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Patient education in orthopaedic nursing
O R I G I N A L
A R T I C L E
Patient education in orthopaedic nursing Kirsi Johansson, Sanna Salantera¨, Jouko Katajisto and Helena Leino-Kilpi The objectives of this study were to describe (1) how the content, structure and educational solutions of orthopaedic patient education were perceived by patients and nurses; (2) what patients knew about their care; and (3) how nurses evaluated their educational skills. The sample consisted of 146 orthopaedic patients (response rate 81%) and 56 nurses (response rate 67%) on three orthopaedic wards in a Finnish university hospital in 2001. Data were collected using two parallel, purpose-designed, mainly structured questionnaires. The bio-physiological and functional aspects of patient education were found to be dealt with most adequately, while experiential, ethical and financial issues received least attention. Personal discussions, written material and demonstration/practice, were the most commonly used educational methods, while videos and PCs were seldom used. Patients’ knowledge about their care was quite sufficient, but in matters concerning unwanted effects of treatment and potential problems it was inadequate. According to nurses’ self-assessments, their educational skills were best in the area of mastering the content and poorest in that of using different educational methods.The results indicated that both the content and methods of orthopaedic patient education should be developed. c 2002 Elsevier Science Ltd. All rights reserved.
Editor’s comment The effectiveness of patient education and the orthopaedic nurse’s ability to deliver it has often been described but rarely investigated. This study begins to address the lack of evidence with an insightful and productive research project. As an editor I was particularly surprised by the findings that; ‘patient education practices were found to be based most often (78%) on work experience and next on current ward practice (62%), while no role was played here by data from foreign scientific journals (39%) and databases (36%).’ PD
KEY WORDS: patient education, orthopaedic patients, orthopaedic nurses
INTRODUCTION AND LITERATURE REVIEW Kirsi Johansson MNSc, RN Doctoral student Sanna Salantera¨ PhD, RN Assistant professor Jouko Katajisto MSocSci Statistician Helena Leino-Kilpi PhD, RN Professor Correspondence to: Kirsi Johansson Department of Nursing, University of Turku, FIN-20014 Turku, Finland. Tel.: +358-40-082-2311; Fax: +358-2-333-8400; E-mail: [email protected]
The number of orthopaedic operations has increased in Finland: from 1993 to 1995 it increased by approximately 4500 operations, totalling about 101 700 operations in 1995 (Paavolainen et al. 1997, Rasilainen et al. 1997), and is projected to rise further in the future as modern surgical methods allow more operations to be performed and an increasing number of elderly patients are being treated (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997). Arthroplastic operations alone will increase by 10–15% annually (Paavolainen et al.
Journal of Orthopaedic Nursing (2002) 6, 220–226 ª 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1361-3111(02)00094-8
1994). In addition, hospital stays have shortened (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997). In view of these considerations, effective patient education is particularly important (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997) and research and further development efforts in this area seem worthwhile (Santavirta et al. 1994). There is a wide variety of benefits from patient education, ranging from reduced anxiety and fear (Gammon & Mulholland 1996a) an increased knowledge about care and rehabilitation (Lin et al. 1997) an improved ability to cope with the health problem and to participate in self-care (Pellino et al. 1998). Lessened post-operative pain
Patient education in orthopaedic nursing 221
(Gammon & Mulholland 1996b, Lilja et al. 1998) and better recoveries have also been reported (Gammon & Mulholland 1996b). When the objective is patient empowerment, patient education can be perceived as a method that emphasizes the patientÕs ability to manage their health problems (Leino-Kilpi et al. 1998). It is possible to place emphasis on patient empowerment when the individualÕs ability to learn is known. Patients do not only receive information and their prior knowledge, experiences and motivation affects learning (Lehtinen et al. 1995). It has been shown that patients can evaluate their own learning needs and anticipate what information they require (Galloway et al. 1995, Galloway & Graydon 1996, Johansson et al. 2002). Patients have also been found not to receive as much information as they feel they need (Showalter et al. 2000). Montin et al. (2002) have pointed out that the orthopaedic patientsÕ own resources should be better taken into account when planning their care. The content of patient education is in part governed by legislation in Finland: patients have the right to know about their health status and goals, alternatives and effects of their treatment as well as issues concerning their care (Act on the Status and Rights of Patients 785/1992). Empowering patients through education can be divided into the following areas: bio-physiological (identification of the symptoms and signs), functional (activities of daily living, illness and care), cognitive (receiving enough information and the ability to utilise it), social (experience of belonging to and support from the social network), experiential (feeling of appreciation with regard to oneÕs experiences, expectations and feelings), ethical (feeling of appreciation as a unique, autonomous individual) and financial (Leino-Kilpi et al. 1998, 1999). Orthopaedic patient education especially includes information about possible complications, physical limitations, exercise, rehabilitation and financial matters (Fisher et al. 1997, Johansson et al. 2002, Pearce et al. 1991), while information about medication (Bostrom et al. 1994) and pain relief also usually play an important role (Boyle et al. 1992, Showalter et al. 2000). The structure of patient education and the educational solutions used generally vary from planned teaching programmes to random question-and-answer sessions and from personal and group counselling to seeking of information independently by patients (Theis & Johnson 1995). In orthopaedic nursing there has been little broad-based research on the structure and educational solutions, although there have been many studies of single applied educational methods or programs (Lilja et al. 1998, Lin et al. 1997, Santavirta et al. 1994) Usually patient education can be seen as, consisting of the following phases: planning
(assessing patientsÕ learning needs and preferences, setting learning objectives), implementation (methods, place, timing) and evaluation of the outcome (Leino-Kilpi et al. 1998). In empowermental education, the educational structure and methods are based on a patient-centered approach and patient participation is seen as important (Pellino et al. 1998, Poskiparta et al. 2001).There is, however, little research evidence of participation by patients in the planning of patient education, especially in the assessment of learning needs and setting of objectives for learning (Latter et al. 2000). There is an evident need to study and further develop orthopaedic patient education. The further development of patient education to empower them within their current life and health situation and to be able to provide information at the right time and in the right way has been stated as one of the objectives in developing nursing practice in Finland (Per€ al€ a 1998). The purpose of the present study was to research current orthopaedic patient education from both patientsÕ and nursesÕ perspectives by determining its content, structure and educational solutions used and by assessing patientsÕ knowledge about their care and nursesÕ educational skills. The ultimate goal is to develop orthopaedic patient education so as to make it more empowering through supporting the patientsÕ own participation and decision-making in their care and to enhance the process of empowerment.
