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The effectiveness of a structured preoperative teaching program for the adult surgical patient Ricci, Joanne Roberta 1977

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THE EFFECTIVENESS OF A STRUCTURED PREOPERATIVE TEACHING PROGRAM FOR THE ADULT SURGICAL PATIENT by Joanne Roberta R i c c i B.S.N. University of B r i t i s h Columbia, 1975 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept this thesis as conforming to the THE UNIVERSITY OF BRITISH COLUMBIA AUGUST, 1977 Co) Joanne Roberta R i c c i , 1977 required standard In presenting this thesis i n p a r t i a l f u lfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t fr e e l y available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. The University of B r i t i s h Columbia Vancouver, Canada Date ABSTRACT This experimental study was designed to determine the effectiveness of a structured preoperative teaching programme for the adult s u r g i c a l patient as measured by several indicators. The major questions asked i n this study were: What are the effects of a structured preoperative teaching programme upon the adult surgical patient's length of hospital stay, postoperative complications, number of analgesics administered postoperatively, r e c a l l of knowledge explained preoperatively, and s a t i s f a c t i o n with his preoperative teaching. This study was conducted over a four month period, on one surgical ward of a large general h o s p i t a l . A t o t a l of f o r t y subjects met the c r i t e r i a of the study, and t h e i r informed consent was obtained. The f i r s t twenty subjects were assigned to the control group, and received the unstructured, pre-existing* preoperative i n s t r u c t i o n from the s t a f f nurses. The second twenty subjects made up the experimental group and received structured preoperative teaching i n small groups conducted by the investigator, with the aid of a slide-taped programme developed s p e c i f i c a l l y for the study. P r i o r to discharge, each subject was given two questionnaires to complete, and data were collected by means of a patient p r o f i l e sheet. The two groups of subjects were found to be s i m i l a r when compared on selected c h a r a c t e r i s t i c s . The alternative hypotheses of the study were analyzed by means of a t - t e s t , and chi square test at the .05 l e v e l of significance. The results revealed no s i g n i f i c a n t effect of the structured preoperative teaching programme upon the adult s u r g i c a l patient's length of hospital stay, postoperative complications, number of analgesics administered iv postoperatively, or the degree of s a t i s f a c t i o n attained from the preoperative teaching he received. However, s t a t i s t i c a l significance was found f o r the patient's a b i l i t y to r e c a l l knowledge explained preoperatively. Implications of this study and recommendations for future research were also suggested. V TABLE OF CONTENTS PAGE LIST OF TABLES v i i i ACKNOWLEDGEMENTS i x CHAPTER I - INTRODUCTION 1 THE PROBLEM 2 Statement of the Problem 2 Significance of the Problem 3 SPECIFICS OF THE STUDY 5 Hypotheses 5 Variables 6 De f i n i t i o n of Terms v 6 Assumptions 7 Limitations of the Study 8 Summary 8 Overview 8 CHAPTER II - REVIEW OF THE LITERATURE 10 Preoperative Teaching i n General 10 Group Instruction 16 Teaching as an Integral Function of the Professional Nurse 18 Summary 22 CHAPTER I I I - METHODOLOGY 23 Introduction 23 The Setting 23 v i CHAPTER I I I Continued PAGE C r i t e r i a f o r Subject Selection 24 Staff Orientation 25 DEVELOPMENT OF THE TOOLS 25 The Structured Preoperative Teaching Programme 25 The Evaluation of Preoperative Knowledge '. 26 Satis f a c t i o n of Preoperative Teaching 27 The Preoperative Letter 27 Patient P r o f i l e Sheet 27 IMPLEMENTATION OF THE STUDY 28 DATA ANALYSIS 29 SUMMARY 29 CHAPTER IV - ANALYSIS OF THE DATA 30 COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS ON SELECTED CHARACTERISTICS 30 Age 31 Sex 31 Diagnosis on Admission 32 Types of Surgery 33 Analysis of Hypotheses 34 Hypothesis I 34 Hypothesis II 36 Hypothesis I I I 37 Hypothesis TV 43 Hypothesis V 4 4 Summary 4^ v i i PAGE CHAPTER V - SUMMARY, FINDINGS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS '. 4 6 Summary" 46 Findings 47 Conclusions 51 Implications 52 Recommendations 53 BIBLIOGRAPHY 55 APPENDICES A Consent Forms 61 B Slides and Script 64 C Evaluation of Preoperative Knowledge 76 D Satisfaction of Preoperative Teaching 79 E Preoperative Letter 82 F Patient P r o f i l e Sheet 87 v i i i LIST OF TABLES TABLE PAGE I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY AGE 3 1 II A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY SEX 31 II I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DIAGNOSIS ON ADMISSION 3 2 IV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' TYPE OF SURGERY 3 3 V A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' LENGTH OF HOSPITAL STAY 35 VI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DEVELOPMENT OF POSTOPERATIVE COMPLICATIONS 36 VII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' TOTAL DOSE EQUIVALENT OF MEPERIDINE ADMINISTERED DURING THE FIRST 24 HOURS POSTOPERATIVE 39 VIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' TOTAL DOSE EQUIVALENT OF MEPERIDINE ADMINISTERED 24-96 HOURS POSTOPERATIVE 4 0 IX A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DOSE OF ORAL ANALGESICS ADMINISTERED POSTOPERATIVELY ... 41 X A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS* PREVIOUS HOSPITALIZATION WITHIN THE PAST SEVEN YEARS ... 42 XI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' POINT SCORE FROM EXAMINATION OF RECALL OF KNOWLEDGE EXPLAINED PREOPERATIVELY 4 3 XII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' SATISFACTION OF PREOPERATIVE TEACHING 44 i x ACKNOWLEDGEMENTS I wish to express much thanks to Betsy La Sor, my committee chairman for her continuous support and advice; to my committee members, Ruth Zitnik for her energy, suggestions, and s e n s i t i v i t y throughout the completion of th i s study; to Sheila Stanton f o r her cooperation; to Jack Yensen for his assistance with the s t a t i s t i c a l analysis; to the i n s t i t u t i o n for permission to conduct the study. A special thanks to my family for t h e i r love and encouragement throughout this study, and always. / 1 CHAPTER I INTRODUCTION The hospitalized surgical patient i s subjected to a variety of interactions which vary i n quantity as well as quality. Many events that occur during the preoperative and postoperative period require explanation. Often, the methods used are inadequate and the explanation surrounding these events remain vague. This incomplete preparation may a l t e r a patient's hospital course. An important function of the professional nurse i n the health care system of today, i s to teach patients and t h e i r families i n the promotion of health and prevention of i l l n e s s . This teaching function i s especially important i n the area of preoperative preparation. I t has been well documented that teaching a patient about routine procedures and exercises p r i o r to surgery promotes an uneventful convalescence. The major focus of preoperative teaching has consisted of deep breathing, coughing, and bed exercises. Dripps and Waters and Bendixen have indicated that these exercises are a means of preventing pulmonary and ci r c u l a t o r y 1 2 complications postoperatively. ' I f , however, both the patient and his family are to be thoroughly prepared for surgery, i n s t r u c t i o n regarding basic procedures from admission through discharge should be incorporated into the ^Robert D. Dripps and Ralph M. Waters, ''Nursing Care of Surgical Patients I - The 'Stir-up,' American Journal of Nursing, XL1, No.5 (May, 1941). p.534. 2 H.H. Bendixen et a l . , Respiratory Care, (Saint Louis: The C.V. Mosby Co., 1965), p.89. 2 preoperative teaching programme. This type of programme requires structure and planning, with input from many members of the health team. A suitable approach to preoperative teaching i s the technique of group inst r u c t i o n . Although preoperative teaching i s usually done on an individual basis, group in s t r u c t i o n has proven effe c t i v e i n many areas of nursing. Redman promotes group in s t r u c t i o n f o r i t s economy of time and the 3 be n e f i c i a l effect of group interaction. This study attempts to evaluate the effectiveness of a structured preoperative teaching programme for the adult surgical patient. THE PROBLEM Statement of the Problem Is a structured preoperative teaching programme for the adult surgical patient ef f e c t i v e i n meeting his informational and safety needs as measured by several indicators? The s p e c i f i c questions investigated were: 1. What are the effects of a structured preoperative teaching programme upon the adult surgical patient's length of hospital stay? 2. What are the effects of a structured preoperative teaching programme upon the adult surgical patient's postoperative complications? 3. What are the effects of a structured preoperative teaching ' programme upon the adult surgical patient's requirement for analgesics postoperatively? 4. What are the effects of a structured preoperative teaching Barbara Klug Redman, The Process of Patient Teaching i n Nursing, (Saint Louis:; The C.V. Mosby Co., 1972,)p. 20, 93. 3 programme upon the adult surgical patient's r e c a l l of knowledge explained preoperatively? 5. What are the effects of a structured preoperative teaching programme upon the adult surgical patient's s a t i s f a c t i o n with his preoperative teaching regime? Significance of the problem Inadequate explanation of presurgical routines has been a common complaint of the preoperative patient and his family. Redman indicated that the teaching of patients has been performed on an ir r e g u l a r basis.^ In order to resolve the inconsistency and inadequacy of preoperative teaching several factors must be investigated. The amount and type of information required, the most suitable time for teaching and the method of i n s t r u c t i o n must be determined. This would seem necessary to s a t i s f a c t o r i l y meet the basic informational and safety needs of the general surgical patient. The findings of th i s study may promote implementation of a structured preoperative teaching programme for groups of surgical patients, i n the i n s t i t u t i o n where the study i s being conducted. Several authors have reported the importance of preoperative preparation f o r the surgical patient to enhance an uneventful convalescence. Studies by Healy, Lindeman and Van Aernam demonstrated that planned inst r u c t i o n i n deep breathing, coughing, and bed exercises were effe c t i v e i n reducing the length of hospital stay for the surgical patient.^'^ ^Redman, The Process of Patient Teaching i n Nursing, p.14 ^Kathryn M. Healy, "Does Preoperative Instruction Make a Difference?" American Journal of Nursing. LXVIII, No. 1 (January, 1968), p. 62. ^Carol A. Lindeman and Betty Van Aernam, "Nursing Intervention With the Presurgical Patient - The Effects of Structure and Unstructured"Preoperative Teaching," Nursing Research, XX, No.4 (July-August, 1971), p. 331. 4 This positive effect i s a necessity, not only i n terms of the increasing cost of health care but also making more readily available the much needed surgical bed. Although there are many advances i n anaesthesiology and techniques of surgery, postoperative pulmonary and ci r c u l a t o r y complications s t i l l occur. Bendixen et a l stated that accurate i n s t r u c t i o n given preoperatively i s h e l p f u l i n preventing atelectasis and pneumonia, thus reducing 7 postoperative complications and, i n turn, length of stay i n h o s p i t a l . Effective prevention of postoperative complications requires a thorough understanding by the patient of the pathogenesis of these complications so t h a t they can cooperate to the best of th e i r a b i l i t y . Physiological and psychological preparation are equally important components of preoperative teaching. The nurse can a s s i s t the patient i n expressing his feelings and concerns regarding h o s p i t a l i z a t i o n and surgery. Instruction and encouragement related to the patient's emotions w i l l improve his morale and affect his physical well-being i n the postoperative period. Janis found patients who did some anticipatory worry about an impending danger increased t h e i r l e v e l of tolerance for subsequent stress. In reference to the surgical patient, he suggested that this moderate amount of preoperative worry w i l l r e s u l t i n optimum postoperative emotional adjustment. Nurses are now recognizing that teaching i s an in t e g r a l part of t h e i r professional r o l e . The rapid development of modern medical technologies has Bendixen et a l . , Respiratory Care, (Saint Louis: The C.V.Mosby Co., 1965), p.89. Irving L. Janis, Psychological Stress. (New York: Wiley § Sons, 1958), pp.376-388. 5 increased the teaching function of the nurse. Consumer groups and patient advocates are demanding f u l f i l l m e n t of t h e i r basic human right to be informed of the health care they receive. Lack of time, heavy workload, and understaffing have been i d e n t i f i e d by Pohl as the major problems i n 9 patient teaching. The use of group ins t r u c t i o n i n preparing patients for surgery may resolve many of the obstacles to effective patient teaching. With group in s t r u c t i o n , the nurse not only saves time, but can ensure adequate inst r u c t i o n for several individuals. Bains and Mezzanotte both found group inst r u c t i o n to be as effective as individual i n s t r u c t i o n for teaching the preoperative patient."