Surgery and Nursing Responsibilities for Patient Preparation

Patient Preparation for Surgery

Preparing Patient for Surgery,Nursing Research on Patient Preparation for Surgery,Types of Informational Interventions,Clinical Experience and Outcomes,Interventions and Outcomes,Practice for Preparing Patient,Discharge after Ambulatory Surgery,Surgical Preparation and Family Role.

Preparing Patient for Surgery

    The preparation of patients for their experience with surgery is one of the largest bodies of investigation relevant to the practice of clinical nursing. The first report of an experimental study was published by a nurse, Rhetaugh Dumas (Dumas & Leonard, 1963), and the topic continued to attract researchers' representing nursing, medicine, and psychology for over 20 years. 

    The interest in psychological preparation for the surgical experience started with the discovery that when patients ambulated within hours after the operation, instead of being in bed for 7 to 10 days, morbidity and mortality decreased. This change in practice was anxiety provoking for both patients and the people who cared for them. Preparing patients for the experience of getting out of bed soon after surgery was a way to deal with the anxiety. 

    Much of the research stemmed from pragmatic concerns about how to help these anxious patients ambulate and perform behaviors believed to reduce postoperative complications. Psychological theories about coping with stressful events began to emerge in the late 1950s and 1960s, but most of the research on preparing patients for the stressful experience of undergoing surgery was atheoretical.     

    Connections between the clinical research and theory, when attempted, were often vague.

Nursing Research on Patient Preparation for Surgery

    Research on the effects of various approaches to preparing patients for surgery has been reviewed by a number of people, using meta-analysis and narrative review. It was difficult to conduct a tightly controlled study in the clinical settings, and there were methodological flaws in the studies. 

    Nevertheless, there was consensus among the reviewers for the overall conclusion that preoperative interventions aimed at helping patients deal with their experiences postoperatively had a substantial positive effect on patients' welfare.

Types of Informational Interventions 

    The interventions varied in content and focus. The most frequently tested intervention was instruction in the exercises and behaviors that patients were expected to engage in postoperatively to reduce complications. 

    For abdominal and chest surgery patients, the intervention usually consisted of instruction in methods of deep breathing to effectively inflate the lungs, effective coughing techniques, leg exercises to increase circulation, and methods of getting out of bed to minimize incisional pain. The next most frequent intervention consisted of information that oriented patients to the routines of care. 

    These descriptions were based on content in text-books, manuals used by care providers, and providers' experiences. Patients were told, for example, that their skin would be prepared, that they would receive preoperative medication, and that they would go to the recovery room. The specifics of patients' experiences during those procedures were not included. This type of information has been referred to as procedural information.

    In another type of informational intervention, the patient's perspective of the experience of undergoing surgery was emphasized. These descriptions focused on physical sensations associated with the events, when events would occur, and how long they would last. 

    For example, the interventions included statements about how long patients could expect to be in the recovery room and about vital signs being checked frequently, descriptions of the sensations caused by preoperative medication (eg, dry mouth and drowsiness), descriptions of sensations that abdominal surgery patients experienced when they coughed, and the expected progression of physical activities.     

This type of information was originally called sensory information and later called concrete objective information because that phrase more accurately described the content. Highly individualized nurse patient interactions, hypnosis, relaxation, and positive thinking also have been used as interventions in a few studies of surgical patients. 

    The impact of these studies on practice was decreased because of inconsistent findings and the special training required to deliver the intervention.

Clinical Experience and Outcomes

    Clinical experience influenced the aspects of patient response, behaviors, and recovery selected as outcome measures in the research on preparing patients for surgery. Length of postoperative stay, pain medication use, complications, and ambulating behavior are representative of measures derived from clinical experience. Some researchers included patients' psychological responses, such as mood or emotions, pain reports, satisfaction with care, and well being. 

    Most researchers limited their measurement of outcomes to the time the patient was hospitalized. However, a few researchers were interested in the influence of the interventions on patients' long term recovery and measured patients return to usual activities and psychological response after discharge from the hospital.

Interventions and Outcomes 

    Although as many as 102 studies have been included in reviews, confident conclusions about relationships between content of interventions and specific outcomes cannot be drawn. The practice of combining content in interventions, instead of studying the effects of each type of content separately, contributes to the inability to sort out the content that was associated with specific outcomes. 

    However, reviewers agree that combined interventions have the most consistent effects on outcomes. A frequently used combined content intervention consisted of instruction in postoperative exercises and behaviors and informing patients about routines of care (procedural information). This combined intervention appeared to have a positive effect on outcomes measured during hospitalization. 

    A combination of descriptions of experiences from the patient's perspective (concrete objective information) and instruction in postoperative exercises and behavior also had a positive effect on outcomes measured during hospitalization. An additional benefit of the concrete objective information intervention was that it was associated with patients returning earlier to their usual activities after discharge.

Practice for Preparing Patient

    The practice of preparing patients for surgery has been widely disseminated and is included in textbooks of nursing. It has become a part of care in most health care settings. The economic impact has been accepted as self-evident because of the reduction in complications and length of hospitalization and the early return to productive activities. 

    In addition, the interventions had a positive effect on patients' subjective reports of well-being, such as mood and satisfaction with care. The combination of a practice activity having positive effects on cost and quality of care makes it an ideal practice to be widely adopted.

Discharge after Ambulatory Surgery

    The recent practice of ambulatory surgery with discharge after patients awaken from anesthesia and that of admitting patients the day of surgery with brief hospital stays have changed the nature of patients' experiences when undergoing surgery. Patients and their families have to provide postoperative care. 

    This includes assessing for complications, making decisions about the patient's status, progression of physical activities, and care of the incision. There has been little research on preparing patients for surgery since this change in practice.

Surgical Preparation and Family Role 

    Because the needs of surgical patients and their families have changed, new research on preparation for surgery is necessary. That research should draw on the prior research on preparing patients for surgery and advances in theory about coping with health care experiences. 

    Relying on informational processing explanations of behavior, self-regulation theory provides explanations for why specific types of information about an experience, combined with instruction in self-care and coping activities, can help patients and families to cope with the surgical experience.

    In the current climate of containment of health care costs, insurance coverage decisions are informed primarily by data about cost of care. There is much less data about how coverage regulations affect patient welfare. Research on preparing surgical patients for their experience at this time has the potential of influencing policies about services covered by health insurance.