SCHOOL OF NURSING COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA LEGON EXPLORATION OF SURGICAL PATIENTS’ PERSPECTIVES OF PERI- OPERATIVE NURSING CARE AT THE REGIONAL HOSPITAL, BOLGATANGA BY ADUGBIRE ATINYAGRIKA BERNARD (10256782) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF M’PHIL NURSING DEGREE JUNE 2015 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care i DECLARATION I declare that this thesis is my own work that was produced from research under supervision. This thesis has not been submitted in any form for any degree or diploma at any university or other institution of tertiary education. Authors and Publishers whose work have been utilized in this study have been duly acknowledged in the text and list of references. ……………………………… ……………………………. Adugbire Atinyagrika Bernard Date (Student) ………………………………. ……………………………… Dr. Lydia Aziato Date (1 st Supervisor) ………………………………. ………………………………….. Dr. Florence Dedey Date (2 nd Supervisor) University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care ii DEDICATION This thesis is dedicated to all patients seeking nursing care at the Regional Hospital, Bolgatanga. It is also dedicated to my family for their continuous support and prayers. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care iii ACKNOWLEDGEMENTS First of all, I thank the Almighty God for guiding me to the end of this project. I express my sincere gratitude to my lovely wife Mrs. Adugbire Elizabeth; my lovely sons Edmund Adugbire, Prosper Adugbire and Bright Adugbire. My greatest gratitude is to my supervisors; Dr. Lydia Aziato and Dr. Florence Dedey for their immense contributions and guidance without which the thesis would not have been completed. I also express my sincere gratitude to Dr. Florence Naab, Dr. Patience Anitteye, Dr. Prudence Mwinituo, Ms.Patricia Avadu, Mrs.Offei Ansah, Mrs. Cecilia Eliason, Mrs. Adzo Kwashie, Mr. Ameyaw Korsah, and Ms. Regina Ankrah for their contribution during my graduate course. My thanks also go to the head and staff of the Regional Hospital, Bolgatanga for their support and cooperation during this study. I also thank my participants for sharing their perspectives of nursing care with me. I also acknowledge the authors and publishers of literature used as reference in this study. I thank all my course mates for their support throughout the programme. Finally, I thank my friends especially Moses Laar, and Madam Mabel Avane for their support and encouragement throughout the programme. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care iv TABLE OF CONTENTS Content Page DECLARATION ............................................................................................................... i DEDICATION .................................................................................................................. ii ACKNOWLEDGEMENTS ............................................................................................ iii TABLE OF CONTENTS ................................................................................................. iv LIST OF FIGURE......................................................................................................... viii LIST OF ABBREVIATIONS .......................................................................................... ix ABSTRACT ...................................................................................................................... x CHAPTER ONE ............................................................................................................... 1 1.0 Background ............................................................................................................. 1 1.1 Statement of the problem ........................................................................................ 5 1.2 Purpose of the study ................................................................................................ 6 1.3 Objectives of the study ............................................................................................ 6 1.4 Research Questions ................................................................................................. 6 1.5 Significance of the study ......................................................................................... 7 1.6 Operational Definition of Terms ............................................................................. 7 CHAPTER TWO .............................................................................................................. 8 LITERATURE REVIEW ................................................................................................. 8 2.1 Introduction ............................................................................................................. 8 2.2 Theoretical Framework ........................................................................................... 9 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care v 2.3 Surgical Patients‘ Perspectives on Preoperative care ............................................ 15 2.5 Surgical patients‘ perspective on postoperative care. ........................................... 26 2.6 Discharge planning / home care ............................................................................ 30 CHAPTER THREE ........................................................................................................ 35 METHODOLOGY ......................................................................................................... 35 3.1 Introduction ........................................................................................................... 35 3.2 Research design ..................................................................................................... 35 3.3 Research setting..................................................................................................... 36 3.4 Target Population .................................................................................................. 37 3.4.1 Inclusion criteria ............................................................................................. 37 3.4.2 Exclusion Criteria ........................................................................................... 37 3.5 Sample Size and Sampling Technique .................................................................. 38 3.6 Data Collection tool and Procedure ...................................................................... 38 3.7 Piloting the instruments ......................................................................................... 40 3.8 Data management .................................................................................................. 40 3.9. Data Analysis ....................................................................................................... 41 3.10 Methodological Rigour ....................................................................................... 42 3.11 Ethical Consideration .......................................................................................... 44 CHAPTER FOUR ........................................................................................................... 45 FINDINGS ...................................................................................................................... 45 4.1 Introduction ........................................................................................................... 45 4.2 Demographic Characteristics ................................................................................ 45 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care vi 4.3 Preoperative perspectives ...................................................................................... 46 4.3.1 Patients‘ Assessment and Triage .................................................................... 46 4.3.2 Patients‘ consultation and pre-habilitation ..................................................... 50 4.4 Intraoperative perspectives .................................................................................... 56 4.4.1 Intraoperative information. ............................................................................. 56 4.4.2 Monitoring of intraoperative vital signs and intravenous fluid. ..................... 58 4.4.3 Integrated pain management ........................................................................... 58 4.4.4 Safety .............................................................................................................. 59 4.4.5 Infection Prevention ....................................................................................... 59 4.5 Postoperative Perspectives .................................................................................... 60 4.5.1 Monitoring and Evaluation ............................................................................. 60 4.5.2Activities of daily living .................................................................................. 64 4.5.3 Discharge planning ......................................................................................... 65 4.5.4 Perceived Quality of Care ............................................................................... 68 4.6 Faith in God. .......................................................................................................... 70 4.7 Summary of the findings ....................................................................................... 71 CHAPTER FIVE ............................................................................................................ 74 DISCUSSION ................................................................................................................. 74 5.1 Introduction ........................................................................................................... 74 5.2 Preoperative perspectives ...................................................................................... 74 5.3 Intraoperative perspectives .................................................................................... 80 5.4 Postoperative perspectives .................................................................................... 82 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care vii 5.4 Faith in God ........................................................................................................... 88 CHAPTER SIX ............................................................................................................... 90 SUMMARY AND CONCLUSION ............................................................................... 90 6.1 Introduction ........................................................................................................... 90 6.2 Summary ............................................................................................................... 90 6.3 Implication for Clinical Nursing Practice ............................................................. 