^' ^ The findings of th i s study may promote implementation of a structured preoperative teaching programme for groups of surgical patients, i n the i n s t i t u t i o n where the study i s being conducted. SPECIFICS OF THE STUDY Hypothesis The hypotheses of t h i s study were: 1. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y reduce the length of hospital stay for the adult surgical patient. 2. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y yMargaret L. Pohl, "Teaching A c t i v i t i e s of the Nursing P r a c t i t i o n e r , " Nursing Research, XIV, No. 1. (Winter, 1965), p.11. •"•^ Chinama Baines, "An Experimental Study to Compare the Effects of Individual and Group Preoperative Instruction" (unpublished Master's Thesis University of B r i t i s h Columbia, 1971), p.75. 11 Elizabeth Jane Mezzanotte, "Group Instruction i n Preparation for Surgery," American Journal of Nursing LXX, No. 1 (January 1970). p.91. 6 reduce postoperative complications. 3. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y decrease the amount of analgesics administered postoperatively. 4. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the patient's r e c a l l of knowledge explained preoperatively. 5. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the patient's s a t i s f a c t i o n of his preoperative teaching regime. Variables The independent variable i n the study was: 1. the structured preoperative teaching programme The dependent variables i n the study were: 1. length of hospital stay 2. postoperative complications 3. amount of analgesics administered postoperatively 4. r e c a l l of knowledge explained preoperatively 5. s a t i s f a c t i o n of preoperative teaching The number of extraneous factors, that influence the dependent variables i n the study are recognized by the investigator. The sample population was limi t e d to subjects with s p e c i f i c c h a r a c t e r i s t i c s , thus reducing the number of organismic variables present among the subjects. To promote homogeneity among the experimental and control groups the subjects were also matched on diagnosis, type of surgery, age within ten years and sex. De f i n i t i o n of Terms Structured preoperative teaching programme... To the subj ects i n the experimental group a preoperative l e t t e r was ci r c u l a t e d and a slide-tape teaching session was presented i n h o s p i t a l , the evening p r i o r to surgery. 7 The preoperative teaching session consisted of a twelve minute slide-tape programme followed by a discussion and return demonstration of the exercises taught. The teaching sessions lasted from twenty to t h i r t y minutes, and were conducted by the investigator. The adult surgical patient: the patient, over nineteen years of age admitted to one surgical ward of a selected general hospital. The length of hospital stay: the number of days the patient was hospitalized. In a l l circumstances the day p r i o r to surgery was counted as the f i r s t day and the day of discharge was counted as the l a s t day. Postoperative complication: a complicating condition pneumonia, atelectasis or thrombophlebitis diagnosed and stated i n the patient's chart by the attending surgeon. Analgesics: any pain-relieving medication as ordered by the surgeon, s p e c i f i c a l l y : Demerol, morphine and Darvon p l a i n . Recall of Knowledge: the subject's a b i l i t y to answer questions corr e c t l y (from a questionnaire) pertaining to the preoperative teaching from either the structured preoperative teaching programme or the nurse's own teaching. Satisfaction of preoperative teaching: the degree of s a t i s f a c t i o n the patient attained through the preoperative teaching he received as measured by a questionnaire. Assumptions This study was based on the following assumptions: 1. Patients and t h e i r s i g n i f i c a n t others have a basic human right to be adequately informed about the health care they receive. 2. Patient teaching i s an integral part of professional nursing 8 practice. 3. Preoperative teaching conducted with small groups i s a suitable method of assuring adequate ins t r u c t i o n to most surgical patients. Limitations of the Study The study was subject to the following l i m i t a t i o n s : 1. The study was limited to one p a r t i c u l a r surgical ward; therefore the results may not be applicable to the general population. 2. The study was l i m i t e d to those subjects who could read and write the English language. 3. The study was l i m i t e d to meeting the basic needs of the general surgical patient, and not specialized surgical interventions. 4. The study was limited to forty patients who met the selected c r i t e r i a of the study, therefore the results may not be applicable to surgical patients at large. 5. The results of the study may not have been s o l e l y the outcome of the structured preoperative teaching programme as i t was impossible to control for a l l the intervening variables affecting the subjects under study. Summary Chapter I has discussed the problems and questions d i r e c t l y related to preparing patients for surgery. I t has also specified the hypotheses and variables under study. The d e f i n i t i o n of terms, assumptions and li m i t a t i o n s were outlined. OVERVIEW The problem of supplying eff e c t i v e preoperative preparation to surgical patients, including necessary information and safety teaching 9 was investigated. The study was designed to include a control group to evaluate ongoing practice as compared to an experimental group of s i m i l a r surgical patients who received a structured preoperative teaching programme. The structure of preoperative teaching programme was evaluated as to i t s effectiveness i n reducing postoperative problems and increasing patient information needs and s a t i s f a c t i o n . 10 CHAPTER I I A review of the l i t e r a t u r e indicated that there was adequate l i t e r a t u r e related to the topic of structured preoperative teaching. A few of the d i r e c t l y related sources have been selected to provide a basis f o r th i s study. The l i t e r a t u r e review i s presented under the following headings: preoperative teaching i n general, group i n s t r u c t i o n , and teaching as an integral function of the professional nurse. PREOPERATIVE TEACHING IN GENERAL Interest i n preoperative teaching as a means of reducing postoperative respiratory and c i r c u l a t o r y complications was discussed i n nursing l i t e r a t u r e as early as 1941. Dripps and Waters focused the i r attention on developing a programme for the management of the surgical patient during the postoperative period. The programme consisted of three basic procedures, turning, coughing and deep breathing. The underlying physiological p r i n c i p l e s were: turning improved overall c i r c u l a t i o n and permitted the pulmonary tissue to function properly. Deep breathing i n f l a t e d collapsed a i r sacs and aided i n guarding against the lodgement of ba c t e r i a l or infectious agents. Coughing cleared away secretions and helped prevent atelectasis."'' Robert D. Dripps and Ralph M. Waters, "Nursing CAre of Surgical Patients I - The 'Stir-up'", American Journal of Nursing XXI, No. 5 (May 1941) p.530-534. 11 Specific instructions i n these exercises were also i d e n t i f i e d by Bendixen et a l as a means of reducing pulmonary and c i r c u l a t o r y complications 2 during the postoperative period. This interest i n the care of the surgical patient appeared to motivate others to begin research i n the area of preparing patients for surgery. The events before and after surgery are often very threatening to the uninformed patient. The patient's expectations of h o s p i t a l i z a t i o n and an impending surgery may be magnified or minimized to u n r e a l i s t i c levels. The psychological impact of surgery was reported i n Janis' study. His research on the work of worry, resulted i n the theory that a moderate degree of worry before exposure to a s t r e s s f u l event, produced an ind i v i d u a l less l i k e l y to develop emotional disturbances during and after the actual stress exposure. This moderate degree of worry i n the preoperative patient stimulated him to inquire as to ways i n which he can cooperate i n order to meet the impending dangers of surgery. Janis saw r e a l i s t i c explanations, teaching, and preparatory guidance as ways of reducing fear of the unknown i n presurgical patients."^ Hospitalization and surgery can be considered to be s t r e s s f u l occurrences. Therefore, preparation of patients for events of surgery should not be done i n a haphazard manner. H. H. Bendixen and Others, Respiratory Care. (Saint Louis: The C.V. Mosby Co., 1965). p. 85. 7. Irving L. Janis, Psychological Stress. (New York: Wiley § Sons, 1958), pp. 374-376. 12 Aasterud i n her paper, "Explanation to the Patient," has i d e n t i f i e d three components that must be considered when explaining procedures and routines to the hospitalized patient. They consist of the type, extent, and timing 4 of the preparatory information. The type of information and extent or d e t a i l i n which events are explained i s very important. Aasterud points out that nurses and other health professionals are often so f a m i l i a r with hospital procedures that they may only give a minimum amount of explanation to the patient.^ Input from a l l members of the health team id e n t i f y i n g content areas and amount of d e t a i l required for adequate explanation must be determined. The patient should also be given an opportunity to express his feelings and understanding towards the impending events. Organization of t h i s content into an appropriate teaching approach would be l i k e l y to eliminate the possible h i t and miss method with everyone teaching what they f e e l i s appropriate. Several factors must be considered i n deciding the appropriate time for teaching patients about the procedures and routines to which they w i l l be exposed. Aasterud states that there are no s p e c i f i c guidelines as to when explanation should be given,^ but i f a patient i s to undergo a major event involving changes i n l i v i n g patterns the ind i v i d u a l may require a period of time to adapt and work through his feeling. Margaret Aasterud, "Explanation to the Patient," Nursing Forum, Vol. I l l , No. 4, 1963. pp. 36-44. 5 I b i d . , p. 39. 6 I b i d . , p. 40. 13 In the case of the surgical patient, the amount of time available between admission and the actual surgery i s often minimal. Other factors to be considered i n selecting a time for teaching are, the normal a c t i v i t i e s of the ward, the patient's previous exposure to hospital and anxiety l e v e l . I t therefore seems most appropriate to teach the patient the evening p r i o r to surgery. The early evening may also allow the patient's s i g n i f i c a n t other to attend the teaching session, therefore allowing them time to adapt to the s i t u a t i o n and increasing the understanding of the patient's major support system. B i r d stated "The patient's welfare often depends on the cooperation of his r e l a t i v e s , and i f they are confused, the patient may 7 s u f f e r . " Johnson used laboratory and c l i n i c a l settings to study the effects of structuring patients' reactions to s t r e s s f u l events. In the laboratory experiment, forty-eight paid subjects were exposed to ischemic pain produced by applying a blood pressure cuff to the upper arm and pumping i t up to 250 mm of mercury. Half of the subjects were t o l d about the procedure and what sensations to expect and f e e l , whereas the remainder of the subjects were informed only of the procedure. Results from t h i s portion of the study indicated that those subjects who were given a description of the sensation reported less stress than those who received only a description of the procedure. In the c l i n i c a l experiment, ninety-nine patients undergoing gastrointestinal examinations were studied. Again, the subjects heard either a description of the sensation or a description of the procedure, or no preparatory information. Reduction of distress was measured by the amount Brian B i r d , "Psychological Aspects of Preoperative and Postoperative Care," American Journal of Nursing, LV, No. 6 (June, 1955), p.686. 