Effect of Preadmission Brochures on Surgical Patients' Behavioral Outcomes

Effect of Preadmission Brochures on Surgical Patients’ Behavioral Outcomes

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ost-cutting efforts in today’s health care envi- deep breathing, and leg exercises.? Previous studies ronment have resulted in shorter stays and a have documented the importance of this nursing interdramatic increase in ambulatory and same day vention in preventing severe postoperative pulmonary admission surgical procedures. The amount of complications associated with anesthesia and surgery.3 time available for nurses to give patients pre- Our study focused on patients admitted the morning of operative instruction is limited, and patients’ anxiety surgery. Nurses surveyed about perioperative research the morning of surgery may interfere with learning. It priorities rated preoperative assessment and education is crucial that patients learn skills to prevent perioper- of ambulatory and morning admission surgical ative complications and promote recovery and that patients 18th out of 70 topics? This study expanded previous research studies5 by patients and their family members assume more sampling morning admission surgical patients, responsibility for preoperative and postoperative care. measuring performance of exerNurses, therefore. should continue cises postoperatively and functo develop and test perioperative tional status after discharge, teaching interventions that are fea- A B S T R A C T reporting the readability of the sible and cost-effective and that This study tested the effects meet the demands of the current of preadmission teaching instruction booklets, and environment. brochures on morning admission e x a m i n i n g participation of patients’ family members and This study tested the effects surgical patients‘ performance of of a preadmission teaching specific postoperative exercises, friends. brochure that contained specific teaching time, state anxiety, postoperative exercises ( e g , length of hospital stay, patient HYPOTHESES W e h a d several research coughing, d e e p breathing, leg satisfaction, and return to funcexercises, getting out of bed). We tional status. The study partici- hypotheses. Hypothesis 1: Participants in the evaluated preoperative and post- pants were 38 women undergoexperimental group will score operative teaching time, state anx- ing abdominal hysterectomies. higher than those in the control iety, length of hospital s t a y , Although the study results show patient satisfaction, and return to no significant difference group on the exercise performance checklist (EPC) adminfunctional status among morning between those who received the admission surgical patients. preoperative teaching brochures istered preoperatively. Hypothesis 2: Participants in the T h i s study addressed a n and those who did not, the experimental group will score important preoperative nursing implications for further research higher than those in the control intervention ( i e , preoperative are clearly defined. Preoperative group on the EPC administered teaching) that has been shown to nursing interventions that may postoperatively. promote recovery and prevent help patients undergoing hysHypothesis 3: Participants in the complications in surgical patients.’ terectomies manage anxiety and experimental group will require The most frequently studied aspect return to function should be testless preoperative and postoperof nurses’ preoperative teaching is ed further. AORN J 60 (August instruction related to coughing, 1994) 232-241. ative teaching time.

