g Room t h e a t e r , where nurses and d o c t o r s are p r e p a r i n g f o r s u r g e r y . 23. In t h i s p i c t u r e the nurses are moving a p a t i e n t from the s t r e t c h e r t o the O p e r a t i n g Room t a b l e . 24. A f t e r the s u r g e r y i s completed you w i l l go by s t r e t c h e r t o the P o s t A n e s t h e t i c Room. I f you have a had a l o c a l a n e s t h e t i c you w i l l p r o -b a b l y be r e t u r n e d d i r e c t l y t o y o u r room. In the P o s t A n e s t h e t i c Room t h e r e are many p a t i e n t s who, l i k e you, are waking up f r o m t h e a n a e s t h e t i c . Many n u r s e s a r e i n a t t e n d a n c e and w i l l be watching you c a r e f u l l y . T h e y . f r e q u e n t l y t a k e y o u r b l o o d p r e s s u r e , p u l s e and o b s e r v e the c o l o u r o f y o u r f a c e t o ensure a l l i s w e l l . They w i l l f r e q u e n t l y ask you your name. T h i s i s not because t h e y don't know you, but because t h e y want t o see how awake you a r e . The bed bars t h a t are up i n t h i s p i c t u r e are t h e r e f o r your s a f e t y . - 144 -At t h i s time I'd l i k e t o d i s p e l two common f e a r s : 1. T a l k i n g under a n e s t h e t i c . P a t i e n t s r a r e l y say a n y t h i n g when th e y are waking up, much l e s s something t h a t can be u n d e r s t o o d . 2. In the P o s t A n e s t h e t i c Room you may f e a r the per s o n next t o you i s t o o c l o s e . You are c l o s e , however, the nurses are v e r y c a r e f u l t o p r o t e c t your modesty. 25. I f you have had a g e n e r a l a n e s t h e t i c , you may wake up w i t h an oxygen mask over your mouth and nose. Do not be alarmed, oxygen i s g i v e n t o everyone who has had a g e n e r a l a n e s t h e t i c . The nurses and d o c t o r s are s k i l l e d i n j u d g i n g when i t i s time f o r you t o r e t u r n t o your ward. Your s t a y i n P o s t A n e s t h e t i c Room may v a r y from 1 hour t o s e v e r a l hours or sometimes o v e r n i g h t . Your r e l a t i v e s and v i s i t o r s w i l l not be a b l e t o v i s i t you i n the P o s t A n e s t h e t i c Room. 26. T h i s i s how you r e t u r n t o your ward. 27. The ward nurses w i l l check your b l o o d p r e s s u r e and p u l s e s e v e r a l t i m e s . 28. They w i l l a l s o check your d r e s s i n g s or y o u r c a s t . I f you have a d r e s s i n g , i t may be b i g or small depending on your d o c t o r and y o u r s u r g e r y . The d r e s s i n g may f e e l t i g h t u n t i l you get used t o i t . C e r t a i n s u r g e r i e s have no d r e s s i n g s . These i n c i s i o n s a re s e a l e d w i t h a s p e c i a l s p r a y . Some s u r g e r i e s may r e q u i r e tubes t o keep y o u r stomach empty or t o p r e v e n t f l u i d from c o l l e c t i n g under y o u r s k i n and c a u s i n g s w e l l i n g and d i s c o m f o r t . Do not be alarmed at the c o l o r of the d r a i n a g e - i t may be r e d , brown or g r e e n i s h but i s p e r f e c t l y normal. - 145 -Soon a f t e r you wake up from the a n e s t h e t i c or get the f e e l i n g back i n y o u r l e g s (depending upon what t y p e o f a n e s t h e t i c you have had) t h e nur s e s w i l l s t a r t y o u r ' s t i r - u p program'. T h i s i n c l u d e s : deep b r e a t h i n g and coughing l e g e x e r c i s e s - push both knees down hard on t h e bed, the n r e l a x , a l s o moving y o u r l e g s up and down i n bed t u r n i n g from s i d e t o s i d e i n bed. The deep b r e a t h i n g and coughing i s done t o h e l p your lungs keep expanded and b r i n g up any b i t s o f phlegm