Programme content and evaluation regarding quality standards

Five core themes comprising sixteen sub-themes emerged from the analysis of narrative field notes. The presence of each of these themes within the pre-operative programme content varied across the facilitating centres, with the five main themes being: THR background; pre-operative process; pain and movement; THR effects and post-operative process; and other information. Consequently, programme content was evaluated with eight aims according to three practice guidelines on page 30. First, (1) explaining THR procedure and effects on patients to understand their THR journey is recommended by RCoA. Secondly, the aim of (2) reducing anxiety is stated by three organisations involved.

Six other aims from COT are (3) maximising independence of function, (4) resumption of occupational roles, (5) low readmissions rate, (6) decreasing length of hospital stay, (7) reduction of demand on support services, and (8) reintegration into the community. The framework of core themes and topics in educational programme is presented in Table 27.

Table 27: Coding frameworks of programme contents from observations in 5 centres and evaluation according to aims of three practical guidelines

Core themes Topics in education programme Centre Aims*

A B C D E

 This symbol is defined that the content of each topic was provided in the centre while observing.

*According to three UK guidelines (1) explaining THR procedure and effects on patients to understand THR journey (2) reducing anxiety (3) maximising independence of function (4) resumption of occupational roles (5) low re-admissions rate (6) decreasing length of hospital stay (7) reduction of demand on support services (8) reintegration into the community

6.3.2.1 THR background

THR background theme addressed three topics - programme introduction, hip introduction, and THR procedure. At the beginning, the providers introduced educational sessions with their aims and outlines. There was also an opportunity to recruit patients for national research (PROMs). Hip anatomy was described to support understanding of osteoarthritis, symptoms and treatment. This topic was presented by animation of DVD media in centre A, and hip model in centre D and E. Importantly, THR procedure was described that the acetabular cup and femoral stem of the thigh bone were prepared to fit an artificial cup and stem in the hip. Duration of THR was also explained. The lecturer in

four centres described this topic by various techniques: animation in centre A; Powerpoint presentation in centre C and E; oral explanation with artificial cup and stem in centre D.

However, some topics in THR background were not identified in three centres. In centre B this core theme was absent in the pre-admission therapy clinic that the researcher observed. Therefore, this sub-theme might be included within the hip surgeon assessment clinic. Centres C and E had an emphasis on the THR procedure but there was lack of support for pain management caused by osteoarthritis. A limitation of time in Centre C that is within one hour that possibly associated with more focus on THR than pre-operative pain. This topic might be included in other visits or in the centre’s hip booklet despite no electronic documents on the website. In centre E, alternative osteoarthritis treatments was provided in patient information leaflet on the website and stated that patients can discuss treatment options with health professionals³¹.

For evaluation with practical guidelines, there were two aims covered this core theme.

Explaining THR procedure and reducing anxiety of patients were reflected from the content in this theme. THR procedure was explained in four centres but this was absent in centre B. The researcher observed the pre-admission therapy clinic provided by OTs and physiotherapist; however, this was explained in the booklet²³¹. Therefore, all patients undergoing THR were received the information of THR procedure; however, their anxiety level may be reduced that should be investigated in other themes.

6.3.2.2 Pre-operative process

Core theme of pre-operative process was grouped from preparation of patients and process at the hospital. There were four main areas of patient preparation relating to their health: dental examination; medications; physical well-being; and personal care. Dental examination was required to confirm the patient had neither infective gum nor tooth in order to prevent the major complication of infection. This was mentioned in centre A only.

Medication was discussed in all centres, and discussion covered updated medication use and anaesthesia information. For instance, patients needed to stop warfarin seven days before THR and bring all medications with packaging to hospital on the admission day.

Suggestions were made for the best health outcomes of patients after the operation to

prevent of risks and complications occurring. These included stopping smoking, reducing alcohol intake, weight loss, exercise, and relevant issues related to infection control.

Personal care topic included clothing and toiletries, looking at home and furniture height.