94 6.4 Implication for Nursing Education ........................................................................ 95 6.5 Implication for policy ............................................................................................ 96 6.6 Avenues for Further Research ............................................................................... 96 6.7 Limitations of the study......................................................................................... 97 6.8 Conclusion ............................................................................................................. 97 6.9 Recommendations ................................................................................................. 99 REFERENCES ............................................................................................................. 101 APPENDIX A: DEMOGRAPHIC INFORMATION .................................................. 118 APPENDIX B: INTERVIEW GUIDE ......................................................................... 119 APPENDIX C: CONSENT FORM ............................................................................. 120 APPENDIX D: GENERAL PROFILE OF THE PARTICIPANTS ............................. 123 APPENDIX E: SUMMARY OF THEMES ................................................................. 125 ETHICAL CLEARANCE ............................................................................................ 126 INTRODUCTORY LETTER FROM THE DEPARTMENT ...................................... 127 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care viii LIST OF FIGURE Figure 1: PSH as a Microsystems Healthcare ................................................................ 10 University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care ix LIST OF ABBREVIATIONS AAGBI Association of Anaesthetics of Great Britain and Ireland AORN Association of periOperative Registered Nurses ASA American Society of Anaesthesiologist ECDC European Center for Disease Control ERAS Enhanced Recovery After Surgery GHS Ghana Health Service HPS Health Protection Scotland MOH Ministry of Health NICE National Institute for Health and Clinical Excellence PSH Perioperative Surgical Home RCN Royal College of Nursing TACS Time of Acute Care Surgery WHO World Health Orgainsation University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care x ABSTRACT The purpose of this study was to explore surgical patients‘ perspective of perioperative nursing care at the Regional Hospital, Bolgatanga. The study was guided by Perioperative Surgical Home (PSH) as Microsystems health care model. The study employed a qualitative explorative descriptive design. Purposive sampling technique was used to recruit participants. The data was saturated with 15 participants aged between 23 and 65 years. All the interviews were audio-taped and transcribed verbatim. Data was analysed using the principles of thematic content analysis. Three major themes emerged from the study: preoperative perspectives, intraoperative perspectives and postoperative perspectives of care. These themes were consistent with the PSH Model. Also, additional theme that emerged was faith in God. Nurses helped to assess and triage patients to identify specific cases for urgent surgery. Nurses provided reassurance, counseling and prehabilitation and physical care to patients but failed to take patients‘ medical history. Nurses contributed effectively to ensure patients‘ safety and performed infection prevention to some extent during surgery but poorly managed patients‘ pain. Some patients sustained minor injuries as a result of poor usage of theatre equipments. Nurses provided inadequate information to patients throughout the perioperative period. Nurses exhibited poor communication attitude toward patients and poorly managed their wounds resulting in wound infection. Also, patients encountered high cost of care and nurses failed to visit patients at home after discharge. It was recommended that health care providers should involve patients in planning care. They should conduct physical assessment and review items used in the theatre. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 1 CHAPTER ONE 1.0 Background Perioperative nursing is a term used to describe a variety of nursing functions associated with the surgical experience. It comprises three phases of the surgical experience: preoperative, intraoperative and postoperative. Each phase begins and ends at a particular point in the sequence of events that constitute the surgical experience (AORN, 2012a). Each phase comprises a wide range of activities that the nurse performs using the nursing process based on standard practices (Spry, 2005). Preoperative phase is an important phase because most of the patients are vulnerable in their needs both psychological and physiological. The important factor is anxiety due to fear of the unknown of the outcome of the surgery, pain and even death. Hence, the care should include physical, emotional preparation, guidance, assessment and possible referral to experts to promote recovery and prevent postoperative complications ( Rosen, Svensson, & Nilsson, 2008). Also, patients should be evaluated for their preparedness for the surgery, identify potential risk of the patients, advice the patient about the surgical procedure and be prepared for postoperative experience and possibly plan with the patients for home care (Pearson & Osbom, 2010). In surgery, it is important for patients to go into the theatre fully prepared physically and emotionally before surgery is done (Bruce, 2001). Surgical patients go through either planned (elective) or emergency surgery. In the planned surgeries, surgical patients go through a multidisciplinary team of experts‘ examination depending on the patient‘s condition. These experts include the nurse, the anesthetist, the surgeon, the clinical psychologist, laboratory technician and the radiologist among others. The aneasthetist assesses the patients and informs them of what is expected of them. In case of any abnormalities the patients are referred to the doctor for management (Aziato & University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 2 Adejumo, 2013). In emergency surgery, the patients do not go through anesthetist assessment clinic and the range of the nursing care varies depending on the urgency of the surgery, existence of disease condition and available facilities (Aziato & Adejumo, 2013). Hence surgical patients are often prepared adequately and depending on the condition and age of the patient; the patient is starved for at least 6-8 hours before the surgery (Brady, Kinn, Ness,& Stuart, 2010). A study conducted in the Western Santa Catarina using a qualitative design, indicated that most patients expressed feeling of insecurity, fear and nervousness prior to surgery. However, nursing care such as physical preparation, guidance to minimize the risk of postoperative complication and psychological approach such as adequate information delivery were rarely performed during preoperative phase. Patients also expressed inconsistency of the care. Some patients said nurses contributed positively during preoperative phase to help them go through the surgery with little fear whilst others were of the view that nurses did not help them at all (Ascaria, Noiss, & Sartori, 2013). Further studies conducted in Ghana showed that, patients are always afraid of the surgery due to the pain associated with it, possible infection and bleeding that may occur. It is also reported that some patients even lost their lives while undergoing the surgery (Badoe, 2009). Hence adequate information should be given to patients during preoperative phase to reduce anxiety and also enhance postoperative recovery (Aziato & Adejumo, 2013b; Guo, East & Arthur 2012). A study in the United State of America stated that, during the intra-operative phase, the patient is usually drowsy due to the preoperative medications but is aware of what is happening to him. Therefore patients should be reassured not only verbally but nonverbally by facial expression, a touch or a warm grasp of the patient‘s hand to relieve their anxiety. It further stated that the patient should never be left alone until the University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 3 surgery begins (Bruce, 2001). However, a qualitative study conducted in Korle-Bu and Ridge hospital in Ghana, using a semi-structured interview questionnaire, indicated that patients often experienced fear when they are in the theatre. The patients become afraid when they see the other patients being brought in and out of the theatre. They wish that they were informed of what is expected of them in the theatre before they enter to help reduce their fear (Aziato & Adejumo, 2013). A quantitative study conducted in Pakistan indicated that postoperative complication is a disturbing phenomenon in the Teaching Hospital of Karachi. It was observed that 29.6% of surgically operated patients had complications. The common complications observed were postoperative pyrexia in (18.2%) patients followed by postoperative nausea and vomiting in (11.6%) patients, wound infection in (11.4%) patients and respiratory tract infection in (7.0%) patients. These complications occurred due to poor preoperative assessment, poor surgical technique and postoperative care and lack of proper follow up care. In line with this, another study showed that patients complained that they were not informed of all possible risk, not advised on what to expect in the postoperative period and were not educated on early recognition and reporting of adverse events in order to prevent these complications ( Masood, Syed & Zubia, 2006). Postoperative symptoms can be disturbing and this causes the delay in patient return to daily life function. The common symptoms that patients complained of are pain, nausea, drowsiness, tiredness, fatigue and dizziness ( Chung & Schnaider, 2006; Rosen, Clabo lanzon & Martensson, 2009). Also, patients often deal with psychological postoperative problems such as mood swings and anxiety due to the changes in the body image like swelling and discolouration of the incised site. The patients therefore stated that they expect nurses to care for them after surgery in order to facilitate their recovery (Demir, Dimamali, Donmez, & Ozsaker, 2008; Mitchell, 2010). However, a study conducted in University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 4 Kenya hospitals showed that, patients at the surgical ward were not satisfied during postoperative nursing care. They said nurses were rude, impolite and feel reluctant to attend to them (Ojwang, Ogutu, & Mata, 2010). Adequate assessment of surgical patients is important before discharge. In a study conducted in USA, 1442 patients were operated between 2009 and 2011 and 11.3% of these patients were readmitted to the hospital within 30 days of discharge due to poor assessment during discharge planning (Sweeney et al, 2013). Postoperative complications were the significant independent risk factor leading to the readmission. Patients who had one or more complications after their surgery were four times more likely to be readmitted to the hospital compared with those who had no complications (Sweeney et al, 2013). Majority of the surgical patients interviewed in another study complained that they were not informed about what to do when they were discharged home and that affected their care at home resulting in some of them developing complications (McDonald, Siegmeth, Deakin, Kinninmonth & Scott, 2011). Due to this, further studies indicated that surgical patients should be prepared for discharge and failure to do so may result in patients being discharged home with uncertainty about their care. Besides, it is important to provide adequate information and discharge planning for surgical patients based on their postoperative needs especially information on postoperative recovery and self care at home ( McMurray, Johnson, Wallis, Patterson, & Grifiths, 2007). From the above studies, it is evident that studies have either explored preoperative or post- operative nursing care with little having been done on perioperative nursing care. The study adopted the Perioperative Surgical Home model as a healthcare Microsystems model adapted by Kash et al, 2013 to guide the study. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 5 1.1 Statement of the problem In Bolgatanga Regional Hospital, statistics indicated that from 2011-2012, the hospital recorded a total of 2,595 surgical patients for operations ranging from elective to emergency surgeries. With this number, 649 (25%) patients developed complications such as wound infection. Five percent (5%) of these patients were readmitted at the Hospital. These statistics presupposes that there may be a problem with the nursing care that needs to be investigated. The Regional Hospital‘s Quality Assurance Team conducted a survey in 2012 on nursing care at the surgical wards and it was revealed that 87.7% of the respondents on the wards were not satisfied with the care rendered to them (Annual Report; Regional Hospital, 2013). The researcher‘s personal experiences during the monitoring of his students on clinical placement indicated that surgical patients often complained of long queues and waiting time for the nurses to attend to them especially when they come for wound dressing. The researcher also realized that majority of the out patients wounds were infected. A qualitative study conducted in Malawi to assess patients perception of care, indicated that patients want nurses to respect them, and treat them with kindness and dignity instead of the bad experiences they encounter with nurses during their stay on the ward (Kumbani, 2012). A review of literature shows that it seems there is lack of research on the perspectives of surgical patients on perioperative nursing care at the Regional Hospital, Bolgatanga. The study therefore seeks to explore surgical patients‘ perspectives on perioperative nursing care at the Regional Hospital, Bolgatanga. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 6 1.2 Purpose of the study The study aims at exploring surgical patients‘ perspectives of perioperative nursing care at the Regional Hospital, Bolgatanga. 1.3 Objectives of the study The main objective is to explore surgical patients‘ perspectives on perioperative nursing care. Specific objectives will be to; 1. Explore surgical patients‘ perspectives on preoperative care 2. Explore surgical patients‘ perspectives on intraoperative care. 3. Investigate surgical patients‘ perspective on postoperative care and discharge planning. 1.4 Research Questions 1. What are the surgical patients‘ perspectives of preoperative nursing care at surgical ward? 2. What are the surgical patients‘ perspectives of intraoperative nursing care at surgical ward? 3. What are the surgical patients‘ perspectives of postoperative nursing care at surgical ward and discharge planning? University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 7 1.5 Significance of the study The study will provide nurse managers at the hospital an insight about the gaps in nursing care for planning training needs of nurses. It will also provide information to the hospital management especially the nursing department for future policy implementation. The research findings will help contribute knowledge to the nursing. The research will provide the public health nurse insight into surgical patients‘ needs at home. 1.6 Operational Definition of Terms Surgical patients: These refer to patients who have had operation (emergency and planned) and have been discharged from the Bolgatanga Regional Hospital. It also includes patients who have stayed in the surgical ward for five days or more. Patients’ perspectives: These refer to patients‘ views on perioperative nursing care. Peri-operative nursing care: This refers to the nursing care rendered to patients before (preoperative), during (intra-operative) and after operation (postoperative) including discharge planning. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 8 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction A critical review of research about the surgical patients‘ perspectives of perioperative nursing care shows that there have been limited studies on perioperative nursing care, especially within the Ghanaian society. The review of literature for the study is focused on the theoretical framework guiding the study, patients‘ perspectives of preoperative nursing care, patients‘ perspectives of intraoperative nursing care and patients‘ perspectives of postoperative nursing care including discharge planning. The researcher searched the electronic database such as ―Sciencedirect‖, ―Google Scholar‖, and ‗Sage‘ among others of the University of Ghana database using the key words ‗nursing models‘, ‗nursing theory‘, ‗conceptual framework‘ to get a theory, model or conceptual framework that will guide the study. In search of a theory, a number of models, theories and conceptual framework such as Rush Medicus Tool developed by Hus et al., 2002, Healthcare Microsystems model developed by Nelson et al., 2011, Perioperative Surgical Home Model developed by the American Society of Anesthesiology (ASA, 2013), and Perioperative Surgical Home as a Microsystems adapted from Nelson et al (2011) by Kash, et al, (2013) were identified. A critical review of these models and frameworks showed that the adapted Periopeative Surgical Home (PSH) as a Microsystems Health care Model would be applicable for this study. The models‘ constructs reflect the phases of perioperative nursing care as compare to the rest of the models discovered. Besides, the PSH model has been used much in explorative researches to solicit patients‘ views in various fields even though it can be used in quantitative research too. Also, the PSH model examines patients care through perioperative period to include home care and their perceptions of the quality of nursing care they received during their hospital stay. Based on these reasons, PSH model is best University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 9 suited for the study since the researcher aims at exploring the perspectives of surgical patients on perioperative nursing care including home care. 2.2 Theoretical Framework The theoretical framework that guides the study is Perioperative Surgical Home as Microsystems Model developed by Nelson et al, (2011) and adapted by Kash et al, (2013). The aim of PSH Model is to achieve triple aim of better health, better health care and reduce cost through continuous improvement for all patients undergoing surgery. The PSH is a physician led multidisciplinary team based system of coordinated care which guides the surgical patients through the entire surgical experience from the decision for the need for surgery to discharge from a medical facility and beyond. Figure 1 shows the framework of the model. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 10 Figure 1: PSH as a Microsystems Healthcare PSH COORDINATION OF CARE FEEDFORWARD PSH Process Perceived quality Improvement Cost and Clinical Outcome Data Source: Adapted from Nelson et al, (2011) The development of the Perioperative Surgical Home as Microsystems Model occurred by integrating the concept of Perioperative Surgical Home into the Clinical Microsystems Model developed by Nelson et al, (2011). Clinical Microsystems are places where patients, families and caregivers meet for health care services and where outcomes and costs are produced. It integrates patient process and resources planning and health outcomes through continuous assessment and Surgery Sche- duling Preoperative Prehabilita -tion and lifestyle counseling Pre- anesthesia consulta- tion Patient assess- ment and triage Surgical operation, including integrated pain management, fluid management and increased or efficiency Transit- ion plan- ning Postoperative Pain management Early mobilization Early discharge home Improved caretaker and patient transition home Intraoperative FEED BACK University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 11 improvement of care (Nelson et al., 2011; Samiei et al, 2011). The Clinical Microsystems have feed-forward and feedback information which makes it more valuable to its functions. The feed-forward information collects data during the time that the care is delivered and this data is being used with the patient in an understandable way throughout the patient‘s healthcare experience (Nelson et al., 2011). The feedback information is used for prospective management of patients in future care episodes, evaluation and management of individual care. It allows simultaneously, individual level data to be accumulated into subpopulation of similar patients to use as a database for evidence-based practice (Nelson et al., 2011). The processes in Clinical Microsystems includes; patient orientation to the healthcare system, provider making an initial health assessment to create a plan of care that incorporate the patient‘s health status, health needs, and individual health preferences (Eugene, 2013). This step builds up feed-forward information from prior healthcare experiences, patient history, physical examination and diagnostic testing. Besides, there is a constant assessment of surgical patients to help minimize error in patient care (Knox, Myers, Wilson & Hurley 2009; Nelson et al, 2011, Samiei et al 2011 ). The patient care plan is created to include all preventive, acute, chronic and palliative care based on the findings of the previous assessment. Also longitudinal measures are collected to assess the patient‘s clinical status, functional status, patient perceptions of care as well as direct and indirect cost tracking. These measures are also used to improve future care for that patient and other patients (Nelson et al., 2011. Tregunno, 2013 ). Based on the assumptions of the Clinical Microsystem, the Perioperative Surgical Home developed