which may be s i t t i n g i n them. The nurse w i l l show you how t o su p p o r t y o u r i n c i s i o n when you cough so t h a t i t doesn't cause p a i n . The l e g e x e r c i s e s and t u r n i n g are done t o s t i m u l a t e b l o o d f l o w t o e v e r y p a r t o f y o u r body. The b l o d tends t o f l o w s l o w l y when you must l i e i n 1 p o s i t i o n i n bed. In o r d e r t o have a speedy and complete r e c o v e r y you must a c t i v e l y p a r t i c i p a t e i n t h i s s t i r - u p program. In some cases the p h y s i o t h e r a p i s t w i l l t e a c h you the b e s t way t o b r e a t h e , cough and do e x e r c i s e s b e f o r e y o u r s u r g e r y and a l s o see you a f t e r s u r g e r y . A f t e r a s u r g i c a l p r o c e d u r e you can e x p e c t d i s c o m f o r t , or an ache, or a p a i n . The n u r s e s cannot remove e v e r y b i t o f d i s c o m f o r t as so much m e d i c a t i o n would put you i n s l e e p . Then you would not b r e a t h e as • d e e p l y or be a b l e t o do the ' s t i r - u p ' program. I s a i d you can ex p e c t t o f e e l u n c o m f o r t a b l e . However, p a i n k i l l i n g m e d i c a t i o n w i l l be g i v e n f r e q u e n t l y and you can a l s o ask f o r i t . As t h e days go by t h e medica-t i o n w i l l be needed l e s s f r e q u e n t l y . - 146 -F o l l o w i n g your s u r g e r y you may n o t i c e an i n t r a v e n o u s g o i n g i n t o your arm. T h i s i s n e c e s s a r y because you are not e a t i n g and/or some medica-t i o n s are g i v e n i n t r a v e n o u s l y . The d u r a t i o n o f the i n t r a v e n o u s w i l l depend upon y o u r d o c t o r ' s o r d e r . E a t i n g o f f o o d a f t e r s u r g e r y w i l l be r e s t r i c t e d a c c o r d i n g t o what' s u r g e r y you have had. Somethimes the a n e s t h e t i c w i l l a f f e c t the s t o -mach and make the bowel s l u g g i s h . T h e r e f o r e your f o o d i s r e s t r i c t e d . When e v e r y t h i n g i s working p r o p e r l y you w i l l be p a s s i n g gas or the n u r s e when l i s t e n i n g t o y o u r abdomen w i l l hear " r u m b l i n g sounds." U s u a l l y abdominal t y p e s o f s u r g e r y a r e f i r s t l i m i t e d t o i n t r a v e n o u s f l u i d s and then t o f l u i d s by mouth. G r a d u a l l y the f o o d i s changed t o a s o f t d i e t and then t o a f u l l r e g u l a r d i e t . F o l l o w i n g c h e s t and abdominal t y p e s o f s u r g e r y you w i l l s l e e p a l o t . R e s t i s i m p o r t a n t i n t h e h e a l i n g p r o c e s s . S l e e p when you can but when awake remember t o do the ' s t i r - u p ' program o f moving your l e g s , deep b r e a t i n g and c o u g h i n g . On o r d e r s from y o u r d o c t o r , p r o b a b l y the f i r s t or second day a f t e r y o u r o p e r a t i o n you w i l l be a s s i s t e d t o s i t on the edge o f the bed f o r a few minutes s e v e r a l times a day. Then you may s t a r t w a l k i n g s h o r t d i s t a n -c e s . I t i s i m p o r t a n t t o get up and about as soon as p o s s i b l e because i t h e l p s y o u r b l o o d t o c i r c u l a t e and p r e v e n t s y o u r muscles from g e t t i n g s t i f f and s o r e . A c t i v i t y a l s o h e l p s you f e e l b e t t e r . - 147 -APPENDIX C NURSING HISTORY OUTLINE - 148 -PREOPERATIVE INTERVIEW GUIDE Gen e r a l O b s e r v a t i o n s : 1. Ge n e r a l appearance 2. F a c i a l e x p r e s s i o n 3. B e h a v i o r d u r i n g i n t e r v i e w 4. Communicativeness P e r c e p t i o n s Re I l l n e s s : 5. What caused you t o come t o the h o s p i t a l ? 