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Volume 64, Issue 6 p. 941-952
Research/Education
Free Access

Preoperative Patient Teaching in Ambulatory Surgery Settings

First published: December 1996
Citations: 37

ABSTRACT

The researchers conducted this descriptive replication study to identity preoperative teaching content deemed important by patients and nurses in ambulatory surgery settings. Thirty ambulatory surgery patients and 29 perioperative nurses participated in the study, which was conducted at a midsized hospital in the southeastern United States. Patients ranked situational information (eg, explaining activities, events) as the most important teaching content areas, whereas nurses ranked psychosocial support (eg, dealing with worries, concerns) as the most important. Patients preferred to have teaching conducted before they were admitted for ambulatory surgery, whereas nurses believed that some teaching could take place after admission. The study results suggest that addressing patients' priorities and initiating teaching earlier in the perioperative process is crucial to ambulatory surgery patients' postoperative outcomes. AORN J 64 (Dec 1996) 941–952.

As health care facilities compete for scarce resources, health care professionals are seeking innovative ways to provide competent, high-quality, personalized care at the lowest possible cost.1 One response to this demand has been the development of ambulatory surgery centers. As in other health care settings, professional practice standards and accreditation agencies mandate that patient education is an integral part of the care provided in ambulatory surgery centers.2 Nurses who admit ambulatory surgery patients on the day of surgery must conduct this intensive preoperative patient education in very short time periods, which presents a difficult challenge in providing optimal patient care.

Studies in traditional surgical settings have demonstrated that preoperative teaching reduces patients' anxiety and postoperative complications, increases patients' satisfaction, and facilitates more rapid return to work.3 Although preoperative teaching positively influences recovery from surgery performed in traditional settings, aspects of preoperative teaching in ambulatory surgery settings have not been studied.

PURPOSE

It is essential for perioperative nurses to explore parameters of preoperative teaching in nontraditional settings to identify successful methods of achieving positive patient outcomes. The purpose of this study was to identify teaching content areas that ambulatory surgery patients and their nurses deemed important to the patients' postoperative outcomes and to discover any differences in the patients' and nurses' perceptions.

THEORETICAL FRAMEWORK

The theory of adult learning developed by Malcolm S. Knowles, PhD,4 and the model of patient teaching created by Jean Jenny, RN, MEd, MSN,5 provided the basis for this research. Dr Knowles examined the learning process as it occurs over a lifetime, where-as Jenny focused on learning in health care environments. Inherent in both models is the belief that teachers should engage learners in a process of mutual inquiry; that education must be based on learners' unique perceptions, beliefs, and values; and that learning and teaching should result in learners' behavior changes.6

LITERATURE REVIEW

The benefits of patient education are well documented in the literature. When patients are well informed, they are more likely to experience positive outcomes and increased satisfaction with their care.7 The method of instruction and the source of the information, however, do not appear to be significant if the information presented is what patients want to know and if patients are ready to receive the information.8

What does appear to be essential, and is the most consistent theme in the literature, is the importance of individualizing the teaching content for each patient. Identifying individual characteristics that influence patients' educational needs is an important nursing concern.9 Standardized teaching packages may not be effective because they do not address patients' individual needs.10 Postoperative follow-up telephone calls to patients are an effective education method because teaching can be adapted to each individual patient.11 Perioperative nurses must validate surgical patients' desires for teaching, the timing of teaching, and the type of information provided.12

Previous researchers identified five dimensions of preoperative teaching that they thought were important to hospitalized surgical patients. These dimensions were psychosocial support (ie, reassurance geared toward reducing anxiety), skills training (ie, teaching skills such as deep breathing), situational information (ie, events and experiences patients would undergo), sensation-discomfort information (ie, descriptions of what the patient would feel), and patient role information (ie, expected patient behaviors). Nurses and patients in this previous study ranked the importance of the dimensions similarly, except the nurses rated skills training second in importance, whereas the patients ranked it last in importance.13

In two studies reported previously in the AORN Journal, nurse researchers studied patients in ambulatory surgery settings. One study examined the quality of care provided and found that only a few patients answered affirmatively to all items on a questionnaire that measured quality.14 In the second study, the researcher examined stress and coping in ambulatory surgery patients and identified six areas of concern that were unique to the outpatient setting.15

Articles in the literature consistently support the belief that preoperative patient education is beneficial for patients (eg, increased satisfaction, fewer complications, more rapid return to work). Individualizing the content that is taught also is essential for achieving successful education outcomes.

The majority of the studies we reviewed were conducted with hospitalized patients. We found very few studies that investigated similar issues in ambulatory surgery patients; therefore, we designed this study to investigate the unique education needs of ambulatory surgery patients.

