Each student is to review the submission of at least one peer and provide detailed feedback regarding the content, organization, writing clarity, grammar, spelling, and APA format. The comments are to be returned to the peer by 12 Midnight on Sunday. I encourage students to use “track changes” and “insert comments” tools to provide the feedback. Both of these tools are available in Word. Here are a few prompts to consider as you review your colleague’s work:

1. Does each chapter begin with an introduction? The introduction should introduce the reader to contents of that particular chapter.

2. Did the author include all required components? Use the chapter guidelines and PowerPoint as a guide. Do they have a comprehensive presentation of the implications of their work? Sometimes, authors tend to present narrow implications. Encourage the author to “think big”!!3. Is writing clear, concise, and free of grammatical and spelling errors? If you are noticing multiple errors, point this out as a general comment to the author. It is not necessary to correct each and every error.4. Was the document prepared according to APA guidelines? Consider margins, pagination, in-text citations, quotations, and appendices, Again, if you notice the same error being made repeatedly, just make a general comment to the author. It is not necessary to keep correcting the same error throughout the paper. Be sure to check the reference list!!5. Provide a few summary comments about the overall product. You are all reaching the final weeks of the DNP program. This document will serve as a reflection of the individual author. Help the author create a quality document!! NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Chapter One:  Overview of the Problem of Interest

Surgery is an important event in an individual’s life, impairing physical functioning thereby fear, anxiety and depression may be experienced by the patient (Ramesh et al., 2017), In 2008, more than 22 million surgeries were performed over 5,000 Ambulatory Surgery Centers in the United States.  Surgery can be a significant and potential danger to the patient’s health and may cause psychological reactions such as anxiety (Gezer & Arslan, 2019). With thousands of patients having elective surgery on a daily basis, it is essential that these patients are adequately prepared prior to their surgery (Kruzik, 2009).  Preoperative education is widely used by health-care professionals all over the world to help patients prepare for their impending surgery and postoperative needs (Spalding, 2004).  Preoperative education is a key element of the Enhanced Recovery After Surgery (ERAS) protocols and guidelines (Foss, 2011).  Preoperative education leads to significant improvements in patient satisfaction, surgical outcomes, and reduction in patient’s anxiety. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Background Information

Each year, an estimated 234 million major surgical procedures are conducted worldwide (Fink et al., 2013).  Evidence suggests that postsurgical complications occur in at least seven million cases annually, resulting in up to one million deaths. These figures illustrate the tremendous socio-economic burden associated with postoperative morbidity and mortality (Fink et al., 2013).  Patients suffer needlessly due to inadequate preoperative preparation and lack of information regarding their postoperative course as indicated by reports of unexpected pain, fatigue, and the inability to care for themselves (Fink et al., 2013). The prevention of these postoperative complications is of the highest medical interest and importance. The impact of well drafted standardized preoperative patient education will result in positive postoperative outcomes (Fink et al., 2013). This suggests that there is a need for improved efforts from all healthcare providers to step up and design preoperative educational interventions for better patient preparedness, reduce their anxiety and post-operative complications.

In late 2016, the American College of Surgeons (ACS) became the national home for Strong for Surgery which is a pre-surgical health optimization program (American College of Surgeons, 2016). The ACS has begun administering and promoting STRONG as a quality initiative aimed at identifying and evaluating evidence-based practices to prepare and optimize the health of patients before their operations. Strong for Surgery was developed by surgeons and empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. These checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes (American College of Surgeons, 2016).

The project implementer’s clinical practice site is an inpatient facility which conducts approximately 40 surgeries a day, including same-day surgery and inpatients. In the project implementer’s clinical practice site only about 50 % of the patients are told by their surgeons to come to the pre-surgical testing area prior to their elective surgery. The preoperative surgical patients either come 1 to 2 days before their surgery, but the majority of them arrive on the day of their surgery. As a result, these patients are not be given the adequate preoperative counseling. Even if they receive preoperative counseling, there is less time for them to be prepared; for example, proper preoperative diet, exercise, medication management, smoking cessation, and co-morbidities such as diabetes and hypertension to be under control.

The key principles of the ERAS protocol include preoperative counseling, preoperative nutrition, avoidance of perioperative fasting and clear liquids up to 2 hours preop. But according to traditional surgical doctrine patients are instructed to take nothing by mouth (NPO) from mid night by the surgeons to avoid pulmonary aspiration after elective surgery; however, there is no evidence to support this. Melnyk, Casey, Black and Koupparis (2011) stated that, preoperative fasting actually increases the metabolic stress, hyperglycemia and insulin resistance, which the body is already prone to during the surgical process. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, the ERAS protocols challenge traditional surgical doctrine, and as a result, their implementation has been slow (Melnyk, Casey, Black and Koupparis, 2011).

Significance of Clinical Problem

Patients must be appropriately educated before any surgical procedure to ensure they understand the complete process and to improve surgical outcomes (Wunderle, Bena & McClelland, 2017). When patients are not adequately prepared for surgery, there is a high chance that their surgery can be canceled on the day of surgery. Surgery cancelations on the operative day cause a huge impact on the organizational effectiveness and the patient satisfaction.

Further, preoperative education plays a major role in prevention of post operative complications. Complications such as Surgical Site Infection (SSI) increase the length of the patient’s stay. The Center for Disease Control (CDC) health care – associated infection (HAI) prevalence survey found that there were an estimated 157,500 surgical site infections (1.9%) in 2008 among the inpatient surgical patients (CDC, 2018). Surgical site infections remain a substantial cause of morbidity, prolonged hospitalization and mortality of the patients. The implementer’s clinical practice site’s SSI task force data showed that the SSI rates among surgical patients was 2.2% in 2017. The preoperative education provides information to patients regarding the measures that can be used to prevent post-operative complications. A well-designed preoperative education with emphasis on SSI prevention measures such as usage of Hibiclens showering prior to surgery, hand hygiene and wound care may result in decrease rate of SSIs. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Other postoperative complications such as venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) affects an estimated 300,000-600,000 individuals in the U.S each year causing significant mortality and morbidity (Beckman et al., 2010). VTE is a leading cause of preventable hospital death in the Unites Stated (CDC, 2015). VTE is the fifth most frequent reason for unplanned hospital readmissions after surgery (CDC, 2015). A recent study of almost 500,000 surgeries performed at Department of Affairs (VA) hospitals found that about 4 in 10 patients developed VTE after surgery while they were still in hospital and approximately 6 in 10 surgical patients developed VTE up to 90 days after discharge from hospital (CDC, 2015). The implementer’s clinical practice site performance improvement (PI) data reported a significant increase in VTE rates in 2017.  Preoperative education plays a major role in educating patients in prevention of such complications. Preoperative education regarding the early ambulation after surgery helps the patient to be more compliant, thereby reducing the risk of VTE.