14 of diazepam needed to achieve sedation. Subjects hearing a description of sensations or procedures were found to require approximately s i x milligrams less diazepam to achieve sedation, as compared to the group who received no information. The results indicated that information regarding accurate expectations and description of the expected procedures and sensation of a threatening event reduces distress and tension. S i m i l a r l y , an experimental study to determine the effectiveness of preoperative i n s t r u c t i o n i n reducing postoperative pain was conducted by 9 Egbert. The findings revealed that those subjects who received i n s t r u c t i o n and reassurance i n regards to postoperative pain required fewer narcotics. Whereas, those subjects receiving no preparatory i n s t r u c t i o n required more narcotics. Thus, i t would seem that preparatory information and in s t r u c t i o n can have a positive impact on patient management. The effectiveness of preoperative i n s t r u c t i o n upon postoperative behaviour was investigated by Healy. In t h i s experimental study, over three hundred patients slated for elective surgery were followed from admission to discharge. Each subject i n the experimental group received ind i v i d u a l explanation about procedures expected and in s t r u c t i o n and demonstration of deep breathing, coughing, turning and bed exercises. The study showed that the experimental group had fewer complications, shorter time period on Jean E. Johnson, "Effects of Structuring Patient's Expectations on t h e i r Reactions to Threatening Events", Nursing Research, XXI, No. 6 (November-December 1972), pp. 499-503. L. Egbert and Others, "Reduction of Postoperative Pain by Encouragement and Instruction of Patients," New England Journal of Medicine, CCLXX, No. 16, (A p r i l 16, 1964), pp.825-827. analgesics, and e a r l i e r discharge, as compared to the control group who did not receive e x p l i c i t instructions. I t was also reported that patients and s t a f f expressed s a t i s f a c t i o n from the experimental portion of the 10 preoperative programme. Lindeman and Van Aernam conducted a study which compared structured preoperative teaching with unstructured preoperative teaching f o r s u r g i c a l patients. Those patients over f i f t e e n years old admitted, under non-emergency conditions, scheduled for a general anaesthetic and surgery other than eye, ear, nose and throat, were admitted to the study. The unstructured preoperative teaching consisted of the nurse teaching when and how much she f e l t was necessary. The structured approach included a lesson plan and a sound-on-slide programme explaining how to do " s t i r - u p exercises" and why they were necessary. The focus of the structured teaching was on deep breathing and coughing exercises measured by ve n t i l a t o r y function tests Results indicated that the experimental group performed better than the control group on the v e n t i l a t o r y function t e s t s , and hence i n t h e i r a b i l i t y to deep breathe and cough postoperatively. S t a t i s t i c a l evidence was also available i n accepting the structured preoperative teaching programme as having an effect on reducing the length of hospital stay. However, there was no s i g n i f i c a n t difference between the two groups on the number of analgesics required during the f i r s t seventy-two hours p o s t o p e r a t i v e l y . ^ x uKatherine M. Healy, "Does Preoperative Instruction Make a Difference?' American Journal of Nursing, LXXIII, No. 1, (January 1968), pp.62-67. "*^Carol Lindeman and Betty Van Aernam, "Nursing Intervention with the Presurgical Patient - The Effects of Structures and Unstructued Preoperative Teaching'', Nursing Research, XX, No. 4 (July-August 1971), pp.319-332. 16 GROUP INSTRUCTION Group in s t r u c t i o n has been and i s presently used i n patient teaching. Some of the areas i n which t h i s teaching approach has proven successful are prenatal and postpartum care, infant and c h i l d care, cardiac care and the management of diabetic patients. Redman and Pohl have implied that small group i n s t r u c t i o n and discussion would help patients having s i m i l a r problems and goals, 12 13 id e n t i f y with each other's fears and concerns. ' Through this i d e n t i f i c a t i o n they would gain moral support and encouragement. Misconceptions of h o s p i t a l i z a t i o n and surgical interventions would hopefully be voiced and corrected through the use of group discussion. Group ins t r u c t i o n i s also an economical way of teaching several individuals at one time. I t would be advantageous i n the area of preoperative teaching, as the s t a f f nurse on a busy surgical ward i s already short of adequate time to carry out the immediate d e t a i l s of bedside care. Although most preoperative teaching has been done on a one to one basis, recent l i t e r a t u r e promotes group instruction. Mezzanote used the group method of inst r u c t i o n to explain pre and postoperative routines, and to teach the techniques of deep breathing, coughing, and leg exercises. She instructed twenty-four patients having elective abdominal surgery i n groups of .four. Postoperative interviews found a l l patients stating that the group in s t r u c t i o n had been b e n e f i c i a l . Twenty participants also expressed they did and would prefer group ins t r u c t i o n over ind i v i d u a l instruction. Since this 1 2Barbara Klug Redman, The Process of Patient Teaching i n Nursing, p.95 1 3Margaret L. Pohl, The Teaching Function of the Nursing P r a c t i t i o n e r . (2nd ed., Debuque, IowaT-Wm. C. Brown Co. Publishers 1973) p.74. 17 study did not have a control group for ind i v i d u a l i n s t r u c t i o n , nor was the sample size very large, d e f i n i t e conclusions could not be made.^ However, pos i t i v e responses from the patients were noted, thus lending added support for group preoperative instruction. Baines conducted an experimental study which compared the effectiveness of ind i v i d u a l and group preoperative instruction."'"^ The focus was on the performance of deep breathing, coughing and bed exercises, i n a l t e r i n g the incidence of postoperative complications and length of hospital stay f o r s i x t y patients having abdominal surgery. There were t h i r t y subjects comprised each of the experimental and control group. A l l subjects received a practice guide consisting of information on how to do the exercises. A booklet with photographs of selected exercises and corresponding instructions was also used i n the preoperative teaching. The findings indicated that preoperative group in s t r u c t i o n was as effective as individual i n s t r u c t i o n on the postoperative performance of deep breathing, coughing, and bed exercises. The length of stay i n hospital was shorter, and the number of complications were fewer for patients receiving group instruction. However, the differences i n these variables between the control and experimental groups 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 . The small group method of in s t r u c t i o n was also employed by Schmitt and Wooldridge to prepare patients psychologically for surgery. The sessions were informal and patients were asked to share t h e i r feelings and concerns about the impending surgery. Deep breathing, coughing, and leg exercises were taught to promote recovery. The majority of these subjects were also Elizabeth Jane Mezzanotte, "Group Instruction i n Preparation for Surgery," American Journal of Nursing LXX, No. 1 (January 1970), pp.89-91. ^Chinima Baines, "An Experimental Study to Compare the Effectiveness of Individual and Group Preoperative Instruction" (unpublished Master's Thesis, University of B r i t i s h Columbia, 1974), p.2. 18 interviewed the morning of surgery to further vent feelings and receive encouragement. Twenty-five subjects i n a control group received routine preparation on a one to one basis with the hospital s t a f f nurse. Results from both verbal indicators and physiologic indicators of blood pressure, pulse, temperature, incidence of nausea, vomiting, and urinary retention,, found that the nursing intervention reduced tension and anxiety i n the experimental subjects. During the postoperative period, the experimental group required less medication, experienced less operative urinary retention, resumed or a l intake sooner and were discharged e a r l i e r as compared with the control group.^ Added psychological preparation given to patients the evening p r i o r to surgery appeared to have b e n e f i c i a l effects. It decreased the patient's anxiety, increased p a r t i c i p a t i o n for t h e i r own care, and i n turn lead to a more rapid and uneventful recovery. TEACHING AS AN INTEGRAL FUNCTION OF THE PROFESSIONAL NURSE The question as to which health professional should be responsible for preoperative teaching has been very controversial. B i r d feels that a l l health professionals have some r e s p o n s i b i l i t y i n preparing the patient for surgery. Yet, no one person r e a l l y claims i t . He sees the r e s p o n s i b i l i t y 17 shared between the surgeon and the nurse. Janis implies that a p s y c h i a t r i s t i s the only health professional suitable for the task and he believes that nurses and doctors are inappropriately trained to provide psychological <- 18 support. "^Florence E. Schmitt and Powhatan J . Wooldridge, "Psychological Preparation of Surgical Patients," Nursing Research, XXII, No.2 (March-April 1973),pp.108-115. 17 Brian Bird. "Psychological Aspects of Preoperative and Postoperative Care." American Journal of Nursing. Vol. 55, No. 6,(June 1955),p.685. 18 Irving L. Janis, Psychological Stress,(New York: Wiley § Sons,1958),p.374. 19 Johnson and Martin suggest that the preparing of patients for surgery i s we l l within the nurse's r o l e , and i n addition, that i t may be a unique 19 function of the nurse as an independent pr a c t i t i o n e r . Pohl also sees the teaching function of the nurse as a unique 20 contribution to the promotion of health and prevention of i l l n e s s . The nurse does th i s by helping patients understand the importance of health pr i n c i p l e s and assuming r e s p o n s i b i l i t y for applying t h i s knowledge to themselves and t h e i r families. Lyons' study on preoperative teaching indicated that the s t a f f nurse on the surgical unit should have a higher p r i o r i t y towards t h i s aspect of patient care. Lyons states that nurses have the most contact with patients and t h e i r f a m i l i e s , give most of the postoperative care, and are i n the best 21 po s i t i o n to judge the patient's learning needs. The educational preparation of nurses enables them to assess the patient and i d e n t i f y expressed and unexpressed learning needs. The nurse i s then able to plan the appropriate content, select a method of teaching and u t i l i z e various teaching aids for in s t r u c t i o n of patients. The f i n a l step i n teaching patients i s evaluating whether or not needs have been met and i n turn whether learning has occurred. Redman feels the above steps are necessary 22 i n the teaching-learning process. 19 Miriam Johnson and Harry E. Martin. "A Sociological Analysis of the Nurse Role," American Journal of Nursing, LVIII (March 1958), pp.373-377. 20 Margaret L. Pohl, The Teaching Function of the Nursing P r a c t i t i o n e r , p.64. 21 Mary Lou Lyons, "What P r i o r i t y Do You Give Preoperative Teaching?: Nursing 77, VII, No. 1 (January 1977), p.11. 22 Barbara Klug Redman, The Process of Patient Teaching i n Nursing, pp. 76-77. 2 0 Monterio suggests that for teaching groups of patients, the structured approach i s often more effe c t i v e . The formal structured approach to teaching i s more than a spontaneous response to a patient's 23 statement or question. Therefore according to the above researchers, a l l aspects of teaching and learning must be c a r e f u l l y planned w e l l i n advance to the presentation of s p e c i f i c material. Redman states that the lecture method of teaching i s an effective way of giving information, demonstrating s k i l l s , and influencing attitudes. Yet, with t h i s approach to teaching, the learner does not always have the opportunity to ask questions, nor can the teacher ensure that they r e a l l y understand the material. Discussion following the lecture and return demonstration of 24 s k i l l s are a means of strengthening learner outcome. Pohl has i d e n t i f i e d several advantages for teaching i n small groups. When the learners have common problems and needs, the flow of questions, concerns, and sharing of experiences makes for a productive discussion. She feels the optimum size f o r group discussion would be from s i x to ten people. I t should also be noted again that much time i s saved by the nurse 25 teaching several patients at one time. 23 Lois Monterio "Notes on Patient Teaching - A Neglected Area" Nursing Forum, V I I I , No. 1, 1964. p.28. 2^Redman, The Process of Patient Teaching i n Nursing, p. 92. Margaret Pohl, The Teaching Function of the Nursing P r a c t i t i o n e r , pp.74-75. General interest towards the content being presented can be increased through i d e n t i f i c a t i o n with the topic, discussion, and use of audio-visual aids. Lindeman and Van Aernam used a sound-on-slide programme i n t h e i r study of the effectiveness of preoperative teaching. Burke used s l i d e s 27 to promote patient learning i n the management of diabetes. Audio-visual aids alone w i l l not make learning more ef f e c t i v e or teaching more 27 28 successful. ' They can, however, be used to organize material and content i n the event that i t can be presented to a group of individuals i n the same manner. Mursell, from h i s work on the psychological p r i n c i p l e s of successful teaching, advocates the use of audio-visual material. He feels the presentation becomes more than mere t a l k i n g , i t i s actually hearing 29 and seeing. Thus, audio-visual aids are a supplement to verbal explanation. They introduce variety into teaching and i n turn stimulate interest i n the learners. The teaching approach used by the investigator i n t h i s study included preliminary written material i n a preoperative l e t t e r , group teaching, u t i l i z i n g audio-visual aids, and group discussion. Patient p a r t i c i p a t i o n was included i n return demonstration of the exercises taught. Evaluation of the teaching programme was also conducted. This multi-dimensional approach provides more opportunity for learners to grasp the necessary informational and safety content i n the pre and postoperative periods. ^ C a r o l Lindeman and Betty Van Aernam, "Nursing Interventions with the Presurgical Patient." p.323. 27 Matilda Burke, "The Effectiveness of the Modified Diabetic Teaching Tool i n Group Instruction" (unpublished Master's Thesis, University of B r i t i s h Columbia, 1974), p.7. 28 James L. Mursell. Successful Teaching - Its Psychological P r i n c i p l e s 2nd ed. (New York, Toronto, London: McGraw-Hill Book Company,Inc.,1954),p.96 2 9 I b i d . , 96-97. 