Pre-operative preparation of patients for total knee replacement: An action research study Brian Lucas PhD, RN (Lead Nurse Practice and Innovation) a, * , Carol Cox PhD, RN (Professor of Nursing) b , Lin Perry PhD, RN (Professor of Nursing Research and Practice Development) c,d,e , Jackie Bridges PhD, RN (Senior Lecturer) f a The Queen Elizabeth Hospital – King’s Lynn, NHS Foundation Trust, King’s Lynn, Norfolk, UK b School of Health Sciences, City University, London, UK c Prince of Wales Hospital, Sydney, Australia d Sydney and Sydney Eye Hospitals, Sydney, Australia e Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia f Faculty of Health Sciences, University of Southampton, UK KEYWORDS Action research; Social Cognitive Theory; Total knee replacement; Service user involvement; Pre-operative assessment; Practice development Abstract Aims and objectives: To examine the development and impact of a mul- tidisciplinary preparation clinic for patients undergoing total knee replacement (TKR) surgery. Background: There is evidence to suggest that patients’ preoperative character- istics such as pain and mental state impact the long term results of TKR surgery. Preparation sessions may help in identifying and working with those patients whose preoperative status could reduce the benefits of surgery. Design: Action research. Method: Actions cycles were carried out to develop an information booklet and multidisciplinary Knee Clinic at an acute Trust in outer London, UK. A sample (n = 23) of patients was recruited to test changes as they were implemented. Results: The Knee Clinic involved nurse practitioners, occupational therapists, physiotherapists and service users (patients recovered from TKR surgery). Elements of physical and social assessment and interventions were carried out using a Social Cognitive Theory framework. Patients reported they benefitted from the informa- tion booklet and attendance at the Knee Clinic. Conclusion: A structured pre-operative information and assessment clinic can be developed using a Social Cognitive Theory framework for the benefit of patients. Further studies are required to examine and utilise psychological assessment of patients at such clinics. c 2012 Elsevier Ltd. All rights reserved. 1878-1241/$ - see front matter c 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijotn.2012.08.005 * Corresponding author. Tel.: +44 01553 214583. E-mail address: [email protected](B. Lucas). International Journal of Orthopaedic and Trauma Nursing (2013) 17, 79–90 www.elsevier.com/locate/ijotn
Transcript
International Journal of Orthopaedic and Trauma Nursing (2013) 17, 79–90
www.elsevier.com/locate/ijotn
Pre-operative preparation of patients for totalknee replacement: An action research study
Brian Lucas PhD, RN (Lead Nurse Practice and Innovation) a,*,Carol Cox PhD, RN (Professor of Nursing) b,Lin Perry PhD, RN (Professor of Nursing Research and PracticeDevelopment) c,d,e, Jackie Bridges PhD, RN (Senior Lecturer) f
a The Queen Elizabeth Hospital – King’s Lynn, NHS Foundation Trust, King’s Lynn, Norfolk, UKb School of Health Sciences, City University, London, UKc Prince of Wales Hospital, Sydney, Australiad Sydney and Sydney Eye Hospitals, Sydney, Australiae Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australiaf Faculty of Health Sciences, University of Southampton, UK
18ht
KEYWORDSAction research;Social Cognitive Theory;Total knee replacement;Service userinvolvement;Pre-operativeassessment;Practice development
78-1241/$ - see front mattetp://dx.doi.org/10.1016/j.i
Abstract Aims and objectives: To examine the development and impact of a mul-tidisciplinary preparation clinic for patients undergoing total knee replacement(TKR) surgery.
Background: There is evidence to suggest that patients’ preoperative character-istics such as pain and mental state impact the long term results of TKR surgery.Preparation sessions may help in identifying and working with those patients whosepreoperative status could reduce the benefits of surgery.
Design: Action research.Method: Actions cycles were carried out to develop an information booklet and
multidisciplinary Knee Clinic at an acute Trust in outer London, UK. A sample(n = 23) of patients was recruited to test changes as they were implemented.
Results: The Knee Clinic involved nurse practitioners, occupational therapists,physiotherapists and service users (patients recovered from TKR surgery). Elementsof physical and social assessment and interventions were carried out using a SocialCognitive Theory framework. Patients reported they benefitted from the informa-tion booklet and attendance at the Knee Clinic.
Conclusion: A structured pre-operative information and assessment clinic can bedeveloped using a Social Cognitive Theory framework for the benefit of patients.Further studies are required to examine and utilise psychological assessment ofpatients at such clinics.
Editor’s commentThere is a long tradition of research and practice development that explores the value of informationand support given to patients prior to elective orthopaedic surgery. It is important to not only know ifsuch information and support is acceptable to patients, but that it is worthwhile in terms of its impacton outcomes. This is, however, a very complex issue. This study has illuminated some of this complex-ity through using the action research process to explore the benefits of both face to face educationsessions and written information in relation to their impact on post-operative outcomes from thepatients’ perspective. What are, perhaps, most important are the approach to user involvement thatensures that the output is focussed on the real world of the patient and the focus on service develop-ment in the unit in which the project took place.
JS-T
80 B. Lucas et al.
Introduction
This paper examines changes made in the prepara-tion of patients with osteoarthritis (OA) for totalknee replacement (TKR) surgery at an English dis-trict general hospital utilising an action researchapproach. TKR surgery is clinically and cost effec-tive for patients whose OA is not successfully man-aged with conservative options and around 60,000procedures are performed in England and Walesannually (Dakin et al., 2012). On average 90% ofTKR prostheses are still in situ with no radiologicalsigns of loosening 15 years after surgery (Labeket al., 2011). However 10–20% of patients havethe same or worse pain 1–7 years after their oper-ation (Brander et al., 2003; Wylde et al., 2007) andup to one-fifth think their reduced functional abil-ity still hampers physical activities (Wylde et al.,2007). Potentially modifiable pre-operative patientcharacteristics such as pain and self-efficacy be-liefs may impact on longer term post-operativeoutcomes, reducing the overall benefits obtainedby the surgical procedure (Escobar et al., 2007;van den Akker-Scheek et al., 2007).
The aim of this project was to develop,implement and evaluate a multidisciplinary pre-operative Knee Clinic to address these patientcharacteristics.