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Hypothesis 4: Participants in the experimental household, social, community, and occupational group will have shorter hospital stays than those in activities performed before surgery) was measured by the revised Inventory of Functional Status after the control group. Hypothesis 5: Participants in the experimental Childbirth.” Patient satisfaction. This included patients’ pergroup will score higher on the inventory of funcceptions and opinions of treatments received, the fashtional status postdischarge form. Hypothesis 6: Participants in the experimental ion in which the treatments were administered, and group will have lower state anxiety scores than the results of the treatments as measured on the patient satisfaction instrument (PSI).12 those in the control group. Involvement of family members or fn‘ends with Hypothesis 7: Participants in the experimental group will score higher on the patient satisfaction preadmission instructions interview form. This instrument measured the extent of participation of instrument than those in the control group. Hypothesis 8: There will be a positive relationship patients’ family members and friends in preadmission between reported involvement of patients’ family instructions as reported by the patients. members and friends with the experimental patients’ VARIABLES admission exercise performance and EPC scores. The independent variable was the specific exercises included in the instruction booklet. Dependent DEFlNmONS The explanations and definitions of certain terms variables were exercise performance, and instruments used in this study are described teaching time, below. state anxiety, Preadmission teaching brochure. We used a recovery of functional status, teaching booklet, developed by Virginia Rice, RN, patient satisfaction, and PhD, that illustrated specific exercises (ie, coughing, involvement of family members or friends with deep breathing, toe pointing, toe circles, leg bends, preadmission instruction. turning in bed, getting up).6 A sixth-grade level reading ability was required to comprehend the booklet as determined by standard readability f o r m ~ l a e . ~ LITERATURE REVIEW Orienting instruction booklet. This general Meta-analyses of the literature have found supinformation booklet explained what patients should port for positive effects of psychological intervention” bring with them to the hospital, what to leave at and psychoeducational intervention on recovery from home, dietary and fluid restrictions, visiting hours, surgery, including clinical and cost-saving effects (eg, and where to park. A 17th-grade (ie, first year of decreased length of hospital stay; decreased medical graduate school) level reading ability was required to complications such as atelectasis; increased productive comprehend the booklet as determined by standard activities after discharge).14 Researchers caution, howreadability formulae.* ever, that the positive effects are “average” and that Exercise performance. This measured patients’ there is still room for improvement.15 demonstration or practice of specific exercises (ie, Patients who receive preoperative instructions coughing, deep breathing, toe pointing, toe circles, have more positive outcomes (eg, less pain, less anxileg bends, turning in bed, getting up) as measured on ety) than those who do not,16 although findings have the EPCY not been ~ 0 n s i s t e n t . lIn~ one study, patients who Teaching time. This was defined as the amount received structured rather than unstructured preoperaof time spent by the research nurse with the patients tive teaching had shorter hospital stays and were betuntil they demonstrated mastery of the exercises. ter able to perform deep breathing and coughing exerState anxiety. State anxiety is a transitory state or cises after surgery.’* Those findings, however, could condition in which a person’s perceived feelings of not be replicated in a later study.19 tension may v a q . State anxiety was measured by the In another study, researchers mailed preadmission State-Trait Anxiety Inventory (STAI), a self-evalua- instruction booklets with specific or nonspecific deep tion questionnaire.In breathing, coughing, and exercise information to 130 Recovery of functional status fie, mobility). surgical patients preoperatively.2nPatients who received This aspect of recovery (ie, resumption of common specific instruction booklets required less total teaching 233 AORN JOURNAL

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Table 1 preoperative instruction has a positive effect on postoperative ambulation activities and postdischarge selfcare activities.24Results of studies regarding the effect Demographic Percent (n = 38) of preoperative teaching on patient satisfaction are inconsistent.25 €thn/cily Including family members in patients’ preoperaAnglo 44 8 tive education is recognized as important and should Black 28 9 be systematically studied.’6 Preadmission may be the best time to include family members because patients Hispanic 26 talk more with their family members about the surgi10 5 Asian cal experience before admi~sion.?~ Studies show that Native American 79 patients are more satisfied with their care and have decreased lengths of stay when family members parOther 50 ticipate in preoperative instruction.2x Mar/t0lstatus We found little information on the preoperative Married, living with significant other 58 0 care provided to women undergoing hysterectomies, yet hysterectomies are among the most commonly Divorced, widowed, separated 42 0 performed procedures. More than 500,000 hysterecFom//y tomies were performed in the United States in 1990.29 Children 79 0 Many hysterectomy patients now are admitted on the day of ~urgery.’~) We found one study that tested the Children less than 18 years living at home 42 0 effects of a preadmission teaching booklet for hysChildren less than 5 years living at home 1 1 0 terectomy patients on patients’ ability to cope with anxiety.” Education In our multicultural society, the reading levels of 38 0 College graduate, graduate student patient education materials need to be addressed. Some high school, completed high Twenty percent of adults and 50% of public hospital 62 0 school, attended technical school or clinic patients in the United States have difficulty reading or are unable to read mateiials written at the income fifth-grade level.i2 The majority of patient education 50 0 Income more than $40,00O/year materials are written at a level greater than the eighth 50 0 Income $40,00O/year or less grade. Patient education materials need to be written at levels that allow patients to comprehend the content.’3 Employment Few studies of preoperative teaching literature Working outside the home 69 0 have addressed constraints and cost concerns with teaching mornFull-time worker 56 0 ing admission surgical patients, Miscelianeous readability of educational materials, or Private insurance 83 0 patients’ performance of coughing and deep breathPrevious surgeries 83 0 ing exercises in the postanesthesia care unit (PACU). Cost and cost-effectiveness are priorities of most rerearch on preoperative teaching.;? Studies indicate time and performed more deep breathing, coughing, leg that using preoperative education booklets decreases exercises, and ambulatory activities than those who teaching time and promotes cost savings.75 received the nonspecific instruction booklet. These findings were replicated in a study of 50 patients undergoing CONCEPNAL FRAMEWORK We based the theoretical framework for our study elective coronary artery bypass graft procedures.” Preoperative teaching has been associated with on the Stress, Appraisal, and Coping model developed reduced preoperative anxiety’? and shorter shut-in by Richard S. Lazarus, PhD, and Susan Folkman, times (ie, time before patients feel ready to venture PhD.x6The model allows the conceptualization of an from home after discharge).?’ Research indicates that individual’s coping response through behaviors (eg, DEMOGRAPHIC CHARACTERISTICS OF STUDY PARTICIPANTS