22 SUMMARY The l i t e r a t u r e review revealed that preoperative teaching f o r the surgical patient has positive effects postoperatively. I t i s evident from the preceding studies that most authors have included s p e c i f i c instructions on deep breathing, coughing, and bed exercises i n t h e i r preoperative teaching programmes. These exercises, when practiced during the postoperative period have been proven as a means of reducing c i r c u l a t o r y and pulmonary complications. I t has, however, been implied that other content areas, such as preoperative procedures, expectations on the day of surgery and during the postoperative period must be included i n a preoperative teaching programme. These content areas seem essential i n order to meet the patient's information and safety needs, as well as to promote an uneventful convalescence. Several studies were concerned with the effectiveness of a structured preoperative teaching programme. Group teaching has also been advocated as a suitable method for teaching preoperative patients, and the professional nurse has been i d e n t i f i e d i n an int e g r a l role i n t h i s teaching. 23 CHAPTER I I I METHODOLOGY The purpose of this study was to determine i f a structured preoperative teaching programme for the adult surgical patient i s an effec t i v e means of meeting his informational and safety needs as measured by several indicators. Forty subjects were included i n the study. The f i r s t twenty subjects made up the control group, and received the unstructured preoperative i n s t r u c t i o n i n varying amounts on an individual basis from the s t a f f nurses. The second twenty subjects made up the experimental group. They received structured preoperative teaching i n small groups, conducted by the investigator. The effectiveness of the structured preoperative teaching programme was determined by comparing the two groups on the length of hospital stay, development of postoperative complications, analgesics administered postoperatively, a b i l i t y to r e c a l l information explained preoperatively, and s a t i s f a c t i o n with the preoperative teaching they received. THE SETTING The study was conducted on one surgical ward of a sixteen hundred bed general h o s p i t a l . Permission to conduct the study i n the hospital was obtained from the hospital's research and administrative committees. Data c o l l e c t i o n on the ward occurred between January 16, 1977 and A p r i l 1, 1977. Both male and female adult patients were admitted to t h i s ward for general surgery. The nursing s t a f f on the selected surgical ward had recently implemented a twelve hour s h i f t rotation. The subjects were therefore under 24 the care of the same nurses for several days. The surgeons, as well as the physiotherapist, were also permanent members of the health team on t h i s ward. Selection of subjects from the same surgical ward was deemed necessary to ensure that a l l subjects would receive the same type of pre and post surgical care, according to the type of surgery performed. CRITERIA FOR SUBJECT SELECTION Subjects meeting the following c r i t e r i a , were selected for this study: 1. over nineteen years of age 2. admitted under non-emergency situations 3. admitted for general abdominal surgery 4. scheduled for a general anaesthetic 5. free of an ongoing secondary i l l n e s s including pulmonary and cardiac conditions, diabetes 6. no known drug or alcohol dependency 7. consenting to participate i n the research study To determine that there was homogeneity between the control and experimental groups on selected variables, the two groups of subjects were compared on selected ch a r a c t e r i s t i c s . The control and experimental groups were compared to: 1. diagnosis 2. type of surgery 3. age within ten years 4. sex Those subjects f i t t i n g the c r i t e r i a and consenting to pa r t i c i p a t e admitted from January 16, 1977 through February 5, 1977 served as the control 25 group. Those subjects admitted to the same ward, from February 15, 1977 through A p r i l 1, 1977, served as the experimental group. Written consent was obtained from a l l subjects. The consent forms for both the control and experimental subjects are contained i n Appendix A of t h i s study. STAFF ORIENTATION The nursing s t a f f was not aware of the investigator's purpose on the ward during the data c o l l e c t i o n period f o r the control group. However, the head nurse and assistant head nurses were thoroughly informed of the study. The reason f o r not informing the s t a f f about the study at t h i s time was to eliminate possible bias that may have occurred i n the pre and postoperative care given to the control subjects. P r i o r to data c o l l e c t i o n for the experimental group, the s t a f f nurses and physiotherapists were informed of the procedure and purpose of t h i s study. The nurses on the ward also viewed the slide-tape teaching programme. The nurses were asked not to do the i n i t i a l preoperative teaching on the selected experimental subjects. The investigator informed them when th e i r patients were included i n the study. The nurses were instructed to answer questions i f asked by the subjects and reinforce exercises as they deemed necessary during the postoperative period. DEVELOPMENT OF THE TOOLS The Structured Preoperative Teaching Programme The content f o r the structured preoperative teaching programme was i n i t i a l l y developed by the investigator from c l i n i c a l involvement while working with surgical patients i n t h i s h o s p i t a l , as w e l l as from a review of pertinent l i t e r a t u r e . From th i s selected content the s c r i p t f o r the slide-tape 26 teaching programme was written. The s c r i p t was written i n concise and simple language. I t was then presented to the hospital administrative committee to gain approval. Minor changes were made i n response to recommendations from the committee. Slides were then taken i n the hospital setting to correspond with the s c r i p t . The s c r i p t was then transferred to a synchronized audio-tape. The completed slide-tape programme was presented to a larger committee of experts for c r i t i c a l review, r e v i s i o n and f i n a l approval. This committee included the o r i g i n a l administrative committee, plus representatives from physiotherapy, anaesthesiology, surgery, education services and nursing. A l l members gave approval for use of the slide-tape programme i n t h i s study. A copy of the s c r i p t and sl i d e s are included i n Appendix B. The Evaluation of Preoperative Knowledge The purpose of this tool was to determine the subjects' a b i l i t y to r e c a l l knowledge explained preoperatively. A l l subjects i n the study were asked to answer twenty-five true and false questions which pertained to the information taught i n the structured preoperative teaching programme, or the nurses' own teaching. This questionnaire was developed by the investigator and approved by the administrative committee before implementing i t into the study. The administrative committee participated i n rev i s i o n of the questionnaire, giving d i r e c t i o n which helped affirm, i t s v a l i d i t y . The members of t h i s committee were a selected group of experts on preoperative teaching practice. R e l i a b i l i t y testing of the questionnaire was not feasible for t h i s study for the following reasons. The questionnaire was administered to a l l subjects at a selected time p r i o r to discharge. This could not be repeated. 27. Time and c r i t e r i a r e s t r a i n t s prevented c o l l e c t i o n of two large populations for comparative r e l i a b i l i t y analysis. Appendix C contains a copy of the questionnaire. S a t i s f a c t i o n of Preoperative Teaching This tool was necessary to evaluate the subject's degree of s a t i s f a c t i o n of the preoperative teaching he received. The questionnaire was developed by the investigator and approved by the hospital administrative committee. Results from t h i s t o o l would determine whether or not the structured preoperative teaching programme increased the subject's s a t i s f a c t i o n i n regards to the way i n which his informational needs were met. Face and content v a l i d i t y were challenged by submitting the questionnaire to the experts on the administrative committee. R e l i a b i l i t y was not sought. A copy of this questionnaire i s included i n Appendix D. The Preoperative Letter This l e t t e r was previously developed, validated, and administratively approved by the hospital where the study was conducted. I t was decided by the hospital administrative committee that the l e t t e r be mailed to each subject's home p r i o r to hospital admission. However, the mailing system f a i l e d , and the subjects i n the experimental group who were to receive the l e t t e r at th e i r home, instead, received i t on admission to the ward. A copy of this l e t t e r i s included i n Appendix E. Patient P r o f i l e Sheet This t o o l was devised to obtain the data relevant to the selected variables under study. The data was extracted from the subject's chart. The p r o f i l e sheet i s i n Appendix F. 28 Implementation of the Study The subj ects i n the control group were approached by the investigator two to three days before discharge. Verbal explanation of the study was given and i f the subject agreed to p a r t i c i p a t e , written consent was obtained. The subject was then asked to complete the true-false questionnaire and the s a t i s f a c t i o n questionnaire. Results of the true-false questionnaire were immediately given to the subject, with explanation, i f a question had been incorrectly answered. Those subjects f i t t i n g the c r i t e r i a and admitted during the specified time, made up the sample for the experimental group. On admission to the ward, these patients were seen by the investigator and i n v i t e d to attend a preoperative teaching session that evening. The subjects and family, i f present, between 1845 and 1900 hours were escorted by the investigator to a c l i n i c room, where the teaching session was conducted. The twelve minute slide-tape programme was shown followed by a discussion. The investigator answered any questions and cleared up misconceptions when voiced. Deep breathing, coughing, and leg exercises were also practiced at t h i s time. In a l l , the sessions did not exceed t h i r t y - f i v e minutes. The size of the group varied from two to seven subjects. As the group size was not too large, a Singer Caramate audio-visual unit was used to view the slide-tape teaching programme, and the seats were arranged i n a semicircle around i t . During the postoperative period, the s t a f f nurses answered any questions that arose and encouraged the subjects to continue with the deep breathing, coughing, and leg exercises. P r i o r to discharge, the subjects were asked to complete the questionnaires. Results were immediately given along with explanation of incorrect items. As this was the f i n a l contact with the investigator, the subjects were thanked for p a r t i c i p a t i n g i n the study. » 29 DATA ANALYSIS The control and experimental subjects were compared on selected variables. Data i n r e l a t i o n to hypotheses I through IV are concerned with quantitative variables, and therefore subjected to t - t e s t analysis. The .05 l e v e l of significance was accepted as s t a t i s t i c a l l y s i g n i f i c a n t . Hypothesis V corresponds to the subject's s a t i s f a c t i o n of his preoperative teaching, and i s considered q u a l i t a t i v e data. This q u a l i t a t i v e data was analyzed using a Chi-Squared 2 x 2 d i s t r i b u t i o n and Fisher's Exact Test. SUMMARY This chapter has presented the methodology of the study. A description was given of the se t t i n g , c r i t e r i a for sample selec t i o n , s t a f f orientation, development of the tools and procedure for data c o l l e c t i o n . A b r i e f discussion of the method of data analysis was also included. 