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278 Occupational Therapy International, 10(4), 278-293, 2003 © Whurr Publishers Ltd

Reducing anxiety by pre-operative

education: Make the future familiar

NICOLA JANE SPALDING School of Occupational Therapy, University of

East Anglia, Norwich, UK

ABSTRACT: Pre-operative education is widely used by occupational therapists all

over the world to help patients prepare for their impending surgery and post-operative
needs. The purpose of this research was to gain understanding of how the pre-
operative education process is beneficial in reducing anxiety for patients awaiting a
total hip replacement provided in one National Health Service Trust in England. The
participants in this study were a convenient sample of health care professionals who
presented information on pre-operative education during a nine-month data collection
period, and a sample of patients who attended the programme. Data were collected
from observing five pre-operative education programmes, 26 written patient evalua-
tions, 16 interviews with seven presenters of the education, observation of three team
meetings, 20 interviews with 10 patients, and documentation pertaining to the
programme. From the results it seems that patient education can reduce anxiety by
making the unknown familiar. Such familiarity can be achieved in three ways by:
providing an understanding of the experiences patients will encounter during and after
surgery; giving an opportunity to meet the staff that will be caring for them; and
familiarizing patients with the environments they will meet when in hospital. Major
limitations of the study were not being able to control for researcher bias and not
providing a standardized instrument to collect data. It is recommended that further
research be carried out to understand the dynamics between patient education and the
reduction of anxiety among patients undergoing hip replacements.

Key words: pre-operative education, hip replacement surgery, qualitative

research

Introduction

This study was based on a pre-operative education programme for patients

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Reducing anxiety by pre-operative education 279

awaiting a total hip replacement in one National Health Service Trust in

England. The researcher worked with a group of health care professionals to
gain insight into how pre-operative education, demonstrated as wanted by
patients (Spalding 2001), can reduce patients’ anxiety (Spalding, 1995).
Use of pre-operative education for patients is widespread, especially in the
USA (Lindeman, 1972; Crabtree, 1978; Wilson, 1981; Ziemer, 1983; Vallejo,
1987; Schoessler, 1989; Haines and Viellion, 1990; Orr, 1990; Allen et al.,
1992; Haines, 1992; Recker, 1994; Roach et al., 1995; Brumfield et al., 1996;
Lookinland and Pool, 1998; Claeys et al., 1998; Daltroy et al., 1998; Pellino et
al., 1998). Other research on patient education has been carried out in Canada
(Wong and Wong, 1985), Sweden (Lilja et al., 1998), Singapore (Lum et al.,
2000), Australia (Lee and Lee, 2000) and the UK (Spalding, 1995; Gammon
and Mulholland, 1996; Cooil and Bithell, 1997; Spalding, 2000).
Pre-operative education can be undertaken with any patient prior to a
surgical intervention, including total hip replacement (Wong and Wong,
1985; Orr, 1990; Santavirta et al., 1994; Roach et al., 1995; Spalding, 1995;
Butler et al., 1996; Gammon and Mulholland, 1996; Cooil and Bithell,
1997; Claeys et al., 1998; Daltroy et al., 1998). A consistent description of
pre-operative education includes the process of informing clients about their
condition, surgery and post-operative care, and instruction about
compliance to a treatment regime. For example, Roach et al. (1995: 83)
provided ‘information about every aspect of hospitalization … This included
steps to minimize complications, teaching exercises that would increase
post-operative function, and quality discharge planning.’ Gammon and
Mulholland (1996: 589) provided ‘procedural, sensory and coping infor-
mation relating to the whole surgical procedure’.

Occupational therapists as educators

A core skill of occupational therapists is patient education (Hagedorn,

1992). It is fundamental to client-centred practice and its content includes
educating about medical conditions, compliance to interventions and use of
special rehabilitation equipment. It follows therefore that occupational
therapists should be involved in pre-operative education for patients
awaiting total hip replacements. In many hospitals this is the case
(Spalding, 2000). Occupational therapists can help patients prepare pre-
operatively at home by educating them about how to be independent
within the confines of the precautions they must take post-operatively.
Such pre-operative education helps to reduce patients’ anxiety and facili-
tates the occupational therapy process leading to an early discharge
(Spalding, 1995). The purpose of this study was to gain further information
about the dynamics of patient education in reducing patient anxiety. This
information can help occupational therapists develop further their pre-
operative patient education services.
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280 Spalding

