rostate cancer is the second leading cause of cancer death for U.S. men
(American Cancer Society,
2013). In a 2012 medical review,
the American Cancer Society estimated that approximately 238,590
new cases of prostate cancer will
occur in the U.S. in 2013. Radical
prostatectomy (RP) by retropubic
or robotic approach is a surgical
option used to treat localized
prostate cancer. Hospital length
of stay (LOS) after RP has decreased. In the University
HealthSystem Consortium Clinical database, the mean LOS
between 2003 and the second
quarter of 2007 for centers with
the highest case volume of RP
was 2.09 days (Mitchell et al.,
2009). Patients undergoing RP at
the study site are routinely dismissed within 1.5 days. After dismissal, their indwelling urinary
catheter remains in place for one
Research Summary
Background
After prostatectomy surgery, a urinary catheter may be
in place for one to three weeks. Anxiety with catheter management has been reported by patients and observed by
nurses. Hospital length of stay has decreased to 1.5 days,
resulting in less time for education. Although preoperative
classes are offered, the majority of patients do not attend.
Purpose/Aims
The primary purpose was to describe the effect of preoperative urinary catheter management education on the
patients level of anxiety following prostatectomy. Aims were
to measure the patients confidence level, with follow-up calls
to physicians after hospital dismissal and with nurses perceptions of the ease of providing postoperative education.
Methods/Strategies
Data from a nonrandomized prospective study of 100
men were compared to determine the effect a specific preoperative prostatectomy class and the standard postoperative education had on postoperative anxiety and level of confidence with management of home catheter care. Data were
also collected of nurses perception of patients anxiety at
Preoperative Education
A literature search using the
search terms education, knowledge, teach, learn, and systematic reviews between 2005 and
2012 yielded a list of 43
Cochrane reviews. Only one of
the 43 results was related to preoperative education. The majority targeted educational efforts in
chronic disease management.
McDonald, Hetrick, and Green
(2004) analyzed the results of
nine randomized studies conducted between 1994 and 2003,
to determine the impact of preoperative education on patients
having surgery to replace a hip or
knee. Outcome variables included anxiety, LOS, pain, time to
standing and climbing stairs, and
290
Effects of Preoperative
Education on Anxiety
The investigators of numerous
studies used STAI (Spielberger,
Gorsuch, & Lushene, 1970) to
measure the effects of preoperative education on pre- and postoperative anxiety (Asilioglu &
Celik, 2004; Bondy et al., 1999;
Giraudet-Le Quintrec et al., 2003;
Hering et al., 2005; Luck et al.,
1999; Mott, 1999; SchwartzBarcott, Fortin, & Kim, 1994).
The effects on postoperative anxiety were mixed, with some studies showing less anxiety (Luck et
al., 1999; Mott, 1999; SchwartzBarcott et al., 1994), and others reporting no difference (Giraudet-Le
Quintrec et al., 2003; Hering et
al., 2005).
Callaghan, Cheung, Yao, and
Chan (1998) used the Chinese
STAI to study the effect of preoperative education for Chinese men
having transurethral resection of
the prostate. The study concluded
the men, having received education, were considerably less anxious postoperatively and reported
higher levels of satisfaction
(Callaghan et al., 1998).
291
Purpose
The purpose of the present
study was to determine the effect
that standardized preoperative
292
Variables
Variables of the study were 1)
level of anxiety, 2) self-reported
confidence to manage home
catheter care, 3) frequency of follow-up calls to physicians after
hospital discharge, and 4) time
spent by nurses in delivering
postoperative urinary catheter
instructions.
Study Design
A single-site, non-randomized, two-group, pre-survey and
post-survey study was conducted
between December 23, 2009, and
January 11, 2011. A randomized
controlled study with an enrollment of 200 patients was initially
considered but was deemed not
feasible because of competing
requests for patients participation in other prostate cancer
studies. Mayo Clinic Institutional
Review Board approval was
secured before the initiation of
any study activity.
lection, 27 patients who had consented were excluded for the following reasons: prior catheter
experience (n = 1), surgery cancelled (n = 2), LOS greater than 3
days (n = 10), incomplete final
paperwork (n = 6), postoperative
education not provided by a urology nurse or admission to an
intensive care unit or both (n =
4), readmission (n = 1), and reason not identified (n = 3). The
study coordinator continued to
enroll patients until a total of 100
patients had completed the
study.
Registered nurses (RNs) on
the two urology nursing units
were invited to participate in this
study for the purpose of providing the standardized postoperative catheter management education. Fifty-one RNs consented,
provided demographic information, and identified their perception of patients anxiety and ability to care for themselves and the
time spent in postoperative education.
Measurement Methods
The STAI consists of 20 statements that describe how a
patient feels (e.g., I feel calm, I
am tense) (Spielberger, 2012).
Responses are selected on a scale
in which 1 = not at all; 2 = somewhat; 3 = moderately so; and 4 =
very much so. Using test-retest
methods, Quek, Low, Razack,
Loh, and Chua (2004) determined the reliability of the STAI
Figure 1.
