Orthopaedic patients ’ perceptions about their pre-operative information

A non-experimental, descriptive and quantitative survey was conducted to explore orthopaedic patients’ perceptions about the pre-operative information received when undergoing elective surgery in two hospitals in the KwaZulu-Natal Province. The findings indicate that most patients perceived the pre-operative information to be useful in their preparation for surgery. Aspects that were not addressed during preoperative information sessions included post-operative nutrition, pain medication, ambulation, deep breathing and coughing exercises. The recommendations include that all these aspects should be addressed in future pre-operative education sessions. Further research should be conducted for enhancing the pre-operative information provided to patients scheduled to undergo elective orthopaedic surgery.


Introduction and background information
Patients undergoing elective surgery experience fear and anxiety because they do not know what to expect.Pre operative information assists the pa tient to become more knowledgeable about the prospective surgery and enables the nurse to learn about the patient and to establish rapport before the patient is taken to the operating theatre (Phillips, 2004:368).Pre-opera tive teaching reduces the patient's ap prehension and fear, increases the pa tient's co-operation and participation in post-operative care and decreases the incidence and severity of post operative complications (Ignatavicius, Workman & Mishler, 1999:321 -322;Lee & Chien, 2002:1).Pre-operative infor mation should provide patients with clear instructions preparing them for their surgical procedures and post-operative care.Prouty, Cooper, Thomas, C hristensen, Strong, Bowie and Oermann (2006:257) describe a pre-operative information programme offered to patients undergoing orthopaedic surgery at a hospital in Michigan in the United States of America.The pro gramme covered pre-operative prepa ration and included aspects such as preparation for surgery and medica tions, a review of the anatomy of the knee or hip, medical devices patients will encounter in the hospital such as drains and catheters and information on how to prevent complications.Pa tients reported that this pre-operative teaching was effective in reducing their anxiety levels about their surgery.
According to Lewis, Heitkemper and Dirksen (2004:369), pre-operative teach ing encompasses three types of infor mation: sensory, process and proce dural.Sensory information relates to what patients see, hear, smell and feel.Process information concerns the gen eral flow of events.For example, the patient may be told that he will be taken to the waiting area first, then to the operating room and after surgery to the recovery room before returning to the ward or to the intensive or high care unit, depending on the surgery.Proce dural information includes post-opera tive fluid and food restrictions, expected drains, tubes, catheters and intrave nous infusions.Fitzpatrick and Hyde (2005:254-255) re ported that surgical nurses in Ireland, used words to convey pre-operative information rather than teaching tools or aids.However, these Irish nurses reportedly recognised the potential benefits of using visual materials.Pa tient information leaflets were available but were specific to the post-operative period.Some nurses used diagrams of bones to illustrate an operative proce dure such as the insertion of pins.Johansson, N uutila, Virtanen and Salantera (2005:220), maintain that booklets, used in pre-operative patient information, enable patients to return to them for information.However, writ ten information alone proved inad equate to provide effective pre-opera tive information.When conducting pre operative teaching, the nurse should explain the operation, the immediate post-operative period's expectations and the mobilisation plan.Evaluating how well the patient understands the procedure is important.This could be done by asking the patient to explain in his/her own words what the opera tion entails in writing on the form where he/she signs consent for the surgery.
According to Altizer (2004:283), an or ganised pre-operative teaching pro gramme should begin with normal anatomy and an explanation of how joints work.Anatomic models showing a normal hip or knee should help the patient to understand the normal anatomy.The patient's own X-rays could be used to show the involved joint with narrowing or complete loss o f jo in t space, fractures and/or displacements.The patient should also be shown a post-operative film of a joint implant in place -if the patient is sched uled for implant surgery.Showing the actual prostheses could also be help ful, but keeping examples for this pur pose might be too expensive to be fea sible.Pre-operative teaching improves post operative compliance (Pellini, Tluczek, Collins, Trimbom, Norwich, Engelke & Broad, 1998:48;Walker, 2007:27;Whyte & Grant, 2005:201).Pre-operative teach ing also involves discussions with the patient and family about the need for assistance with activities of daily liv ing and the need for support once the patient is discharged.This may involve informing the patient and family on ways to modify the home environment in order to accommodate the altered mobility of the patient after surgery as well as referral to the social worker (Smeltzer & Bare, 2004:2041).Spalding (2004:152) states that pre-op erative information has the potential to increase patients' confidence and en able them to take control of their health and well-being.Comprehensive pre operative information should help both the family and the patient understand the procedure and what to expect postoperatively.Pre-operative information also assists the patient to set realistic recuperation goals.