30 CHAPTER IV ANALYSIS OF THE DATA A t o t a l of forty-four subjects were i n i t i a l l y included i n t h i s study. Twenty-two agreed to participate i n the control group. Two were l a t e r eliminated, as both were found to have a history of alcoholism. Twenty-two also agreed to par t i c i p a t e i n the experimental group. One of these two subjects was transferred to another ward following surgery, and one contracted an in f e c t i o n and was placed on i s o l a t i o n . The data were analyzed and presented i n two sections. The f i r s t section i s a comparison of demographic characteristics of the control and experimental subjects as obtained from the c r i t e r i a and p r o f i l e sheet. The second section contains analysis of the data i n r e l a t i o n to the hypotheses of the study. COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS ON SELECTED CHARACTERISTICS AGE A comparison of the control and experimental group by age within ten years i s contained i n Table I. The mean age for subjects i n the control group was 52.1 years and the mean age for the subjects i n the experimental groups was 51.6 years. In reference to Table I where the ages range from twenty to eighty, the control group and experimental group were homogeneous i n r e l a t i o n to the ch a r a c t e r i s t i c of age. 31 TABLE I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY AGE Age (Years) Control Subjects Experimental Subjects 20-31 2 3 31-40 2 2 41-50 3 2 51-60 7 4 61-70 5 7 41-80 1 2 TOTAL 20 20 SEX A comparison of the control and experimental group i n r e l a t i o n to sex i s contained i n Table I I . Although there were more males than females i n both the control and experimental group, the groups were s i m i l a r according to sex d i s t r i b u t i o n . TABLE II A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS BY SEX Sex Control Experimental Subjects Subjects Male 12 14 Female 8 6. TOTAL 20 20 DIAGNOSIS Table I I I gives the comparative d i s t r i b u t i o n of the control and experimental subjects according to t h e i r diagnosis on admission. TABLE I I I A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DIAGNOSIS ON ADMISSION Diagnosis Control Experimental on Admission Sub j ects Subjects a o r t o - i l i a c stenosis 2 2 ranal artery stenosis 1 -bowel obstruction 2 2 c h o l e l i t h i a s i s 4 4 hernia 3 7 duodenal ulcer • 4 -appendicitis 2 -abdominal a o r t i c aneurysm 1 3 abdominal pain 1 2 Total 20 20 33 TYPE OF SURGERY Table IV gives the comparative d i s t r i b u t i o n of the control and experimental subjects according to the type of surgery they had. The surgeries were categorized as to either abdominal surgery or lower-abdominal surgery. The abdominal surgeries included, resection repair of abdominal ao r t i c aneurysm, b i l a t e r a l aorto-femoral bypass, cholecystectomy, appendectomy, vagotomy and pyloroplasty, hemicolectomy, and abdominal-perineal resection. The lower abdominal surgeries included repair of inguinal or femoral hernias, and femoral bypass grafts. The groups were s i m i l a r . TABLE IV A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' TYPE OF SURGERY Type of Surgery Control Subj ects Experimental Subjects Abdominal 16 13 Lower-Abdominal 4 7 TOTAL 20 20 34 ANALYSIS OF HYPOTHESES The data obtained i n r e l a t i o n to each hypothesis were subjected to s t a t i s t i c a l analysis i n order to compare the results between the control group and experimental group. The dependent variables i n Hypotheses I through IV were tested by means of a t-test at the .05 l e v e l of significance. The dependent variable i n Hypothesis V was tested using the chi-square test of s i g n i f i c a n c e with a 2 x 2 contingency table and Fisher's Exact Test. Hypothesis I The f i r s t hypothesis of the study was: structured preoperative teaching programme w i l l s i g n i f i c a n t l y reduce the length of hospital stay for the adult surgical patient. The comparative d i s t r i b u t i o n of the control and experimental subject's length of hospital stay i s included i n Table V. There was no s i g n i f i c a n t difference i n the average duration of hospital stay between the two groups. In the two diagnostic categories that contained enough patients for a meaningful comparison, there was no difference i n stay for patients with c h o l e l i t h i a s i s , but the trend was toward a shorter stay for the experimental group with hernia. Hypothesis I was rejected i n this study.. 35 TABLE V A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' LENGTH OF HOSPITAL STAY 1. • Control ': Sub j ect Number days average A o r t o - i l i a c Stenosis 1 11 ,.. 7 11 1 1 Experimental Subject Number days average 16 19 • TC 20 11 i b Renal Artery Stenosis 2 13 Bowel 3 9 -Obstruction 12 12 7 9 15 22 x*'* Chole- 4 11 l i t h i a s i s 9 8 i n x 19 14 U' 5 20 8 3 9 5 10 6 9 i U 17 12 Hernia 5 7 11 14 15 6 9 1 4 2 5 4 6 9 9 5.9 10 5 12 5 13 7 Duodenal 6 9 Ulcer 8 10 1 A 14 30 1 4 17 7 Appendi- 13 5 fi c i t i s 18 7 0 Abdominal 10 12 Ao r t i c Aneurysm 8 13 11 11 11.3 14 10 Abdominal 16 10 Pain 18 20 lr. . 19 11 x = 10.3 . SEM = 1.1 t = 0.216 (not s i g n i f i c a n t ) p > .05 ^Standard Error of the Mean 36 Hypothesis II The second hypothesis was: structured preoperative teaching w i l l s i g n i f i c a n t l y reduce postoperative complications. Observation of the data revealed that none of the subjects i n either the control or experimental groups developed a postoperative respiratory or ci r c u l a t o r y complication (Table VI). Therefore t h i s alternate hypothesis was rejected. TABLE VI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DEVELOPMENT OF POSTOPERATIVE COMPLICATIONS Control Experimental Subj ects Sub j ects n = 20 n = 20 Development of postoperative 0 0 complications TOTAL 0 0 37 Hypothesis I I I The t h i r d hypothesis was: structured preoperative teaching w i l l s i g n i f i c a n t l y reduce the number of analgesics administered postoperatively. For ease of data analysis the analgesics were categorized as to the method of administration which was either intramascular or o r a l . The intramuscular analgesics consisted of either meperidine hydrochloride (Demerol) or morphine sulfate (Morphine). The pharmacologic equivalent dose of 1 mg morphine i s 7.5 mg meperidine, and the results for intramuscular analgesia are expressed i n terms of equivalent meperidine dose. The t o t a l dose of analgesics administered was then categorized into the i n i t i a l 24 hours postoperatively for each subject i n each diagnostic category. The remaining intramuscular analgesics were t o t a l l e d for each subject and divided by the number of days they were given, beyond the i n i t i a l 24 hours, and for a l l cases was from 24 to 96 hours postoperatively. A comparison of the control and experimental subjects' amount of intramuscular analgesics required postoperatively i s contained i n Tables VII and VIII. The t-t e s t analysis revealed no o v e r a l l s i g n i f i c a n t difference between the control and experimental groups for the amount of analgesics administered postoperatively. Table IX, comparing the amount of o r a l analgesia administered postoperatively to control and experimental subjects, indicates no s i g n i f i c a n t difference between the groups. The o r a l analgesia other than propoxyphene (Darvon Plain) administered was minimal, and was not included i n the analysis. Even i n the two diagnostic categories with a large number of patients, c h o l e l i t h i a s i s and hernia, no persistent trend existed i n the t o t a l dose of analgesics administered to the control or experimental group. For example, although a s l i g h t l y smaller t o t a l dose of oral analgesia was administered to 38 the experimental group with c h o l e l i t h i a s i s , a s l i g h t l y higher dose of parenteral analgesia was administered to these patients. 39 TABLE VII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' TOTAL DOSE EQUIVALENT OF MEPERIDINE ADMINISTERED DURING THE FIRST 24 HOURS POSTOPERATIVELY Control Subject m i l l i - Aver-Number grams age Aor t o - I l i a c 1 150 1 1 0 Stenosis 7 70 Experimental Subject m i l l i - Aver-Number grams age 16 135 1 W r 20 190 Renal Artery-Stenosis 2 187.5 Bowel 3 Obstruction 12 200 7 137.5 5 15 67.5 Chole- 4 175 l i t h i a s i s 9 675 ^?!-19 250 " 20 200 3 600 5 600 r 7 , 6 300 17 600 Hernia 5 150 11 225 15 232.5 2 Q 2 S 1 225 2 300 4 200 1 7 r. 9 25 1 / : > 10 75 12 200 13 200 Duodenal 6 375 Ulcer 8 525 7 i ? c 14 200 ° 17 150 Appendi- 13 300 ^ c i t i s 18 75 Abdominal 10 Aort i c Aneurysm 8 112.5 11 135 125 14 127.5 Abdominal 16 112.5 Pain 18 37 • 5 Q*Z Q 19 150 •N = 18 N = 20 x = 236.2 x = 220.8 SEM= 36.2 .' ' SEM= 40.1 t= 0.282 NS . p> .05 40 TABLE VIII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS" TOTAL DOSE EQUIVALENT OF MEPERIDINE ADMINISTERED 24-96 HOURS POSTOPERATIVELY Control Subject m i l l i - Aver-Number grams age A o r t o - i l i a c 1 75 ?Q? r Stenosis 7 490 Experimental Subject m i l l i - Aver-Number grams age 16 390 ?rj r 20 125 * Renal Artery Stenosis 2 325 Bowel 3 Obstruction 12 7 337 7QQ c. 15 462 Chole- 4 350 l i t h i a s i s 9 332.5 7 ? Q . 19 150 20 125 3 275 5 143 9 S4 "i 6 100 17 500 Hernia 5 11 112 15 1 75 2 4 9 36.4 10 12 13 180 Duodenal 6 262 Ulcer Jj 172.5 2 Q 2 A 17 375 Appendi- 13 75 7r. c i t i s 18 75 7 : 5 Abdominal 10 Aor t i c Aneurysm 8 202.5 11 202.5 135 14 Abdominal 16 112.5 Pain 18 220 19 450 N = 14 N = 14 x = 216.5 x = 261.5 SEM = 36.4 SEM = 38.1 t=0.855 NS p > .05 TABLE IX A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' DOSE OF ORAL ANALGESICS ADMINISTERED POSTOPERATIVELY Arot o - I l i a c Stenosis Control Subj ect Number 1 7 m i l l i -grams 100 Aver-age Subject Number 16 20 Experimental m i l l i -grams 314 Aver-age Renal Artery Stenos i s 2 200 Bowel Obstruction 3 12 200 7 15 Chole- 4 450 3 150 l i t h i a s i s 9 19 450 330 358.3 5 6 200 120 159 20 200 17 166 Hernia 5 11 15 1 2 4 9 10 12 13 150 Duodenal Ulcer 6 8 14 17 450 Appendi-c i t i s 13 18 1 0 0 200 300 Abdominal Aor t i c Aneurysm 10 160 8 11 200 14 200 Abdominal Pain 16 133 18 19 400 N = x = SEM = 12 256. 39. 0 2 N = 9 x = 211.1 SEM = 29.9 t = 0.860 NS p>.05 42 Hypothesis IV The fourth hypothesis was: a structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the patient's r e c a l l of knowledge explained preoperatively. A subject's f a m i l i a r i t y or previous exposure to hospital may have an effect on his r e c a l l of knowledge. Comparison of control and experimental subjects' previous h o s p i t a l i z a t i o n within the past seven years (Table X) reveals no s i g n i f i c a n t difference between the groups. Table XI follows with a comparison of the control and experimental subjects' r e c a l l of knowledge explained preoperatively as measured from a true-false questionnaire. The t-test analysis revealed 'a si g n i f i c a n t difference beyond the .05 l e v e l of pr o b a b i l i t y . Hypothesis TV was therefore accepted. TABLE X A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' PREVIOUS HOSPITALIZATION WITHIN THE PAST SEVEN YEARS Control Experimental Subjects Subj ects n = 20 n = 20 Hospitalization within the past 12 11 7 years. 43 TABLE XI A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' POINT SCORE FROM EXAMINATION OF RECALL OF : Control Subj ect Score Number Aor t o - I l i a c 1 21 Stenosis 7 20 (NOWLEDGE EXPLAINED PREOPERATIVELY Experimental Subj ect Score Number 16 21 20 23 Renal Artery Stenosis 2 17 Bowel 3 21 Obstruction 2 17 7 24 15 22 Chole- 4 20 l i t h i a s i s 9 17 19 18 20 19 3 22 5 23 6 24 17 20 Hernia 5 16 11 17 15 20 1 24 2 22 4 23 9 22 10 23 12 21 13 21 Duodenal 6 19 Ulcer 8 19 14 22 17 20 Appendicitis 13 18 18 22 Abdominal 10 19 Aortic Aneurysm 8 24 11 22 14 22 Abdominal 16 22 Pain 18 21 19 20 .'• N = 20 : N = 20 e =' 19.3 E = 22.2 SEM = .4 SEM = .3 t = 5.913 si g n i f i c a n t p< .0005 44 Hypothesis V The f i f t h hypothesis was: a structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the patient's s a t i s f a c t i o n of his preoperative teaching regime. Table XII contains the comparative d i s t r i b u t i o n of control and experimental subject's degree of s a t i s f a c t i o n with t h e i r preoperative teaching. Using a chi-squared d i s t r i b u t i o n and Fisher's Exact test the results indicated no s i g n i f i c a n t difference between the two groups. This f i n a l hypothesis i s , therefore, rejected. TABLE XII A COMPARISON OF CONTROL AND EXPERIMENTAL SUBJECTS' SATISFACTION OF PREOPERATIVE TEACHING Control Experimental Subj ects Subjects n=20 n=20 D i s s a t i s f i e d with preoperative teaching 5 0 S a t i s f i e d with preoperative teaching 15 20 NS 45 SUMMARY The analysis of the data and results are presented i n this chapter. A comparison of control and experimental subjects i n r e l a t i o n to each hypothesis was presented. The findings revealed no s i g n i f i c a n t difference between the control and experimental groups for length of hos p i t a l stay, postoperative complications, amount of analgesics administered postoperatively and s a t i s f a c t i o n of preoperative teaching. The structured preoperative teaching programme did prove effe c t i v e as a means of increasing the experimental subjects' r e c a l l of knowledge explained preoperatively. 46 CHAPTER V SUMMARY, DISCUSSION OF FINDINGS; CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS SUMMARY The purpose of t h i s experimental study was to determine the effectiveness of a structured preoperative teaching programme upon the adult surgical patient as measured by several variables. The hypotheses tested i n the study were: 1. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y decrease the surgical patient's length of hospital stay. 2. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y decrease postoperative complications. 3. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y decrease the amount of analgesics administered postoperatively. 4. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the surgical patient's r e c a l l of knowledge explained preoperatively. 