This post continues the Pre-Op Education Series by Dr. Luke Pederson, DPT. To catch up, check out Part 1 and Part 2.
Although some studies show that PE results in reduced post-op pain levels, especially in the acute stages (1, 17, 25, 28, 29), there are also many studies that show no change in post-op pain levels with the addition of PE (1, 3, 4, 9, 11, 30). There are also some studies that show no change in post-op pain levels but do show a decrease in the use of pain medications post-op (9, 12, 26). According to Doering et al. (2000), this is possibly due to the fact that patients who receive PE have a better idea of what to expect and anticipate post-op pain and experiences. This, in turn, leads to better self-efficacy and the ability to better cope with post-op pain (9).
A number of studies also note the limited impact of PE delivery on pain levels may be due to a lack of pain-specific education and overemphasis on pathoanatomy, biomedical models, and surgical correction of anatomical impairments. A focus on anatomy, biomedical models and Cartesian models of pain may actually increase pre-op fears and anxieties (3, 13, 30).
An alternative focus should be on pain neuroscience education. This includes a discussion of the neurophysiology of pain and pain experiences. Content can include a discussion of the sensitivity of the nervous system, peripheral and central sensitization, plasticity of the nervous system, and strategies to calm down the nervous system. The authors discuss how post-op pain can be described by the hypervigilant nervous system and increased nervous system sensitivity rather than persistent tissue pathology (3, 30).
Pain education should also aim to change the overall perception and threatening aspects of pain in order to decrease fears and anxieties. A key to this is a change in pain beliefs. Mainly, reduce beliefs that pain is directly associated with tissue or structural damage or that pain is associated with disability (30).
Reinforcement and Multiple Forms of Delivery
The percentage of information a patient learns via one session of learning is limited, be it from reading, video, verbal instruction or other methods. One must also consider logistically, the limited amount of time that can be dedicated to in-person instruction and teaching. For these reasons, PE should take on multiple forms and be reinforced multiple times.
PE should begin immediately in the physician’s office when the patient schedules her surgery. A simple way to do this is through written material such as a booklet or pamphlet with relevant pictures and diagrams. The patient should also receive relevant logistical information such as addresses, names, and phone numbers, and simple preoperative exercises to perform. Another option is connecting the patient with an online or software-based educational resource. This allows the use of multimedia to create an interactive learning platform (34).
An interactive multimedia platform can cater to multiple learning styles and improve patient adherence and engagement. Written material can be boring and difficult to understand, especially for someone with a lower educational status or reading level, or someone with cognitive impairments (35).
Through a multimedia platform, the patient can read text, view videos, listen to audio, and engage with diagrams. They can view the material as many times and as often as they desire (or don’t desire). Providers can also incorporate things such as individualized patient portals, questionnaires, outcome measures, surveys, and assess individuals’ level of engagement. This also provides an initial exposure to important pre-op information. Now, when patients attend the pre-op educational session, they already have a basic understanding of the information. This makes the session more efficient and directed toward the patients’ specific questions, concerns, and needs.
There are also a number of techniques that can be used to maximize information retention during the educational sessions. One technique is the utilization of technology and multimedia resources during the actual session. Additionally, the session should be relaxed and informal so the patient is comfortable asking questions. The instructor should use examples, pictures, diagrams, and metaphors where appropriate.
When information is recalled or utilized immediately after it’s learned, it’s retained better (35). This can be achieved by completing a simple pre-test and post-test, completing a fill in the blank handout, explaining or teaching-back important information to the instructor, or discussing the information with other patients, a family member, or friend.
After the PE session there should be continued follow-up and reinforcement to ensure that information is optimally absorbed and all concerns are addressed. This can take the form of a follow-up phone call or brief in person meeting as the surgery nears. It can also include reinforcement postoperatively. After surgery, it is important to touch base with the patient to check-in, answer questions, and drive home some of the most important keys to a successful and efficient recovery.
Familiarity
A great qualitative study by Spalding (2003) highlights the importance of making the unknown familiar (5). By helping patients know what to expect, providers help alleviate fears and anxieties of the unknown. This improves patient satisfaction and allows patients to better anticipate and cope with post-op pain and other stressors.
Spalding notes three key ways that PE can help make the unknown familiar. First, by helping the patient understand the experiences they will have peri-operatively and post-operatively. She suggests chronologically describing the different events the patient will go through during the surgery and while at the hospital. Second, she notes the importance of the patient meeting the staff and people they will be seeing and working with in the hospital. This improves comfort and trust between the staff and patient and increases the personal connection. Lastly, Spalding says the patient should be familiarized with the different environments they will be exposed to including where they will be staying in the hospital. This can be accomplished by holding PE sessions in the hospital facility and by spending time touring some of the different parts of the hospital (5).
