Chapter One:  Overview of the Problem of Interest

Surgery is an important event in an individual’s life, impairing physical functioning thereby fear, anxiety and depression may be experienced by the patient (Ramesh et al., 2017), In 2008, more than 22 million surgeries were performed over 5,000 Ambulatory Surgery Centers in the United States.  Surgery can be a significant and potential danger to the patient’s health and may cause psychological reactions such as anxiety (Gezer & Arslan, 2019). With thousands of patients having elective surgery on a daily basis, it is essential that these patients are adequately prepared prior to their surgery (Kruzik, 2009).  Preoperative education is widely used by health-care professionals all over the world to help patients prepare for their impending surgery and postoperative needs (Spalding, 2004).  Preoperative education is a key element of the Enhanced Recovery After Surgery (ERAS) protocols and guidelines (Foss, 2011).  Preoperative education leads to significant improvements in patient satisfaction, surgical outcomes, and reduction in patient’s anxiety.

Background Information

Each year, an estimated 234 million major surgical procedures are conducted worldwide (Fink et al., 2013).  Evidence suggests that postsurgical complications occur in at least seven million cases annually, resulting in up to one million deaths. These figures illustrate the tremendous socio-economic burden associated with postoperative morbidity and mortality (Fink et al., 2013).  Patients suffer needlessly due to inadequate preoperative preparation and lack of information regarding their postoperative course as indicated by reports of unexpected pain, fatigue, and the inability to care for themselves (Fink et al., 2013). The prevention of these postoperative complications is of the highest medical interest and importance. The impact of well drafted standardized preoperative patient education will result in positive postoperative outcomes (Fink et al., 2013). This suggests that there is a need for improved efforts from all healthcare providers to step up and design preoperative educational interventions for better patient preparedness, reduce their anxiety and post-operative complications.

In late 2016, the American College of Surgeons (ACS) became the national home for Strong for Surgery which is a pre-surgical health optimization program (American College of Surgeons, 2016). The ACS has begun administering and promoting STRONG as a quality initiative aimed at identifying and evaluating evidence-based practices to prepare and optimize the health of patients before their operations. Strong for Surgery was developed by surgeons and empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. These checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes (American College of Surgeons, 2016).

The project implementer’s clinical practice site is an inpatient facility which conducts approximately 40 surgeries a day, including same-day surgery and inpatients. In the project implementer’s clinical practice site only about 50 % of the patients are told by their surgeons to come to the pre-surgical testing area prior to their elective surgery. The preoperative surgical patients either come 1 to 2 days before their surgery, but the majority of them arrive on the day of their surgery. As a result, these patients are not be given the adequate preoperative counseling. Even if they receive preoperative counseling, there is less time for them to be prepared; for example, proper preoperative diet, exercise, medication management, smoking cessation, and co-morbidities such as diabetes and hypertension to be under control.

The key principles of the ERAS protocol include preoperative counseling, preoperative nutrition, avoidance of perioperative fasting and clear liquids up to 2 hours preop. But according to traditional surgical doctrine patients are instructed to take nothing by mouth (NPO) from mid night by the surgeons to avoid pulmonary aspiration after elective surgery; however, there is no evidence to support this. Melnyk, Casey, Black and Koupparis (2011) stated that, preoperative fasting actually increases the metabolic stress, hyperglycemia and insulin resistance, which the body is already prone to during the surgical process. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, the ERAS protocols challenge traditional surgical doctrine, and as a result, their implementation has been slow (Melnyk, Casey, Black and Koupparis, 2011).

Significance of Clinical Problem

Patients must be appropriately educated before any surgical procedure to ensure they understand the complete process and to improve surgical outcomes (Wunderle, Bena & McClelland, 2017). When patients are not adequately prepared for surgery, there is a high chance that their surgery can be canceled on the day of surgery. Surgery cancelations on the operative day cause a huge impact on the organizational effectiveness and the patient satisfaction.

Further, preoperative education plays a major role in prevention of post operative complications. Complications such as Surgical Site Infection (SSI) increase the length of the patient’s stay. The Center for Disease Control (CDC) health care – associated infection (HAI) prevalence survey found that there were an estimated 157,500 surgical site infections (1.9%) in 2008 among the inpatient surgical patients (CDC, 2018). Surgical site infections remain a substantial cause of morbidity, prolonged hospitalization and mortality of the patients. The implementer’s clinical practice site’s SSI task force data showed that the SSI rates among surgical patients was 2.2% in 2017. The preoperative education provides information to patients regarding the measures that can be used to prevent post-operative complications. A well-designed preoperative education with emphasis on SSI prevention measures such as usage of Hibiclens showering prior to surgery, hand hygiene and wound care may result in decrease rate of SSIs.

