Introduction

The surgical procedure is an activity performed by a specialized team due to its complexity. The specificity of this procedure requires care that needs to be developed with guidelines and therapeutic interventions that transcend technical and physical aspects, or that is, that takes into consideration the human being that merits attention, respect and the right to be heard.¹

In this sense, it is considered essential to develop educational actions directed to both patients and their caregivers, in order to promote the importance of assuming behaviors and attitudes according to their care needs. Furthermore, in the perioperative period, health teams need to develop their procedures with the surgical patient in order to ensure safety and tranquility. Therefore, communication is recommended as a strategy to guide and inform, aiming at meeting the particularities of each human being, which will lead to specific care, according to the needs and expectations of the individual undergoing a surgical procedure.^{2 -3}

Interest in this research was due to the researcher`s prior experience within the general surgery unit, thus seeking to deepen knowledge on the subject. Therefore, the relevance of this study is noted for constant reflection and action among the multiprofessional health team, in perioperative educational actions and well-being of the surgical patient.

Given the above context, this research asks: what is the perception of surgical patients in a university hospital regarding the educational actions developed by the multiprofessional health team? Thus, this study aims to analyze the perception of surgical patients in a university hospital concerning the educational actions developed in the perioperative period.

Method

This is a qualitative, exploratory and descriptive research project. The study was developed at the General Surgery Unit at a University Hospital of the State of Rio Grande do Sul, Brazil. The study scenario included 50 beds and served nine surgical specialties: head and neck, general, plastic, thoracic, vascular, proctology, traumatology, gastroenterology and urology.

The inclusion criteria were: patients admitted to the General Surgery Unit of the referred University Hospital that were in the postoperative period (implying that they could have already experienced pre and / or postoperative educational actions) and 18 years of age or over. Only one patient from each specialty was considered as a participant. Therefore, in cases where there was more than one patient able to participate in the study in each specialty, these were excluded because there was already representation in the investigation. Note that the selection of participants was intentional, following contact with the management of the surgical nursing service to identify hospitalized patients.

Exclusion criteria were patients with impaired verbal communication capacity, since these were considered unfit for the research. During the data collection process, three patients refused to participate without specifying a reason, and two withdrew during the interview due to postoperative discomfort and pain. The final sample of this research numbered eight participants, considering that there were no patients during the data collection period in the gastro-digestive specialty that met the inclusion criteria.

Data collection was performed by the nursing student that is the author of the research from March to May 2016, through semi-structured interview and audio recorded for later transcription and non-participant observation. The observations were made with the help of a script, in order to identify the patients who were counseled, which health professional performed the counseling, as well as the manner that these were performed. The observed data were recorded in a script. After the interviews were conducted, the following were identified: socio-demographic profile of the participants, how the guidelines were developed, what actions were developed, who performed them and the patents` perceptions during the perioperative period. The researcher had previous experience in these data collection techniques, from participation in other research. Also, a pilot test was conducted with the semi-structured interview following which some adjustments were made. The invitation to participate was made in person at which time the researcher presented the research objectives, reasons for its accomplishment and interests in relation to it.

The interviews took place according to the availability of patients and in their preferred location, ranging from the bed to a private room and individualized to favor confidentiality and privacy. When participants requested that the interview be conducted in their bed, a screen was used to promote privacy. The duration of the interviews ranged from 35 minutes to one hour and 40 minutes. Participants were identified alphanumerically with the letter “P” corresponding to participant, followed by a numeral (P1 ... P8).

Data were analyzed according to Content Analysis.⁴ In the pre-analysis stage, a floating reading of the transcribed interviews was performed, aiming to identify the nuclei of meaning. At the same time, the process of highlighting (marking) of these nuclei that responded to the object of study began. In the exploration phase of the material, a thorough reading was performed, proceeding to the identification and extraction of the registration and context units, thus starting the grouping process by similarity, in accordance with the criteria of completeness, representativeness, homogeneity, relevance and exclusivity. In the treatment and interpretation stage, the units were grouped, which led to the emergence of three analytical categories: the patients' perception of educational actions developed in the perioperative period; contribution of educational actions in the perioperative period; and perceptions of patients during the perioperative period. Finally, in the stage involving treatment of the data obtained and interpretation, inferences and interpretations were made, guiding the meanings and knowledge of the messages issued by the participants, correlating and contrasting them with the specific references related to health education and approach to the surgical patient.