In addition, Oshodi (2007) suggested that preoperative information about surgical procedures and outcomes alleviates patient anxieties, lessens the need for postoperative analgesia, and allows the patient to be discharged earlier. The patients when educated before surgery know what to expect after their procedure, such as pain. Through preoperative education, the capability of patients to take care of themselves improves through meeting their postoperative self-care needs at home (Oshodi, 2007).  For example, information about appropriate behavior after discharge (mobility, exercise, relaxation, appropriate diet or adequate pain control) will facilitate full recovery and prevents postoperative complications.

Question guiding inquiry (PICO). A clinical question needs to be relevant to the patient or problem in the current practice, it should facilitate the search for the solution. PICO makes the search process easier. The formulation of a question used to challenge a current practice and provide evidence for new practice change is called a “PICO” question. The “P” stands for patient or problem, “I” for intervention, “C” for control/comparison and “O” for outcome. (Melnyk & Fineout-Overholt, 2015).  The PICO question that guided a literature inquiry for the problem of surgical patients is: In pre-surgical patients, does individualized one-on-one pre-operative counseling decrease the post-operative complications?

Variables of the PICO question

Population.  The population of interest was individuals eighteen years of age and older located in New Jersey.  Patients who participated were scheduled for ortho-spine procedures and was not limited by gender, education, nationality, religion, ethnicity, or race. The targeted population of interest that participated in the EBP change project were 18 years of age and older.

Intervention.  The intervention for this project was the implementation of individualized one-on-one pre-operative counseling.  Educational materials and a question and answer session were offered during the educational session.

Comparison.  There was no comparison group, but a comparison was made to assess the fear and anxiety of pre-surgical patients. There was a pre-test given before the start of the educational session. Immediately after the educational session, the participant was given a surgical fear post- test to determine if there were a decrease in fear and anxiety.

Outcomes.  Knowledge is the first step of prevention; therefore, the intended outcome of the EBP change project is to reveal if an increase in knowledge and decrease in fear occurred by comparing the pre-test and post-test scores after the educational sessions.      NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Summary

Preoperative education provides the surgical patients with the pertinent information concerning the surgical process and the intended surgical procedures, as well as anticipated patient behaviors (e.g., anxiety, fear); expected sensations; and probable surgical outcomes (Kruzik, 2009). Preoperative teaching plays a vital role in preoperative, intraoperative and postoperative management of patient. The preoperative education can help patients to be prepared for surgery, to decrease post-operative pain, reduce length of stay, decrease anxiety and increase patient satisfaction (Garretson, 2004). Lack of preoperative education can lead to postoperative complications such as DVT, SSI.

Chapter Two: Review of the Literature

Preoperative education includes instruction about the preoperative period, the surgery itself, and the postoperative period. Patients who undergo surgical procedures experience a high level of stress and anxiety, which could have negative consequences on post-operative outcomes. Patient education appears to be effective in improving knowledge and reducing days of stay at the hospital (Chevillon, Hellyar, Madani, Kerr and Chae, 2015). The goal of preoperative education is to not only prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene et al., 2017).

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Anxiety has been noted among patients who have been waiting for scheduled procedures ( Harkness, Morrow, Smith, Kiczula, and Arthur, 2003). Nurse-initiated preoperational education and counseling was associated with a reduced rate of perioperative complications and a reduced level of anxiety following surgery (Ji et al., 2012). Therefore, it is crucial that the patients are adequately educated and prepared for their surgery. To this end, various types of preoperative education have been evaluated to help reduce patient’s anxiety and complications after surgery. The purpose of this paper is to provide an overview of the literature regarding preoperative education. This chapter will review the literature regarding specific interventions utilized in preoperative education.

Methodology

In order to study the concept of preoperative education and its importance in patient preparedness, a comprehensive literature review was performed. After considering the concept and perusing several articles through the online library and databases, the decision was made on the possible search terms that will be covered to find scholarly articles on preoperative education and its importance in preparing the patients. The selection of the literature was based on the level of evidence and the relevancy to the EBP change project.

Sampling strategies. The databases searched for the literature review were as follows: ProMED , CINAHL Complete, the allied and complementary medicine database (AMED),  EBSCO Host, PyscINFO, the Cochrane Database of Systematic Reviews on preoperative education. The key terms included preoperative teaching, preoperative education, preoperative preparation, surgery preparedness, preoperative teaching and anxiety, preoperative education and surgery, preoperative teaching and surgical site infection, preoperative education and postoperative complications using the Boolean operator AND. Google scholar search was also performed to include possible additional literature. Please see Appendix A for the Literature Search Strategy Log.

Inclusion /Exclusion Criteria. After performing a literature review, titles were reviewed for relevance. If the title was unclear, the abstract was reviewed. Articles were included for further review if they related to preoperative education and preoperative teaching. Exclusion criteria included articles not in English and published prior to 2012.

A hierarchical rating system for evaluation of strength of the evidence was used in evaluating articles for inclusion or exclusion. As part of the EBP process, assessing individual articles for strength of the evidence is appropriate to ensure that findings are “best evidence” (Melnyk & Fineout-Overholt, 2015, p. 11). Articles were ranked according to the following Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions:

Level I: Evidence from a systematic review or meta-analysis of all relevant RCTs

Level II: Evidence from well-designed RCTs

Level III: Evidence obtained from well-designed controlled trials without randomization

Level IV: Evidence from well-designed case-control and cohort studies

Level V: Evidence from systematic reviews of descriptive and qualitative studies

Level VI: Evidence from single descriptive or qualitative studies

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

(Melnyk & Fineout-Overholt, 2015, p. 11).

Articles from Level I through Level VI were considered for inclusion. The total number of articles reviewed was 695.  Of those, the total number kept for inclusion was 30. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Literature Review Findings

In many institutions, when a patient is scheduled for surgery, the patient is contacted before the procedure and given instructions as to how to prepare for the surgery.  Preoperative anxiety is a common occurrence leading up to procedures in a hospital setting, owing to fear of the unknown and loss of control, and may cause an array of detrimental physiological effects  (Chevillon, Hellyar, Madani, Kerr, and Son Chae, 2015).