The patients were recommended to bring suitable clothes such as warm night clothing, supportive low heels slippers and shoes. Moreover, house adaptations were individually discussed in detail with the OT after the session or on home visits.

Clinical examinations were made in hospital before the surgery, and patients met with the surgical team on admission day. Prior to admission, patients went through a physical examination, including an assessment of their physical ability by the OT or physiotherapist.

The physiotherapist in centre D stated that on admission day the nurse of the surgical team checked up with and confirmed surgery with the patient on the ward. Then, patients were moved to theatre, checked up again against the checklist and met the anaesthetist and the hip surgeon prior to the THR.

This core theme reflected two aims in the standard guidelines. The patients understood THR process and were reduced their anxiety. Explanation of the THR procedure focused on the preparation of patients and the process in hospital. Equipping patients with knowledge before THR reduced patient anxiety.

6.3.2.3 Pain and movement

Pain and movement theme was created from pain and movement function management.

Pre-operatively, the staff provided treatment to cope with chronic osteoarthritis pain and recommended to keep active. Following THR in the early post-operative period, pain management was emphasised. A health professional in the pain management team gave options of painkillers for patients and advised that the rehabilitation was usually started as soon as possible once the pain was relieved. For example, in centre E patients could take analgesia to relieve pain and maintain their mobility before THR. Post-operative pain was also eased by three options of pain medications under the assistance of ward nurses and the pain team. When the patients were relieved from pain, they were allowed to start their movement under supervision of the physiotherapist.

The other topic is function management after THR. Staff of all centres explained management of function to prepare patients in particular shortly after THR. In centre B, the OT measured the angle of the hip and knee on the operated side, and a test of thigh strength of patients to assess their movement function. Then they practised walking with two crutches up and down stairs and hip specific exercises under guidance of the physiotherapist. Almost all centres reported that once they were moved back on the ward after THR around 4 hours or more, the physiotherapist and nurse assisted patients to mobilise. This was also benefited in reducing stiffness and swelling on the operated leg. All patients practised walking under supervision of the physiotherapist until they were reassured to walk independently.

Regarding aims of standard guidelines, this theme was evaluated and fitted into three aims: explaining the THR effects; reducing anxiety levels; and maximising functional independence. Post-operative management of pain and function were described in the programme that was identified in enhancing the understanding of patients about the effects of THR. Following this, anxiety might be reduced because of understanding in coping with their pain and function and receiving support from health professionals.

Particularly, movement support on wards associated with maximising functional independence with respect to the physiotherapist who reassured walking independence of patients.

6.3.2.4 THR effects and post-operative process

This core theme emerged from six initial topics: nature of patient; post-operative managements; hip precautions; infection and blood clotting prevention; wound care; and discharge process. First, health care staff described patient’s characteristics in the recovery room after the operation. Patients received analgesia and had oxygen via a face mask or nasal spec. A drip was put in the patient’s hand for hydration as well as a wound drain and pillow/wedge were given. The surgical team visited patients to check up on their clinical status. Once good clinical status was confirmed, they were then moved to the ward.

A topic of post-operative managements included management on ward; follow-up process; information of daily activities, home circumstances and helper. On the ward, the

nurse was described in checking up on vital signs and feelings unwell of patients while the physiotherapist was in charge with mobility of patients as noted above in the previous theme. Variety of follow-up process was described. Whilst, a patient in centre B was informed for an appointment with the physiotherapist within 3 weeks post-operatively, centre E described an appointment with hip consultant from six weeks after THR.

Moreover, the OT explained how to use helping aids in daily activity for patients, and discussed their home environment such as furniture height. Contact details of staff were also provided for further questions of patients.

Three topics were separated from risks and complications. There were hip dislocation, infection and blood clotting prevention, and wound care. To prevent hip dislocation, limitation on use of hip after THR was explained in the programme. For example, driving was stopped in a range of six to twelve weeks post-operatively. Patients were advised to use walking aids for at least 3 weeks, to avoid bending down, crossing their legs and twisting. They were recommended to sleep on their back for 6 weeks post-operatively.