RESEARCH QUESTIONS The following research questions were addressed: 1. How do orthopaedic patients and nurses perceive the content and the structure and educational solutions (including assessment of learning needs and preferences, setting of learning objectives, use of educational methods and evaluation of learning outcomes) in current patient education? 2. What do orthopaedic patients know about their care? 3. How do orthopaedic nurses evaluate their educational skills?
MATERIAL AND METHODS The data were collected using two parallel, purpose-designed, mainly structured questionnaires, one for patients and the other for nurses. The questionnaires were based on a literature review and views of an expert panel consisting of two university-based researchers (PhD), two polytechnic nurse educators (LicNSc), and three hospital directors of nursing (PhD, MPolSci).
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The questionnaires were tested using pilot data on 35 patients and 30 nurses. The subjects for this descriptive study were orthopaedic patients ðn ¼ 146Þ and nurses ðn ¼ 56Þ. The data were collected from three orthopaedic wards of one of the university hospitals in Finland (which total five) over a period of five weeks in the spring of 2001. The response rate for patients per ward ranged from 66% to 93%, averaging 81% and that for nurses from 54% to 100%, averaging 67%. The patientsÕ questionnaire was designed for Finnish-speaking post-operative patients aged 18 and over who had undergone orthopaedic surgery and were able to understand the questions and complete the questionnaire. Patients on the participating wards were asked by nurses to participate in the study. Those willing filled in the questionnaire by themselves and returned them to mailboxes placed on the wards for his purpose. Nurses were asked to answer and similarly return their questionnaires. Participation in the study was completely voluntary. Research permission was obtained from the hospitalÕs Committee for Medical Research. The basic principles of research ethics (Burns & Grove 1997) were followed at all stages of the study and the data were handled confidentially. The questionnaires included demographic variables and parallel questions concerning the
content, structure and educational solutions of patient education. The questions that were different in the two questionnaires concerned the patientsÕ knowledge about their care and the nursesÕ educational skills. Use was made of yes/ no, four-point (1-4) and five-point (1-5) scales (Table 1). The statistical analyses were carried out using SPSS for Windows (10.0) software. Descriptive statistics (frequencies, percentages, means, standard deviations and range) were used to summarize the demographic data on the patients. PearsonÕs v2 test was used to examine the relationships between the patientsÕ demographic data and individual questions. The sum variables relating to the patient education content were formed based on a former theory (Leino-Kilpi et al. 1998, 1999). Sum variables relating to the patientsÕ knowledge about their care, nursesÕ assessments of their educational skills, basis of the skills and educational practices were also calculated. To obtain parallel sum scores for nurses and patients, the categories ‘‘insufficient information’’ (4) and ‘‘canÕt say’’ (5) of the five-point patient scales were combined; as a result the sum scores for both patients and nurses ranged from 1 to 4. The closer the value comes to 1 the more positive the answer. The differences between the demographic variables concerning sum variables were analysed using the appropriate parametric
Table 1 The questionnaires Questions about
In patients’ questionnaire
In nurses’ questionnaire
Demographic variables 11 items (gender, age, education, elective/emergency) Content of patient 23 items formed into 7 sum education variables: bio-physiological, functional, cognitive, social, experiential, ethical, financial; sufficient information (1) – cannot say (5)
12 items (age, level of training, work experience, working environment) 23 items formed into 7 sum variables: bio-physiological, functional, cognitive, social, experiential, ethical, financial; the area considered with every patient (1) – none of patients (4)
Educational structure and solutions Assessing learning 1 item (opportunity to discuss), needs and 4 items (specific preferences); preferences responses yes/no
5 items (how to assess patient’s learning needs and preferences); every patient (1) – none of patients (4)
Setting of learning objectives
Use of educational methods Evaluation of learning outcome Only for patients Knowledge about care
Only for nurses Patient education skills Basis of patient education skills and practice
4 items (how objectives were asked about); responses yes/no
5 items (how to set objectives) and 4 items (what objectives); every patient (1) – none of patients (4)
21 items; responses yes/no
24 items; every patient (1) – none of patients (4) 8 items (ways of confirming); every patient (1) – none of patients (4)
6 items (ways of confirming); responses yes/no 5 items (examinations, treatments, unwanted treatment effects, problems, further care); sufficient (1) – cannot say (5)
5 items (assessment, objectives, content, methods and evaluation); good (1) – poor (4) 4 items (skills based on) and 6 items (practice based on); very much (1) – not at all (4)
Patient education in orthopaedic nursing 223
tests (t-test, one-way analysis of variance with Tukey or Tamhane tests). By convention 0.05 was accepted as the level of significance (Burns & Grove 1997). CronbachÕs a test was used to assess the reliability of the questionnaires.
RESULTS Demographic data Women accounted for 54% and men for 46% of the patient group; the mean age was 50.8 years (range 18–79, SD ¼ 15:8). About a third (33%) had received primary and lower secondary school education, slightly over a third (34%) had completed secondary school or vocational school, about a quarter (24%) had college-level vocational training and 9% a university degree. Most of the operations were elective, over half involving an orthopaedic problem in the hip, knee or ankle. The length of the hospital stay ranged from 1 to 18 days (M ¼ 4:3 days, SD ¼ 3:9). Most patients (94%) were discharged and 6% were moved to other hospitals for rehabilitation. The nursesÕ mean age was 41 years (range 22–56 years, SD ¼ 9:5). They had worked as nurses on the same ward from 3 months to 32 years (M ¼ 11:8 years, SD ¼ 8:4). They assessed their work as physical very (54%) or quite (46%) stressful.
Content of patient education as perceived by patients and nurses The questions inquiring about the content of education were identical for patients and nurses. The former were also asked to evaluate the sufficiency of the information and the latter asked to indicate how many patients they counsel in each area. The
area dealt with most sufficiently was, according to patients, that of functional issues (M ¼ 1:57), the bio-physiological area ranking second (M ¼ 1:63) and, according to nurses, the bio-physiological area (M ¼ 1:63), followed by the functional area (M ¼ 1:65). In the other content areas a similar pattern was found for patients and nurses: cognitive (patients M ¼ 1:76, nurses M ¼ 2:04), social (M ¼ 1:97 and M ¼ 2:05, respectively), experiential (M ¼ 2:23; M ¼ 2:24), ethical (M ¼ 2:47; M ¼ 2:38) and financial (M ¼ 2:69; M ¼ 2:51) (Table 2). The content of patient education was considered adequate more often by patients with elective surgery than by emergency cases (p ¼ 0:003). The difference was found for the cognitive (p ¼ 0:008), experiential (p ¼ 0:002) and ethical (p ¼ 0:02) areas. Also the patients hospitalized for only one day regarded patient education as sufficient more often than those hospitalized for five or more days (p ¼ 0:002) as regards ethical issues in particular (p ¼ 0:02).
