Life and Healthcare Sciences

NURSES' PERCEPTIONS OF SURGICAL CLIENT PREPARATION: CONTRIBUTIONS TO STRUCTURING A PREOPERATIVE CONSULTATION

PERCEÇÃO DOS ENFERMEIROS SOBRE A PREPARAÇÃO DO CLIENTE CIRÚRGICO: CONTRIBUTOS PARA ESTRUTURAR UMA CONSULTA PRÉ-OPERATÓRIA

PERCEPCIONES DE LAS ENFERMERAS SOBRE LA PREPARACIÓN DEL CLIENTE QUIRÚRGICO: CONTRIBUCIONES A LA ESTRUCTURACIÓN DE UNA CONSULTA PREOPERATORIA

Gonçalves, Marco; Pereira, Aurora; Machado, Natália

Marco Gonçalves

marcogoncalves@esenfc.pt

Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto Portugal

Aurora Pereira

aurorapereira@ess.ipvc.pt

Instituto Politécnico de Viana do Castelo, Escola Superior de Saúde, Viana do Castelo Portugal

Natália Machado

natalia@esenf.pt

Escola Superior de Enfermagem do Porto, Porto Portugal

Millenium

Instituto Politécnico de Viseu, Portugal

ISSN: 0873-3015

ISSN-e: 1647-662X

Periodicity: Cuatrimestral

vol. 2, no. 25, e36971, 2024

millenium@sc.ipv.pt

Received: 05 August 2024

Accepted: 24 October 2024

URL: https://portal.amelica.org/ameli/journal/786/78652317865231002/

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Abstract: Introduction: The implementation of a preoperative nursing consultation should be seen as an intervention strategy that gives visibility to nurses’ autonomous interventions. Its structure and operationalization should take into account the opinion of the nurses who will be involved in its implementation.

Objective: To determine nurses' opinions on the structure and operationalization of the preoperative nursing consultation.

Methods: Descriptive and exploratory study with a qualitative approach. Twenty-three interviews were conducted with operating room or general surgery inpatient nurses in a Portuguese hospital in January 2021. Data were analyzed according to Bardin’s assumptions.

Results: Two thematic units emerged: Contributions of the preoperative nursing consultation and Aspects to consider when organizing the consultation, which includes several categories and subcategories. The contributions of the preoperative nursing consultation focused on the patient, the organization, and nursing care. The aspects to consider when organizing the consultation should focus on the patient, the conditions for quality care, and some organizational procedures.

Conclusion: The implementation of a preoperative nursing consultation will help give visibility to nurses’ autonomous interventions during this period. The nurse's interaction with the patient before surgery can reduce their anxiety and fears and meet their information needs.

Keywords: nursing, preoperative care, general surgery, qualitative research, office nursing.

Resumo: Introdução: A implementação de uma consulta pré-operatória de enfermagem deve ser vista como uma estratégia de intervenção que em muito contribui para destacar aquilo que é a intervenção autónoma do enfermeiro. A sua estruturação e operacionalização deve considerar a opinião dos enfermeiros que participarão nessa implementação.

Objetivo: Conhecer a opinião dos enfermeiros sobre a estruturação e operacionalização da consulta pré-operatória de enfermagem.

Métodos: Estudo descritivo e exploratório, de abordagem qualitativa. Realizaram-se 23 entrevistas a enfermeiros de bloco operatório ou internamento de cirurgia geral, num hospital português, em janeiro de 2021. Os dados foram analisados de acordo com os pressupostos de Bardin.

Resultados: Emergiram 2 unidades temáticas: contributos da consulta de enfermagem pré-operatória e aspetos a atender na sua organização, as quais integram diversas categorias e subcategorias. Os contributos da consulta pré-operatória de enfermagem direcionaram-se para o cliente, organização e cuidados de enfermagem. Os aspetos a atender na sua organização devem dirigir- se ao cliente, condições para a qualidade dos cuidados e alguns procedimentos organizacionais.