5. A structured preoperative teaching programme w i l l s i g n i f i c a n t l y increase the patient's s a t i s f a c t i o n of his preoperative teaching programme. The study was conducted on one surgical ward of a large general h o s p i t a l . I t involved forty subjects, who met the c r i t e r i a of the study. Twenty subjects 47 were then selected for the experimental group and received a structured preoperative teaching programme i n small groups, conducted by the investigator. This programme consisted of a preoperative l e t t e r , a twelve minute slide-tape programme, followed by a discussion. A l l subjects completed two questionnaires p r i o r to discharge. A review of selected l i t e r a t u r e consistently emphasized the need for structured preoperative teaching. Specific preoperative i n s t r u c t i o n i n deep breathing, coughing, and leg exercises were found to minimize postoperative ci r c u l a t o r y and pulmonary complications, as well as promote a speedy recovery. Explanation of procedures and routines associated with surgery and venting of concerns were found to e n l i s t the patient's cooperation, and increase t h e i r morale. Group in s t r u c t i o n was deemed to be an adequate method for preoperative teaching. Teaching as an i n t e g r a l function of the professional nurse's role was also reviewed. The two groups of subjects were compared on selected characteristics obtained from the patient p r o f i l e sheet. A one t a i l e d t - t e s t was used to analyze hypotheses I through IV. A chi-square test of significance using a 2 x 2 d i s t r i b u t i o n and Fisher's Exact test was applied to hypothesis V, which was concerned with the degree of s a t i s f a c t i o n obtained from the preoperative teaching the subjects received. DISCUSSION OF THE FINDINGS The control and experimental subjects were s i m i l a r when compared for the selected characteristics of the study. The average age was s i m i l a r for both groups, as was the sex d i s t r i b u t i o n . C l a s s i f i c a t i o n of the type of surgery (abdominal and lower abdominal) contained s i m i l a r numbers of patients for both groups, and minor differences existed i n the number of patients from each group i n each diagnostic category. These differences resulted 48 from the control group being weighted toward duodenal ulcer and appendicitis whereas the experimental group was weighted toward hernia repair, a procedure having s l i g h t l y less surgical morbidity. Nevertheless, since hypotheses I to I I I were rejected, i t i s u n l i k e l y that the minor differences i n the diagnostic category influenced the f i n a l r e s u l ts. The independent t-t e s t analysis of the data i n r e l a t i o n to hypothesis I showed no s i g n i f i c a n t difference i n the length of hospital stay f o r the control and experimental groups. I t i s recognized by the investigator that a number of other factors may influence the dependent variable i n t h i s f i r s t hypothesis. Previous work has indicated that the type of i n c i s i o n influences the length of time spent i n h o s p i t a l . In the presented study, the subjects were compared on type of surgery which was then categorized as to abdominal or lower abdominal. Both groups were found to be s i m i l a r ; however, the type of i n c i s i o n was not s p e c i f i c a l l y accounted for. In addition to type of surgery and age, both of which may influence the complication rate and thus the length of stay, other uncontrolled factors such as postoperative physiotherapy, oxygen administration, postoperative day of ambulation and food intake, duration of intravenous therapy, and physician s u b j e c t i v i t y and influence may have affected the length of hospital stay. When the data i s analyzed i n terms of diagnostic categories, a trend appears toward a shorter hospital stay f o r the experimental group having hernia. This suggests that a structured preoperative teaching programme may provide b e n e f i c i a l effects i n terms of length of hospital stay f o r some diagnostic categories. A larger number of patients i n each group may have produced more s i g n i f i c a n t changes. Findings for hypothesis II revealed that none of the subjects i n either group were found to develop a postoperative complicating condition of pneumonia, a t e l e c t a s i s , or thrombophlebitis. A s t a t i s t i c a l analysis was 49 therefore not applied. Several possible reasons for t h i s finding include the fact that the physiotherapist f o r the ward where the study was conducted, does attempt to v i s i t each patient during the f i r s t few postoperative days. On these v i s i t s she assists the patients with deep breathing and coughing exercises, as well as getting out of bed. Other reasons include those uncontrolled factors mentioned above i n the discussion of length of hospital stay. Most important i s that the complication rate for the surgeries performed i s very small --as l i t t l e as 1%, necessitating a very large sample size (possibly several hundred patients i n each group) to achieve s t a t i s t i c a l significance i f differences did e x i s t . Analysis of the data i n r e l a t i o n to hypothesis I I I showed no . s t a t i s t i c a l difference between experimental and control groups for the amount of analgesics required postoperatively. No s i g n i f i c a n t relationship was obtained between the experimental and control groups on the amount of oral analgesics (Darvon) administered postoperatively. The general nature of t h i s structured preoperative teaching programme did not, therefore, affect the patient's analgesic requirement. The appreciation of and response to pain i s very individualized. In addition to the physical trauma of surgery, emotional and psychologic factors influence the patient's need for postoperative analgesia. Although some mention of pain was included i n the teaching programme, no detailed discussion was made of the numerous objective and subjective factors responsible for pain. I t i s possible that a programme having more emphasis on these factors may have influenced the analgesic requirement. Although both groups were s i m i l a r when compared on selected c h a r a c t e r i s t i c s , the lack of o v e r a l l significance may have been due to variables other than the teaching. A one to one matching of control subjects and experimental subjects as to t h e i r s p e c i f i c surgeries may have 50 found a difference i n the r e s u l t s . This i s suggested by the analysis of length of hospital stay i n patients with hernia. The manner i n which the analgesics were ordered by the surgeons may have also influenced the lack of o v e r a l l difference i n these findings. Some surgeons i n s i s t that the analgesics be given on a consistent four hourly basis, while others encourage the patients to request the analgesic when they f e e l i t i s necessary. The r e l a t i v e l y small sample size may also have affected the results. A s i g n i f i c a n t difference i n the two groups of subjects' r e c a l l of knowledge explained preoperatively was found. These findings resulted i n acceptance of hypothesis IV. The investigator i s aware that several other factors may have contributed to the s i g n i f i c a n t difference i n the experimental subjects' a b i l i t y to r e c a l l preoperative knowledge. These subjects received a preoperative l e t t e r p r i o r to the evening teaching session and discussion period. The teaching session included a slide-tape programme which covered basic information that was covered i n the questionnaire. Each subject i n the control group received teaching i n varying amounts from t h e i r nurse. Such factors as patient educational status, vocation, paramedical i n t e r e s t s , and physician counselling may have influenced the results i n t h i s section. Although these factors l i k e l y influenced the results i n a random fashion, s t r i c t control of them would strengthen the conclusions based on the acceptance of hypothesis IV. The f i n a l s t a t i s t i c a l analysis was a comparison of the experimental and control groups' degree of s a t i s f a c t i o n obtained from the preoperative teaching they received, using a chi-square d i s t r i b u t i o n and Fisher's Exact test. The findings indicated no s i g n i f i c a n t difference between the two groups, and thus the hypothesis was rejected. I t would appear that patients have no regard for the method through which they obtain t h e i r preoperative-51 education, possibly because the average patient has never appreciated that preoperative teaching i s an integral part of his management. As the trend i n patient education i s towards a structured programme, i t i s l i k e l y that patients w i l l recognize that a comprehensive approach to preoperative teaching enables them to share a more active and knowledgeable role i n t h e i r own care. I t was clear from the discussions concluding the teaching sessions, that the experimental subjects were very pleased to be involved i n and informed of the events of t h e i r h o s p i t a l i z a t i o n and surgery. They gave positive feedback i n regards to the presentation of the material. They f e l t they had a better understanding as to the rationale behind the procedures, and were better able to see the sequence of events. CONCLUSIONS The conclusions drawn from the findings of th i s study are that the structured preoperative teaching programme presented here: 1. Did not s i g n i f i c a n t l y reduce the adult surgical patient's length of hospital stay. 2. May reduce the adult surgical patient's postoperative complications. In the presenting study, neither the control nor experimental subjects developed a postoperative complication of pneumonia, atelectasis or thrombophlebitis. 3. Was not effec t i v e i n s i g n i f i c a n t l y reducing the amount of analgesics administered postoperatively. 4. Was effective i n s i g n i f i c a n t l y increasing the patient's r e c a l l of knowledge explained preoperatively. 5. Was not effec t i v e i n s i g n i f i c a n t l y increasing the patient's s a t i s f a c t i o n of t h e i r preoperative regime. IMPLICATIONS The implications of the presenting study include the following; 1. A structured preoperative teaching programme may contribute to a shorter hospital stay i n selected groups of patients (e.g. those undergoing hernia r e p a i r ) . I f th i s i s borne out i n subsequent studies of a si m i l a r nature, the monetary saving to patients and insurance plans r e s u l t i n g from the reduced cost of h o s p i t a l i z a t i o n may be wel l worth the investment i n time, e f f o r t , and dollars of a structured preoperative teaching programme. 2. A structured preoperative teaching programme may contribute to an ove r a l l reduction i n patient analgesic requirement during the postoperative period i f such a programme i s s p e c i f i c a l l y designed to emphasize a discussion of postoperative pain. 3. The s i g n i f i c a n t increase i n the patient's a b i l i t y to r e c a l l facts presented preoperatively implies effectiveness of the structured approach to teaching. The teaching of small groups of patients should, therefore, be done by a professional nurse who i s competent i n applying the princ i p l e s of learning and teaching as well as those p r i n c i p l e s associated with group process, i f teaching i s to occur i n groups. 4. Since a structured preoperative teaching programme i s associated with improved r e c a l l of facts during the postoperative period, better patient understanding of nursing and surgical procedures may be expected. This may result i n better patient cooperation, improved patient-nurse interaction, and ultimately, improved patient care. 5. Since a structured preoperative teaching programme was found to be associated with improved r e c a l l of facts during the postoperative period, a si m i l a r programme designed f o r medical patients undergoing therapy Ce-g- chemotherapy or radiation therapy f o r cancer, or exercise r e h a b i l i t a t i o n after myocardial i n f a r c t i o n or cardiac surgery) may prove to be eff e c t i v e i n improving patient understanding of his disease process and i t s management. RECOMMENDATIONS The following recommendations are suggested for further research: 1. An extension of the present study to determine i t s effectiveness i n reducing the anxiety l e v e l of the adult surgical patient and t h e i r s i g n i f i c a n t others. 2. A r e p l i c a t i o n of the present study using a large sample i s needed before the results can be generalized to surgical patients at large. 3. Future studies of a si m i l a r nature should attempt to control the variables mentioned i n the discussion of each hypothesis (e.g. physician counselling and medication orders, patient educational status and paramedical i n t e r e s t , postoperative physiotherapy, e t c . ) . A study should be designed to determine whether a structured preoperative teaching programme has any effect upon the physician's or the surgical nurse's impression of a patient's understanding or cooperation during the postoperative period. 55 BIBLIOGRAPHY A BOOKS Beland, Irene L. C l i n i c a l Nursing Pathophysiological and Psychosocial  Approaches. 2nd ed. London: The Macmillan Company, 1970. Bendixen, H.H.; Egbert, L.D.; Hedley-Whyte, J . ; Laver, M.B.; and Pontoppidan, H. Respiratory Care. Saint Louis. The C.V. Mosby Co., 1965. Finney, D.J.; Bennet, B.M.; Hsu, P.; and Pearson, E.S. Tables f o r Testing  Significance i n a 2 x 2 Contingency Table. Cambridge: Cambridge University Press, 1963. Glass, Gene V., and Stanley J u l i a n C. S t a t i s t i c a l Methods i n Education  and Psychology. Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1970. Janis, Irving L. Psychological Stress psychoanalytic and behavioural studies of surgical patients. New York: John Wiley $ Sons, Inc., 1958. Mursell, James L. Successful Teaching: Its Psychological P r i n c i p l e s . 2nd ed. Toronto: McGraw-Hill Book Company, Inc., 1954. Pohl, Margaret L. The Teaching Function of the Nursing P r a c t i t i o n e r . 2nd ed. Dubuque, Iowa: Wm. C. Brown Company Publishers, 1973. Redman, Barbara K. The Process of Patient Teaching i n Nursing. Saint Louis: The C.V. Mosby Company, 1972. Smith, H.W. Strategies of Social Research: The Methodological Imagination. Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1975. 