CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A PATIENT EDUCATION PROGRAI'1 FOR PRE-SURGERY
GYNECOLOGIC PATIENTS
A graduate project submitted in partial satisfaction
of the requirements for the degree of
Master of Public Health in
Community Health Education
by
Karen L. Safranski
January, 1981
The
of Karen L. Safranski is approved:
Eva
waleed Alkhateeb, Dr. PH
Chairman
California State University, Northridge
ii
'
ACKNOWLEDGEMENTS
This author wishes to express her sincere
appreciation to those people whose involvement in this
project helped make its execution and completion possible.
To Dr. Arnold Bresky whose foresight and concern
for his patients provided the concept for this project,
as well as the participants.
To Eva
~:-Jong
whose experience and supervision
saved me from innumerable mistakes, yet allowed me the
freedom to complete this project in a way that made it a
more meaningful field experience.
Dr. Tony Alcoccer's graduate courses helped
prepare me for the process of completing my Master's
Thesis, and his participation on this committee is greatly
appreciated.
The chairman of my committee, Wally Alkhateeb,
receives many thanks for his patience, encouragement, and
highly valued supply of humor, which ultimately makes all
difficult things less painful to accomplish.
iii
'
TABLE OF CONTENTS
Page
ACKNQ"\:\TLEDGEMENTS .
iii
LIST OF TABLES .
vi
ABSTRACT
. viii
Chapter
1.
2.
3.
INTRODUCTION . .
1
Statement of the Problem
1
Purpose of the Study .
3
Limitations of Study .
3
Definition of Terms
4
REVIEW OF THE LITERATURE .
6
Goals of Patient Education
6
Types of Programs
9
Purpose and Content of Programs
11
Modes of Response
15
Summary of the Literature Review .
18
20
METHODS
Background
20
Program Design
.
.
.
.
.
Selection of the Population
4.
PROGRAM EVALUATION • .
23
30
32
Program Evaluation Methods .
32
Discussion • • .
53
.
iv
Chapter
5.
Page
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . 55
Summary . . .
.
.
. .
Conclusions • .
.
. .
.
. .
. . .
. . 55
. . 56
Recommendations .
REFERENCES
.
•
. 56
• • 58
APPENDICES
A.
PATIENT PRETEST .
•
B.
PATIENT POSTTEST
. . 66
c.
PATIENT EDUCATION TAPE RECORDING
•
D.
PRE AND POSTTEST RESULTS
v
• 63
• 69
. 80
LIST OF TABLES
Table
I.
Page
Variable l . Marital Status of
Respondents
. . . . . . .
II.
Variable 2.
Age of Respondents
III.
Variable 3.
Number of Surgeries
IV.
Variable 4.
Method of Payment
v.
33
. . . .
. . . . .
. .
Variables
VII.
Variables
VIII.
Variables
IX.
Variables
X.
Variables
XI.
Variables
XII.
Variables
XIII.
Variables
XIV.
Variables
XV.
Variables
XVI.
Variables
. . . . . . .
6 and 7 . .
. . . . . . .
8 and 9 . . .
. . . .
10 and 11 . . . . . . .
.
12 and 13 . .
. . . . . .
14 and 15 . . . . . .
. .
16 and 17 .
. . . . . . .
18 and 19 .
. . .
20 and 21 .
. . .
22 and 23 . . . . . . . . . .
24 and 25 .
. . . . . . .
26 and 27 .
. . . . .
XVII.
Variables 28 and 29
XVIII.
Variables 30 and 31
XIX.
Variables 32 and 33
XX.
Variables 34 and 35
XXI.
Variables 36 and 37
. .
c
•
35
36
. .
. .
. .
. .
37
38
39
40
41
42
43
. .
. .
. .
. . .
. . . . . . . . .
. . . . . . . . . . . .
. . . . . .
.
. . . . . . . .
.
.
vi
34
35
Variable 5.
Amount of Pre-Surgery
Information
VI.
33
44
45
46
47
48
49
50
51
Table
XXII.
Page
Variables 38 and 39 . . . . . . • . • . . .
vii
52
ABSTFACT
A PATIENT EDUCATION PROGRAM FOR PRE-SURGERY
GYNECOLOGIC PATIENTS
by
Karen L. Safranski
Master of Public Health in
Community Health Education
This program was developed to aid pre-surgery
patients about to experience non life threatening gynecologic surgery in increasing their level of knowledge
of their hospital stay and recovery phase.
One major
goal the study hoped to achieve, was the reduction of
each patient's perceived levels of fear and anxiety
related to their surgery and hospital stay.
The program was administered the evening before
surgery and consisted of a verbal introduction of the
program, a written pre-test, playing of a 14 minute
cassette tape recording accompanied by a visual aid
viii
booklet, a written posttest, and a discussion of the
program and its contents.
The subject areas addressed in the program
included, an introduction to the hospital, a discussion
of fear and anxiety associated with surgery and coping
with these states, pre-surgery preparations, the surgical
suite, the surgical experience, and the recovery phase.
It was planned that these areas would cover material most
needed and interesting to the patient, thereby making
surgery and the hospital stay a less threatening experience.
The program was implemented over a five month
period, and served a sample size of 27.
Because fear and
anxiety are such abstract terms and elude objective evaluative tools, the results presented in this project
related to differences in fear and anxiety means are a
combination of written responses, observations and subjective evaluation.
The means of the pre and posttest responses to
semantic differential attitude scales and other questions
showed a level of significant change was achieved in 8
out of 17 questions, producing responses toward the more
positive adjective on the scale.
While only about half
of the questions showed a significant change for the
positive, it should be noted that almost all showed a
ix
slight change toward the positive adjective (but too
small to be statistically significant) and in none of
the questions was there a significant change toward the
negative adjective in the pre and posttest responses.
The questions aimed at measuring the principal
objectives of the study, reducing the patients levels of
fear and anxiety, included all the responses with statistical significance.
Questions dealing with areas that
were not a primary objective, i.e., dispensing technical
information concerning the patients condition and surgical procedures, showed the least effect from the educational program.
X
Chapter 1
INTRODUCTION
The health care industry is growing and changing
as rapidly as any other consumer service field in our
society.
As the providers of these services change, ex-
pand their technologies and capabilities, so do the consumers of these services change.
With the advent of the
consumer movement of the early 70's, today's health care
consumer is usually a more informed, demanding and more
conscientious consumer of these services than their
counterpart of a decade ago.
Many attitudes concerning health care services
have changed.
Gone are the days for many consumers when
a physician's opinion was accepted without question and
his advice for treatment or surgery followed without concern for cost or need.
Today many people "shop around"
for a second opinion, compare physician and hospital
fees and services, and want to know what to expect for
the skyrocketing costs they face for health care.
Statement of the Problem
Since patients are often faced with the
responsibility of making the ultimate decision regarding
treatment and procedures to be used in their health care,
1
2
they are beginning to be recognized as an integral part
of the health care team by some.
To assume this respon-
sibility they must be provided with the proper services
and information to help them make sound health care
decisions.
This challenge presented by health care consumers
is being met in part by health educators in the development of patient education programs.
These programs have
been developed for use in hospitals, and other health
care facilities, by health educators, private physicians
and agencies, to educate patients and help them participate more in their own health care.
Although patient education in one form or
another has always existed, it is only recently that it
has been recognized as an area demanding the special attention of health education specialists.
Patient educa-
tion can take the form of a patient simply reading some
health care information or exchanging experiences with a
friend, to a more elaborate preplanned audiovisual presentation followed by a group discussion lead by a health
care professional in the education auditorium of a community hospital.
Regardless of the form a program takes, who
presents it or where, a similar qoal is usually present,
to develop a more informed, better educated health care
consumer.
This new consumer, it will be shown, can be
3
an asset not only to himself, but also to the facility
and staff that treat him.
Purpose of the Study
It was this author's intention to introduce a
patient education program designed for pre-surgery gynecologic patients, that would study, and hopefully lower
the levels of preceived fear and anxiety experienced by
patients associated with their surgery.
The author strived to provide patients
information, insight, and an opportunity to question and
discuss their hospital stay, through a multi-media presentation developed specifically for these pre-surgery patients at Parkwood Community Hospital.
The program was developed in conjunction with
the participating physician, Dr. Arnold Bresky, who had
voiced a need for such a program for his patients, and
provided information and encouragement for the implementation of the program.
After the completion of the study,
the program will be made available to the Parkwood staff
to use in full or in part as they see most effective.
Limitations of Study
The largest limiting factor on the validity of
the test results of this study, is that the program was
administered to a self selected (v.s. a random) sample
population consisting of the cooperating physician's
4
patients.
This limitation resulted in access to a small
sample population during the five months the author
administered the program and gathered sample results.
No control group was used in this study because the
physician wanted all of his patients to receive the education program once it was completed.
However a pretest
was given to the sample group hoping to represent findings similar to a control group.
Definition of Terms
D. and C. -
(dilation and currettage) - The enlargement
of the cervix to facilitate removal of diseased
or unwanted tissue in the uterus with a curet.
Hysterectomy - Excision of all or part of the uterus
performed through the abdominal wall or through
the vagina.
Non Life-threatening Gynecologic Surgery - Gynecologic
surgeries not related to the diagnosis or treatment of a life threatening condition such as
cancer.
Perceived Anxiety - The level of apprehension or
uneasiness the patient feels she is experiencing
associated with her surgery, as opposed to the
level experienced judged by an outside source.
5
Perceived Fear - The level of alarm or disquiet the
patient feels she is personally experiencjthg
associated with her surgery, as opposed to the
level experienced judged by an outside source.
Chapter 2
REVIEW OF THE LITERATURE
The literature that has been written dealing
with the concept and practice of patient education is
extensive, but very little can be found that addresses
itself specifically to gynecologic patient education programs or those that study the fear and anxiety levels of
such pre-surgery patients.
Because of the lack of liter-
ature directly related to this project this author has
included literature dealing with any area included in
this study in the literature review.
The author has incorporated material dealing
with the goals of patient education programs, different
techniques of patient education, studies performed to
detect differing physical and psychological effects from
education, literature exploring the causes, effects, and
responses to fear and anxiety experienced by the presurgery patients, roles of health care personnel in providing education for patients as well as other areas
incorporated under these topics.
Goals of Patient Education
Patient education programs have been developed
and instituted to achieve many goals and benefits.