Other postoperative complications such as venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) affects an estimated 300,000-600,000 individuals in the U.S each year causing significant mortality and morbidity (Beckman et al., 2010). VTE is a leading cause of preventable hospital death in the Unites Stated (CDC, 2015). VTE is the fifth most frequent reason for unplanned hospital readmissions after surgery (CDC, 2015). A recent study of almost 500,000 surgeries performed at Department of Affairs (VA) hospitals found that about 4 in 10 patients developed VTE after surgery while they were still in hospital and approximately 6 in 10 surgical patients developed VTE up to 90 days after discharge from hospital (CDC, 2015). The implementer’s clinical practice site performance improvement (PI) data reported a significant increase in VTE rates in 2017.  Preoperative education plays a major role in educating patients in prevention of such complications. Preoperative education regarding the early ambulation after surgery helps the patient to be more compliant, thereby reducing the risk of VTE.

In addition, Oshodi (2007) suggested that preoperative information about surgical procedures and outcomes alleviates patient anxieties, lessens the need for postoperative analgesia, and allows the patient to be discharged earlier. The patients when educated before surgery know what to expect after their procedure, such as pain. Through preoperative education, the capability of patients to take care of themselves improves through meeting their postoperative self-care needs at home (Oshodi, 2007).  For example, information about appropriate behavior after discharge (mobility, exercise, relaxation, appropriate diet or adequate pain control) will facilitate full recovery and prevents postoperative complications.

Question guiding inquiry (PICO). A clinical question needs to be relevant to the patient or problem in the current practice, it should facilitate the search for the solution. PICO makes the search process easier. The formulation of a question used to challenge a current practice and provide evidence for new practice change is called a “PICO” question. The “P” stands for patient or problem, “I” for intervention, “C” for control/comparison and “O” for outcome. (Melnyk & Fineout-Overholt, 2015).  The PICO question that guided a literature inquiry for the problem of surgical patients is: In pre-surgical patients, does individualized one-on-one pre-operative counseling decrease the post-operative complications?

Variables of the PICO question

Population.  The population of interest was individuals eighteen years of age and older located in New Jersey.  Patients who participated were scheduled for ortho-spine procedures and was not limited by gender, education, nationality, religion, ethnicity, or race. The targeted population of interest that participated in the EBP change project were 18 years of age and older.

Intervention.  The intervention for this project was the implementation of individualized one-on-one pre-operative counseling.  Educational materials and a question and answer session were offered during the educational session.

Comparison.  There was no comparison group, but a comparison was made to assess the fear and anxiety of pre-surgical patients. There was a pre-test given before the start of the educational session. Immediately after the educational session, the participant was given a surgical fear post- test to determine if there were a decrease in fear and anxiety.

Outcomes.  Knowledge is the first step of prevention; therefore, the intended outcome of the EBP change project is to reveal if an increase in knowledge and decrease in fear occurred by comparing the pre-test and post-test scores after the educational sessions.


Preoperative education provides the surgical patients with the pertinent information concerning the surgical process and the intended surgical procedures, as well as anticipated patient behaviors (e.g., anxiety, fear); expected sensations; and probable surgical outcomes (Kruzik, 2009). Preoperative teaching plays a vital role in preoperative, intraoperative and postoperative management of patient. The preoperative education can help patients to be prepared for surgery, to decrease post-operative pain, reduce length of stay, decrease anxiety and increase patient satisfaction (Garretson, 2004). Lack of preoperative education can lead to postoperative complications such as DVT, SSI

Chapter Two: Review of the Literature

Preoperative education includes instruction about the preoperative period, the surgery itself, and the postoperative period. Patients who undergo surgical procedures experience a high level of stress and anxiety, which could have negative consequences on post-operative outcomes. Patient education appears to be effective in improving knowledge and reducing days of stay at the hospital (Chevillon, Hellyar, Madani, Kerr and Chae, 2015). The goal of preoperative education is to not only prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene et al., 2017).