Ethical principles were respected, according to Resolution 466/12. The study was approved by the Research Ethics Committee of the Federal University of Santa Maria on January 13, 2016, under Resolution number 52275916.0.0000.5346.

Results

Eight (100.0%) surgical patients participated in this research, 62.5% were men and 37.5% women. Regarding the age of the patients, 62.5% were over 50 years and 37.5% under 25 years. Regarding education, 62.5% of postoperative patients had incomplete elementary school, 12.5% incomplete high school, 12.5% complete high school and 12.5% incomplete higher education. Regarding profession, 50% were retired, 12.5% cash clerk, 12.5% caregiver for the elderly, 12.5% student and 12.5% bricklayer. Regarding the time interval between hospitalization and surgical procedure, 37.5% of respondents were submitted to surgery within 24 hours, 25% 24 hours after hospitalization, 25% 48 hours after hospitalization and 12.5% more than 72 hours after hospitalization.

The results were organized into three categories. In the category entitled “the patients' perception of educational actions developed in the perioperative period”, one can understand the way patients identify these actions, the place where they were performed and the demands for such actions. In sequence, the category “Contribution of educational actions in the perioperative period” covers the positive effect in relation to the actions performed by professionals, especially highlighting tranquility. Finally, the category “Perceptions of patients during the perioperative period” details the main perceptions during this period, and to what they are related.

Patients' perception of educational actions developed in the perioperative period

From the questions raised about the educational actions developed in the perioperative period, 50% of the participants stated they had some kind of counseling regarding the hospitalization and routines of the unit, while the other 50% did not identify the development of educational actions, affirming that no professional would have performed this practice. Of the participants who said they had received some kind of guidance, 12.5% stated that they were guided by nursing and medical professionals, while 87.5% of the participants only received medical advice. It was observed that in general the participants had difficulty identifying any guidance provided by health professionals.

I was in the corridor waiting for an appointment and the doctor saw me and called me. We spent a half hour talking and he explained everything to me. (P3)

I don’t think so. They only told me to wait to be called (P4).

They explained to me at the Emergency Room what the hospitalization was like, the doctor and the nurses explained it to me. ... Here nobody has explained anything to me. (P7).

When asked if any professional had provided guidance regarding the surgical procedure to which they would be submitted, and which professional performed it, it is highlighted that 87.5% of participants mentioned having been guided only by medical professionals, and 12.5% by medical and nursing professionals. Furthermore, it is evident from the statements that the explanations (educational actions) performed by the doctors were the result of their inquiries. During the data collection, from gestures and tone of the participants' voice, it was possible to notice dissatisfaction with the time and place chosen to perform the educational actions. These actions were performed either inside the operating room during anesthesia preparation or after the surgical procedure when the patient had already returned to the surgery clinic bed.

The doctor who performed the surgery explained to me when I was receiving anesthesia. He said he was responsible for the surgery and would remove part of my intestines. (P2)

No, practically not. I met the doctor after surgery. ... He only came later to explain what he had done, how he had done it. (P4)

On the other hand, one of the participants expressed satisfaction regarding the manner and place where these actions were performed. He was having periodic consultations before hospitalization and had already discussed with his doctor the procedure that would be performed and the possible consequences.

In the appointment here to show the exams, the doctor explained everything about the surgery. How it would be, she said it was long, that I could have some sequels. This well before surgery. (P3)

On questioning the participants about how they were and how they would like to be counseled, 62.5% thought that the educational actions performed did not address their greatest concerns. It can be observed, in their manifestations, that the orientations focus on how the surgery will be or was performed, with a focus on the biophysiological aspects.

I was told that I could have sequels, it would be a very difficult surgery and I would have to remove a rib. Just like it was. The doctor said and explained everything I wanted to know. (P3)

The doctors came to talk to me after the surgery, how it went. [what the patient would like] To talk about recovery time. If I could go back to work, if I could remove the colostomy. This I think is the most important to me. The rest I do not even understand much. (P4)

I wanted to know the risks of losing my leg, I was very afraid of that, but they didn't talk about it, even when I asked. (P5)

The doctor said he had to remove the clots. [what the patient would like] I wanted to know how long I will have to rest, unable to do anything. (P6)

It is possible to observe that 37.5% of the participants expressed satisfaction with the educational actions performed. However, one of the most recurrent concerns in the discourses concerns the need for some patients to receive information about their recovery after surgery and the possibility of resuming their lifestyle without permanent impairment.