RESEARCH OBJECTIVES

We identified three research objectives for this study. The objectives were to
  • identify the teaching content that patients perceive as important to receive preoperatively from nurses in ambulatory surgery settings.

  • determine the teaching content that nurses perceive as important to teach preoperatively in these settings, and

  • detect differences and commonalities between patients' and nurses' perceptions of what is important to teach preoperatively in ambulatory surgery settings.

STUDY DESIGN

We designed this study as an extension of the previously cited descriptive study that explored patients' and nurses' perceptions of the importance of preoperative teaching in traditional hospital settings.16 Our study focused on patients undergoing surgical procedures in ambulatory rather than inpatient surgery settings.

SETTING AND SAMPLE

We conducted this study in a private, for-profit 200-bed hospital in a large metropolitan city in the southeastern United States. We used a purposive (ie, selected to be representative of the population) sample that consisted of the nurses and patients in two of the ambulatory surgery centers attached to the hospital. To control for the effects that specific types of surgical procedures could have on patients' responses, we invited only alert, English-speaking, adult patients who were scheduled to have laparoscopic surgical procedures. We excluded patients who underwent emergency laparoscopic procedures or who were admitted to the hospital after surgery. We asked nurses who had worked a minimum of one year in either of the ambulatory surgery units, the preoperative holding area, the OR, or the postanesthesia care unit (PACU) to participate.

Thirty patients, whose ages ranged from 19 to 68 years, participated in the study. All patients had at least a high school education or its equivalent. They underwent the following laparoscopic surgical procedures: 12 had diagnostic procedures; nine had inguinal herniorrhaphies; five had cholecystectomies; three had ovarian cysts or ovaries removed; and one had a bladder suspension.

Twenty-nine registered nurses, whose ages ranged from 26 to 58 years, participated in the study. Most were associate degree graduates. Three had nonnursing bachelor's degrees, and one had a nonnursing master's degree. The nursing experience of the nurse participants ranged from five to 40 years. Table 1 summarizes the demographic characteristics of the study sample.

Table 1. DEMOGRAPHIC CHARACTERISTICS
Characteristics Patients Nurses
Gender
Female 22 27
Male 8 2
Age
15 to 24 yr 5 0
25 to 34 yr 9 5
35 to 44 yr 8 13
45 to 54 yr 4 9
55 to 64 yr 2 2
65 to 74 yr 2 0
Education
High school or general equivalency diploma 5
Some college 14
Bachelor's degree 7
Graduate degree 4
Diploma in nursing 7
Associate degree in nursing 13
Bachelor's degree in nursing 4
Master's degree in nursing 1
Other degrees 4

SURVEY INSTRUMENT

We used the Perceptions of Preoperative Teaching Questionnaire developed by the nursing research committee at Providence Medical Center, Portland, Ore,17 and operationalized (ie, defined in identifiable processes) five dimensions of preoperative teaching and seven types of preoperative teaching from this questionnaire. Reliability coefficients for this instrument range from .82 to .94 for the five dimensions of preoperative teaching.18

There are two versions of this instrument: one is designed for patients and the other for nurses. The differences are in wording (eg, “before surgery, the nurses asked me…” for the patient version, compared to “before surgery, nurses have patients…” for the nurse version). Patients also are asked to indicate if they are taught particular items by nurses.

Dimensions of teaching. The instrument contains 73 specific teaching topics that reflect the five dimensions of preoperative teaching. The first dimension consists of 11 items that measure psychosocial support. The second dimension uses 27 items to measure situational information. The third dimension consists of 11 items that measure patient role information, and the fourth dimension uses 13 items that measure sensation-discomfort information. The fifth dimension consists of nine items that measure skills training. The only revisions we made to the original instrument were to remove two items that were specific to hospitalized patients. Thus, the instrument that we used contained 71 of the original 73 items. We asked our subjects to rank each of the items according to importance of teaching, using a five-point Likert-type scale with responses that ranged from “very important” to “not important.”

Types of teaching.

We also asked our subjects to rank seven types of preoperative teaching in order of importance using a seven-point Likert-type scale. The seven types of teaching were
  • the preoperative nursing care;

  • the what, when, and why of perioperative events;

  • when these events would occur;

  • what these events would feel like;

  • what patients were expected to do;

  • expressing concerns or worries; and

  • new skills to prevent complications.

After our subjects assessed the importance of these types of teaching, we asked them to note the time they believed this teaching should occur (ie, before admission, after admission but before surgery, at the time of the event or surgical procedure).

