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.