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exercise) to a stressful situation such as surgery. In this model, individuals evaluate the implications of a new stressful event on their well-being; weigh resources such as health-related information for coping with the stress; and may alter their original perceptions and solicit an appropriate coping strategy. METHODOLOGY

We chose a quasi-experimental design for our study. We conducted the study at a 235-bed, nonprofit medical center serving a multicultural population in the east San Francisco Bay area. The average daily census was 188. Fifteen percent of the patients were covered by Medi-Cal, and 50% were covered by Medicare. The other 35% had private insurance, paid privately, or received charity care. Approximately 370 surgical procedures were performed each month. Half of the surgical patients were admitted on the day of their scheduled surgeries. Sample description. A convenience sample of 38 women who were scheduled for abdominal hysterectomies were recruited to participate in the study. The women’s ages ranged from 29 to 74 years (mean = 54, standard deviation [SD] = 9.13). Additional demographics of the participants are shown in Table 1. A series of chi-square tests of association were run on the experimental group versus the control group to determine the homogeneity of the sample. None of the chi-square tests were significant at the p < .05 level of significance. We concluded, therefore, that the sample was homogeneous. Fifty-three percent of the women received preoperative narcotics. The mean anesthesia time for these patients was 2.3 hours (SD = 1.0) Eighty-three percent of the women had general anesthesia, 71% received narcotics during surgery, and 55% received muscle relaxants during surgery. Seventy-nine percent of the women had total abdominal hysterectomies with or without bilateral salpingoophorectomies. The mean length of stay was 3.93 days (SD = 1SO). Twenty-three percent reported at least one postoperative complication such as urinary tract infection, delayed return of bowel function, and/or wound infection. Fifty-eight percent reported transient episodes of elevated temperature postoperatively. We found no statistical differences between the experimental group and the control group for any of these variables. Data collection procedure. We randomly assigned the 38 participants to the experimental group (n = 18) or the control group (n = 20). To be eligible for inclusion in the study, women had to

be between 21 and 75 years of age, read and understand English, not be employees or members of the nursing or medical professions, be available by telephone and mail 10 days before surgery, have had no hospitalizations for major medical problems within the previous year, have no other major health problems (eg, preexisting pulmonary or cardiac disease, impaired mobility), be free of respiratory infection at the time of surgery, have no history of allergic respiratory reactions to medications, and have no history of hospitalization for psychiatric disorders. Approximately two weeks before scheduled abdominal hysterectomy procedures, a research nurse obtained patients’ names, surgeons’ names, and surgery dates from the surgery scheduling computer. The research nurse obtained permission from the surgeons to contact each patient regarding participation in the study. The research nurse then telephoned each patient to inform her about the study and ascertain her willingness to participate. The research nurse screened interested patients for eligibility using the preadmission intake eligibility telephone screen guidelines, which we had developed. The researcher obtained the patients’ verbal permissions to send instructional materials to them before hospitalization. The nurse encouraged the participants to follow the instructions carefully and told them that a research nurse would visit them when they were admitted for surgery. Using the flip of a coin, we randomly assigned participants to either the experimental group or the control group. Each participant received a cover letter and an orienting instruction booklet approximately 10 days before admission. Participants in the expenmental group also received a preadmission teaching brochure containing specific exercise instructions. On the days of their scheduled surgeries, patients met individually with one of the research nurses who explained the study, reviewed criteria for inclusion in the study, and asked them to read and sign consent forms approved by the institution’s review board. The participants completed the demographic questionnaire and the STAI and responded to questions about the involvement of family members or friends. The research nurse asked the patients to demonstrate the