Problem statement
Pre-operative information was not pro vided regularly by nurses in the two hospitals where this research was con ducted.The first author, a nurse edu cator teaching operating theatre nurs ing, noticed that patients, who did not receive pre-operative information, ap peared to be more anxious than those who had done so.According to Perry and Potter (2002:959) and Clancy, Me Vicar and Baird (2002:219), anxiety can interfere with the effectiveness of anaesthesia, the patients' abilities to participate in their care as well as their stress and pain levels.

Purpose of the research
The purpose of the study was to ex plore and describe the perceptions of orthopaedic patients, who had under gone elective surgery, about the pre operative information provided to them.

Objectives of the research
The study aimed to identify: • Whether the orthopaedic pa tients received information prior to their elective surgery • Which aspects were included/ not included in the pre-opera tive information education • How pre-operative information was conveyed to orthopaedic patients • Who provided pre-operative information to orthopaedic pa tients.

Research design
A non-experimental, exploratory, de scriptive and quantitative research de sign was used.This study was nonexperimental because no variables were manipulated.It was descriptive be cause structured interviews were con ducted with 50 orthopaedic patients requesting information about their per ceptions concerning the pre-operative information they had received.The responses to questions on the com pleted structured interview schedules were coded and quantified.Responses to open-ended questions were grouped and quantified.

Research population
The population for this study included all orthopaedic patients admitted for elective surgery at all the provincial hospitals in the KwaZulu-Natal Prov ince from 10 May till 27 July 2007.The target population comprised all ortho paedic patients admitted for elective surgery over a period of ten weeks (10 May till 19 July 2007) at the two partici pating provincial hospitals in the KwaZulu-Natal Province.

Sample
It could not be predetermined whether or not specific orthopaedic patients would be willing to be interviewed about their perceptions relating to pre operative information and no census existed of persons scheduled for elec tive orthopaedic surgery at these hos pitals.Therefore a random sample could not be selected.
All patients, aged 18 or older, who were admitted to the orthopaedic wards at the two participating hospitals for elec tive surgery, from 10 May till 27 July 2007, were requested to participate in the study.Orthopaedic patients were selected because post-operatively they are usually well enough to be inter viewed and because they require pre operative information.

Research instrument
The interview schedules consisted of a combination of open and closed ended questions designed to assess how patients perceived their pre-opera tive information.The interview sched ule comprised the following sections: Section A collected demographic data from orthopaedic patients, such as gen der, age, marital status, educational qualifications and the number of ad missions for elective orthopaedic sur gery.
Section B consisted of questions about the pre-operative information ortho paedic patients had received.
Section C consisted of questions relat ing to the persons who provided infor mation pre-operatively to orthopaedic patients.
Section D's questions attempted to determine whether the information pro vided to orthopaedic patients helped them with their post-operative adapta tions, expectations and/or recuperation processes.

Validity and reliability
The instrument was constructed so that it could measure the attributes to be studied, namely the perceptions of or thopaedic patients regarding pre-operative information received prior to their elective surgical procedures, amounting to face validity.Two nurse educators teaching orthopaedic and operating theatre nursing science, who did not participate in the actual study, as well as two nurse researchers, re viewed the interview schedule items to ensure that the questions were rel evant, unambiguous and clear, accept ing the interview schedule's construct validity.
The content of the interview schedule was derived from literature on pre-op erative information.