6
The
7
majority of literature dealing with such programs
usually stated one of its goals as to increase the patient's level of knowledge concerning her condition and
surgery.
Williams (1976), points out the importance of
pre-surgery programs for the hysterectomy patient because
hospital personnel regard this as a common procedure with
little mortality, so these patients are often overlooked
and educational emphasis is placed on the cardiac or
similarly more serious patients.
Lyons (1977), found programs that increased
patient knowledge helped motivate their patients to cooperate in their post-operative phase.
run,
h~s
This in the long
helped ease the load on the hospital staff.
Coombe (1976), stressed programs to help patients
cope with this new situation they find themselves in that
produces high levels of anxiety, feelings of helplessness, and lack of confidence.
The emphasis to reduce
anxiety so that learning can take place is found frequently in the literature.
Anxiety levels in patients
who received pre-operative reassurance from the staff
were significantly lower than those in the group where
no support was given (Leigh, 1977).
Prsala (1974), in a Halifax Infirmary study
aimed to help patients adjust to the hospital
8
environment and alleviate fears through an admission
unit program for elective surgery patients.
Training patients how to undergo the event of
surgery and the effects it will have upon their bodies
was a goal often expressed in the literature (Barnett,
1973; Thomas, 1972).
The goal of fighting fear with
information and support was suggested by Skillings (1977).
Many health professionals see the benefits of
encouraging patients in their own health care, and the
possibility that the patient's willingness to accept
this responsibility could reduce the cost of health care
(Skillings, 1977).
Felton (1976) aims to build a rela-
tionship with the patient and assist him in accepting
some of the responsibility for his care.
He has found
this to favorably influence client satisfaction and psychological well being, and produce a marked decrease in
anxiety.
A variety of goals were stated in the literature
dealing with programs for the pre-operative patient.
The goals most frequently stated included; l) to provide
information for a better understanding of the patient's
condition and surgery. 2) To reduce the patient's levels
of fear and anxiety related to the patient's condition
and surgery.
3) To provide the patient some emotional
support and reassurance, and an opportunity to ask questions that may have gone unanswered.
4) To encourage
9
the patient to participate in his own health care and
hopefully make that patient's recovery period as comfortable and rapid as possible.
5) To improve the patient's
physical and psychological well being through education,
thus increasing the quality of care delivered.
Types of Programs
There was as large a diversity of types of
programs found in the literature as there were goals
they tried to achieve.
Leigh (1977) compared patients
who were given personal reassurance from staff members,
patients who were given booklets to read, and patients
who were exposed to no form of pre-surgery programs.
Personal programs provided by nurses that
included medical information, verbal discussions, and
tours of the hospital to become familiarized with the
facility and equipment were discussed (Long, 1974).
Many of the studies found in the literature dealt with
patients on a one to one basis for the pre-surgery interview and discussion (Giroud, 1978; Felton, 1976; Thomson,
1972; Boegli, 1972; Johnson, 1978; Laird, 1975; Roccella,
1976; Birkenshaw, 1978; Freeman, 1978}.
Sly (1975}, compared patients exposed to
sound slide programs and those who received a direct
interview from their physician, both supplemented with
printed material.
It was found that detailed
10
instructions are best given through personal interview,
but lengthy dialogues can impair retention.
A combina-,
tion of methods was thought most effective.
Both groups
increased their level of knowledge after instruction,
the sound slide method was judged most convenient.
Group sessions in which information was presented
and questions were answered were found effective by many
of the researchers.
Phillips (1977) found women who were
counseled by their private physicians had many more unanswered questions, wives tales and fears, and may have
felt more reluctant to ask questions.
Women in her
group sessions had a chance for group exploration of
values, and had a more positive outlook on their postoperative period.
A study comparing individual and group
preoperative teaching on postoperative ventilatory
function, length of stay and need for analgesics also·
found the g'roup method more effective (Lindeman, 1972).
A combination method was used in a Halifax
Infirmary Study where a special admission unit taught
exercises and skills on an individual basis, and later
reinforced them by means of an audio-visual presentation
to a group.
A group audio-visual preoperative class to help
alleviate fear; increase knowledge and involve patients,
was discussed which included a close relative for
11
additional support.
It was felt that in the group
sessions, patients may have gained confidence by seeing
many of their fellow patients scheduled for similar surgery (Morgan, 1973).
Similarly it has been suggested
that groups help conquer the isolation many pre-surgery
patients experience (Park, 1972).
Fairview-Southdale Hospital in Edins, Minnesota
has instituted a variety of programs for their presurgery population.
A teaching staff has group sessions
to explain the hospital and its staff.
The chaplain and
a nurse present a slide show and encourage questions.
Family group sessions are held in the hospital cafeteria
where families are invited to dinner upon a patient's
admission (Skillings, 1977).
Purpose and Content of Programs
A wide variety of program contents were found in
the literature.
'·\Thile some researchers were concerned.
with the precise information that should be covered,
others felt the emphasis should be placed on how and when
information is presented instead of what is specifically
included.
A few authors presented the view that it is
not so important what is to be presented, as the fact
that a program for pre-surgery patients is being presented at all.
12
Birkinshaw (1978) concentrated on explanations
that would reduce fears.
He felt that though the patient
may not remember all that was said, she will remember
that the effort was made to reassure her.
He found that
many patients signed consent forms without explanations.
He felt it was better for the patient to get details
from the physician, but that a short simple, logical,
explanation using understandable language can do much to
bolster patient's preoperative moral.
Schrader (1977) felt that some visits to presurgery patients were needed to solely help manage patient anxiety, as did Coombe (1976), who expressed that
growth and learning cannot occur when the anxiety level
is overwhelming.
Freeman (1978) viewed preoperative
visits as a time to make one's self availalbe to teach,
reassure and empathize with the patient.
Williams (1976) pointed out that certain
information that seems elementary to the health professional may be difficult to grasp for some patients they
will be in contact with.
Again simple language and
explanation was stressed along with graphs, drawings or
visual aids that may help facilitate understanding.
Murphy (1977) and Lyons (1977) felt that
assessing patient needs and progress on an individual
basis, then providing the general information that patient requires would provide the most effective patient
13
education.
This individual approach is echoed by
Kapsar (1976) who suggests using the patient's verbal
tone as a guide in explaining hospital and surgical
procedures.
Long (1974) stressed that preoperative care
should involve physiologic and psychologic nursing.
While assessing the patient's needs and obtaining medical
information, the nurse should be cognizant of the patient's tone, manner and gestures, to help determine his
perceptions and help him explore his feelings.
The pa-
tient's knowledge and anxiety should guide the nurse in
her explanations which should avoid scientific or technic~l
terms.
The author stressed that the educator should
respect the few patients who will ask that all explanations be omitted.
Morgan's (1973) program to alleviate patient fear
of pain, the unknown, and of becoming dependent on others,
contained knowledge content and an explanation of procedures that would hopefully involve patients in their own
care.
Bryant (1977) found that there may be better
retention of explanations made in advance of surgery, but
it was still important to stress that individual differences exist in patient recovery and equipment, and that
a large amount of equipment does not mean that the patient is abnormally unwell.
Long (1974) also stressed
14
that patients should become familiar with devices, tubes,
catheters and other equipment they may see used and be
taught that special equipment is a safeguard to ensure a
successful postoperative course and shouldn't be interpreted as signs of clinical deterioration.
Girourd (1978) views preoperative teaching as a
time to prepare the patient physically and emotionally.
She felt programs should assist the individual in his
recovery, and meet personal needs.
Prsala (1974) recog-
nized the patient's need for information and also suggested that the depth of the information should be left
up to the patient.
Thomson (1972) saw the need for addi-
tional information and instructed the educator to tell
the patient enough to relieve anxiety but don't go into
unnecessary detail which can cause more worry.
Laird (1975) feels that a little knowledge is
not a dangerous thing and since the expected is usually
less traumatic than the unexpected, the patient should
be told what to expect, how they
wi~l
feel, and how they
can help make their recovery period less difficult and
return home quickly.
gauged
Again, the information should be
to the patient's emotional and intellectual
receptivity.
Some of the studies this author reviewed were
aimed at measuring the differences a preoperative program
could have on the length of hospitalization, and amount
15
of narcotics and other pain relievers requested post
operatively.
Kinney (1977) stated that preoperative teaching
has been slow to favorably influence these variables, but
believes they may not have been measured properly.
No
statistical difference for prescribed pain relievers was
found between an experimental and control group by
Fortein (1977), or on their length of stay.
But she did
find a significant difference between the two groups in
their reports of physical comfort.
The group exposed to
preoperative teaching expressed less discomfort post
operatively.
In one study, doctors divided a group of intraabdominal patients in half.
They told one group what to
expect after their surgery, exercises for reducing pain,
and use of the trapeze.
The other half were uninformed.
The educated group were found to request 50% fewer narcotics for pain and went home an average of three weeks
earlier (Roccella, 1976).
Modes of Response
Some amount of anticipatory fear is normal when
preparing and responding to an experience that may be
perceived as threatening, such as surgery.
Some anxiety
can be useful when it serves as a signal that helps the
individual readjust and meet the threat (Kinney, 1977).
16
When the anxiety is misplaced and out of control, causing
t'
feelings of helplessness, lack of confidence and isolation, ,the individual may feel overwhelmed and simply
withdraw (Coombe, 1976).
Fear for the surgery patient is a normal response
to the unknown, i.e., hospitals and surgery, and becoming
dependent on others and losing their independence as a
result of surgery.
It is for these reasons that many
authors have recognized the need to study and deal with
the potential responses, anxiety, fear and denial as well
as how they may be put to good use.
Speilberg (1966) distinguished between two types
of anxiety.
Trait anxiety was explained as a personality
trait that is always present to some degree, and state
anxiety, which is a reaction to a perceived threat.
Sur-
gery, it was suggested, could produce many types of
anxiety.
In his study, he found that regardless of what
type of anxiety an individual displayed, or how he responded to a threat, there was usually some decrease in
anxiety following teaching.
Felton (1976) studied the outcomes of three
alternate intervention approaches on post operative
surgery complications, manifest anxiety and the patient's
perception of psychological well being.
He found an in-
verse linear relationship between preoperative levels of
fear and postoperative recovery adjustment.
17
high .
level
of
fear
low
high
post-op recovery
Slightly different results were found by Janis,
Bragul, Boyd, et al.
