Journal of Community Medicine & Health Education
Open Access

Perception of a surgical operation can be stressful, and it also leads to feelings of fear [1,2]. Fear occurs in different ways, including fear from the unknown, fear of losing control, and fear from ineffective pain control [3]. As a result, these fears lead to stress and anxiety for the patient [1,4]. Preoperative patients undergoing through planned surgical interventions with anesthetic are prone of high levels of fear and stress, followed by feelings of insecurity, anger and lack of confidence, which are indicated by failure to properly inform preoperative patients, leading to pre-intra and postoperative complications [5].

The term preoperative experience refers to all events related to operational or invasive procedures and integrates the patient's perception of events. Preoperative experience is associated with negative physiological and psychological post-operative outcomes in young children and adults. It is estimated that 80% of surgical patients manifest stress and anxiety before going through surgical procedures, which lately indicates the postoperative healing process. Intensive stress levels prior to surgical procedure, beside that require more anesthetic use in adult patients, are also associated with more postoperative pain and slow wound healing. In addition, young children and adults that experience high levels of stress before the surgical procedure had more postoperative complications [6], About 1.3 million patients experience postoperative complications per year, which costs about $25 billion for treatment continuity.

Even though children, adolescents and adults perceive different experiences due to different cognitive development and personal experiences numerous of studies have analyzed preoperative experiences in adults and young children, excluding studies with adolescents [7-14]. In recent years the number of studies on the perceptions of children and their adaptation to stressful medical events have increased [15,16]. Studies have shown that preoperative stress is associated with poor health in adults and young children, but there is lack of data in the literature about stressful experiences among adolescents. Clinical experience, however, has shown that adolescents behave differently from adults and children in preoperative stage. Adolescents often come out of anesthesia by striking, crying, and resisting. In addition, teenagers rarely ask questions (unlike adults and children), and when talking about providing short answers, they tend to avoid eye contact, and often have different movements that show that they are nervous [17].

Preoperative interventional programs provide important educational information that impact positively health care providers, children and parents [18]. Positive outcomes related to health include reduction of stress levels in children, improvement of co-operation with health care providers, and stronger reliance to medical procedures [19]. Preoperative interventional programs are usually provided by nurses in preoperative outpatient ’ s settings. Preoperative interventional programs provided by nurses are useful interventions in anxiety reduction among children and parents [20]. Results from preoperative interventional programs are interconnected with children increased self-control, reduction of unrealistic and inappropriate expectations related to hospitalization and surgery procedures, and also faithfulness in health care providers [19,21]. In the other hand, these benefits may also indicate the reduction of post-operative emotional and behavioral responses, reduction of perception of pain, and promote faster recovery [18].

However, in some ongoing developing countries, where Kosovo is part of, latest preoperative interventional programs are rare, but still practiced in a traditional way. We are aware that preoperative interventional programs are a key factor for patient ’ s health and wellbeing, so to have a bigger picture for this approach the research focus is directed on finding how the traditional preoperative education provided by nurses in Kosovo hospitals affect the level of perception and wellbeing of preoperative adolescents.

Research purpose

This study aims to investigate how preoperative education provided by nurses affects the reduction of preoperative patient concerns and distress. By identifying their concerns, in the future it will be easier to design programs that integrate direct psychological preparation of preoperative care.

Research questions

How does the preoperative education provided by nurses affect managing the distress caused by separation from parents among children in preoperative care?

Which is the impact of preoperative education provided by nurses on reduction of preoperative patient's concerns about illness, hospitalization, and medical procedures.

Participants

By using randomized sampling, 185 subjects were select at the University Clinical Center of Kosovo. Out of these, 46.4% of adolescents are women and 53.5% are men. Since the questionnaire is dedicated only to the adolescent age group, the criteria for inclusion in the research was the age of subjects from 11 to 14 years. The largest number of subjects (30.3%) belong to the 12-year age group, while the lowest number (16.8%) of participants belongs 14-year-old group (Tables 1 and 2).

Table 1: Frequency and percentage of subjects divided by age groups.

Table 2: Frequency and percentage of subjects divided by economic incomes.

The total of 46.4% of subjects were from rural areas and 53.6% were from urban areas. Only 2 subjects did not have both parents alive, and 28 of them did not have one of the parents alive. In general, only 17.6% of respondents were previously operated and for 82.4% of them was the first time they will go under surgery. Out of 185 subjects, 23.3% reported poor economic conditions, 46.7% average conditions and only 30% reported very good economic conditions in the family; see the Table 2 for more.

Procedure

The directorate of the University Clinical Center of Kosovo was initially notified about the research process and then the permission to continue the research has been received. Since the study sample comprised adolescents, permission to conduct the study has been also received from adolescents’ parents or caregivers. Moreover, children were also asked for their willingness to participate in the research and were informed that at any moment they are free to leave, and this will not penalize them.

