Optimizing the Effectiveness of Preoperative Education Part 2

Is Preoperative Education Beneficial?

For part 1 of this post click here

Does PE achieve any of its goals, and is PE worth the time and financial resources required of it? A 2014 systematic review by Jordan et al. concludes, “There is currently insufficient evidence to recommend routine implementation of pre-operative education programmes (2).” Then there is another 2014 systematic review by McDonald et al. that states, “...we are unsure if it (preoperative education) offers benefits over usual care in terms of reducing anxiety, or in surgical outcomes, such as pain, function, and adverse events” (1).

There arises different difficulties when assessing the effectiveness of PE. One difficulty is the heterogeneity as described before. There are wide differences in PE in terms of goals, delivery methods, content, timing, duration, and instructor. There are also different outcomes for different surgeries and different patient populations.

The research on PE also has inherent limitations. Many of the studies were performed retrospectively. Other studies utilized quasi-experimental designs. In theses studies, instead of random assignment to an experimental or control group, participation in the PE was voluntary. It is more than likely there are important differences between individuals who voluntarily attend or participate in PE and those who decline to participate.

Patient education itself is also complex and multifactorial. As Ronco et al. state in their 2012 systematic review, “education represents a complex variable in which the whole is not simply the sum of the parts, and in which there is an inherent difficulty in specifying the ‘active ingredient’ that makes the intervention itself effective” (8).

With all this considered, some studies do find positive benefits from PE. For other outcomes, there is either conflicting results or no impact found. Here is a general overview of some of the results in the literature:

Reduced pre-op anxiety levels (1, 4, 9, 10, 15, 16, 17)
Reduced post-op anxiety levels (1, 9, 12)
No effect on anxiety (4, 18, 12, 19)
Reduced patient expectations (20)
Increased patient knowledge (4, 8, 17, 18, 21, 22)
Increased regularity of exercise performance post-op (4, 18)
Shorter hospital length of stay (4, 12, 14, 23, 24, 25, 26, 27)
No change in hospital length of stay (1, 4, 10, 11)
Increased likelihood of being discharged directly home (14, 23)
No change in post-op complications (1, 10, 11)
Reduced post-op pain levels (1, 17, 25, 28, 29)
No change in post-op pain levels (1, 3, 4, 9, 11, 30)
No change in analgesic utilization (10)
Less utilization of post-op analgesics (9, 12, 26)
Reduced time to return to pre-op functional level (24, 28, 31, 32)
No change in time frame of post-op return of function (1, 4, 27)
Improved post-op mobility (4)
No difference in post-op mobility (1)
Improved patient satisfaction (6, 26)
No change in patient satisfaction (1)

Optimizing Preoperative Patient Education
It’s often the knee-jerk reaction for researchers and health professionals to just say “more research is needed” or “the results are inconclusive.” They may just accept how things are done because intuitively they seem appropriate and beneficial. Yet, it’s extremely important to synthesize the research and information available in order to optimize healthcare practices. Here are some ways to optimize the effectiveness of PE.

Highly Individualized Patient Education
Both small group classes and one-on-one education sessions have their pros and cons, but individualized one-on-one sessions are more effective. When you instruct a group, your style and techniques cater to the average of the group and information is generalized. This is ineffective as there are significant differences between patients in matters such as personal circumstances, personal/medical history, learning style, learning ability, and levels of fear and anxiety.

For example, let’s say two patients are receiving PE at the same time. The one patient is very involved and participatory in preoperative preparation and she follows all the instructions provided to her. She also has a high level of anxiety and fear leading up to surgery. The other patient has a low level of participation and involvement. He is either unaware or in denial of the importance of being an active participant in the preparation and recovery from surgery. He demonstrates very low anxiety and fear leading up the surgery.

The best methods and content utilized to educate these two patients preoperatively will vary significantly. When teaching both together, the effectiveness of your teaching can be considered roughly 50% effect for each of them (or worse). However, if you have a customized one-on-one session with each by themselves, you’ll be more effective and better meet their specific needs. They’ll also be more comfortable asking questions and addressing personal health-related concerns.