We computed scores by summing the responses for items in each of the five dimensions of preoperative teaching and then dividing these results by the number of questions in each dimension to derive a single score for each dimension. Thus, scores for each dimension ranged from one (ie, not important) to five (ie, very important). We computed scores on the seven types of preoperative teaching in a similar manner, but the scores for each type of teaching ranged from one (ie, least important) to seven (ie, most important).

DATA COLLECTION

Patients who agreed to participate in the study signed a consent form on the day they were admitted to the ambulatory surgery unit. They received the survey instrument just before discharge and were requested to mail it back within one week. Patients who agreed to participate but who did not return completed instruments within seven days either were mailed a second instrument or received a telephone reminder. Two weeks after we distributed instruments to patients, we asked perioperative nurses to participate in the study. We used this two-week interval between data collection for patients and for nurses so the nurses would not be as likely to base their responses on their recall of particular study patients and so they would not change their usual teaching practices by incorporating topics listed in the instrument. Nurses who signed consent forms to participate received survey instruments and were asked to mail them back within one week.

RESULTS

We examined patients' and nurses' perceptions of preoperative teaching separately, and then we compared both groups' perceptions to determine any differences in perceptions.

Patients' perceptions.

As shown in Table 2, patients ranked the situational information dimension as the most important aspect of preoperative teaching and skills training as the least important. The order of importance in which patients ranked the seven types of preoperative teaching is shown in Table 3. Most important to patients was knowing when events and procedures would occur and least important was knowing about the preoperative nursing care they would receive.

Table 2. SUBJECTS' RANKINGS OF THE IMPORTANCE OF FIVE DIMENSIONS OF PERIOPERATIVE TEACHING*
Patients Mean (standard deviation) Rank order Nurses Mean (standard deviation) Rank order
Situational information 4.19 (0.56) 1 3.97 (0.54) 3
Psychosocial support 4.15 (0.76) 2 4.32 (0.48) 1
Patient role 4.15 (0.63) 3 4.04 (0.63) 2
Sensation/discomfort 3.79 (0.96) 4 3.45 (0.76) 5
Skills training 3.76 (1.14) 5 3.74 (0.89) 4
  • * Rankings obtained using a five-point Likert-type scale
Table 3. SUBJECTS' RANKINGS OF THE IMPORTANCE OF SEVEN TYPES OF PERIOPERATIVE TEACHING*
Patients Nurses
Mean Rank order Mean Rank order
When events will occur 4.52 1 5.04 1
What patient is expected to do 4.48 2 3.64 5
What, when, and why of events 4.09 3 4.68 2
Expressing concerns, worries 4.04 4 4.36 4
Skills to prevent complications 3.96 5 2.79 7
What events would feel like 3.78 6 4.46 3
Preoperative nursing care 3.13 7 3.04 6
  • * Rankings obtained using a seven-point Likert-type scale

More than 50% of the patients believed that six of the seven types of preoperative teaching (ie, topic areas) should be taught before admission to the ambulatory surgery center (Table 4). They identified only the teaching of new skills (eg, coughing, deep breathing to prevent complications) as being appropriate for the time after admission.

Table 4. TIMES PREFERRED FOR PREOPERATIVE TEACHING*
Category Before admission (% preferring) After admission (% preferring) During admission (% preferring)
Preoperative nursing care
Nurse 28 61 11
Patient 46 40 14
What, when, and why of events
Nurse 38 45 17
Patient 50 37 13
When events will occur
Nurse 73 24 3
Patient 50 43 7
What events will feel like
Nurse 38 34 28
Patient 50 37 13
What patients are expected to do
Nurse 52 41 7
Patient 57 40 3
Expressing concerns and worries
Nurse 76 21 3
Patient 72 28 0
Skills to prevent complications
Nurse 7 76 17
Patient 24 59 17
  • * Underlined figures represent times preferred by nurses and patients.

Patients' perceptions of the importance of particular items in the five dimensions depended on whether nurses had taught them about those items. Patients' importance rankings differed significantly for items explained by the nurses and items nurses did not explain (paired t test, P < .0001). Although patients' perceptions of the importance of the teaching dimensions varied with their education backgrounds and gender, only the psychosocial support dimension was significantly more important to the female patients than it was to the male patients (analysis of variance [ANOVA]; Tukey's Honestly Significance Difference [HSD] test to locate group differences; P < .05). Although not statistically significant, patients with bachelor's degrees consistently ranked all five dimensions of preoperative teaching as being more important than did patients with less education, and female patients ranked the remaining four dimensions of preoperative teaching as more important than did male patients.

Nurses' perceptions.