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Table 2 INSTRUMENTS

Instrument

Description

VolidityReliability measures

Exercise performance checklistfleaching time scale

34-item observation tool that measures performance of deep breathing, coughing, toe pointing, toe circles, leg bends, turning in bed, and getting up; teaching time is measured'

Content validity Face validity2

Patient satisfaction instrument

25-item Likert-type scale developed from 5 clinical and administrative studies with a total of 600 patients; 3 subscales of patient satisfaction are measured (ie, technical-professional care, trust, patient education)

Reliability (ie, internal consistency) Face validity3

State Trait Anxiety Inventory

40-item questionnaire that uses a 4-point Likert-type rating scale to measure the state of anxiety and the tendency or trait4

Reliability Construct, concurrent, convergent, and divergent validity

Inventory of functional status

Revision of a 45-item semi-structured questionnaire that gives informationabout return to household, social, community, and occupational activities5

Content and construct validity Interrater, testhetest, and internal consistency reliability6

NOTES 1 . V H Rice, J E Johnson, "Preadmission self-instruction booklets, postadmission exercise performance, and teaching time," Nursing Research 33 (May/June 1984) 147-151 2. V H Rice, M H Mullin, P Jarosz, 'Preadmission self-instruction effects on postadmission and postoperative indicators in CABG patients: Partial replication and extension," Research in Nursing & Hea/th 15 (August 1992) 253-259, 3. A S Hinshaw, J R Atwood, "A patient satisfaction instrument: Precision by replication," Nursing Research 31 (May/June 1982) 170-191. 4. C Spielberger, Manual for the Stote-TraitAnxiety inventory (Palo Alto, Calif: Consulting Psychologists Press, 1983). 5 L Tulman, J Fawcett, "Return of functional ability after childbirth," Nursing Research 37 (March/April 1988) 77-81; J Fawcett, L Tulman, S Taylor-Myers, "Development of the inventory of functional status after childbirth," Journal of Nurse Midwifery 33 (NovembedDecember 1988) 252-260. 6. /bid.

EPC exercises preoperatively. The researcher noted the amount of time it took each patient to master the exercises. Postoperatively, when patients were awake and/or the spinal anesthesia was no longer in effect, one of the nurse researchers asked them to perform the EPC exercises again while in the PACU. Patients were not asked to ambulate in the PACU. Before discharge. the research nurse reminded the participants to complete and return the patient satisfaction instrument and the inventory of functional status, which would be mailed to them at home one month later. The research nurse called participants five weeks after discharge if they had not yet returned their questionnaires.

INSTRUMENTS

The instruments used are described in Table 2. We collected additional data on the five following forms. These forms were developed by the researchers, and validity and reliability were not determined. Patient short data form. This 42-item patient record abstraction form provides information about demographics, lengths of hospital stay, secondary diagnoses, types of anesthesia, surgical procedures, previous surgeries, preoperative and intraoperative medications, and complications of surgery. Preadmission intakeleligibility telephone screening guidelines. We used this 10-item guideline to determine patients' eligibility for this study. Admission eligibility screening form. We used 236

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this six-item checklist for screening and doublechecking eligibility of patients for this study and for data collection. The research nurse completed this form when the patients were admitted to the hospital. Demographic questionnaire. This 1 1-item checklist was used to identify age, ethnicity, marital status, number of children, ages of children living at home, education, income, occupation, and employment status. Involvement of family or friends with preadmission instructions interview form. The tool measured the extent of reported participation of family members or friends in the patients’ preadmission instructions as measured by responses to the following questions. Did a family member or friend read the preadmission instructions before the patient’s admission to the hospital? Did a family member or friend remind the patient to read the preadmission instructions before the patient’s admission to the hospital? Did a family member or friend physically help the patient carry out the preadmission instructions before the patient’s admission to the hospital? FINDINGS