by the American Society of Anaesthesiology (2013) fits the definition of the healthcare Microsystems. The PSH is also a place where care is planned, University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 12 delivered and managed, and outcomes are achieved with various providers such as nurses, physicians, anaesthetists among others meeting patients and family members (Kash et al., 2013). The Clinical Microsystems theory also suggests integrated information management system to be essential in the development of the PSH hence the development of the Perioperative Surgical Home as Microsystem Models. The adapted PSH as healthcare Microsystems model by Kash et al, (2013) is appropriate for this study. The main constructs which formed the feed forward information of the model include Preoperative care which comprises; patient assessment and triage to identify patients that need preadmission clinic or program, preanaesthesia consultation, prehabilitation and lifestyle counseling. Intraoperative care where there is surgical operation, including integrated pain management, fluid management and increase or efficiency of care which included patient safety, prevention of infection and information and communication. Postoperative care which included pain management, early mobilization through physical therapy and integrated acute-care and rehabilitation care, early discharge home by improving coordination of care from preoperative to discharge home. It also involves nurses improving caretaker and patient transition home by increasing patient and caretaker education concerning post-discharge care. The feed back formation which is part of the postoperative care includes the patients‘ perception about the quality of care received. This deals with patients‘ clinical outcome as well as patients‘ cost tracking with possible improvements for future care. The researcher is applying the entire Perioperative Surgical Home (PSH) Model as Microsystems constructs including patients‘ perception of quality of care to guide the study. The model would guide the researcher to explore participants‘ perspectives on preoperative care on patient assessment in areas such as, vital signs, laboratory and University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 13 radiological examinations, pre-anaesthetic consultation and prehabilitation and lifestyle counseling to improve participants‘ recovery and prevention of postoperative complications. Also the researcher would use the model to explore participants‘ perspectives on integrated pain management, fluid management, infection prevention and how the participants‘ safety was ensured during the operation. The researcher also explores surgical participants‘ perspectives on postoperative pain management; early mobilization to increase participants‘ recovery, and how early discharge home planning can improved participants efficiency and effectiveness to care for themselves at home. Feedback information would be solicited from participants on how they perceive the quality of care given in terms of clinical outcome, cost of care including care areas that need improvement. The PSH model used in a study to assess pre-habilitation counseling of patients before surgery indicated that, pre-habilitation counseling reduces postoperative complications and also increases patients‘ ability to mobility and functional task performance (Nielsen, et al., 2010; Swank et al., 2011). This confirmed the survey conducted at Bolgatanga Regional Hospital where about 25% of the surgical patients were readmitted to the ward due to infection after surgery. It may be due to the fact that these patients did not receive pre-habilitation counseling before the surgery. Besides, the assessment of patients‘ readiness for surgery using the model in a quantitative study in areas such as risk based on age, co- morbidities and functional capacity before surgery, shows that it has greater impact on patients‘ improvement after surgery ( Mythen, 2011). This also shows that assessing patients before surgery is very important hence the model is used as guide to solicit patients‘ views on their assessment before surgery by using qualitative exploratory descriptive approach. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 14 A study conducted in seven hospitals in Western Europe using Perioperative Surgical Home Model indicated that increasing intraoperative fluid management improves patients‘ health condition after surgery (Knott, et al., 2012). It further indicated that restricting the intake of fluids before surgery has 95% chance of patients having a longer period to recover after operation. However, patients who are allowed to take in clear fluid on day of operation and whose Foley‘s catheters are discontinued early have 95% chance of being discharged home early (Aarts, et al., 2012). Contrary to this findings, a study conducted in USA to determine the effect of intraoperative fluid management on outcome after intraabdominal surgery involving 157 patients in which 75 patients were given liberal fluid and 77 patients were restricted in their fluid intake indicated that patients whose fluid intake was restricted had fewer postoperative morbidity and short hospital stay as compared to the patients who took the fluid before the surgery (Nisanevich, Felsenstein, & Almongy, 2005). However, the study failed to justify how fluid management enhances speedy recovery in surgical patients. The study did not also point out the types of surgical cases that require this form of regimen and therefore may not be applicable to the African cultural context. A meta-analysis of postoperative care of patients using the model as a guide revealed that patient‘s lifestyle has both positive and negative effects on surgical recovery. It is stated that patients who stop smoking for more than four weeks before surgery have lower risk of respiratory complications by 23%, eight weeks has 47% and more than eight weeks is comparable to non-smokers risk. Also patients who stop smoking for three to four weeks before surgery showed a higher reduction of wound healing complications (Wong, et al., 2012). However, Leichtle et al., ( 2012), in their study at Michigan on surgical quality, indicated that wound infection is due to contamination of the wound. This shows that educating patients on the need to change their lifestyle University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 15 especially smoking is very important, hence, the study would add more knowledge to previous studies. Discharge planning with the patient and family members is an effective measure for speedy recovery of patients at home. Studies that use PSH model as a guide have shown that, inadequate discharge teaching time, inability of family members to meet post discharge needs and poor continuity of care at home affect patients‘ recovery leading to readmission due to complications, bowel disturbance, nausea and extreme anxiety in patients (Wennström et al., 2010). Also, a study at Tertiary Care Hospital in Brisbane, showed that improper discharge planning results in patients‘ experiencing pain, heightened body awareness and lifestyle adjustment problems that need support from the nurses (Theobald, Karen, McMurray & Anne 2004). The researcher sent an Email to the model developers (bakash@srph.tamhsc.edu) informing them the researchers‘ decision to apply the model to the study but there has not been a response. 2.3 Surgical Patients’ Perspectives on Preoperative care A qualitative study conducted on patients‘ assessment indicated that preoperative history taking and physical examination is concerned with obtaining information directly from the patient (Bohmer, Wappler, & Zwissler, 2014). Also, about 25.7% of anaestheiosologists surveyed confirmed that they performed regular history and physical examination of surgical patients to obtain baseline information from patients prior to surgery. Further studies have indicated that the purpose of this history taking and physical examinations were to identify patients with high risk that could have an adverse effect on the forthcoming surgery and perioperative care. It focused on the indication for surgical procedure, allergies, undesirable side-effect to medication and possible referral for correction (AAGBI, 2010; Akhtar, MacFarlane, & Waseem, 2013). University of Ghana http://ugspace.ug.edu.gh mailto:bakash@srph.tamhsc.edu Patients’ Perspectives of Perioperative Nursing Care 16 Further studies have shown that when clinicians thoroughly assess surgical patients‘ condition and examine them physically it helps to identify and correct any abnormality before surgery (Aziato & Adejumo, 2013; Aditya & Uma, 2011). However, another study has indicated that sometimes, patients‘ history and physical examination during assessment may be hindered by patients‘ expression of pain which make them uncooperative (Aziato & Adejumo, 2014c). According to the Ghana Patients‘ Charter, patients have the right to certain information such as confidential information obtained about them and right to privacy during consultation, examination and treatment (Ghana Health Service, 2002). As a result, it is important that during such nursing procedure, patients‘ comfort and dignity must be maintained through the provision of privacy (NICE, 2008). Preoperatively, routine laboratory investigations are performed to assess whether patients have pre-existing health problems or any medical condition unknown to the patients. It would also help to predict post-operative complication and also establish a reference point for comparison (Garcia-Miguel, Lopez-Bastida, & Serrano-Aguilar, 2003). Moreover, investigation will also guide the decision of implementing protocol such as fasting and administration of regular medication (AAGBI, 2010). A qualitative study conducted at Korle-bu Teaching Hospital in Ghana on preoperative experience among 13 patients, showed that surgical patients went through some preoperative preparation such as laboratory and radiological investigations. It was reported that health professionals such as nurses, doctors, and the anaesthetists were involved in preoperative care. Hence, the anesthetists assessed patients and declared them fit for the surgery (Aziato & Adejumo, 2013). Besides, studies have indicated that nurses do monitor surgical patients‘ vital signs and any abnormal reading are reported for possible correction before surgery (Aziato & University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 17 Adejumo, 2013, NICE, 2008). This confirms a study that showed that preoperatively, nurses monitored surgical patients conditions and identify medical risk factors to promote health and optimize patients condition ( Verma, Alladi & Jackson, 2011). A qualitative study conducted at Pakistan University teaching Hospital among 28 surgical patients, found that nurses and other healthcare providers performed a complete and thorough assessment of surgical patients. They provided them with adequate education