Structure and educational solutions of patient education as perceived by patients and nurses The main areas of structure and educational solutions identified were: learning needs and preferences, setting of learning objectives, use of different educational methods, and evaluation of learning outcomes from both patientsÕ and nursesÕ point of view. A majority of the nurses (94%) reported that they assessed all or many patientsÕ learning needs while only 6% made such assessments for a few or no patients. A third of patients (30%), however, considered that they had not had the chance of discussing these issues. Patients aged 60–69 felt more often than those aged 20–29
Table 2 The rank order of dealing with content by areas (means) and examples of items (means) reported by patients and nurses From patients’ perspective
From nurses’ perspective
1. Functional area (M = 1.57) how to manage in everyday life (M = 1.57)
1. Bio-physiological area (M = 1.63) physical symptoms and signs (M = 1.53)
2. Bio-physiological area (M = 1.63) physical symptoms and signs (M = 1.58)
2. Functional area (M = 1.65) how to manage in everyday life (M = 1.56)
3. Cognitive area (M = 1.76) how care is provided (M = 1.60)
3. Cognitive area (M = 2.04) how care is provided (M = 1.64)
4. Social area (M = 1.97) how to look after my family and relatives (M = 2.22)
4. Social area (M = 2.05) how patient can keep in contact with his/her family and friends (M = 1.80)
5. Experiential area (M = 2.23) how to cope with different feelings (M = 2.62)
5. Experiential area (M = 2.24) how patient can express his/her feeling towards the care (M = 2.35)
6. Ethical area (M = 2.47) my rights (M = 2.62)
6. Ethical area (M = 2.38) patient’s rights (M = 2.42)
7. Financial area (M = 2.69) how to manage money matters related to my care (M = 2.69)
7. Financial area (M = 2.51) how to deal with financial matters (M = 2.51)
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years (p ¼ 0:013) that these issues had been dealt with adequately. The assessments were made most commonly during informal interviews and discussions (80%) and somewhat less often according to a plan made in advance (54%). Patients in hospital for less than five days (p ¼ 0:01) considered that many different ways had been used to find out what they felt important to learn. Learning objectives had been set for every patient by a quarter of nurses, for many patients by over half and for a few patients by a fifth of nurses. In most cases (79%) the objectives had been primarily set and explained by discussion with nurses; a fifth of patients (21%), however, considered that objectives had not been dealt with at all. Older patients, i.e., those aged 60–69, considered more often than younger patients (30–39 years) that their learning objectives had been discussed (p ¼ 0:009). The objectives had been dealt with in more various ways in patients with a health problem involving the arm than in those with leg problems (p ¼ 0:01). The questions concerning the use of different educational methods were answered similarly by patients and nurses: Personal education sessions were used most often and group sessions very rarely. Written educational material, practising and demonstrations were used commonly contrary to PCs and videos, which were used very rarely. According to most patients (83%) and nurses (82%) learning outcomes were evaluated mostly through interviews. A majority of patients reported that the nurse checked the outcome by asking the patient to show how to do something (56%) or to repeat the care instructions (33%); quite similar figures were obtained here for the nurses: 75% and 52%, respectively. Men found more often than women that their learning was confirmed in many ways (p ¼ 0:027).
Patients’ knowledge of their care PatientsÕ knowledge about their care was most adequate in issues concerning treatments (67%), examinations (60%) and further care (60%) and most inadequate in those concerning potential problems (25%) and unwanted effects of treatment (23%). Elective surgery patients tended to know more about their care than emergency patients (p ¼ 0:008).
Nurses’ educational skills The nurses were asked to evaluate their educational skills in assessing patientsÕ learning needs, setting learning objectives, mastering the content of patient education, using different educational methods and evaluating learning outcomes. All nurses assessed their skills on the whole as fairly
good (item means 1.96–1.74). The highest rated skills area was mastery of content and the lowest the use of different educational methods. The nursesÕ educational skills were based mostly on experience (M ¼ 1:16), less often on independent learning (M ¼ 2:22) or pre-registration training (M ¼ 2:24) and rarely on various additional post-registration courses (M ¼ 2:59). Also patient education practices were found to be based most often (78%) on work experience and next on current ward practice (62%), while no role was played here by data from foreign scientific journals (39%) and databases (36%).
VALIDITY AND RELIABILITY OF THE STUDY Efforts were made to ensure validity and reliability in many different ways. The content validity of the questionnaires was based on an extensive review of the literature on patient education and views of an expert panel. The questionnaires were pre-tested and written instructions for answering the questions were provided. The questionnaire response rate was 81% for the patients and 67% for the nurses, which can be considered satisfactory (Burns & Grove 1997). The reliability of the scales was examined using CronbachÕs a coefficient when relevant. It was 0.77 for patientÕs knowledge of care-related matters and ranged from 0.77 to 0.89 for the sum variables relating to education content (biophysiological 0.86, functional 0.78, cognitive 0.89, social 0.78, experiential 0.85 and ethical 0.77). The a coefficient for nursesÕ educational skills was 0.82 and ranged from 0.49 to 0.78 for the sum variables relating to educational content (bio-physiological 0.78, functional 0.49, cognitive 0.78, social 0.67, experiential 0.75, and ethical 0.72). This indicates that the internalconsistency reliability of the nursesÕ instrument needs to be improved by developing or changing items concerning the functional area, while the patientsÕ instrument seems to be quite reliable. These questionnaires have not been used in previous studies; more testing is therefore needed. The study concerned orthopaedic patients and nurses in a Finnish university hospital. The results can be generalized to other Finnish university hospitals because these are all very similar and the patients were representative of the orthopaedic patient population of university hospitals (Paavolainen et al. 1997, Rasilainen et al. 1997). There was, however, a limitation related to the sampling criteria: the patients had to be able to answer the questions by themselves, which meant that those who were very ill or debilitated were excluded from the study. Despite this limitation an overview of the current
Patient education in orthopaedic nursing 225
situation of orthopaedic patient education was obtained for purposes of further development.