Nonetheless, one-on-one education sessions are not enough. The content and delivery of the education should be individualized, too. Daltroy et al. in their 1998 study do a great job describing the different needs and approaches of PE for individuals with high versus low levels of anxiety and for individuals with high versus low levels of denial (12).

It seems best for patients prior to surgery to have a medium level of anxiety and arousal. This level of anxiety can stimulate active involvement, positive actions, and attention to important and useful information, while at the same time not be too intense to cause overwhelm and debilitation. This theory is very similar to the inverted-U theory between stress and performance created by psychologists Robert Yerkes and John Dodson in 1908 (33).

When it comes to PE, certain content can be very arousing such as discussing the specifics of surgery, pain and other impairments post-op, complications risks, or stressful scenarios post-op. For patients with a high level of anxiety and fear, this information can cause more harm than good. These individuals would benefit more from information regarding coping strategies, self-management strategies, and general reassurance (12).

For patients with low levels of anxiety and/or high levels of denial, description of procedural information may be more beneficial. Someone in denial will do less to prepare for surgery and the rehab and recovery afterwards. Providing information regarding the procedure, risks, and the importance of preparation and recovery can arouse a level of anxiety that encourages greater preparation and a more active role in the surgical process (12).

The other type of patient to consider is someone who is highly anxious and has a high level of denial. These patients may benefit from alternative strategies rather than providing information. They may benefit from distraction strategies such as relaxation techniques (12).

For all patients, Daltroy et al. highlight the importance of focusing on aspects the patient can control rather than focusing on things they cannot actively control or influence. This leads to patient empowerment and self-efficacy, improved patient expectations, and limits negative post-op surprises (12).

Through quick and easy to fill out questionnaires, providers can get a good picture of patients’ levels of anxiety and levels of denial. It would also be beneficial to ask questions about patients’ perceptions and expectations prior to surgery. With this information, providers can determine the most beneficial PE content for each patient. It may be beneficial to create different PE classification groups based on patients’ levels of anxiety and denial in a similar fashion to treatment-based classification systems.