Preoperative education may be done by staff from the surgeon’s office or staff at the institution where the surgery will be performed. Some institutions also send written instructions. Often the patient is anxious and may have difficulty understanding or remembering the instructions. It has been repeatedly proven a well instituted preoperative education reduces anxiety, and post-operative complications (Greene et al., 2017). It is essential in helping pre-surgical patients cope with these changes and to recover quickly after surgery. Surgical patients who perceive they did not receive proper preoperative education experience more dissatisfaction after surgery and have greater difficulty understanding the changes they face (Guo,  2015).

According to Chevillion et al.  (2015) patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation. Preoperative pain neuroscience education (NE) for lumbar radiculopathy resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments (Louw, Diener, Landers and Puentedura 2014)

Preoperative education is a broad term that encompasses many modalities. Common preoperative teaching techniques include a) instructional printed material, b)one-on-one sessions, c) group classes, d) seminars, e) counseling, f) video tapes, g) picture guides, h) online apps, and i)YouTube videos. The amount of pre-surgical information and education to which a patient is exposed has shown to improve the patient’s overall anxiety and stress levels (Gadler, 2016; Liebner  2015). It also highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction.

One-on-one education and individual teaching can decrease their anxiety and gain reassurance while allowing patients to obtain specific information more pertinent to them.

According to Kalogianni et al. (2016), preoperative education delivered by the nurses reduced anxiety and postoperative complications of patients undergoing surgery.  By providing preoperative education by inpatient urology RN decreased patients’ anxiety, answered their questions, and introduced the urinary catheter and leg bag. This helps patients develop confidence and autonomy after hospital discharge (Delano, 2017).

According to Guo et al. (2012) Chinese patients undergoing cardiac surgery who received preoperative education experienced a greater decrease in anxiety score (mean difference −3.6 points, 95% confidence interval −4.62 to −2.57; P <0.001) and a greater decrease in depression score (mean difference −2.1 points, 95% CI −3.19 to −0.92; P <0.001) compared with those who did not. There was no difference between groups in average pain, current pain, and interference in general activity, mood and walking ability. Patients randomized to the preoperative education group reported less interference from pain in sleeping (mean difference −0.9 points, 95% CI −1.63 to −0.16; P =0.02).

Chevillon et al. (2015) evaluated the impact of multifaceted preoperative patient education on postoperative delirium, anxiety, and knowledge and to explore predictors of postoperative delirium, days of mechanical ventilation, and days in the intensive care unit (ICU) among patients undergoing pulmonary thromboendarterectomy. A prospective, randomized controlled trial was conducted on consented patients from October 2011 to April 2013. Patients were randomized in a 1 to 1 ratio to receive either an individualized 45-minute multifaceted preoperative education (experimental group, n = 63) or standard education (control group, n = 66). Participants completed the State-Trait Anxiety Inventory and Knowledge Test before and after the education. Data on incidence of delirium, days of mechanical ventilation, ICU days, and cardiopulmonary parameters were collected. The experimental group had significantly more knowledge about postoperative care (P< .001) and fewer days of mechanical ventilation (P= .04) than the control group. The patient education appeared to be effective in improving knowledge and reducing days of mechanical ventilation.

Wunderle, Bena, & McClelland ( 2017) in their systematic review of the sample patient’s EMR found that patients who were given tailored preoperative education felt empowered than the general group of patients. Tailored preoperative education increased patients’ comfort and willingness to contact providers, which may have resulted in improved outcomes.  Preoperative education offers patient undergoing surgery with relevant information regarding their surgery and thereby minimize their worry and anxiety (Ramesh et al., 2017).

Zhang et al. (2012) conducted prospective and randomized trial, 40 patients were divided into the study and control groups. All patients received standard preoperative and postoperative care, but the study group patients also completed a structured education and counseling course supervised by designated nurses before surgery. Anxiety symptoms were assessed by Zung’s self-rating anxiety scale (SAS) on the day of admission and at three days after the surgery. Following surgery, the rate of complications such as lower extremity edema, urinary retention, constipation, respiratory infection, and deep venous thrombosis in the study group was lower than in the control group (P < .05). The mean postoperative SAS scores in the study group was lower than in the control group (40.1 [SD, 6.5] vs 48.9 [SD, 7.3]; P = .01), and the proportion of patients with a SAS score greater than 40 in the study group was also lower than in the control group (15% vs 45%, P = .041). Nurse-initiated preoperational education and counseling were associated with a reduced rate of perioperative complications and a reduced level of anxiety following CABG.

Kalogianni and Brokalaki (2016) conducted randomized controlled trials, the sample consisted of 395 patients (intervention group: 205, control group: 190). Patients in the intervention group received preoperative education by specially trained nurses and the control group received the standard information. The state of anxiety on the day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease in state score during the follow-up period was greater in the intervention group (P=0.001). Lower proportions of chest infection were found in the intervention group (10 (5.3) versus 1 (0.5); P=0.004). Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients undergoing cardiac surgery.

O’Donnell (2015) stated that patients who received the preoperative education intervention reported less severe pain during the first 24 hours postoperatively, experienced less pain medication and fewer side effects, returned to normal activities sooner, and used more non pharmacologic pain management methods postoperatively compared with those who did not receive the education.

Printed education material can be presented prior to surgery, during the hospital stay and/or after surgery, and post-discharge. Studies discussed below show that preoperative teaching has a beneficial effect on postoperative outcomes for patients. Based on the SAM methodology, printed dietary guidelines may increase in suitability by emphasizing aspects related to health literacy and accommodating the needs of different food cultures within a population (Garnweidner-Holme, Dolvik, Frisvold and Mosdol  2016).

According to Jacob et al (2016) the reading level and understandability of many written patient education materials do not align with the literacy and health literacy skills of the general population Patient education materials should be created or revised that allow individuals with low literacy and physically challenged to understand their condition.  Sayin & Aksoy (2012) stated that the patients and their family members wanted to be given more information about the surgical process than they had received. Patients wanted more information about the intraoperative period, whereas their family members wanted more information about the postoperative period.