6. How l o n g have you had yo u r problem? 7. What do you t h i n k caused your i l l n e s s ? 8. When d i d you f i r s t go t o the d o c t o r ? 9. How l o n g have you been g o i n g t o yo u r f a m i l y d o c t o r ? 10. D i d you see a s p e c i a l i s t as w e l l ? 11. What has b o t h e r e d you most about your i l l n e s s ? 12. Have you been on any m e d i c a t i o n s or s p e c i a l d i e t s at home? 13. Do you have any o t h e r m e d i c a l problems which might r e s t r i c t y o u r a c t i v i t y i n h o s p i t a l ? P e r c e p t i o n s Re H o s p i t a l i z a t i o n and Treatment: 14. Have you been i n h o s p i t a l b e f o r e ? 15. When? F o r what r e a s o n s ? 16. What do you miss most i n h o s p i t a l ? 17. What i s the n i c e s t t h i n g t h a t happened t o you i n h o s p i t a l ? 18. What has yo u r d o c t o r t o l d you about your i l l n e s s ? 19. Your o p e r a t i o n ? 20. When do you e x p e c t t o be a b l e t o go home? - 149 -21. To go back t o s c h o o l , work, e t c . ? 22. What k i n d s o f t h i n g s make you f e e l b e t t e r when you are s i c k ? 23. What k i n d s o f problems do you t h i n k someone who i s g o i n g t o have an o p e r a t i o n l i k e y o u r s w i l l have? 24. How do you t h i n k a p e r s o n f e e l s b e f o r e an o p e r a t i o n l i k e y o u r s ? F a m i l y and Home L i f e : 25. With whom do you l i v e ? 26. Do you have a f a m i l y ? Where do the y l i v e ? 27. C h i l d r e n ? 28. W i l l t h e y be coming t o v i s i t you i n h o s p i t a l ? 29. Do you want any r e s t r i c t i o n s on yo u r v i s i t o r s ? 30. Where w i l l you be g o i n g f o l l o w i n g h o s p i t a l i z a t i o n ? 31. Who w i l l be a b l e t o h e l p you when you go home? 32. W i l l you have t r o u b l e g e t t i n g around at home? 33. Are the bedrooms, bathrooms, k i t c h e n c o n v e n i e n t ? 34. Do you l i v e near a drug s t o r e ? f o o d market? 35. How i s the f a m i l y c o p i n g w i t h o u t you at home? 36. Is t h e r e any f i n a n c i a l s t r a i n caused by t h i s i l l n e s s and h o s p i t a l i z a t i o n ? L i f e S t y l e : 37. Do you work? 38. What typ e o f work do you do? 39. Have you always done t h i s k i n d o f t h i n g ? 40. Do you e n j o y your work? 41. How has you r i l l n e s s a f f e c t e d y o u r work? 42. What do you l i k e t o do f o r fun? - 150 -4 3 . Has y o u r i l l n e s s a f f e c t e d any o f y o u r hobbies or s p o r t s a c t i v i t i e s ? 4 4 . How has y o u r i l l n e s s a f f e c t e d y o u r s o c i a l l i f e ? - 151 -APPENDIX D PREOPERATIVE COGNITIVE ASSESSMENT QUESTION GUIDELINES - 152 -NO. 1 QUESTION GUIDE 1. D i d you get s e t t l e d i n t o the ward a l l r i g h t ? F i n d out where e v e r y t h i n g i s ? Any problems about t h a t ? 2. Have you had any o f y o u r s p e c i a l v i s i t o r s ? Prep Nurse? P h y s i o t h e r a p i s t ? I n t e r n ? A n a e t h e t i s t ? Other? 3. Have you had your enema? How d i d you f e e l about t h a t ? 4. D i d you s i g n y o u r consent? 5. What d i d your a n a e t h e t i s t t e l l you? Your P h y s i o t h e r a p i s t ? Your nurse? 6. How do you f e e l about t a k i n g a s l e e p i n g p i l l t o - n i g h t ? 7. How do you e x p e c t t o f e e l a f t e r y o u r n e e d l e tomorrow morning? 8. Can you remember what you have t o do tomorrow morning? 9. Any q u e s t i o n s about v a l u a b l e s ? make-up? removables? 