DISCUSSION PatientsÕ and nursesÕ perceptions concerning current patient education showed both similarities and differences. Both groups considered that the bio-physiological and functional content areas had been dealt with most adequately, although the order in the two groups was different. These areas, including e.g. identification of complications such as infection and measures to prevent infection, seem to form a very important part of orthopaedic patient education according to a previous study (Santavirta et al. 1994). The areas which received least attention according to both of the study groups were the experiential, ethical and financial areas, a finding consistent with previous study results (Boyle et al. 1992, Galloway & Graydon 1996, Showalter et al. 2000). However, orthopaedic surgery has a major socio-economic health impact on the patientsÕ lives (Santavirta et al. 1994), it is therefore important to discuss social and financial issues in patient education. It would also be useful to provide more information, in more accurate terms, about unwanted treatment effects and potential problems and give more consideration to ethical and experiential matters. There were some differences in patientsÕ and nursesÕ views concerning the structure and educational solutions of patient education. According to nurses, patientsÕ learning needs and preferences had been given due consideration, contrary to the views of a third of patients. Similar differences were found between the two groupsÕ views about learning objectives. These findings raise the question as to whether the needs and objectives were perceived so differently or whether patients were really not given the opportunity to express their views. There is no comparative research available. However, in one recent study (Latter et al. 2000) patientsÕ opportunities to influence their education were shown to be inadequate. Patients can assess quite well what information they need (Galloway et al. 1995, Galloway & Graydon 1996, Johansson et al. 2002) and should therefore be allowed and motivated to participate more actively in their education. The educational methods used were ranked similarly for both patients and nurses: Personal discussions, written material and practising were used most commonly and PCs and videos least commonly. In the future, methods other than the ‘‘traditional’’ ones should be included in patient education because today many people are familiar with videos and PCs. These methods also allowed education to continue in places other than hospitals; a video can for
example be taken home or a PC programme or the Internet can be used at home before and after the hospital stay. Viewed from the perspective of empowerment patients can rather be seen as collaborators in their care (Pellino et al. 1998, Poskiparta et al. 2001) and their needs, preferences, perceptions and participation should therefore be taken more into consideration. The patientsÕ knowledge about their care was predominantly sufficient, although there were some inadequacies related to, for example, unwanted treatment effects and possible problems such as complications and physical limitations. When these results are considered in relation to empowermental patient education, in which patient-centered information is essential (Per€ al€ a 1998) and in relation to orthopaedic nursing, in which these are important part of patientÕs care and information (Fisher et al. 1997, Johansson et al. 2002, Pearce et al. 1991), it is evident that much has to be done. In the future more consideration should be given to knowledge about side effects and possible problems. Elective and emergency cases differed in terms of the level of knowledge, about their care which was inadequate in the latter. It is important to address this problem, because hospital stays are short and it is quite distressing for inadequately informed patients in hospital to wait to know what will happen to them. Also young patients and those hospitalized for five or more days were not satisfied with patient education and should thus receive more attention. On the other hand, the needs of old people, who form the main group of orthopaedic patients, should not be forgotten. From the economic point of view it is important to develop effective patient education for these patients (Paavolainen et al. 1997). NursesÕ educational skills are undergoing development. The skills identified in this study were mostly based on experience and rarely on research evidence from journals or databases, a finding supported by previous research (Latter et al. 2000). Nurses reported that they mastered the educational content; in the use of different educational methods and solutions, on the other hand, there was room for improvement. Despite mastery of the content, it seems evident that patients have to be viewed by nurses more holistically. It is not enough to deal only with biophysiological and functional issues. Ethical considerations such as patientsÕ rights, financial matters and patientsÕ experiences and expectations related to their care are important issues in patient education. Nurses have to be encouraged to make use of research data and work out new contents and methods when planning and providing patient education. This should be noted in nursing education and, after graduation, various courses should be offered to update nurses on these matters.
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Journal of Orthopaedic Nursing
The results of this study are based on patientsÕ and nursesÕ perceptions. A study of written educational material is also needed to complement the picture of current practices and development needs. How the patient education provided is perceived by spouses would also be worth studying. Although many patients discharged are cared for by their spouses during convalescence, there has been little research on the spousesÕ views on patient education (Showalter et al. 2000). The main purpose of this study was to elucidate the current state of orthopaedic patient education. To gain a more profound understanding and more focused knowledge of the topic, further research is needed using different research methods such as interviews or observation. However, these results will allow the further development of orthopaedic patient education interventions and the examination of their effectiveness.