Literature review

That anxiety levels can be reduced by pre-operative education has been

proven many times in previous research and Hathaway (1986) reviewed 68
experimental studies. The effectiveness of pre-operative education was
inferred from its association with the reduced incidence of physical and
emotional problems during patients’ rehabilitation in hospital. Hathaway
reported a 20% improvement in post-operative outcomes, which included
reduced anxiety levels. Devine and Cook (1986) reviewed 102 experimental
design studies to determine how pre-operative ‘psychoeducational interven-
tions’ influence post-operative outcomes. They found positive effects in
patients’ psychological well-being, including reduced anxiety. Subsequent
experimental research has continued to provide experimental evidence on
the effectiveness of pre-operative education for reducing anxiety (Meeker,
1994; Roach et al., 1995; Spalding, 1995; Gammon and Mulholland, 1996;
Clode-Baker et al., 1997; Daltroy et al., 1998; Lookinland and Pool, 1998;
Bondy et al., 1999; Lum et al., 2000).
A strong reason for the importance of reducing patients’ anxiety can be
found in the relationship between anxiety and pain, both subjective
elements of patients’ experience (Strong, 1987; French, 1989; Pearce and
Mays, 1994).
Anxiety can result in an increase in the levels of patients’ experience of
pain which usually requires management through analgesia. Analgesia
consumption is therefore seen as one measure of anxiety level. The more
anxious patients are, the more they will experience pain and therefore the
higher their likely analgesia consumption. Early researchers of pre-operative
education therefore used analgesia usage as an indicator of anxiety level.
They claimed that reduced analgesia usage in such patients was due to their
reduced anxiety, and the reduced anxiety was due to pre-operative education.
Another reason, however, might have been that patients chose not to ask for
pain relief, for whatever reason. Other critiques of these studies (Anderson
and Masur, 1983; Ley, 1988) have suggested that such studies were flawed in
their reliability and validity.
Later studies have used control and experimental patient groups to
correlate pain experience, reduced analgesia usage and pre-operative
education (Worley, 1986; Orr, 1990; Shade, 1992; Spalding, 1995;
Gammon and Mulholland, 1996; Daltroy et al., 1998). Other researchers
have used various psychological anxiety measures to attribute reduced
anxiety to patient education, for example, the Hospital Anxiety and
Depression Scale, the Nottingham Health Profile and the Stress Arousal
Checklist (Clode-Baker et al., 1997) and Spielberger’s State Trait Anxiety
Inventory (Bondy et al., 1999). These later studies demonstrated that
patients who had received pre-operative education were less anxious than
control patients.
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Reducing anxiety by pre-operative education 281

Method

Data were collected from observing five pre-operative education programmes,

26 written patient evaluations, 16 interviews with seven presenters of
education, observation of three team meetings, 20 interviews with 10 patients,
and documentation pertaining to the programme.

Participants
The voluntary participants for this study were health care professionals who
presented on the pre-operative education programmes during the nine-month
data collection period, and a sample of patients who attended the programmes.

Ethical issues
Strategies were developed to ensure ethical correctness and to safeguard the
rights of those involved in the research in respect of informed consent and
confidentiality (Pope and Mays, 1999). These strategies were approved by the
Trust’s local research ethics committee.

Informed consent
All potential participants were informed, in writing and by explanation, of the
nature of the research and the implications of involvement for them. Patient
information sheets and consent forms were sent out with pre-operative
education invitations so they could be read and considered before the
programme. Patients then approached the researcher at the programme if they
wanted to be involved. The presenters were sent the forms prior to a meeting
at which the researcher gave a full explanation of the study. Presenters
approached the researcher after this meeting if they wanted to be involved.

Confidentiality
Pseudonyms were used throughout to protect the anonymity of participants. To
preserve the anonymity of the presenters the researcher used the term ‘health
care professional’ rather than referring to their specific professional identity.

Data collection
Data were collected from observations, interviews and documentation.

Observations
The researcher observed all pre-operative education programmes and
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282 Spalding

presenters’ team meetings during the study period. Observation appears to be a

valuable part of the case study approach: ‘Observations work the researcher
toward greater understanding of the case’ (Stake, 1995: 60). Stake advocates
this method because it does not disturb the ordinary activity of the case, being
‘non-interventive’. Stake’s point that observation is a naturalistic method can
be argued but his claim that it would not disturb the working activity was
questioned because the researcher appreciated that her presence could
influence the research. For example, her observations might alter the
behaviour of the participants.
Spradley’s (1980, cited in Robson, 1993) descriptive schedule was used to
guide the researcher’s observations. Spradley’s nine dimensions are: space,
actors, activities, objects, acts, events, time, goals and feelings.

Interviews
Semi-structured interviews were conducted so the researcher could gain under-
standing of people’s experiences, unachievable by observation alone. Stake
(1995: 64) claims ‘much of what we cannot observe for ourselves has been or is
being observed by others’. He says that interviews in a case study enable the
researcher to ‘obtain the descriptions and interpretations of others’. Different
participants would have different experiences that would enable the researcher
to find out about multiple realities in the case.
All presenters were interviewed at least twice. The interviews took place in
a quiet hospital room. Patients were interviewed twice: the first interview,
within two weeks of their attendance on the education programme, was held at
their home, the second, a week post-operatively, was conducted in an office to
ensure privacy while they were on the rehabilitation unit.
The interviews were tape-recorded then transcribed in full as data
collection progressed. This allowed the researcher to pursue any issues raised
by one participant with another and to follow up themes at second interviews.