Ethical considerations
The respondents were fully informed about the process and the purpose of the study.Respondents were not co erced to participate in this study and they had the right to withdraw from the study at any stage without incurring any negative consequences whatso ever.An opportunity was provided for each respondent to ask questions and to clarify misunderstandings.
During the data collection process, the respondents' names were not recorded on the interview schedules, ensuring anonymity.The research report only portrays figures, statistics and discus sions but no names.All completed in terview schedules were secured under lock and key.No respondent was paid.
Permission to conduct the study was obtained from the Kwazulu-Natal Pro vincial Department of Health, the chief executive officers of the two participat ing hospitals, and the from the Re search and Ethics Committee of the Department of Health Studies, Univer sity of South Africa.Signed consent was obtained from every respondent.

Method of data analysis
The quantitative data collected was analysed using the Statistical Package for Social Sciences (SPSS) version 13.A statistician identified and calculated appropriate statistics.

Demographic data
Of the 50 respondents, 34 (68.0%) were males and 16 (32.0%)were females, only 10 (20.0%) respondents were married and 25 (50.0%) were between 18 and 38 years of age.Most of these patients were actively involved in contact sports such as soccer, while some were in volved in car accidents.Only 6 (12.0%) respondents were between 49 and 68 years of age, of whom most had sus tained falls in their homes.
No respondent had a tertiary educa tion qualification and 25 (50.0%) had completed grades 3-10.More than half (64.0%; n=32) of the respondents had no previous experience with orthopae dic surgery while 18 (36.0%)respond ents had been admitted for surgery for the second or third time.O f the re spondents 35 (70.0%) had sustained injuries to the lower limbs and 15 (30.0%) to the upper limbs.The ortho paedic procedures performed on the respondents included: reduction and internal fixation of the radius/ulna (30.0%; n=l 5), open reduction and in ternal fixation of the tibial plateau (24.0%; n=12) and pin and plate fixa tions of the femur (18.0%; n=9).

Pre-operative information received by orthopaedic patients
Of the respondents, 39 (78.0%) reported pre-operative information to be useful for their preparation for surgery but only 17 (34.0%>)considered this to be the case for their post operative recov ery.Similar findings were reported by other researchers (Elkin, Perry & Pot ter, 2004:496497;Lewis et al., 2004:369; Shuldham, Flem ing & Goodman, 2002:666).

Pre-operative information provided the night before surgery
All respondents (100%; n=50) were re- ) were asked to shave the op eration site, 2 (4.0%) were asked to shampoo their hair and only 1 (2.0%) respondent was asked to have a light supper.Although all these aspects should be attended to during the pre operative stage, specific pre-operative information and/or preparation could be influenced by the type of surgery and by the surgeon's preferences.For example, some orthopaedic surgeons might prefer their patients not to be shaved pre-operatively because any skin cuts could increase the risk of post-operative infections with poten tially hazardous risks for the patients.

Pre-operative information provided the morning of the surgery
Information provided on the morning of surgery lacked information on shav ing of the operative site (16.0%;n=8), removing make-up (2.0%; n=l) and pre medication (2.0%; n=l).No respond ent was reportedly instructed to empty his/her bladder prior to receiving pre medication.However, patients sched uled for major orthopaedic surgery usu ally have urinary catheters inserted prior to these operations, explaining why this pre-operative instruction might have been irrelevant -at least to some respondents.
Of the respondents 35 (70.0%) were not made aware of the operating room en vironm ent, implying that only 15 (30.0%) respondents received informa tion about the operating room environ ment.
Patients' preferences for receiving pre-operative information All 100% (n=50) of the respondents received pre-operative information orally whereas 88.0% (n=44) indicated that X-rays were used during such in formation sessions.
The respondents' preferences for pre operative information included oral com m unication (50.0% ; n=25), videotapes (30.0%; n=15), X-rays (10.0%; n=5) and pamphlets/books (2.0%; n=l).Oral presentations were reportedly simple and easy to under stand, and presented possibilities to ask questions.Video recordings (tapes and/or compact discs) were interesting to watch, and afforded opportunities to watch the video presentation repeat edly to improve their understanding.X-rays enabled the respondents to see where the actual fractures were and how the operations were going to be performed.Most of the respondents had televisions (785; n=39), DVD play ers (66.0%; n=33) and video machines (52.0%; n=26) at home, making these methods of providing pre-operative information feasible.Kulik (1999:3) andPager (2005:6) reported that respond ents who viewed videotapes of their surgical procedures spent less time in the hospital post-operatively and ex perienced lower stress levels than those who had not done so.

