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 DOI: 10.1177/1054773814549992

published online 17 September 2014Clin Nurs ResUnosson and Kirsi Valkeapää

Brynja Ingadottir, Natalja Istomina, Jouko Katajisto, Evridiki Papastavrou, Mitra Seija Klemetti, Helena Leino-Kilpi, Esther Cabrera, Panagiota Copanitsanou,

Undergoing Knee or Hip Replacement in Seven European CountriesDifference Between Received and Expected Knowledge of Patients

  

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Article

Difference Between Received and Expected Knowledge of Patients Undergoing Knee or Hip Replacement in Seven European Countries

Seija Klemetti, PhD, RN1, Helena Leino-Kilpi, PhD, RN1,2, Esther Cabrera, PhD, RN3, Panagiota Copanitsanou, PhD, BSc, MSc, RN4, Brynja Ingadottir, CNS, RN, PhD5,6, Natalja Istomina, PhD, RN7, Jouko Katajisto1, Evridiki Papastavrou, PhD, RN8, Mitra Unosson, PhD, RN5, and Kirsi Valkeapää, PhD, RN1,9

AbstractThe purpose of the study was to examine received and expected knowledge of patients with knee/hip arthroplasty in seven European countries. The goal was to obtain information for developing empowering patient education.

1University of Turku, Finland2Hospital District of Southwest Finland, Finland3Pompeu Fabra University, Mataró, Spain4University of Athens, Greece5Linköping University, Sweden6Landspítali University Hospital, Reykjavik, Iceland7Klaipeda University, Lithuania8Cyprus University of Technology, Limassol, Cyprus9Lahti University of Applied Sciences, Finland

Corresponding Author:Seija Klemetti, Department of Nursing Science, FI-20014 University of Turku, Turku 20500, Finland. Email: seija.klemetti@utu.fi

549992 CNRXXX10.1177/1054773814549992Clinical Nursing ResearchKlemetti et al.research-article2014

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The data were collected (during 2009-2012) from patients (n = 943) with hip/knee arthroplasty prior to scheduled preoperative education and before discharge with the Received Knowledge of hospital patient scale (RKhp) and Expected Knowledge of hospital patient scale (EKhp). Patients’ knowledge expectations were high but the level of received knowledge did not correspond to expectations. The difference between received and expected knowledge was higher in Greece and Sweden compared with Finland (p < .0001, p < .0001), Spain (p < .0001, p = .001), and Lithuania (p = .005, p = .003), respectively. Patients’ knowledge expectations are important in tailoring patient education. To achieve high standards in the future, scientific research collaboration on empowering patient education is needed between European countries.

Keywordsempowering patient education, educational nursing practice, received knowledge, arthroplasty patients

Introduction

Empowering patient education is of increasing importance in orthopedic sur-gery due to demographic changes, increase in orthopedic operations and shortened hospital stay (Allen, Mor, Ravels, & Houts, 1993; Hellström & Hallberg, 2001). For instance, during the years 2000-2009, the rate of hip and knee arthroplasties in Organization for Economic Co-Operation and Development (OECD) countries increased by more than 25%. The world-wide estimation is that 10% of men and 18% of women aged above 60 years have symptomatic osteoarthritis (OECD, 2010, 2011). This fact calls for increasing attention on prevailing nursing practices, the outcomes of patient education and international scientific research on European level (Coudeyre et al., 2007; Suhonen et al., 2008).