Programme documentation
The documents consisted of patient invitation letters, timetables, written
evaluation forms and booklets. Documents were used because they gave the
researcher access to data on the education programme that was unobtainable
from observation or interview. Hodder (1998) refers to written texts as ‘mute
evidence’. This is why Stake (1995) encourages their use in qualitative
research: ‘Documents can be key repositories or measures for the case.’

Data analysis
Data were analysed by the coding and categorizing of themes. Coding is
described as the linking of different segments or instances in the data to create
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Reducing anxiety by pre-operative education 283

a common category (Coffey and Atkinson, 1996). Coding has the potential to
open up themes beyond any planned focus. The first round of data analysis
took place after each first interview and team meeting. Diary notes of
emerging themes were made during transcription, to begin the analytical
process. The patient evaluation questionnaires were collated to give a list of
responses to each question. Other documentation was also included within
themes. The researcher carefully reviewed the data, reading and rereading
them for the purpose of coding to develop an overview to facilitate their use in
problem solving the issues. Seidel and Kelle (1995:58) state, ‘Codes do not
serve primarily as denominators of certain phenomena but as heuristic devices
for discovery.’

Trustworthiness
Credibility was enhanced by the triangulation of data collection methods and
time triangulation of data collection with interviewees; peer examination with
a mentor; member checks of data analysis and draft reports with participants;
and reflexivity using a research diary for an audit trail and to facilitate the
researcher’s reflections (Lincoln and Guba, 1985). Transferability of the case
study can be evaluated by the readers. Stake (1995:7) claims, in case studies,
‘Seldom is an entirely new understanding reached but refinement of under-
standing is.’ The researcher therefore has attempted, as Lincoln and Guba
(1985: 316) state, to ‘provide the data base that makes transferability judge-
ments possible on the part of potential appliers’.
Time allowed the researcher to leave some coded data for at least two weeks
before returning to recode data and compare the analysis (Krefting, 1991).
Member checks, previously discussed, also aid dependability, as stated by
MacDonald and Walker (1977: 188), ‘Cross-checking rather than consistency
is the main strategy of validation’ and so reliability of this case study was
enhanced through continuous negotiation of findings with participants. To
establish confirmability an audit was kept so a peer could progress through the
study, to understand the basis for decisions (Guba, 1981).

Findings

The education programme

Patients from the Trust’s total hip replacement waiting list were invited to attend
the pre-operative education programme via a letter outlining the purpose. A
timetable of the events in the programme (see Table 1) was included with the
invitation. Approximately 12 patients were invited to each programme and were
expected to be admitted into hospital for their hip replacement within three
months of attending. They were also invited to bring a companion.
The timetable was organized as a chronological account of having a total
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284 Spalding

TABLE 1: Programme timetable

Time Content Presenters

1.30 pm Arrival and welcome Helen/Christina

1.35 pm Video presentation
1.55 pm Admission to hospital and
life on the ward Heather/Hilary
2.10 pm Pain control Charlotte
2.25 pm Tea and questions All presenters
2.40 pm Exercises, mobility and
safe transfers Colin/Harry
3.00 pm Preparation for
returning home Helen/Christina
3.20 pm What it is like and life after
a hip replacement Ex-patient
3.30 pm Questions and finish All presenters

hip replacement from admission to full rehabilitation after discharge. The

programme provided as much explanatory information as possible within
the two hours. The presenters explained the events that patients could
expect, and provided demonstrations of joint protection movements and
the use of equipment. For example, one presenter demonstrated how to use
patient controlled analgesia and two others demonstrated using dressing
aids. The presenters preferred demonstration, sometimes with medical
equipment, to accompany their verbal explanations to try and ensure
patients understood what was being explained to them. Question opportu-
nities enabled patients to clarify individual concerns. A video provided
explanations and visual images of events and showed patients rehabilitating
and managing at home while adhering to post-operative joint precautions.
Former patients were invited as guest speakers and provided a positive
message on the worth of undergoing a total hip replacement, and to answer
any questions from the audience. In addition, booklets provided written
summaries of the main points, with diagrams. Throughout the programme,
there was reinforcement of important points, such as in a video on joint
precautions and the need to prepare at home. Consequently it appeared that
the programme provided patients with a comprehensive account of the total
hip replacement experience.