on surgery to reduce bounce back rate from operating room and to avoid any risk (Barkat, Lalani, & Malik, 2012, Cathy, 2013). Apart from that, provision of adequate education to patients and their relatives would help them to understand the nature and the consequences of any proposed procedure prior to giving informed consent ( AAGBI,2010; Crawford, 2012; Babitu & Cyna, 2010, ). Also patients who have learning or mental disability and cannot consent, including children should have their relatives present and be given written information so that consent, capacity and reasonable adjustment can be discussed (Cathy, 2013). Fraczyk and Godfrey, (2010), in a study of 275 participants, indicated that 80% of the patients undergoing the surgery seem to be highly motivated to change their lifestyle when they were informed about the increasing rate of complications associated with smoking, alcohol drinking and overweight before surgery. This shows that if nurses focus their assessment on medical investigations during preoperative assessment without assessing patients‘ lifestyle, it may also have an impact on the patient surgical outcome. A study conducted by world society of emergency surgery group initiate on Timing of Acute Care Surgery classification (TACS) including other study indicates that, patients triage should be used during assessment as a base of prioritizing patient‘s management. Patients are triaged according to the severity of the patients‘ disease process and clinical University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 18 outcome rather than age. It is a process that ensures that proper care in a timely manner is given to the sickest (Abularrage, Crawford & Cambria, 2010; Kluger, et al, 2013). For instance, (Papandria et al., 2012) indicate that a delay in surgical treatment for patients with acute appendicitis is associated with increase perforation rate in both children and adults. The finding suggests that patients‘ assessment and triage should be done early enough to identify patients that need emergency treatment in order to prevent complications. Hence the study would add more knowledge to this aspect of care. Studies have indicated that effective information delivery to surgical patients has an empowering effect that enables them to take control over their health care and to comply with treatment. It lets the patients understand whatever is expected of them (Leino-Kilpi & Suhonen, 2006; Mulsow, Feeley, & Tierney, 2012 ). However, patients‘ level of understanding is an important factor that should be assessed before educating them. This will help nurses to manage patient‘s stress and anxiety during education. It will also help the nurses to find out ways of reducing risk such as pressure ulcer, venous thromboembolism and malnutrition. Inadequate education and information increases patient anxiety, inability to cope and planning for discharge (Rhodes, Gail, & Alan, 2006). In a study at a University Hospital in Germany using a quantitative method, with a sample size of 461 surgical patients, 106 of them viewed staff friendliness, professionalism and good interpersonal communication during pre-anaesthetic consultation to be helpful in reducing their surgical concerns such as fear and anxiety (Schnoor, Ulrike, Engelmann, & Burkhardt, 2013). For instance, in Sweden where six patients were interviewed on their experiences of care, it was indicated that, patients expressed fear about the surgery due to anaesthesia, paralysis or severe pain after surgery and therefore express the desire for pre-anaesthetic counseling before surgery University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 19 (Anna-Clara, et al, 2010)). This confirms a qualitative study conducted by Mavridou., Dimitriou, Manataki, Arnaoutoglou, & Papadopoulos, (2013) among 12 patients that revealed that pre-anaesthetic consultaion reduce these concerns by 60% . However, a descriptive cross-sectional study conducted at the surgical unit of two hospitals in Ponta Grossa revealed that, nurses provide only physical care to patients with little information about the surgical procedure and nursing care delivery. This created more fear and anxiety among the patients (Bouwman & Carvalho, 2009). In a quantitative study at a South Australia tertiary Hospital, it was found that out of 416 participants, about half of the participants (45%) failed to understand the terms used during pre-anaesthetic consultation. The anaesthetist used terms such as ‗reflux‘, ‗aspiration‘, ‗allergy‘ among others that the patients never understood (Babitu & Cyna, 2010). As a result, it is expected that nurses use simple language during consultation for the patients to understand (Fields, Freiberg, Fickenscher, & Shelley, 2008). This can be generalized since the sample size is large to indicate that nurses used technical language that the patients did not understand. It therefore shows that patients go in for the surgery without adequate prior information. However, this finding may be different in a different cultural setting. A study conducted in Ghana using qualitative approach of 13 patients, indicated that surgical patients did not receive adequate information about their surgery and subsequent care especially preoperative care and their expectation in the theatre during pre-anaesthetic consultations (Aziato & Adejumo,2013). This has been confirmed by a study that stated that nurses did not inform surgical patients of what will happen. The patients stated that only the medical officer told them that they were going to be operated without any pre-anaesthetic consultation (Berg, Arestedt & Kjellgren 2013). However, further study conducted to understand the patients perspective of emotional support to improve overall patient satisfaction indicated that information to patient University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 20 about their treatment plan, diagnosis, procedures and prognosis help to reduce patients anxiety and worries (Adamson et al., 2012). Also, some patients admitted that nursing care has contributed positively to their ability to go through surgery and for some patients nursing care was absent making them more afraid. Some patients mentioned that they received information whilst they were lying on the operating table waiting for the anaesthesia to start (Igna, Monika, Kerstin, & Kaety, 2011). Hence, since each patient is unique and has unique characteristics it is important to establish effective communication with patient and significant others during pre-admission contact. This will provide an opportunity for the patients to obtain relevant and specific information and education to enable them go through the surgery (Rhodes et al., 2006). Apart from this, nursing staff may also rely on patient information that will enhance an individualized care and guidance in the preoperative period to promote physical and psychological preparation of the surgical patients for the surgery (Ascari, Neiss, & Sartori, 2012). Also studies indicated that providing appropriate support such as orientation of patients to ward environment and advice that is easily accessible for those patients that need it are key areas for improvement during preoperative period (Rachel, Davis, Charles, Ania, & Alison, 2011). Further studies indicated that allowing patients and their relatives to familiarize themselves with the environment through orientation and to meet staff who will provide perioperative care or a visit of nurses to ward may relieve patients‘ anxiety and answer patients‘ questions relating to anaesthesia and surgical process( Crawford, 2012). Maintenance of personal hygiene before surgery is very vital in preventing infection. The European Center for Disease Control ( ECDC) in a study estimated that 4.1 million patients per year develop infection within the European Union as a result of poor health University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 21 care and that 37,000 death results annually due to such infection (WHO, 2011). It is therefore important that surgical patients shower using soap and water the evening before surgery. Practicing personal hygiene provides the framework for achieving quality nursing care and also indicates nurses contributions to improving health care outcome (Currie, et al 2011). Also, the removal of hair around the incision site where necessary, should be done on the day of surgery. Patients that have been prepared for surgery should remove the pants, brassier, jewellery, earrings, dentures and this should be done in a manner that patient comfort and dignity is maintained (NICE, 2008). According to Snowdo, Haines, & Skinner, (2014), it is important that nurses educate surgical patients on the importance of deep breathing and coughing, regular gentle leg exercise and early mobilization. This would reduce patients‘ risk of postoperative complications such as chest infection and deep vein thrombosis. Physiologically, it is recommended that surgical patients should not take food the night before the surgery the following day. However, patients could be given clear fluid up to two hours and food up to six hours before surgery since fasting can be difficult to manage when the operation can be cancelled or delayed (Royal College of Nursing, 2010; Crawford, 2012). Further study revealed that shortening fluid fasting time leads to less anxiety preoperatively and also less nausea and vomiting postoperatively. Hence, liberal fasting regimen such as drinking clear fluid until two hours before elective surgery, increases patient comfort and satisfaction with anaesthesia (Ian et al, 2011; Bopp et al., 2011). These studies therefore suggest that the overnight routine fasting is gradually coming to end in most modern medical societies (Anguilar-Nascimento & Dock-Nascimento, 2010). Also prescribed preoperative medications should be given to patients and only essential medicine should be given with those that need to be taken orally given with little water. It is stated that preoperative medications help to relieve University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 22 patients‘ anxiety, pain, prevent nausea and vomiting, and reduces aspiration (NICE, 2008; Crawford, 2012). Prolonged waiting time for surgery often creates fear and panic in patients. Also, studies have indicated that there are many factors that contribute to surgical patients developing anxiety. These may include fear of anaesthetic effect, the procedure itself and the potential outcome of the surgery (Degen, Christen, Rovo & Gratwohl, 2010). Besides, since some patients may not have experienced surgery before it could create more fear and anxiety in them (Tessa, Alison & Wiseman, 2014). It is therefore argued that perhaps the relatives of the patients should be allowed to sit with the patients before the surgery to help reduce patients‘ anxiety ( Cathy, 2013; Pritchard, 2009b; Rhodes et al., 2006 ). It is indicated that during perioperative care, most patients wish that nurses