The nurses ranked psychosocial support as the most important dimension of preoperative teaching and the dimension of sensation-discomfort as the least important. When we asked the nurses to rank the seven types of preoperative teaching, they ranked “when events would occur” as most important and “teaching new skills to prevent complications” as least important. Most nurses expressed the belief that patients should be taught when events would occur, what they would feel like, what would be expected of them, and the importance of expressing their concerns and worries before they are admitted to the ambulatory surgery unit. The nurses also believed that teaching about preoperative nursing care; the what, when, and why of events; and new skills to prevent complications should occur after admission. Only a few nurses preferred that any teaching be conducted at the time of surgical procedures.

Using ANOVA to compare nurses' perceptions of the importance of the five preoperative teaching dimensions to the units on which they worked, their education backgrounds, full- or part-time employment, and years of experience, we found only one significant difference. Nurses who had 10 or more years of experience ranked the sensation-discomfort dimension as significantly more important than did nurses with less than 10 years of experience (Tukey's HSD, P < .05). The more experienced nurses also ranked the remaining four dimensions higher in importance than did the less experienced nurses, although these differences were not statistically significant. The PACU nurses ranked the five dimensions as higher in importance than did the nurses working in either the ambulatory surgery unit or the OR, although these differences were not statistically significant. Responses grouped by type of nursing education did not differ significantly. Nurses who were employed full-time ranked four of the five dimensions higher in importance than did nurses who worked part-time.

Comparison of patients' and nurses' perceptions.

Overall, patients and nurses agreed on the content of what is important to teach patients in ambulatory surgery settings. The pooled t tests that we used to compare patients' and nurses' composite scores for each of the five preoperative teaching dimensions did not detect any significant group differences.

For the seven types of preoperative teaching, two of the three types that patients ranked highest in importance also were ranked highly by nurses. Similarly, two of the three types ranked lowest in importance by patients also were ranked lowest by nurses. The two major group discrepancies were “teaching patients about what they would be expected to do” (ie, patients ranked this as much more important than did nurses) and “what events would feel like” (ie, patients ranked this as much less important than did nurses). Although patients and nurses ranked items differently, no statistically significant group differences were detected.

Using the Fisher's Exact test, we found no significant differences between patients and nurses regarding preferred times for teaching. Most patients and nurses agreed that teaching patients about when events would occur, what they would feel like, what patients would be expected to do, and expressing their concerns and worries should occur before admission to ambulatory surgery units. Similarly, both groups believed that teaching patients new skills to prevent complications should occur after admission.

Most patients believed that they should be taught about preoperative nursing care before admission, whereas the nurses preferred to wait until patients were admitted to impart this information. Most patients preferred to wait until after admission to learn new skills to prevent complications. Very few nurses and patients preferred to either teach or learn new knowledge at the time surgical procedures were being performed.

LIMITATIONS

The sample size of 59 was small and mostly female, which affects the generalizability of the results. Patients and nurses were given the survey instrument to complete at home and return by mail, and it is possible that they received assistance in completing the instrument or that other individuals answered the questions. Patients' recall of events about surgery may have decreased with time. Although the sample was small, the study results can help nurses define the parameters of preoperative teaching in ambulatory surgery settings, just as previous studies have helped define parameters of preoperative teaching in traditional inpatient settings.

DISCUSSION

We compared our findings with those of the earlier study of hospitalized surgical patients' preferences for education.19 The hospitalized patients ranked the five preoperative teaching dimensions in the same order as did our ambulatory surgery patients, except that situational information and psychosocial support were reversed in order of importance.

Nurses in both studies ranked psychosocial support as first in importance and situational information as third. Nurses in the earlier study ranked skills training as second in importance, whereas it was ranked fourth in our study. Nurses in the earlier study ranked patient role information fourth, and it was second in our study. Teaching about sensation-discomfort was ranked last by nurses in both studies.

Patients' priorities.

Overall, there were more discrepancies between the nurse-patient importance rankings in the earlier study of hospitalized surgical patients and their nurses. These findings suggest that patients have similar education needs regardless of surgical settings (ie, inpatient versus ambulatory) but that nurses view patients' needs differently according to settings. It is important for nurses to recognize what patients consider priorities for preoperative education.

Timing of teaching.

Nurses and patients in the earlier study preferred that most teaching be conducted after patients were admitted, whereas nurses and patients in our study preferred that the teaching be conducted before admission. This finding may reflect the differences in time available for teaching in inpatient and ambulatory settings.

The nurses in our study identified only three of the seven types of preoperative teaching as being important to teach before the day of surgery. These results may reflect the current ambulatory surgery care system rather than the timing that nurses truly believe would be best for their patients.