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Latter S, Yerrell P, Rycroft-Malone J, Shaw D (2000) Nursing, medication education and the new policy agenda: the evidence base. International Journal of Nursing Studies 37: 469–479 Lehtinen E, Vauras M, Salonen P, Olkinuora E, Kinnunen R (1995) Long-term development of learning activity: Motivational, cognitive and social interaction. Educational Psychologist 30: 21–35 Leino-Kilpi H, Luoto E, Katajisto J (1998) Elements of empowerment and MS patients. Journal of Neuroscience Nursing 18: 116–123 Leino-Kilpi H, M€aenp€a€a I, Katajisto J (1999) Nursing study of the significance of rheumatoid arthritis as perceived by patients using the concept of empowerment. Journal of Orthopaedic Nursing 3: 138–145 Lilja Y, Ryden S, Fridlund B (1998) Effects of extended preoperative information on perioperative stress: an anaesthetic nurse intervention for patients with breast cancer and total hip replacement. Intensive and Critical Care Nursing 14: 276–282 Lin PC, Lin LC, Lin JJ (1997) Comparing the effectiveness of different educational programs for patients with total knee arthroplasty. Orthopaedic Nursing 16: 43–49 Montin L, Suominen T, Leino-Kilpi H (2002) The experiences of patients undergoing total hip replacement. Journal of Orthopaedic Nursing 6: 23–29 Paavolainen P, Rissanen P, Aro S, Sintonen H, Sl€atis P (1994) El€am€anlaatu ja toimintakyky tekonivelleikkauksissa. Suomen Ortopedia ja Traumatologia 17: 354–357 Paavolainen P, Seitsalo S, Nenonen M (1997) Ortopedisten leikkausten aluevaihtelut Suomessa vuonna 1995. Suomen ortopedia ja traumatologia 20: 199–202 Pearce P, McKenzie M, Taylor G (1991) Wound infections in orthopaedic surgery: Effect of extended surveillance on infection rate. Canadian Journal of Surgery 34(1): 31–34 Pellino T, Tluczek A, Collins M, Trimborn S, Norwick H, Engelke ZK, Broad J (1998) Increasing self-efficacy through empowerment: preoperative education for orthopaedic patients. Orthopaedic Nursing 17: 48–51, 54–59 Per€al€a M.-L. (ed) (1998) The Direction of Nursing. A strategy for quality and effectiveness. National Research and Development Centre for Welfare and Health, Helsinki Poskiparta M, Liimatainen L, Kettunen T, Karhila P (2001) From nurse-centered health counseling to empowermental health counseling. Patient Education and Counselling 45: 69–79 Rasilainen J, Paavolainen P, Talja M, Nenonen M (1997) Ortopedisten ja urologisten leikkausten aluevaihtelut vuonna1995. Tilastotiedote 17/1997. Stakes, Helsinki Santavirta N, Lillqvist G, Sarvim€aki A, Honkanen V, Konttinen YT, Santavirta S (1994) Teaching of patients undergoing total hip replacement surgery. International Journal of Nursing Studies 31: 135–142 Showalter A, Burger S, Salyer J (2000) PatientsÕ and their spousesÕ needs after total joint arthroplasty: a pilot study. Orthopaedic Nursing 19(1): 49–52, 62 Theis SL, Johnson JH (1995) Strategies for teaching patients: a meta-analysis. Clinical Nurse Specialist 9: 100–105, 120
A R T I C L E
Patient education in orthopaedic nursing Kirsi Johansson, Sanna Salantera¨, Jouko Katajisto and Helena Leino-Kilpi The objectives of this study were to describe (1) how the content, structure and educational solutions of orthopaedic patient education were perceived by patients and nurses; (2) what patients knew about their care; and (3) how nurses evaluated their educational skills. The sample consisted of 146 orthopaedic patients (response rate 81%) and 56 nurses (response rate 67%) on three orthopaedic wards in a Finnish university hospital in 2001. Data were collected using two parallel, purpose-designed, mainly structured questionnaires. The bio-physiological and functional aspects of patient education were found to be dealt with most adequately, while experiential, ethical and financial issues received least attention. Personal discussions, written material and demonstration/practice, were the most commonly used educational methods, while videos and PCs were seldom used. Patients’ knowledge about their care was quite sufficient, but in matters concerning unwanted effects of treatment and potential problems it was inadequate. According to nurses’ self-assessments, their educational skills were best in the area of mastering the content and poorest in that of using different educational methods.The results indicated that both the content and methods of orthopaedic patient education should be developed. c 2002 Elsevier Science Ltd. All rights reserved.
Editor’s comment The effectiveness of patient education and the orthopaedic nurse’s ability to deliver it has often been described but rarely investigated. This study begins to address the lack of evidence with an insightful and productive research project. As an editor I was particularly surprised by the findings that; ‘patient education practices were found to be based most often (78%) on work experience and next on current ward practice (62%), while no role was played here by data from foreign scientific journals (39%) and databases (36%).’ PD
KEY WORDS: patient education, orthopaedic patients, orthopaedic nurses
INTRODUCTION AND LITERATURE REVIEW Kirsi Johansson MNSc, RN Doctoral student Sanna Salantera¨ PhD, RN Assistant professor Jouko Katajisto MSocSci Statistician Helena Leino-Kilpi PhD, RN Professor Correspondence to: Kirsi Johansson Department of Nursing, University of Turku, FIN-20014 Turku, Finland. Tel.: +358-40-082-2311; Fax: +358-2-333-8400; E-mail: [email protected]
The number of orthopaedic operations has increased in Finland: from 1993 to 1995 it increased by approximately 4500 operations, totalling about 101 700 operations in 1995 (Paavolainen et al. 1997, Rasilainen et al. 1997), and is projected to rise further in the future as modern surgical methods allow more operations to be performed and an increasing number of elderly patients are being treated (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997). Arthroplastic operations alone will increase by 10–15% annually (Paavolainen et al.
Journal of Orthopaedic Nursing (2002) 6, 220–226 ª 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1361-3111(02)00094-8
1994). In addition, hospital stays have shortened (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997). In view of these considerations, effective patient education is particularly important (Fisher et al. 1997, Paavolainen et al. 1997, Rasilainen et al. 1997) and research and further development efforts in this area seem worthwhile (Santavirta et al. 1994). There is a wide variety of benefits from patient education, ranging from reduced anxiety and fear (Gammon & Mulholland 1996a) an increased knowledge about care and rehabilitation (Lin et al. 1997) an improved ability to cope with the health problem and to participate in self-care (Pellino et al. 1998). Lessened post-operative pain
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(Gammon & Mulholland 1996b, Lilja et al. 1998) and better recoveries have also been reported (Gammon & Mulholland 1996b). When the objective is patient empowerment, patient education can be perceived as a method that emphasizes the patientÕs ability to manage their health problems (Leino-Kilpi et al. 1998). It is possible to place emphasis on patient empowerment when the individualÕs ability to learn is known. Patients do not only receive information and their prior knowledge, experiences and motivation affects learning (Lehtinen et al. 1995). It has been shown that patients can evaluate their own learning needs and anticipate what information they require (Galloway et al. 1995, Galloway & Graydon 1996, Johansson et al. 2002). Patients have also been found not to receive as much information as they feel they need (Showalter et al. 2000). Montin et al. (2002) have pointed out that the orthopaedic patientsÕ own resources should be better taken into account when planning their care. The content of patient education is in part governed by legislation in Finland: patients have the right to know about their health status and goals, alternatives and effects of their treatment as well as issues concerning their care (Act on the Status and Rights of Patients 785/1992). Empowering patients through education can be divided into the following areas: bio-physiological (identification of the symptoms and signs), functional (activities of daily living, illness and care), cognitive (receiving enough information and the ability to utilise it), social (experience of belonging to and support from the social network), experiential (feeling of appreciation with regard to oneÕs experiences, expectations and feelings), ethical (feeling of appreciation as a unique, autonomous individual) and financial (Leino-Kilpi et al. 1998, 1999). Orthopaedic patient education especially includes information about possible complications, physical limitations, exercise, rehabilitation and financial matters (Fisher et al. 1997, Johansson et al. 2002, Pearce et al. 1991), while information about medication (Bostrom et al. 1994) and pain relief also usually play an important role (Boyle et al. 1992, Showalter et al. 2000). The structure of patient education and the educational solutions used generally vary from planned teaching programmes to random question-and-answer sessions and from personal and group counselling to seeking of information independently by patients (Theis & Johnson 1995). In orthopaedic nursing there has been little broad-based research on the structure and educational solutions, although there have been many studies of single applied educational methods or programs (Lilja et al. 1998, Lin et al. 1997, Santavirta et al. 1994) Usually patient education can be seen as, consisting of the following phases: planning
(assessing patientsÕ learning needs and preferences, setting learning objectives), implementation (methods, place, timing) and evaluation of the outcome (Leino-Kilpi et al. 1998). In empowermental education, the educational structure and methods are based on a patient-centered approach and patient participation is seen as important (Pellino et al. 1998, Poskiparta et al. 2001).There is, however, little research evidence of participation by patients in the planning of patient education, especially in the assessment of learning needs and setting of objectives for learning (Latter et al. 2000). There is an evident need to study and further develop orthopaedic patient education. The further development of patient education to empower them within their current life and health situation and to be able to provide information at the right time and in the right way has been stated as one of the objectives in developing nursing practice in Finland (Per€ al€ a 1998). The purpose of the present study was to research current orthopaedic patient education from both patientsÕ and nursesÕ perspectives by determining its content, structure and educational solutions used and by assessing patientsÕ knowledge about their care and nursesÕ educational skills. The ultimate goal is to develop orthopaedic patient education so as to make it more empowering through supporting the patientsÕ own participation and decision-making in their care and to enhance the process of empowerment.