57 B ARTICLES Aasterud, Margaret. "Defenses Against Anxiety," Nursing Forum (Summer 1962), pp.35-59. Aasterud, Margaret. "Explanation to the Patient," Nursing Forum, I I , No. 4, 1963, pp.36-44. ' Bir d , Brian. "Psychological Aspects of Preoperative and Postoperative Care," American Journal of Nursing, LV, No. 6 (June, 1955), pp.685-687. Cashel Weiler, Sister M. "Postoperative Patients Evaluate Preoperative Instruction," American Journal of Nursing, LXVIII, No. 7 (July, 1968), pp.1465-1467. Dumas, R.G.; Anderson B.J.; and Leonard, R.C. "The Importance of Expressive Function i n Preoperative Preparation," American Journal of Nursing, LXIII, No. 8 (August, 1963), pp.52-54. Dripps, Robert D., and Waters, R.M. "Nursing Care of Surgical Patients I. The 'Stir-up'," American Journal of Nursing, XLI, No. 5 (May, 1941) pp.530-534. Egbert, L.D., and Others. "Reduction of Postoperative Pain by Encouragement and Instruction of Patients," New England Journal of Medicine, CCLXX (April 16, 1964), pp.825-827. Hallburg, Jeanne C. "Teaching Patients Self-Care" Nursing C l i n i c s of  North America, V, No. 2 (June, 1970), pp.223-231. Healy, Katherine M. "Does Preoperative Instruction Make a Difference?" American Journal of Nursing, LXVIII No. (January, 1968), pp.62-67. Johnson, Jean E. "Psychosocial Factors i n the Welfare of Surgical Patients," Nursing Research, XIX, No. 1 (January-February, 1970), pp.18-28. Johnson, Miriam and Martin Harry. "A Sociological Analysis of the Nurse Role," American Journal of Nursing, LVIII (March, 1958).pp.373-377. > Lindeman, C.A. and Van Aernam, B. "Nursing Intervention with the Presurgical Patient - The Effects of Structured and Unstructured Preoperative Teaching," Nursing Research, XX (July-August, 1971), pp.319-332. Mezzanotte, Elizabeth J . "Group Instruction i n Preparation for Surgery," American Journal of Nursing, LXX (January 1970), pp.89-91. Monteiro, Lois A. "Notes on Patient leaching - A Neglected Area," Nursing Forum, I I I (Winter, 1964), pp.26-33. Pohl, Margaret L. "Teaching A c t i v i t i e s of the Nursing P r a c t i t i o n e r , " Nursing Research, XIV, No. 1 (Winter, 1965), p.11. ARTICLES Continued Redman, Barbara K. "Patient Education as a Function of Nursing Practice, Nursing C l i n i c s of North America, VI, No. 4 (December, 1971), pp..573-580. Schmitt, Florence E., and Wooldridge, Powhatan J . "Psychological Preparation of Surgical Patients," Nursing Research, XXII, No.2 (March-April, 1973), pp.108-115. 59 C UNPUBLISHED WORKS Baines, Chinnama. "An Experimental Study to Compare the Effectiveness of Individual and Group Preoperative Instruction," Unpublished Master's Thesis, University of B r i t i s h Columbia, 1974. Burke, Matilda. "The Effectiveness of the Modified "Diabetic Teaching Tool" i n Group Instruction, Unpublished Master's Thesis, University of B r i t i s h Columbia, 1974. 60 APPENDICES APPENDIX A CONSENT FORMS GROUP ONE - Experimental Subjects GROUP TWO - Control Subjects 62 CONSENT FORM - GROUP ONE I, the undersigned, agree to participate i n th i s study and understand that: 1. the aim i s to investigate the patient's knowledge about basic pre and postoperative procedures. 2. there w i l l be two in-hospital contacts with the investigator. (i) a slide-tape teaching programme p r i o r to surgery ( i i ) two questionnaires p r i o r to discharge (maximum ten minutes). 3. there are no r i s k s involved. 4. a l l information gathered w i l l be con f i d e n t i a l . 5. I am free to withdraw from the study at any time. Date Signature of Participant Signature of Nurse CONSENT FORM - GROUP TWO I, the undersigned, agree to participate i n t h i s study, and understand that: 1. the aim i s to investigate the patient's knowledge about the basic pre and postoperative procedures. 2. there w i l l be one in-hospital contact with the investigator. (i) two questionnaires p r i o r to discharge (maximum ten minutes). 3. there are no r i s k s involved. 4. a l l information gathered w i l l be con f i d e n t i a l . 5. I am free to withdraw from the study at any time. Date Signature of participant Signature of Nurse APPENDIX B PREOPERATIVE TEACHING PROGRAMME Slides and Script PREPARING YOU" FOR YOUR OPERATION 65 Welcome to Vancouver General Hospital. You are here to become fam i l i a r with the events that w i l l occur before and after your operation. This preparative teaching programme w i l l hopefully make your hospital stay more pleasant. Please save any questions u n t i l after the sli d e s are over. While i n h o s p i t a l you w i l l meet many members of the health team. I t takes many s k i l l s to look after one patient. Each member of the team i s specialized i n c e r t a i n ways to help you meet your needs. mm Now that you have already gone through the admitting procedure, i t i s time for you to learn about your pre-operative preparation. You must remember that not a l l the procedures mentioned are required for every patient. I t i s also important that you abide by our regulations i n regards to smoking. Please try NOT to smoke at a l l during your stay i n the hospital. 66 As this i s a teaching h o s p i t a l , an intern or medical student may take your history on behalf of your surgeon. I t i s necessary that you co-operative and answer his or her questions. A history must be on your chart, as i t i s an essential source of information. A urine sample i s required from each patient. Please use the bedpan, or u r i n a l , and set i t aside f o r the nurse. The urine w i l l then be sent to the laboratory to discover i f there i s anything abnormal which may affect the course of your surgery. A sample of your blood w i l l also be taken and sent to the laboratory. Like the urine specimen, i t too w i l l be analyzed for any abnormalities. For most patients, a prep, or skin shave, i s required, and w i l l be done by a nurse or orderly. As skin h a i r i s a possible source of i n f e c t i o n , i t must be removed. Do not be alarmed as the i n c i s i o n i s not as large as the area that i s shaved. After the shave, you w i l l most l i k e l y either wash or bathe with an antiseptic soap to remove loose h a i r s , and cleanse the skin. 67 An enema or cleansing of the bowel i s necessary for abdominal surgery, as wel l as several other types of surgery. The enema prevents a bowel movement immediately following surgery. The nurse on the ward w i l l l e t you know i f you need an enema. The evening before your surgery an anesthetist (a doctor who i s specialized i n putting patients to sleep and making sure the area to be operated on i s numb,) may v i s i t you or review your chart to obtain the information he requires. I f he v i s i t s , f e e l free to ask him any questions. There are three basic types of anesthesia. With a general anesthetic, the drugs are injected into your arm and you w i l l be completely asleep within seconds. With a spinal anesthetic, you w i l l have no sensation from the waist downwards, whereas a l o c a l anesthetic, numbs only a s p e c i f i c area. The choice of anesthetic i s made by your doctor and the anesthetist. I t i s also necessary that you sign a medical authorization form. This grants the doctor permission to perform the surgery, and also indicates that you have had the surgery explained to you. I f you do not sign the consent form, the surgery cannot be done. 68 I For those of you who are over f i f t y years of age, an electrocardiogram, or E.C.G. may be necessary. Electrodes are attached * JfH to parts of your body, and a machine w i l l || record the pattern of your heart-beat. You w i l l experience no sensation. Depending on the type of surgery, a chest x-ray and/or other x-rays may be needed. I f so, you w i l l be taken to the x-ray department either the day before or the morning of your surgery. As everyone i s a b i t nervous before surgery, i t i s customary for your doctor to order a sleeping medication for you. This w i l l help you get a good night's sleep. I f the time of your surgery i s f a i r l y early the next day, you w i l l not be allowed to eat or drink anything after midnight. This i s what we c a l l N.P.O., or nothing by mouth. Your stomach must be completely empty to ensure safety during your operation. So, PLEASE obey th i s request. 69 On the morning of your surgery, we request that a l l patients remove: eyeglasses, contact lenses, hair pieces, hearing aids, and a l l jewellery. A p l a i n wedding band may be l e f t on. For denture wearers, a special cup i s provided for your teeth, and they w i l l be l e f t at your bedside u n t i l you return to the ward. I t i s necessary to remove dentures so as they w i l l not be broken during your operation. Ladies, must remember to remove a l l makeup, n a i l p o l i s h , f a l s e f i n g e r n a i l s and eyelashes before going to the operating room. I t i s essential that the anesthetist be able to observe the colour of your n a i l s and l i p s . Skin colour i s an indication of your need for oxygen. Your hair w i l l be covered during surgery, and i f i t i s long, i t should be braided and t i e d with an e l a s t i c . A l l hair pins and barretts must be removed. About one hour before your surgery time, you w i l l be given a preoperative medication. This may be a p i l l , but i s usually an in j e c t i o n . I t i s advisable to empty your bladder before the medication i s given, as i t may make you f e e l drowsy, relaxed, and unsteady on your feet and we w i l l ask you to stay i n bed. Do not be alarmed i f your mouth gets very dry, as this i s an effect some drugs have. Wearing apparel to the Operating Room i s a hospital gown only. Please, do not wear underwear. 70 The exact time of your surgery may be moved ahead or delayed, according to the operating room schedule. Sometimes the surgery before yours takes more or less time than planned. You w i l l be informed i f the time of your surgery has been changed. When i t i s time for you to go to the operating room, a porter w i l l transfer you there by stretcher. Outside the operating room, you w i l l be greeted by a member of the O.R. s t a f f . This nurse w i l l check the i d e n t i f i c a t i o n on your chart by asking you your name and your doctor's name. Once you are transferred to the Anesthetic Room, the anesthetist w i l l put you to sleep and you w i l l not remember anything about your surgery. After the surgery i s completed, you w i l l go by stretcher to the Post Anesthetic Room, or the P.A.R. 71 In the Post Anesthetic Room, there are many patients l i k e you, who are also waking up from the anesthetic. At this time, we would l i k e to clear up the miscon-ception of patients revealing anything personal while under anesthetic. Patients rarely say anything when they are waking up, much less something that can be understood. The nurse i n the P.A.R. w i l l frequently take your I pulse, blood pressure, check your dressing, and observe the color of your skin to ensure a l l i s well. If5 II mm I f you had a general anesthetic, you w i l l wake up with an oxygen mask over your mouth and nose. This i s a common procedure for everyone who has a general anesthetic. Your stay i n the post anesthetic room may vary from one hour to several hours. Your re l a t i v e s and v i s i t o r s are usually not able to v i s i t you i n the Recovery Room, but they w i l l be to l d where you are, and how you are when they phone or come i n . When the nurses f e e l you are ready, you w i l l be transferred to your ward by stretcher. 72 The ward nurses w i l l again check your blood pressure, pulse,-and dressing. Do not be alarmed i f you do not have a dressing, or, i t i s much larger than you expected. Your surgeon l i k e s to ensure that your i n c i s i o n i s protected and well covered. The dressing may also f e e l t i g h t u n t i l you get used to i t . Following your surgery, you may notice an intravenous going into your arm or hand. Your food intake w i l l then be r e s t r i c t e d accordingly. The length of time you w i l l require an intravenous w i l l depend on the type of surgery you had. Some surgeries may require tubes or drains to keep your stomach empty, or prevent f l u i d from c o l l e c t i n g under the skin. The colour of the drainage may be red, brown or greenish. These tubes w i l l help decrease swelling and discomfort. Some patients may also require a urinary catheter, which w i l l keep your bladder empty. The length of time that the catheter i s needed, w i l l vary, depending on the type and extent of your surgery. In order to make your recovery smoother, you w i l l be asked to c o - o p e r a t e i n a series of exercises. Following an anesthetic, deep breathing and coughing exercises are done to help clear away secretions, f u l l y expand your lungs, and prevent pneumonia. 73 You must breathe deeply i n through your nose to the count of three, and out through your mouth to the count of three. After several deep breaths, t r y and make yourself cough. This should be a deep abdominal cough and not a shallow throat cough. Deep breathing and coughing exercises should be done every hour after surgery. It i s also very important to s p l i n t your i n c i s i o n with a small p i l l o w and bend your knees while doing the exercises. This w i l l give you added support and reduce discomfort. DO NOT WORRY AS COUGHING WILL NOT CAUSE YOUR STITCHES TO BREAK OPEN. Leg exercises are also important for a smooth recovery, as they not only improve c i r c u l a t i o n to a l l parts of your body, but also keep your muscles i n tone. As often as you can remember, you should wiggle your toes, move your ankles i n a c i r c u l a r motion, and relax and contract the muscles i n your legs. Following a surgical procedure, you can expect discomfort, an ache, or pain. The nurse cannot remove every b i t of discomfort, as so much medication would put you to sleep. Then you would not be able to do the necessary exercises. Pain medication w i l l be given frequently, and f e e l free to ask for i t when you are uncomfortable. As the days go by, your need for medication w i l l decrease. 74 You may even be asked to s i t at the side of the bed the evening of your surgery. This i s c a l l e d "dangling", and i s a s t a r t on the road to recovery. You must t r y not to over-exert yourself the f i r s t few days after surgery. Rest i s very important i n the healing process. Sleep when you can, but when awake,' remember to do your exercises. Then you may s t a r t walking short distances. Getting up and moving about as soon as possible, w i l l help your blood to c i r c u l a t e , and prevents your muscles from getting s t i f f and sore. A c t i v i t y also helps you f e e l better. 