In this sense, there was clearly invisibility or difficulty in identification of nursing professionals within the multidisciplinary health team, which makes us reflect on how we are developing these educational actions and at what time, since the patients do not remember or do not understand them. Nevertheless, the participants' discourse confirms that which the literature reports regarding the benefits related to educational actions on health in the perioperative period. However, it is necessary to develop these actions based on the needs expressed by the patients.

Contribution of educational actions in the perioperative period

When asked if the educational actions developed would have made any contribution, the research participants reported noticing a positive effect in relation to the actions taken by the professionals. It is noticed that one of the greatest contributions of educational actions was the tranquility they generate. Other contributions reported were also related to an improved understanding of the current events and facing the surgical situation and hospitalization.

Not to be so nervous, feel calmer, to know what would be done and how it could be. Then we do not think so much nonsense, how it can be. Think straight about what was said. (P1)

They helped me cope with the situation and it was very good. If you arrive raw, then you will not be able to face the situation. And knowing what you are going to do, you are ready. ... I think it worked very well. (P3)

They helped to better understand how things are going. It helps a little to organize the family too, ...you have to know things from here on to organize everything. (P4)

When asked if the educational actions performed were sufficient to clarify their doubts, 87.5% of participants reported that they were sufficient. However, it is possible to see an association between the presence of doubts and a difficulty in understanding the use of technical terms in the health area during communication between professionals and patients. Failure to explain the meaning of such technical terms demonstrates that the communication process was sometimes not effective.

No, because I do not understand health terms very well, the technical terms used often slowed my understanding.... (P2)

... they [doctors] have a harder way of talking, and I'm more humble. But I always asked when I had questions. (P8)

In contrast, one participant reported no doubts because the explanations and clarifications provided by health professionals were considered satisfactory.

For me it was well explained, with all the dots in their place. I had no doubt. (P3)

It was observed that one of the greatest contributions of the educational actions developed in the perioperative period was the peace of mind, security, confidence and autonomy generated after these actions. Other contributions also reported were helping to understand the moment experienced and coping with the surgery and hospitalization. However, these were not sufficient for the understanding of all patients. It is necessary to rethink the way we speak and the language used in these actions.

Perceptions of patients during the perioperative period

When asked about the feelings experienced in the preoperative period, the research participants perceived feelings and sensations of fear, nervousness, worry and sadness. It is clear that the participants' concerns are related to the uncertainty of events and possible post-surgical risks, ranging from fear of losing a limb, lifestyle change, incessant pain, fear of loneliness and death.

When I arrived I was very nervous, very scared ... I was a little scared [of being alone without my family]. I had several sad moments. (P1)

I was very worried, confused, because I didn't know very well what I had and what would happen to me. (P2)

I had no choice. ... if I wanted to live I would have to have surgery, and I wanted to live. I was afraid of dying. (P6)

In the postoperative period participants reported feelings and sensations of tranquility, relief, discomfort and worry. Peace of mind is directly linked to the dialogue with the multiprofessional health team. The discomfort is linked to the postoperative condition and some restrictions that this implies, such as locomotion. Also, one of the participants reported awareness of the risks that the hospital offers, when referring to concern about infections.

... now I'm much calmer, much calmer, because the nurses come to reassure us, I'm much calmer. (P1)

Ah, a discomfort, why delimit a number of things .... (P2)

It's very good here, but it's full of bacteria out there, we worry about getting an infection. (P8)

Regarding the feelings experienced about hospitalization, participants reported nervousness, loneliness, longing and sadness. It is possible to observe that the feelings of sadness and longing are related to the loss of family contact in this hospitalization process. Whether due to the lack of time with the family due to visiting hours, or the impossibility of family visits caused by distance from the municipalities where they reside.

Sad to be alone ... I missed my family so much! Now it's getting better. (P1)

I was very nervous, I was because ... I think it's because of the change in habits. I was very well attended, but it's different from home. (P8)

In contrast, one participant reported feeling well due to the care received by the health team that sometimes promotes relaxation within the hospital environment, through conversations, games and also music.

I am being well treated in every way. ... We are treated with love, like people, with jokes, with smiles. Then time goes by and we don't have time to think about sadness, about negative things. Here everyone [health team] greets you, looks you in the eye, and this is very important. (P6)

When questioning participants about their feelings before and after the educational actions, some reported being anxious, frustrated, insecure, afraid and nervous before the educational actions. After the educational actions, they reported greater peace of mind and awareness of what would happen later, which contributed to coping with the hospitalization.