We performed a series of independent group t tests to test the null form of the hypotheses posed in this study. The level of significance was preset at p < .05. We encountered difficulties using the EPC with the first 10 participants. The first three hypotheses, therefore, were tested with only 28 participants. Hypothesis 1 . Analysis was performed on 12 experimental patients and 16 control patients for a total sample of 28. The null form of the hypothesis was rejected (n = 28, t = 0.57, degrees of freedom [DF] = 26, p < 3 3 ) . No significant difference was found on the preoperative scores on the EPC between the experimental group receiving the booklet and the control group, which did not receive the booklet. Hypothesis 2. The null form of the hypothesis was rejected (n = 28, t = -0.38, DF = 26, p < .70). No significant difference was found on postoperative scores on the EPC between the experimental group receiving the booklet and the control group. Hypothesis 3. The null form of the hypothesis was rejected (n = 28, t = 1.1, DF = 26, p < .28). We found no significant difference in teaching time between the experimental and control groups. Hypothesis 4. The null form of the hypothesis was rejected (n = 38, t = 1.3, DF = 36, p < .2). No significant difference in length of stay was found

between the experimental and control groups. Hypothesis 5. The null form of the hypothesis was rejected (n = 38, t = 1.03, DF = 36, p < .31). We found no significant difference in scores on the inventory of functional status between the experimental and control groups. Hypothesis 6. The null form of the hypothesis was rejected (n = 38, t = 0.54, DF = 36, p < S9). We found no significant difference on anxiety scores between the experimental and control groups. Hypothesis 7. The null form of the hypothesis was rejected (n = 36, t = 1.42, DF = 34, p < .16). (Two patients in the experimental group did not return the PSI.) No significantdifference was found on satisfaction scores between the experimental and control groups. Hypothesis 8. We did not analyze the data on the relationship between family members’ involvement and the patients’ exercise performance and EPC scores. Only eight patients reported family member or friend involvement. DISCUSSION

This study did not support the use of preadmission teaching booklets containing specific exercises for women scheduled for abdominal hysterectomies. Numerous factors (eg, high reading level of subjects) may have contributed to the lack of supportive findings. The study did support previous findings that postadmission teaching time does not differ significantly between the specific and nonspecific exercise teaching groups. Although studies have revealed less anxiety in patients receiving preoperative instruction, findings are inconsistent. One study revealed that surgical patients demonstrating a moderate level of preoperative anxiety, as measured on the STAI, did not have a significant change in anxiety after teaching.37In addition, patients may prefer to receive preoperative psychological support rather than skills training and may prefer preoperative instruction after admission rather than before a d m i s ~ i o nThis . ~ ~ presents a major challenge because most patients who undergo abdominal hysterectomies are admitted on the day of surgery, and teaching time is limited. There most likely were other intervening conditions (eg, fear of surgery and anesthesia, issues of body image and sexuality) that affected the women’s anxiety levels, satisfaction, and return to function. The STAI, the patient satisfaction instrument, and the inventory of functional status may not be discriminating enough to measure differences between the experimental and control groups. In

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addition, 83% of the women had undergone previous surgeries and may have learned coughing and deep breathing exercises before this study. In a review of literature on the effects of interventions on postoperative outcomes of elective surgery. researchers noted that only four studies included interventions carried out by hospital staff nurses rather than by researchers.’’ Only one of these studies had results in the predicted direction. Those authors questioned whether comprehensive interventions added to the already heavy workload of staff nurses can have the same effect on patient outcomes as interventions carried out by researchers.

cems with morning admissions and what they find is needed to help them return to functional status after discharge. Preoperative nursing interventions that may help patients undergoing hysterectomies manage anxiety and return to function should be tested further. Additional studies are needed to determine effective interventions for increasing family members’ and friends’ involvement with preoperative patient preparation. A

LIMITATIONS

Carolina P. de Guman, RN, BSN, CCRN, CPAN, is a clinical stafs nurse level IV at Summit Medical Center, Oakland. Calif.

The study was limited by a small convenience sample of 38 patients at one medical center on the west coast. A larger sample was not possible because ofdifficulty securing eligible patients, merging and reorganization of the medical center. and the fact that two of the investigators were no longer employed at the medical center. This study also was limited because we did not exclude patients taking antianxiety medications or those who had been diagnosed with cancer. IMPLICATIONS FOR RlRllluI RESEARCH