recognize their religious background and incorporate it into the care process (Jan, et al, 2012). A qualitative study conducted in Akwa Ibom State of Nigeria, to assess the relevance of religion in health care among 560 participants in both public and government hospitals indicated that, patients have faith in God and combined prayers with medicine. These patients often pray alone or with their family members or call the spiritual leaders to pray for them. Besides, the medical officers also recognizing the importance of religion in care, advised patients to seek spiritual help through prayers (Abiodun & Umoh, 2011). Also in our Ghanaian culture, especially in the indigenous societies, the spiritual world is often consulted for different purposes in which one aim is the attainment of good health. As a result people often consult the diviners and the soothsayers for good health (Azongo & Adadow, 2015; Adadow, Rothenburg, Sackmann, & Thompson, 2014).This confirms a qualitative study conducted by Aziato & Adejumo, (2014a) at Korle-bu Teaching Hospital, Ghana, to assess the psychological factors associated with University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 23 pain in which family members recognized the need for spirituality, prayed for their relatives to go through surgery and recover successfully. These studies stress the importance of religion to the health care delivery systems in Ghana. Hence it is expected that health professionals, especially nurses, attach seriousness to patients‘ religion during care and respect them. 2.4 Surgical patients’ perspective on intraoperative care According to the Association of periOperative Registered Nurses AORN, ( 2012a), intraoperative period begins when the surgical patient is transferred to the operating table and ends with the transfer of the patient to the Postanaesthesia Care Unit or in an area where immediate postsurgical recovery care is given. However, Antipuesto,( 2011) argued that intraoperative phase extends from the time the patient is admitted to the operating room to the time that anaesthesia is administered, followed by surgical procedure and continues when the client is transported to the recovery room or the Postanaesthesia Care Unit. Based on these two schools of thoughts of intraoperative period, the researcher reviewed literature on patients‘ perspectives of intraoperative care to include patients that are sent to the operating room and not necessarily on the operating table. The review will also be extended to the recovery room or Postanaesthesia Care Unit. During the intraoperative phase, nurses need to assess the patient to identify signs of anxiety such as restlessness, raised vital signs, nausea and heightened senses or psychological problems. Besides, surgical patients‘ blood pressure, pulse, respiration, temperature, oxygen saturation are monitored and recorded accurately in the theatre before and during surgery (Pritchard, 2009b; Cathy, 2013). University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 24 In a retrospective study in the USA involving 26 surgical patients using qualitative method, it indicated that patients‘ perspective of care reflects in nurses demonstrating understanding, confidence, and commitment and respect during the surgery (Tinnfalt & Nilsson, 2011). They should also improve on patients participation, pain management, reduction of anxiety and proper positioning during surgery to avoid pressure sores or neurological injuries and pain (Kelvered, Joakim, Birgitta, kesdotter, Gustafsson, 2012). Also, Fraczy and Godfrey, (2010), used a cross sectional survey among 275 patients on preoperative assessment of patients in the theatre and the results showed that some patients expressed general nervousness about a hideous death in theatre and pain after surgery. The participants indicated that they experienced a real challenge in theatre with regards to nursing management especially integrated pain management and anxiety. A study at Sweden to assess patients‘ needs for a genuine caring encounter in the theatre using semi-structured interview involving a smaller sample size of nine patients, and some others studies, have stated that in terms of proximity, patients express the desire for Nurse Anaesthetists to be closed to them. The anaesthetist should handle them with trust, monitor and touch them during surgery to provide security and reduce the pain they are going through. This will make them have the feeling that not everything on them is monitored by devices (Ann-christin, Margaretha, Annika, & Sofia Almerud, 2013, Kelvered et al, 2011). Also some studies have shown that patients who are awake during surgery wish that the nurse anaesthetist communicate and interact with them during surgery. Besides they want to be received, listened to and respond to whatever need they convey to them during surgery (Ann-christin et al., 2013; Kaymackci, Yavuz, & Orgun, 2006). This study shows that it is important to be with the patients throughout the surgery. However this study used a smaller sample size and was University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 25 conducted in Sweden which a different cultural background hence, making it applicability difficult. Studies conducted to assess specific pain management and outcome strategies during surgery using a semi-structured interview indicated that it is important to use multimodal analgesics and preventive analgesia that are aimed at reducing the sensitization during surgery. Other strategies that can be adopted to reduce pain during surgery are the use of minimally invasive procedures, adopting approaches to reduce stress responses and also optimizing fluid therapy (Girish, Stephan., & Henrik, 2014). Ensuring that surgical patients‘ safety and prevention of infection is maintained is very important during surgery as expressed by surgical patients (Leape, & Berwick,, 2009; Vaismoradi, Salsali,, & Marck, 2011) . It is the nurses‘ responsibility to ensure the safety of the patients during surgery. Nurses need to be alert to dangers signs and conducting preventive interventions such as assisting patients to position well on operating table, walking and getting up from the operation table after operation and proper disposal of sharp objects (Butterwork, Jones, & Jordan, 2011; Kohlbrenner, Whitelaw, & Cannaday, 2011). Furthermore, it is stated that there is high risk of injury with the use of diathermy machine to both patients and staff which could lead to permanent disfigurement or death (Spruce & Braswell, 2012). Hence, before the operation starts nurses must ensure that the patients‘ body does not touch any earthed object such as the trim of the operating table or intravenous drip stand. Also the nurses should place a minimal material such as draw sheet or blanket between the patients‘ body and the return electrode mat. These activities would prevent any injury to patients (Rothrock & McEwan, 2011; AORN, 2009). Also studies have shown that to prevent infection during surgery, nurses need to ensure that they comply with a number of good practices such as ensuring clean theatre University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 26 environment, applying aseptic techniques during surgery such as applying skin disinfectant, doubling gloving and elimination of sharp objects to reduce injuries to patients (AORN 2012a; Kelvered et al, 2011; Pratt et al., 2007). . Studies have indicated that without proper coordination during intraoperation, critical information is easily lost and treatment delayed or misdirected. Also, it leads to a situation where contradictory information is given to patients to sort out alone (Toussaint, 2012). It stated that unclear information to patients about how a procedure is going to be performed or who is going to perform the activity creates worry and anxiety among patients (Birgitta et al, 2010). Hence providing adequate information to patients and using terms that patients can understand during operation is essential to ensure patient comfort which reduces worries during surgery (Degen et al, 2010). Also, patients who have had received information on what the surgery is about could develop a mental strategy and experience less unbearable pain during surgery (Nikolaj, Emil, Kazimierz, & Emilian, 2013). 2.5 Surgical patients’ perspective on postoperative care. The aim of postoperative monitoring and evaluation is to ensure that surgical patients return to normal activities as soon as possible. The main activities include fluid management, monitoring of vital signs, early mobilization including pain management (Janine & Teresa, 2010). Vital signs are often affected by surgery and anaesthesia and one of the functions of a nurse is surveillance which deals with monitoring of patients vital signs such as temperature, pulse, blood pressure, respiratory rate and oxygen saturation ( Ahrens, 2008; Rogers, Dean, Hwang, & Scolt, 2008 ). These vital signs are monitored every 30 minutes for two hours and then hourly for two hours for the first 24 hours to detect any change in the patients condition that can be reported for correction to prevent complications (Zeitz & McCutcheon, 2006). University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 27 In the United State of America, studies have indicated that poor nursing care causes many surgical patients to get complications such as phlebitis due to prolonged intravenous lines in situ (Royal College of Nursing, 2010). It is therefore recommended that intravenous line should be checked daily to ensure that it flows well and it should be removed when it has been in situ for more than 72 hours (RCN, 2010; Health Protection Scotland, 2012). Studies have shown that for surgical patients who have undergone non-gastrointestinal surgery, early oral hydration after recovery from anaesthesia was safe since it brings rapid return of patients to normal diet, early ambulation, early bowl movement and reduced thirst. It also decreases duration of intravenous fluid administration and shortened hospital stay (Al-Ghareeb, Ahmad, & Turki, 2013 Yin et al, 2014). Weiran, Zhang, & Mu-Lian Woo, (2013), in a study of postoperative management in Chinese hospitals using quantitative method, reported that 82.8% of patients claimed that their post-operation pain was relieved within three days of their operation due to the analgesic drugs nurses administered. Hence some patients were thankful to the nursing staff for their good work. However, 51.6% of the patients mentioned that they received no treatment for their pain, 14.9% claiming medical personnel failed to manage their pain and 20.2% were unsatisfied with their pain management. Also, Maier, Nestler, & Richter, (2010), investigating the quality of pain management using quantitative approach for 2255 postoperative patients in 25 German hospitals, reported that 29.5% of surgical patients had moderate to severe pain and 55% of them were not satisfied with their pain management due the failure of the nurses to