The impact of preoperative education

on postoperative pain. Part 1

I
t has been made explicit in The NHS
Plan (Department of Health, 2000) that
patients need to be empowered with
greater information to enable them to
look after their own health. Gammon and
Mulholland (1996) note that providing
information to patients is important because
of an increasing emphasis on self-care. The
average stay in hospital is shorter because
of surgical advancements (Gammon and
Mulholland, 1996a). This success depends
largely on comprehensive preparation
of patients preoperatively (Dierking and
Hockenberger, 1984), making information
giving an important aspect of the process.
Background
French (1983) views anxiety as a biological
defence mechanism operating in the face
of impending, actual or imaginary danger.
Preoperative patients usually express
anxiety, which causes psychic disturbance.
people perceive a threatening situation,
their level of anxiety, coping styles and
postoperative pain (Schwartz-Barcott et al,
1994; Krohne et al, 1996; Mitchell, 2000).
Surgery, anxiety, preoperative
education, and postoperative pain
Hospitalization, even in patients who are
not faced with the prospect of surgery, is
known to cause anxiety and provokes a
physiological stress response which impedes
the healing process (Grieve, 2002). Bowers
(1968) points out that the greater a persons
anxiety about pain, the greater the reactive
pain. Reactive pain is a component of
the total pain experience. One variable
engendering anxiety about pain, and which
therefore contributes to the degree of
the reactive pain, is the perceived lack
of control a person has over a present or
potential stressor (Bowers, 1968). In an
experimental study, Bowers (1968) found
that the perception of little or no control
over a painful stressor increases anxiety
about it and that the anxiety thus generated,
magnifies the pain perceived.
This finding is supported by Breemhaar
and Van de Borne (1991) who reported
that a greater perceived control or an
ability to influence an aversive stimulus
is accompanied by a greater tolerance of
that event. They identify that perceived
control through the provision of education
and support is able to reduce the stress
experience in connection with surgery and
to determine the manner in which stress
is dealt with. They argue that increasing
the perceived control of patients who tend
to attribute little control to themselves is
not accompanied by an improvement in
adaptation to treatment and recovery. In
the case of patients who attribute more
control to themselves, measures to increase
control appear to help them in developing
expectations with regard to surgery.
It has been suggested that several cognitive
biases contribute to high anxiety: selective
attention to threatening information, enhanced
memory of threatening information, negative
Abstract
This article, the first of two parts, explores the general concept of preoperative
education through a literature review. The relatively complex relationships
between the ways people perceive a threatening situation, their levels of anxiety,
coping styles and postoperative pain is explored. In dealing with these complex
relationships, teaching strategies and forms of presentation of preoperative
education are also discussed. The second part will examine the impact of
preoperative education on postoperative anxiety, pain and recovery. This will
be achieved by analysing the evidence available to provide a rigorous appraisal
of the literature.
Key words: Critical review n Preopertive education n Postoperative pain
and recovery
Titilayo O Oshodi is recent graduate, University
of Worcester, Henwick Grove, Worcester
Accepted for publication: May 2007
It may also contribute to problems during
anaesthesia, which may include raised pre-
and perioperative plasma adrenaline levels
(Combley et al, 1991). If a patient is unduly
anxious, physical recovery and well-being
may be affected, prolonging hospital stay and
increasing the cost of care (Hughes, 2002).
Overview of preoperative
education
Lorig (2001) views patient education as any
set of planned, educational activities designed
to improve patients health behaviours, health
status or both. Such activities are aimed at
facilitating the patients knowledge base.
Changes in knowledge may be necessary
before a change in behaviours or health status
can take place (Lorig, 2001). Caress (2003)
notes that giving information, which is a
part of the process of patient education, can
be a passive process with no confirmation
of whether the information is understood.
Education, by contrast, implies a more active
process, with confirmation that learning
has taken place. Preoperative education
informs patients of specific actions they
can take to facilitate their own recoveries
(Cupples, 1991). It has been demonstrated
in the literature that a relatively complex
relationship exists between the way that
Titilayo O Oshodi
706 British Journal of Nursing, 2007, Vol 16, No 12
contributing to muscle breakdown, it was
suggested that anxiety may serve to reduce
surgical stress.