RESEARCH QUESTIONS The following research questions were addressed: 1. How do orthopaedic patients and nurses perceive the content and the structure and educational solutions (including assessment of learning needs and preferences, setting of learning objectives, use of educational methods and evaluation of learning outcomes) in current patient education? 2. What do orthopaedic patients know about their care? 3. How do orthopaedic nurses evaluate their educational skills?
MATERIAL AND METHODS The data were collected using two parallel, purpose-designed, mainly structured questionnaires, one for patients and the other for nurses. The questionnaires were based on a literature review and views of an expert panel consisting of two university-based researchers (PhD), two polytechnic nurse educators (LicNSc), and three hospital directors of nursing (PhD, MPolSci).
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The questionnaires were tested using pilot data on 35 patients and 30 nurses. The subjects for this descriptive study were orthopaedic patients ðn ¼ 146Þ and nurses ðn ¼ 56Þ. The data were collected from three orthopaedic wards of one of the university hospitals in Finland (which total five) over a period of five weeks in the spring of 2001. The response rate for patients per ward ranged from 66% to 93%, averaging 81% and that for nurses from 54% to 100%, averaging 67%. The patientsÕ questionnaire was designed for Finnish-speaking post-operative patients aged 18 and over who had undergone orthopaedic surgery and were able to understand the questions and complete the questionnaire. Patients on the participating wards were asked by nurses to participate in the study. Those willing filled in the questionnaire by themselves and returned them to mailboxes placed on the wards for his purpose. Nurses were asked to answer and similarly return their questionnaires. Participation in the study was completely voluntary. Research permission was obtained from the hospitalÕs Committee for Medical Research. The basic principles of research ethics (Burns & Grove 1997) were followed at all stages of the study and the data were handled confidentially. The questionnaires included demographic variables and parallel questions concerning the
content, structure and educational solutions of patient education. The questions that were different in the two questionnaires concerned the patientsÕ knowledge about their care and the nursesÕ educational skills. Use was made of yes/ no, four-point (1-4) and five-point (1-5) scales (Table 1). The statistical analyses were carried out using SPSS for Windows (10.0) software. Descriptive statistics (frequencies, percentages, means, standard deviations and range) were used to summarize the demographic data on the patients. PearsonÕs v2 test was used to examine the relationships between the patientsÕ demographic data and individual questions. The sum variables relating to the patient education content were formed based on a former theory (Leino-Kilpi et al. 1998, 1999). Sum variables relating to the patientsÕ knowledge about their care, nursesÕ assessments of their educational skills, basis of the skills and educational practices were also calculated. To obtain parallel sum scores for nurses and patients, the categories ‘‘insufficient information’’ (4) and ‘‘canÕt say’’ (5) of the five-point patient scales were combined; as a result the sum scores for both patients and nurses ranged from 1 to 4. The closer the value comes to 1 the more positive the answer. The differences between the demographic variables concerning sum variables were analysed using the appropriate parametric
Table 1 The questionnaires Questions about
In patients’ questionnaire
In nurses’ questionnaire
Demographic variables 11 items (gender, age, education, elective/emergency) Content of patient 23 items formed into 7 sum education variables: bio-physiological, functional, cognitive, social, experiential, ethical, financial; sufficient information (1) – cannot say (5)
12 items (age, level of training, work experience, working environment) 23 items formed into 7 sum variables: bio-physiological, functional, cognitive, social, experiential, ethical, financial; the area considered with every patient (1) – none of patients (4)
Educational structure and solutions Assessing learning 1 item (opportunity to discuss), needs and 4 items (specific preferences); preferences responses yes/no
5 items (how to assess patient’s learning needs and preferences); every patient (1) – none of patients (4)
Setting of learning objectives
Use of educational methods Evaluation of learning outcome Only for patients Knowledge about care
Only for nurses Patient education skills Basis of patient education skills and practice
4 items (how objectives were asked about); responses yes/no
5 items (how to set objectives) and 4 items (what objectives); every patient (1) – none of patients (4)
21 items; responses yes/no
24 items; every patient (1) – none of patients (4) 8 items (ways of confirming); every patient (1) – none of patients (4)
6 items (ways of confirming); responses yes/no 5 items (examinations, treatments, unwanted treatment effects, problems, further care); sufficient (1) – cannot say (5)
5 items (assessment, objectives, content, methods and evaluation); good (1) – poor (4) 4 items (skills based on) and 6 items (practice based on); very much (1) – not at all (4)
Patient education in orthopaedic nursing 223
tests (t-test, one-way analysis of variance with Tukey or Tamhane tests). By convention 0.05 was accepted as the level of significance (Burns & Grove 1997). CronbachÕs a test was used to assess the reliability of the questionnaires.