respond to their to call when they were in pain. However, it has been indicated in a study that patients appreciate nurses showing confident and reassuring attitude toward them when they are in pain. This reduces their anxiety, promotes their physical activity and University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 28 reinforces their self-management strategies (Leonard, Tousignant-Laflamme, & Mercier, 2013) Postoperatively, some patient mentioned that they received information when they were experiencing the lingering effect of the anaesthestic agent and consequently were drowsy and this influenced their ability to understand the postoperative information given to them (Blandford, Gupta, Montgomery, & Stocker, 2011). Those who could remember said they received contradictory information from the nurses making them more confused. Patients rather appreciated information from other sources such as physiotherapist, occupational and family members as most valuable information (Berg, Arestedt & Kjellgren, 2013). The study seems to suggest that nurses do not wait for the patient to fully recover from anesthesia before educating them. This often makes them confused and they do not appreciate the education given. A qualitative study on wound dressing had shown that nurses remove their rings, watches, and also wear mask and gloves during wound dressing. Nurses also observe patients‘ wound more often when they are dressing the wound and report to patients the state of their wound. This makes them feel comfortable and happy ( AORN, 2010; Reiko et al., 2013). Early mobilization of surgical patients is very important for speedy recovery. Anna- Clara et al, (2010), in their qualitative study indicated that patients expressed difficulties and hardness to sit up, stand up and walk in and out of the ward after surgery due to postoperative pain. However, the patients described nursing staff as coaches as they turned them on bed, educated them on deep breathing and coughing exercise, regular gentle leg exercises to reduce complications such as chest infection, deep vein thrombosis and pulmonary embolism (Kibler et al., 2012; Masood, Zubia, & Abdullah, 2006). Other study also stated that patients praise nurses, saying that nurses assisted University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 29 them to bath, were quick to respond to their needs and help them to solve any problem that they encountered during their stay in the surgical ward (Beth Happ, et al, 2010). Nurse- patient interaction and communication according to studies are the core component of nursing care in the ward (Stephanie & Zoe, 2015; Sieger, Fritz, & Them, 2012) with the main intention of this interaction and communication being to influence the patient health status or state of well being (Fleisher et al, 2009). Hence surgical patients believe that it is important for nurses to have open and honest discussions of the surgical goals with them (Kourkouta & Papathanasiou, 2014). Qualitative studies conducted also showed that patients were highly satisfied with nurses who came after the operation to check if they were feeling fine and were pleased with nurses who kept their promises and remembered to follow up their request (Mcmurray, Johnson, Patterson, & Griffiths, 2007). Contrary to this study, a descriptive cross-sectional study in Malaysia and some other studies indicated that some patients were least satisfied with the nursing care provided. The patients claimed nurses spent little time with them and were always in hurry and busy giving them the impression that they lacked time to talk to, listen or be with them (Inga et al, 2011,Teng & Norazliah, 2012). A study conducted on 26 Jordanian patients‘ perspective of nursing care using qualitative design indicated that, nurses provided good nursing which included pain management interventions, health education regarding specific health concerns, timely answering of calls, safety and hygienic practices, discharge planning, follow-up and continuity of care (Al-Zaru et al, 2011). Some patients also said nurses continuously checked on them and asked if they needed anything. Nurses also establish and maintain a trusting, respectful relationship, protecting their privacy and integrity. They also involve them and their relatives in decisions regarding their plan of care, as well as University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 30 collaboration and coordination of care among the health care team ( Al-Zaru et al, 2011; Khan, Anwar, Babar, & Babar, 2006). Family support in nursing care during hospitalization is an indispensible fact in providing quality care. It has been reported in Ghana that, there are inadequate health personnel such as nurses to meet all the care needs of the patients. This therefore indicates that family members need to take part in the care of their patients (Ministry of Health, 2007). Also a study conducted to assess family preference for participation in care indicated that nurses are in a unique position to work with families as partners to provide quality care to hospitalized patients (Boltz, 2012). Also a qualitative study conducted in Malawi on family support and other studies stated patient are often accompanied by family members such as parents, spouses and children when they are hospitalized. These relatives are always at the bed side taking care of them by performing a variety of tasks on the ward. They bath their loved ones, collect medicine at the pharmacy or buy medicine in town for their relatives. They also make meals and feed their patients, serve medications and empty bedpan and urinal content (Osso, 2012; Hoffman et al., 2014; (Aziato & Adejumo, 2014b). It is therefore very important to encompass informed caregivers with the health care system and improve their training to perform medical care giving task (Levine, Halper, Peist, & Gould, 2010). 2.6 Discharge planning / home care Educating patients on self-care upon discharge especially wound care and personal hygiene are very important to speedy recovery (Berg, Arestedt, & Kjellgren, 2013). Bodily care includes looking after oneself, eating well and exercising regularly through proper teaching. Ineffective teaching following discharge may lead to lack of knowledge about how to care for self at home and awareness of signs and symptoms of University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 31 any impending infections or complications (Pieper et al 2007; Tanner, Padley, & Davey, 2012). A qualitative descriptive study conducted aimed at exploring ways of smoking cessation in post-discharged patients indicated that effective cessation counseling involves encouraging patients to modify their lifestyle through education (Chuan, Shoou-Yih Lee, & Yu-Qian Jeng, 2014). Surgical patients wound care is the most important part of self-care. The patients need to change the dressing, assess the healing process and intervene if necessary. However, a study has shown that surgical discharge patients lack the required knowledge for wound monitoring due to poor discharge teaching, lack of self-efficacy for wound care at home and inaccessible communication with nurses about wound concerns resulting in wound infection (Sanger et al., 2013). Due to the failure of patients to get education from the nurses, more than 85% of them said they received help at home from family or friends‘ especially with wound care, household activities, and mobility (Foust, Vuckovic & Henriquez, 2012). Also, in others studies, nurses failed to explain the purpose and side effect of the medications to some patients when they were discharged. Those patients who received information on medications said the information they received was not clear ( Ann Schoofs et al, 2009; Diane, Mnistiae, & Kathryn, 2011). However, some patients had adequate discharge instructions on the list of medication, how to take the medicine at home, to take the medicine on time, to do exercise and to take good diet to improve recovery (Foust, Vuckovic, & Henriquez, 2012). A study on nurses‘ performance on hospital discharge using a descriptive semi- structured method involving 65% females and 34% males with an average age of 48 in University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 32 Sao Paulo State of Brazil involving 43 patients showed that 83% of the participants received tailored discharge instruction on medications, wound dressing and prevention of infection. However 72% of these patients received discharge instruction from other health personnel instead of nurses(Alcala et al, 2007).The study focused more on females than males even though the sample size was large. There should have been a balance in the sample size of the females and males to give a true picture of the findings. Patients who were discharged home stated that the nurses only told them to go home with no assessment of what awaited them. No nurse even accompanied them out of the building or making sure their departure needs were met. In addition, there was no time a nurse assessed their learning needs, gave them advice on resources or enquired about their home situation with regards to their home care that could help limit their burden (Mcmurray et al., 2007; Mottram, 2011) These studies have shown that the nursing staff never planned for the patient discharged and this may compound patients post operative complications such as infection among others. Studies have indicated that patients do have shorter number of days stay in the hospital do not get adequate communication from the nurses. Also, there is untimely, infrequent follow up; hence surgical site infection now occurs post-discharge. This puts much burden on patient at home who are not well prepared to manage it resulting in readmission (Kazaure, Roman, & , Sosa, 2012; Sanger et al, 2013; Saunders et al 2014). As a result, surgical patients believed that mobile health monitoring is highly acceptable. Nurses need to provide more frequent, thorough and convenient follow-up to assess their state of health at home upon discharge and this could reduce post- discharge anxiety and to help minimize the risk of adverse drug event after hospital (Mueller, Cunningham, Kripalani, & Schnipper, 2012; Sanger et al, 2013). University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 33 Studies have indicated that, in perioperative care, patients‘ perspectives is important since many outcomes such as health related quality of life which includes the desire to regain health and satisfaction of care can only be reported by the patients (Grøndah, 2012; Pusic & Andrea, 2014). This confirms a quantitative study conducted in Kenyatta National Hospital involving 167 participants that indicate that, 52.4% of the participants are satisfied with their wound dressing (Shawa, 2012). Cost of hospital care according to studies, extend well beyond cost of medications, surgery and related treatment. Patients also incur indirect cost such as transportation and feeding (Kim, 2007). A prospective