Background

The quality of patient education improves patients’ knowledge levels of postoperative skills and activities decreasing postoperative complications (Thomas & Sethares, 2008). However, research focusing on orthopedic patient education in the surgical context is still limited. An increasing num-ber of surgical patients suffering from osteoarthritis (EU Commission Directorate General for Health and Consumers, 2008), an aging population

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Klemetti et al. 3

(Eurostat, 2010a, 2010b, 2010c; Hellström & Hallberg, 2001), and the cur-rent trend of increased day-case surgery (Eurostat, 2010a, 2010b, 2010c) have led to high emphasis on national and international strategies in patient education (“Directive 2011/24,” 2011; Euractiv.com, 2008; Osborne, Buchbinder, & Ackerman, 2006). Earlier studies on the educational needs of orthopedic patients (Mancuso et al., 2008; Montin, Johansson, Kettunen, Katajisto, & Leino-Kilpi, 2010) and the content and methods of education (Kinnersley et al., 2007; Thomas & Setheres, 2008) have been identified, as have the outcomes of patient education (Yoon et al., 2010). However, most of the studies are descriptive without follow-ups, the outcomes of patient education are less measured, and there is a lack of international perspectives. International perspective is important because of the increasingly multicul-tural structure of the health care system. Cultural aspects should to be taken into account in designing patient education pathways (“Directive 2011/24,” 2011; Johansson, Nuutila, Virtanen, Katajisto, & Salanterä, 2005; Suhonen & Leino-Kilpi, 2006). Moreover, in the event problems in health care, rec-ognized as common and prolific in several countries, comparative collabora-tion between different countries is desirable (Aiken et al., 2012; Theodorou, Charalambous, Petrou, & Cylus, 2012). Furthermore, patient education is given limited time in current health care and therefore, it is crucial that the education patients receive from health care professionals during the periop-erative period has relevant content and corresponds to their self-defined expectations for knowledge regarding their own care (Gruman et al., 2010; Heikkinen et al., 2007).

Empowering patient education is the theoretical basis of this study (Figure 1). The empowerment theory is based on social-psychological theo-ries and constructive learning where the emphasis is on one’s own cognitive process and use of knowledge (Kuokkanen & Leino-Kilpi, 2000). Empowering patient education is an educational intervention improving patients’ critical thinking and autonomy to make informed decisions (Anderson & Funnell, 2010; Freire, 1993). In this study, the basic hypoth-esis that the smaller the difference between a patient’s received and expected knowledge, the more potential there is for empowerment of the patient (Heikkinen et al., 2007; Ryhänen et al., 2012b). To be empowering, the knowledge received needs to be multidimensional. For instance, orthopedic hip and knee arthroplasty patients represent many different age groups with long-term health problems. They need empowering knowledge according to their current phase of life. The content of the knowledge of empowering patient education is therefore divided into six dimensions: biophysiologi-cal, functional, experiential, social, ethical, and financial (Heikkinen et al., 2007; Johansson, Salanterä, & Katajisto, 2007; Leino-Kilpi et al., 2005;

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Leino-Kilpi, Luoto, & Katajisto, 1998; Leino-Kilpi, Mäenpää, & Katajisto, 1999; Rankinen et al., 2007; Ryhänen et al., 2012a ).

Previous studies have shown, for example, that older patients experience that they have received education on social, experiential, ethical, and finan-cial issues according to their expectations (Johansson et al., 2003). The bio-physiological and functional aspects seem to be covered more adequately than experiential, ethical, and financial issues in patient education of orthope-dic patients (Johansson, Hupli, & Salanterä, 2002; Johansson et al., 2010; Johansson et al., 2003; Rankinen et al., 2007). Studies also indicate a lack of correspondence between educational needs and the education received (Merkouris et al., 2011a; Merkouris et al., 2011b; Papastavrou et al., 2012; Suhonen, Papastavrou et al., 2011). Furthermore, patients may consider the knowledge they have received to be sufficient, but still expect more (Heikkinen et al., 2010). However, nurses and patients may have different understanding about relevant knowledge (Bourne, Chesworth, Davis, Mahomed, & Charron, 2010). Patients’ background factors seem to have an effect on their expectations and received knowledge as well. For example, as mentioned above, cultural differences in multicultural countries, also in Europe, may cause variation in patients’ knowledge expectations. To be empowered, patients in different cultures may have equal knowledge

Perioperativeknowledge

Received knowledge

Difference between received and expected

knowledge

Expectedknowledge

Empowerment of the

patient

Demographics - gender- education- employment

status

Clinical factors- other chronic illness- reason for current

hospital stay

Country- Cyprus- Finland- Greece- Iceland- Lithuania- Spain- Sweden

Backgroundfactors

Figure 1. Theoretical basis of the study.