(Felton, 1976) who discovered a
curvelinear relation between preoperative ·fear and postoperative welfare.
Both high and low levels of anxiety
being associated with more difficult postoperative convalescence (Felton, 1976).
high
level
of
fear
low
high
post-op recovery
A common finding is shared by Boegli (1972) who
suggests that learning is more effective where there's a
slight amount of anxiety, less effective where the patient's anxiety level is extreme.
He reported that pa-
tients with extreme unrelieved preoperative anxiety have
a much higher incidence of postoperative complications as
compared with a slight to moderate amount of anxiety.
she points out, the presence of preoperative anxiety or
As
18
fear can block the transmission of information, resulting
in a powerful learning disability.
The response of denial by the preoperative
patient has generally been regarded as an inadequate
defense mechanism because it can't possibly be effective
postoperatively.
However, it was found that paired with
an overwhelming desire to get \vell, a history of denial
blocked out fear of anesthesia and surgical complications
(Kinney, 19 7 7) .
Although fear and anxiety are generally viewed
as negative responses, some positive uses of patient response mechanisms
were stated in the previous section.
This included, use as a guide to the extent of the presurgery education, and as a tool to explore the patient's
feelings, discover their causes, and help cope with these
reactions.
Summary of the Literature
Review
The literature used in reviewing this topic used
many diverse techniques, studied different areas of education, and reached various conclusions, but there were
some common theories and findings presented throughout.
The authors seemed to agree through the findings
of their many studies, that almost any form of patient
education did more good than harm.
The fact that some
interest and understanding was given to the patient, was
19
as important as the specific information they received.
The form and content the program should take is dependent
on the subjeqt matter, the program goals, the setting,
the patient's needs and other variables.
It is this author's feeling that because of the
potential positive effects shown through studies of the
research done and being conducted, more investigation and
evaluation concerning the forms and affects, will be conducted in the diverse field of patient education.
Chapter 3
METHODS
Background
This project was administered at Parkwood
Community Hospital, a small community hospital in the
west San Fernando Valley.
Although Parkwood had no
formal patient education programs, their use and benefits were recognized by some members of the hospital
staff.
During graduate field work at Parkwood Community
Hospital, this author was asked to create a patient education program.
Since Parkwood had no existing education
programs to follow, the author had freedom in deciding
the content and form of the program, as well as the confusion and inevitable mistakes, lack of a model can
cause.
The author, cooperating physician, and education
coordinator formulated goals and objectives we hoped to
achieve with the program so that some guidelines would
exist for the development of the program.
The objectives
for the patient education program were:
1)
To orient the patient to her new hospital
environment.
20
21
2)
To demonstrate Parkwood's dedication to the
holistic approach in medical treatment of the
surgical patient.
3)
To provide patients with information giving them
realistic expectations concerning pre-surgical
preparations, the surgical suite, the recovery
room and their recovery phase.
4)
To increase patient awareness of the causes and
effects of surgery associated with fear and
anxiety, the normalcy of these reactions, and
coping techniques.
5)
To develop an evaluative tool that will be used
to measure change the paitent may experience as
a result of exposure to the education program.
The patient
e~ucation
program developed for this
project was to serve women entering the hospital for
elective gynecologic surgery.
Although the education
portion of the program could be administered to any of
the cooperating physician's patients, the results of the
written pre and posttest were used only from the patients
about to experience non life threatening surgery, i.e.,
dilation and currettage, and complete or partial
hysterectomy.
The program was designed to supplement the more
detailed information the patient discussed with her
physician, and provide her with a broad overview of the
22
hospital, the surgical experience, and her recovery
phase.
Special concern was given to the topic of fear
and anxiety associated with surgery.
It was this
author's premise that if increasing the knowledge of the
patient was a primary objective, first trying to decrease
the fears and anxiety they may be experiencing would help
to increase the effectiveness of an education program
that followed.
This belief was mentioned in the litera-
ture when it was stated that very little actual learning
took place when patients expressed a lot of fear about
their illness and surgery.
The causes of these normal
reactions were discussed, as well as the importance of
understanding and coping with them.
A written pre and posttest was included with the
program as a tool to measure the change the patient may
experience, hopefully as a result of the program, in her
perceived levels of fear and anxiety associated with her
surgery.
This affect on her fear and anxiety, along with
increased information and awareness, were the major goals
of the program.
The hypothesis developed for this pro-
gram is stated in the null form:
Patient's perceived levels of fear and anxiety
are not affected by exposure to a selected
health education program.
23
Program Design
While deciding on what form would be the most
effective and useful for the Parkwood program, many
limitations had to be considered.
Since Parkwood had
no other programs, and the staff as a whole were more
clinically than educationally oriented, we concluded
that a simple, easily administered program would be the
best way of introducing patient education into the hospital.
Some hospitals have programs adapted to their
closed circuit television systems, videotape equipment,
or aimed at group education.
Because of the small number
of patients that would receive the education program and
the lack of sophisticated audio-visual equipment, it was
decided that a program presented by this author on a one
to one basis with the patients would be the most feasible
and effective.
It was felt that this one to one presentation
would give a more personal touch to the program, and promote discussion or questions from the patients.
Since
the program would hopefully continue being presented
after this study, and no patient educators were employed
at that time, it was necessary to keep the methods and
media used simple enough for the nursing staff, or patient herself to operate.
An easily transportable cas-
sette tape would contain the educational information and
24
would be accompanied by a visual supplement.
Since a
slide or movie projector would be too complicated to
operate, the visual portion would take the form of a
booklet of photographs or illustrations, reiterating
information on the tape.
For purposes of this study a written pre and
posttest would be administered to help the researcher detect any changes in the patient's attitude and responses
as a result of the program.
The cooperating obstetrician-gynecologist had
developed a short outline listing some of the basic content areas he intended the program to address.
This
author expanded the outline and asked a hospital anesthesiologist, an operating room nurse, and other medical
professionals to contribute more specific information
concerning their expertise for development of the tape.
The outline was revised repeatedly until it seemed to
met the objectives formulated for the program.
A script
for the tape was devised and submitted to many of the
contributing personnel for additions or changes.
It
soon became apparent that five or six health professionals from different areas, with different personal
and professional concerns, would not be able to totally
agree on one program's educational content and goals.
Since this program was to be used for one
physician's patients, it was his preferences and
25
suggestions that were ultimately used to develop the
final script (Appendix II).
The final outline used for
the script was as follows:
I.
II.
Introduction
A.
Overview of material to be discussed
B.
The holistic approach
l.
physical
2.
emotional
3.
spiritual
Reactions produced by hospitalization
A.
Fear
l.
when faced with the unknown
2.
becoming dependent on others
B.
Hospital as a new environment
C.
Dependency during hospitalization
D.
l.
for food
2.
clothing
3.
transportation
4.
cleaning yourself
5.
basic bodily functions
Conforming to your physician's and hospital
orders
l.
for eating
2.
sleeping
3.
walking
4.
bathroom use
26
III.
Role of fear
A.
Plays a part in medical treatment
B.
Effect of fear
1.
IV.
V.
physiological changes
a.
blood pressure
b.
pulse
c.
strength
2.
length of hospital stay
3.
amount of medication required
4.
speed of recovery
5.
coping with fear
Discussion of anesthesia
A.
Tests and diagnostic procedures performed
B.
Evaluation of medical history
C.
Pre-surgery anesthestic visit
Discussion by operating room nurse
A.
Consent form
B.
Admission
C.
Introduction to hospital environment
D.
Pre-surgery preparations
E.
1.
shaving of surgical site
2.
special baths or showers
3.
douche or enemas
4.
explanation of N.P.O.
5.
pre-operative medication
Transportation to surgical suite
27
F.
G.
H.
VI.
Recovery Room (pre-surgery)
1.
check in
2.
begin I. V.
Operating Room
1.
explain equipment and personnel
2.
anesthesia
Recovery Room (post surgery)
1.
increased awareness
2.
medical checks
Post Operative Phase
A.
Pain medication
B.
Medical checks
C.
D.
E.
1.
blood pressure
2.
pulse
Movement and activity
1.
helps digestion
2.
avoid gas pains
3.
reduce the risk of pneumonia
Changes caused by surgery
1.
bladder and bowel habits
2.
strength
3.
diet
4.
sensitivity
Visitation rules
'
'
28
F.
Recovery at home
1.
G.
possible changes in family routine
Invite questions and discussion.
A cassette tape was recorded with the cooperating
physician giving the introduction, the author discussing
the role of fear as it applies to surgery, the anesthesiologist briefly describing the process used to develop
the patient's personal anesthetic program, and the operating room nurse discussing the remainder of the outline.
The visual aid to accompany the cassette
recording was a 22 page booklet of drawn illustrations,
some taken from an introductory booklet the hospital
occasionally gives to new patients, and nine 35 mm color
photographs taken by the author of different areas of the
hospital.
These pictures had captions to help the pa-
tient synchronize the booklet with the education tape.
The content of the booklet was designed to compliment or
reiterate information on the tape, instead of to present
new educational content.
The written pretest administered to patients was
developed to gather some demographic information and
solicit patient satisfaction and suggestions on their
pre-surgery preparations by their physician, concerning
information given and questions answered.
To gather
information measuring the patient's attitudes toward
being a patient, hospitals, and the surgery she will soon
29
experience, semantic differential attitude scale
questions were developed.
The patient was given two
polar adjectives and asked to scale her feelings toward
that subject somewhere in between these adjectives.
It
was thought this technique would be easy to understand
and give the patient more freedom of response than objective questioning would provide.
Since one of our goals was addressed at lowering
the patient's perceived levels of fear and anxiety,
questions were given where the patient was asked directly
to rate what she believed was her level of reaction between the high and low ends of the scale.
The author
chose to measure the patient's perceived levels of fear
and anxiety because of the time factor involved, indepth
objective evaluative tests to establish internal levels
of these reactions require long testing periods, and to
reduce the inconvenience to patients.
Since the average
interview and presentation of the program took 60-75
minutes, more indepth testing might interfere with the
patient's preoperative preparations or actually make
them more apprehensive.
It was also felt that since
most of these surgeries had few risks involved, and the
recovery period was generally short the fear and anxiety
that was being experienced at the moment would have the
greatest effect and was the most important to uncover
and discuss.
In the literature, most studies that
30
incorporated indepth personality,
anx~~t:y,~ancl._fear
testi!l;9 were done with patients with a much longer
hospitalization period before and after their surgeries,
and/or those having more life-threatening procedures performed.