Conclusão: A implementação de uma consulta pré-operatória de enfermagem deve ser vista como uma estratégia de intervenção que em muito contribui para destacar aquilo que é a intervenção autónoma do enfermeiro nesse período. A interação do enfermeiro com o cliente antes da cirurgia pode contribuir para a diminuição da ansiedade e medos, e satisfação das suas necessidades informativas.

Palavras-chave: enfermagem, cuidados pré-operatórios, cirurgia geral, pesquisa qualitativa, consulta de enfermagem.

Resumen: Introducción: La realización de una consulta de enfermería preoperatoria debe considerarse una estrategia de intervención que contribuye en gran medida a destacar el papel autónomo de las enfermeras. Su estructuración y operacionalización deben tener en cuenta la opinión de las enfermeras que participarán en su aplicación.

Objetivo: Conocer la opinión de las enfermeras sobre la estructuración y operacionalización de la consulta de enfermería preoperatoria.

Métodos: Estudio descriptivo y exploratorio con enfoque cualitativo. Se realizaron 23 entrevistas a enfermeros de quirófano o de hospitalización de cirugía general en un hospital portugués en enero de 2021. Los datos se analizaron según los supuestos de Bardin.

Resultados: Surgieron 2 unidades temáticas: contribuciones de la consulta de enfermería preoperatoria y aspectos a tener en cuenta en su organización, que conforman varias categorías y subcategorías. Las aportaciones de la consulta de enfermería preoperatoria se centraron en el cliente, la organización y los cuidados de enfermería. Los aspectos a tener en cuenta en su organización se centran en el cliente, las condiciones para una atención de calidad y algunos procedimientos organizativos.

Conclusión: La implementación de una consulta de enfermería preoperatoria debe ser vista como una estrategia de intervención que contribuye en gran medida a resaltar la intervención autónoma de las enfermeras durante este período. La interacción de la enfermera con el cliente antes de la cirugía puede ayudar a reducir la ansiedad y los miedos, y a satisfacer sus necesidades de información.

Palabras clave: enfermería, cuidados preoperatorios, cirugía general, investigación cualitativa, enfermería de consulta.

INTRODUCTION

The information provided to patients admitted on the day of surgery is of limited value due to the presence of anxiety and the short time frame. Insufficient or non-existent preoperative information increases patients’ psychological distress (Brown et al., 2018).

Preoperative nursing consultations reduce anxiety and provide an opportunity for education and counseling, allowing patients and their families to be informed, emotionally supported, and more involved in the surgical experience (Brown et al., 2018). This type of intervention is complementary to perioperative care, which includes the preoperative nursing visit. In addition, it allows patients’ questions to be answered in a short period of time, strengthening the bond with nurses and increasing patient satisfaction (Schulz et al., 2020). Nursing interventions in this area aim to reduce stress and anxiety factors, as well as situations that are thought to affect or may affect postoperative recovery (Akhlaghi et al., 2021).

More informed patients are more aware of their responsibility for recovery and collaborate more in post-operative care, which improves the surgical process and patient outcomes (Mendes et al., 2020). Regardless of the type of postoperative complications, a structured assessment of patients undergoing elective surgery is essential for the early identification of risk factors (Bagheri et al., 2018). These authors corroborate that incorporating preoperative education should be seen as a valuable intervention.

Preoperative nursing consultations prioritize proximity, empathy, and building a therapeutic relationship, which are crucial to meeting surgical patients’ information needs. Individual patient assessment, based on their doubts and expectations, is fundamental for setting up the initial care plan (Breda, 2020).

Nurse-led preoperative preparation requires a person-centered approach to help patients get more involved and use health information appropriately, resulting in a better surgical experience. This preparation goes beyond the physiological dimension and is also influenced by the patient’s mental and emotional health (Torres et al., 2020).

Overall, it can be said that a preoperative nursing consultation is essential for assessing and drawing up a nursing care plan, thus giving visibility to nurses’ autonomous interventions (Gonçalves et al., 2024).