Presenters’ experiences
An agreed purpose of the education programme for the presenters was to reduce
patients’ anxiety prior to and during their admission into hospital. One presenter,
who had many years of experience working in orthopaedics, suggested that having
a hip replacement ‘needn’t be such an awful gut wrenching, stress-level increasing
event’. He commented that education could make it ‘less arduous’.
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Reducing anxiety by pre-operative education 285

The presenters believed, from their clinical experiences, that pre-operative

education does reduce patients’ anxiety. One presenter commented, ‘I would
say it has a tremendously beneficial effect on patients’ stress levels.’ Presenters
could also make judgements based on their own comparisons with other
patients who had not been educated in this way. For example, one said, ‘They
are definitely less worried because they know what is happening.’ The
presenters believed their programme reduced anxiety because of the educa-
tional content and the delivery processes they used.

The educational content

The presenters agreed that, from their experiences, giving patients infor-
mation did help them to be less anxious. As one said, this was about ‘getting
across information to patients that was going to be useful’. Her comment,
‘useful’, shows that she believes information could support patients’ own
purposes. She provided an example of a patient being less anxious: ‘She knew
the procedure because I was talking to her about the height charts and
equipment. None of it was alien. It was what she expected.’
Similarly, another presenter said that, in her experience, because of the
information patients had gained, post-operatively they had a ‘logical step plan
for getting home’. This, she said, meant they ‘understand … they know what
to expect because of what we have told them’. Knowing what to expect was
reassuring and this, she thought, was the means by which pre-operative
education helped to reduce anxiety.

The delivery processes

The delivery processes the presenters used were also seen by them as reducing
anxiety. They felt demonstrations made it easier for patients to understand and
remember what they were being told. One presenter said: ‘I much prefer to
demonstrate what I am saying with the dressing aids, because then patients
have a visual image of exactly what they look like and how to use them. Less is
likely to be misinterpreted. Then they will understand and be less anxious
about using them.’
In the same way, the visual images on the video and in the booklet were
seen as helping clarify the information content.
All presenters felt that meeting the patients was important because they
became a familiar face to them, which was appreciated later when the patients
met them again in hospital. One presenter explained: ‘When they’re in
hospital and they’re vulnerable, they’re frightened, but it’s easier if they’ve
already met you, because you are someone familiar.’
This presenter suggested that the presence of a familiar health care profes-
sional is reassuring to patients once they are in hospital, and this reassurance is
needed because of their vulnerable position. Another presenter in the third
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286 Spalding

meeting explained this vulnerability as: ‘In hospital there’s a risk of being
dehumanized, so when someone is familiar that’s good.’
Another presenter depicted it further: ‘I think they are quite vulnerable
really, so they call you over, or call out hello.’ She felt familiarity was very
important because if patients remembered her they would not be afraid to speak
to her and ask for her help when they needed it in hospital. This, she believed,
would help them to feel less anxious both before and during their admission.
Presenters saw providing ample time for patients to ask questions, within a
relaxed atmosphere, as essential to ensuring the education was client-centred.
In this way, patient’s individual concerns could be addressed. ‘They sometimes
need to be pushed to ask questions. You can tell they have them, but at first
aren’t able to, dare not ask. You have to wait a while, and then they all start.
You have to facilitate this by being friendly and by the whole atmosphere being
welcoming and friendly.’
The presenters chose to hold their meetings in the dining room of the
rehabilitation ward, so that patients could see where they would later be
staying, to get an impression of their future surroundings. This, presenters
thought, would reduce patients’ anxiety by giving them a visual image to refer
to. They also believed the dining room and ward had a pleasant atmosphere,
further reassuring patients. One presenter suggested that if patients could see
the unit ‘it might make them more relaxed’. Another explained, ‘I think it is
reassuring for them to see where they will be staying and to get a sense of what
it will be like.’ Another gave an example of how she saw a patient as benefiting
from seeing the ward before her admission, ‘She was very happy to be here,
very content and I don’t think anything felt strange to her.’

Patients’ experiences
Patients themselves, when asked how they felt pre-operative education had
been helpful, suggested that it had reduced their anxiety. For example, on the
programme evaluation forms typical written comments were, ‘small doubts now
obliterated’, ‘reassured’, ‘all fears expelled’, and ‘not worried now’. One patient,
in her first interview, described how ‘It’s put my mind at ease’. Patients
explained why they felt this way: ‘It helped me understand what will happen’;
‘to have procedures explained’; and ‘it helped to know what to expect’. This was
also explained in the interviews: ‘I think I knew everything I wanted to know
about the operation because it was in the booklet and from the teaching.’
Another patient talked about how useful it had been for him: ‘Now I’ve had
the operation I’m even more pleased with the information I was given … For
example, Harry came to me to say I could try walking with one stick and I’d
read all about it in the booklet so I knew what to expect.’
In their pre-operative interviews, presenters explained to patients what
they should expect, such as what would happen on the day they were admitted,
how their pain would be managed using the patient controlled analgesia pump,
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Reducing anxiety by pre-operative education 287