The patients were also asked to rate what they
considered their level of knowledge concerning their condition and surgery.
These questions, it was hoped,
might cause the patient to consider what they thought
was lacking in the way of pre-surgery information if
they rated themselves low, and may produce some suggestions or questions.
The posttest repeated the thirteen scale
questions on hospitals, surgery, and being a patient,
and the knowledge scales so that the means could be compared with the pretest.
It also included an area of
evaluation of the program, its length and information
content.
Selection of the Population
The population included in this project were
patients of the cooperating physician.
All of this
physician's patients admitted to the hospital for gynecologic surgery were eligible for the education program,
however, those admitted for diagnosis or treatment of a
life-threatening condition, i.e., cancer, and those
receiving therapeutic ,abortions were not included in
31
the sample receiving the pre and posttests.
It was
thought these conditions would produce a much greater
stress level, and were too emotionally charged to provide valid test results to be included with the rest of
the
sa~ple.
Also excluded were a few patients who
received the tape recording, and either requested not
to be given the pre and posttests, or whom the author
was unable to communicate with because of a language
barrier.
Chapter 4
PROGRAM EVALUATION
Program Evaluation Methods
The semantic differential scale positions were
converted to numberical values between 1.0 to 5.0.
Adjective
1
1 . 0-1 • 9
i
2 . 0- 2 . 9
3 . 0- 3 . 9
r4.
0- 4 . 9
5.0 Opposite
Adjective
The patient's responses were assigned a value between
these digits depending on its location on the scale.
The means of the 27 responses to each question were computed, then the differences between the means of the pre
and posttests were compared and t-tests were performed
to determine any significant differences that existed
between pre and posttest means.
The results of these computations and demographic
breakdowns are presented below in table form.
The first
5 tables represent the demographic statistics derived
from the questionnaire.
Table I shows that the majority of the
respondents (17) were married at the time of the study,
while decreasing numbers, seven and three, were single
or in an undescribed relationship.
32
33
TABLE I
Variable 1.
Marital Status of Respondents
Frequency
Married
%
17
62.9
Single
7
25.9
Other
3
11.1
Total
N
=
27
100.0%
TABLE II
Variable 2.
Age of Respondents
Frequency
%
20
-
under
1
3.70
21
-
25
4
14.81
26
-
30
5
18.51
31 - 35
5
18.51
36
-
40
7
25.92
41
-
45
4
14.81
46
-
50
1
3.70
27
100.0%
Total
N
=
I
34
Table II explores the age breakdown of the
respondents.
The majority (17) of the women, fell in
categories between 26 and 40 with even number of respondents above and below these ages.
TABLE III
Variable 3. Number of Surgeries
(include this one)
Frequency
%
1
7
25.9
2
12
44.4
3
8
29.6
Total
N
=
27
100.0%
Table III showed that almost 1/3 of the patients
were experiencing surgery for the first time.
For 12
this would be their second surgery, and the third for
eight of the respondents.
Table IV established that the large marjoity of
the patients (85.1%) were covered by some health care
insurance plan that would pay for all or part of their
surgery.
This left only four of the respondents paying
cash or covered by Medi-Cal insurance.
•
35
TABLE IV
Variable 4.
Method of Payment
Frequency
%
2
7.40
23
85.10
2
7.40
27
100.0%
Cash
Insurance
Medi-Cal
Total
N
=
TABLE V
Variable 5.
Amount of Pre-Surgery Information
Frequency
%
Less than I'd like
3
11.10
More than I'd like
4
14.81
20
74.07
27
100.0%
Just right amount
Total
N
=
Table V showed that most of the patients felt
they had received an adequate amount of pre-surgery
information before entering the hospital.
This question
was included upon the request of the co-operating
36
physician to learn how his pre-surgery preparation was
viewed by his patients.
Tables VI through XVIII compare the pre and
posttest means of the 13 semantic differential questions.
TABLE VI
Mean
Standard
Deviation
2.7889
0.840
# Cases
Variable
6
(Pretest)
by
Standard
Error
Difference
Mean
0.162
-0.1926
27
Variable
7
(Posttest)
2.9815
Standard
Deviation
0.789
Standard
Error
0.152
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 6
0.591
0.114
-1.69
26
0.102
Variable 7
Variables 6 and 7 (Table VI) measured the
patient's pre and posttest mean responses respectively
to the question:
37
Being a patient makes me feel:
dependent
independent
TABLE VII
Mean
Standard
Deviation
3.0444
0.787
# Cases
Standard
Error
Difference
Mean
Variable
8
(Pretest)
0.151
27
by
0.1444
Variable
9
(Posttest)
2.9000
Standard
Deviation
0.762
Standard
Error
0.147
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 8
0.448
0.086
1.167
26
0.106
Variable 9
Variables 8 and 9 (Table VII) measured the
patient's pre and posttest mean responses respectively
to the question:
Being a patient makes me feel:
good
bad
38
TABLE VIII
He an
Standard
Deviation
Standard
Error
3.3074
0.712
0.137
# Cases
Variable
10
(Pretest)
by
Difference
Mean
27
0.4148
Variable
11
(Posttest)
2.8926
Standard
Deviation
0.795
Standard
Error
0.153
T-Value
Degrees
Freedom
2 tail
Prob.
Variable 10
0.441
0.085
4.89*
26
0.000
Variable 11
*
The asterisk beside the T-value in Table VIII
indicates significance at the .05 level.
Variables 10 and 11 (Table VIII) measured the
patient's pre and posttest mean responses respectively
to the question:
Being a patient makes me feel:
/
relaxed
L - - - - - L - - - - - - - L - - - - - - ' - - - - - - ' anxious
v/
/
39
TABLE IX
Mean
Standard
Deviation
Standard
Error
3.1741
0.726
0.140
# Cases
Variable
12
(Pretest)
by
Difference
Mean
26
0.3333
Variable
13
(Posttest)
2.8407
Standard
Deviation
0.724
Standard
Error
0.139
T-Vale
Degrees
Freedom
2 Tail
Prob.
Variable 12
0.574
0.110
3.02*
26
0.006
Variable 13
* The asterisk beside the T-value in Table IX indicates
significance at the .05 level.
Variables 12 and 13 (Table IX) measured the
patient's pre and posttest mean responses respectively
to the question:
Being a patient makes me feel:
calm
~--------~-----------L----------~--------~
fearful
40
TABLE X
Mean
Standard
Deviation
Standard
Error
3.2333
0.945
0.182
# Cases
Variable
14
(Pretest)
Difference
Mean
27
by
Variable
15
(Posttest)
0.1667
3.0667
Standard
Deviation
0.894
Standard
Error
0.172
T-Value
Degrees
Freedom
2 tail
Prob.
26
0.329
Variable 14
0.351
0.068
2.47*
Variable 15
*
The asterisk beside the T-value in Table X indicates
significance at the .05 level.
Variables 14 and 15 (Table X) measured the
patient's pre and posttest mean responses respectively
to the question:
Hospitals make me feel:
happy
sad
41
TABLE XI
Mean
Standard
Deviation
3.0407
0.781
# Cases
Variable
16
(Pretest)
by
Standard
Error
Difference
r1ean
0.150
27
0.0963
Variable
17
(Posttest)
2.9444
Standard
Deviation
0.804
Standard
Error
0.155
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 16
0.503
0.097
1.00
26
0.329
Variable 17
Variables 16 and 17 (Table XI) measured the
patient's pre and posttest mean responses respectively
to the question:
Hospitals make me feel:
good
bad
42
TABLE XII
Mean
Standard
Deviation
3.1778
0.761
# Cases
Variable
18
(Pretest)
Standard
Error
Difference
Mean
0.147
27
by
0.2370
Variable
19
(Posttest)
2.9407
Standard
Deviation
0.698
Standard
Error
0.134
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 18
0.457
0.088
2.70*
0.012
26
Variable 19
* The asterisk beside the T-value in Table XII indicates
significance at the .05 level.
Variables 18 and 19 (Table XII) measure the
patient's pre and posttest mean responses respectively
to the question:
Hospitals make me feel:
calm
fearful
43
TABLE XIII
Mean
Standard
Deviation
3.1926
0.845
# Cases
Variable
20
(Pretest)
Standard
Error
Difference
Mean
0.163
27
by
0.3593
Variable
21
(Posttest)
2.8333
Standard
Deviation
0.880
Standard
Error
0.169
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 20
0.337
0.065
5.55*
26
0.000
Variable 21
* The asterisk beside the T-value in Table XIII indicates
significance at the .05 level.
Variables 20 and 21 (Table XIII) measured the
patient's pre and posttest mean responses respectively
to the question:
Hospitals make me feel:
relaxed
anxious x///
44
TABLE XIV
He an
Standard
Deviation
2.7037
0.573
# Cases
Variable
22
(Pretest)
by
Standard
Error
Difference
Mean
0.129
27
0.2407
Variable
23
(Posttest)
2.4630
Standard
Deviation
0.587
Standard
Error
0.113
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 22
0.402
0.077
3.11*
26
0.004
Variable 23
*
The asterisk beside the T-value in Table XIV indicates
significance at the .05 level.