Further studies are needed regarding the delivery of preoperative care to morning admission patients. Qualitative studies are needed to describe patients’ conNOTES I . J E Johnson, “Coping with elective surgery,” in Annual Review ofNursing Research. fourth ed, H H Werley. J J Fitzpatrick. eds (New York City: Springer Publishing Co, Inc, 1984) 107-132; E C Devine, T D Cook, “A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay,” Nursing Research 32 (September/October 1983) 267-274; E C Devine, T D Cook, “Clinical and cost-saving effects of psychoeducational interventions with surgical patients: A meta-analysis,” Research in Nursing and Health 9 (June 1986) 89-105: D Hathaway, “Effect of preoperative instruction on postoperative outcomes: A meta-analysis,” Nursing Researc.h 35 (SeptembedOctober 1986) 269-275: J C Rothmck, “Perioperative nursing research. part I:

Roberta Young, RN, MSN, is a quality assessment1 improvement analyst at Kaiser Medical Center, Oakland, Gal$ She also is a facrdty member at the University of Phoeiiis*Northern California campus.

Mary S. Matis, RN, is a nurse care manager at the Visrtrng Nirrse Association of Northern California, Emer-yville. Kate McClure, RN, MS, CCRN, is a senior lecturer in the Department ($Nursing, Samuel Merritt College, Oakland, Calf. This research study was supported by a grant from the AORN Nursing Research Committee. The authors acknonlledge Jan Swanson, RN, PhD,faculty member, Samuel Merritt College, Oakland, Calif, and Marianne Zalar, RN, EdD,for serving as consultants on this study.

Research in Nursing and Health 15 Preoperative psychoeducational (August 1992) 253-259. interventions,” AORN Journal 49 6. Rice, Johnson, “Preadmission (February 1989) 597-619. 2. Johnson, “Coping with elective self-instruction booklets, postadmission exercise performance, and teachsurgery,” 107-132. ing time,” 147-151. 3. N L Risser, “Preoperative and 7. N D Hardy, M E Jeman, postoperative care to prevent pulmonary complications,”Heart & Lung Reading Level Analysis Ver 3.3 (Seattle: Berta-Max, Inc). 9 (JanuaryFebruary 1980) 57-67. 8. Ibid. 4. L Marchette, D R Faulconer, 9. Rice, Johnson, “Preadmission “Penoperative nursing research: A self-instruction booklets, postadmisstudy of priorities,’’AORN Journal sion exercise performance, and teach44 (September 1986) 387-394. 5. V H Rice, J E Johnson, “Pread- ing time,” 147-151. 10. C Spielberger, Manualfor the mission self-instruction booklets, postadmission exercise performance, State-Trait Anxiety Inventory (Palo Alto, Calif Consulting Psychologists and teaching time,” Nursing Press, 1983). Research 33 (May/June 1984) 1471I. L Tulrnan, J Fawcett, “Return 151;VHRice,MHMullin,P Jarosz, “Preadmission self-instruction of functional ability after childbirth,” Nursing Research 37 (March/April effects on postadmission and postop 1988) 77-8 1. erative indicators in CABG patients: 12. A S Hinshaw, J R Atwood, “A Partial replication and extension,”

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patient satisfaction instrument: Preci$ion by replication,”Nursing Research 31 (MayiJune 1982) 170-191. 13. E Mumford, H J Schlesinger, G V Glass, “The effect of psychological intervention on recovery from surgery and heart attacks: An analysis of the literature,” American Journal of Public Health 72 (February 1982) 141-151. 14. Devine, Cook, “A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay,” 267-274; Devine, Cook, “Clinical and costsaving effects of psychoeducational interventions with surgical patients: A meta-analysis,” 89-105. 15. Devine, Cook, “Clinical and cost-saving effects of psychoeducational interventions with surgical patients: A meta-analysis,” 89-105. 16. Ibid, Hathaway, “Effect of preoperative instruction on postoperative outcomes: A meta-analysis,” 269275; Rothrock, “Perioperativenursing research, part I: Preoperative psychoeducational interventions,”597-619. 17. Johnson, “Coping with elective surgery,” 107-132; V Canieri, “Effect of an experimental teaching program on postoperative ventilatory capacity,” in CommunicatingNursing Research: Critical Issues in Access f o Data, ed M V Batey (Boulder, Colo: Westem Interstate Commission for Higher Education, 1975) 121; I King, B Tarsitano, “The effect of structured and unstructured preoperative teaching: A replication,” Nursing Research 3 1 (November/ December 1982) 324-329. 18. B Van Aemam, C A Lindeman, “Nursing intervention with the presurgical patient-the effects of structured and unstructured preoperative teaching,” Nursing Research 20 (July/August, 1971) 319-332. 19. V Archuleta, 0 B Plummer, K D Hopkins, A Demonstration Model Patient Education: A Model for the Project “TrainingNurses to Improve Putienf Education” (Boulder, Colo: Western Interstate Commission for Higher Education, 1977). 20. Rice, Johnson, “Preadmission