Anxiety has been noted among patients who have been waiting for scheduled procedures ( Harkness, Morrow, Smith, Kiczula, and Arthur, 2003). Nurse-initiated preoperational education and counseling was associated with a reduced rate of perioperative complications and a reduced level of anxiety following surgery (Ji et al., 2012). Therefore, it is crucial that the patients are adequately educated and prepared for their surgery. To this end, various types of preoperative education have been evaluated to help reduce patient’s anxiety and complications after surgery. The purpose of this paper is to provide an overview of the literature regarding preoperative education. This chapter will review the literature regarding specific interventions utilized in preoperative education.


In order to study the concept of preoperative education and its importance in patient preparedness, a comprehensive literature review was performed. After considering the concept and perusing several articles through the online library and databases, the decision was made on the possible search terms that will be covered to find scholarly articles on preoperative education and its importance in preparing the patients. The selection of the literature was based on the level of evidence and the relevancy to the EBP change project.

Sampling strategies. The databases searched for the literature review were as follows: ProMED , CINAHL Complete, the allied and complementary medicine database (AMED),  EBSCO Host, PyscINFO, the Cochrane Database of Systematic Reviews on preoperative education. The key terms included preoperative teaching, preoperative education, preoperative preparation, surgery preparedness, preoperative teaching and anxiety, preoperative education and surgery, preoperative teaching and surgical site infection, preoperative education and postoperative complications using the Boolean operator AND. Google scholar search was also performed to include possible additional literature. Please see Appendix A for the Literature Search Strategy Log.

Inclusion /Exclusion Criteria. After performing a literature review, titles were reviewed for relevance. If the title was unclear, the abstract was reviewed. Articles were included for further review if they related to preoperative education and preoperative teaching. Exclusion criteria included articles not in English and published prior to 2012.

A hierarchical rating system for evaluation of strength of the evidence was used in evaluating articles for inclusion or exclusion. As part of the EBP process, assessing individual articles for strength of the evidence is appropriate to ensure that findings are “best evidence” (Melnyk & Fineout-Overholt, 2015, p. 11). Articles were ranked according to the following Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions:

Level I: Evidence from a systematic review or meta-analysis of all relevant RCTs

Level II: Evidence from well-designed RCTs

Level III: Evidence obtained from well-designed controlled trials without randomization

Level IV: Evidence from well-designed case-control and cohort studies

Level V: Evidence from systematic reviews of descriptive and qualitative studies

Level VI: Evidence from single descriptive or qualitative studies

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

(Melnyk & Fineout-Overholt, 2015, p. 11).

Chapter Three:  Theory and Model for Evidence-based Practice

Concept- Theoretical- Empirical system (C-T-E) structure provides an outline and framework for the study project. Using C-T-E structure offers the advantages of improved readability and ease in understanding of complex problems. A concept is a mental formulation experience (perception) (Chinn & Kramer, 2015). The concept can be divided into separate, simple, logical building blocks and theory development is the product of research, which is a systematic process of inquiry (Fawcett, 2013).  A theory is a framework that guides nursing practice (Chinn & Kramer, 2015).  The empirical indicator is a measurement tool used to evaluate a proposed theory (Chinn & Kramer, 2015).  C-T-E structure for theory testing proceeds from the conceptual model to the theory to the empirical indicators (Gigliotti & Manister, 2012). As a doctoral prepared nurse, it is important to implement evidence-based practice for the identified clinical problem at the chosen site which is based on theoretical and empirical research background. Preoperative Education is the concept of the EBP project (C), Orem’s Self Care Theory (T) provides the theoretical outline and the empirical indicator used in this project is Surgical Fear Questionnaire (E).


The identified concept for this evidence-based practice (EBP) change project is preoperative education. The concept of preoperative education can be described as a nursing intervention used to assist the patient to understand and mentally prepare for surgery and the postoperative period (Chevillion et al., 2015).  Preoperative education includes instruction about the preoperative period, the surgery itself, and the postoperative period. Education plays an integral part in promoting health by increasing the knowledge and empowering skills needed for a healthier lifestyle.  The population selected is all adults scheduled for elective ortho spine surgery, the concept of the EBP and the desired change is to increase the impact of preoperative education to the patients in patient preparedness, post-operative care, reduction in surgical anxiety.  Patient education appears to be effective in improving knowledge and reducing days of stay at the hospital (Chevillion et al., 2015). The goal of preoperative education is to not only to prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Preoperative education and patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene et al., 2017).