and post-operative precautions they needed to follow. Following this, most

patients went on to make pre-operative preparations at home. For example,
some patients raised their chairs and beds, and some reported purchasing
dressing aids which they had practised using before their operation.
In addition, many patients stated on their evaluation questionnaires that
meeting the health care professionals was beneficial to them because it showed
they were ‘understanding’ and ‘professional’. One patient said before he went
into hospital that the class had been ‘good’ because he had met the staff. ‘I
know them already, so that’s a comfort, knowing they will help me.’ Another
described how much he appreciated this once he was in hospital: ‘You meet
some of the staff which I think is really important. It’s important because you
remember them when you go in and it starts the conversation, “Oh hello, I
remember you”.’
Several patients specifically valued meeting the staff to ask them questions,
for example, one said, ‘You could ask anything that might occur to you’,
indicating they were comfortable enough to ask. One patient said, ‘All the
staff were accessible. I’d have thought that if anyone had questions they could
have asked them.’
Patients spoke of the presenters using terms such as ‘warm’, ‘friendly’,
‘caring’, and ‘relaxing’. For one patient, the presenters’ teaching suggested to
her that they were ‘wonderfully caring people, the way they spoke. Heather
was really great the way she put it over and she sort of put you at your ease.
Harry was wonderful, very relaxing. You know now exactly what’s going to
happen and the people who will be there to help you.’
A further positive feature that several patients highlighted in relation to
the programme was its location on the ward. One said, ‘The class was good
because you could see the place.’ Another explained that seeing the ward was a
benefit, ‘It was good to see where I will be staying because it was very pleasant,
not frightening like I had imagined.’ Another patient explained that she
appreciated seeing the ward because she had never been into hospital before: ‘I
can now picture what it will be like and where I will be. Before I couldn’t do
that and your imagination sort of gets carried away imagining scary things.’

Discussion

These subjective findings of the presenters’ observations and patients’ lived

experiences concur with the experimental studies presented in the literature
which demonstrated that pre-operative education reduces anxiety. However,
the purpose of this study was to explain how pre-operative education achieves
such a beneficial outcome. The findings suggest that pre-operative education
gives patients an understanding of what to expect: ‘It is about preparing
patients, making sure they know what to expect so they know what’s going to
happen and when it’s going to happen.’
For most patients, going into hospital is an unfamiliar experience, and, as
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288 Spalding

such can raise anxieties. One presenter used the word ‘alien’ to describe this
unfamiliarity. It seems an apt description for patients in a strange environment,
encountering unknown processes. Another used the word ‘lost’ to suggest this.
She compared patients who had been to a pre-operative education programme
with others who had not, ‘They’re not so lost it’s not something that’s new, you
can see it when you’re talking to them.’
Therefore, pre-operative education can help the patient prepare, by
providing an impression of what to expect. It is suggested this is achieved by
familiarizing the patient with future experiences, personnel and the
environment.

Familiar experiences
Implicit within the presenters’ team meetings and interviews was the impor-
tance they placed on sharing information about experiences that patients could
expect from the admission, surgery and rehabilitation. The educational content
and processes reflected this with presenters explaining and demonstrating as
many as possible of the experiences that patients could expect from having a
total hip replacement. Demonstration aids the explanation process by providing
visual images. Familiarity is gained, therefore, both by verbal explanation and
by seeing what to expect, for example, seeing how to do daily living tasks within
their confined movements after the operation, using aids and adaptations.
Demonstration was found to be an effective learning strategy in Theis and
Johnson’s (1995) meta-analysis of experimental studies of patient education.
The education booklets also had illustrations to aid understanding of infor-
mation. Ley’s (1988) many studies of patient communication indicate that
written information usefully supports teaching. He commented that patients
forget within five minutes half of what they have been told but, if they are
given written instruction for reference, they can review information regularly,
and this improves recall. Theis and Johnson (1995) and Cooil and Bithell
(1997) also found written pre-operative education helps patients. Wallace
(1985) believed that patients reading booklets prior to admission became more
knowledgeable than a control group, and they had fewer worries and a faster
recovery. The researcher suggests that the hip education booklet, by explaining
the processes involved in the operation, can help patients to continue to famil-
iarize themselves with what is going to happen after the programme has ended.
The patients in this case would observe the demonstrations and practise them
at home, aided by the booklet, while preparing for surgery. Consequently,
many of the post-operative joint precautions, such as using dressing aids, were
already familiar to them.
All of these processes enabled patients to gain knowledge and under-
standing and to have visual images of their future experiences. In this way, the
experiences become more familiar and this familiarity has the potential to
reduce their anxiety.
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Reducing anxiety by pre-operative education 289