Contents of Prostate Education Packet
Indwelling Catheter Care With Drainage Bag Instructions Mayo Clinic
Prostate Cancer Support Group Mayo Clinic
Hematuria Scale Mayo Clinic
Emergency Care after Your Prostatectomy Mayo Clinic
Catheter Care for Men after Urologic Surgery (video) Mayo Clinic
Exercises for Men with Urinary Leakage Mayo Clinic
Causes and Treatment of Erectile Dysfunction Mayo Clinic
What You Need to Know about Prostate Cancer National Cancer Institute
Sexuality for the Man With Cancer American Cancer Society
Figure 2.
Postoperative Patient Survey
Score*
Question
1. How confident are you in managing the catheter, leg bag, and overnight bag?
2. How confident do you feel in maintaining the cleanliness of the catheter/bags?
3. How confident are you in your ability to clean the leg bag and overnight bag?
4. How confident are you in switching between the leg bag and the overnight bag?
5. How confident are you in securing the catheter?
6. How confident are you in knowing when and whom to call for any trouble with the catheter?
7. How confident are you in knowing what to do about bladder spasms?
1. Have you called your surgeon or other health care provider since you have been home?
If yes, how many times and for what reason?
Yes/No
2. Did you have the opportunity to watch the video before surgery on home catheter care?
If so, did watching the catheter care video first help you in understanding the nurses
further instructions on how to care for your catheter?
Yes/No
Yes/No
*Likert-type scale in which 1 = not at all confident; 2 = somewhat confident; 3 = confident; and 4 = very confident.
UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6
293
Figure 3.
Staff Nurse Survey
As the survey is completed, please try to separate out time and focus on only the
aspects of dismissal teaching for home management of the urinary catheter.
Patient identification number ___________________________
Number of minutes you spent in
teaching/reinforcing/observing
demonstrations on your shift
Date
Time
Total:
Dismissal Nurse
Perception Ratings*
0
9 10
Perception of patients
anxiety level about
home urinary catheter
management
Note: RN = registered nurse.
*Ratings range from not anxious (0) to very anxious (10).
Figure 4.
Objectives and Checklist Related to Leg Bag Instruction:
Preoperative Leg Bag Class
Objectives
1.
2.
3.
4.
Checklist
1.
2.
3.
4.
294
Statistical Methods
Patient anxiety was measured preoperatively and postoperatively using the STAI. A total
STAI score was obtained by calculating individual items in
accordance with the STAI scoring grid (Spielberger, 2012).
According to Spielberger (2012),
higher STAI scores are correlated
with (or are indicative of) greater
anxiety.
Continuous features were
summarized with means, standard deviations, medians, and
ranges; categorical features were
summarized with frequency
counts and percentages. Comparisons of features among patients
who did and did not attend the
preoperative class and among
patients who did and did not call
their surgeon were evaluated
using Wilcoxon rank sum, 2,
and Fisher exact tests. Associations of features with the difference (postoperative preoperative) in STAI scores were evaluated using Spearman rank correlation coefficients and KruskalWallis and Wilcoxon rank sum
tests. Statistical analyses were
performed using the SAS software package (SAS Institute Inc,
Cary, North Carolina). All tests
were two-sided, and p-values
less than 0.05 were considered
statistically significant.
Results
The purpose of the study was
to describe the effect of preoperative urinary catheter management
education on patients level of
anxiety following RP. In Table 1,
the median LOS for participants
who did not attend the class was
36.6 hours; median LOS for participants who attended the class
was 29.8 hours (p < 0.001). No
statistical difference was ob-
Table 1.
Comparison of Patients Who Did and Did Not Attend the Preoperative Class STAI
Patients (N = 100)
Did Not Attend, Mean
(Median) (n = 53)
Feature
Age in years
LOS
Preoperative STAI
Postoperative STAI
Postoperative STAIpreoperative STAI
Total nurse teaching time, min
Discharge anxiety scale (n = 99)
62.9
36.6
34.2
29.3
-4.9
55.4
2.4
(64)
(38)
(33)
(26)
(5)
(55)
(2)
Attended, Mean
(Median) (n = 47)
60.9
29.8
35.5
25.9
-9.6
56.3
2.4
(60)
(25)
(34)
(24)
(10)
(55)
(2)
p-Value
0.140
< 0.001
0.690
0.040
< 0.020
0.960
0.770
Table 2.