References

1. McDonald, Steve, et al. "Preoperative education for hip or knee replacement." Cochrane Database of Systematic Reviews 5 (2014).
2. Jordan, R. W., et al. "Enhanced education and physiotherapy before knee replacement; is it worth it? A systematic review." Physiotherapy 100.4 (2014): 305-312.
3. Louw, Adriaan, et al. "Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods." Physiotherapy theory and practice 29.3 (2013): 175-194.
4. Johansson, Kirsi, et al. "Preoperative education for orthopaedic patients: systematic review." Journal of advanced nursing 50.2 (2005): 212-223.
5. Spalding, Nicola Jane. "Reducing anxiety by pre‐operative education: Make the future familiar." Occupational therapy international 10.4 (2003): 278-293.
6. Papanastassiou, Ioannis, et al. "Effects of preoperative education on spinal surgery patients." SAS journal 5.4 (2011): 120-124.
7. Shuldham, Caroline. "1. A review of the impact of pre-operative education on recovery from surgery." International journal of nursing studies 36.2 (1999): 171-177.
8. Ronco, Monica, et al. "Patient education outcomes in surgery: a systematic review from 2004 to 2010." International Journal of Evidence‐Based Healthcare 10.4 (2012): 309-323.
9. Doering, Stephan, et al. "Videotape preparation of patients before hip replacement surgery reduces stress." Psychosomatic Medicine 62.3 (2000): 365-373.
10. Giraudet-Le Quintrec, Janine-Sophie, et al. "Positive effect of patient education for hip surgery: a randomized trial." Clinical Orthopaedics and Related Research® 414 (2003): 112-120.
11. Kearney, Marge, et al. "Effects of preoperative education on patient outcomes after joint replacement surgery." Orthopaedic Nursing 30.6 (2011): 391-396.
12. Daltroy, Lawren H., et al. "Preoperative education for total hip and knee replacement patients." Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 11.6 (1998): 469-478.
13. O'donnell, Katherine F. "Preoperative pain management education: A quality improvement project." Journal of PeriAnesthesia Nursing 30.3 (2015): 221-227.
14. Tait, M. A., C. Dredge, and C. L. Barnes. "Preoperative patient education for hip and knee arthroplasty: financial benefit?." Journal of surgical orthopaedic advances 24.4 (2015): 246-251.
15. Belleau, France Provençal, Louise Hagan, and Benoît Masse. "Effects of an educational intervention on the anxiety of women awaiting mastectomies." Canadian Oncology Nursing Journal/Revue canadienne de soins infirmiers en oncologie11.4 (2001): 177-180.
16. Bondy, Lois R., et al. "The effect of anesthetic patient education on preoperative patient anxiety." Regional Anesthesia and Pain Medicine 24.2 (1999): 158-164.
17. Cheung, Li Ho, Patrick Callaghan, and Anne M. Chang. "A controlled trial of psycho-educational interventions in preparing Chinese women for elective hysterectomy." International journal of nursing studies 40.2 (2003): 207-216.
18. Lin, Pi-Chu, Li-Chan Lin, and Jin-Jen Lin. "Comparing the effectiveness of different educational programs for patients with total knee arthroplasty." Orthopedic nursing 16.5 (1997): 43-49.
19. Clode-Baker, Edward, et al. "Preparing patients for total hip replacement: A randomized controlled trial of a preoperative educational intervention." Journal of Health Psychology 2.1 (1997): 107-114.
20. Mancuso, Carol A., et al. "Randomized trials to modify patients’ preoperative expectations of hip and knee arthroplasties." Clinical orthopaedics and related research466.2 (2008): 424-431.
21. Heikkinen, Katja, et al. "A comparison of two educational interventions for the cognitive empowerment of ambulatory orthopaedic surgery patients." Patient education and counseling 73.2 (2008): 272-279.
22. Heikkinen, Katja, et al. "Ambulatory orthopaedic surgery patients' emotions when using two different patient education methods." Journal of perioperative practice 22.7 (2012): 226-231.
23. Yoon, Richard S., et al. "Patient education before hip or knee arthroplasty lowers length of stay." The Journal of arthroplasty25.4 (2010): 547-551.
24. McGregor, Alison H., et al. "Does preoperative hip rehabilitation advice improve recovery and patient satisfaction?." The Journal of arthroplasty 19.4 (2004): 464-468.
25. Pellino, Teresa, et al. "Increasing self-efficacy through empowerment: preoperative education for orthopaedic patients." Orthopaedic Nursing 17.4 (1998): 48.
26. Kruzik, Nancy. "Benefits of preoperative education for adult elective surgery patients." AORN journal 90.3 (2009): 381-387.
27. Huang, S-W., P-H. Chen, and Y-H. Chou. "Effects of a preoperative simplified home rehabilitation education program on length of stay of total knee arthroplasty patients." Orthopaedics & Traumatology: Surgery & Research 98.3 (2012): 259-264.
28. Douglas, Tania S., N. Horace Mann, and Arleen L. Hodge. "Evaluation of preoperative patient education and computer-assisted patient instruction." Journal of spinal disorders 11.1 (1998): 29-35.
29. LaMontagne, Lynda, et al. "Effects of coping instruction in reducing young adolescents’ pain after major spinal surgery." Orthopaedic Nursing 22.6 (2003): 398-403.
30. Louw, Adriaan, et al. "Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up." Spine 39.18 (2014): 1449-1457.
31. Arthur, Heather M., et al. "Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery: a randomized, controlled trial." Annals of internal medicine 133.4 (2000): 253-262.
32. Rönnberg, Katarina, et al. "Patients' satisfaction with provided care/information and expectations on clinical outcome after lumbar disc herniation surgery." Spine 32.2 (2007): 256-261.
33. Mind Tools Content Team. “The inverted-U theory balancing performance and pressure with the Yerkes-Dodson law.” Mind Tools. November 2016, www.mindtools.com/pages/article/inverted-u.htm
34. Huber, Johannes, et al. "Multimedia support for improving preoperative patient education: a randomized controlled trial using the example of radical prostatectomy." Annals of Surgical Oncology 20.1 (2013): 15-23.
35. Mcclure, Grace. “How to Run a Successful Preoperative Class.” PeerWell. PDF. 15 May 2019.

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