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expectations overall, but to a different extent in different dimensions (Epner & Baile, 2012; Suhonen, Efstathiou, et al., 2011). This study was conducted in collaboration between seven European countries, that is, Cyprus, Finland, Greece, Iceland, Lithuania, Spain, and Sweden, all of which share a common concern: How empowering patient education can be delivered to hip or knee patients undergoing joint replacement surgery. The goal was to enhance the international perspective on patient-centered, empowering patient education of orthopedic patients.

Aim of the Study

The aim of this study was to explore empowering patient education in seven European countries by analyzing the difference between received and expected knowledge of hip and knee arthroplasty patients and to identify pos-sible connections between this difference and background factors.

The research questions were as follows:

Research Question 1: What is the difference between received and expected knowledge among European hip and knee arthroplasty patients?Research Question 2: What background factors are associated with the difference between received and expected knowledge among European hip and knee arthroplasty patients?

Design

A comparative survey of patients undergoing knee or hip arthroplasty in seven European countries was performed during the years 2009-2012. The study is part of a larger European project on empowering patient education of osteoarthritis patients in the surgical context (Empowering Surgical Orthopedic Patients Through Education [ESOPTE], 1998).

The aim of this study within this larger ESOPTE project is to identify and explain the differences between received and expected knowledge of patient education on a European level.

Participants

The required sample size, at least 1,540 patients, was based on power calcula-tion of the instruments Received Knowledge of hospital patient scale and Expected Knowledge of hospital patient scale (RKhp, EKhp) with a power level of 0.90 and 0.8 differences of mean scores with 0.95 standard deviation within groups at the significance level of 0.01 (Petrie, 2006). The included

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participants were required to (a) be attending elective knee or hip arthroplasty for osteoarthritis, (b) be able to answer the questionnaires independently or with help from significant others to score marks, (c) understand Finnish/Greek/Icelandic/Lithuanian/Spanish/or Swedish, (d) have volunteered to par-ticipate and to have signed an informed consent. However, prior to surgery, 1,634 EKhp questionnaires were collected whereas after surgery, 943 RKhp questionnaires from the sample were accepted in the analysis. Responses of a participant to both EKhp and RKhp questionnaires and to all background fac-tors were required. Thus, data included in this analysis consisted of 943 (58%) patients.

Data Collection

Educational knowledge consisting of upcoming surgery, patients’ self- management and symptom management, recovery, and health-related quality of life was provided by health care professionals during the patients’ hospital stay on orthopedic wards. The contents of patient education were provided to the patients according to educational model of each country. The instruments RKhp and EKhp (Leino-Kilpi et al., 2005; Rankinen et al., 2007) were used in the data collection. The instruments, RKhp and EKhp, are parallel 40-item instruments measuring received (RKhp) and expected knowledge (EKhp) of hospital patients. The instruments include six dimensions of knowledge con-tent: biophysiological (eight items: for example, illness and symptoms), func-tional (eight items: for example, mobility and nutrition), experiential (three items: for example, emotions and experiences), ethical (nine items: for exam-ple, rights and confidentiality), social (six items: for example, significant oth-ers and patient organizations), and financial (six items: for example, costs and benefits) dimensions. Statements are ranked on a 4-point scale (1 = fully dis-agree to 4 = fully agree, 0 = not applicable in my case). The scores for each dimension are the mean scores for included items and range between 1 and 4; the higher the score, the more received knowledge/knowledge expectations.