I was very lost! I was very nervous, a little frustrated due to not knowing what to do at the time. It was very bad this lack of information, before entering the operating room! After [the educational actions] I felt much calmer because I clarified these more immediate doubts. (P2)

I was very anxious before. ... I got much better later, because we get more Peace of mind and awareness of things that can happen. (P8)

One of the participants reported that after the educational actions their fear regarding the surgical procedure decreased considerably. However, the fear of being without a family companion during the operative procedure and during the postoperative period did not diminish. Also, it is possible to notice that other patients attributed their strength from faith to face the hospitalization and surgical procedure.

Before I was scared, because I didn't know what I had, what the doctors were going to do. ... afraid of being alone, not having someone in my family around, an insecurity. Then after they explained it relieved the fear of surgery but not of being alone! (P1)

I was calm, I was in God's hands! I am saved, so I was always calm. I knew what medicine could and would do, so I never felt upset! (P4)

The feelings perceived by patients during the perioperative period were fear, nervousness, worry and sadness in the preoperative period. Concern related to the uncertainty of the events that would happen, the possibility of amputation of a limb and the possibility of no longer being able to speak and their repercussions in the routine of life. The fear reported by some participants was related to being alone without a family member, to not being able to reduce or end the pain. In the postoperative period, the participants expressed feelings and sensations of peace of mind, worry, comfort, discomfort and relief.

Discussion

Hospitalization is an unwanted event with stressful characteristics. Patients are faced with much new information related to the surgical procedure and hospitalization. In this context, the responsibility of caring for life, which was previously solely the patient's, is then shared with family and health professionals.^5-6

Hospitalized patients experience changes in their routine. To help overcome these, the multidisciplinary team needs to develop health actions in an articulated manner, to use familiar language and to reinforce the necessary counseling.^7-8

During the observations made in the surgical clinic, it was seen that the counseling regarding the unit's operation and its routines are given at the time of hospitalization by the nursing staff. However, in the present research, only one of the participants recalled the moment when the head of nursing together with a medical professional conducted the counseling in the unit. The others remembered only the medical guidance provided. Therefore, the educational actions regarding the hospitalization and surgical procedure should be performed clearly and succinctly, seeking to clarify any questions and provide information regarding the main procedures that will be performed.

Possible weaknesses in the counseling involve a lack of information about the recovery time and rehabilitation process after hospital discharge, since it is common during this period to voice questions about any change to routines and habits resulting from the surgery. This lack of information is often due to the fact that there is no standardization in the guidelines and surgical routines. Patients may feel helplessness to regain their autonomy, because during their hospital stay and until the period before discharge, the patient needs third-party care.

It should be noted that the patient requires guidance at the moment the surgical procedure is scheduled, because the closer the procedure becomes, the greater the difficulty to assimilate information due to nervousness, which in turn increases anxiety.⁷ Thus in the preoperative period, surgical patients necessitate counseling and educational actions by the health team.⁹

These educational actions help to reassure the patient regarding what will happen at the time of surgery, thus reducing anxiety levels. In addition, they help clarify doubts that surgical intervention causes, such as length of hospital stay, rehabilitation time, and can minimize postoperative complications by clarifying what care patients need to take during the recovery period.

For this process to be effective, it is important that health professionals carry out educational actions directed at the patient, in a clear manner and taking care to ask and answer questions according to the patient's level of information and understanding, as well as be performed in a suitable place that provides privacy.¹⁰ During the observations, it was noted that educational actions are performed at the bedside during the visit or a procedure.

It is necessary to listen and identify what information the patient requires, in order to develop an effective counseling that minimizes doubts, fears, anxiety and other stress factors. Often, their questions are not focused on the physiological and technical issues of the surgical procedure, but on the recovery time and possibility of resuming their previous routines. Information regarding recovery is often related to (re)structuring family and budget, and the event of hospitalization and surgical procedures are not always planned by the patient and family.

Within the health team, each professional has their own routine. Nursing professionals perform these actions at the bedside and, sporadically, during shifts with less demand for care activities, when they can invite patients to move to a private room. These rooms also have didactic material available (for example dolls with drains and dressings, anatomical images and manuals) that help in the development of the actions. Other health professionals such as physiotherapists, nutritionists and psychologists provide timely and necessary guidance for the patient's present moment. Also, health professionals such as dentists are requested for orientation, according to the evaluation by nursing professionals.