Therefore, this study aimed to determine nurses’ opinions on the structure and operationalization of a preoperative nursing consultation.

1. METHODS

A descriptive and exploratory study was conducted using a qualitative approach based on the Consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al., 2007).

Twenty-three semi-structured interviews were conducted with nurses involved in surgical care in a Portuguese university hospital. The inclusion criteria were: having 5 or more years of professional experience and working in general surgery inpatient units or in the operating room.

After being invited in person to voluntarily participate in the study, and considering the inclusion criteria, the nurses were informed about the objectives and design of the research. After each participant gave their informed consent, the interviews were audio- recorded and transcribed verbatim. The participant validated the content of the interview transcripts.

The interviews took place in a room that ensured the privacy of the participants. They followed a script developed by the researchers based on their professional experience and scientific literature, consisting of the following questions: “What issues/topics do you consider important to address in a preoperative nursing consultation?”, “How would you structure this consultation?”, “In your opinion, what factors can influence the implementation and quality of a nursing consultation?”, “What attributes do you value in the nurse responsible for the consultation?”, “To what extent do you think the preoperative nursing consultation can improve quality of care and patient satisfaction? What impact does it have on postoperative recovery?”, and “To what extent do you think the preoperative nursing consultation can influence the social representation of nurses?”. The script was pre-tested on three participants who considered it to be adequate. After each interview, the interviewee was asked if there was any content that they wished to exclude from the transcript, and in no instance was this indicated. The average duration of each interview was 30 minutes.

The interviewer met frequently with the other researchers to analyze the main topics mentioned by the participants. The content was analyzed based on Bardin’s assumptions (2018) without the use of software tools.

After a pre-analysis that included skimming the text and preparing the material, data were coded and the coding units were identified. Then, categories and subcategories were identified using semantic, lexical, or expressive criteria. In the end, the analysis was explained and shared with the participants so that they could validate it, and no changes were made.

This research was approved by the Ethics Committee of a Portuguese Hospital and University Center (074/CES-CHUC-138-18). Participants were informed of the objectives, procedures, and benefits of the study, as well as assured of confidentiality and availability to clarify any doubts.

The rigor of this study was ensured by the researchers’ comprehensive understanding of the object of study and the context in which it took place. In addition, several debriefing meetings were held between the researchers throughout the data collection process, particularly to evaluate and interpret the findings.

2. RESULTS

The sample consisted of 23 nurses, 21 women and 2 men, with a mean age of 45 years. Around 65% of participants had been working for 21 years or more: 12 in inpatient units and 11 in operating rooms. Five held a master's degree and 11 were nurse specialists.

Two thematic units emerged from content analysis: Contributions of the preoperative nursing consultation and Aspects to consider when organizing the consultation.

When asked about the implementation and impact of a preoperative nursing consultation, particularly on the surgical patient’s postoperative recovery, the participants identified contributions at three levels: to the patient, to the organization and to nursing care (Table 1).

Table 1 - Characterization of the thematic unit “Contributions of the preoperative nursing consultation”

Table 1

Characterization of the thematic unit "Contributions of the preoperative nursing consultation"

Categories | Subcategories
To the patient | Decrease in level of anxiety and fear Increase in acceptance of health status Increase in patient satisfaction Increase in patient knowledge Decrease in postoperative complications
To the organization | Decrease in length of stay Decrease in associated costs
To nursing care | Increase in safety and quality of nursing care Visibility of nursing care

Content analysis revealed that the preoperative consultation could help reduce the anxiety and fear of surgical patients:

“It can alleviate patient’s fears of the operating room or even the surgery or the preoperative procedures” (IN_3);

“Another benefit is that it reduces anxiety” (IN_9).