Background
To identify modifiable pre-operative patient physi-cal and psychosocial factors affecting longer term(>6 weeks) post-operative outcomes after TKR sur-gery and potential interventions to mediate the ef-fects of these factors, a search of electronicdatabases (Cochrane, CINAHL, MEDLINE, EMBASE,PsycINFO) was performed to identify Englishlanguage literature published since 2000. Older
work was considered if it was seminal, such as thaton self-efficacy (Bandura, 1977). Keywords in-cluded total knee replacement, total knee arthro-plasty, pre-operative, post-operative outcomes.Thesaurus mapping and Boolean operands wereused. Titles and abstracts were read to identify rel-evant articles and their reference lists scanned toidentify further literature. Articles for inclusionwere assessed for quality using published frame-works (Greenhalgh, 2001).
Much of the literature retrieved used mixedsamples of TKR and total hip replacement (THR)patients. Whilst the reasons for surgery andrecovery profiles are generally similar, they arenot identical and studies involving THR patientswere therefore included with caution.
Physical characteristics
Studies identified that pre-operative pain and func-tion impact post-operative outcomes. Patientswith more severe pain pre-operatively had higherpain levels up to 2 years post-surgery (Fitzgeraldet al., 2004; Lingard et al., 2004; Escobar et al.,2007) and worse function at 1 year (Branderet al., 2003). Patients with poorer pre-operativefunction had poorer post-operative function at1 year (Fitzgerald et al., 2004; Lingard et al.,2004) although at 2 years post-surgery co morbidi-ties and age were equally able to predict post-operative function (Lingard et al., 2004).
In a systematic review exercise was demon-strated to reduce pre-operative pain for patientswith knee OA awaiting TKR surgery, but therewas little evidence that it impacted pain or func-tion after TKR surgery (Wallis and Taylor, 2011).Pre-operative education alone did not reducepost-operative pain (McDonald et al., 2004;Johansson et al., 2005) and the psychosocialfactors considered below need to be taken intoaccount.
Pre-operative preparation of patients for total knee replacement: An action research study 81
Psychosocial factors
Pre-operative psychological factors and social fac-tors such as isolation may impact on the outcomesof TKR surgery. Poorer pre-operative psychologicalhealth has been reported as predictive of reducedfunction and higher pain levels at up to 3 yearspost-surgery (Ayers et al., 2004; Lingard andRiddle, 2007; Gandhi et al., 2010; Vissers et al.,2012) and with dissatisfaction with the results ofsurgery at 1 year post-surgery (Gandhi et al.,2008; Scott et al., 2010). Low self-rated overallpre-operative health was found to predict poorersocial health (participation in socially expected lifetasks and activities) at 3 months and mentalwell being at up to 6 months after TKR surgery(Perruccio et al., 2011). Post-operative health-related quality of life was not affected by socio-economic status (Murray et al., 2006; Davis et al.,2008), but was impacted by environmental factorssuch as living conditions, availability of transport,health services and leisure activities at 3 years(Rat et al., 2010). Social support in the form offriends and family was linked with positive exercisebehaviour before surgery (Campbell et al., 2001;de Jong et al., 2004) and helped improve patients’motivation after orthopaedic surgery (Resnick,2002).
Personal factors within Social Cognitive Theory(SCT) of self-efficacy and outcomes expectationhave also been shown to help explain post-opera-tive outcomes. Self-efficacy is the conviction thatone can successfully execute the behaviour re-quired to produce the desired outcomes; outcomeexpectations is a person’s estimate that a givenbehaviour will lead to particular outcomes(Bandura, 1977). Pre-operative self-efficacy beliefshave predicted post-operative function (Orbellet al., 2001; van den Akker-Scheek et al., 2007;Wylde et al., 2012). Pre-operative outcomesexpectations and post-operative functional recov-ery have been demonstrated to correlate at6 weeks to 1 year post-surgery (Orbell et al.,2001; Mahomed et al., 2002; Engel et al., 2004;Smith and Zautra, 2004). Patients with lower pre-operative expectations of post-operative pain hadless pain at 1 year (Lingard et al., 2006) and satis-faction with TKR surgery at 1 year correlated withfulfilment of pre-operative expectations (Nobleet al., 2006).
Self-efficacy beliefs are influenced by masteryexperience (the individual’s interpretation ofresults of previous performance), vicarious experi-ence (observations of others), social persuasions(the verbal judgements of others) and somatic
and emotional states (the emotional state experi-enced when an action or task is contemplated)(Bandura, 2004). Self-efficacy is context specificand requires knowledge of the task or action tobe undertaken. There is evidence that patientswant accurate information to support formationof realistic expectations for self-care (Edwards,2002, 2003; Marcinkowski et al., 2005). Patientknowledge has been increased by provision of writ-ten information prior to admission (Hodgkinsonet al., 2000; Johansson et al., 2005) although ef-fects were relatively moderate. Preoperativeexpectations were more realistic prior to TKR sur-gery following preoperative education classes(Mancuso et al., 2008). Monthly telephone contactby lay personnel for patients with knee OA im-proved self-care (Zhang et al., 2008) and boostersessions positively impacted exercise adherencein people with knee OA (Pisters et al., 2007). Inter-ventions delivered through multimedia such as a CDincreased self-efficacy beliefs in patients havingTHR surgery (Yeh et al., 2005). However, suchinterventions have been predominantly introducedclose to the time of surgery which may havereduced their potential impact.
In summary, potentially modifiable pre-opera-tive patient characteristics such as pain, mobilityand psychosocial status may impact the outcomesof TKR surgery. Pre-operative preparation pro-grammes may be a means of identifying appropri-ate patients and delivering interventions aimed atimproving their physical and/or psychosocial statesbefore surgery.
Preparation programmes for TKR surgery
Preparation programmes may be combined withpre-operative assessment (POA) or provided atseparate education/assessment clinics. A recentimpetus for this development in elective surgicalcare has come from the Enhanced RecoveryProgramme concept (Wainwright and Middleton,2010; McDonald et al., 2011), which emphasisedthe importance of management of patientexpectation through pre-operative education andcounselling and of pre-operative interventions tooptimise health and medical conditions. SCT canbe used within preparation programmes to providean environment to facilitate patients to alter theirpersonal beliefs about their capabilities and try tochange their behaviours, for example by practisingpost-operative exercises prior to admission forsurgery.