Variables 22 and 23 (Table XIV) measured the
patient's pre and posttest mean responses respectively
to the question:
Hospitals make me feel:
///~
safe
unprotected
c/
45
TABLE XV
Mean
Standard
Deviation
3.1593
0.758
# Cases
Variable
24
(Pretest)
by
Standard
Error
Difference
Mean
0.146
27
0.1593
Variable
25
(Posttest)
3.0000
Standard
Deviation
0.862
Standard
Error
0.166
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 24
0.882
0.170
0.94
26
0.357
Variable 25
Variables 24 and 25 (Table XV) measured the
patient's pre and posttest mean responses respectively
to the question:
Knowing I will soon experience surgery makes me feel:
good
't
bad
46
TABLE XVI
Mean
Standard
Deviation
3.0593
0.860
# Cases
Variable
26
(Pretest)
by
Standard
Error
Difference
Mean
0.165
27
0.1778
Variable
27
(Posttest)
2.8815
Standard
Deviation
0.781
Standard
Error
0.150
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 26
0.673
0.129
1.37
26
0.181
Variable 27
Variables 26 and 27 (Table XVI) measured the
patient's pre and posttest mean responses respectively
to the question:
Knowing ,I will soon experience surgery makes me feel:
well
unhealthy
47
TABLE XVII
Mean
Standard
Deviation
3.3667
0.839
# Cases
Variable
28
(Pretest)
by
Standard
Error
Difference
Mean
0.162
27
0.1852
Variable
29
(Posttest)
3.1815
Standard
Deviation
0.904
Standard
Error
0.174
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 28
0.536
0.103
1. 79
26
0.084
Variable 29
Variables 28 and 29 (Table XVII) measured the
patient's pre and posttest mean responses respectively
to the question:
Knowing I will soon experience surgery makes me feel:
calm
fearful
48
TABLE XVIII
Mean
Standard
Deviation
3.3111
0.763
# Cases
Variable
30
(Pretest)
by
Standard
Error
Difference
Mean
0.147
-0.1222
27
Variable
31
(Posttest)
3.4333
Standard
Deviation
0.699
Standard
Error
0.135
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 30
0.408
0.079
-1.56
26
0.132
Variable 31
Variables 30 and 31 (Table XVIII) measured the
patient's pre and posttest mean responses respectively
to the question:
Knowing I will soon experience surgery makes me feel:
confused
knowledgeable
The last four tables represent the responses to
scale questions asking the patients to rate thf:!mselves
(from high to low) concerning the amount of fear and
49
anxiety they perceived themselves of experiencing pre
and posttest, and the levels of knowledge they felt they
possessed pre and posttest.
TABLE XIX
Mean
Standard
Deviation
3.2000
0.643
# Cases
Variable
32
(Pretest}
by
Standard
Error
Difference
Mean
0.124
27
-0.2222
Variable
33
(Posttest}
3.4222
Standard
Deviation
0.650
Standard
Error
0.125
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 32
0.509
0.098
-2.27*
26
0.032
Variable 33
*
The asterisk beside the T-value in Table XIX indicates
significance at the .05 level.
Variables 32 and 33 (Table XIX) measured the
patient's pre and post test mean reasponses respectively
to the question:
50
I would rate my level of fear as:
high
low
TABLE XX
Mean
Standard
Deviation
2.4815
0.881
# Cases
Variable
34
(Pretest)
Standard
Error
Difference
Mean
0.169
27
by
-0.2481
Variable
35
(Posttest)
2.7296
Standard
Deviation
0.835
Standard
Error
0.161
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 34
0.610
0.117
-2.11*
26
0.044
Variable 35
* The asterisk beside the T-value in Table XX indicates
significance at the .05 level.
Variables 34 and 35 (Table XX) measured the
patient's pre and posttest mean responses respectively
to the question:
51
I
would rate my level of anxiety as:
high
low
TABLE XXI
Mean
Standard
Deviation
2.2259
0.894
# Cases
Variable
36
(Pretest)
Standard
Error
Difference
Mean
0.172
27
by
0.1741
Variable
37
(Posttest)
2.0519
Standard
Deviation
0.889
Standard
Error
0.171
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 36
0.655
0.126
1. 38
26
0.179
Variable 37
Variables 36 and 37 (Table XXI) measured the
patient's pre and posttest mean responses respectively
to the question:
My level of knowledge concerning my condition ls:
high
~--------~----------~--------4---------~
low
52
TABLE XXII
Mean
Standard
Deviation
2.1741
0.764
# Cases
Variable
38
(Pretest)
by
Standard
Error
Difference
Mean
0.147
27
0.1926
Variable
39
(Posttest)
1. 9815
Standard
Deviation
0.710
Standard
Error
0.137
T-Value
Degrees
Freedom
2 Tail
Prob.
Variable 38
0.531
0.102
1.89
26
0.070
Variable 39
Variables 38 and 39 (Table XXII) measured the
patient's pre and posttest mean responses respectively
to the question:
tiJ.y level of knowledge concerning my surgery is:
low
high
The computer was used to perform t-tests
comparing the pre and posttest means of the semantic
differential, subjective scales, and knowledge scale
53
questions for any significant difference between the
means.
With a .05 level of significance, eight of the
t-values comparing the variables were found to be significant.
bers.
Four of the t-values resulted in negative numThis can be attributed to the four 1nstances where
the polar adjectives progressed from the negative value
towards positive, whereas the other 13 comparisons went
from positive to negative.
Discussion
The findings and data generated by the Parkwood
study were supportive of most other work that has been
done in the health education field related to this subject that has been mentioned in this study.
The results
of the t-tests seem to support the theory and objectives
behind this study, decreasing perceived patient fear and
anxiety through patient education.
This part of the program was considered a
success because 8 of the 15 questions measuring attitudes
that could be influenced by fear and anxiety showed statistical significance between pre and posttest means.
It should be mentioned that the seven other questions
showed a slight positive change between pre and posttest
means but not enough to be statistically significant.
The two questions that directly asked the patients to
rate her knowledge, did not produce significant changes.
54
This could have resulted due to the fact that increasing
patient knowledge was not a main objective of the study,
therefore little emphasis was placed upon it in the
education program.
There are other explanations that could have
contributed to the success of this program besides simple program effectiveness;
{1) Patients were given the
choice to participate in the program or not to,
{2) The
participating physician usually mentioned the education'
program to his patients prior to their hospital admission,
{3) The majority of the patients who accepted to
take part in the program had favorable expectations and
were very co-operative.
These conditions might have had
a positive affect on the outcome of the test results.
Chapter 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
Summary
The field of patient education is evolving into
a science with its own theories, methods and evaluative
tools.
The research being completed and published fur-
ther show health education to be a beneficial element of
modern health care.
With the infinitive variety of methods that can
be used, from one to one discussion of a health topic,
to multi-media presentations complete with in depth evaluative techniques, some type of health education program
can be developed for most any set of goals, any type of
patient, to be presented anywhere.
This project was developed for pre-surgery
gynecological patients at Parkwood Community Hospital.
Emphasis was placed not only on providing useful information dealing with surgery and the hospital, but any
effect education may have had upon the levels of fear
and anxiety the patients perceived in themselves, was of
special interest.
It was hoped that a program incorpo-
rating information, education, and discussion would
result in a decrease in levels of perceived fear and
55
56
anxiety between pre and posttest responses to questions
aimed at subjectively measuring these variables.
Perceived levels of variables were concentrated
on and measured as opposed to actual changes, because
they required less in depth testing and evaluation.
It
was felt that a perceived change that the patient herself
judged to have taken place, would contribute to the patient's confidence and well being, and therefore was a
valid goal to try to achieve with this program.
Conclusions
The education program was presented over a five
month period to patients of the participating physician
the evening before their surgery.
From the data col-
lected, statistics drawn, and evaluation methods, the
program was shown to have met its objectives of increasing patient knowledge, decreasing patient's perceived
levels of fear and anxiety, and providing patients an
opportunity to discuss their hospital stay.
Recommendations
The author recommends that this program should
be re-instituted in full or in part at Parkwood Community
Hospital to aid pre-surgery patients with similar needs
as those used in this study.
While administering this
program, patient education was beginning to be accepted
as an important part of health care by some of the staff
57
at Parkwood.
Since that time there have been many
changes in the staff, such as the hospital administrator
and director of nursing, so that the emphasis on patient
education is unknown.
It is recommended that this and
other studies be used to show the potential effectiveness of such programs, and aid in their development and
administration.
In the area of research, more studies need to be
done exploring some of the specifics of patient education.
Examining what methods are the most effective for,
certain subject areas, types and numbers of patients, and
various places of presentation could be very useful for
people in the field developing programs.
More specific experimentation dealing with these
problems could only favorably add to the amount of information showing the positive potential patient education
programs hold for patients, physicians, and hospital
staffs.
REFERENCES
1.
Axford, R., and L. Cutchen.
"Using Nursing
Research to Improve Preoperative Care." Journal
of Nursing Administration, Volume 7(10) :16-20,
December, 1977.
2.
Barnett, Lane.
"Preparing Your Patient for the
Operating Room." AORN, Volume 18(3) :534-9,
September, 1973. ----
3.
Birkinshaw, K.
"Pre-operative Approach to Patients."
Anesthesia, Volume 33(6) :355-61, June, 1978.
4.
Boegli, E., R. Boegli.
"Can Preoperative Learning
be Improved?" AORN Journal, Volume 16(5) :43-5,
November, 1972.
5.
Bryant, R.
"The Desirability of a Pre-operative
Teaching Program for Cardiac Surgical Patients."
Australian Nurses Journal, Volume 6(11) :28-30,
May, 1977.
6.
Chan, J.
"Preparation for Hospitalization,
Procedures and Surgery Through Play." V
Australian Nurses Journal, Volume 5(4) :41-4,
October, 1976.
7.
Coombe, E.
"Tuning in on Stress Signals." Journal
of Nursing Education, Volume 15(4) :16-21,
July, 1976.
8.
Connors, P.
"Comments on Informed Consent."
Maryland State Medical Journal, Volume 27(1} :467, September, 1978.
9.
Daniels, L.
"How Can You Improve Patient
Compliance?" Nursing (Horsham), Volume 8(5) :407 , May , 19 7 8 .
10.
Felton, G., K. Huss, E. Payne, K. Srsic.
"Preoperative Nursing Intervention with the
Patient for Surgery: Outcomes of Three Alternative Approaches." International Journal of
Nurses Studies, Volume 13(2) :83-96, 1976.
58
59
11.
Fortin, F., S. Keronuac.
"A Randomized Controlled
Trial of Preoperative Patient Education."
International Journal of Nurses Studies,
Volume 13{1) :11-24, 1976.
12.
Fortin, F., S. Kerouac.
"Validation of
Questionnaires on Physical Function." Nursing
Reach, Volume 26{2) :128-35, March-April, 1977.
13.
Freeman, D.
"Visits by Recovery Room Nurses
Defended." AORN Journal, Volume 28 ( 1): 29,
July, 1978.
14.
Girouard, s.
"The Role of the Clinical Specialist
as Change Agent: An Experiment in Preoperative
Teaching." International Journal of Nurses
Studies, Volume 15{2) :57-65, 1978.
15.
Gordon, R.
"Efficacy of a Group Crisis-Counseling
Program for Men who Accompany Women Seeking
Abortions." American Journal of Community
Psychology, Volume 6{3) :239-46, June, 1978.
16.
Gruendemann, B.
"Preoperative Program Group
Sessions Part of Nursing Process." AORN Journal,
Volume 26(2) :257-62, August, 1977.