10. Is t h e r e a n y t h i n g i n the pamphlet "You and Your O p e r a t i o n " t h a t you don't u n d e r s t a n d or would l i k e t o t a l k about a l i t t l e b i t ? - 153 -NO. 2 QUESTION GUIDE 1. Do you remember what k i n d o f a n a e s t h e t i c you w i l l have? 2. What k i n d o f m e d i c a t i o n s a re you g i v e n t o make your a n a e s t h e t i c work b e t t e r on the ev e n i n g b e f o r e ? t he morning o f s u r g e r y ? 3. What f e a r s do you t h i n k p e o p l e have about an a n a e s t h e t i c ? 4. How w i l l y o u r a n a e s t h e t i c be g i v e n t o you? 5. How w i l l you f e e l when you get your a n a e s t h e t i c ? 6. Have you e v e r y had an i n t r a v e n o u s b e f o r e ? 7. What d i d you t h i n k about the i n t r a v e n o u s , t he f i r s t time you saw i t ? ( D i s p e l 3 major m i s c o n c e p t i o n s ) 8. Why do you' t h i n k you w i l l need an i n t r a v e n o u s a f t e r your o p e r a t i o n ? 9. How long do you ex p e c t t o have an i n t r a v e n o u s a f t e r your o p e r a t i o n ? 10. What k i n d o f f o o d do you e x p e c t t o be a b l e t o e a t when the i n t r a v e n o u s f i r s t comes out? - 154 -11. Do you e x p e c t t o have t r o u b l e w i t h f o o d s f o r any time a f t e r you go home? 12. When do you e x p e c t t o f i r s t get out o f bed? To s t a r t your l e g e x e r c i s e s , deep b r e a t h i n g and coughing and t u r n i n g ? 13. How much moving about do you e x p e c t t o do when you f i r s t g e t o u t o f bed? 14. Why do we encourage you t o do l e g e x e r c i s e s ? Deep b r e a t h i n g and coughing? T u r n i n g and g e t t i n g up and walking? 15. How o f t e n do you have t o do your e x e r c i s e s ? 16. Why do we ask you t o h e l p " s p l i n t " y o u r wound d u r i n g coughing? 17. Can you g i v e me a q u i c k d e m o n s t r a t i o n o f how you w i l l do yo u r e x e r c i s e s ? 18. Can you remember s e e i n g t h e s e p i c t u r e s o f the O.R. and the P.A.R. or Reco v e r y Room? 19. Is t h e r e a n y t h i n g i n t h e s e p i c t u r e s t h a t b o t h e r s you? 20. Would you l i k e t o ask me any q u e s t i o n s about t h e s e p i c t u r e s ? - 155 -APPENDIX E POSTOPERATIVE PATIENT QUESTIONNAIRE - 156 -SECTION A DIRECTIONS: How IMPORTANT do you t h i n k i t i s f o r a person t o KNOW ABOUT th e f o l l o w i n g p e o p l e and p r o c e d u r e s b e f o r e h a v i n g an op e r a -t i o n l i k e y o u r s . CIRCLE t he number (1,2,3,4 or 5) which BEST shows how you f e e l about each q u e s t i o n . Each q u e s t i o n w i l l have a 5-number s c a l e which means: DON'T KNOW Very Q u i t e F a i r l y Not V e r y Not Important Important Important Important Important A t A l l I f you DON'T-KNOW about a q u e s t i o n and c a n ' t answer i t , mark a / i n the box headed DON'T KNOW. DON'T KNOW 5 4 3 2 1 1. Who the head nurse i s 5 4 3 2 1 2. What the i n t e r n or r e s i d e n t does 5 4 3 2 1 3. What the p h y s i o t h e r a p i s t does f o r you 5 4 3 2 1 4. Why you have a med i c a l h i s t o r y and p h y s i c a l e x a m i n a t i o n b e f o r e your o p e r a t i o n 5 4 3 2 1 5. How the a n a e t h e t i s t h e l p s you 5 4 3 2 1 6. Why you have a s l e e p i n g p i l l t h e n i g h t b e f o r e the o p e r a t i o n 7. Why you get a nee d l e the morning o f s u r g e r y 5 4 3 2 1 8. Why your s k i n i s shaved b e f o r e s u r g e r y 5 4 3 2 1 9. Why you s i g n a consent form b e f o r e s u r g e r y 5 4 3 2 1 10. Why you may have an enema b e f o r e s u r g e r y 5 4 3 2 1 11. Why you c a n ' t e a t or d r i n k the n i g h t b e f o r e s u r g e r y 5 4 3 2 1 12. Why your v a l u a b l e s are l o c k e d away 5 4 3 2 1 - 157 -13. Why you remove yo u r make-up b e f o r e s u r g e r y 14. How a g e n e r a l a n a e s t h e t i c i s g