Programme formats have included a singlesession (MacDonald et al., 2005; Wainwright and
82 B. Lucas et al.
Middleton, 2010), or a more intensive programmeover many months (Berge et al., 2004). Group edu-cation sessions (Wainwright and Middleton, 2010;McDonald et al., 2011), individual assessments(Crowe and Henderson, 2003; Sandell, 2008) anda combination of both have been used (MacDonaldet al., 2005; Nunez et al., 2006). Staff have in-cluded nurses, physiotherapists and/or OTs, withlesser involvement from other professionals suchas orthopaedic surgeons, rheumatologists or psy-chiatrists (Giraudet-Le Quintrec et al., 2003);patients who have already had surgery have alsobeen involved (Spalding, 2004).
Session content has entailed a combination ofpatient education, healthcare professional demon-stration, patient participation in activities such asexercises and assessment of discharge needs(Prouty et al., 2006; Wainwright and Middleton,2010; McDonald et al., 2011). There is little indica-tion that psychological assessment or interventionhas been undertaken but details of interventionsundertaken were generally scanty. Few studiesused a theoretical framework for their educationalprogramme or described how they were developedor the factors influencing this.
Further, results were difficult to compare as avariety of outcome measures and time frames formeasurement were used. A pre-operative multi-faceted intervention had a positive impact on theachievement of functional goals before surgery(Nunez et al., 2006) and up to 1 year after THR sur-gery (Berge et al., 2004; Siggeirsdottir et al.,2005). Self-efficacy and outcome expectationswere improved (McGregor et al., 2004) and prepa-ration sessions were popular with patients(MacDonald et al., 2005; Sandell, 2008), reducedanxiety (Prouty et al., 2006) and led to a greaterfeeling of empowerment (Spalding, 2004).
Overall this literature demonstrated potentiallymodifiable pre-operative patient characteristicswhich impact post-operative outcomes of TKR sur-gery. Evidence for development and organisationof interventions to ameliorate these outcomeswas less clear.
Methods
Aims and objectives
The overall aim of the project was to develop,implement and evaluate a multidisciplinary KneeClinic to improve patient preparation for TKR sur-gery. This paper examines what was developed inpractice and its impact on patients; a second paperexplores the change process (reference to follow).
Project design
The project used an action research design. Actionresearch is ‘a period of inquiry, which describes,interprets and explains social situations while exe-cuting a change intervention aimed at improvementand involvement. It is problem-focused, context-specific and future-orientated’ (Waterman et al.,2001, p. 11). There are many models of actionresearch but the three key factors are participation,democratic impulse anda simultaneous contributionto social science and social change (Meyer, 2000). Acyclical process is employed where potentialchanges are identified and planned, introduced intopractice (implemented) and the findings fed back toproject participants so that learning can take placeand future action cycles planned (evaluated andreviewed). In this study an iterative process ofrepeated small-scale cycles was used to test thefeasibility and acceptability of the interventionsand to evaluate (rather than trial) their impact.
The intervention
The project consisted of action cycles, with serviceuser involvement. One cycle related to the devel-opment of a patient information booklet, run con-currently with another series of cycles related todeveloping a multidisciplinary Knee Clinic. The re-searcher (BL) had previously developed a unidisci-plinary ‘Knee Club’ at the research site, whichincluded provision of verbal information for pa-tients waiting for TKR surgery. This was expandedusing SCT to frame the interventions. SCT providesa framework for understanding, predicting andchanging human actions and identifies such actionsas an interaction between personal factors, behav-iours and the environment (Bandura, 1977, 1986).
Setting and sample
The project was undertaken at a UK outer Londonacute hospital NHS Trust over 10 months (Decem-ber 2005–October 2006).
For the action research project a Project Manage-ment Group (PMG) was established at an initiallaunch event. Membership consisted of Trust staffand service users who were patients who had hadTKR surgery at the project site. Purposive samplingwas used which means people were recruited basedon their knowledge and insight of the topic underexamination. Nineteen clinical and non-clinicalstaff members were approached via e-mail and 17agreed to be involved. Ten service users from aclinical list of patients were contacted via tele-
Pre-operative preparation of patients for total knee replacement: An action research study 83
phone and five responded – three females and twomales, with a mean age of 61 (range 57–73) years.
A sample of patients waiting for TKR surgery wasrecruited from the waiting list, to examine the im-pact of the changes on their experience. Twenty-three patients consented to take part. Of these17 had TKR surgery within the data collectionperiod of the study, four after the study had endedand two decided they did not want to proceed witha TKR as their symptoms had improved.
Role of the researcher
The researcher (BL) was an insider within the organi-sation, working as a nurse practitioner assessingpatients before TKR surgery and reviewing them inthe outpatient clinic after surgery. Insiders studyingtheir own organisation have ‘preunderstanding’:knowledge of their organisation’s everyday life, jar-gon, informal organisational structure and whatcritical events are occurring (Coghlan, 2001). How-ever theymaymake assumptions aboutwhat is beingsaid or heard and can be denied access to relevantdata due to hierarchical departmental boundaries(Coghlan, 2001). A reflective diary and discussionwith academic supervisors (CC, LP, JB) was used toreduce the risk of assumptions being made.
Ethical considerations
The acute Trust’s Research and Development Com-mittee and the Local Research Ethics Committeeapproved the project. Consent in action researchis a complex issue, as the project is a journey andneither researcher nor participants know exactlywhere this will take them in advance, hence theycannot fully know to what they are initially consent-ing (Williamson and Prosser, 2002). However initialwritten consent was gained on the understandingthat as the project unfolded members could optout, which did not occur.
Data collection and analysis
Data were collected throughout the study in rela-tion to the planning, implementation, evaluationand review stages of the action cycles. Action cy-cles were planned and reviewed in nine monthlyPMG meetings. The researcher took notes duringPMG meetings which were distributed to PMGmembers for checking and correction. The re-searcher kept a reflective diary throughout the pro-ject, providing an audit trail and an account ofproject implementation and review processes.
The Knee Clinic was evaluated via observationsundertaken by two PMG members using criteriapreviously described (Spalding, 2004) and agreedby the PMG.