On the other hand, the interviewees felt that this preoperative intervention will increase patient involvement in the perioperative process, facilitate their acceptance of their health status, and improve their adherence to the therapeutic regime, as they will better understand the sequence of care to be provided:

“... there is greater acceptance of the clinical situation itself, greater collaboration and participation of the patient in their care” (IN_1).

In addition, providing the patient with information will also increase their level of knowledge, making them more autonomous in their decisions. According to the participants, patients feel more in control of the situation, thus improving their level of satisfaction. This aspect is highly valued by healthcare institutions today:

“It will empower the patient with knowledge and resources to cope with the difficulties of hospitalization and the postoperative period” (IN_10);

“If patients understand what is happening to them, they are certainly able to better manage their expectations and be more satisfied” (IN_10).

According to the participants, these aspects will have an impact on the patient’s recovery by helping to reduce postoperative complications, such as the risk of infection:

“... with an impact, for example, on reducing the number of infections” (IN_11)

“They’re more aware of what’s going to happen to them and take things more naturally. The postoperative period will improve” (IN_20)

As a result of the implementation of a preoperative nursing consultation, two major advantages emerged for the organizations: on the one hand, a shorter length of stay, as the patient would be better prepared for surgery and the postoperative period, and, consequently, a reduction in the associated costs:

“It would reduce length of stay” (IN_1);

“It's beneficial for nurses and above all for patients (...) Even for the institution itself because it decreases costs as a result of this consultation” (IN_16).

The interviewees reported that this consultation would improve the safety and quality of nursing care, as it would allow a better understanding of patients and consider them as the focus of action:

“We will get to know the patient better and work for their overall well-being” (IN_4);

“(...) it is a key factor to better care” (IN_22).

According to the interviewees, this intervention would give greater visibility to nursing care and could have a positive influence on the social representation of the profession:

“It would be an initial contact with the nursing team, which would give visibility to our work and our importance, with the results that could come from that.” (IN_7)

Several aspects should be considered in structuring and organizing a preoperative nursing consultation. These aspects were divided into three categories: those focused on the patient, those focused on the conditions for quality nursing care, and organizational procedures (Table 2).

Table 2 - Characterization of the thematic unit “Aspects to consider when organizing the consultation”

Table 2

Characterization of the thematic unit “Aspects to consider when organizing the consultation”

Categories
Subcategories

Focused on the patient
Initial patient assessment Nursing care in preoperative preparation Nursing care in postoperative preparation Organization of nursing care

Focused on the conditions for quality nursing care
Team dimension Individual dimension Professional/academic dimension

Organizational procedures
Guided tours Defining the right time for the consultation Using a flexible script Organizing the consultation documentation in the Information System Involving the significant person/family in the consultation Providing written support Suitability of the physical space Logistical/administrative aspects of the patient’s process

With regard to patient-focused aspects, the participants consider it important to conduct an initial assessment of the patient to explore their health-disease and/or surgical history, lifestyle habits, and psychosocial/physical dimensions:

“It would be important to understand if they had undergone previous surgeries because it can influence their adherence, their understanding of the surgery itself, and the hospitalization process” (IN_1);

“the patient's habits, medication” (IN_17);

“First of all, I find it very important to provide psychological support to the patient” (IN_14).

Moreover, they considered it relevant to address nursing care during pre- and postoperative preparation, taking into account nurses’ autonomous and interdependent interventions:

“Explain the need for hygiene care with chlorhexidine in the afternoon” (IN_23);

“Explain them that they have to take certain tests” (IN_13);

“What can happen in the postoperative period, especially in the immediate postoperative period, is extremely important to prepare people for what will happen to them” (IN_8);

“Talking about medical devices, so that people are not surprised after surgery” (IN_1).

Still regarding patient-focused aspects, the organization of nursing care emerged, in which the interviewees mentioned structuring the consultation according to the perioperative stages, as well as organizing the information and plan care:

“... taking into account the various stages of the perioperative period when organizing the consultation” (IN_4);

“... it's important to understand what they want to know (...) to meet each patient’s needs (...) each patient is different” (IN_2);

“patient care can be planned, you get to know the patient better in the consultation, what their needs are, making it easier to draw up the patient’s care plan” (IN_13).