Influence of teaching.

Patients' rankings of importance in both studies were associated with the dimensions taught by nurses (ie, if nurses emphasized and taught certain information, patients judged that information to be more important than information the nurses did not teach). This finding has significant implications for what nurses teach. For example, if nurses in ambulatory surgery settings could devote more time to teaching skills to patients, patients might consider these skills more important to their postoperative recoveries. More research is needed to clarify this aspect of learning priorities and patient education.

Important content.

Situational information, patient role information, and psychosocial support were the most important dimensions identified by both nurses and patients in this study. This may reflect patients' awareness that this information will help them through their surgical procedures as well as prepare them for postoperative recovery, which they must man-age independently. For example, ambulatory surgery patients sometimes are dismayed to discover that their pain and fatigue last longer than they expect20 from the information they receive before surgery.

Knowing what is expected of them is an essential component for ambulatory surgery patients who need to know what they should be doing and when they should be doing it so they will have a way to determine if their progress is normal. The fact that patients ranked these two dimensions highly is an indicator of their readiness to learn, which is an important component in the teaching-learning process. The nurses and patients in our study clearly recognized that any surgical experience causes anxiety and fear and that these feelings must be dealt with appropriately.

New teaching roles.

The PACU nurses ranked the various dimensions higher in importance than did the other nurses, which may reflect their experiences in answering patients' and family members' queries about surgical experiences and discharge care. If PACU nurses have a heightened awareness of ambulatory surgery patients' teaching needs, perhaps these nurses can be more involved in preadmission patient education.

Educational alternatives.

Given the time constraints in ambulatory surgery settings, it is not appropriate to teach essential information on the day of surgery. One alternative is to improve communication between staff members in surgeons' offices and hospital preadmission nurses. Another option is to develop structured teaching materials (eg, videotapes, pamphlets, onsite visits by hospital staff members) that are appropriate for ambulatory surgery patients, are specific to the institutions involved, and supplement verbal teaching.21

At least one hospital's staff members have created a formal orientation program once a month for patients scheduled for ambulatory surgery procedures.22 Lectures, videotapes, question-and-discussion opportunities, and tours of the ambulatory surgery suite are part of this program. Another hospital's staff members make home visits to patients who are scheduled for cataract extraction procedures. These staff members have not documented changes in patients' knowledge, skills, or anxiety levels, but they believe the preventive benefits of home teaching may be the most important outcome.23 Although some of these alternatives appear expensive, costs may be recovered by preventing delays or cancellations in surgery, increasing patient satisfaction, and reducing complications that require readmission.

If patients could receive all important information before the day of surgery, perioperative nurses would be under less pressure to provide essential information on the day of surgery. Nurses could use the time on the day of surgery to evaluate patients' learning, focus on information particular to individual patients, and spend more time providing the situational information and psychosocial support that patients in our study identified as most important.

IMPLICATIONS FOR FUTURE RESEARCH

The effectiveness of these recommendations should be evaluated through formal research. Surgery and other invasive procedures are being performed increasingly on an outpatient basis, and the potential for poor patient outcomes increases when professional observation and care are not immediately available. More research is needed to establish the settings in which safe, cost-effective care can be provided. Identifying when, where, and how preoperative teaching is most effective for ambulatory surgery patients is an important topic for future research. Another urgent research topic is the potential influence of age on ambulatory surgery patients' outcomes. Scarce social and community support systems, coupled with the physiologic changes of aging, may affect this particular age group differentially and adversely and require special adaptations to their perioperative nursing care.

CONCLUSION

Ambulatory surgery patients are making known their preferences for preoperative teaching before they are admitted for surgery. Whether it is at the physician's office or the ambulatory surgery center, the preoperative phase is when patients want to learn about their impending surgical experiences. Having this information early allows patients time to plan, consider alternatives for postoperative care, cognitively rehearse events and thus allay some of their anxiety, and identify and ask questions important to their situations.

When surgery units face funding crises, the costs of providing perioperative patient care must be assessed carefully. In the current health care environment, perioperative nurses must continue to provide quality care in less time and with fewer resources. This study provides an introductory glimpse at where nurses should be focusing their time and energy so that quality of care is not compromised in time-constricted nurse-patient encounters in ambulatory surgery settings.

Biographies

  • Valerie C. Brumfield, RN, MS, is a clinical nurse specialist at the South Fulton Medical Center, East Point, Ga.

  • Carolyn C. Kee, RN, PhD, is an associate professor of nursing at Georgia State University, Atlanta.

  • Joyce Y. Johnson, RN, PhD, CCRN, is an assistant professor of nursing at Georgia State University, Atlanta.