To evaluate patient preparation for surgerypatients completed two evaluation questionnairesat the Knee Clinic 5 months before surgery and againat the POA clinic 2 weeks before surgery. One toolcollected data on the patients’ perception of knowl-edge gain from attending the Knee Clinic and POAclinic and the other examined their self-efficacyand outcomes expectations after these clinics. Nopre-existing validated questionnaires were identi-fied for use so these tools were developed duringthe project by the researcher and agreed by thePMG members. The questions related to knowledgewere based on the content of the Knee Clinic and theexpert opinion of PMG members on what knowledgepatients should gain from the clinic. The self-effi-cacy and outcomes expectations questionnaire wasalso reviewed by a Consultant Psychologist to checkconsistency with SCT. Due to time constraints theirvalidity and reliability were not fully established andtheir results must be viewed with caution.
Patients’ exercise frequency and crutches useprior to admission was evaluated via self-report.Physiotherapists’ assessments evaluated the im-pact of these pre-operative activities on immedi-ate post-operative mobility.
Nine of the 17 patients who had surgery reflectedon (evaluated) their preparation for surgery in twofocus groups held 3 months after their surgery.
Semi-structured interviews were carried outwith staff at the end of the project to reflect on(evaluate and review) the project and theirinvolvement. These are explored in a second paperin a subsequent issue of this journal.
Qualitative data were analysed using Burnard’s(1991) method, which included open coding andmember checking. Quantitative data from the pa-tient questionnaires were entered onto an Excelspreadsheet and descriptive statistics calculated.
Demonstration of rigour was addressed by main-taining an audit trail to enhance dependability andcredibility. Details of the study setting and partic-ipants enable readers to consider the transferabil-ity of study findings.
Results
Action cycle: development of theinformation booklet
A 32 page patient information booklet whichexplained the patient pathway from listing for
84 B. Lucas et al.
surgery to long term follow-up was developedthrough a series of action test cycles. It was de-signed to ensure that patients had an accurateunderstanding of preparation and recovery fromTKR surgery to inform realistic self-efficacy andoutcome expectation assessments.
The first test cycle involved collecting andexamining existing patient information leaflets toidentify areas for development. In subsequent testcycles draft booklets were reviewed by the PMGand patients at the Knee Clinic and in outpatients.The final version followed testing with patients atthe Knee Clinic. The Hospital League of Friendsagreed to fund printing of the booklet. Develop-ment of a DVD was discussed by the PMG but fund-ing could not be identified.
The booklet incorporated details of self-management of pre-operative pain and used theprinciples of self-efficacy, for example photo-graphs of exercises and crutches use featured ser-vice users rather than staff, to enhance vicariousexperience.
Action cycle: physical assessment andintervention in the Knee Clinic
A series of action test cycles developed elementsof physical health assessment and intervention.An initial test cycle introducing a physical healthquestionnaire at the Knee Clinic was not continuedas the hospital was planning a similar tool for usewhen patient’s names were added to the waitinglist. Subsequent test cycles concentrated on phys-iotherapists teaching exercises and use of crutchesso that patients could practice at home prior toadmission (mastery experience). One cycle testedteaching of crutches on an individual basis at thePOA clinic; this was not sustainable for the physio-therapists as it was difficult to predict when pa-tients would be available for teaching. Furthercycles tested ways of incorporating teaching ofcrutches use and post-operative exercises withinthe Knee Clinic. This was achievable with the nursepractitioner measuring patients for the correct sizeof crutches at the beginning of the clinic sessionand physiotherapists teaching use of crutches andthe exercises during the session.
Action cycle: social assessment andintervention in the Knee Clinic
A series of test cycles tested the introduction ofearly social assessment and intervention to ensurethat patients were prepared for discharge andrehabilitation at home. After an initial scoping
exercise by the occupational therapist (OT) subse-quent tests involved devising and refining a homecircumstances assessment form and piloting it inthe Knee Clinic to determine if it identifiedpatients who needed additional support. Assess-ments included measuring the leg length of the pa-tients to check if they would require alteration totheir furniture height after surgery; this proved dis-ruptive when performed by the OT during the ses-sion but achievable with the nurse practitionermeasuring both leg length and for crutches use atthe beginning of the session.
Action cycle: service user involvement inthe Knee Clinic
A final series of test cycles led to service userinvolvement in the Knee Clinic. Two service usersfrom the PMG attended the Knee Clinic in the firstcycle to share their experiences of TKR surgery(vicarious experience) and reflected on the processat a subsequent PMG meeting. The PMG agreedthat service user involvement should be developedand the feasibility of recruiting service users wastested via articles in the hospital magazine and ina local newspaper. Subsequently, an expression ofinterest letter sent to every patient who had hada TKR within the previous 6 months resulted in apool of twenty service users for the Knee Clinic.A patient led support group – the Joint InformationGroup (JIG) – developed along with a rota of ser-vice users for the Knee Clinic and regular coffeemornings to enable patients post-surgery to meetand discuss their recovery. This is discussed furtherin the subsequent paper.
Achieving implementation of changes inpractice
By conclusion of the series of action cycles changeshad been successfully integrated into the patientadmission process. The information booklet andthe OT assessment form were given to patients bythe Admissions Office together with an invitationto the Knee Clinic on the day their name was addedto the waiting list. The researcher (BL) organisedthe rota of physiotherapists and OTs for the KneeClinic and liaised with JIG for the rota of serviceusers.
Observation of the Knee Clinic demonstratedthat it consisted of a ninety-minute session withthe involvement of a nurse practitioner,physiotherapist, OT and service users. The nursepractitioner co-ordinated the session, performedthe crutches and leg length measurements and
Pre-operative preparation of patients for total knee replacement: An action research study 85
provided education on aspects of preparation forsurgery, the inpatient stay and recovery. The phys-iotherapist taught the group the post-operativeexercises and the use of crutches which patientstook home with them. The OT assessed patients’home circumstances and arranged a pre-operativehome visit if necessary. Service users shared theirexperiences of surgery and recovery with the pa-tients. No psychological assessment or interventionhad been introduced, beyond the self-efficacy/out-comes expectations questionnaires for the patientsample. The reasons for this are explored in thesubsequent paper.