How much information to give
It is believed that the best type of anxiety-
reducing intervention should support the
patients coping styles while guiding him/
her from destructive behaviour (Krohne et
al, 1996). Krohne et al defines two groups of
people: the vigilant copers and the avoidant
copers. Vigilant copers tend to use active
coping mechanisms. They desire to know
everything about their operations. On the
other hand, avoidant copers tend to use
passive coping mechanism: they desire only
a minimal amount of information about
their operation, just what is necessary and
no more; while for the most part they prefer
not to think about it. The two methods of
coping are not exclusive but rather they
represent the opposite ends of a continuum
(Krohne et al, 1996). Preoperative preparation
should always involve matching the amount
of information provided with the patients
preferred coping style (Mitchell, 2000).
Preoperative education, decision
making and consent
Kriwanek et al (1998) reveal that patients
can participate in surgical decisions only
with complete understanding of all factors
relevant to the proposed treatment. Examples
of surgical decisions/care management
include preferred options in certain
situations, e.g. a Jehovahs witness refusing
a blood transfusion, living wills and advance
directives, and how much the patient will
like friends or relatives to know about their
treatment. Through preoperative education,
the capability of patients to take care of
themselves improves through meeting their
postoperative self-care needs at home
(Gammon and Mulholland, 1996a,b). For
example, information about appropriate
behaviour after discharge (mobility, exercise,
relaxation, appropriate diet or adequate pain
control) will facilitate full recovery.
In more recent years, there has been great
emphasis on patient autonomy and the
importance of informed consent (Garden
et al, 1996). The issue relevant to informed
consent is that of comprehension at the time
the consent is obtained (Garden et al, 1996).
Information should be tailored to suit the
patients general level of comprehension,
education and cultural background (Sowden
et al, 2001). Patients can hardly be considered
informed unless they have been told explicitly
interpretations of ambiguous information,
and a tendency to perceive a higher
likelihood of negative events happening
to one (Chen and Craske, 1998). Ng et al
(2004) conducted an experimental study
to analyse the effectiveness of preoperative
information provision for anxiety reduction
during dentoalveolar surgery in patients with
high or low trait anxiety. In their study, Ng
et al demonstrated that with the provision
of preoperative information a persons
cognition can be changed and an event that
is normally threatening can be rendered less
so. Spielberger et al (1968) identify two types
of anxieties - trait anxiety, which refers to
the relatively stable individual differences
in anxiety proneness, and state anxiety,
which is a momentary subjective feeling of
tension, apprehension, worry, nervousness
and increased autonomic activities.
Salmon (1993), however, argues that
moderate levels of preoperative anxiety can
help patients to prepare for surgery and
reduce its stressfulness. On this basis, attempts
to reduce anxiety are not necessarily in the
patients best interest, but would amount to
the medicalization of a natural and emotional
response which serves an important function.
Salmon (1993) points out that for some time
evidence has suggested a simpler relationship
between preoperative anxiety and recovery,
such that the lower the preoperative anxiety
the better the postoperative state (e.g. less
complaints of symptoms and shortening of
postoperative stay). Salmon (1993) warns
against relying on such indices of recovery
but posits that more objective indices of
surgical stress, such as measurements of
postoperative endocrine and metabolic
changes should be used as they display a
conflicting situation. Some of these changes
include increases in circulating cortisol,
adrenaline and noradrenaline.
In earlier experimental studies, Salmon et
al (1988) measured preoperative state anxiety
in patients undergoing major abdominal
surgery. Plasma cortisol, adrenaline and
noradrenaline were also measured on the
preoperative day and at various times
over the next 4 days. Higher preoperative
anxiety predicted lower adrenaline levels
postoperatively, and trait anxiety (Salmon et
al, 1989) correlated negatively with cortisol
levels postoperatively and adrenaline levels
during surgery and postoperatively. Since,
it has been noted that elevated circulating
cortisol levels might impair immune function
after surgery (Salmon et al, 1988); while
adrenaline and noradrenaline are catabolic,
about the risks involved in their surgery
(Garden et al, 1996), as they also have the
right to withhold consent if they are not
happy about accepting these risks. If medical
negligence is to be minimized (Waxman
and Simons, 1999), and potential numbers
of litigation reduced (Walker, 2002), it is
vital that doctors ensure that the patient has
carefully considered both the potential risks
and the likely benefits.
The patient as a learner
Anderson et al (1998) define learning as
knowledge, wisdom, or a skill acquired through
systematic study or instruction. Lindeman
(1988) points out that influencing human
learning is a complex process affected by six
major categories of variables: characteristics of
the patient as a learner; characteristics of the
nurse as a teacher; nurse-patient interaction
as instructional strategy; characteristics of the
target group; health care setting as learning
environment; and the content. The process
of teaching and learning is an interactive one
with both the learner and the teacher having
to be actively involved.