i v e n 15. How i t f e e l s t o have a g e n e r a l a n a e s t h e t i c 16. What the o p e r a t i n g room l o o k s l i k e 17. What the O p e r a t i n g Room Nurse does f o r you 18. What the r e c o v e r y room l o o k s l i k e 19. How you are taken t o the o p e r a t i n g room 20. Why you are checked so o f t e n i n the r e c o v e r y room 21. Why you might r e c e i v e oxygen by mask i n the r e c o v e r y room 22. What an i n t r a v e n o u s i s 23. Why you have an i n t r a v e n o u s 24. How l o n g you w i l l have an i n t r a v e n o u s 25. How you f e e l when you have an i n t r a v e n o u s 26. Where yo u r i n c i s i o n w i l l be 27. What yo u r d r e s s i n g s w i l l be l i k e 28. Why you have a d r a i n i n your i n c i s i o n 29. What the d i s c h a r g e from y o u r i n c i s i o n l o o k s l i k e 30. How f a s t your i n c i s i o n h e a l s 31. How s t r o n g t he s t i t c h e s a r e 32. How much p a i n you w i l l have 33. How yo u r p a i n i s c o n t r o l l e d DON'T KNOW 5 4 3 2 1 | | 5 4 3 2 1 | [ 5 4 3 2 1 j | 5 4 3 2 1 | | 5 4 3 2 1 j | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 [ | 5 4 3 2 1 | [ 5 4 3 2 1 | | 5 4 3 2 1 [ [ 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 | | 5 4 3 2 1 I I - 158 -34. How long your p a i n w i l l l a s t 5 4 3 2 35. How h a b i t - f o r m i n g p a i n k i l l e r s and s l e e p i n g p i l l s a r e f o r you 5 4 3 2 36. How you do p o s t o p e r a t i v e e x e r c i s e s 5 4 3 2 37. Why you do p o s t o p e r a t i v e e x e r c i s e s 5 4 3 2 38. Why the nurses keep p e s t e r i n g you t o get out o f bed and e x e r c i s e when you don't f e e l l i k e i t 5 4 3 2 39. Why you might have a stomach tube a f t e r s u r g e r y 5 4 3 2 40. How i t f e e l s t o have a stomach tube 5 4 3 2 41. When yo u r stomach tube comes out 5 4 3 2 42. When you s t a r t e a t i n g a f t e r your o p e r a t i o n 5 4 3 2 43. What k i n d s o f f o o d you can e a t a f t e r s u r g e r y 5 4 3 2 44. When you can ex p e c t your f i r s t bowel movement 5 4 3 2 45. When you f i r s t get out o f bed 5 4 3 2 46. When you can e x p e c t t o go home 5 4 3 2 47. When you can ex p e c t t o go back t o work or c a r r y on yo u r normal a c t i v i t i e s 5 4 3 2 48. Why you can sometimes f e e l " b l u e " a few days a f t e r your o p e r a t i o n 5 4 3 2 49. The i n f o r m a t i o n g i v e n t o you i n the pamphlet "You and Your O p e r a t i o n " 5 4 3 2 50. The i n f o r m a t i o n g i v e n t o you i n the s o u n d - a n d - s l i d e p r e s e n t a t i o n c a l l e d " O p e r a t i o n To-morrow" 5 4 3 2 - 159 -SECTION B DIRECTIONS: CIRCLE t h e l e t t e r (A,B,C OR D) b e s i d e the answer you b e l i e v e i s t h e BEST answer t o each o f t h e f o l l o w i n g q u e s t i o n s . 1. Leg e x e r c i s e s are i m p o r t a n t a f t e r s u r g e r y because t h e y A. h e l p you t o keep up muscle s t r e n g t h B. h e l p you t o get b e t t e r f a s t e r C. speed up y o u r b l o o d c i r c u l a t i o n D. p r e v e n t problems due t o slow b l o o d c i r c u l a t i o n 2. A s l e e p i n g p i l l t h e n i g h t b e f o r e s u r g e r y A. i s n e c e s s a r y t o s t o p w o r r y i n g B. h e l p s you t o r e l a x and need l e s s a n a e s t h e t i c C. i s a p a r t o f the p r e p a r a t i o n f o r your a n a e s t h e t i c D. c o u l d be a d d i c t i v e and i s not n e c e s s a r y t o take 3. You are asked t o s u p p o r t o r " s p l i n t " y o u r i n c i s i o n when c o u g h i n g  because A. coughing might cause your i n c i s i o n t o open B. i t makes c o u g h i n g l e s s p a i n f u l C. i t t a