RESULTS Demographic data Women accounted for 54% and men for 46% of the patient group; the mean age was 50.8 years (range 18–79, SD ¼ 15:8). About a third (33%) had received primary and lower secondary school education, slightly over a third (34%) had completed secondary school or vocational school, about a quarter (24%) had college-level vocational training and 9% a university degree. Most of the operations were elective, over half involving an orthopaedic problem in the hip, knee or ankle. The length of the hospital stay ranged from 1 to 18 days (M ¼ 4:3 days, SD ¼ 3:9). Most patients (94%) were discharged and 6% were moved to other hospitals for rehabilitation. The nursesÕ mean age was 41 years (range 22–56 years, SD ¼ 9:5). They had worked as nurses on the same ward from 3 months to 32 years (M ¼ 11:8 years, SD ¼ 8:4). They assessed their work as physical very (54%) or quite (46%) stressful.
Content of patient education as perceived by patients and nurses The questions inquiring about the content of education were identical for patients and nurses. The former were also asked to evaluate the sufficiency of the information and the latter asked to indicate how many patients they counsel in each area. The
area dealt with most sufficiently was, according to patients, that of functional issues (M ¼ 1:57), the bio-physiological area ranking second (M ¼ 1:63) and, according to nurses, the bio-physiological area (M ¼ 1:63), followed by the functional area (M ¼ 1:65). In the other content areas a similar pattern was found for patients and nurses: cognitive (patients M ¼ 1:76, nurses M ¼ 2:04), social (M ¼ 1:97 and M ¼ 2:05, respectively), experiential (M ¼ 2:23; M ¼ 2:24), ethical (M ¼ 2:47; M ¼ 2:38) and financial (M ¼ 2:69; M ¼ 2:51) (Table 2). The content of patient education was considered adequate more often by patients with elective surgery than by emergency cases (p ¼ 0:003). The difference was found for the cognitive (p ¼ 0:008), experiential (p ¼ 0:002) and ethical (p ¼ 0:02) areas. Also the patients hospitalized for only one day regarded patient education as sufficient more often than those hospitalized for five or more days (p ¼ 0:002) as regards ethical issues in particular (p ¼ 0:02).
Structure and educational solutions of patient education as perceived by patients and nurses The main areas of structure and educational solutions identified were: learning needs and preferences, setting of learning objectives, use of different educational methods, and evaluation of learning outcomes from both patientsÕ and nursesÕ point of view. A majority of the nurses (94%) reported that they assessed all or many patientsÕ learning needs while only 6% made such assessments for a few or no patients. A third of patients (30%), however, considered that they had not had the chance of discussing these issues. Patients aged 60–69 felt more often than those aged 20–29
Table 2 The rank order of dealing with content by areas (means) and examples of items (means) reported by patients and nurses From patients’ perspective
From nurses’ perspective
1. Functional area (M = 1.57) how to manage in everyday life (M = 1.57)
1. Bio-physiological area (M = 1.63) physical symptoms and signs (M = 1.53)
2. Bio-physiological area (M = 1.63) physical symptoms and signs (M = 1.58)
2. Functional area (M = 1.65) how to manage in everyday life (M = 1.56)
3. Cognitive area (M = 1.76) how care is provided (M = 1.60)
3. Cognitive area (M = 2.04) how care is provided (M = 1.64)
4. Social area (M = 1.97) how to look after my family and relatives (M = 2.22)
4. Social area (M = 2.05) how patient can keep in contact with his/her family and friends (M = 1.80)
5. Experiential area (M = 2.23) how to cope with different feelings (M = 2.62)
5. Experiential area (M = 2.24) how patient can express his/her feeling towards the care (M = 2.35)
6. Ethical area (M = 2.47) my rights (M = 2.62)
6. Ethical area (M = 2.38) patient’s rights (M = 2.42)
7. Financial area (M = 2.69) how to manage money matters related to my care (M = 2.69)
7. Financial area (M = 2.51) how to deal with financial matters (M = 2.51)
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years (p ¼ 0:013) that these issues had been dealt with adequately. The assessments were made most commonly during informal interviews and discussions (80%) and somewhat less often according to a plan made in advance (54%). Patients in hospital for less than five days (p ¼ 0:01) considered that many different ways had been used to find out what they felt important to learn. Learning objectives had been set for every patient by a quarter of nurses, for many patients by over half and for a few patients by a fifth of nurses. In most cases (79%) the objectives had been primarily set and explained by discussion with nurses; a fifth of patients (21%), however, considered that objectives had not been dealt with at all. Older patients, i.e., those aged 60–69, considered more often than younger patients (30–39 years) that their learning objectives had been discussed (p ¼ 0:009). The objectives had been dealt with in more various ways in patients with a health problem involving the arm than in those with leg problems (p ¼ 0:01). The questions concerning the use of different educational methods were answered similarly by patients and nurses: Personal education sessions were used most often and group sessions very rarely. Written educational material, practising and demonstrations were used commonly contrary to PCs and videos, which were used very rarely. According to most patients (83%) and nurses (82%) learning outcomes were evaluated mostly through interviews. A majority of patients reported that the nurse checked the outcome by asking the patient to show how to do something (56%) or to repeat the care instructions (33%); quite similar figures were obtained here for the nurses: 75% and 52%, respectively. Men found more often than women that their learning was confirmed in many ways (p ¼ 0:027).
Patients’ knowledge of their care PatientsÕ knowledge about their care was most adequate in issues concerning treatments (67%), examinations (60%) and further care (60%) and most inadequate in those concerning potential problems (25%) and unwanted effects of treatment (23%). Elective surgery patients tended to know more about their care than emergency patients (p ¼ 0:008).
Nurses’ educational skills The nurses were asked to evaluate their educational skills in assessing patientsÕ learning needs, setting learning objectives, mastering the content of patient education, using different educational methods and evaluating learning outcomes. All nurses assessed their skills on the whole as fairly
good (item means 1.96–1.74). The highest rated skills area was mastery of content and the lowest the use of different educational methods. The nursesÕ educational skills were based mostly on experience (M ¼ 1:16), less often on independent learning (M ¼ 2:22) or pre-registration training (M ¼ 2:24) and rarely on various additional post-registration courses (M ¼ 2:59). Also patient education practices were found to be based most often (78%) on work experience and next on current ward practice (62%), while no role was played here by data from foreign scientific journals (39%) and databases (36%).