Skills of educators
The provider of health education requires
several skills, which include understanding
educational principles; sound, up-to-
date, subject-specific knowledge; as well
as resources available to support this
information (Caress, 2003). Effective
communication is a pivotal component of
preoperative teaching (Caress, 2003; Sheehan,
2005), as it is necessary to achieve adequate
understanding of the information provided
(Mordiffi et al, 2003). Clark (1999) points
out that the most important persuasive
mode of communication takes place when
there is personal interaction between the
communicator and the recipient. Caress
(2003) states that relevant educational
principles include awareness of theories
of learning, understanding of the needs of
different learners and appreciation of the
potential effects of ill-health and vulnerability
of learners.

Approaches to preoperative
education
Different approaches to delivering
information have been investigated by many
authors (Mavrias et al, 1990; Walker, 2002).
The three main types of information which
have been studied alone and in combination
are: procedural, sensory and coping (Mavrias
et al, 1990). It is generally believed that
British Journal of Nursing, 2007, Vol 16, No 12 707
PAIN MANAGEMENT
procedural information that focuses on the
what, where and why of the surgery is best
aimed at the less anxious populace; and
that sensory information which focuses on
any sensations and feelings to be expected
throughout the surgical experience is best
directed towards the more nervous patients
(Walker, 2002).
Furthermore, Wilson (1981) found a
significant reduction in the self-rating of pain
distress and intensity, increased reports of
mobility and increased strength and energy in
patients exposed to both sensory information
and coping strategies. This conclusion
was supported by Schwartz-Barcott et als
(1994) findings, which reveal that sensory
information provides patients with a clear
image of the threat while relaxation training
and postoperative exercise instructions gave
them a set of action instructions to cope
with the threat.
Teaching strategies of
preoperative education
One-on-one vs group education
One-on-one education is the most common
type of patient education. It is what doctors,
nurses and other health professionals do
at the bedside or in the clinic (Lorig and
Harris, 2001). In one-on-one education,
there are four major considerations: time,
knowing what to teach, knowing how to
teach, and documenting what has been
taught (Lorig and Harris, 2001). Everything
said about one-to-one education is also true
for group education, the difference is that
the patient educator is going to do more
than just lecture; he/she must have skills in
group process (Lorig and Harris, 2001).
There ahev been few studies in the recent
past to compare outcome via one-to-one
and group patient outcome. Lindeman
(1972), in a comparative study of the
effect of individual and group preoperative
teaching on postoperative outcomes, found
group teaching to be as effective as, and
more efficient than individual teaching.
According to Crabtree (1978), choosing
between an individual or group teaching
programme is termed an alternative choice
problem. Crabtree conducted a cost-benefit
analysis relating patient education to patient
outcomes. The results showed that compared
with those individually taught, group
teaching required less nursing time. There
was also a lower incidence of postoperative
respiratory infection, making more efficient
bed utilization possible. This conclusion is
supported in a more recent quantitative
study by Way et al (2003) who found that
group teaching generated clear cost savings
associated with its impact on length of stay.
Structured vs unstructured
education
Structured teaching, which is based on
course objectives and an outline, is used in
some healthcare facilities, while unstructured
teaching which leaves the teaching
contents to the discretion of the teacher
is used in others (Good-Reis and Pieper,
1990). Structured education can allow for
preparation, identification of patient goals
and development, and identification of
educational resources; while unstructured
education has the benefit of spontaneity and
can be patient-focused, as it often occurs in
response to an individuals questions (Caress,
2003). Due to the wide variations of sensory
and procedural information that may be
presented, essential contents could be missed
(Good-Reis and Pieper, 1990). However,
with most wards running on minimal staffing
levels it would be advantageous to introduce
preadmission teaching and orientation clinics
to ensure that this procedure is conducted in
a structured, comprehensive and unrushed
manner (Walker, 2002).
Lindeman and Van Aernam (1971) studied
the effects of structured and unstructured
preoperative teaching in a variety of surgical
patients and reported a decrease in hospital
stay and fewer postoperative complications
in the group that received structured
preoperative instructions. In similar studies,
King and Tarsitano (1982) and Lookiland and
Pool (1998) have also supported preoperative
structured teaching.