k e s y o u r mind o f f the p a i n D. you can f e e l y o u r c h e s t expand t h a t way. 4. In o r d e r f o r the a n a e s t h e t i s t t o be a b l e t o check y o u r c i r c u l a t i o n  d u r i n g the a n a e s t h e t i c you are asked t o remove y o u r A. r i n g s B. watch C. n a i l p o l i s h D. d e n t u r e s 5. A stomach tube a t t a c h e d t o s u c t i o n may be put i n p l a c e t h r o u g h y o u r  nose because A. y o u r G a l l B l a d d e r i s n ' t working any more B. y o u r D o c t o r wants t o measure the d r a i n a g e from y o u r stomach C. y o u r bowel i s n ' t v e r y a c t i v e D. you w i l l p r o b a b l y be nauseated and vomit o t h e r w i s e - 160 -6. Your i n t r a v e n o u s w i l l be stopped A. about the 4 t h day a f t e r s u r g e r y B. when you are a b l e to t a k e f l u i d s by mouth C. when you f e e l w e l l enough t o e a t D. when you are p a s s i n g gas 7. You have a d r a i n i n yo u r i n c i s i o n because A. i t h e l p s t o d r a i n o f f b i l e B. f l u i d s c o l l e c t i n g i n the wound can become i n f e c t e d C. i t h e l p s h e a l i n g D. you have a l o t o f d r a i n a g e a f t e r your o p e r a t i o n 8. A g e n e r a l a n a e s t h e t i c i s when you are A. c o m p l e t e l y a s l e e p B. c o m p l e t e l y f r e e o f p a i n C. u n c o n s c i o u s D. unable t o move and f e e l but awake 9. You can ex p e c t t o go home a f t e r y o u r o p e r a t i o n A. when you f e e l w e l l enough B. i n 8 t o 10 days C. when your i n c i s i o n has h e a l e d s a t i s f a c t o r i l y D. when you can e a t w i t h o u t any t r o u b l e 10. A f t e r your o p e r a t i o n you can e x p e c t t o e a t A. a f a t - r e s t r i c t e d d i e t f o r 2 weeks B. a normal d i e t C. a l l the f o o d s you l i k e D. a n y t h i n g t h a t agrees w i t h you - 161 -SECTION C DIRECTIONS: Put i n the box p r o v i d e d t o show how you p r e f e r t o l e a r n about your o p e r a t i o n b e f o r e s u r g e r y . B r i e f l y t e l l why you made your c h o i c e . A PRIVATE SESSION WITH YOUR NURSE A GROUP SESSION WHERE YOU CAN SHARE YOUR FEELINGS WITH OTHER PATIENTS A CLASS A COMBINATION OF ONE OR MORE OF THE ABOVE OTHER 6. P l e a s e w r i t e any a d d i t i o n a l comments which you t h i n k would be h e l p f u l i n p l a n n i n g t o g i v e o t h e r p a t i e n t s l i k e y o u r s e l f the i n f o r m a t i o n you f e e l i s i m p o r t a n t . COMMENTS: - 162 -APPENDIX F FACTOR ANALYSIS PREOPERATIVE LEARNING NEEDS - 163 -APPENDIX F FACTOR ANALYSIS: PREOPERATIVE LEARNING NEEDS * Item Appears In Other F a c t o r s FACTOR 1: 44.19% o f V a r i a n c e E x p l a i n e d FACTOR 2 ITEM AND DESCRIPTION LOADING h 31. How s t r o n g t he s t i t c h e s are 0.818 1.000 30. How f a s t y o u r i n c i s i o n h e a l s 0.811 1.000 24. How l o n g you w i l l have an i n t r a v e n o u s 0.811 1.000 27. What yo u r d r e s s i n g s w i l l be l i k e 0.791 0.932 33. How yo u r p a i n i s c o n t r o l l e d 0.750 1.000 *34. How l o n g y o u r p a i n w i l l l a s t 0.635 0.966 *45. When you f i r s t get out o f bed 0.595 0.98 22. What an i n t r a v e n o u s i s 0.556 0.948 29. What the d i s c h a r g e from your d r e s s i n g l o o k s l i k e 0.524 1.000 44. When you can e x p e c t your f i r s t bowel movement 0.523 1.000 *37. Why you do p o s t o p e r a t i v e e x e r c i s e s 0.411 1.000 *19. How you are taken t o the o p e r a t i n g room 0.424 0.962 *32. How much p a i n you w i l l have 0.480 1.000 *41. When yo u r stomach tube comes out 0.437 1.000 *40. How i t f e e l s t o have a stomach tube 0.449 1.000 47. The i n f o r