Following the randomized sampling technique, children were divided into two groups, those who have received preoperative educational intervention and those who have not received it yet. Preoperational educational intervention in this study implies educational counseling by nurses given to preoperational adolescents regarding operational procedures.

The preoperative educational intervention procedure lasted 7 to 9 minutes, and the nurses apart from fully explaining the operation procedure, they let children opportunity to ask questions they would like to know. Afterwards, they have been asked to fulfill the survey. In general, the survey procedure lasted from 10 to 12 minutes. To avoid patient refusals and fatigue, a short form of questionnaire was used. The questionnaire used in this research was translated and adapted in Albanian based on the standards procedure of Brislin. Patients were assured about confidentiality. Upon completion of the survey, patients were asked to include the questionnaire in envelope, and submit it to the interviewer.

Instrument

The Child Surgery Worries Questionnaire Adolescents Form was used, this questionnaire is a valuable and important tool for measuring the concerns related to the operation. Such a questionnaire, as described by the authors, has been conducted after a wide search of literature, and deep interviews were also conducted to identify the main concerns related to preoperative process.

In total, the questionnaire contains 27 questions, all closed questions, and are divided in ten major dimensions related to illness, pain, death, injections, anesthesia, operation, operation hall, parents, hospital stay, and interpersonal relationships. Answers are in Likert scale, from 0 - not at all worried, 1 - a little worried, 2 - moderately worried, 3 - considerably worried, to 4 - extremely worried.

The factorial analysis carried out in 2000 by the authors, brings up three main factors. The main factor measured by this questionnaire is the concern related to hospitalization, the second factor is the concern related to medical procedures, and the third factor is concern related to illness. In addition to the questionnaire that measures children's concerns related to preoperative procedures, the questionnaire also contained demographic questions like age, gender, etc.

In this section results from different analysis are presented. Data were analyzed by using IBM SPSS Statistics 21.0 for Windows.

As according to the Figure 1, 34.4% of children without intervention reported that they feel considerably worried for the fact that they will be separated from parents during surgery and 24% of them reported that they feel extremely worried. Whereas, 34.8% of patients with intervention report that they are not at all worried about surgery and 43.8% of them reported that they feel a little worried. T-tets confirms that the differences between the two groups are significant t (186)=20.03, p<0.01

Figure 1: Fear of separation from parents before operation.

Linear regressive analysis was conducted to see the impact of preoperative educational counselling in concerns about illness, hospitalization, and medical procedures, among Kosovar adolescents (Table 3).

Table 3: Preoperative educational counselling impact on concerns about illness.

A simple linear regression was calculated to predict concerns about illness among adolescents based on preoperative educational counselling, β=6.52, t (186)=26.97, p<0.001. A significant regression equation was found (F (1.182)=134.616, p<0.000) with an R² of 0.425 (Table 4).

Table 4: Preoperative educational counselling impact on concerns about hospitalization.

A simple linear regression was calculated to predict concerns about hospitalization among adolescents based on preoperative educational counselling, β=7.88, t (186)=20.749, p<0.000. A significant regression equation was found (F (1.174)=285.141, p<0.000) with an R2 of 0.621.

Independent t-test analysis was calculated to see the differences between gender and distress of separation from parents (Table 5).

Table 5: Preoperative educational counselling impact on concerns about medical procedures.

A simple linear regression was calculated to predict concerns about medical procedure among adolescents based on preoperative educational counselling, β=0.763, t (186)=26.34, p<0.000. A significant regression equation was found (F (1.181)=252.173, p<0.000) with an R2 of .582.

Preoperative educational preparation is an effective way in the reduction of negative effects from medical treatments [18,19]. Preoperative situation often can lead to feeling of fear [1,2]. As a result, fear leads to stress and anxiety for the patient [4], even when the operation is planned, [5]. The need for preoperative educational preparation has been shown to be very important in anxiety reduction among children and parents, especially it increases self-control among children and reduces unrealistic and inappropriate expectations related to hospitalization and surgery procedures, which also raises the trust in health care providers [18-21]. These benefits indicate the reduction of post-operative emotional and behavioral responses, reduction of perception of pain, and promote faster recovery [18]. On the other hand, similar results have been found in Kosovo context study too, where significant differences have been found between children who have gone through preoperative education and those who have not. Results from descriptive statistics analysis and t-test analysis have shown significant differences between children with interventions and those without interventions in the level of distress of separation from parents t (186)=20.03, p<0.01. Moreover, even regression analysis shows the same thing. If intervention is set as an independent variable in a regression model, it can be seen that in the dimension of hospitalization, it explains 62% of the variance (p<0.01).

Indeed, the intervention extends the impact on the concern about medical procedures, significantly reducing it. About 58% of the opacity or variance in dependent variables is explained by the intervention (p<0.01).

And finally, the impact of intervention is also noticeable in reducing the distress of the concern about illness among children, as the intervention has the opportunity to explain 42% of variance at this level (p<0.01).