Preoperative counseling and psychological support are seen as beneficial whenever they are based on the individual needs of the patient, because as their doubts are clarified they experience less anxiety.¹¹ Consequently, health professionals should be well prepared and provide the necessary information in humanistic and holistic form, thereby helping the patient to have a better understanding of their situation and find effective coping mechanisms, which alleviates anxiety.^11-15

In this context of expectation and anxiety that encompasses the surgical process, family members are also closely involved and share with the patient their feelings and uncertainties. This makes management of the situation even more complex for the health team, due to their proximity during preoperative care. The multidisciplinary team needs to be aware of the patients' clinical condition, but also need to know how to listen, support and help the patient to understand and cope with the situation they are experiencing.^14-16

No less importantly, the postoperative period requires continuous health surveillance from the healthcare team to detect any change in the patient's general condition. It is necessary for the health professional to talk to the patient in the postoperative period, as well as to be always close at hand to offer guidance and reassurance about their feelings and emotions, as well as offering support for family members. In this context, the family is considered essential for a much faster recovery, because they help in restoring the patient's psychological balance and reducing suffering, as well as providing courage and hope.¹⁷

Health work from a perspective that involves religiosity and spirituality contributes to a sense of well-being and reduces levels of anxiety and helplessness. In this context, religion sometimes offers a place of refuge from the disorder caused by the disease, and comfort for the fears and insecurities aroused by the sense of death. Through religion, patients find meaning to becoming ill, providing an explanation for the impossibility of controlling their situation.¹⁸

In view of the above, the well-being of the patient should be the main objective of the professionals who provide care, since in the perioperative period patients may present a high level of stress, anxiety and discomfort, as well as develop feelings that may negatively affect their emotional state, thereby making them vulnerable and dependent. Thus, educational actions are important to alleviate fear and anxiety, while providing patients and family the emotional strength to face the surgical act.

Conclusion

This study demonstrated the numerous contributions of educational actions for surgical patients in the perioperative period. It also suggested the need for deep reflection on how health professionals are developing educational actions, the quality of communication/personal presentation, the period invested for these actions and the moment they are being performed.

The health team needs to carry out educational actions with the patient throughout the perioperative period aiming at physical, psychological and spiritual preparation. For the counseling to really meet the needs of patients, professionals need to pay attention to the language used during educational actions, in that scientific terms should be avoided for a better understanding of the guidance. Discordancy in the guidance by professionals needs to be avoided; this information should be planned by health professionals and constantly reinforced.

In this sense, the various sectors and health care networks can help in the restructuring of educational actions. Furthermore, they provide continuity and comprehensiveness of care to surgical patients, favoring a better understanding of the moment they experience. Finally, the aim of this study is to instigate reflections on the way we communicate with patients, rethink our language and approach, as well as instigate reflection on the role of health professionals related to educational actions.

A limitation of this study involved the number of research participants, which may not have fully demonstrated the perception of surgical patients regarding the educational actions developed in the perioperative period. Additionally, the study was conducted in a single hospital, thus requiring further research in other hospitals to confirm the results and thereby enabling eventual comparisons and generalizations.

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Corresponding Author

Andressa Böck

E-mail: bockandressa@gmail.com

Address: Praça Oswaldo Aranha, nº 85, Centro, Alegrete, Rio Grande do Sul, Brazil.

CEP: 97541-540

Contribution by Authors

1 – Andressa Böck

Design and planning of the research project, obtaining or analyzing and interpreting data, redaction and critical review.

2 – Elisabeta Albertina Nietsche

Design and planning of the research project, obtaining or analyzing and interpreting data, redaction and critical review.

3 – Marlene Gomes Terra

Design and planning of the research project, obtaining or analyzing and interpreting data.

4 – Liege Gonçalves Cassenote

Design and planning of the research project, obtaining or analyzing and interpreting data.

5 – Camila Fernandes Wild

Design and planning of the research project, obtaining or analyzing and interpreting data.

6 – Cléton Salbego

Redaction and critical review.

How to cite this article

Böck A, Nietsche EA, Terra MG, Cassenote LG, Wild CF, Salbego C. Educational actions developed in the perioperative period at a university hospital: perception of surgical patients. Rev. Enferm. UFSM. 2019 [Acss at: Year, Month, Day];vol9 e28: P1-P20. DOI:https://doi.org/10.5902/2179769234760