Forms of presentation
Verbal education
Verbal instruction is the cornerstone tool
of preoperative teaching and whoever
conveys information verbally must be
cognizant of the recipients intellectual level
and interest in acquiring the information
(Whyte and Grant, 2005). Mordiffi et al
(2003) investigated the preferred method
of preoperative information delivery in 67
patients, and found that about 90% of the
respondents preferred information to be
delivered verbally.
There are problems which need to be
taken into account with verbal education.
These include limited recall (Caress, 2003),
language barriers, learning disabilities and
cultural barriers (Whyte and Grant, 2005).
For this reason, written educational materials
are beneficial as a supplement to not a
replacement for verbal education (Walker,
2002; Caress, 2003; Whyte and Grant, 2005).
Supplementing oral instructions with written
materials is an application of the education
principle that information, which is repeated,
will be retained and recalled more readily
than information that is not repeated; written
instructions can be referred to repeatedly by
the patient (Lepczyk et al, 1990).
Written materials
Webber (1990) indicates that written materials
are desired and appreciated by patients. Doak
et al (2001) point out that many health
professionals write for patients as if they were
writing for scientific journals. The application
of a readability formula will reveal that the
material may not be understandable and
needs to be reviewed (Doak et al, 2001).
For information leaflets to be useful they
must be up to date, accurate, relevant, and
unambiguous, with short words and no jargon
(Cooper, 1999). Garden et al (1996) highlight
that if the provision of written material is
done well before surgery, the patient is given
time to seek an additional explanation. In
a clinical setting where teaching time is
limited, this type of information is useful
(Estey et al, 1993). Caunt (1992) contends
that it is of no significance which medium is
used, as long as the information is presented
clearly, thus giving the patient the advantage
of predictability and control.
The use of other media
A variety of techniques are currently being
used to educate patients. They include
cassette tapes, video and information through
the telephone. Whyte and Grant (2005)
identify that much of this information is also
available on the internet, but they caution
that information obtained on the web can
be highly biased, poorly referenced, and even
self serving and promotional in nature but
the reputable sources can provide valuable
insights into treatment options available.
Cost-effectiveness
Webber (1990) notes that there is much
interest in patient education as a means
of reducing health care costs, but only
a few studies have attempted to measure
costs. Devine and Cook (1983) in a meta-
analysis of the effect of psychoeducational
interventions on length of hospital stay, using
49 studies, reveal that such interventions are
cost effective as they reduce hospital stay by
1 days. Earlier discharge will encourage
708 British Journal of Nursing, 2007, Vol 16, No 12
PAIN MANAGEMENT
and Viellion (1990) assert that timing is
important in patient education, and point
out that preoperative teaching is usually
done the evening before surgery, when the
patients anxiety could be so intense that
learning is blocked.
Intense anxiety and learning
Anxiety is related to the level of arousal
which at a high level may be detrimental
to learning (Kiger, 1995). An extremely
high level of arousal is associated with very
high anxiety or even panics. In this case, the
individual is likely to be distracted and unable
to attend properly to any type of cognitive
task (Payne and Walker, 2001). Memory for
information is likely to be poor, or may focus
only upon the most salient aspect to them.
The best cognitive performance is obtained
from someone whose adrenaline is flowing,
who is alert and slightly anxious, and whose
attention is focussed upon the task in hand
and the content of what is being said. This
indicates that the patients emotional state
should be noted and time taken to listen to
and calm someone who is highly anxious
(Payne and Walker, 2001). It is thought to
be beneficial to deliver information at times
when anxiety is not elevated as patients
might be more able to make rational choices
about alternatives (Kent, 1996).
Conclusion
Having explored the concept of preoperative
patient education, there appears to be a lot
of arguments in the literature about its
effectiveness but very few studies have
sought to measure its impacts. The second
part of this article will conduct a further
literature search and a critical review through
a rigorous methodology to evaluate the
impact of preoperative patient education on
postoperative recovery.
BJN

Acknowledgements
The author would like to thank Louise Toner, Lecturer at the
University of Worcester, for her help and inspiration.
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KEY POINTS
The prospect of surgery can engender emotions, such as anxiety, fear of pain
and incapacitation.
The perception of pain and anxiety is usually intensified when patients feel a lack
of control over their situation.
Through preoperative education, anxiety is reduced, and patients are helped to gain control
over their situation by getting them involved in their healing process, facilitating their own
recoveries.
Patients who understand more about their condition will comply with their care needs.
Preoperative education contributes to early discharge which facilitates and encourages cost-
effectiveness.
710 British Journal of Nursing, 2007, Vol 16, No 12