Regarding the conditions for quality nursing care, the nurses focused on the team, the individual, and the professional/academic dimensions. Concerning the team dimension, they highlighted the importance of teamwork and the benefits of having a nursing team responsible for the consultation:

“It’s important that the operating room team also understands what the inpatient team does and vice versa (...) the consultation will also improve communication between the teams” (IN_21);

“It is important for the nurse who carries out the consultation to follow up with the patient in the inpatient unit, this link would be very important” (IN_9).

In the individual dimension, the participants mentioned the importance of ensuring that nurses are motivated to carry out the preoperative consultation and possess communication skills based on assertiveness and empathy:

“The favorable factors are the availability of nurses, in the sense of wanting to do it, motivation” (IN_18);

“You have to like talking to people and have a more than satisfactory level of communication skills” (IN_6).

Finally, with regard to the professional and academic dimension, most participants believed that the nurse present at this consultation must have knowledge and professional experience in the surgical area and hold the title of nurse specialist conferred by the professional nursing regulator:

“Be someone with experience in the surgical area” (IN_7);

“As for professional training, I think that specialists are important because they have specialized skills” (IN_4).

As regards the aspects to consider when organizing the consultation, the participants mentioned some organizational procedures, namely defining the appropriate time for the consultation, ensuring the suitability of the physical space in terms of environmental conditions and privacy, as well as the possibility of making guided tours of the operating room and the inpatient unit:

“The consultation should be scheduled to allow enough time for patients to assimilate and reflect on aspects that they didn't remember at the time” (IN_14);

“The consultation might take place a week before the surgery” (IN_9);

“The physical space is very important” (IN_16);

“The ideal would be to walk the patient through the route they will take on the day of surgery, namely to the operating room” (IN_11).

The interviewees also mentioned other relevant aspects, such as the use of a flexible script to structure the consultation, documenting it in the information system in use at the institution, and providing written materials to summarize the information provided:

“I think there could be a flexible script that could be adapted more or less to the type of surgery, indicating any complications of the surgery (...) I think it should be structured” (IN_10);

“the importance of electronic nursing records and then linking what is documented in the operating room and outside it” (IN_13); “I believe we should provide written information (...) for example a leaflet” (IN_18).

Finally, the content analysis revealed the importance of involving a significant person or family member in the consultation to help patients understand the information, as well as the logistical and administrative aspects related to the patient’s experience throughout the surgical process:

“I think there should be a significant person present for the patient because sometimes it helps. Having someone present who can then help clarify any doubts” (IN_3);

“We should tell them what they have to bring” (IN_7);

“how the hospital works in terms of visits so that the family is also informed” (IN_18).

3. DISCUSSION

According to the participants, implementing a preoperative nursing consultation has advantages for the patient, the organization, and nursing care.

According to Ataro et al. (2024), patient satisfaction with preoperative care reflects its quality, as it is directly related to potentially fatal complications in the postoperative period. On the other hand, aspects such as patients’ preoperative fear and anxiety, expectations, and preoperative education will influence their satisfaction, contributing to an increase in acceptance of their health status, as revealed by this study.

Reducing the patient’s level of preoperative anxiety and improving their knowledge will increase their acceptance of their health status and their satisfaction. The identification of preoperative anxiety and fear allows the nurse to implement a more personalized and effective intervention, which, together with the patient’s own coping strategies, can help reduce these feelings (Arakelian et al., 2018). The literature indicates that a nurse-led educational and informative consultation with patients in the preoperative period will have a positive impact on their level of anxiety (Fernández Fernández et al., 2023).

Gao et al. (2024) also argue that nurse-led preoperative interventions can have a positive impact on patient’s psychological stress, pain relief, reduce the incidence of complications, and improve their satisfaction with nursing care.