The data were collected pre- and postoperatively from hip and knee arthro-plasty patients. The questionnaires were distributed to the patients by the researcher, research assistant, or staff nurse. The preoperative questionnaire (EKhp) was delivered prior to surgery (Cyprus, Finland, Iceland, Spain, Sweden) or handed out during admission (Greece, Lithuania) before sched-uled counseling. Patients returned the questionnaire at admission or by post prior to their surgery. Prior to discharge, the postoperative questionnaire (RKhp) was distributed to the patients. They were asked to return the com-pleted questionnaire to the mailboxes placed on the wards for this purpose, or send it back in a prepaid envelope.

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Ethical Considerations

The study was approved by the regional ethical authorities in each country. The approvals are based on national standards (reference numbers of ethical approvals: Cyprus Y.Y.15.6.17.9 (2); Finland ETMK:102/180/2008; Greece 3029/17.08.2010; Iceland 09-084-SI; Lithuania Sv 14,17/04/2009; Spain 2010/5955; Sweden Dnr. M69-09). Participants were informed of the pur-pose and procedure of the study and the principles of voluntariness and con-fidentiality. A written informed consent was obtained from all participants.

Data Analysis

In RKhp and EKhp, each dimension of knowledge was constructed by calculat-ing the means of the corresponding items (range = 1-4). The patients who had answered at least 50% of the items were included. Furthermore, for each patient, the difference between received (RKhp) and expected (EKhp) knowl-edge scores was calculated for each dimension and total scale. If this differ-ence of scores was negative, the patient had higher expected than received knowledge, and if positive, the patient had received more knowledge than she or he had expected. These score differences were used as an outcome variable in multifactor ANOVA. Statistical significance was set at 0.05 (Petrie, 2006). The statistical analyses were performed using SPSS 19.0. This study is focused on the received knowledge of the patients; how the knowledge patients received corresponds to the knowledge they have expected. The data of expected knowledge are analyzed and results are published in earlier face of the project (Valkeapää et al., 2013).

Validity and Reliability

The data collection process in each country was guided by the same protocol. In the protocol, the main principles for data collection were determined, and the data were collected in selected hospitals (one to five per country). The protocol was described on the study’s homepage and was accessible to all collaborators. However, all patients had not responded to both questionnaires and missing background factors dropped out patients from the multifactor analysis.

The data collection instruments, RKhp and EKhp, have been used and tested before with surgical patients (Rankinen et al., 2007; Ryhänen et al., 2012a, 2012b), also in orthopedic settings (Heikkinen et al., 2007). The internal con-sistencies of RKhp and EKhp were satisfactory in a previous study (Cronbach’s α, total scale: RKhp = .93, EKhp = .91, Rankinen et al., 2007), similar to the

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present study, where Cronbach’s alphas for the six dimensions ranged between .89 and .95 in RKhp and between .87 and .94 in EKhp. The question-naires and other forms were first translated from Finnish to English, after which all questionnaires were translated to each language of the participating countries, and then back to English again. This was performed by profes-sional translators. The first and second English versions were compared for similarity (Maneesriwongul & Dixon, 2004). The pilot studies of 30 patients gave satisfactory result in each participating country and did not result in any changes.

Results

Sample

The data of this study consist of responses from 943 arthroplasty patients in Cyprus, Finland, Greece, Iceland, Lithuania, Spain, and Sweden. The number of participants in the countries ranged between 91 (10%) and 179 (19%). The majority were female, retired people, and people with lower education. Their mean age was 67 years (SD = 10.7, range = 25-91). The background factors of the patients are presented in Table 1.

Difference Between Patients’ Received and Expected Knowledge

Received knowledge was significantly lower than expected knowledge in all of the countries and in all knowledge dimensions. The lowest difference between received and expected knowledge was seen in functional and bio-physiological dimension and the highest in financial dimension (Table 2).

Associations of the Difference in Patients’ Received and Expected Knowledge With Their Background Factors

There were significant associations between the difference in received and expected knowledge and patients’ background factors. The difference was significantly higher among females in comparison with males (Difference of means [DM] = −0.811/−0.557, n = 565/378, p < .0001, respectively) and among unemployed patients in comparison with employed (DM = −1.141/−0.556, n = 19/264, p = .048, respectively) and retired patients (DM = −1.141/−0.510, n = 19/508, p = .026, respectively). Compared with patients without chronic illness, chronically ill patients also felt significantly more commonly that they had received less knowledge than they had expected (DM = −0.808/−0.561, n = 445/498, p < .0001, respectively).