Familiar personnel

There was evidence that patients appreciated meeting the staff who would
eventually be caring for them. This reflected the recognition by Hoermann et
al. (2001) in their study of patients’ needs before surgery, that it was ‘the most
crucial need of surgical patients’. A familiar face, it seemed, enabled a patient
to ask for help. Knowing they will be able to ask someone familiar and ‘acces-
sible’ for help has the potential to reduce anxiety. The choice of the word
‘accessible’ suggests that presenters were available for questions and easy to
understand, both of which are important for educators who wish to reduce
patients’ anxiety. Encountering presenters who were accessible could convey
to patients that they would remain accessible once they were in hospital, so
patients would feel able to ask them for help with ongoing concerns. Knowing
there would be accessible health care professionals happy to help and answer
questions could reduce patients’ anxiety. This is good grounds for providing
pre-operative education by the health care professionals who will also be
caring for the patients once they are in hospital.

Familiar environment
Within the literature on pre-operative education there has been little
attention paid to the environment used for the teaching, except assertions that
an environment that is conducive to teaching is an important consideration
(Davidhizar et al., 1998). In the same way that a familiar face proved to be
significant, for similar reasons a familiar environment could be seen to reduce
anxiety. The patients gained reassurance from experiencing the environment
and this helped them to feel reassured about their future stay. They were
provided with visual images of their future environment and actual positive
experiences of being on the ward. The video also proved effective here in
providing visual images of other settings in the hospital where the patients
would find themselves, such as the anaesthetic room and the recovery room.

Summary
It is suggested that the educational content and delivery of the programme, by
making the patients’ future familiar, helped them to feel less anxious. Patients
gained knowledge and understanding of their future experiences, the personnel
delivering it, and the institution associated with it. Having this knowledge and
understanding of expectations enabled patients to feel less anxious.

Evaluation of the research

Walker (1983) states that ‘an uncontrolled intervention in the lives of others’
is intrusive. In this study, the researcher’s observations, interviews and
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290 Spalding

presence in meetings could be deemed intrusive. Walker (1983) explains how

participants can be affected by being observed or questioned, because the
process can ‘heighten some self-perceptions and sensitivities’. In this study it
appeared that the research was emotive for some participants, for example, for
patients when recalling pain and disability, and for presenters when reflecting
on shortcomings in their presentation skills. Such emotional experiences for
the researcher raised concern for the degree of informed consent (Conneeley,
2002). If the researcher, as investigator, did not appreciate that such emotion
would ensue from the research, how could the participants? If participants
were not aware that the research might incite emotional experiences, then
consent was not fully informed in respect to possible effects the research
might have on them.
Such intrusion and emotion suggests that the research cannot be deemed
‘non-interventive’ (Stake, 1995). The researcher was influential. Conse-
quently it follows that transferability of findings to other contexts could be
judged as difficult, although Sandelowski (1986) considers achieving trans-
ferability in interpretive research to be unnecessary because of the
uniqueness of each situation and each researcher. Green (1999) states that
transferability beyond the particular context occurs when readers raise
questions about their own practice, which offers the possibility for new ways
of working.

Recommendations

Occupational therapists who engage in pre-operative education need to

consider the importance of both the educational product and the process. Pre-
operative education is more than just transferring items of relevant
information to reduce anxiety. Patients need to have their future made more
systematically familiar to them. The occupational therapist can achieve this in
three ways:

1. The programme should be structured around a chronological account of the

experience of having a total hip replacement. Attention must be given to
demystifying the medical arena and jargon so patients can understand.
Demonstrations should provide visual images. Activities of daily living
equipment should be used in these demonstrations so patients can see what
they look like and how they can use them. In this way, patients can gain
understanding of what experiences to expect.
2. Presenters should be those occupational therapists likely to care for the
patients once in hospital to achieve the benefits of familiarity.
3. The future environment should be made familiar to patients by presenting
the programme on or near the ward or therapy area so they can see and
experience it. Visual images should be provided of other settings patients
will encounter in hospital.
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Reducing anxiety by pre-operative education 291

It is also recommended that further research is undertaken on how to

reduce patient anxiety about hip replacement surgery and by so doing increase
the benefits of rehabilitation.