Impact of changes on patients
Data from the patient questionnaires (Table 1 and2) and focus groups indicated that the patients feltprepared for surgery. This was as a result of in-creased knowledge and enhanced self-efficacy.
Each of the four questions was scored on a scale of 1 (= nothingmaximum score = 20. Higher score indicates greater knowledge/fea 5 months before surgery.b 2 weeks before surgery.
Table 2 Self-efficacy and outcome expectations scores.
Higher score indicates greater self-efficacy beliefs/outcomes expea 5 months before surgery.b 2 weeks before surgery.
Increased knowledge
The patient focus group transcripts suggestedthat patients generally believed the Knee Clinicand information booklet increased theirknowledge:
We understood more, we had more informationthan a normal doctor would give you (Focus Group(FG) 1).
I think the information was pretty comprehensive. . . I don’t think you could add any more (FG 2).
The scores for the knowledge and preparationquestionnaire (Table 1) were high at both pointsin time, suggesting that the patients felt knowl-edgeable about, and prepared for, their surgeryfollowing the Knee Clinic and that this percep-tion was generally well maintained over time.Actual knowledge gain was not measured as partof the study and could be examined in futurestudies.
Pre-operative assessment (POA) clinicb
Total sample n = 20nnaires n = 23 Completed questionnaires n = 19
Mean (SD)
15.1 (3.1)7.3 (1.4)7.7 (1.9)
/not at all) to 5 (= full knowledge/well prepared). The totaleling prepared.
a Pre-operative assessment(POA) clinicb
n = 23 Total sample n = 20estionnaires n = 23 Completed questionnaires n = 19
Mean (SD)
28.5 (2.3)13.4 (1.8)15.1 (1.1)
ctations.
86 B. Lucas et al.
Enhanced self-efficacy
Patients reported that knowing the correct way touse crutches and perform the post-operative exer-cises helped in developing self-efficacy and thatthey were able to develop realistic outcomeexpectations.
It did get you prepared for the operation and ofcourse walking on crutches, having the crutchesat home, it was a good idea, to get crutches andlearn how to walk on them (FG 1).
I think it helps because you have to get to a certaindegree (of knee flexion) and they like you to be atthat, so that helps you with knowing what you’vegot to do (FG 1).
Patients did not have the opportunity to be as-sessed using the crutches or performing the exer-cises in the Knee Clinic, which meant that theydid not receive positive reinforcement about theircapabilities (social persuasion). Table 2 indicatesthat the patients’ reported self-efficacy and out-comes expectations were high after the Knee Clinicand remained consistently so at the pre-operativeassessment clinic.
Some patients gained positive benefits from per-forming the exercises which they believed helpedthem both before and after surgery.
I did all the exercises because I’ve got bad bothlegs and I found that, I do them now because I’mwaiting for the other one to do. The physio peoplesay this is much stronger now (the unoperated leg)than when I started, which is good (FG 1).
The frequency with which patients reportedpracticing the exercises and crutches prior toadmission for surgery varied (Table 3). There wassome evidence of family influences.
Table 3 Patient self-report exercise and crutchesuse pre-surgery: n = 17 patients, 100% of those under-going surgery.
Frequency Exercises(number ofpatientscompletingat thisfrequency)
Every day 10 4Most days 5 1Once weekly 1 3Less than weekly 0 1Few times only 0 5Did not perform 1 3
Luckily I had my grandchildren, my grandson hasbad legs as well so we were doing our exercisestogether, which is great, we made it into a thing(FG 2).
Some patients perceived that following KneeClinic advice pain was reduced and functionimproved:
This summer I have been undertaking your exer-cises and swimming a lot and my knees have beenso good. I have come off all anti-inflammatories/pain killers and do not suffer too much pain atnight anymore (e-mail from patient, who decidednot to proceed with TKR surgery).
Physiotherapists reported that some patientswho had exercised and practiced crutches use be-fore admission mobilised more quickly after sur-gery, indicating the positive impact of masteryexperience.
Patients reacted positively to changes sug-gested by the OT to the home environment be-fore admission for TKR surgery. These changesranged from provision of furniture aids to morecomplex packages of care for patients or theirrelatives:
My biggest concern at that time was not the actualoperation but the fact that I’m sole carer for mywife and arranging the respite for her. Once thathad been put in place I was quite happy about it(FG 2).
Discussion
The project demonstrates how an informationbooklet and a single education/assessment sessioncan begin to address some of the patient physicaland social characteristics which impact post-operative recovery, such as worse pre-operativepain (Lingard et al., 2004; Escobar et al., 2007)and function (Fitzgerald et al., 2004; Lingardet al., 2004). The test cycles demonstrated thatthese interventions were both feasible for clini-cians and acceptable to patients. The teaching ofexercises and crutches use so that patients couldpractice them before admission was based on theconcept of mastery experience (Bandura, 1997)and the evidence that exercise is important inreducing pain and improving function in patientswith knee OA (Wallis and Taylor, 2011).
The patient questionnaire and focus group datasuggested that patients felt prepared for surgeryand rehabilitation. The provision of writteninformation such as the information booklet can
Pre-operative preparation of patients for total knee replacement: An action research study 87
increase patient knowledge (Hodgkinson et al.,2000; Johansson et al., 2005). Multimedia informa-tion may have been more effective (Yeh et al.,2005) but was not possible without funding. Pa-tients lack information and need advice pre-opera-tively so that they can manage their OA symptomsbefore surgery and form realistic outcome expecta-tions and goals for post-operative recovery (Orbellet al., 2001; van den Akker-Scheek et al., 2007;Wylde et al., 2012). The Knee Clinic providedverbal reinforcement of the information bookletand helped patients form realistic self-efficacyand outcome expectations about their surgeryand rehabilitation. Other studies have used a simi-lar combination with positive results on preopera-tive pain and function (Berge et al., 2004; Nunezet al., 2006). Service user involvement providedpeer support and perhaps the opportunity for vicar-ious experience-patients learning about the experi-ence from others similar to themselves. Serviceuser involvement was described in one other study(Spalding, 2004) where it consisted of a ten minutepresentation only. By contrast, in this study the ser-vice users were present for the whole 90 minutesession and contributed throughout to the explana-tions and discussions. However, no formal evalua-tion of this was sought or offered.