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The differences between received and expected knowledge were negative, which means that the knowledge the patients received was less than the knowledge they had expected. There were, however, differences between the countries (Table 3).

The difference between the received and expected knowledge was the low-est in Finland (DM = −456, n = 134) and the highest in Sweden (DM = −963,

Table 1. Background Factors of the Patients (n = 943).

Background factor n %

Gender Female 565 60 Male 378 40Education Primary school 499 53 Comprehensive school 253 27 Matriculation examination 191 20 No vocational education 493 52 Secondary vocational education 216 23 College-level vocational education 138 15 Academic degree 96 10Employment status Employed 264 28 Retired 508 54 Working at home 117 12 Unemployed/job applicant 19 2 Other 35 4Employed in health/social care Yes 136 14 No 807 86Other chronic illness Yes 445 48 No 498 52Country Cyprus 126 13 Finland 134 14 Greece 153 16 Iceland 179 19 Lithuania 91 10 Spain 140 15 Sweden 120 13

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Table 3. Significant Relationships Between Countries and Mean Differences in Received and Expected Knowledge, in Total (RKhp Scalea; EKhp Scalea; 1= Fully Disagree to 4 = Fully Agree).

Country n Difference M Difference between countries p valueb

Cyprus 126 −.747 Spain 140 −.489 Greece 153 −.949 vs. Spain −.460 <.0001 vs. Lithuania −.473 .005 vs. Finland −.493 <.0001Lithuania 91 −.476 Sweden 120 −.963 vs. Spain −.474 .001 vs. Lithuania −.487 .003 vs. Finland −.507 <.0001Finland 134 −.456 Iceland 179 −.710

Note. RKhp = Received Knowledge of hospital patient; EKhp = Expected Knowledge of hospital patient.a©Leino-Kilpi, Salanterä, and Hölttä (2003), Version 2.0.bMultifactor ANOVA.

Table 2. Difference of Means (DM) Between Received and Expected Perioperative Knowledge, Evaluated by the Patients (RKhp Scalea; EKhp Scalea; 1= Fully Disagree to 4 = Fully Agree).

Dimensions of knowledge n

Received M (SD) (n = 943)

Expected M (SD) (n = 1,634)

Difference M (SD) p valueb

Biophysiological 939 3.361 (0.77) 3.724 (0.50) −.363 (0.82) <.001Functional 931 3.358 (0.69) 3.650 (0.58) −.292 (0.79) <.001Experiential 870 2.801 (1.09) 3.426 (0.79) −.625 (1.23) <.001Ethical 919 2.855 (0.98) 3.500 (0.65) −.645 (1.07) <.001Social 909 2.823 (0.99) 3.430 (0.66) −.607 (1.12) <.001Financial 853 2.556 (1.14) 3.465 (0.77) −.909 (1.30) <.001

Note. RKhp = Received Knowledge of hospital patient; EKhp = Expected Knowledge of hospital patient.a©Leino-Kilpi, Salanterä, and Hölttä (2003), Version 2.0.bt test for dependent samples.

n = 120) and Greece (DM = −949, n = 153). In addition to Finland, the differ-ences in Sweden and Greece were significantly larger in comparison with

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Spain and Lithuania. In Cyprus and Iceland, the differences between received and expected knowledge were similar in comparison with the other participat-ing countries.

Differences between received and expected knowledge in the separate dimensions of empowering knowledge were larger in females compared with males (p = .0001-.033) and larger among patients reporting another chronic illness than those without, except social dimension.

Unemployed patients had a significantly larger difference in the social dimension than employed and retired patients, and a larger difference in the experiential dimension compared with retired patients (Table 4).