References
Allen M, Knight C, Falk C, Strang V (1992) Effectiveness of a pre-operative teaching program
for cataract patients. Journal of Advanced Nursing 17: 303–9.
Anderson K, Masur F (1983) Psychological preparation for invasive medical and dental proce-
dures. Journal of Behavioral Medicine 6: 1–40.
Berg D (1988) Anxiety in research relationships. In D Berg, K Smith (eds) The Self in Social
Enquiry (Chapter 10). Newbury Park, CA: Sage.
Bondy L, Sims N, Schroeder D, Offord K, Narr B (1999) The effect of anaesthetic patient
education on pre-operative patient anxiety. Regional Anaesthetic and Pain Medicine
24(2): 158–64.
Brumfield V, Kee C, Johnson J (1996) Pre-operative patient teaching in ambulatory surgery
settings. Association of Operating Room Nurses Journal 64(6): 941–52.
Butler G, Hurley C, Buchanan K, Smith-Vanhorne J (1996) Prehospital education: Effec-
tiveness with total hip replacement surgery patients. Patient Education and Counselling
29(2): 189–97.
Claeys M, Mosher C, Reesman D (1998) The POP program: The patient education advantage.
Orthopedic Nursing 17(4): 37-47.
Clode-Baker E, Draper E, Raymond N, Haslam C, Gregg P (1997) Preparing patients for total
hip replacement: A randomised controlled trial of a pre-operative educational intervention.
Journal of Health Psychology 2(1): 107-14.
Coffey A, Atkinson P (1996) Making Sense of Qualitative Data. London: Sage Publications.
Conneeley A. (2002) Methodological issues in qualitative research for the researcher/practi-
tioner. British Journal of Occupational Therapy 65(4): 185–90.
Cooil S, Bithell C, (1997) Pre-operative education for patients undergoing total hip
replacement: A comparison of two methods. Physiotherapy Theory and Practice 13:
163–73.
Crabtree M (1978) Application of cost–benefit analysis to clinical nursing practice: A
comparison of individual and group pre-operative teaching. Journal of Nursing Adminis-
tration 8(12): 11–16.
Daltroy L, Morlino C, Eaton H, Poss R, Liang M (1998) Pre-operative education for total hip
replacement patients. Arthritis Care and Research 11, (6): 469–78.
Davidhizar R, Bechtel G, Dowd S (1998) Patient education: A mandate for health care in the
21st Century. Journal of Nuclear Medicine Technology 26(4): 235–44.
Devine E, Cook T (1986) Clinical and cost-saving effects of psychoeducational interventions
with surgical patients: A meta-analysis. Research in Nursing and Health 9: 89–105.
French S (1989) Pain: Some psychological and sociological aspects. Physiotherapy 75(5):
255–60.
Gammon J, Mulholland C (1996) Effect of preparatory information prior to elective total hip
replacement on post-operative physical coping outcomes. International Journal of Nursing
Studies 33(6): 589–604.
Green K (1999) Defining the field of literature in action research: A personal approach. Educa-
tional Action Research 7(1): 105–24.
Guba EG (1981) Criteria for assessing the trustworthiness of naturalistic inquiries. Educational
Resources Information Centre Annual Review Paper 29: 75–91.
Hagadorn R (1992) Occupational Therapy: Foundations for Practice. London: Churchill
OTI 10 (4) 11/11/03 1:53 pm Page 292