Patients' satisfaction levels with the pre-operative information received
Reportedly pre-operative information decreased the anxiety levels about their impending surgery of 39 (78.0%) re spondents.As many as 33 (66.0%) re spondents were satisfied with the pre operative information they had re ceived.
Although most respondents under stood the information, 16 (32.0%)found it difficult to understand medical terms and 27 (54.0%)would have appreciated more opportunities to ask further ques tions.
Only 58.0% (n=29) of the respondents received information on pain medica tion.Reportedly respondents did not receive pre-operative information on general aspects of post-operative care, early ambulation and nutrition.

Conclusions
Most young orthopaedic respondents required surgery after accidents and most older respondents after sustain ing falls in their homes.Although all respondents had reportedly received some pre-operative information, some aspects were not addressed.
Pre-operative information provided on the morning of the surgery did not ad dress the removal of nail polish and make-up, did not familiarise the major ity of the respondents with the operat ing theatre environment and did not request any respondent to empty his/ her bladder prior to being given pre medication.
All respondents received pre-operative information orally and most were shown their x-rays during these oral sessions.Prostheses and anatomic models were not used.Many respond ents would have appreciated more op portunities for asking questions, and for clarifying medical terms.Although pre-operative information had been provided the reasons for procedures and expected post-operative actions were not always supplied.Only ap proximately half of the respondents had been informed about post-operative pain medication.Post-operative nutri tion, early ambulation, deep breathing and coughing exercises were not ad dressed.

Recommendations
Based on the conclusions of this study, recommendations will be provided for enhancing the pre-operative informa tion provided to orthopaedic patients and for conducting future research.
Recommendation for improving the quality of pre-operative information provided to orthopaedic patients In addition to the pre-operative infor mation routinely provided to orthopae dic patients, the following recommen dations could enhance the quality thereof: • Information provided on the evening preceding the opera tion should include shaving of the operation site (depending on the specific surgeon's pref erences), washing of hair and removal of nail polish and make up.

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The patients should also be fa miliarised with the operation procedures such as going to the waiting area, operating theatre, recovery room and ward/inten sive care unit.Patients without urinary catheters must be re quested to empty their bladders prior to the administration of pre-medication.

Recommendations for future studies
The recommendations listed in the pre ceding section should be included in the pre-operative checklists of the hos pitals concerned.Once these changes have been implemented the study should be repeated to determ ine whether or not the pre-operative infor mation provided to orthopaedic pa tients have actually improved.A peri odic audit check should be done of the pre-operative information recorded on a specific patient's file correlated with the patient's report.This could help to ensure that orthopaedic patients re ceive adequate pre-operative informa tion.
The study should be repeated but should include orthopaedic patients who cannot communicate in English.
Qualitative semi-structured interviews should be conducted with orthopae dic patients to learn about their actual experiences concerning pre-operative information.
Orthopaedic ward nurses and operat ing theatre nurses should be ques tioned about the pre-operative infor mation provided by them.Based on this information a feasible plan for provid ing pre-operative information should be designed, implemented, evaluated and improved on an ongoing basis.
A multidisciplinary study should be conducted to specify the expected pre operative information to be provided by the surgeon, anaesthetist, ward nurse, operating theatre nurse (if any) and physiotherapist.By avoiding du plication, much time could be saved.
Depending on the research results the surgeon could provide information about the actual surgical procedures; the anaesthetist about pre-and post operative medication; the ward nurse about the expected pre-operative pro cedures, the actual process through the operating theatre and immediate post operative expectations; while the physiotherapist could explain the ne cessity of deep breathing and cough ing exercises as well as the use of any orthopaedic aids and the anticipated post-operative exercises.
Limitations of the study

Concluding remarks
More effective pre-operative informa tion could help orthopaedic patients to participate more effectively in their post-operative care and in their long term rehabilitation.Surgeons, anaes thetists, nurses and physiotherapists should collaborate to avoid duplication but to ensure that each patient receives all the required information -preferably verbally and in written format.