Lacking agreement of the PMG to proceed withthis, the project did not include routine psycholog-ical screening of patients with regard to specificfactors which may have impacted post-operativerecovery such as self-efficacy beliefs, outcomeexpectations or general psychological health sta-tus. Thus the interventions of the informationbooklet and Knee Clinic were not specifically tai-lored to individual patient’s psychological needs.No studies including formal psychological assess-ment as part of preparation for TKR surgery wereidentified and further studies are required to exam-ine this.
Pre-operative social factors potentially impact-ing post-operative outcomes were partiallyaddressed through the OT assessment and interven-tions. Previous studies have described OT involve-ment in preparation programmes (MacDonaldet al., 2005; Prouty et al., 2006) but no study hasspecifically examined the impact of early OTassessment and intervention on post-operative out-comes in TKR surgery. Findings suggest there maybe benefits following OT intervention but more re-search is needed to establish this.
The changes implemented may have beneficiallyinfluenced the patients’ behaviour and psychologi-cal beliefs and knowledge as their scores for thesedomains can be considered high. However, thesefindings are tentative as the questionnaires de-
signed for the project have not yet been thoroughlytested. Participants’ scores for both questionnairesremained high, only reducing a little at the POAclinic appointment approximately 2 weeks beforesurgery. Participants may have become moreanxious as surgery came closer, lowering theirself-efficacy beliefs/outcome expectations andperceptions of knowledge. Self-efficacy and out-come expectations are context specific (Bandura,1986) and the context of imminent surgery approx-imately 5 months after the Knee Clinic may havemoderated patients’ beliefs about their ability tomanage the immediate preoperative and perioper-ative period. The Knee Clinic was designed toensure patients had realistic outcome expectationsabout surgery and recovery and to address self-efficacy and outcome expectations about theimmediate pre-operative stage. A follow-up sessionnearer the time of surgery may have been helpful,allowing patients the opportunity to consider be-liefs about their imminent surgery. This would haveresource implications.
The findings indicated differences in patientbehaviours after the Knee Clinic and provision ofthe information booklet. The home environmentmay have impacted on the time patients spentpractising the exercises and crutches. Some withsupport from relatives reported this encouragedthem to practice, perhaps resulting in the greateramounts of practice also found in relation to exer-cise behaviour in patients with knee OA (Campbellet al., 2001; de Jong et al., 2004). Amounts ofpractice should have equated to patients’ masteryexperience in crutches use, which may also havebeen influential. Almost half the patients reportedthat they had practiced crutches a few times onlyor never before admission and this may have beenreflected in lower self-efficacy and outcomeexpectations.
Findings of this study add to the argument thatmore consideration should be made to ongoing sup-port for patients after the initial Knee Clinic, asprevious studies have demonstrated that telephonefollow-up (Zhang et al., 2008) or booster sessions(Pisters et al., 2007) increase exercise participa-tion of patients with OA. Patients’ intentions toexercise need to be examined further and appro-priate support systems put into place.
The project has provided some evidence thatSCT may be an appropriate theoretical frameworkfor organising a preparation programme beforeTKR surgery for the benefit of patients. The infor-mation booklet and the Knee Clinic were designedto address the personal, environmental and behav-ioural factors impacting patient preparation forTKR surgery and recovery afterwards. The project
88 B. Lucas et al.
was not able to introduce all the intended ele-ments of SCT into the Knee Clinic and further stud-ies are required which actively pay attention tofactors such as measuring self-efficacy and out-come expectation beliefs, tailoring interventionsto these, and evaluating their impact on patientactions.
Strengths and limitations of the project
The project was an example of action research inwhich an insider researcher worked with colleaguesto change practice. The insider status allowed ac-cess to material and events which would have beendifficult, if not impossible for an outsider to accessusing formal data collection methods. The projectwas conducted on one site, allowing an in-depthinvestigation of change in a particular setting with-in its environmental context. This adds credibilityto the findings by allowing a rich picture to emerge.It allows the reader to judge the ‘fittingness’ of thefindings with their own particular settings andmake a judgement about its usefulness in theirown practice (Somekh, 2006).
The project had a short time frame of9 months, which limited what could be achieved.Further studies are needed on the impact of mul-tidisciplinary preparation of patients for TKR sur-gery, as this study relied on questionnaires whosevalidity and reliability had not been established.A stronger evaluation framework is required todemonstrate effectiveness in relation to patientoutcomes.
Conclusion
The project has demonstrated how action re-search can be used to make service changesand the positive impact these changes may effecton patients’ preparation for TKR surgery. Theproject resulted in a multidisciplinary assessmentand intervention Knee Clinic with service userinvolvement based on a SCT framework. Suchclinics are vital if the aims of current initiativessuch as the Enhanced Recovery Programme areto be met and cost and patient benefits from sur-gery maximised.
Contributions
Research design: BL, CC, LP. Data collection: BL.Analysis: BL, CC, LP, JB. Manuscript preparation:BL, CC, LP, JB.
Conflict of Interest Statement
I confirm that there are no financial or personalrelationships with other people or organisationsthat inappropriately influenced this work.
Ethical Approval
The acute Trust’s Research and Development Com-mittee and the Local Research Ethics Committeeapproved the project.
Funding Source
No funding was sought for this study.
References
Ayers, D., Franklin, P., Trief, P., Ploutz, S., Freund, D., 2004.Psychological attributes of preoperative total joint replace-ment patients: implications for optimal physical outcome.The Journal of Arthroplasty 19 (Suppl. 2), 125–130.
Bandura, A., 1977. Self-efficacy: toward a unifying theory ofbehavioural change. Psychological Review 84 (2), 191–215.
Bandura, A., 1986. Social Foundations of Thought and Action: ASocial Cognitive Theory. Prentice-Hall, Englewood Cliffs,New Jersey.
Bandura, A., 1997. Self-Efficacy: The Exercise of Control. WHFreeman and Company, New York.
Bandura, A., 2004. Health Promotion by Social Cognitive Means.Health Education & Behavior 31 (2), 143–164.
Berge, D., Dolin, S., Williams, A., Harman, R., 2004. Pre-operative and post-operative effect of a pain managementprogramme prior to total hip replacement: a randomizedcontrolled trial. Pain 110 (1–2), 33–39.