Two other major risks and complications were infection and blood clotting. Infection control was explained since pre-operative period. The staff in centre A mentioned that a document of confirming oral hygiene of patients was needed to report the surgical team prior to THR. In addition, rivaroxaban was selected to prevent possible blood clotting leading to life threatening complications such as deep vein thrombosis or ischemic stroke.

Furthermore, wound care was also concerned. Instructions were given to patients in order to prevent skin or wound infection that might lead to deep infection. The health care team described the process of wound dressing at hospital and the district nurse was responsible for follow-up at home. Additionally, when the patients had improved their health status, they were discharged with the permission of the surgeon. Other healthcare staff gave advice on safe discharge, and other things causing concern to patients such as identifying a helper, organising transport home, and stocking food after THR.

However, two centres were found lacking in giving patient information. Centre B was found lacking in giving information about infection control and blood clotting prevention.

This was noted during observation carried out in the pre-assessment therapy clinic. These

complications were described in the patient information booklet and might be included in another visit with the surgeon or other health professionals. In centre D, the discharge process was omitted, although this might be included in the booklet or another meeting with the health care team.

Content of this theme expressed the relation to four aims of standard guidelines. They consisted of explaining THR effects, reducing anxiety, maximising independence of function and low readmissions rate. Explaining THR effects and reducing anxiety of patients were reflected from all topics because post-operative process and management were provided to patients that might reduce anxiety level in preparation for their recovery.

In addition, increasing functional independence was reported in only topic of hip-pre-cautions, while low readmission rate was expressed in post-operative managements, hip pre-cautions, prevention of infection and blood clotting, and wound care.

6.3.2.5 Other information

Other information comprised the booklet, positive thinking, and questions and answers topics. First of all, the booklet was provided as the other source of information. During the programme in centre A, B and E, patients were emphasised on the importance of the booklet. Secondly, the staff in centre A, D and E attempted to encourage patients by use of positive words during the sessions. In centre D, the provider suggested positive words twice during the session which were

‘…tell yourself it’s not too bad / just get a bit sore’

‘Patients’ hip will be better after their operation in the theatre. Please remember you are not ill you just can’t capacitate to move by pain. Don’t let it beat you’.

On the contrary, no use of positive words was reported in centre B and C whereas neither centre C nor D emphasised on the booklet from observational result. These might probably provide in another visit with the health care team.

At the end of the education programme, the patients raised their issues with the staff. A variety of questions were asked in centre A and B, such as medications and co-morbidities that patients have and management during surgery period. In centre C patients asked

about putting the stockings on and off. In centre D, healthcare professionals described the difference between osteoarthritis and rheumatoid arthritis raised from the audience whereas the OT in centre E answered the period of returning to work.

Three topics of this theme were assessed with aims of guidelines. It was seen that positive thinking was an instrumental in reduction of anxiety. Similarly, health professionals gave a positive side of THR. It was also noted that questions and answer session reduced anxiety and increased resumption of occupational roles. The latter one occurred in centre E only.

6.4 Conclusion

Appropriate characteristics of the pre-operative education programme to educate patients about THR and effects were widely different. Commonalities of the programmes were found in three themes, that is, THR process, pain and movement, and THR effects and post-operative process. This followed standard guidelines in the UK.

On the contrary, two lesser common themes comprised THR background and other information. The content of the programme in five centres was appropriate to educate patients in relation to the five aims set out in the practice guidelines. For three other aims recommended in COT guidelines, there were decreasing length of stay, reduction of demand of support services and reintegration into the community. They were not evaluated from the contents of pre-operative educational programme because COT guideline covers interventions of THR journey by multidisciplinary health care staff.

Therefore, this result should be integrated with questionnaire results and qualitative findings. This triangulation is described in chapter 7.