Past Patients’ Perspectives
Many articles highlight the importance of including perspectives from past patients. This can be done through video format, having past patients volunteer to attend PE sessions, or having past patients meet with current patients during a separate time. This serves many purposes. The patient is able to speak with someone who has gone through the surgical process and had a positive outcome. It also decreases fears and anxieties. Past patients’ are able to answer certain experiential questions that healthcare providers cannot. They also provide a support system built on shared experiences.
Logistics
It’s also important for logistical details regarding PE to be optimized. When is the best time to provide the PE session? There is no definitive answer but about 3-6 weeks pre-op seems to be ideal. The patient has enough time to absorb the material through reinforcement but not too much time that they forget important information. This also allows time to make final adjustments and preparations before surgery.
How long should the PE session be? Again, there is no definitive answer. Most resources suggest no more than 1-2 hours. You must consider that typical humans have a limited attention span and it’s likely the longer an educational session runs, the less information they absorb and remember. In the spirit of education that is individualized, PE sessions should take as long or as short a time as they need to. Ensuring that all of the patient’s needs are met is more important than trying to fit the session into a certain time frame.
Who should administer the PE sessions? Besides verbal instruction/classes, a majority of PE can be self-administered by the patient. In-person sessions should ideally be administered by someone who is going to work with the patient during their hospital stay. This provides the added benefit of developing trust and connection between the patient and one or more staff members.
Either nurses, physical therapists, or occupational therapists are the best options to provide PE. These are typically the individuals who will spend the most time with the patient postoperatively and have an intimate understanding of the pragmatic aspects of post-op pain management, rehabilitation, and recovery.
Where should PE sessions take place? Ideally, in the same facility as the surgery and the acute care stay. As discussed above, familiarity with the hospital environment where they’ll be staying can help decrease patients fears and anxieties.
Should PE sessions be mandatory or voluntary? The answer to this question can be argued either way. Voluntary participation provides a sense of control for the patient. Someone may not want to attend PE sessions because the information will further increase the fears and anxieties they already have. Alternatively, someone in denial may benefit from attending an educational session because it will arouse a level of anxiety that encourages more active participation in the surgical process. One suggestion is to make PPE sessions necessary by coordinating them with pre-op labs, MRSA swabs, and/or handing out of antiseptic soaps (35).
It is my opinion that attending an educational session preoperatively should be mandatory, especially for more significant surgical procedures. If a patient isn’t involved enough in the surgical process to attend a PE session, how active and involved will they be postoperatively when it comes to attending physical therapy and follow-up appointments, following precautions/ contraindications, or with other necessary self-care. Surgeons and healthcare systems alike are rated on their outcomes and more and more this is being tied directly to financial compensation. There are many surgeons who won’t operate on a patient if they are a smoker or if they are too overweight/obese. For something as simple as a couple hour time commitment, it’s perfectly reasonable to make attendance mandatory.
Another logistical consideration is the course of clinical care both pre and postoperatively. This must work in concert with the goals of PE. There are typically standardized order sets that are widely used in hospitals to direct post-op treatment. For example, patients having a knee replacement often follow a very similar clinical pathway after surgery.
If one of the goals is reduced medical utilization and reduced hospital length of stay, then hospitals should have practices in place to facilitate sooner discharge when appropriate. This means instead of time-based discharge criteria, utilizing specific objective outcomes to determine appropriateness for discharge. This also means initiating discharge planning early preoperatively. This includes preparation of the patient’s home environment for return from the hospital and establishing appropriate social supports via family or friends. On a grander scale, this may mean adjustments to insurance companies qualifications and coverage for surgeries, hospital stays, inpatient rehab (when appropriate), and outpatient services.
Where Does this Leave Us?
There are certainly still many logistical considerations and difficulties when it comes to implementing preoperative patient education, especially when trying to address multiple considerations. A specific difficulty is that in most cases healthcare professionals’ time is already being thinly spread between multiple tasks and duties. Plus, financial resources must be divided among multiple needs. When trying to maximize effectiveness and efficiency, it’s imperative that pre-op patient education is worth the time and financial investment. The current research does not definitively prove this, but by synthesizing the literature, we can at least hypothesize a number of best practices.
The saying goes “if you’re going to do something, do it well.” When hospital systems create and implement preoperative patient education it’s a disservice to themselves if they only utilize clinical experience and what intuitively makes sense. It’s extremely important to assess the literature to better inform clinical strategies and techniques. It’s also important to consider preoperative education within the bigger picture of hospital systems and clinical pathways. In this way, financial resources aren’t wasted on something that “just seems good to do,” and instead, resources are utilized efficiently and optimally.
Via Dr. Luke Pederson, DPT
References
References
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