A preoperative education class for patients undergoing prostatectomy and their caregivers significantly reduced anxiety and increased confidence in the immediate postoperative period. The group education class also increased patient satisfaction regarding at-home urinary catheter care and post-discharge instructions (Bisbey, 2017).  Gadler (2016) demonstrated that take-home video education can improve patient knowledge retention and reduce anxiety. Patients were satisfied with the delivery format, and provider time spent on re-educating was reduced. Advanced cancer patients report that participation in an educationally-oriented legacy video project is enjoyable and potentially beneficial. Patients reported that they really enjoyed the experience, and it had helped them process their cancer experience (Fitch, Tjia, Doering, Makowski, and Wachholtz 2016). NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

According to Paich  et al., (2016) a 2.5 hour preoperative seminar for couples in a group setting is a viable methodology for promoting realistic expectations of prostate cancer surgery outcomes and rehabilitation activities that enhance recovery from the side effects of surgery.  Wieser, Steurer, Steurer, and Dullenkopf, (2017) found that only few patients used the internet to obtain information about their upcoming procedure and the anesthetic part played an even smaller role. However, many patients would have appreciated guidance to find trustworthy internet sites.  Bhamrah et al., (2015) stated that patients look to the Internet to supplement information regarding their proposed treatment. This may suggest a possible gap in the provision of information by health care professionals. However, it is clear that patients use Internet forums to seek additional information, support, and reassurance from peers undergoing similar treatment. Therefore, there is a need for clinicians to ensure that patients have access and are guided to appropriate and relevant Internet resources.

Ji (2016) discussed that online MD APP-aided pre-operative education is effective in the reduction of parental pre-operative anxiety and in improvement of parents’ satisfaction,  but has no influence on children.  López-Jornet, Pons-Fuster,  Ruiz-Roca, López-Jornet and Ruiz-Roca, (2016) stated video-sharing websites can be a useful platform for disseminating information. YouTube is a tool that can help supply information and promote health care education among of patients.

Discussion

Preoperative education is a required exercise before any surgery or procedure. Different hospitals and doctor’s offices use various methods or a combination of several methods for preoperative education and answer questions from patients and their family members. This literature review identified many studies using various methods that have served effectively for preoperative education that reduces patient anxiety, and post-operative complications. It highlights the methods of preoperative education that is evidence based and popularly used as a tool for surgery preparedness.

Limitations of literature review. Limitations to this literature review include overlapping concepts of preoperative education. In particular, preoperative education followed for different surgeries can be different, with different hospitals following a combination of interventions. All studies analyzed in this review are specific to certain surgery situations. The inclusion criteria stated articles in English language only, hence this review of literature could eliminated any new techniques of preoperative teaching and educational methods discussed in other languages.

Conclusion of findings. The review of literature identified many techniques practiced in preoperative education for patient preparedness, decrease anxiety, reduce post-operative complications and readmits (O’Donnell, 2015). It should also be noted that in many cases the preoperative education addresses the questions about post-operative care of the family members and care givers (Sayin, and Aksoy. 2012 ).  Knowledge gained from the preoperative education counseling did affect patient experiences (Delano. A 2017).

This literature review provides evidence to support the fact that preoperative education in all forms has had a positive impact on reducing patient anxiety and complications. A combination of various teaching techniques appear to be helpful in educating the patients about surgery-preparedness and post-operative self-care. In the selected healthcare site the potential change is to implement one-one-one counseling as a method to improve patient preparedness and reduce surgical fear and anxiety. The review also reveals that one-on-one preoperative counseling makes patients feel more informed and confident prior to surgery (Bhamrah et al., 2015).

Preoperative educational counseling is associated with a reduced rate of perioperative complications and a reduced level of anxiety (Zhang et al., 2012). One-on-one counseling enables patients to discuss personal, sensitive and anxious queries about surgery preparedness. One-on-one preoperative educational counseling can be used as a tool for perioperative patient preparedness with a combination of other preoperative educational tools like printed pamphlets, latest methods using internet such as websites, blogs, DVDs and Online APPs (Ji et al., 2016).  The variety of multimedia supplemental preoperative resources will help target all age-groups and generations of patients who prefer different sources to access pre-operative educational information (Frentsos, 2015).

Potential project.  The literature reviewed support one-on-one educational counseling as the most effective intervention to help patients scheduled for surgery. The potential EBP change project involved one-on-one educational sessions which incorporated educational materials, and pre and post-test in a clinical setting. The goal of this EBP change project is to increase an individual’s knowledge and thereby decrease fear and anxiety prior to surgery.

Summary

The provision of effective preoperative patient education is vital to the quality of preoperative nursing care.  Preoperative education methodologies are constantly evolving and this review of literature has identified studies that prove a well scheduled preoperative education program considerably reduces patient anxiety and reduces complications. It also helps increase patients’ and caregivers confidence during the post-operative period (Bisbey, 2017).  After reviewing literature of all preoperative education interventions, one-on-one preoperative educational counseling will be implemented at the clinical practice site as it is an evidence-based, effective intervention which is individualized for all types of surgeries. Nurse-initiated preoperational education and counseling were associated with a reduced rate of perioperative complications and a reduced level of anxiety (Zhang et al., 2012). One-on-one individualized preoperative educational counselling sessions help patients develop confidence and autonomy after hospital discharge. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review 

Chapter Three:  Theory and Model for Evidence-based Practice

Concept- Theoretical- Empirical system (C-T-E) structure provides an outline and framework for the study project. Using C-T-E structure offers the advantages of improved readability and ease in understanding of complex problems. A concept is a mental formulation experience (perception) (Chinn & Kramer, 2015). The concept can be divided into separate, simple, logical building blocks and theory development is the product of research, which is a systematic process of inquiry (Fawcett, 2013).  A theory is a framework that guides nursing practice (Chinn & Kramer, 2015).  The empirical indicator is a measurement tool used to evaluate a proposed theory (Chinn & Kramer, 2015).  C-T-E structure for theory testing proceeds from the conceptual model to the theory to the empirical indicators (Gigliotti & Manister, 2012). As a doctoral prepared nurse, it is important to implement evidence-based practice for the identified clinical problem at the chosen site which is based on theoretical and empirical research background. Preoperative Education is the concept of the EBP project (C), Orem’s Self Care Theory (T) provides the theoretical outline and the empirical indicator used in this project is Surgical Fear Questionnaire (E).

