Programme delivery/structure characteristics

Characteristics of pre-operative education were described and compared in terms of duration, frequency, number of participants, delivery methods, provider, materials and room plan operating the programme observed. Summary of characteristics from field notes and education programme in each centre is described in Table 26 below. Following this, teaching strategies, providers and characteristics of learning process were discussed.

Table 26: Summary of pre-operative programme characteristics from observation Centre Duration Remarks: OT = occupational therapist, PT = physiotherapist, NA = not available

*2 OTs provided information in the session.

Centre A established the programme at the preoperative assessment clinic twice a week for three hours – Wednesday morning for mixed patients undergoing THR and total knee replacement, and Thursday afternoon for only THR patients. When the researcher was observing, nine patients attended the programme on Wednesday in the afternoon at the

pre-operative assessment department. Five rooms were arranged: one large room big enough for twenty four people and used as a waiting room; one room for a small group observing a DVD presentation of surgery overview; and three other rooms for individual discussion with health professionals (Appendix 29). Patients confirmed their details and received information leaflets in the large room prior to the programme starting. There were four sessions which comprised of a group session of twenty-minute DVD media in THR procedure shown to patients and three one-on-one sessions to discuss their health issues and THR preparation with the chief nurse, pre-operative nurse and OTs. The participants received advice of daily activity, personal care and home environment by OTs including how to use helping aids after THR. In addition, a pre-operative nurse assessed patients by conducting a physical examination, looking at the medical history and medication. The other session was set up to describe details of the surgery such as implant used in THR and answer any questions that the patients might have. The patients were freely to attend each session depending on the availability of providers. Time taken in each session ranged from fifteen to thirty minutes depending on the contents of each section.

At centre B, individual sessions were organised by the OT in the pre-operative assessment clinic every Wednesday between nine to twelve o’clock. Patients were scheduled in time slots for one-hour sessions. When they came to the clinic, each patient, and a carer were invited by the OT to the private area partitioned by a curtain and sat facing each other next to a bed (Appendix 30). The OT assessed the patient’s movement function and pain around the hip following the checklist and discussed home environment, movement and personal care. Helping aids for post-operative use in daily activities were also demonstrated. Finally, the physiotherapist asked the patient to walk with two crutches on a flat surface, upstairs and downstairs in the assessment gym.

At the occupational therapy department of centre C, patients were scheduled for one-hour group sessions of the education programme every Tuesday lunch time. Seven patients attended this class while the researcher observed. This took place in a hall comprising of two rows of chairs for the patient and their carer to sit side-by-side and listen to the lecture given at the front of the hall by health professionals from the surgical team (Appendix 31).

There were three parts of the programme, starting with a presentation (Microsoft

PowerPoint®) of THR overview and procedure by a hip consultant. The ward manager then educated participants about the post-operative process and provided anaesthesia information leaflets. Finally, the physiotherapist and OT gave advice and illustrated post-operative movement to patients. At the end of each session, patients had an opportunity to ask the lecturer any questions. Each session lasted around fifteen to twenty minutes.

In centre D, a two-hour education programme took place on Wednesday morning at the physiotherapy department in a room large enough to hold 30 people. When the researcher observed, ten patients attended the programme with their carers, and were invited to sit side-by-side on chairs arranged in a U-shape (Appendix 32). The physiotherapist began by confirming patients’ names and gave a lecture in relation to THR information in front of the room without a media presentation. During this session, hip models, cup and stem were demonstrated for THR process to enhance the understanding of patients. In addition, the post-operative effects of surgery and helping aids for use in daily living were described.

At the end of session, the physiotherapist answered patient’s questions.

In the occupational therapy department of centre E, a one-hour education programme took place every Wednesday by two OTs. Seven patients and their carers sat side-by-side, as displayed in Appendix 33. Prior to the group session the patients met the staff for a health check-up. This programme utilised media presentation (Microsoft PowerPoint®), hip model, cup and stem, and the demonstration of helping aids. After the presentation, patients met with the physiotherapist or OT to discuss their home circumstances and individual problems or worries they might have.

Mixed teaching strategies were used to educate patients in all facilitating hospitals. They combined several teaching methods as well as group sessions and individual discussion.

There were several materials combined in the programmes, such as verbal instruction, DVD, visual aids materials (including presentation), demonstrations, written materials, and sample of artificial cup and stem. Previous report reviewed teaching strategies and delivery methods, and recommended that multiple strategies of teaching were used to educate patients due to effective results of such programmes²²⁶. Additionally, the survey examined current practices in the pre-operative programme before THR by 57 OTs in the

US. This also suggested that a variety of teaching methods should be included in the programme, such as video tape, individual discussion and group session for demonstration of exercises or how to use helping aids²²⁷. Moreover, a Finnish quantitative study comparing oral with written information via leaflets reported that giving information by two methods resulted in better knowledge and related care than by only giving written information²²⁸. This was also qualitatively reported in a Swedish study, that is, the combination of written and verbal information showed good effects for patients along their THR journey²²⁹. Therefore, a mix of strategies to provide information for patients should be utilised to enhance patients’ understanding about THR and its relevant effects.

All centres observed are using appropriate methods to educate patients.

All centres consisted of at least one physiotherapist or one OT within the team of providers. Three UK guidelines recommend a physiotherapist or OT to deliver education for this session^7,30,113. Therefore, health professionals giving a lecture and demonstrating walking aids in five centres were compatible with practical guidelines in the UK.

The education programme in all centres was accompanied with written materials; a hip booklet. It may affect in the long term period after THR, whilst the education programme and care by the health care team probably have an effect in the early post-operative period. Previous research studied the effects of active and passive learning. Active learning was defined as playing a game without verbal instruction but participants in passive learning obtained the verbal guide in the training session. This study compared participants at four times, whilst playing games: baseline; training; immediate test (after training); and delayed test (one week after training). The active group showed better performance in the delayed test than passive group. On the contrary, the active group performance was worse than the passive group in the immediate test. It was concluded that active training benefited the long term learning process but passive learning positively affected the short term outcome²³⁰. Combination of both methods should be recommended for educating patients.

In summary, programme delivery methods, materials, and structure characteristics were various in all centres. These were supported by the existing research in the effective ways

to enhance the understanding of patients for THR process. In addition to the characteristics of the programme, content of the programme in all centres were investigated in next section.