17.
Johnson, J., v. Rice, S. Fuller, M. Endress.
"Sensory Information, Instruction in a Coping
Strategy, and Recovery from Surgery." Research
in Nursing Health, Volume 1(1) :4-17, April, 1978.
18.
Kapser, P.
"The Preoperative Visit-O.R. Nurses and
Patients Interact." Hospitals, Volume 50(8) :878, April, 1976.
19.
Kessler, H.
"Preoperative Education and the
Informed Patient." Journal of Legal Medicine,
Volume 5(10) :46-7, October, 1977.
20.
Kinney, M.
"Effects of Preoperative Teaching Upon
Patients with Differing Modes of Response to
Threatening Stimuli." International Journal of
Nurses Studies, Volume 14(1):49-59, 1977.
21.
Laird, M.
"Techniques for Teaching Pre- and Postoperative Patients." American Journal of
Nursing, Volume 75(8) :1338-40, August, 1975.
60
22.
Lebourdais, E.
"Pre-operative Teaching Makes
Happier Patients." Dimensions in Health Services,
Volume 54(1) :13, January, 1977.
23.
Leigh, J., J. Walker, P. Janaganathan.
"Effect of
Preoperative Anesthetic Visit on Anxiety."
British Medical Journal, Volume 2(6093) :987-9,
October 15, 1977.
24.
Lindeman, C.
"Influencing Recovery Through Preoperative Teaching." Heart and Lung, Volume 2
(4) :515-21, July-August, 1973.
25.
Lindeman, C.
"Nursing Intervention with the Presurgical Patient: Effectiveness and Efficiency
of Group and Individual Preoperative Teaching."
Nursing Research, Volume 21(3) :196-209, May-June,
1972.
26.
Long, M. L., Scherhing, Christain.
"Cardio
Pulmonary Bypass." American Journal of Nursing,
Volume 74(5) :860-7, May, 1974.
27.
Lyons, M.
"What Priority do you Give Preop
Teaching?" Nursing (Jenkintown), Volume 7(1):
12-4, January, 1977.
28.
Merkatz, R., D. Smith, P. Seitz.
"Preoperative
Teaching for the Gynecologic Patient." American
Journal of Nursing, Volume 74(5) :1072-4, June,
1974.
29.
Morgan, D.
"Prepared Patients make Faster Surgical
Recovery." Canadian Hospital, Volume 50(7) :45,
Passim, July, 1973.
30.
Murphy, M., C. Roglitz.
"Preoperative Teaching,
Integration of Nursing and Social Work Services."
Journal of Neurosurgical Nursing, Volume 9(1) :511, March, 1977.
31.
Needs, J.
"Attitudes to Hysterectomy." Australian
Nurses Journal, Volume 5(1) :27-8, July, 1976.
32.
Park, s.
"Preoperative 'Teach-in'." Canadian
Nurse, Volume 68(10) :38-9, October, 1972.
33.
Phillips, C.
"The Hysterectomy Patient in the
Obstetrics Service: A Presurgery Class Helps
Meet Her Needs." Journal OBGYN Nursing, Volume
6(1) :45-9, January-February, 1977.
61
34.
Prsala, H.
"Admission Unit Dispels Fear of
Surgery." Canadian Nurse, Volume 70(12) :24-6,
December, 1974.
35.
Roccella, E.
"Potential for Reducing Health Care
Costs by Public and Patient Education. Summary
of Selected Studies." Public Health Reports,
Volume 91(3) :223-5, May-June, 1976.
36.
Schrader, E.
"Group Teaching can Supplement Patient
Interviews." AORN Journal, Volume 26(2) :223-4,
226, August, 1977.
37.
Schrankel, D.
"Preoperative Teaching." Supervisory
Nursing, Volume 9(5) :82-90, May, 1978.
38.
Skillings, I.
"Emotional Support for Surgery
Patients." AORN Journal, Volume 26(2) :263-5,
August, 1977.
39.
Sly, Michael.
"Evaluation of a Sound Slide Program
for Patient Education." Annals of Allergy,
Volume 34, 94-97, February, 1975.
40.
Storch, M., M. Shanahan.
"Preparation and Education
for the Patient Undergoing Hysterectomy: Case
Report." QRB, Volume 3(3):25-7, March, 1977.
41.
Thomson, E.
"Preop Visits-For the Nurse-For the
Patient?" AORN Journal, Volume 16(4) :75-81,
October, 1972.
42.
Williams, M.
"Easier Convalescence From
Hysterectomy." American Journal of Nursing,
Volume 76(3) :438-40, March, 1976.
43.
Wren, B.
"Counseling the Hysterectomy Patient."
Medical Journal of Australia, Volume 1(2) :87-9,
28 January 1978.
APPENDICES
62
APPENDIX A
PATIENT PRETEST
Please answer in space provided.
NAME
MARITAL STATUS
Single
Married
Other
AGE
PHONE NUMBER
1.
Is this your first surgical experience?
No
Yes
If no, what was the nature of your previous
experience(s)?
2.
Method of payment for hospital services?
Cash payment
Insurance
Medicare or Medical
3.
The information concerning your surgery given to
you before admission \117aS:
less than I'd like
more than I'd like
just about right
63
64
4.
Do you feel that you have had the opportunity to
ask questions concerning your condition and surgery?
and received adequate explanation?
5.
If you could receive more information concerning
condition and surgery, what areas would interest you?
The following questions are scale questions. Because it
is often difficult to give a definite yes or no answer
to many questions, answering on a scale lets you respond
somewhere in between. Here you are given two opposite
responses, placB your response somewhere on the line
between that best shows your true feelings.
Being a patient makes me feel:
dependent
L--------~------~--------~------4 independent
good
relaxed
bad
L------~~-------+--------._------~
calm
anxious
fearful
Hospitals make me feel:
happy
sad
good
bad
calm
fearful
relaxed
safe
L
anxious
unprotected
65
Knowing I will soon experience surgery makes me feel:
good
bad
well
unhealthy
calm
fearful
I would rate my level of fear as:
high
low
I would rate my level of anxiety as:
low
high
I
My level of knowledge concerning my condition is:
low
high
.r-1:y level of knowledge concerning surgery is:
high
~----------~----------~------------~--------~
low
APPENDIX B
PATIENT POSTTEST
Post- test
I found the information in the program:
New
Yes
Technical
Yes
General
Yes
Useful
Yes
Needed
Yes
Understandable
Yes
Valuable
Yes
1
2
3
4
5
----------------------------2
1
3
4
5
-----------------------------
No
2
1
------------~3
______4~----~5
No
No
5
No
1
2
3
4
5
----------------------------1
2
3
4
5
----------------------------1
2
3
4
5
-----------------------------
No
2
1
3
4
--------------~------------~
No
No
The length of the tape was
Too long
Too short
Additional Information Needed:
Information you feel could be omitted:
I would rate my level of fear:
high
low
66
67
I would rate my level of anxiety as:
high
low
My level of knowledge concerning my condition is:
high
low
My level of knowledge concerning my surgery is:
high
low
Please use the same instructions given on the pre-test
for answering scale questions to answer the following
set of scale questions.
Knowing I will soon experience surgery makes me feel:
good
well
bad
L----~------~------~----~
calm
confused
unhealthy
fearful
L------~--------~--------~------~ knowledgeable
Hospitals make me feel:
happy
sad
good
bad
calm
fearful
relaxed
anxious
safe
unprotected
68
Being a patient makes me feel:
dependent
independent
good
bad
relaxed
anxious
calm
fearful
APPENDIX C
PATIENT EDUCATION TAPE RECORDING
This is your physician Dr. Bresky.
I'd like to
warmly welcome you to Parkwood Community Hospital.
You
of course are very familiar with me, but Parkwood Community Hospital is probably a strange and perhaps frightening place to you at this moment.
I want to reassure you
that from my past experiences here at Parkwood, that all
the members of the Parkwood Hospital staff are here to
serve you and provide you with high quality, personal
care.
In order to lower the amount of nervousness you
may be feeling now, we would like to provide you with
some information and insight, in what your care will be
like before surgery and upon your return from surgery.
Prior to going to surgery, a few tests will be done, as
ordered by me.
In many respects you are feeling fine and
are totally aware of what is happening to you at this
moment, however after surgery, you will not be quite as aware of what is occurring, and that is why we feel it is
important for us to take this opportunity to give you a
fuller sense of awareness.
Let me now introduce one of
the members of the hospital staff to tell you a little
more about what is going to happen during your hospital
stay.
69
70
Welcome to Parkwood Community Hospital.
At this
time we would like to present to you this tape recording
designed to help you before your surgery.
In the next
few minutes we will explore the routine procedures all
surgery patients experience during the pre-operative,
post operative, and recovery phases of your stay in
Parkwood.
We at Parkwood hope to demonstrate our dedication
to the holistic approach to medicine.
We aim to deal
with the physical, emotional, and spiritual needs of the
patient by providing complete medical care, as well as
answering your questions, helping you understand the ways
of the hospital so you can make your stay here as pleasant and comfortable as possible.
We believe the more at
ease you are, the smoother and safer your surgery will
be, and the quicker and more complete recovery you will
make.
As you may be experiencing at the moment, being
hospitalized can produce many reactions.
Fears are a
natural reaction of the surgery patient, or any one,
when faced with the unknown and the fear problem of
being dependent on others.
The hospital is a new environment to you.
It is
full of new people, strange equipment, and different
surroundings than you are accustomed to.
You probably
have many previous feelings and attitudes about hospitals
71
and many questions about your condition and the surgery.
Discuss these questions with your doctor.
The nurses
attending you are not prepared to answer all these questions correctly for you.
They want to do what is best
for you to make your stay as comfortable as possible,
get the detailed information from your physician.
We are all reluctant to lose the power and
control we normally have over our bodies and become dependent on others for
our care.
This situation is one
we must inevitably face to some extent while a surgery
patient.
During your stay in the hospital, depending on
your condition, you may have to depend on others for
food, a change of clothing, transportation, cleaning
yourself, and help with basic bodily functions.
You must
conform to the hospital's schedule and your doctor's orders, for eating, sleeping, walking, and bathroom use.
Remember, these requests are for your well being as a
patient at Parkwood.
This dependency may be temporary,
during your stay in the hospital, or until you have recovered.
The changes in your lifestyle and in relations
with others that you may need to make should be discussed with your physician.