Concept

The identified concept for this evidence-based practice (EBP) change project is preoperative education. The concept of preoperative education can be described as a nursing intervention used to assist the patient to understand and mentally prepare for surgery and the postoperative period (Chevillion et al., 2015).  Preoperative education includes instruction about the preoperative period, the surgery itself, and the postoperative period. Education plays an integral part in promoting health by increasing the knowledge and empowering skills needed for a healthier lifestyle.  The population selected is all adults scheduled for elective ortho spine surgery, the concept of the EBP and the desired change is to increase the impact of preoperative education to the patients in patient preparedness, post-operative care, reduction in surgical anxiety.  Patient education appears to be effective in improving knowledge and reducing days of stay at the hospital (Chevillion et al., 2015). The goal of preoperative education is to not only to prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Preoperative education and patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene et al., 2017).

Theory

The use of theory furthers nursing knowledge in practice by educating and providing direction. Dorethea Orem’s theory of self-care has been chosen to guide and support the concept of preoperative education. Dorethea Orem’s theory is comprised of three related parts: theory of self-care; theory of self-care deficit; and theory of nursing system (Nursing Theory, 2016). The theory of self-care includes self-care, which is the practice of activities that an individual initiates and performs on his or her own behalf to maintain life, health, and well-being (Nursing Theory, 2016). The second part of the theory, self-care deficit, specifies when nursing is needed. According to Orem, nursing is required when an adult is incapable or limited in the provision of continuous, effective self-care (Nursing Theory, 2016). The theory of nursing systems describes how the patient’s self-care needs will be met by the nurse, the patient, or by both (Nursing Theory, 2016).  Orem’s approach to the nursing process is a method to determine the self-care deficits and then to define the roles of patient or nurse to meet the self-care demands. The steps in the approach can be used in educating patients preoperatively, so they can be prepared adequately and recover more quickly from surgery. According to Sürücü, & Kizilci (2012), nursing planning has been guided by the self-care agency of the patient who is supposed to take care of requisites and how the responsible person can help by means of nursing systems. The implementation of education has demonstrated improved self-care behaviors and brought positive changes to the health status of the patients.

Empirical Indicator

The goal of preoperative education is to prepare the patient for their surgery, and prepare them for what to expect following the surgery. Preoperative surgical fear is an emotional reaction that can be observed in many patients who are waiting to undergo a surgical procedure.  Surgical fear is associated with impaired psychosocial and physical recovery, such as increased levels of acute and chronic postoperative pain (Theunissen et al., 2014). The Surgical Fear Questionnaire (SFQ) an empirical tool developed to determine the level of fear in patients who are to undergo surgery (Theunissen et al., 2014). The SFQ is a valid and reliable eight-item index of surgical fear consisting of two subscales: fear of the short-term consequences of surgery and fear of the long-term consequences.  According to Theunissen et al. (2014) SFQ indicated good convergent validity and internal consistency (Cronbach’s alpha) was between 0.765-0.920 (SFQ-total), 0.766-0.877 (SFQ-s), and 0.628-0.899 (SFQ-l).

Application to practice change.  There was a recognized need for patient preparedness for surgery prior to the induction of the EBP. The increase in surgery cancelation due to patients not being optimized prior to surgery caused concern in the surgery department. The consensus between the preoperative staff concluded that an educational intervention was needed for pre-operative patients. Dorethea Orem’s theory of self-care will be utilized in structuring the intervention. Preoperative education was implemented by using one on one educational sessions to empower and motivate surgical patients to make healthier lifestyle choices and be prepared for surgery.

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Evidence-Based Practice Change Model

The Johns Hopkins Evidence-based Practice Model was utilized to guide and address the clinical problem. The Johns Hopkins Evidence-based Practice Model offers support for problem-solving to clinical decision-making and offers tools to assist with evidence-based practice change (Johns Hopkins, 2017). The model uses PET, a three-step process, PET stands for practice question, evidence, and translation (Johns Hopkins, 2017). There are several useful tool sheets to assist with the model process.  Some examples of these tools are a PET management guide, a PICO tool, stakeholder analysis tool, evidence level and guide sheet, and many more (Johns Hopkins, 2017).The purpose of the model is to assist with finding and using the latest research and best practice to integrate it into patient care .

Application to practice change.  Implementation Evidence Based Model, a qualitative change is expected in the surgical department in the chosen site. SFQ and Self-care theory is used to find the anxiety and fear level of the patient. Customized preoperative education is planned to each individual patient. As a result of the EBP change model of preoperative education,  patients’ and their family members’  are educated in the following areas: a) Better understanding of their surgery,  b)  Feel more in control, preparedness before and on the day of surgery.  c)  What to expect before, during and after surgery- Preoperative procedures and the rationale for these procedures such as fasting, stopping anticoagulation therapy, etc. Preparations required such as insertion of intravenous cannula, pre-medications and what sensations may be felt when the anesthesia is induced.  d) Experience decreased postoperative pain and anxiety. e) Help them understand post-operative self-care. What to expect postoperatively; for example IV fluids and wound drains. Postoperative activities the patient will be expected to do, such as deep breathing and coughing, early mobilization and pain management. f) Have a decreased length of hospital stay.  g) Have a quicker recuperative period. h) Decreased number of post-operative complications. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Fig 3.1 John Hopkins Evidence Based Model

Summary

Addressing surgical patients with a lack of knowledge requires a systemic approach to implement a practice change to promote better health comes. Therefore, a C-T-E conceptual framework was integrated to guide this practice change. The promotion of better health outcomes requires patient education to increase knowledge and decrease fear and anxiety. Components used to enhance the implementation were preoperative education, Orem’s theory of self-care and Johns Hopkins Evidence-based Practice Model. A well drafted evidence-based perioperative education process will improve the quality of the perioperative care. The use of the John Hopkins Model provided a step by step guide for the EBP change project to be implemented while addressing the clinical problem.  The empirical indicator used was the SFQ to assess and evaluate if fear and anxiety had decreased after one on one educational sessions.

Chapter Four: Pre-implementation Planning

Pre-implementation is the process that includes project design and development. Evidence-based practice (EBP) is a critical element of an effective change management process to ensure the highest quality care, and successful outcomes are met.  Lack of preoperative education often results in fear and anxiety prior to surgery. Therefore, preoperative educational programs are the key in achieving better health outcomes by increasing knowledge.  Research suggests that ongoing preoperative education facilitates knowledge necessary for surgical patients and results in positive postoperative outcomes (Fink et al., 2013). The purpose of this chapter is to discuss organization readiness for change, planning, implementation, and evaluation of an educational program.