Comparison of Self-Confidence Levels
Patients, Number (%)
Did Not Attend
Preoperative Class
(n = 53)
Feature
Securing catheter
All other responses
Very confident
Switching leg, overnight bag
All other responses
Very confident
Maintaining cleanliness
All other responses
Very confident
Knowledge of bladder spasms
Attended Preoperative
Class (n = 47)
p-Value
27
26
(51)
(49)
13
34
(28)
(72)
< 0.020
17
36
(32)
(68)
7
40
(15)
(85)
< 0.050
18
35
(34)
(66)
8
39
(17)
(83)
0.050
32
21
(60)
(40)
20
27
(43)
(57)
0.080
21
32
(40)
(60)
11
36
(23)
(77)
0.080
17
(32)
(19)
Very confident
Knowledge of when and whom to call
All other responses
Very confident
Called surgeon
No
Yes
Watched video preoperatively
No
Yes
36
(68)
38
(81)
0.140
18
35
(34)
(66)
11
36
(23)
(77)
0.250
44
9
(83)
(17)
38
9
(81)
(19)
0.780
44
9
(83)
(17)
0
47
(0)
(100)
< 0.001
Table 3.
Patients Who Did Not and Did Call Their Surgeon STAI
Patients (N = 100)
Feature
Age, years
Length of stay (hours)
Preoperative STAI
Postoperative STAI
Postoperative STAI preoperative STAI
Total nurse time, minutes
Discharge anxiety scale (n = 99)
p-Value
0.80
< 0.05
0.46
< 0.05
0.08
0.24
0.83
296
Recommendations
For Further Research
Further study should explore
the implications of specialty
nurse teaching versus general surgical nurse teaching. Further
research or the next most logical step would be to alter the
teaching, perhaps providing this
education online or in a Webbased format to determine
whether the teaching method
makes a difference. The use of
follow-up phone calls by a nurse
after dismissal as an intervention
to reduce anxiety and improve
patient satisfaction is another
potential study. Identification of
the man at risk for the inability
to provide catheter care at home,
reasons for phone calls to the surgeon, and need for home health
care would be interesting to investigate further. Distress, identified
by the National Comprehensive
Cancer Network as a sixth (or seventh) vital sign, is another variable to consider for assessment.
References
American Cancer Society. (2013). Learn
about cancer: Prostate cancer. Retrieved March 5, 2013, from http://
www. cancer. org/ cancer/ prostate
cancer/ detailed guide/ prostatecancer-key-statistics
Asilioglu, K., & Celik, S.S. (2004). The
effect of preoperative education on
anxiety of open cardiac surgery
patients. Patient Education and
Counseling, 53(1), 65-70. doi:10.
1016/S0738-3991(03)00117-4
Bondy, L.R., Sims, N., Schroeder, D.R.,
Offord, K.P., & Narr, B.J. (1999). The
effect of anesthetic patient education
on preoperative patient anxiety.
Regional Anesthesia and Pain Medicine, 24(2), 158-164. doi:10.1016/
S1098-7339(99)90078-0
Burt, J., Caelli, K., Moore, K., & Anderson,
M. (2005). Radical prostatectomy:
Mens experiences and postoperative needs. Journal of Clinical Nursing, 14(7), 883-890. doi:10.1111/j.13
65-2702.2005.01123.x
Callaghan, P., Cheung, Y.L., Yao, K.Y., &
Chan, S.L. (1998). Evidence-based
care of Chinese men having transurethral resection of the prostate
(TURP). Journal of Advanced Nursing, 28(3), 576-583. doi:10.1046/j.13
65-2648.1998.00712.x
Chaudhri, S., Brown, L., Hassan, I., &
Horgan, A.F. (2005). Preoperative
intensive, community-based vs. traditional stoma education: A randomized, controlled trial. Diseases
of the Colon and Rectum, 48(3), 504509. doi:10.1046/j.1365-2648.1998.
00712.x
Coslow, B.I., & Eddy, M.E. (1998). Effects
of preoperative ambulatory gynecological education: Clinical outcomes
and patient satisfaction. Journal of
Perianesthesia Nursing, 13(1), 4-10.
doi:10.1016/S1089-9472(98)80074-9
Davison, B.J., Moore, K.N., MacMillan,
H., Bisaillon, A., & Wiens, K. (2004).
Patient evaluation of a discharge
program following a radical prostatectomy. Urologic Nursing, 24(6),
483-489.
Devine, E.C., & Cook, T.D. (1983). A metaanalytic analysis of effects of psychoeducational interventions on
length of postsurgical hospital stay.
Nursing Research, 32(5), 267-274.
doi:10.1097/00006199-19830900000003
Giraudet-Le Quintrec, J.S., Coste, J.,
Vastel, L., Pacault, V., Jeanne, L.,
Lamas, J.P., Courpied, J.P. (2003).
Positive effect of patient education
for hip surgery: A randomized trial.
Clinical Orthopaedics and Related
Research, 414, 112-120. doi:10.
1097/01.blo.0000079268.91782.bc
Guruge, S., & Sidani, S. (2002). Effects of
demographic characteristics on preoperative teaching outcomes: A
meta-analysis. Canadian Journal of
Nursing Research, 34(4), 25-33.
Hathaway, D. (1986). Effect of preoperative instruction on postoperative
outcomes: A meta-analysis. Nursing
297
298
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.