292 Spalding

Livingstone
Haines N (1992) Same day surgery: Co-ordinating the education process. Association of
Operating Room Nurses Journal 55(2): 573–80.
Haines N, Viellion G (1990) A successful combination: Pre-admission testing and pre-operative
education. Orthopedic Nursing 9(2): 53–7.
Hathaway D (1986) Effect of pre-operative instruction on post-operative outcomes: A meta-
analysis. Nursing Research 35: 269–75.
Hodder I (1998) The interpretation of documents and material culture, In N Denzin, Y Lincoln
(eds) Collecting and Interpreting Qualitative Materials (pp. 110–29). London: Sage Publi-
cations
Hoermann S, Doering S, Richter R, Walter M, Schuler G (2001) Patients’ needs for infor-
mation before surgery. Psychotherapie Psychosomatik Medizische Psychologie 51(2): 56–61.
Krefting L (1991) Rigor in qualitative research: The assessment of trustworthiness. American
Journal of Occupational Therapy 45(3): 214–22.
Lee D, Lee S (2000) Pre– operative teaching: How does a group of nurses do it. Contemporary
Nurse 9(1): 80–8.
Ley P (1988) Communicating with Patients. Cheltenham: Stanley Thornes.
Lilja Y, Ryden S, Fridlund B (1998) Effects of extended pre-operative information on perioper-
ative stress: An anaesthetic nurse intervention for patients with breast cancer and total hip
replacement. Intensive and Critical Care Nursing 14: 276–82.
Lincoln Y, Guba E (1985) Naturalistic Inquiry Beverly Hills: Sage Publications.
Lindeman C (1972) Nursing intervention with the presurgical patient. Nursing Research 21(3):
196–209.
Lookinland S, Pool M (1998) Study on effect of methods of pre-operative education in somen.
Association of Operating Room Nurses Journal 37(1): 203–12.
Lum BS, Soh M, Aziz S, Yang S (2000) A descriptive and comparative study of pre-operative
teaching on patient’s satisfaction, self-efficacy and anxiety levels in elective surgical
patients. Singapore Nursing Journal 27(2): 37–9.
Macdonald B, Walker R (1975) Case study and the social philosophy of educational research.
Cambridge Journal of Education 5: 2–11.
Macdonald B, Walker R (1977) Case-study and the social philosophy of educational research. In
D Hamilton, D Jenkins, C King, B Macdonald, M Parlett (eds) Beyond the Numbers Game.
London: Macmillian Education.
Meeker B (1994) Pre-operative patient education: Evaluating post-operative outcomes. Patient
Education and Counselling 23: 41–7.
Orr PM (1990) An education program for total hip replacement and knee replacement patients
as part of a total arthritis centre program. Orthopedic Nursing 9(5): 61–9.
Pearce S, Mays J (1994) Chronic pain: Psychological approaches to management. In S Lindsay,
G Powell (eds) The Handbook of Clinical Adult Psychology (2nd ed) Routledge, London.
Pellino T, Tluczek A, Collins M, Trimborn S, Norwick H, Engelke ZK, Broad J (1998)
Increasing self-efficacy through empowerment: Pre-operative education for orthopedic
patients. Orthopedic Nursing 17(4): 48–59.
Pope C, Mays N (1999) Qualitative Research in Health Care. London: BMJ Publishing Group.
Recker D (1994) Patient perception of pre-operative cardiac surgical teaching. Critical Care
Nurse 14(1): 52–8.
Roach J, Tremblay L, Bowers D (1995) Pre-operative assessment and education program: Imple-
mentation and outcomes. Patient Education Counselling 25(1): 83–8.
Robson C (1993) Real World Research. Oxford: Blackwell.
Sandelowski M (1986)Telling stories: Narrative approaches in qualitative research. Journal of
Nursing Scholarship 23(3): 161–6.
OTI 10 (4) 11/11/03 1:53 pm Page 293

Reducing anxiety by pre-operative education 293

Santavirta N, Lillqvist G, Sarvimaki A, Honkanen V, Konttinen Y, Santavirta S (1994)

Teaching of patients undergoing total hip replacement surgery. International Journal of
Nursing Studies 31(2): 135–42.
Schoessler M (1989) Perceptions of pre-operative education in patients admitted the morning of
surgery. Patient Education and Counselling 14: 127–36.
Seidel J, Kelle U (1995) Different functions of coding in the analysis of textual data. In A
Coffey, PAtkinson (eds). Making Sense of Qualitative Data. London: Sage Publications.
Shade P (1992) Patient-controlled analgesia: Can client education improve outcomes? Journal
of Advanced Nursing 17: 408–13.
Spalding N (1995) A comparative study on the effectiveness of a pre-operative education
program for total hip replacement patients. British Journal of Occupational Therapy 55(12):
526–31.
Spalding N (2000) Empowerment of clients through pre-operative education. British Journal of
Occupational Therapy 63(4): 148–54.
Spalding N (2001) Clients. views of pre-operative education before hip replacement. British
Journal of Therapy and Rehabilitation 8(4): 130–5.
Stake R (1995) The Art of Case Study Research. Calfornia: Sage Publications.
Strong J (1987) Chronic pain management: The occupational therapist’s role British Journal of
Occupational Therapy 50(8): 262–3.
Theis S, Johnson J (1995) Strategies for teaching patients: A meta-Analysis. Clinical Nurse
Specialist 9(2): 100–5.
Vallejo B (1987) Is structured pre-surgical education more effective than non-structured
education? Patient Education and Counselling 9: 283–90.
Walker R (1983) Three good reasons for not doing case studies in curriculum research. Journal
of Curriculum Studies 15(2): 155–65.
Wallace LM (1985) Communication variables in the design of pre-surgical preparatory infor-
mation. British Journal of Clinical Psychology 24: 111–8.
Wilson J (1981) Behavioral preparation for surgery: Benefit or harm? Journal of Behavioral
Medicine 4(1) 79–102.
Wong J, Wong S (1985) A randomized controlled trial of a new approach to pre-operative
teaching and patient compliance. International Journal of Nursing Studies 22(2): 105–15.
Worley B (1986) Pre-admission testing and teaching: More satisfaction at less cost. Nursing
Management 17(12): 32.
Ziemer M (1983) Effects of information on post-surgical coping Nursing Research 32: 282–7.

Address correspondence to Nicola Jane Spalding, School of Allied Health Professions,

University of East Anglia, Norwich NR4 7TJ. Tel: 01603 593075, Fax: 01603 593166. e-mail:
n.spalding@uea.ac.uk