Brander, V.A., Stulberg, S.D., Adams, A.D., Harden, R.N.,Bruehl, S., Stanos, S.P., Houle, T., 2003. Predicting totalknee replacement pain: a prospective, observational study.Clinical Orthopaedics and Related Research 416, 27–36.
Burnard, P., 1991. A method of analysing interview transcripts inqualitative research. Nurse Education Today 11 (6), 461–466.
Campbell, R., Evans, M., Tucker, M., Quilty, B., Dieppe, P.,Donovan, J.L., 2001. Why don’t patients do their exercises?Understanding non-compliance with physiotherapy inpatients with osteoarthritis of the knee. Journal of Epidemi-ology and Community Health 55 (2), 132–138.
Coghlan, D., 2001. Insider action research projects: implicationsfor practising managers. Management Learning 32 (1), 49–60.
Crowe, J., Henderson, J., 2003. Pre-arthroplasty rehabilitationis effective in reducing hospital stay. The Canadian Journalof Occupational Therapy 70 (2), 88–96.
Dakin, H., Gray, A., Fitzpatrick, R., MacLennan, G., Murray, D.,2012. Rationing of total knee replacement: a cost-effective-ness analysis on a large trial data set. BMJ Open 2 (1), 1–9.
Davis, E.T., Lingard, E.A., Schemitsch, E.H., Waddell, J.P.,2008. Effects of socioeconomic status on patients’ outcomeafter total knee arthroplasty. International Journal forQuality in Health Care 20 (1), 40–46.
Pre-operative preparation of patients for total knee replacement: An action research study 89
de Jong, O.R.W., Hopman, R., Tak, E.C.M., Klazinga, N.S., 2004.An implementation study of two evidence-based exercise andhealth education programmes for older adults with osteoar-thritis of the knee and hip. Health Education Research 19 (3),316–325.
Edwards, C., 2002. A proposal that patients be consideredhonorary members of the healthcare team. Journal ofClinical Nursing 11 (3), 340–348.
Edwards, C., 2003. Exploration of the orthopaedic patient’s‘need to know’. Journal of Orthopaedic Nursing 7 (1),18–25.
Engel, C., Hamilton, N., Potter, P., Zautra, A., 2004. Impact oftwo types of expectancy on recovery from total kneereplacement surgery (TKR) in adults with osteoarthritis.Behavioral Medicine 30 (3), 113–123.
Escobar, A., Quintana, J.M., Bilbao, A., Azkarate, J., Guenaga,J.I., Arenaza, J.C., Gutierrez, L.F., 2007. Effect of patientcharacteristics on reported outcomes after total kneereplacement. Rheumatology 46 (1), 112–119.
Fitzgerald, J., Orav, E.J., Lee, T., Marcantonio, E., Poss, R.,Goldman, L., Mangione, C., 2004. Patient quality of lifeduring the 12 months following joint replacement surgery.Arthritis and Rheumatism 51 (1), 100–109.
Gandhi, R., Davey, J.R., Mahomed, N.N., 2008. Predictingpatient dissatisfaction following joint replacement surgery.Journal of Rheumatology 35 (12), 2415–2418.
Gandhi, R., Dhotar, H., Razak, F., Tso, P., Davey, J.R.,Mahomed, N.N., 2010. Predicting the longer term outcomesof total knee arthroplasty. The Knee 17 (1), 15–18.
Giraudet-Le Quintrec, J.S., Coste, J., Vastel, L., Pacault, V.,Jeanne, L., Lamas, J., Kerboull, L., Fougeray, M., Conseiller,C., Kahan, A., Courpied, J., 2003. Positive effect of patienteducation for hip surgery: a randomized trial. ClinicalOrthopaedics and Related Research 414, 112–120.
Greenhalgh, T., 2001. How to Read a Paper. BMJ Books, London.Hodgkinson, B., Evans, D., O’Neill, S., 2000. Knowledge Reten-
tion From Pre-operative Patient Information. The JoannaBriggs Institute for Evidence Based Nursing and Midwifery,Adelaide, Australia.
Johansson, K., Nuutila, L., Virtanen, H., Katajisto, J., Salantera,S., 2005. Preoperative education for orthopaedic patients:systematic review. Journal of Advanced Nursing 50 (2), 212–223.
Labek, G., Thaler, M., Janda, W., Agreiter, M., Stockl, B., 2011.Revision rates after total joint replacement: cumulativeresults from worldwide joint register datasets. Journal ofBone and Joint Surgery 93B (3), 293–297.
Lingard, E.A., Katz, J., Wright, E., Sledge, C.Kinemax OutcomesGroup, 2004. Predicting the outcome of total knee arthro-plasty. The Journal of Bone and Joint Surgery 86A (10),2179–2186.
Lingard, E.A., Riddle, D.L., 2007. Impact of psychologicaldistress on pain and function following knee arthroplasty.Journal of Bone and Joint Surgery 89A (6), 1161–1169.
Lingard, E.A., Sledge, C., Learmonth, I.Kinemax OutcomesGroup, 2006. Patient expectations regarding total kneearthroplasty: differences among the United States, UnitedKingdom, and Australia. The Journal of Bone and JointSurgery 88A (6), 1201–1207.
Mahomed, N., Liang, M., Cook, E., Daltroy, L., Fortin, P., Fossel,A., Katz, J., 2002. The importance of patient expectations inpredicting functional outcomes after total joint arthroplasty.The Journal of Rheumatology 29 (6), 1273–1279.
Marcinkowski, K., Wong, V., Dignam, D., 2005. Getting back tothe future: a grounded theory study of the patient perspec-tive of total knee joint arthroplasty. Orthopaedic Nursing 24(3), 202–209.
McDonald, D.A., Siegmeth, R., Deakin, A.H., Kinninmonth,A.W.G., Scott, N.B., 2011. An Enhanced Recovery Pro-gramme for primary total knee arthroplasty in the UnitedKingdom � follow up at one year. The Knee. http://dx.doi.org/10.1016/j.knee.2011.07.012.
McDonald, S., Hetrick, S., Green, S., 2004. Pre-operativeeducation for hip or knee replacement. Cochrane Databaseof Systematic Reviews. Issue 1. Art. No.: CD003526. http://dx.doi.org/10.1002/14651858.CD003526.pub2.