Project Purpose

The purpose of the EBP change project is to improve the preoperative education program using one-on-one counseling for patients scheduled for ortho-spine surgery.  Preoperative education is important to reduce the risk of postoperative complications from occurring as it also allows the individual to take an active role in their recovery process. The goal of preoperative education is not only to prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene, et al., 2017). Anxiety has been noted among patients who have been waiting for scheduled procedures (Harkness, Morrow, Smith, Kiczula, & Arthur, 2003). Ji, et al., (2012) study demonstrated that nurse-initiated preoperational education and one on one counseling were associated with a reduced rate of perioperative complications, such as surgical site infections and a reduced level of anxiety following surgery.  An educational intervention using individualized one-on-one counseling will be offered to the patient to help promote change and wellbeing of the patients prior to their scheduled surgery. The intervention will focus on type of surgery, diet, exercise, medication management, preoperative care, postoperative care and optimization of co-morbidities. Knowledge and understanding of procedures and rationale, promotes feeling of a sense of control to allay anxiety.

Project Management

According to Harris et al. (2016) management of any project entails the consistent integration of skills, tools, application of knowledge and techniques to project activities. The project investigator oversees the project and must be clear about the aim of the project and the stakeholder’s needs and wants to establish the appropriate baseline for comparison of outcome data (Harris et., 2016). The program investigator ultimately is responsible for the success or failure of a project.  The steps that were explored prior to implementing the project will be discussed below.

Organizational readiness for change.  An assessment of readiness for change analyzes the level of preparedness of the conditions, attitudes and resources, at all levels in an organization (Harris et al. 2016).  One crucial factor in an organization readiness for change is to recognize that there is a need for change (Harris et., 2016).  Readiness for change in an organization influences the successful outcome of a clinical change project.  The project implementer’s clinical practice site is a large urban multi-specialty inpatient facility which conducts approximately 40 same day and inpatient surgeries a day. There had been increasing concern regarding the surgery cancelations and rate of Surgical Site Infection rate among the ortho spine surgical patients. To address this concern, the preoperative team agreed on the implementation of an EBP change project focused on increase patient preparedness, reduction in anxiety, increase patient understanding of post-operative care, and thereby prevent postoperative complications such as surgical site infection.

Inter-professional collaboration. Inter-professional collaboration involves the shared input of all the members of the team (Harris et al. 2016). Within the inter-professional team, all members will play an active role in the process which required ongoing engagement, commitment and collaboration; not only from the healthcare professionals but also included other stakeholders such as the surgeon’s office staff, patients and departmental director. The team consists of one lead advance practice nurse (APN), two registered nurses (RN), one medical assistant (MA), two secretaries.  The project investigator (PI) is the lead APN who conducted regular meetings with all the team members and to get their input to develop the preoperative educational plan.  The surgeon’s office secretary informed the patient regarding the EBP project.  The front desk secretaries were responsible for greeting participants when arrivied and gave the cover letters to the participants. The interested participants were escorted by the medical assistant to the PI office.  PI was responsible for overseeing and completing the planning, implementation and data analysis of the change project.

Risk management assessment.  Leadership, values, and culture are important for achieving any change, whether that change is implemented by an individual or an organization-wide initiative (Harris et al. 2016). The SWOT analysis was utilized as part of the risk management tool to help provide the team with insight both positive and negative impact that could affect the process of the change project. According to Harris et al. (2016), the SWOT analysis helps the team to identify strengths, weakness, opportunities and threats. Strength and opportunities are factors that played a vital role in successful implementation while weakness and threats could potentially harm the outcome of the EBP implementation. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review

Strengths. There are many strengths of the practice facility including, department leadership support, the unit staff members eagerness to participate in the practice change project, willingness of the organization to grant access to the preoperative patients, availability of the location and willingness to adopt practice change project.

Weakness. Potential project weakness includes participants dropping out of EBP project and allotted time for educational sessions.  To minimize the inconvenience of time constraint flexibility had been added in the project, whereby participants may meet the PI before, during their wait time or after the pre-surgical workup.

Opportunities. The opportunities include, implementation of an effective preoperative educational program and one-on-one counseling to the preoperative patients.  Also, patient optimization prior to surgery and enhanced recovery after surgery, thereby increasing patient satisfaction and decrease post-operative complications such as surgical site infection.

Threats. Threats included minimal participation from the staff after agreeing to take part in the EBP project.  Providers not informing the surgical patients regarding the EBP project. Threats were addressed by keeping the line of communication open with the staff and providers by emailing reminders.

Organizational approval process.  The PI sent an email to the medical director and nursing director of preoperative services describing the project and the impact it could have on the patient and organization. The nursing director invited the PI to the research committee meeting. The PI presented the project to the committee members and a few weeks later an approval letter was sent from Research Utilization Group ( RUG) to the PI.  The medical director and the nursing director expressed their full support for the project and promised to assist in any way to ensure that the project was successful.

Use of information technology.  Information Technology is the foundation for healthcare and is essential for the development of most if not all the practice change project’s success.  Information technology not only added to the resources used in the proposed project, but were used to search multiple databases for best evidence to support the project.  Information technology also supported ongoing communication within the interprofessional team using emails. The PI used Microsoft word to design the cover letters, pretest, posttest, consent and other necessary documents. Microsoft Word and PowerPoint were used to develop effective educational intervention for the pre-surgical patients. Excel was also used to enter data, analyze and disseminate the results of the project among stakeholders.  The PI was the only person with access to the primary data.  Respondents did not have to provide any personally identifiable information.

Materials Needed for Project. 

There was a variety of materials used to implement the EBP change project. A total of 150 flyers were printed and used for the recruitment of participants. There were a total of 100 cover letters, 100 pre-test questionnaires and 100 post-test questionnaires initially printed; therefore, a copier and printer was needed.  A laptop was used to access Microsoft Excel to analyze the collected data.  Preoperative educational handouts, pens, and folders were given to each participant.  A locked cabinet in the PI office was used to reserve all participants information.  The Preoperative unit patient appointment/scheduled book, surgical schedule, private room with needed furniture, cabinet and key were only accessible to the PI.

Plans for Institutional Review Board Approval

The institutional review board (IRB) is a group of institutional representatives who have experience in the research process.  They play an integral role in protecting the rights and welfare of human subjects who are involved in research.  Every research and quality improvement project involving human subjects must be reviewed, modified, and approved by the IRB before the process of data collection is launched (Harris et al., 2016).   An exempt proposal is chosen because this is an educational project that has less than minimal risk for participating patients and all participants were over the age of 18.  Approval for the IRB was obtained from Chatham University in Pittsburgh, Pennsylvania.