The use of theory furthers nursing knowledge in practice by educating and providing direction. Dorethea Orem’s theory of self-care has been chosen to guide and support the concept of preoperative education. Dorethea Orem’s theory is comprised of three related parts: theory of self-care; theory of self-care deficit; and theory of nursing system (Nursing Theory, 2016). The theory of self-care includes self-care, which is the practice of activities that an individual initiates and performs on his or her own behalf to maintain life, health, and well-being (Nursing Theory, 2016). The second part of the theory, self-care deficit, specifies when nursing is needed. According to Orem, nursing is required when an adult is incapable or limited in the provision of continuous, effective self-care (Nursing Theory, 2016). The theory of nursing systems describes how the patient’s self-care needs will be met by the nurse, the patient, or by both (Nursing Theory, 2016).  Orem’s approach to the nursing process is a method to determine the self-care deficits and then to define the roles of patient or nurse to meet the self-care demands. The steps in the approach can be used in educating patients preoperatively, so they can be prepared adequately and recover more quickly from surgery. According to Sürücü, & Kizilci (2012), nursing planning has been guided by the self-care agency of the patient who is supposed to take care of requisites and how the responsible person can help by means of nursing systems. The implementation of education has demonstrated improved self-care behaviors and brought positive changes to the health status of the patients

Chapter Four: Pre-implementation Planning

Pre-implementation is the process that includes project design and development. Evidence-based practice (EBP) is a critical element of an effective change management process to ensure the highest quality care, and successful outcomes are met.  Lack of preoperative education often results in fear and anxiety prior to surgery. Therefore, preoperative educational programs are the key in achieving better health outcomes by increasing knowledge.  Research suggests that ongoing preoperative education facilitates knowledge necessary for surgical patients and results in positive postoperative outcomes (Fink et al., 2013). The purpose of this chapter is to discuss organization readiness for change, planning, implementation, and evaluation of an educational program.

Project Purpose

The purpose of the EBP change project is to improve the preoperative education program using one-on-one counseling for patients scheduled for ortho-spine surgery.  Preoperative education is important to reduce the risk of postoperative complications from occurring as it also allows the individual to take an active role in their recovery process. The goal of preoperative education is not only to prepare the patient for their surgery, but also to prepare them for what to expect following the surgery. Patient preparedness for surgery has important implications for patient satisfaction and the perception of improvement after surgery (Greene, et al., 2017). Anxiety has been noted among patients who have been waiting for scheduled procedures (Harkness, Morrow, Smith, Kiczula, & Arthur, 2003). Ji, et al., (2012) study demonstrated that nurse-initiated preoperational education and one on one counseling were associated with a reduced rate of perioperative complications, such as surgical site infections and a reduced level of anxiety following surgery.  An educational intervention using individualized one-on-one counseling will be offered to the patient to help promote change and wellbeing of the patients prior to their scheduled surgery. The intervention will focus on type of surgery, diet, exercise, medication management, preoperative care, postoperative care and optimization of co-morbidities. Knowledge and understanding of procedures and rationale, promotes feeling of a sense of control to allay anxiety.

Project Management

According to Harris et al. (2016) management of any project entails the consistent integration of skills, tools, application of knowledge and techniques to project activities. The project investigator oversees the project and must be clear about the aim of the project and the stakeholder’s needs and wants to establish the appropriate baseline for comparison of outcome data (Harris et., 2016). The program investigator ultimately is responsible for the success or failure of a project.  The steps that were explored prior to implementing the project will be discussed below.

Organizational readiness for change.  An assessment of readiness for change analyzes the level of preparedness of the conditions, attitudes and resources, at all levels in an organization (Harris et al. 2016).  One crucial factor in an organization readiness for change is to recognize that there is a need for change (Harris et., 2016).  Readiness for change in an organization influences the successful outcome of a clinical change projectThe project implementer’s clinical practice site is a large urban multi-specialty inpatient facility which conducts approximately 40 same day and inpatient surgeries a day. There had been increasing concern regarding the surgery cancelations and rate of Surgical Site Infection rate among the ortho spine surgical patients. To address this concern, the preoperative team agreed on the implementation of an EBP change project focused on increase patient preparedness, reduction in anxiety, increase patient understanding of post-operative care, and thereby prevent postoperative complications such as surgical site infection