Table 4. Significant Relationships Between Gender, Employment Status, and Chronic Illness and Differences of Means (DM) in Received and Expected Knowledge Dimensions (RKhp Scalea; EKhp Scalea; 1 = Fully Disagree to 4 = Fully Agree).

Dimension of knowledge n Difference M p valuea

Biophysiological Female vs. male 562/377 −0.508/−0.380 .033 Chronic illness vs. no chronic illness 444/495 −0.526/−0.362 .003Functional Female vs. male 557/374 −0.462/−0.340 .033 Chronic illness vs. no chronic illness 442/489 −0.485/−0.317 .001Experiential Female vs. male 520/350 −1.134/−0.786 <.0001 Unemployed vs. retired 18/470 −1.604/−0.934 .018 Chronic illness vs. no chronic illness 415/455 −1.102/−0.817 .001Ethical Female vs. male 547/372 −0.961/−0.645 <.0001 Chronic illness vs. no chronic illness 435/484 −0.951/−0.655 <.0001Social Female vs. male 542/367 −1.030/−0.704 <.0001 Unemployed vs. employed 19/254 −1.440/−0.778 .027 Unemployed vs. retired 19 /489 −1.440/−0.797 .023Financial Female vs. male 509/344 1.223/0.872 <.0001 Chronic illness vs. no chronic illness 445/498 1.194/0.901 .001

Note. RKhp = Received Knowledge of hospital patient; EKhp = Expected Knowledge of hospital patient.a©Leino-Kilpi, Salanterä, and Hölttä (2003), Version 2.0.bMultifactor ANOVA.

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Discussion

In this study, our goal was to produce, for the purposes of empowering patient education, knowledge on what the patients expect to learn and what they actually do learn. We examined the principles of empowering patient educa-tion, that is, what education should consist of so that patients’ potential empowerment is enabled. The main finding is a significant difference between received and expected knowledge in patients undergoing knee and hip arthro-plasty. In all countries, this difference was associated with gender, unemploy-ment, and other chronic disease. The patients did not experience that they received knowledge according to their expectations. In this study, the patients’ empowerment may not have been enabled to a sufficient extent (Heikkinen et al., 2007; Ryhänen et al., 2012b).

The issue of unmet knowledge expectations in all dimensions seems to be relevant in all participating countries, although to a different extent. Differences between received and expected knowledge (Sweden and Greece), for example, may be explained by patients’ better or more active access to knowledge. Thus, a higher difference between received and expected knowl-edge does not necessarily mean poor patient education; the population may be used to adequate access to knowledge and may have learned to require more. Therefore, further development of the different ways in which people can access health care knowledge is necessary, such as access to computer-based education and educational material online (Heikkinen et al., 2010). However, there were also countries such as Cyprus and Iceland where patients’ knowledge expectations were better met. In the case of Cyprus, it is estimated that 83% of the population has the right to access the public health system free of charge, whereas the rest must pay to use public services or they use the private system (Theodorou et al., 2012). The Cyprus sample was drawn from the public hospitals and all subjects were of retirement age mean-ing that they received services free of charge. It is therefore possible that when people do not have to pay for the services they receive, they may have lower expectations; this finding can also be explained by the high satisfaction rates for Cypriot patients reported in several studies (Merkouris et al., 2011a; Palese et al., 2011). In addition, the current national health care system in Cyprus is in a transitional state and needs restructuring and reorganization, which probably means that people do not expect much from the system, so that whatever they get may seem sufficient to them.

Low differences between received and expected knowledge may also be due to cultural reasons, for example, the extent of participation of significant others when less attention may be expected from health care professionals (e.g., Spain) or practices in surgical procedures, such as the length of stay in

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hospital (e.g., Lithuania). The lowest difference between received and expected knowledge seen in Finland may not be attributed to a single reason. However, it seems that the expectations of patients undergoing arthroplasty in Finland have been recognized to a good extent in patient education. One of the promoting issues in this respect has apparently been the fact that Finnish hospitals have participated in many previous studies on empowering patient education (e.g., Heikkinen et al., 2007; Johansson et al., 2002; Johansson et al., 2010; Johansson et al., 2003; Johansson et al., 2005; Johansson et al., 2007; Kuokkanen & Leino-Kilpi, 2000; Leino-Kilpi et al., 2005; Leino-Kilpi et al., 1998; Leino-Kilpi et al., 1999; Montin et al., 2010; Rankinen et al., 2007) and development of patient education has therefore been prioritized in Finnish clinical nursing practice. However, differences between different countries cannot wholly be explained by professionals’ skills or experience.