Plan for Project Evaluation

Project evaluation involves reviewing all aspects of the project outcomes, performances of the project team and stakeholder involvement (Harris et. 2016). The evidence-based practice change project used SFQ as a pre-test to assess baseline fear and anxiety prior to surgery and post-test to determine if increased preoperative knowledge after educational sessions decreases fear and anxiety prior to surgery.

 Plan for demographic data collection. The demographic information collected for this evidence-based practice change project will be from pre-surgical patients at the facility where the project will be implemented. The data included age, and gender, all participants were 18 years of age or older.  Other data to be collected include type of surgery, date of surgery.  The demographic data will be reported as mean, median, range and percentage of respondents and  presented through bar graphs and tables.

Plan for the outcome data collection and measurement.  Outcome measures are considered the cornerstone of quality improvement ( Harris et al.,  2016).  The outcome evaluated for this change project was to determine if there was a decrease in fear and anxiety and thereby an increase in preoperative knowledge after receiving the one on one educational sessions. The increase in knowledge will help the patients to be well prepared and optimized prior to surgery.  The determination of decreased fear and anxiety prior to surgery was confirmed by using the Surgical Fear Questionnaire (SFQ) as the tool for measurement.

Plan for evaluation tool.  SFQ is a valid and reliable eight-item index of surgical fear consisting of two subscales: fear of the short-term consequences of surgery and fear of the long-term consequences. The SFQ was given as pre-test to the participant prior to the educational session to evaluate fear and anxiety prior to surgery.  Educational materials were also given to participants along with the one on one educational sessions to help increase preoperative knowledge. The same SFQ was provided as a post-test after the educational session to determine if fear and anxiety has decreased. The surgical fear questionnaire is available publicly, thus no separate permission was obtained.

Plan for data analysis. The data analysis is important to measure the success of the intervention and to determine the effectiveness of the change project. The data collected from the pre and post questionnaires will be entered into an excel worksheet for analysis. To determine whether the intended outcome will be met, the mean, pre-test, post-test and mean retention scores will be compared pre and post intervention. These tests will help evaluate the increase in knowledge level and preparedness of the patients thereby reducing fear and anxiety. The benchmark of the change project is to expect to see participants score 80% or better in the post test than the pre-test. A paired t-test was used to determine if there was a statistical significance with the aggregated group scores.

Plan for data management. Confidentiality will be maintained by the use of coded pre-test and post-test. No demographic information will be shared with anyone and will be available only to the PI and staff of Chatham University. This information will be coded to prevent any identifying information from being known to anyone other than the PI. The assigned four digit code will be written instead of the name on pre-test and post-test document for tracking and ease of analysis. The hard copy list will be stored in a locked file cabinet at the practice change site. All analysis done and the resulting scores of tests and results will be stored in the same Excel file, on a separate sheet. After the practice change project is completed, the Microsoft word document will be deleted from the computer and all identifying information will no longer be available. Hard copies will be destroyed and shredded after a period of three years, to prevent participant information from being accessed, thereby maintaining client confidentiality.

Summary

This chapter has outlined crucial steps that are needed during the pre-implementation process of the EBP project. An EBP change project requires strategic planning to be successful.  Strategic planning requires organization and structure prior to implementation.  Components of the strategy focused on obtaining readiness for an EBP change project, inter-professional collaboration, effective communication with the staff involved and ultimately having the same goals.  During the strategic planning, it was imperative that a SWOT analysis was used to identify favorable and unfavorable internal and external factors that could have effect on a successful EBP project.  Another part of the planning that was crucial was obtaining the organizational approval and to have all the needed supplies to support the EBP project. The SFQ questionnaires were appropriated to use to determine if fear and anxiety decreased after the one on one educational session. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review 

Chapter Five:  Implementation Process

Implementation is the ending process of moving the evidence base project from a development to production status ( Harris et al., 2016). A successful implementation starts with the creation of an executable work plan ( Harris et al., 2016). The implementation process includes the project’s setting, participants, recruitment, and any variations that can occur. The implementation site aims to promote positive patient outcomes and provide optimal care. Implementation began May 2019 and continued through June, 2019.

Setting

The EBP project was implemented in the pre surgical unit at a large urban  multi-specialty hospital located in New Brunswick, NJ with more than 1500 beds and an average of 50-60 surgeries are done on a daily basis. The latest advancements in surgeries are offered including advanced, minimally invasive procedures. The surgery team are diversely experienced in a wide array of both inpatient and outpatient procedures.

Participants

The planned population used for the EBP change project were patients of various socioeconomic and ethnic backgrounds. The criteria for participating patients in the EBP change project were male and female adults ages eighteen years of age and older scheduled for ortho-spine surgery. Participants were part of the EBP change project voluntarily and had ortho-spine surgery scheduled within a month.

Recruitment

The desired minimum number of participants to participate in the project is 25. Participants were recruited from pre-surgical unit by delivering a cover letter ( Appendix B). by the front desk secretary.  The cover letter disseminated explains the EBP change project in detail such as the background information, statistics, participant descriptions, benefits, risk, expected outcomes, and the project investigators contact information. For patients who express interest, the project investigator (PI)  also explained the EBP project in detail. The PI clearly explained that the participation is  voluntary and that there will be no repercussions if an individual chooses not to participate. All clinical staff and surgeon’s office secretaries took part in recruitment by word of mouth to their patients regarding the preoperative educational counseling sessions.

Implementation Process

            The evidence based change project was implemented in three  steps with a total time duration of approximately one hour. Participants that volunteered in the EBP change project met with the PI during the preadmission testing or after the pre admission testing. In step one, the participant was escorted to the pre-surgical unit PI office where the one-on one educational session would take place. The PI  reviewed the EBP change project, cover letter, and participants’ risk and benefits. Participants were instructed to read the cover letter. Time was allotted for questions after reading the cover letter. After all questions were answered, the PI  provided the   Surgical Fear Questionnaire and it took 10 minutes for the participant to complete it. The PI  informed participants that the questionnaire is being administered to assess their surgical fear and anxiety, knowledge and preparedness for surgery.