A consultation, even by telephone, is an opportunity to identify factors that increase the risk of postoperative complications and helps perioperative nurses implement interventions that prevent or mitigate delayed recovery (Schulz et al., 2020).

Regarding the advantages for institutions, the literature corroborates the findings, suggesting that the preoperative consultation has the potential to reduce costs, improve the quality of care, and increase patient satisfaction (Breda & Cerejo, 2021). In addition, this study indicates that the reduction in length of stay is one of the benefits of preoperative nursing consultations. This finding is corroborated by the study of Sisak et al. (2019), which focused on patients undergoing orthopedic surgery and highlighted the importance of preoperative education.

In line with these findings, Breda and Cerejo (2021) also state that preoperative nursing consultations contribute to improving the quality and visibility of nursing care by strengthening the nurse-patient relationship.

As regards the aspects to be considered when organizing a preoperative consultation, this study revealed the need to make a correct initial assessment of the patient and address the nursing care to be provided in the pre-and postoperative preparation. Assessing sociodemographic, clinical, surgical, and psychosocial aspects allows for predicting postoperative recovery times. Some of these aspects can be modified through preoperative patient preparation, particularly in consultations (Heit et al., 2020).

Although it is essential to facilitate the patient’s access to information in various forms, the nurse-patient relationship is strengthened by face-to-face consultations that allow for providing personalized and accurate information, reducing anxiety, and increasing patient involvement (Barros et al., 2019).

Empowering the patient with knowledge is essential to help them understand the perioperative period. On the other hand, nurses must have communication skills to identify the patient’s level of health literacy and information needs and personalize their approach, which should be face-to-face whenever possible (Gonçalves et al., 2023).

Regarding the characteristics of the team responsible for the consultation, as well as the professional requirements, the findings highlight the importance of having a team dedicated to the consultation, made up mainly of nurse specialists, which is in line with the Regulation of the Specific Competencies of the Nurse Specialist in Medical-Surgical Nursing in the area of Perioperative Nursing Care, where perioperative consultation is indicated as one of its areas of intervention (Regulation no. 429/2018 of July 16, 2018). The limitation of this study is that it was only carried out in a single hospital center, compared to the diversity of perspectives that a multicenter study could provide. On the other hand, the lack of implementation of the preoperative nursing consultation in the participants' contexts may have limited the development of some aspects such as its structure and operationalization.

CONCLUSION

This study identified the opinions of a group of nurses working in operating rooms and general surgery inpatient units about the contributions of preoperative nursing consultations. This study also identified aspects that should be considered when organizing them. These contributions to the patients, the organizations, and nursing care will certainly make it clear to health institutions that the implementation of a preoperative nursing consultation will improve the quality of patient care and patient outcomes. On the other hand, this study synthesized a set of aspects to consider when organizing this nursing consultation. These aspects focus on patient assessment and intervention, conditions for quality care, and organizational procedures that facilitate its operationalization in clinical practice.

In fact, perioperative nurses do not always intervene in the preoperative period in a structured, systematized, and individualized way. Future studies should, therefore, be carried out to develop preoperative consultation models to guide nursing care during this period. The operationalization of this type of intervention will give visibility to nurses’ autonomous role in preparing patients for elective surgery.

ACKNOWLEDGEMENTS

We would like to thank the nurses interviewed for sharing their knowledge and experience, which was essential for the development of this work.

AUTHOR CONTRIBUTIONS

Conceptualization, M.G., A.P. and N.M.; data curation, M.G., A.P. and N.M.; formal analysis, M.G., A.P. and N.M.; investigation, M.G., A.P. and N.M.; methodology, M.G., A.P. and N.M.; project administration, M.G., A.P. and N.M.; resources, M.G., A.P. and N.M.; supervision, A.P. and N.M.; validation, A.P. and N.M.; visualization, M.G., A.P. and N.M.; writing-original draft, M.G.; writing- review and editing, M.G., A.P. and N.M.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

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