NUR799 Capella Preoperative Education Using One-On-One Counseling Peer Review
Running head: PREOPERATIVE EDUCATION 1 PREOPERATIVE EDUCATION USING ONE-ON-ONE COUNSELING by Annie Daniel, MSN NP-BC Capstone Paper submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice Chatham University Date Signature Faculty Reader Date Signature Program Director Date PREOPERATIVE EDUCATION 2 Acknowledgments I would like to first acknowledge GOD for his grace, mercy, and blessings. I know that without GOD I would not have or be able to accomplish anything. I would like to acknowledge my faithful family and friends that were patient with me during this journey. To my beloved husband Daniel and my kids Rhema, Rebecca and Ryan, thank you all for being understanding of my tight time constraints due to school and work obligations. I would like to acknowledge my mom and dad for praying for me everyday and encouraging me all the time. I would like to acknowledge Dr. Sandra, for taking the time to precept me and always being available to meet and talk with me during this journey. Thank you, Chatham University staff, for being do helpful and willing to give me your time so I can truly understand the process. PREOPERATIVE EDUCATION 3 Abstract Start typing here…. Key words: PREOPERATIVE EDUCATION 4 Table of Contents
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Acknowledgments……………………………………………………………………………………………………X Dedication ………………………………………………………………………………………………………………X Abstract ………………………………………………………………………………………………………………….X Chapter One: Overview of the Problem of Interest ……………………………………………………..X Background Information ………………………………………………………………………………..X Significance of the Problem ……………………………………………………………………………X Question Guiding Inquiry (PICO) …………………………………………………………………..X Variables of the PICO question ……………………………………………………………X Summary ……………………………………………………………………………………………………..X Chapter Two: Review of the Literature/Evidence ……………………………………………………….X Methodology ………………………………………………………………………………………………..X Sampling strategies …………………………………………………………………………….X Inclusion/Exclusion criteria …………………………………………………………………X Literature Review Findings…………………………………………………………………………….X Discussion ……………………………………………………………………………………………………X Limitation of literature review. …………………………………………………………….X Conclusions of findings ………………………………………………………………………X Potential practice change …………………………………………………………………….X Summary ……………………………………………………………………………………………………..X Chapter Three: Theory and Model for Evidence-based Practice ……………………………………X Theory …………………………………………………………………………………………………………X Application to practice change……………………………………………………………..X PREOPERATIVE EDUCATION 5 Model for Evidence-Based Practice ………………………………………………………………..X Application to practice change……………………………………………………………..X Summary ……………………………………………………………………………………………………..X Chapter Four: Pre-implementation Plan …………………………………………………………………….X Project Purpose …………………………………………………………………………………………….X Project Management ……………………………………………………………………………………..X Organizational readiness for change ……………………………………………………..X Inter-professional collaboration ……………………………………………………………X Risk management assessment ………………………………………………………………X Organizational approval process …………………………………………………………..X Use of information technology …………………………………………………………….X Materials Needed for Project ………………………………………………………………………….X Plans for Institutional Review Board Approval …………………………………………………X Plan for Project Evaluation …………………………………………………………………………….X Plan for demographic data collection ……………………………………………………X Plan for outcome data collection and measurement ………………………………..X Plan for evaluation tool ………………………………………………………………X Plan for data analysis …………………………………………………………………X Plan for data management ……………………………………………………………………X Summary ……………………………………………………………………………………………………..X Chapter Five: Implementation Process ………………………………………………………………………X Setting …………………………………………………………………………………………………………X Participants …………………………………………………………………………………………………..X PREOPERATIVE EDUCATION 6 Recruitment ………………………………………………………………………………………………….X Implementation Process …………………………………………………………………………………X Plan Variation ………………………………………………………………………………………………X Summary ……………………………………………………………………………………………………..X Chapter Six: Evaluation and Outcomes of the Practice Change …………………………………….X Participant Demographics ………………………………………………………………………………X Table or Figure X ……………………………………………………………………………….X Table or Figure X ……………………………………………………………………………….X Outcome Findings …………………………………………………………………………………………X Outcome One …………………………………………………………………………………….X Table or Figure X ……………………………………………………………………………….X Table or Figure X ……………………………………………………………………………….X Summary ……………………………………………………………………………………………………..X Chapter Seven: Discussion ………………………………………………………………………………………X Recommendations for Site to Sustain Change …………………………………………………X Plans for Dissemination of Project ………………………………………………………………..X Project Links to Health Promotion/Population Health ……………………………………..X Role of DNP-Prepared Nurse Leader in EBP ………………………………………………….X Future Projects Related to Problem ……………………………………………………………….X Implications for Policy and Advocacy at All Levels ………………………………………..X Summary ……………………………………………………………………………………………………X Chapter Eight: Final Conclusion ……………………………………………………………………………….X Clinical Problem …………………………………………………………………………………………..X PREOPERATIVE EDUCATION 7 Evidence Base ………………………………………………………………………………………………X Theory and Model for Evidence-based Practice ………………………………………………..X Project Management ……………………………………………………………………………………..X Project Implementation ………………………………………………………………………………….X Outcome Findings …………………………………………………………………………………………X Discussion Summary …………………………………………………………………………………….X Final Conclusions…………………………………………………………………………………………………….X References ………………………………………………………………………………………………………………X Appendix A: XXXXXX ………………………………………………………………………………………….X Appendix B: XXXXXX …………………………………………………………………………………………..X Appendix C: XXXXXX…………………………………………………………………………………………..X Appendix D: XXXXXX ………………………………………………………………………………………….X Appendix E: XXXXXX …………………………………………………………………………………………..X Appendix F: XXXXXX …………………………………………………………………………………………..X Appendix G: XXXXXX ………………………………………………………………………………………….X Running head: PREOPERATIVE EDUCATION 8 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 healthcare 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. 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 PREOPERATIVE EDUCATION 9 (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 comorbidities 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 PREOPERATIVE EDUCATION 10 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- PREOPERATIVE EDUCATION 11 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. Other postoperative complications such as venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) affects an estimated 300,000600,000 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 PREOPERATIVE EDUCATION 12 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. PREOPERATIVE EDUCATION 13 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. 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. PREOPERATIVE EDUCATION 14 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). 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 PREOPERATIVE EDUCATION 15 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 PREOPERATIVE EDUCATION 16 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. 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 presurgical 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 PREOPERATIVE EDUCATION 17 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
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