The Development and Feasibility Testing of a Patient-Centred Discharge Education Intervention to Improve the Postoperative Recovery of General Surgery Patients

Abstract

Background. Postoperative complications resulting in unplanned hospital readmission are common and avoidable. Discharge education enables general surgery (GS) patients to manage their recovery and seek professional help when required, but evidence gaps in this education exist. Aims. The purpose of this thesis was 1) to develop an evidence-based discharge education program using web-based technology for GS patients to self-manage their postdischarge recovery and 2) to test the feasibility of implementing the web-based education program. Methods. This research was guided by the Knowledge-to-Action (KTA) framework and UK Medical Research Council (MRC) guidance for developing and evaluating complex interventions. Phase 1 was a systematic mixed studies review (MSR) to identify the who, what, when and how relevant to discharge education being given to GS patients. Phase 2 included a qualitative study using individual and focus group interviews with patients and health care providers. The aim was to gain an understanding of the problem and the barriers and enablers in delivering discharge education. Phase 3 described the comprehensive approach used to develop the web-based education intervention. Phase 4 involved a pilot randomised controlled trial (RCT) to assess the feasibility of implementing the web-based discharge education intervention. Results. In Phase 1, the MSR of seven studies identified four themes: 1) the quality of discharge education influences its uptake, 2) health care professionals’ perceptions of their role in the delivery of discharge education to patients, 3) patients’ preferences for education delivery, and 4) patients’ participation in their self-care. In Phase 2, telephone interviews with 13 patients uncovered four themes: 1) the quality of discharge information influences patients’ postdischarge experience, 2) the negative impact of contextual influences on delivery of discharge education, 3) patients actively participating in their surgical journey, and 4) patients’ preferences with the delivery of discharge education. Interviews with 21 nurses revealed four themes: 1) assuming responsibility for patient education in the absence of discharge communication; 2) supporting patients to participate in self-management after hospitalisation; 3) variability in the resources, content, and delivery of discharge education; and 4) meeting operational demands compromises the quality of patients’ discharge education. Five themes emerged from the individual interviews with 10 doctors: 1) challenges of delivering quality discharge education, 2) complexities of the discharge planning process, 3) production pressures imposed by the organisation impede delivery of discharge education, 4) anticipating patients’ needs and preferences, and 5) coordinating the discharge process requires a team effort. In Phase 3, a logic model was used in the co-design of the intervention, which was underpinned by the concept of patient activation and Knowles theory of andragogy. It included three components:1) warning signs of potential postoperative complications, 2) information on postdischarge care, and 3) video on surgical wound care and signs of wound complication. In Phase 4, 85 GS patients were recruited and randomised to receive the web-based education intervention or standard education. Feasibility criteria of recruitment, randomisation was met although participants’ loss to follow up was high (27%). Patients in the intervention arm accessed the education an average of three times (SD 3.14) with 4 minutes (SD 16) spent on the website. Most patients were satisfied with its content and found it useful and straightforward. Patient activation, self-care ability, and unplanned health care utilisations improved for patients in the intervention arm, although were only statistically significant for patient activation (F[1,60] = 9.347, p = .003). Conclusions. This web-based discharge education intervention is easily accessed and is an additional support for GS patients to support their recovery after hospital discharge.