The reason we are concerned with your feelings
and fears is because they play a large part in your
medical treatment.
They may affect your confidence in
your doctor and all the hospital staff you come in
72
contact with.
Taking these unresolved feelings into
surgery with you can produce physiological changes in
yciur blood pressure, pulse, strength, and influence the
success and safety of your surgery.
Many doctors have
found that patients who were prepared for their surgery
and hospital stay, needed to stay in the hospital a
shorter period of time, often needed less medication,
and made a more rapid and complete recovery.
Let us try to help you understand and cope with
your fears to make your hospital stay more pleasant for
everyone.
Now, hospital staff will explain your
preparation for surgery, the operating room and your
post operative care.
As chief of the Department of Anesthesia, I
welcome you to Parkwood Community Hospital and hope that
your hospital stay will be pleasant.
Depending on your
age, past medical history, physical condition, and contemplated surgery, you will have a variety of procedures
performed prior to your operation.
These may include
blood and urine tests, and X-rays, and may include
electrocardiogram, breathing studies and special diagnostic procedures as indicated.
When these studies have been completed and
results obtained, a member of the anesthesia staff will
73
evaluate your past medical history and preoperative
laboratory studies to make sure you are in optimal condition for your scheduled surgery.
He will then visit you
either the night before or early the morning of your
surgery to discuss the anesthesia best suited for you
and answer any questions you may have.
Hello, I am one of the operating room nurses.
By now your physician has explained clearly your surgical procedures and you should understand what is to be
done.
On your consent form, your procedure is typed in
exactly as your doctor described it.
Your consent form
also tells you of possible risks involved, and may be
frightening to you.
If so, perhaps you should further
discuss these fears with your doctor, who will explain
the surgical procedure to you.
I want to tell you what
to expect during the hospital admission and later after
you enter the double doors of our surgical suite.
When you are admitted, you will be taken to your
room on the surgical floor.
There your nurse will demon-
strate the use of all equipment and acquaint you with
your environment.
Depending on the doctor's
order~,
your surgical area may be ''prepped" or prepared in certain ways.
You may have the area gently shaved of hair,
you may be asked to bathe or shower with a special soap
solution.
These activities are designed to reduce the
74
bacteria on the skin.
There may be other preps, again
depending on your condition, such as a special douche,
or enemas to cleanse the lower bowel of stool.
These
procedures are also designed to reduce the possibilities
of infection, and although uncomfortable and or annoying,
will be gently administered by your nurse in a manner
that will protect your dignity and privacy as much as
possible.
If you are admitted in the evening prior to
surgery you will be kept N.P.O. after midnight.
Kept
N.P.O. means that nothing is to be taken by mouth the
night before your operation.
This is very important.
Even chewing gum stimulates stomach juices which could
be vomitted while in a drowsy state, and sucked into
your lungs thereby causing pneumonia.
To further avoid
any such occurrences, your preoperative medication ordered by your anesthesiologist will probably contain a
drug which will tend to further dry your body secretions.
You will notice this from a dry mouth sensation.
Your
pre operative medication is usually given within one
hour of your procedure's start.
Approximately one half hour prior to your
scheduled surgery time, an orderly from surgery will
bring a querney or rolling bed into your room, push it
against your bed, cover you with a blanket and ask you
to slide over from your bed onto the querney.
He will
75
put up the side rails to protect you from falling and
take you down the elevator to the surgical suite.
First you are rolled in to the recovery room to
be checked in by the secretary, all necessary papers will
be prepared, your last checklist completed and an R.N.
will start an I.V. in your hand.
I.V. stands for
intravenous and an I.V. tube will bring fluids and medication into your body.
This may hurt a little, but only
for a very short time and will be done as gently and
skillfully as possible.
When all preparations are completed in the
recovery room, and you have met the nurse who will take
care of you immediately following your surgery, your
operating room nurse will come in and introduce him or·
herself and take you to the operating room.
In the operating room you will see several
people, your anesthesiologist, who will sit at the head
of the operating table, your surgeon, a scrub technician,
skilled at handing the correct instruments to the surgeon,
and one or two R.N.'s (Registered Nurses).
You will see a large set of lights overhead, and
a good deal of strange equipment and instruments set up.
The room may feel cold to you.
Soon you will be covered
completely with surgical sheets except for the small
area of your surgery.
76
The nurses will assist you to slide from your
querney onto the operating table.
A safety strap may be
placed around you to protect you from falling.
Small
sticky EKG electrodes pads will be placed on your chest
so that your heart may be monitored during surgery.
An-
other sticky cold feeling pad may be placed on your
upper thigh.
safety.
This is another grounding pad for your
Your I.V. arm will be extended out from your
body on an arm board attached to the table in a comfortable position.
The anesthesiologist will begin to give
you small test doses of drugs to check their effect and
a special oxygen mask will be placed over your nose and
mouth.
You may feel your eyelids become very heavy but
will be aware of what is happening until the doctor
signals he is going to put you to sleep, usually by
telling you goodnight.
Many people are more afraid of
helplessness than they are of actual surgery.
Be as-
sured that your anesthesiologist, surgeon, and nurse
understand this and will treat you with kindness, gentleness, and respect for your personal dignity.
After your procedure, you are awakened by the
anesthesiologist to a safe level of reaction before you
are moved back to the recovery room.
not remember this.
You will probably
More awareness will gradually come
to you, as the recovery room nurse continually checks
your blood pressure and pulse, your reaction to being
77
spoken to, your ability to coordinate movement, and of
course she will check your surgical site and/or any
dressing or bandages for bleeding.
Your I.V. will con-
tinue to run in the recovery room.
It will be taken out
when the condition requires it.
If you feel cold your
recovery room nurse will give you a blanket heated in a
special warmer.
When the recovery room nurse and the
anesthesiologist notice that you are sufficiently
recovered from the effects of the anesthetic drugs and
gases, you will be taken by a nurse and an orderly back
to your room.
POST OP
During the post operative phase you may
experience pain and discomfort associated with your
surgery.
You can ask for pain relief medication, but
remember, your doctor has left strict orders concerning
the amount and time intervals of your dosages.
Larger
doeses administered more often could be very dangerous
to your health.
Your blood pressure and pulse will frequently
be checked by nurses.
All this attention is normal and
necessary to help you recover quicker.
Most post operative patients receive an I.V.
This is normal procedure to help supplement your fluids
and as a safety precaution.
78
During the period a certain amount of movement
and activity will be advised, such as turning in bed.
This is very important to help along with your recovery.
Movement can help with your digestion, avoiding gas pains,
and reduce the risk of pneumonia.
So even if you exper-
ience pain, remember, you would not be allowed any possibly damaging movement.
Your bladder and bowel habits may be changed
during this time due to your surgery, diet, inactivity
and medication.
You may experience some gas pains as a
result of these changes.
Your body as a whole is in a weakened state so
your diet and amount of activity may need to be changed
or controlled.
If you smoke your body may be highly
sensitive to cigarettes at this time.
You may even find
this a good time to quit.
You probably realize that your body is going
through many changes related to your surgery.
Although
most are nothing to be alarmed about, don't hesitate to
notify a nurse if you experience unreasonable pain, or
notice any bleeding.
During your post-op period you will be allowed
visitors in your room.
Many people will be anxious to.
see you but please, be sure they follow the hospital's
rules regarding times and numbers of visitors.
Two ,
visitors per patient, between one and eight o'clock,
79
and over 12 years of age.
Be careful not to overexert.
Start with short visits, then as your strength returns
have visitors stay a little longer.
Although you have been the surgery patient and
can see and feel how your surgery has affected you, you
may wonder how it will affect others close to you.
Your
recovery period may continue for some time after you
return home.
This may cause a few adjustments in every-
one's routine at home.
We hope you will take the time
to open up your feelings on this subject with family members.
You may also need to discuss any restrictions your
doctor may place on you concerning activity or diet.
We hope this discussion has been informative
and enjoyable for you and will make your experiences at
Parkwood Hospital more pleasant.
APPENDIX D
PRE AND POSTTEST RESULTS
Being A Patient Makes Me Feel:
Independent
Dependent
Bad
Good
Anxious
Relaxed
Fearful
Calm
Subject
Pre
Post
Pre
Post
Pre
Post
Pre
Post
1
2.8
2.9
4.5
4.3
4.5
4.6
4.5
4.6
2
1.5
3.2
3.5
3.2
3.5
2.2
3.2
3.2
3
4.8
4.3
4.5
3.9
4.5
4.2
4.5
4.4
4
3.0
3.0
1.5
1.5
1.5
1.5
1.5
1.5
5
2.5
4.5
2.5
3.8
2.5
1.8
4.5
1.8
6
2.6
2.5
3.3
3.5
3.3
3.5
3.3
2.5
7
3.5
2.8
3.5
3.7
3.5
3.2
3.0
2.8
8
4.5
4.5
4.5
3.5
4.5
3.5
2.8
2.8
9
3.2
3.1
3.2
3.1
4.0
3.5
3.0
3.2
10
3.0
3.5
2.8
3.0
3.5
3.0
3.5
3.0
11
3.5
3.5
2.5
2.2
2.5
2.2
2.2
2.5
12
2.8
3.2
3.0
2.8
2.5
1.5
2.8
2.8
00
0
PRE AND POSTTEST RESULTS
Being A Patient Makes Me Feel:
Independent
Dependent
(Continued)
Bad
Good
Anxious
Relaxed
Fearful
Calm
Pre
Post
Pre
Post
Pre
Post
Pre
Post
13
2.8
2.8
2.8
2.2
2.8
2.2
2.8
2.8
14
2.5
3.0
2.5
2.0
3.2
2.0
3.2
2.0
15
4.5
4.0
3.5
3.2
3.5
3.2
3.5
3.2
16
2.0
1.5
3.2
3.2
3.5
3.5
3.2
3.0
17
2.5
2.2
2.8
3.5
3.2
3.5
3.5
3.5
18
1.5
1.5
3.5
3.2
4.2
4.2
3.8
3.2
19
2.2
2.8
3.2
2.5
3.5
2.5
2.5
2.2
20
2.2
2.5
2.5
2.5
2.8
2.8
3.8
3.5
21
2.5
2.5
3.2
3.0
3.0
2.8
2.0
2.0
22
3.0
3.5
3.5
3.5
2.5
2.5
3.5
3.0
23
3.2
3.5
2.0
2.0
3.5
3.0
2.8
2.5
Subject
00
.......