McGregor, A.H., Rylands, H., Owen, A., Dore, C.J., Hughes,S.P.F., 2004. Does preoperative hip rehabilitation adviceimprove recovery and patient satisfaction? The Journal ofArthroplasty 19 (4), 464–468.
Meyer, J., 2000. Qualitative research in health care: usingqualitative methods in health related action research. BMJ320 (7228), 178–181.
Murray, J.R.D., Birdsall, P.D., Sher, J.L., Deehan, D.J., 2006.Deprivation and outcome of total knee replacement. TheKnee 13 (2), 98–101.
Nunez, M., Nunez, E., Segur, J.M., Macule, F., Quinto, L.,Hernandez, M.V., Vilalta, C., 2006. The effect of an educa-tional program to improve health-related quality of life inpatients with osteoarthritis on waiting list for total kneereplacement: a randomized study. Osteoarthritis and Carti-lage 14 (3), 279–285.
Orbell, S., Johnston, M., Rowley, D., Davey, P., Espley, A.,2001. Self-efficacy and goal importance in the prediction ofphysical disability in people following hospitalization: aprospective study. British Journal of Health Psychology 6(1), 25–40.
Perruccio, A.V., Davis, A.M., Hogg-Johnson, S., Badley, E.M.,2011. Importance of self-rated health and mental well-beingin predicting health outcomes following total joint replace-ment surgery for osteoarthritis. Arthritis Care and Research63 (7), 973–981.
Pisters, M., Veenhof, C., van, M., Ostelo, R., de, B., Schellevis,F., Dekker, J., 2007. Long-term effectiveness of exercisetherapy in patients with osteoarthritis of the hip or knee: asystematic review. Arthritis and Rheumatism 57 (7), 1245–1253.
Prouty, A., Cooper, M., Thomas, P., Christensen, J., Strong, C.,Bowie, L., Oermann, M., 2006. Multidisciplinary patienteducation for total joint replacement surgery patients.Orthopaedic Nursing 25 (4), 257–261.
Rat, A.C., Guillemin, F., Osnowycz, G., Delagoutte, J.P.,Cuny, C., Mainard, D., Baumann, C., 2010. Total hip orknee replacement for osteoarthritis: mid- and long-termquality of life. Arthritis Care and Research 62 (1), 54–62.
Resnick, B., 2002. Geriatric rehabilitation: the influence ofefficacy beliefs and motivation. Rehabilitation Nursing 27(4), 152–159.
Sandell, C.L., 2008. A multidisciplinary assessment and inter-vention for patients awaiting total hip replacement to
improve their quality of life. Journal of Orthopaedic Nursing12 (1), 26–34.
Scott, C.E.H., Howie, C.R., MacDonald, D., Biant, L.C., 2010.Predicting dissatisfaction following total knee replacement:a prospective study of 1217 patients. Journal of Bone andJoint Surgery 92B (9), 1253–1258.
Siggeirsdottir, K., Olafsson, O., Jonsson, H., Iwarsson, S.,Gudnason, V., Jonsson, B., 2005. Short hospital stay aug-mented with education and home-based rehabilitationimproves function and quality of life after hip replacement.Acta Orthopaedica 76 (4), 555–562.
Smith, B.W., Zautra, A.J., 2004. The role of purpose in life inrecovery from knee surgery. International Journal of Behav-ioral Medicine 11 (4), 197–202.
Somekh, B., 2006. Action Research: A Methodology for Changeand Development. Open University Press, Maidenhead,Berkshire.
Spalding, N., 2004. Preoperative education: empoweringpatients with confidence. International Journal of Therapyand Rehabilitation 11 (4), 147–153.
van den Akker-Scheek, I., Stevens, M., Groothoff, J.W., Bulstra,S.K., Zijlstra, W., 2007. Preoperative or postoperative self-efficacy: which is a better predictor of outcome after totalhip or knee arthroplasty? Patient Education and Counseling66 (1), 92–99.
Vissers, M.M., Bussmann, J.B., Verhaar, J.A.N., Busschbach,J.J.V., Bierma-Zeinstra, S.M.A., Reijman, M., 2012. Psycho-logical factors affecting the outcome of total hip and kneearthroplasty: a systematic review. Seminars in Arthritis andRheumatism 41 (4), 576–588.
Wainwright, T., Middleton, R., 2010. An orthopaedic enhancedrecovery pathway. Current Anaesthesia & Critical Care 21(3), 114–120.
Wallis, J.A., Taylor, N.F., 2011. Pre-operative interventions(non-surgical and non-pharmacological) for patients with hipor knee osteoarthritis awaiting joint replacement surgery � asystematic review and meta-analysis. Osteoarthritis andCartilage 19 (12), 1381–1395.
Waterman, H., Tillen, D., Dickson, R., de Koning, K., 2001.Action research: a systematic review and guidance forassessment. Health Technology Assessment 5 (23), iii-157.
Williamson, G., Prosser, S., 2002. Action research: politics,ethics and participation. Journal of Advanced Nursing 40 (5),587–593.
Wylde, V., Dieppe, P., Hewlett, S., Learmonth, I.D., 2007. Totalknee replacement: is it really an effective procedure for all?The Knee 14 (6), 417–423.
Wylde, V., Dixon, S., Blom, A.W., 2012. The role of preoperativeself-efficacy in predicting outcome after total knee replace-ment. Musculoskeletal Care. Available from: <http://onlin-elibrary.wiley.com/doi/10.1002/msc.1008/abstract>.
Yeh, M.L., Chen, H.H., Liu, P.H., 2005. Effects of multimediawith printed nursing guide in education on self-efficacy andfunctional activity and hospitalization in patients with hipreplacement. Patient Education and Counseling 57 (2), 217–224.
Zhang, W., Moskowitz, R.W., Nuki, G., Abramson, S., Altman,R.D., Arden, N., Bierma-Zeinstra, S., Brandt, K.D., Croft,P., Doherty, M., Dougados, M., Hochberg, M., Hunter,D.J., Kwoh, K., Lohmander, L.S., Tugwell, P., 2008. OARSIrecommendations for the management of hip and kneeosteoarthritis, part II: OARSI evidence-based, expert con-sensus guidelines. Osteoarthritis and Cartilage 16 (2),137–162.