randomized pilot study conducted involving 1,061 patients undergoing ambulatory surgery showed that the elimination of routine does not affect perioperative adverse events but rather increases cost (Chung, Yuan, Yin, Vairavanathan, & Wong, 2009). Hence, to reduce this cost, studies indicate that, surgical assessment should be done on the surgery day, and urgent treatment should be given since a delay with these activities would increase patients‘ hospitalization and cost ( Eko et al., 2013; Sehmbi, Wong, & Wong, 2015 ). Qualitative studies that engaged patients during health care delivery indicate that, patients want improvement on certain surgical outcomes. These included pain management, post surgical exercise and wish that they should be incorporated into education during preoperative preparation. Besides basic training of nurses on communication skills, regular in-service training and workshops are recommended as ways that could improve on the quality of nursing care (Lane-Carlson & Kumar, 2012; Mensah, 2013). In addition, surgical patients prefer wound dressing materials that promote quick wound healing, reduce pain and ensure shortest hospitalization time (Corbett & Ennis, 2014). University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 34 In summary, chapter two examined extensively literature on surgical patients‘ perspectives on preoperative, intraoperative and postoperative nursing care both at the hospital setting and postoperative home care. The literature covered the three research objectives which were developed taking into consideration the constructs of the PSH model used as an organizing framework of the study. The extensive review showed that there is inadequate exploration of perioperative experiences of patients in Ghana especially from the Northern sector of the country. This study will therefore fill the gap identified. The next chapter discusses the methodology used for the study. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 35 CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter describes the research design, the study setting, the sampling method and the nature of the sample, data collection procedure and analysis, rigour, and ethical considerations. 3.2 Research design The researcher employed exploratory and descriptive qualitative approach for the study. Qualitative research design inquiry is of ten employed to describe a phenomenon by looking at the feelings, behavior, thoughts, insight and actions rather than number which is characteristic of quantitative methods. The researcher is able to describe the process relative to its context rather than outcomes (Mayan, 2009). Qualitative method is appropriate for understanding individuals‘ and groups‘ subjective experiences of health and disease and interaction among participants and health care setting (Fossey, Harvey, McDermott, & Davidson, 2002). According to Polit & Hungler, (1999), the researcher obtains the information directly from the participants who are actually having the problems. Also, qualitative research relies on the belief that humans are complex and have the ability to shape their own experiences from the perspectives of the participants and create meaning from it (Polit & Hungler, 1999). This approach was used to obtain information from the participants by capturing their perspective with regards to the perioperative nursing care they received. This approach was best for the study because it enabled the researcher to explore discharged general surgical patients‘ perspectives on perioperative nursing care they received while on the surgical ward. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 36 3.3 Research setting The study was conducted at the Regional Hospital, Bolgatanga which is located at the middle of the Upper East Region. The Upper East Regional capital is Bolgatanga. The region has a total land area of 729 square Kilometers and is bordered to the North by Bongo District, South and East by Taliensi-Nabdam District and Kassena-Nankana District to the West. The dominant tribe within the municipality is Frafra, however, there are almost every tribe in Ghana in Bolgatanga Municipality. Some of these tribes include Akan, Ewe, Dagomba and Ga. The dominant religions in the region are Christians and Muslims followed by the Traditionalists The participants were identified and contacted at the Regional Hospital, Bolgatanga, which is located in the capital of the Upper East Region. The hospital is situated in the North-Eastern part of Bolgatanga in the suburb of Zaare. It was established on 13 th January, 1953 to take care of an average of 300 in-patients and out-patients daily. It is about 0.50 kilometers from the Ghana Broadcasting Co-operation. The hospital is the largest hospital in the region and serves as a referral center to the other hospitals in the region. The hospital is bounded by Yikene to the West, Nyariga to the South, Bukere to the East and Tindonmolgo to the North. The hospital currently, has a total nursing population of about 160 nurses. Bolgatanga central hospital is a government hospital and it has twelve (12) Departments, which include: Surgical, Medical, Theatre, Maternity, Emergency, Psychiatric, Out Patient Department, Chest, Pediatric, Maternal and Child Health/Family Planning, physiotherapy and Ear, Nose and Throat Units. The surgical department in the Regional Hospital caters for about fifty (50) patients a day. The unit is attached to the theatre and located at the Northern part of the hospital. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 37 3.4 Target Population The target population for the study was postoperative patients who were discharged within the last one month and stayed within Bolgatanga Municipality. The study involved both males and females general surgical patients. 3.4.1 Inclusion criteria Eligible participants included: 1. Patients who had general surgery at the surgical unit of the Regional Hospital, Bolgatang and were admitted for at least 3 days. 2. Participants who have been discharged at least five days to one month and live within Bolgatanga. 3. Participants aged between 18 and above 4. Participants who can communicate in English or Grune language 5. Participants who gave informed consent and were willing to participate in the interview. 3.4.2 Exclusion Criteria The exclusive criteria included: 1. Participants who were still in the ward and were receiving treatment. 2. Participants aged below 18 3. Participants who could not speak English or Grune language 4. Participants who were terminally/ seriously ill University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 38 3.5 Sample Size and Sampling Technique The sampling size for the study depended on the data saturation when there was no new information. The data was saturated on the 15 th participant. The participants were recruited using purposive sampling technique. Purposive sampling refers to situation where the researcher selects the participants based on the experiences the participants have. Besides the researcher selects the participants that can provide the needed information about the phenomenon understudy (Patton, 2002). The researcher used this purposive sampling due to the fact that the researcher‘s target population was surgical patients who have had surgical experience and had received perioperative nursing care at the surgical ward. These participants were identified at the surgical wards when they were discharged. The participants were then contacted at their homes following the identification at the hospital. 3.6 Data Collection tool and Procedure A semi-structured interview guide was used to conduct face-face interview to explore surgical patients‘ perspectives on perioperative nursing care. According to Khan, (2012), interview method is used to collect data from participants through face-face interaction and able to record the participants‘ responses which can later be cross checked for clarity. The semi-structured interview was appropriate for the study due to the fact that it allowed the participants to express themselves freely and also allowed the researcher to use probes during the interview to solicit for more divergent views that may arise (Kusi, 2012). The formulation of the semi-structured interview was guided by the Perioperative Surgical Home (PSH) Model as a Microsytems Healthcare and the research objectives. Section A of the interview guide consist the demographic information about the University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 39 participants while section B consisted the interview guide (Appendix A) that made up of open-ended questions and probes. The researcher booked an appointment with the participants after making an initial contact with the participants at the dressing unit or the outpatient department when they came for medical review. Later the researcher contacted the participants on phone or home visit to confirm the appointment date before he met the participants. The interview was conducted using English or Grune language since the researcher understands and speaks the two languages fluently. The researcher maintained participants‘ anonymity by assigning them with pseudonyms. The researcher did an in- depth interview with each participant face-face and followed by probing questions to allow the participants express their feelings, thoughts and behavior about the nursing care they received on the surgical ward. The researcher ensured that the participants felt comfortable. In a situation where a participant showed signs of tiredness or emotional distress the interview was stopped and continued later according to participant‘s desire. The interview allowed the researcher to clarify participants‘ responses to questions and probe on particular statements in more detail. The researcher collected demographic data information which included age, type of surgery, and days on admission, sex, education, religion and occupation before audio taping the interviews. The interview was recorded and then later transcribed verbatim. The researcher also wrote field notes on all observations at the time of the interview. The interview lasted for 45 - 90 minutes. University of Ghana http://ugspace.ug.edu.gh Patients’ Perspectives of Perioperative Nursing Care 40 3.7 Piloting the instruments The interview guide was piloted at Builsa District Hospital, Sandema in the Upper East Region of Ghana. The Builsa District Hospital performs general operation just like the Regional Hospital at Bolgatanga Municipality. The Builsa District and Bolgatanga Municipality have similar geographical distribution and socio-economic conditions and similar cultural background. The participants that were chosen from the hospital were discharged patients. The interview guide was conducted on three participants to ensure that the questions were clear and lacked ambiguity. However the information gathered during the pilot interview was not part of the study data. 3.8 Data management Data management refers to the storage