Nursing Care for Preoperative Psychological Factors

Preoperative Psychological Factors and Nursing Care

Preoperative Psychological Preparation for Surgery,Pulmonary and Gastrointestinal Complications,Nursing Literature About Surgery Stress and Copping,Outcome of Literature,Preparatory Interventions,Challenges Surgical Care,Surgical Practices and Nursing Research Needs.

Preoperative Psychological Preparation for Surgery

    Study of methods for preparing adult patients for the experiences associated with having surgery comprises one of the largest bodies of research important to the practice of nursing. 

    The first experimental study of preparation for surgery was published in the early 1960s by a nurse, Rhetaugh Dumas (Dumas, RG, & Leonard, 1963). Since then, more than 190 investigations of preparation for surgery were conducted by nurses, physicians, or psychologists.

Pulmonary and Gastrointestinal Complications

    Concerns about the prevention of pulmonary, gastrointestinal, or circulatory complications of surgery guided much of the early research. 

    Many investigators examined various strategies to help patients deal with the discomfort and anxiety caused by getting out of bed, walking, and coughing, and deep breathing exercises were designed to aid recovery and prevent surgical complications. 

    These studies were often guided by pragmatic concerns, such as whether structured or unstructured teaching, group versus individual teaching, or different methods of information delivery produced less anxiety and aided patients in performing these preventive activities. 

    Other early studies examined the effects of provider-patient interaction. These interventions were highly individualized to identify and meet patient needs.    

Another approach to preparation for surgery included descriptions of routines of care such as skin preparation, preoperative medication, and transport to surgery and to the recovery room following surgery. 

    This type of orienting information was derived from content found in textbooks or hospital procedure manuals and was often called procedural information.

Nursing Literature About Surgery Stress and Copping 

    Although theories about stress and coping began to appear in the literature in the 1950s and 1960s, the research about preparing patients for the stressful experience of having surgery generally remained atheoretical through much of the 1970s. 

    Beginning in the mid-1970s some investigators began to test more theoretically derived interventions to help patients cope with the experience of having surgery. One of these interventions was preparatory sensory information, later called concrete objective information. 

    Based on self-regulation theory (Johnson, JE, 1999), this intervention describes in concrete and objective terms the typical physical sensations associated with the experience of having surgery; that is, what patients would see, feel, hear, or taste. These sensory experiences are linked to their cause. 

    Examples include description of the sensations associated with preoperative medication (eg, drowsiness), incisional sensations (eg, burning, stinging) and how these sensations may change with activity and over time , being in the recovery room with frequent checks of vital signs, and the timing of expected changes in physical activity following surgery. 

    Other interventions related to stress and coping that have been studied include a variety of relaxation methods, hypnosis, and positive thinking. Relaxation strategies have been more frequently studied in persons having surgery than have the latter two interventions.

Outcome of Literature

    Because many studies were atheoretical, most outcome indicators used to assess intervention effects were based on expectations drawn from clinical experience and inferences made about how the intervention was expected to improve specific patient outcomes. 

    Outcomes most frequently used included length of stay, medications, pain, and emotions. Most studies assessed outcomes only during hospitalization; however, a few investigators assessed intervention effects on continued recovery and return to usual activities following hospital discharge.

Preparatory Interventions 

    The authors of a series of meta-analyses of studies testing preparatory interventions in patients having surgery (Devine & Cook, 1986; Hathaway, 1986; Devine, 1992) and at least one narrative review (Johnson, JE, 1984) have drawn similar conclusions : patients who received any of the experimental preoperative preparatory interventions experienced more positive outcomes than patients not receiving such intervention, and these effects are substantive. 

    There was also some evidence that combining intervention strategies produced greater positive effects than did single interventions. Cost savings derived from intervention effects on length of stay and medical complications also were demonstrated in the meta-analysis of studies published between 1961 and 1983 (Devine & Cook), although the magnitude of the effect was less, particularly for length of hospital stay, in the later years. 

    Cost savings were also demonstrated in one study of psychoeducational care delivered by staff nurses after implementation of the diagnosis-related groups prospective payment system (Devine, O'Con nor, Cook, Wenk , & Curtin, 1988). 

    The ability to replicate similar cost savings in today's clinical environment is less likely because of even more changes in the delivery of surgical care that reduce the length of hospitalization for many patients.

    Research concerning the preparation of patients for surgery has a long history, and it is clear that patients benefit from these interventions. The research findings were published in numerous journals over these years and they are also now included in nursing textbooks. 

    The use of preparatory interventions for surgical patients is a common singular practice. Because interventions were frequently combined in many studies, it is difficult to determine the specific contribution of each intervention to these positive effects. Such information would enhance clinical decision-making in selecting an intervention(s) to include in the preoperative care of surgical patients. 

    Increased use of theories in the study of preoperative care, such as was done with self-regulation theory, will aid clinician decisions in selecting interventions for preoperative care and the appropriate outcomes for evaluation.

Challenges Surgical Care

    The nature of surgical care has changed dramatically in recent years. The shift to “same day” or ambulatory surgery with admission the day of surgery, discharge upon recovery from anesthesia, or very short post operative hospital stays created the need for changes in the delivery of preoperative care. 

    It also shifted much of the responsibility for ensuring that preoperative procedures were followed and that postoperative assistance and monitoring of recovery were provided to patients and their families. 

    Even when patients are hospitalized following surgery, the postoperative stays are shorter and patients frequently return home with need for continuing assistance from their families. The practice of minimally invasive surgery also has become prevalent. 

    These changes in surgical practices not only require changes in how preoperative nursing care is provided, but also suggest that new or different care for patients and families may be needed. At the same time there were fewer studies of preoperative preparation for surgery.

Surgical Practices and Nursing Research Needs

    Because of these changes in surgical practices and postoperative care, there is a need for new research about psychological preparation for surgery. This research should draw on prior research about preparation for surgery and theories relevant to coping with health care experiences.     

In an environment of cost containment, new research must consider assessing cost outcomes. While preoperative preparation most likely will not decrease hospital stays, using theory may suggest new ways to assess intervention cost effects . 

    For example, in a study of cardiac surgical patients (Kim, Garvin, & Moser, 1999), one group received routine preoperative information consistent with procedural information. Another group received concrete objective information about mechanical ventilation and communication during ventilation plus procedural information. 

    Patients receiving concrete objective information reported less negative mood and communication difficulties, as expected. They also were intubated for less time than the comparison group. The latter effect was unexpected but interpreted within self regulation theory.     

Considering intubation time as a recovery indicator for intervention effects suggests using intubation-related costs as an outcome. Social costs of care, such as family member loss of income, out-of-pocket costs, or other costs related to recovery and care in the home, might also be considered when relevant to theoretical expectations.

    Lastly, it is acknowledged that many of the insightful, important ideas expressed by Johnson in the first edition of The Encyclopedia of Nursing Research are retained in the above paragraphs-although possibly in less detail or in different ways.