m a t i o n g i v e n t o you i n the pamphlet "Your and Your O p e r a t i o n " 0.462 0.928 FACTOR 2: 8.696% o f the V a r i a n c e E x p l a i n e d 13. Why you remove yo u r make-up b e f o r e s u r g e r y 8. Why yo u r s k i n i s shaved b e f o r e s u r g e r y 12. Why yo u r v a l u a b l e s are l o c k e d away 4. Why you have a m e d i c a l h i s t o r y and p h y s i c a l e x a m i n a t i o n b e f o r e your o p e r a t i o n 6. Why you have a s l e e p i n g p i 1 t h e n i g h t b e f o r e your o p e r a t i o n 9. Why you s i g n a consent b e f o r e s u r g e r y 5. How the a n a e t h e t i s t h e l p s you 7. Why you get a n e e d l e the morning o f s u r g e r y 20. Why you are checked so o f t e n i n the r e c o v e r y room 11. Why you c a n ' t e a t or d r i n k t h e n i g h t b e f o r e s u r g e r y *49. The i n f o r m a t i o n g i v e n you i n the pamphlet "You and Your O p e r a t i o n " 21. Why you might r e c e i v e oxygen by mask i n th e r e c o v e r y room 0.893 0.843 0.815 0.954 1.000 1.000 0.761 0.978 0.680 0.676 0.402 0.424 1.000 0.929 0.989 0.939 0.447 0.979 0.466 1.000 0.458 0.928 0.431 1.000 - 164 -APPENDIX F - Cont'd. FACTOR 3: 6.685% o f the V a r i a n c e E x p l a i n e d FACTOR 2 ITEM AND DESCRIPTION LOADING h 3. What the p h y s i o t h e r a p i s t does f o r you 0.832 1.000 * 5. How the a n a e s t h e t i s t h e l p s you 0.768 0.989 15. How i t f e e l s t o have a g e n e r a l a n a e s t h e t i c 0.646 0.959 *37. Why you do p o s t o p e r a t i v e e x e r c i s e s 0.544 1.000 *45. When you f i r s t get out o f bed 0.563 0.98 39. Why you might have a stomach tube a f t e r s u r g e r y 0.493 1.000 14. How a g e n e r a l a n a e s t h e t i c i s g i v e n 0.475 0.971 50. The i n f o r m a t i o n g i v e n t o you i n the S l i d e - a n d - S o u n d P r e s e n t a t i o n " O p e r a t i o n To-morrow" 0.409 0.970 *20. Why you are checked so o f t e n i n the r e c o v e r y room 0.405 0.979 FACTOR 4: 5.7016% o f the V a r i a n c e E x p l a i n e d 1. Who the head nurse i s 0.836 0.953 18. What the r e c o v e r y room loo k s l i k e 0.826 0.948 2. What the i n t e r n or r e s i d e n t does 0.701 0.941 *19. How you are taken t o the o p e r a t i n g room 0.581 • 0.962 16. What the o p e r a t i n g room l o o k s l i k e 0.545 0.988 *50. The i n f o r m a t i o n i n the p r e s e n t a t i o n " O p e r a t i o n To-morrow" 0.506 0.970 17. What the o p e r a t i n g room nurse does f o r you 0.405 0.939 *49. The i n f o r m a t i o n g i v e n t o you i n the pamphlet "You and Your O p e r a t i o n " 0.425 0.928 - 165 -APPENDIX F - Cont'd. FACTOR 5: 4.711% o f the V a r i a n c e E x p l a i n e d FACTOR 2 ITEM AND DESCRIPTION LOADING h *32. How much p a i n you w i l l have 0.658 1.000 25. How you f e e l when you have an i n t r a v e n o u s 0.610 0.984 *39. Why you might have a stomach tube a f t e r s u r g e r y 0.564 1.000 *41. When yo u r stomach tube comes out 0.514 1.000 26. Where y o u r i n c i s i o n w i l l be 0.512 0.898 *22. What an i n t r a v e n o u s i s 0.542 0.948 *34. How long your p a i n w i l l l a s t 0.460 0.966 *15. How i t f e e l s t o have a g e n e r a l a n a e s t h e t i c 0.457 0.959 23. Why you have an i n t r a v e n o u s 0.436 0.881 *40. How i t f e e l s t o have a stomach tube 0.473 1.000 FACTOR 6: 4.174% o f the V a r i a n c e E x p l a i n e d 46. When you can e x p e c t t o go home 0.808 0.973 42. When you s t a r t e a t i n g a f t e r your o p e r a t i o n 0.689 1.000 43. What k i n d s o f f o o d you can e a t a f t e r s u r g e r y 0.657 1.000 28. Why you have a d r a i n i n yo u r i n c i s i o n 0.615 0.985 *41. When your stomach