VALIDITY AND RELIABILITY OF THE STUDY Efforts were made to ensure validity and reliability in many different ways. The content validity of the questionnaires was based on an extensive review of the literature on patient education and views of an expert panel. The questionnaires were pre-tested and written instructions for answering the questions were provided. The questionnaire response rate was 81% for the patients and 67% for the nurses, which can be considered satisfactory (Burns & Grove 1997). The reliability of the scales was examined using CronbachÕs a coefficient when relevant. It was 0.77 for patientÕs knowledge of care-related matters and ranged from 0.77 to 0.89 for the sum variables relating to education content (biophysiological 0.86, functional 0.78, cognitive 0.89, social 0.78, experiential 0.85 and ethical 0.77). The a coefficient for nursesÕ educational skills was 0.82 and ranged from 0.49 to 0.78 for the sum variables relating to educational content (bio-physiological 0.78, functional 0.49, cognitive 0.78, social 0.67, experiential 0.75, and ethical 0.72). This indicates that the internalconsistency reliability of the nursesÕ instrument needs to be improved by developing or changing items concerning the functional area, while the patientsÕ instrument seems to be quite reliable. These questionnaires have not been used in previous studies; more testing is therefore needed. The study concerned orthopaedic patients and nurses in a Finnish university hospital. The results can be generalized to other Finnish university hospitals because these are all very similar and the patients were representative of the orthopaedic patient population of university hospitals (Paavolainen et al. 1997, Rasilainen et al. 1997). There was, however, a limitation related to the sampling criteria: the patients had to be able to answer the questions by themselves, which meant that those who were very ill or debilitated were excluded from the study. Despite this limitation an overview of the current
Patient education in orthopaedic nursing 225
situation of orthopaedic patient education was obtained for purposes of further development.
DISCUSSION PatientsÕ and nursesÕ perceptions concerning current patient education showed both similarities and differences. Both groups considered that the bio-physiological and functional content areas had been dealt with most adequately, although the order in the two groups was different. These areas, including e.g. identification of complications such as infection and measures to prevent infection, seem to form a very important part of orthopaedic patient education according to a previous study (Santavirta et al. 1994). The areas which received least attention according to both of the study groups were the experiential, ethical and financial areas, a finding consistent with previous study results (Boyle et al. 1992, Galloway & Graydon 1996, Showalter et al. 2000). However, orthopaedic surgery has a major socio-economic health impact on the patientsÕ lives (Santavirta et al. 1994), it is therefore important to discuss social and financial issues in patient education. It would also be useful to provide more information, in more accurate terms, about unwanted treatment effects and potential problems and give more consideration to ethical and experiential matters. There were some differences in patientsÕ and nursesÕ views concerning the structure and educational solutions of patient education. According to nurses, patientsÕ learning needs and preferences had been given due consideration, contrary to the views of a third of patients. Similar differences were found between the two groupsÕ views about learning objectives. These findings raise the question as to whether the needs and objectives were perceived so differently or whether patients were really not given the opportunity to express their views. There is no comparative research available. However, in one recent study (Latter et al. 2000) patientsÕ opportunities to influence their education were shown to be inadequate. Patients can assess quite well what information they need (Galloway et al. 1995, Galloway & Graydon 1996, Johansson et al. 2002) and should therefore be allowed and motivated to participate more actively in their education. The educational methods used were ranked similarly for both patients and nurses: Personal discussions, written material and practising were used most commonly and PCs and videos least commonly. In the future, methods other than the ‘‘traditional’’ ones should be included in patient education because today many people are familiar with videos and PCs. These methods also allowed education to continue in places other than hospitals; a video can for
example be taken home or a PC programme or the Internet can be used at home before and after the hospital stay. Viewed from the perspective of empowerment patients can rather be seen as collaborators in their care (Pellino et al. 1998, Poskiparta et al. 2001) and their needs, preferences, perceptions and participation should therefore be taken more into consideration. The patientsÕ knowledge about their care was predominantly sufficient, although there were some inadequacies related to, for example, unwanted treatment effects and possible problems such as complications and physical limitations. When these results are considered in relation to empowermental patient education, in which patient-centered information is essential (Per€ al€ a 1998) and in relation to orthopaedic nursing, in which these are important part of patientÕs care and information (Fisher et al. 1997, Johansson et al. 2002, Pearce et al. 1991), it is evident that much has to be done. In the future more consideration should be given to knowledge about side effects and possible problems. Elective and emergency cases differed in terms of the level of knowledge, about their care which was inadequate in the latter. It is important to address this problem, because hospital stays are short and it is quite distressing for inadequately informed patients in hospital to wait to know what will happen to them. Also young patients and those hospitalized for five or more days were not satisfied with patient education and should thus receive more attention. On the other hand, the needs of old people, who form the main group of orthopaedic patients, should not be forgotten. From the economic point of view it is important to develop effective patient education for these patients (Paavolainen et al. 1997). NursesÕ educational skills are undergoing development. The skills identified in this study were mostly based on experience and rarely on research evidence from journals or databases, a finding supported by previous research (Latter et al. 2000). Nurses reported that they mastered the educational content; in the use of different educational methods and solutions, on the other hand, there was room for improvement. Despite mastery of the content, it seems evident that patients have to be viewed by nurses more holistically. It is not enough to deal only with biophysiological and functional issues. Ethical considerations such as patientsÕ rights, financial matters and patientsÕ experiences and expectations related to their care are important issues in patient education. Nurses have to be encouraged to make use of research data and work out new contents and methods when planning and providing patient education. This should be noted in nursing education and, after graduation, various courses should be offered to update nurses on these matters.
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The results of this study are based on patientsÕ and nursesÕ perceptions. A study of written educational material is also needed to complement the picture of current practices and development needs. How the patient education provided is perceived by spouses would also be worth studying. Although many patients discharged are cared for by their spouses during convalescence, there has been little research on the spousesÕ views on patient education (Showalter et al. 2000). The main purpose of this study was to elucidate the current state of orthopaedic patient education. To gain a more profound understanding and more focused knowledge of the topic, further research is needed using different research methods such as interviews or observation. However, these results will allow the further development of orthopaedic patient education interventions and the examination of their effectiveness.
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