The results of this study indicate the influence of some background factors on patients’ evaluation of the received knowledge, which is also reported in other studies (Johansson et al., 2003; Vogel, Bengel, & Helmes, 2008). It seems that patients who are already experiencing some kind of uncertainty in their lives, such as unemployment or chronic illness, do not receive enough knowledge. However, health care providers may evaluate chronically ill patients’ knowledge expectations to be lower compared with others because of their experience of hospitalization, illness, and patient’s role. This evalua-tion is supported by the results of this study. This does not mean, however, that chronically ill patients do not expect more knowledge in other fields. It is possible that unemployed patients are more worried about the influence of surgery and its social impact than retired or employed patients, whose social environments might be more established. Also, females may experience more distress about everyday life with their significant others and therefore have more expectations for comprehensive knowledge in all dimensions compared with males.

Can patients become empowered if they receive exactly the knowledge they have expected, or do they need something more, something they did not expect, to be empowered? There is some evidence supporting the view that patients and nurses have different opinions (Papastavrou et al., 2012; Suhonen, Efstathiou, et al., 2011), which means that nurses do not always fulfill patients’ expectations. Therefore, it is worth considering who deter-mines patients’ knowledge expectations and what the importance of includ-ing patients in the process is. More research and development of empowering patient education aimed at orthopedic patients is clearly needed internation-ally because fulfilled expectations of patients are an essential part of recovery (Vogel et al., 2008). As a research recommendation, a randomized controlled intervention study with assessment of expected knowledge, education

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according to individual knowledge expectations, and evaluation of received knowledge and empowerment would be relevant. We also need to follow the patients’ recovery process and evaluate whether those with a low or no differ-ence between received and expected knowledge have better self-care and self-management than those with greater difference.

The study contained some limitations. Patients may have received knowl-edge preoperatively from some other sources, such as the Internet. However, the main principles for data collection were determined by common proto-cols. Some (n = 691, 42%) of the patients did not return the questionnaires about received knowledge. The reason for this may be that they were tired, unwell, or had forgotten the questionnaires after discharge. The patients were mostly older people and patients’ response activity may also have been influ-enced by their lower level of education. More than half of the questionnaires were returned and the sample size can be considered satisfactory. The hospi-tals were not randomly selected in the different countries. Generalization of the results can be made with a caution. They can be exploited in other European countries as far as it comes to the six dimensions of empowering knowledge. Patients, internationally, expect and should receive this kind of multidimensional knowledge according to their preferences, although to a different extent.

The instruments RKhp and EKhp have not been validated internationally. However, the internal consistencies of RKhp and EKhp have been shown to be satisfactory by Cronbach’s alpha. The translation and piloting of translated instructions, questionnaires, and processes were conducted according to gen-eral scientific practices in the participating countries, where the instruments were found easy to use. Participants in each country received written instruc-tions on how to fill out the questionnaires, but it is possible that some patients did not find alternative suitable for themselves or did not want to answer some of the questions. The data were collected in several countries and the results may have been influenced by cultural or language-based issues, for example (Aiken et al., 2012), although the instruments were piloted.