tube comes out 0.499 1.000 *26. Where your i n c i s i o n w i l l be 0.491 0.898 *19. How you are taken t o the o p e r a t i n g Room 0.483 0.962 44. When you can e x p e c t your f i r s t bowel movement 0.432 1.000 *34. How long your p a i n w i l l l a s t 0.417 0.966 - 166 -APPENDIX G PATIENT COMMENTS PREOPERATIVE LEARNING PROGRAMS - 167 -Re Need f o r Knowledge " P a t i e n t s s h o u l d be informed; i g n o r a n c e i s not b l i s s " (INDIVIDUALIZED LEARNING GROUP) "For some p a t i e n t s , perhaps most, the l e s s t h e y know, the b e t t e r " (INCIDENTAL LEARNING GROUP) Re P r i v a t e T a l k w i t h Nurse "I f e e l the nurse has t o have the a b i l i t y t o f e e l out the p a t i e n t and know how much she can t e l l the p a t i e n t b e f o r e t he p a t i e n t c r a c k s or gets c o m p l e t e l y u p s e t " (INDIVIDUALIZED LEARNING GROUP) "Never h a v i n g had an o p e r a t i o n b e f o r e , I p e r s o n a l l y , f e l t h a v i n g a p r i -v a t e t a l k about i t the n i g h t b e f o r e h e l p e d answer many q u e s t i o n s and took away some o f the t e n s i o n I f e l t " (INDIVIDUALIZED LEARNING GROUP) "I f i n d i t e a s i e r t o ask q u e s t i o n s when on my own r a t h e r than i n a group (INCIDENTAL LEARNING GROUP) "I do not b e l i e v e t h a t any two c a s e s are a l i k e " (INCIDENTAL LEARNING GROUP) "She can f i l l you i n on what t o e x p e c t and you don't have t o worry so much" (INCIDENTAL LEARNING GROUP) "You can f e e l f r e e t o ask as many q u e s t i o n s as you l i k e about y o u r o p e r a t i o n " (INCIDENTAL LEARNING GROUP) - 168 -APPENDIX G - Cont'd. "They have worked w i t h many cases and knew what t o look f o r and can t e l l you each s t a g e you w i l l be g o i n g t h r o u g h " (INCIDENTAL LEARNING GROUP) "Some o f the i n f o r m a t i o n t h e y ( t h e n u r s e s ) gave me made me a l i t t l e s c a r e d , but not as much as i f I had not known" (INCIDENTAL LEARNING GROUP) Re Group S e s s i o n s "We can calm each o t h e r down" (INCIDENTAL LEARNING GROUP) "A group s e s s i o n . . . would put a p a t i e n t ' s mind at ease. Worry over some of the m a t t e r s can do a l o t o f harm. I know O p e r a t i o n To-morrow ( s l i d e - a n d - s o u n d p r e s e n t a t i o n ) h e l p e d me a l o t (CLASS LEARNING GROUP) Re I n d i v i d u a l i z e d L e a r n i n g Program "I was v e r y impressed w i t h the amount o f i n f o r m a t i o n made a v a i l a b l e t o me i n the form o f p r i n t e d and c l a s s - s l i d e i n f o r m a t i o n ( s l i d e - s o u n d p r e s e n t a t i o n ) (INDIVIDUALIZED LEARNING GROUP) "I f e e l the movie ( s l i d e - s o u n d p r e s e n t a t i o n and t a l k ) was a b i g h e l p and we a i r e d our thoughts and f e a r s , b u t , a l s o , a p r i v a t e t a l k w i t h the n u r s e i s r e a l l y more h e l p f u l , e s p e c i a l l y f o r a person's f i r s t s u r g e r y , as he or she may be too shy or embarrassed t o ask p e r s o n a l q u e s t i o n s i n f r o n t o f o t h e r p e o p l e " (INDIVIDUALIZED LEARNING GROUP) - 169 -APPENDIX G - Cont'd. Re E x p l a n a t i o n s From t he Doct o r "He i s the one you are u s u a l l y most c o n f i d e n t i n " (INCIDENTAL LEARNING GROUP) "I f e e l he ( t h e d o c t o r ) knows the most about my problem" (INCIDENTAL LEARNING GROUP) "And v e r y i m p o r t a n t i s a c l o s e r communication w i t h your d o c t o r and surgeon and i n t e r n , and b e i n g g i v e n a c h o i c e t o ask a l l k i n d s o f q u e s t i o n s about your c a s e " (INCIDENTAL LEARNING GROUP) 

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