In step two, the PI did the educational session on preoperative preparedness and optimization prior to surgery and the time duration was about 30 minutes. The participants will receive the preoperative educational pamphlet. The educational session was interactive and patients were encouraged to ask questions and one-to-one individual counseling was given. In step three, the participant was asked to complete the post intervention questionnaire which took 10minutes to complete. The total time duration for each participant was approximately one hour. The completed pre- test and post -test questionnaires were placed in the locked cabinet in the PI office.

Upon completion of one-on-educational session, collected data was analyzed using descriptive statistics.  The collected data was placed into charts and graphs, and a paired t-test was conducted.  The paired t-test compared the results of the pre-test and post-test mean scores. The results showed a benchmark of 80% and a t-test score of p<0.05; this implicates a decrease in surgical fear.  The results supported the intended outcome of decreased fear and anxiety and thereby increased patient knowledge after individual one on one educational counseling.

Plan Variation

A team member forgot to issue the cover letter to 2 patients.  So the patients left the Pre

Admission testing center without participating in the project..  So I conducted a huddle with team members to educate them about importance of the process. An email was also sent out to the team members reminding them about the data collection process. Two patients left without filling in the post intervention survey due to emergency.  The patient was contacted by a follow up phone call, but the patient could not return to complete the survey.  So the patients data will not be included for analysis.

Summary

Preoperative education plays a major role in prevention of post-operative complications, such as Surgical Site Infections ( SSI). Nurse-initiated preoperational education and counseling were associated with a reduced rate of perioperative complications and a reduced level of anxiety following surgery (Ji et al., 2016). The purpose of the proposed EBP change project is to determine if individual educational session decrease fear and anxiety prior to surgery. This chapter demonstrated the recruitment of participants based on specific criteria and the implementation process. The criteria were based on male or females age 18 years of age and older scheduled for ortho spine surgery were welcomed to participate. Therefore, it is crucial that the patients are adequately educated and prepared for their surgery.

A comprehensive review of literature revealed that the individualized one-on-one counseling is an effective and creative method for educating patients about preoperative management. This EBP change project will provide an individualized one-on -one counseling which aims at decreasing surgical fear and anxiety thereby increasing preoperative knowledge and preparedness for surgery. Evaluation of the project outcome is expected to reveal a decrease in surgical fear and anxiety and increase in the knowledge level of patients prior to surgery thereby reducing the risk of post- operative complications such as SSI.

The data collected will be analyzed, the mean scores of each question in the pre and post intervention survey will be used to calculate the effectiveness of the one-on-counseling intervention. The difference between the mean scores of the pre-test survey and the post-test survey will be used to find the change in the surgical fear and anxiety level of the patient. The results of the analysis of pre-test and post-test surveys will be represented as graphs and charts showing the mean scores and the difference between the pre and post intervention survey. The difference in the mean scores will help ascertain the change in the fear level of the patient and the increased level of readiness for the surgery and post-operative care. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer ReviewChapter Six: Evaluation and Outcomes of the Practice Change

One of the most important but often challenging steps in the evidence-based practice (EBP) process is ensuring that the change we wanted to happen actually occurred. The process of uncovering the effectiveness of an EBP change project involves evaluation and analyzing of collected data. Evidence based practice ( EBP) allows for the application of research to clinical practice. New efforts to improve clinical issues should be supported by evidence. Measuring outcomes of practice should be viewed as a powerful catalyst for change ( Melnyk and Finout-

Overholt, 2015). This chapter reflects on the evaluation of the collected data and its effectiveness in achieving the desired outcome.

Participant Demographics

Fig 6.1 Gender of Participants

There was a total of 25 pre-operative surgical participants for the evidence-based practice (EBP) project. For the participants to qualify and volunteer in the EBP change project, they had to have ortho-spine surgery scheduled. The demographic breakdown used for this project included age and gender. The criteria for participating patients in the project were male and female adult’s ages 18 years of age and older.  The participants for the project was not limited by ethnicity. The percentage of male participants 48% (n=12) and female participants consisted of 52% (n=13) ( see Figure 6.1).  The participant’s ages ranged from 26 to 81 years of age ( see Fig 6.2).

Fig 6.2  Age of Participants

Outcome Findings

Evaluating outcomes generated from an EBP change project is important at the patient, clinician, organization, and system level ( Melnyk and Fineout- Overhold, 2015). The intended outcome of the EBP change project is that participants displayed decrease in surgical fear and anxiety. The SFQ was used as a pre-test and post-test to measure if decreased fear and anxiety was met.

Fig 6.3 Pre-test and Post-test scores

Decreased fear and anxiety. The desired outcome of the EBP project was to decrease surgical fear and anxiety. The same SFQ was used as a pre-test and post-test during the educational session. A SFQ was given to each participant as a pre-test before their educational session to determine baseline surgical fear and anxiety. After the one-on-one preoperative educational counseling the participants was given an identical SFQ to determine if there was a decrease in surgical fear and anxiety. After completion of all the educational sessions, the PI gathered all collected data and descriptive statistics using Microsoft Excel was used to compare the SFQ pre-test and post-test results. Results were entered in Microsoft Excel to determine the pre-test and post-test score. The average score on the pre-test was 80.36%%, and the average post test score was 6%. The decrease from the test scores suggests that the one on one educational counseling is effective with decreasing the surgical fear and anxiety. ( see Fig 6.3). The overall change in the level of surgical fear and anxiety was 93% which is above the bench mark of 80%.

Fig 6.4 Overall change in the level of fear & anxiety.

For this EBP project, participants were forecast to reach a benchmark of 80% or higher to confirm the decrease in fear and anxiety. The SFQ consisted of 10 questions with a rating scale one to ten, one being not afraid at all and ten being very afraid. A t-test analysis was conducted and proved significant with a p-value of 0.000, using a p-value of 0.05. After reviewing the test scores the pre-test and post-test, results show that a benchmark of 80% was attained ( see figure 6.4). Therefore, the EBP change project proved that one on one educational counseling decrease surgical fear and anxiety and thereby increase knowledge.

Summary

This chapter focused on the evaluation and outcome of an EBP change project. Data collected and used were participants age and gender. The collected data were compared using descriptive statistics. A projected goal for the participants to reach was 80%, showing that an decrease in fear and anxiety was achieved. The percent change between the SFQ pretest and post-test scores was 93%, the results showed that the benchmark of 80% was achieved. Therefore, it is determined that the EBP project was successful in decreasing the surgical fear and anxiety after one on one individual educational counseling. NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review