self-instruction booklets, postadmission exercise performance, and teaching time,” 147-151. 21. Rice, Mullin, Jarosz, “Preadmission self-instructioneffects on postadmission and postoperative indicators in CABG patients: Partial replication and extension,” 253-259. 22. Rothrock, “Perioperative nursing research, part I: Preoperative psychoeducational interventions,” 597619; L E Graham, E M Conley, “Evaluation of anxiety and fear in adult surgical patients,” Nursing Research 20 (MarcWApril1971) 113-122; D Orr, “Preoperative teaching: Reducing presurgical anxiety,” Canadian Operating Room Nursing Journal 4 (February 1986) 29-31; C Shimko, “The effect of preoperative instruction on state anxiety,” Journal of Neurosurgical Nursing 13 (December 1981) 318-322. 23. F Fortin, S Kirouac, “A randomized controlled trial of preoperative patient education,” International Journal of Nursing Studies 13 no 1 (1976) 11-24; J E Johnson et al, “Sensory information, instruction in a coping strategy, and recovery from surgery,” Research in Nursing and Health 1 (April 1978) 4-17; B J Hill, “Sensory information, behavioral instructions and coping with sensory alteration surgery,”Nursing Research 31 (Januarypebruary 1982) 17-21. 24. P D Williams et al, “Effects of preparation for mastectomyhysterectomy on women’s postoperative selfcare behaviors,” International Journal of Nursing Studies 25 (March 1988) 191-206. 25. J Wong, S Wong, “A randomized controlled trial of a new approach to preoperative teaching and patient compliance,” International Journal of Nursing Studies 22 (February 1985) 105-115. 26. Rothrock, “Penoperativenursing research,part I: Preoperative psychoeducational interventions,”597-619. 27. M C Silva et al, “Caring for those who wait,” Today’s OR Nurse 6 (June 1984) 26-30. 28. Wong, Wong, “A randomized controlled trial of a new approach to

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preoperative teaching and patient compliance,” 105-115; M M Dziurbejko, J C Larkin, “Including the family in preoperative teaching,” American Journal of Nursing 78 (November 1978) 1892-1894. 29. National Center for Health Statistics, Health, United States, 1991, pub1 no 9288-1232 (Washington DC: US Government Printing Office, 1992). 30. J Llewellyn et al, “Postoperative complications in same day admission surgery,” Quality Review Bulletin 15 (February 1989) 49-53. 31. L Young, M Humphrey, “Cognitive methods of preparing women for hysterectomy:Does a booklet help?’British Journal of Clinical Psychology 24 (November 1985) 303-304. 32. L G Doak, C C Doak, “Patient comprehension profiles: Recent findings and strategies,” Patient Counseling and Health Education 2 (Third Quarter 1980) 101-106. 33. L D Streiff, “Can clients understand our instructions?” IMAGE: Journal of Nursing Scholar.ship 18 (Summer 1986) 48-52. 34. Rothrock, “Perioperativenursing research,part I: Preoperative psychoeducational interventions,” 597-619. 35. [bid; Young, Humphrey, “Cognitive methods of preparing women for hysterectomy: Does a booklet help?” 303-304. 36. R S Lazarus, S Folkman, Stress, Appraisal, and Coping (New York City: Springer Publishing Co, Inc, 1984). 37. M Lepczyk, E H Raleigh, C Rowley, “Timing of preoperative patient teaching,” Journal of Advanced Nursing 15 (March 1990) 300-306. 38. S Yount, Y M Schoessler, “A description of patient and nurse perceptions of preoperative teaching,” Journal of Post Anesthesia Nursing 6 (February 1991) 17-25. 39. E Devine et al, “Clinical and financial effects of psychoeducational care provided by staff nurses to adult surgical patients in the postDRG environment,”American Journal of Public Health 78 (October 1988) 1293-1297.