75 As the days go by, you w i l l s t a r t to f e e l better. You w i l l most l i k e l y progress from a diet of f l u i d s to soft foods, and then to a normal diet. As soon as the nurse feels you are able, she may encourage you to sta r t looking after yourself. This w i l l help you regain your strength and s e l f confidence, and w i l l prepare you for going home. APPENDIX C QUESTIONNAIRE Evaluation of Preoperative Knowledg 77 QUESTIONNAIRE  EVALUATION OF THE PREOPERATIVE KNOWLEDGE The following items are TRUE - FALSE statements. Please CIRCLE the answer you f e e l i s correct. 6. 10. 11. 12. 13. A urine and blood sample i s required from each patient before surgery, i n order to detect any abnormalities which may affect the course of your anaesthetic or surgery. Hair, removal, of the area to be operated on, i s usually required before surgery, as ha i r i s a possible source of infe c t i o n . Patients are not allowed to eat or drink anything twenty-four hours before t h e i r surgery. An enema i s given before surgery to eliminate stomach and abdominal pain after surgery. Although you are t o l d not to eat or drink anything before your surgery, a glass of water w i l l not be harmful. I t i s important to stay i n bed after the preoperative medication has been given, as you may become very drowsy and unsteady on your feet. I t i s important to empty your bladder after the preoperative medication i s given. After your surgery has been completed, you w i l l wake up i n your own room on the ward. I f you wear dentures, i t i s permissible to leave them i n your mouth during the surgery. Oxygen i s given to a l l patients following a general anaesthetic. Patients often reveal personal secrets while they are under anaesthetic. The nurses i n the post-anaesthetic room continuously check your pulse and blood pressure to ensure that a l l i s w e l l . The nurses i n the post-anaesthetic room may frequently ask you your name to f i n d out who you are. TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE 78 14. I f your throat feels i r r i t a t e d following surgery, you are probably developing a cold. 15. Depending upon the type of surgery performed, you may require tubes or drains to prevent f l u i d s from c o l l e c t i n g i n certain parts of your body. 16. I f a tube i s required, and the colour of the drainage i s red, brown, or greenish, i t i s an abnormal condition. TRUE TRUE TRUE FALSE FALSE FALSE 17. Following some surgeries, an intravenous may be necessary, but this w i l l not interfere with your normal di e t . 18. The dressing from your surgery may be much larger than you expected, because the surgeon l i k e s to make sure everything i s w e l l protected and covered. 19. Deep breathing and coughing exercises are done to help clear away secretions and f u l l y expand your lungs. 20. While doing the deep breathing and coughing exercises, i t i s important to support your i n c i s i o n to prevent the stitches from breaking open. 21. Leg exercises are done while you are i n bed to stimulate blood flow to every part of your body and keep your muscles toned. 22. I t i s important to l i e i n one po s i t i o n following surgery. 23. After surgery pain medications w i l l be available to help decrease your discomfort. 24. The day after having had your surgery, you w i l l be f u l l y responsible for your own care. 25. Patients are never allowed out of bed the same day as the surgery. TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE TRUE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE FALSE 79 APPENDIX D QUESTIONNAIRE Satis f a c t i o n of Preoperative Teaching Programme GROUP ONE - Experimental Subjects GROUP TWO - Control Subjects POST-SURGICAL QUESTIONNAIRE GROUP ONE PLEASE indicate with a check the statement you f e e l best applies to the following questions 1. I f you were previously hospitalized for surgery, d i d you receive preoperative teaching? ' yes no 2. On your present admission to h o s p i t a l , did you receive preoperative teaching ?' yes no 3. How s a t i s f i e d were you with the preoperative teaching you received? 4. How s a t i s f i e d were you with the way procedures and routines were explained to you? 5. How s a t i s f i e d were you with the slide-tape programme? 6. Which was more helpf u l to you? the preoperative l e t t e r , or the slide-tape teaching programme POST-SURGICAL QUESTIONNAIRE GROUP TWO PLEASE indicate with a check the statement you f e e l best applies to the following questions 1. I f you were previously hospitalized for surgery, did you receive preoperative teaching? ' yes ' ' ' no 2. On your present admission to h o s p i t a l , did you receive preoperative teaching? yes no 3. How s a t i s f i e d were you with the preoperative teaching you received? 4. How s a t i s f i e d were you with the way procedures and routines were explained to you? APPENDIX E PREOPERATIVE LETTER 83 Dear Patient: We are taking this opportunity to contact you p r i o r to your admission to Vancouver General Hospital to supply you with some basic information. We hope th i s w i l l make your admission easier. Time of a r r i v a l We expect you sometime between 11 a.m. and 2 p.m. The elective admission o f f i c e closes at 4 p.m. Special permission i s required for emergency admitting after 4 p.m. Admission You w i l l be informed which entrance to come to. The Heather Entrance i s on Heather Street between 11th and 12th Avenue. Drive into the Doctor's and Admitting parking l o t . I f you do not have your parking t i c k e t validated at the admission o f f i c e you must pay for parking when you e x i t . The Centennial Main Entrance i s on 12th Avenue. There i s a c i r c u l a r drive to drop o f f luggage and patients plus some meter parking i s available. Additional parking may be found i n the general parking l o t across the street or i n the Emergency parking whose entrance i s on Laurel Street. Once again have your parking t i c k e t validated at the admission o f f i c e f o r free parking. A map of the admitting entrances i s attached to t h i s l e t t e r . Parking i s l i m i t e d I t i s advised that you arrange to have someone take your car home during your stay i n hospital. The Unit When you have completed the admission procedure you w i l l be accompanied to your hospital room. Name tags and emblems A l l s t a f f wear name tags or shoulder emblems ide n t i f y i n g t h e i r position. Try to watch for these to prevent asking questions of the wrong person. Pont, however, be a f r a i d to ask questions as one member of the hospital team can summon another. Supplied by the Hospital You w i l l be given an i d e n t i f i c a t i o n bracelet to wear while you are a patient with your name and your doctor's name on i t . 84 The hospital supplies pyjamas, gowns, house coats, s l i p p e r s , towels, face cloths and soap. You are free to bring a l l of these a r t i c l e s yourself i f you wish. Do bring your personal t o i l e t a r t i c l e s - tooth brush, tooth paste, deodorant, brush and comb and shaving a r t i c l e s . For admission bring: 1. i d e n t i f i c a t i o n . 2. your Medical Insurance Card. 3. the name and permanent address and telephone number of a fri e n d or acquaintance who has known you for s i x months. 4. a l i s t of any medication you are currently taking. Do not bring: 1. additional clothes or suitcases as there i s li m i t e d storage space and they could get l o s t . 2. valuables, money and jewellery as they cannot be kept safely on the unit. 3. personal medication and alcohol. These are not to be consumed i n the hospital as t h e i r action could be very dangerous when combined with hospital treatment. 4. personal e l e c t r i c a l appliances such as fans, televisions and hairdryers. They cannot be used unless they are i n good working order and have been approved by the hospital maintenance department. Ask your nurse for help with t h i s . Services the hospital provides The g i f t shop i s at the main entrance i n Centennial P a v i l i o n . (Hours: Monday to Friday 10 a.m. to 7:30 p.m. Saturday 10 a.m. to 5 p.m. Sundays § Holidays 1 p.m. to 5 p.m.) The newstand i s on the main f l o o r of Heather P a v i l i o n (rotunda). Television rental service forms are available at each nursing s t a t i o n to make application. The service i s purchased day by day ($1.75 per day) plus $1.35 for a personal ear phone. Daily newspaper service: The paper i s delivered morning and evening. The delivery person w i l l c i r c u l a t e to a l l the rooms with the "Sun" and the "Province". Hairdresser and Barber services are available by appointment 2-3 days i n advance (through your nurse). A percentage of the fee i s demandable i f the service i s refused without a cancellation. V i s i t i n g Hours V i s i t i n g i s from 2-8 p.m. on a l l regular wards. Children are not denied but d i s c r e t i o n should be exercised. The r u l i n g of two v i s i t o r s to a patient i s i n force. 85 What to expect the evening before surgery Although surgical procedures may vary from case to case, they a l l have some things i n common, some do's and don'ts that w i l l be important for you to know. To help make th i s experience as reassuring and safe as possible, information given below w i l l be discussed with you when you are admitted and you w i l l be encouraged to ask any questions you wish. Please remember your safety and well-being are our primary concern, and your co-operation i s very important. A c t i v i t y - You may be up and about as you desire the evening before your operation. Diet - You w i l l receive your usual d i e t , unless your doctor has ordered otherwise. Smoking and any alcohol beverages are not allowed. Neither food NOR f l u i d s (including water) are allowed after midnight p r i o r to your day of surgery. This includes chewing gum, hard candy, "Certs", etc. In other words NOTHING BY MOUTH! thi s i s extremely important - EVEN A TINY  VIOLATION w i l l mean that your operation w i l l be cancelled. Smoking i s p o t e n t i a l l y hazardous to patients having surgery. You are encouraged to stop smoking now so that your lungs are clear and healthy by the time of your surgery. Smoking i s prohibited i n patient rooms. Examinations and Diagnostic Tests - The house doctor w i l l give you a complete physical examination, take a medical history and arrange for any necessary laboratory or other diagnostic tests. This may have been completed by your own doctor before your admission. - The nurse w i l l v i s i t you and would appreciate any information from you that would help her personalize your nursing care. - The doctor who w i l l give the anaesthetic w i l l also v i s i t you and prescribe the necessary medications to be given on the evening p r i o r to surgery and on the day of surgery. Procedures: 1. Skin Preparation: Generally, t h i s i s a skin shave or cl i p p i n g and a cleansing of the area with an antiseptic solution. A tub bath or shower may be taken p r i o r to your surgery. 2. Breathing Exercises - Leg Exercises: Instructions w i l l be given by your nurse or physiotherapist. You w i l l be encouraged to do these exercises after your operation, as they w i l l improve your c i r c u l a t i o n and hasten your recovery. 3. Enema: W i l l be given to cleanse the bowel, i f ordered by your doctor. 86 4. Urine Specimens: One i s to be collected on admission and a second one early i n the morning of your operation. Please use the bedpan or u r i n a l and n o t i f y the nurse. 5. Care of valuables: EVERY EFFORT SHOULD BE MADE TO LEAVE YOUR VALUABLES AT HOME. I f this i s impossible, the nurse w i l l remove a l l jewellery and valuables and store them i n safekeeping for you. 6. Other Effects: You w i l l be required to remove hair pins, hai r pieces or wigs, n a i l p o l i s h or false n a i l s and make-up. Remove dentures and place i n i d e n t i f i e d container at your bedside. You are allowed to wear only a hospital gown. The day of surgery Approximately one hour before operation, you w i l l be given medication which may make you f e e l relaxed and your mouth dry. You should empty your bladder before t h i s medication i s given. NOTE OF CAUTION: Do not get out of bed af t e r taking t h i s medication without c a l l i n g your nurse f i r s t . You may f e e l drowsy and unsteady on your feet. Half an hour before surgery, you w i l l be taken to the operating room and met by the Operating Room s t a f f . They w i l l check your i d e n t i f i c a t i o n bracelet before you are given your anaesthetic. Following your surgery, you w i l l be taken to the recovery room where you w i l l be cared f o r by nurses who are s p e c i a l l y trained and constantly present, u n t i l you awaken. On return to your room, you w i l l be cared f o r by the s t a f f on the nursing unit u n t i l you are ready to go home. Medications are ordered by your doctor w i l l administered to rel i e v e pain and keep you relaxed and comfortable. V i s i t o r s are not permitted i n the recovery room, but regular v i s i t i n g hours are maintained on the nursing unit. To help make your hospital experience as reassuring and safe as possible, the information above w i l l be discussed at a teaching session the evening before your surgery. The session w i l l s t a r t at 7:00 p.m., and both you and your family are invi t e d to attend. Your nurse w i l l d irect you to the location. KNOWING WHAT TO EXPECT IS HALF THE BATTLE. WE HOPE THIS INFORMATION WILL HELP YOU FEEL MORE COMFORTABLE, AND WE WILL DO OUR BEST TO MAKE YOUR STAY IN HOSPITAL AS PLEASANT AS POSSIBLE. • APPENDIX F PATIENT PROFILE SHEET PATIENT PROFILE SHEET PATIENT 01: AGE: SEX: DIAGNOSIS ON ADMISSION: TYPE OF SURGERY: SURGEON: PREVIOUS HOSPITAL ADMISSION: 1. LENGTH OF HOSPITAL STAY: ADMISSION DATE -DATE OF DISCHARGE 2. POSTOPERATIVE COMPLICATIONS: 3. ANALGESICS ADMINISTERED POSTOPERATIVELY: (24 hours) I.M. (24-96 hours) TABS 4. RECALL OF PREOPERATIVE KNOWLEDGE: 5. POST-SURGICAL QUESTIONNAIRE: /25 

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