PRE AND POSTTEST RESULTS
Being A Patient Makes Me Feel:
Independent
Dependent
(Continued)
Bad
Good
Anxious
Relaxed
Fearful
Calm
Subject
Pre
Post
Pre
Post
Pre
Post
Pre
Post
24
2.5
3.0
3.2
3.0
4.0
3.0
3.2
3.0
25
1.7
2.0
3.5
3.0
3.5
3.2
3.8
3.5
26
2.0
2.2
1.5
1.5
2.8
2.5
2.5
2.0
27
2.5
2.5
2.0
1.5
3.0
2.5
2.8
2.2
co
l'V
PRE AND POSTTEST RESULTS
Hospitals Make Me Feel:
Sad Happy
Bad Good
Subject
Pre
Post
Pre Post
Pre
Post
Pre
Post
Pre
Post
1
4.2
4.6
4.2
4.6
4.2
4.2
4.2
4.2
2.2
2.8
2
4.5
4.5
2.5
4.5
2.2
2.8
3.5
2.6
2.6
2.6
3
4.6
4.3
4.5
3.9
4.5
4.2
4.6
4.5
2.8
2.4
4
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
5
2.5
2.2
2.5
2.2
2.5
1.8
1.8
1.8
1.8
1.8
6
3.5
3.5
3.5
3.5
3.5
2.5
3.5
3.5
3.5
2.5
7
3.3
3.8
4.0
3.8
3.0
3.6
3.0
2.5
3.0
3.2
8
4.5
4.3
4.5
4.3
3.5
3.2
3.5
2.8
1.5
1.5
9
3.0
3.0
3.0
3.0
3.2
3.1
4.0
3.5
3.0
3.0
10
3.5
3.0
3.2
3.0
3.2
2.2
3.0
2.2
3.0
2.8
11
2.5
2.2
2.5
2.2
2.5
2.2
2.5
2.2
2.5
2.2
Fearful Calm
Anxious Relaxed
Unprotected Safe
00
w
PRE AND POSTTEST RESULTS
Hospitals Make Me Feel:
Fearful Calm
(Continued)
Sad Happy
Bad Good
Unprotected
Safe
Subject
Pre
Post
Pre Post
Pre
Post
Pre
Post
Pre
Post
12
3.5
2.8
2.5
2.5
2.5
2.5
3.5
2.8
2.5
2.5
13
2.8
2.5
2.8
2.5
2.5
2.8
2.5
2.8
2.5
2.8
14
1.5
2.0
1.5
2.0
1..5
2.0
1.8
1.0
1.8
1.0
15
4.2
4.2
3.5
3.5
3.5
3.5
3.5
3.5
2.5
2.5
16
3.2
3.0
2.8
2.8
3.2
3.0
3.5
3.0
3.2
3.0
17
3.2
3.5
3.2
3.2
3.2
3.2
3.8
3.2
2.3
2.3
18
4.5
3.5
3.8
3.2
4.2
3.2
4.2
4.2
4.2
3.2
19
3.5
3.2
3.2
2.5
3.2
2.2
3.2
2.2
3.2
2.2
20
2.5
2.5
3.0
2.8
4.0
3.8
4.2
4.0
3.0
3.0
21
1.5
1.5
2.5
2.5
3.5
3.0
3.8
3.5
2.5
2.2
22
2.8
2.5
3.2
3.0
2 .. 8
2.5
2.5
2.0
2.5
2.0
Anxious Relaxed
00
,:,.
PRE AND POSTTEST RESULTS
Hospitals Make Me Feel:
Sad Happy
Bad Good
Pre
Post
Pre Post
Pre
Post
Pre
23
3.5
3.0
2.8
2.2
3.2
3.0
24
2.0
2.0
3.5
3.0
4.2
25
3.5
3.2
2.2
2.0
26
4.5
4.0
3.5
27
3.0
2.5
2.2
Subject
Fearful Calm
(Continued)
Anxious Relaxed
Unprotected
Safe
Post
Pre
Post
4.0
3.5
3.2
3.0
4.0
1.8
1.8
2.2
2.0
3.8
3.2
2.5
2.2
4.2
3.5
3.3
3.5
3.0
3.5
3.0
3.0
2.8
2.0
3.2
3.2
2.8
2.5
2.8
2.2
co
Ul
PRE AND POSTTEST RESULTS
Surgery Makes Me Feel:
Well
Fearful
Calm
Knowledgeable
Confused
Pre
Post
Pre
Post
Pre
Post
3.8
4.8
4.8
4.1
4.5
4.8
4.8
2.5
4.3
4.2
4.2
2.6
2.6
2.6
2.6
3
4.4
2.5
2.5
2.5
4.6
4.2
4.5
4.3
4
1.5
1.5
1.5
1.5
1.5
1.5
2.5
2.5
5
2.5
3.2
2.5
3.2
2.5
2.5
4.5
4.5
6
4.5
2.5
3.5
2.5
3.5
3.6
2.5
3.5
7
4.0
3.8
3.0
3.0
3.2
3.5
2.8
3.7
8
4.5
4.5
4.5
3.5
4.5
3.5
2.8
2.8
9
3.5
3.0
3.0
3.0
3.5
3.5
3.0
3.0
10
3.5
3.0
3.5
3.4
3.0
3.5
3.0
3.5
11
2.5
2.3
2.5
2.2
2.5
1.5
4.5
4.5
Bad
Good
Subject
Pre
Post
1
3.1
2
Unhealthy
00
0'1
PRE AND POSTTEST RESULTS
Surgery Makes Me Feel:
Bad
Good
Well
Fearful
Calm
Knowledgeable
Confused
Pre
Post
Pre
Post
Pre
Post
Pre
Post
12
2.5
2.5
3.5
2.8
3.8
3.0
3.0
3.5
13
2.8
1.8
2.8
1.8
2.8
1.8
2.8
2.8
14
2.5
4.0
2.5
3.0
2.5
4.0
3.5
4.0
15
3.5
4.1
3.2
3.2
4.0
3.5
3.5
3.2
16
2.8
2.5
3.2
3.0
3.8
3.5
3.2
3.0
17
3.2
3.5
3.2
2.8
3.2
3.2
2.8
3.8
18
3.2
2.8
1.2
3.5
4.5
4.5
4.5
4.5
19
2.5
2.5
3.5
3.2
4.5
4.2
2.5
3.2
20
3.5
3.2
2.8
2.5
2.8
2.5
4.5
4.5
21
2.8
2.5
2.5
2.2
3.8
3.5
3.2
3.0
22
3.2
3.0
3.2
3.0
3.2
3.0
3.5
3.0
Subject
Unhealthy
(Continued)
00
-.J
PRE AND POSTTEST RESULTS
Surgery Makes Me Feel:
Bad
Good
Well
Fearful
Calm
Knowledgeable
Confused
Pre
Post
Pre
Post
Pre
Post
Pre
Post
23
3.5
3.0
3.2
2.8
4.5
4.2
2.8
2.8
24
2.5
2.0
1.5
1.5
2.5
2.5
3.0
3.2
25
2.2
2.0
3.5
3.2
3.5
3.5
2.8
2.5
26
2.8
4.5
3.8
2.5
4.5
3.8
4.0
3.5
27
4.0
3.5
4.2
4.0
2.5
2.0
3.5
3.2
Subject
Unhealthy
(Continued)
-
00
00
PRE AND POSTTEST RESULTS
Fear Level
Anxiety Level
Knowledge Level
(Condition)
Knowledge Level
(Surgery)
Subjects
Pre
Post
Pre
Post
Pre
Post
Pre
Post
1
2.2
2.2
1.9
2.2
1.5
1.5
1.5
1.5
2
4.5
4.5
3.5
3.5
1.2
1.2
1.2
1.2
3
2.0
2.0
2.0
2.5
2.3
4.5
2.0
2.0
4
3.5
4.5
3.5
4.5
4.5
3.5
2.5
3.5
5
4.2
4.2
4.2
4.2
2.3
2.1
2.3
2.2
6
2.5
3.5
1.5
3.5
2.5
2.5
2.5
2.5
7
3.0
3.5
3.0
3.2
3.5
3.5
2.5
1.2
8
2.8
3.2
3.2
2.8
1.2
1.2
1.2
1.2
9
3.5
3.0
2.0
2.2
2.5
2.5
2.0
1.5
10
3.5
3.0
3.5
2.2
2.5
1.5
2.0
1.5
11
3.5
3.5
3.5
3.5
1.5
1.5
1.5
1.5
12
3.0
3.0
2.5
3.0
2.5
1.5
3.5
3.5
00
"'
PRE AND POSTTEST RESULTS
Fear Level
Anxiety Level
Knowledge Level
(Condition)
Knowledge Level
(Surgery)
Subjects
Pre
Post
Pre
Post
Pre
Post
Pre
Post
13
4.0
4.5
1.0
1.0
1.0
1.0
1.0
1.0
14
4.0
3.8
3.0
2.8
2.0
2.0
1.0
2.0
15
3.0
3.0
3.8
3.5
3.8
2.0
3.8
2.2
16
3.2
3.5
1.2
1.5
2.2
2.2
2.2
1.5
17
3.5
2.8
2.2
2.8
1.8
1.5
3.0
2.8
18
2.5
4.2
2.5
2.5
1.5
1.5
1.5
1.5
19
3.8
3.5
2.8
2.5
1.5
1.5
2.2
2.2
20
2.5
2.8
2.0
2.5
3.8
3.8
3.0
2.8
21
4.2
4.2
1.8
2.8
2.0
1.5
2.2
2.0
22
3.0
3.5
1.2
1.5
1.0
1.2
1.0
1.0
23
3.2
3.5
2.5
2.8
2.5
2.5
2.0
1.5
24
3.0
3.2
3.0
3.0
2.2
2.0
2.5
2.0
"'
0
PRE AND POSTTEST RESULTS
Knowledge Level
(Surgery)
Fear Level
Anxiety Level
Knowledge Level
(Condition)
Subjects
Pre
Post
Pre
Post
Pre
Post
Pre
Post
25
2.8
3.5
2.0
2.2
1.5
1.2
3.0
3.0
26
2.5
2.8
2.5
2.5
2.3
2.0
2.8
2.2
27
3.0
3.5
1.2
1.5
3.0
2.5
2.8
2.5
1.0
I-'