Conclusion

The results of this study indicate that patients with knee or hip arthroplasty consider that their received knowledge during perioperative period did not meet their knowledge expectations. The knowledge they received did not suf-ficiently support their empowerment in the process. This was true in all the participating European countries, but on different levels. To be able to pro-vide individualized education, more knowledge about what constitutes high-quality standardized education is needed. This study provides new knowledge

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and emphasizes that standardized principles of information should not con-sist only of physical and functional issues, as is common, but should be more holistic and multidimensional. With this knowledge, we can move forward to individualized education, but to do so, we need to base our assessment on knowledge expectations including all dimensions of empowering knowledge. To achieve high and comparable principles of standard in future nursing edu-cation and nursing practice throughout Europe (Directive 883/2004), further scientific research and development of empowering patient education in col-laboration between different countries is needed.

Acknowledgments

The study has required contribution by many people in the participating countries. We thank the following persons for their contribution: Chryssoula Lemonidou, Arun K. Sigurdardottir, Adelaida Zabalegui, Gudjona Kristjansdottir, Gunnhildur Gunnlaugsdottir, Kolbrun Kristiansen, Panayota Sourtzi, Andreas Charalambous, Åsa Johansson Stark, Sara Cano, Darius Kurlys, Panayiota Vasileiou, Theologia Tsitsi, Melanie Charalambous, Androulla Ioannou, Markas Fiodorovas, Teresa Faura, Cristina Moreno, Laia Lacueva, Olga Monistrol, Juan Manuel Verge, and Teresa Camps.

Author Contributions

K.V., H.L.-K. were responsible for the study conception and design, S.K. for the drafting of the manuscript. K.V., M.U., P.C., A.C., E.P., B.I., and N.I. performed the data collection and J.K. the data analysis. All authors S.K., E.C., P.C., B.I., N.I., J.K., H.L.-K., E.P., M.U., and K.V. have made their critical revisions and approved the final version.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financially supported by the following: Finland—University of Turku; the Academy of Finland; the Finnish Association of Nursing Research; the Finnish Foundation of Nursing Education; Cyprus—the Cyprus University of Technology; Spain—Colegio Oficial de Enfermeria de Barcelona; Sweden—the Swedish Rheumatism Association and the County Council of Östergötland; Iceland—the Landspitali University Hospital Research Fund; the Akureyri Hospital Science Fund; the University of Akureyri Science Fund; the KEA fund, Akureyri; the Icelandic Nurses’ Association Science Fund; and Lithuania—University of Klaipeda.

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Author Biographies

Seija Klemetti, PhD, RN is Researcher at the Department of Nursing Science, in University of Turku and Clinical Nurse Specialist at the Department of Head- and Neck Surgery in University Hospital of Turku, Finland.

Helena Leino-Kilpi, Professor, PhD, RN is Director of the Department of Nursing Science in University of Turku and Nurse Manager in Hospital District of Southwest Finland (secondary office).

Esther Cabrera, PhD, RN is Director of School of Health Sciences TecnoCampus, University Pompeu Fabra, Mataro, Spain.

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Panagiota Copanitsanou, PhD, MSc, BSc, RN is working in General Hospital of Piraeus “Tzaneio”, at the Department of Orthopaedics and is Researcher at the Faculty of Nursing, University of Athens, Greece.

Brynja Ingadottir, CNS, RN, PhD- student is Clinical Nurse Specialist at the Department of Surgery in Landspítali University Hospital in Reykjavik. She is study-ing Nursing Science at the Department of Social and Welfare Studies, Faculty of Health Sciences in Linköping University, Sweden.

Natalja istomina, PhD, RN is Vice Dean for development and Adjunct Professor at the Department of Nursing, Klaipeda University, Lithuania

Jouko Katajisto, MSocSci, is Lecturer at the Department of Statistics in University of Turku, Finland

Evridiki Papastavrou, PhD, MSc, BSc, RN is Assistant Professor at the Department of Nursing School of Health Sciences in Cyprus University of Technology, Cyprus

Mitra Unosson, PhD, RN is Professor emeritus in the Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Sweden

Kirsi Valkeapää, PhD, RN is Assistant Professor at the Department of Nursing Science in University of Turku and Dean, Principal lecturer at the Faculty of Social and Health Care in University of Applied Sciences in Lahti, Finland.

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