Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

OBJECTIVES

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses' recognition and response to patients at-risk of deterioration and improve patient outcomes.

METHODS

A prospective non-randomised pre-post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

RESULTS

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

CONCLUSION

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses' recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

Strategies to Decrease Maternal Request for Early Elective Induction

Severe maternal discomfort in the third trimester is not a diagnostic risk justification for elective induction before 39 weeks gestation. Alternative methods of intervention and supportive resources to help sustain a woman at the end of pregnancy have been largely absent in discussions pertaining to best practices. Nurses and midwives are in an ideal position to play a leadership role in working with physician colleagues as well as other members of the health care team to broaden the conversation to include alternative and complementary interventions, and to provide guidance and assistance to help women cope with and manage the discomforts of late pregnancy.

A typical day in cardiac theatres... or was it? Expect the unexpected

The operating theatre department is a high risk area and the expectations from the surgical teams are very high in terms of delivering safe and good quality patient care. As healthcare practitioners working in this complex environment we are the guardians of our patients and are their eyes and ears. Scrub practitioners need to be focused, alert and vigilant during all surgical procedures and avoid complacency. As this incident account shows, never take anything for granted.

The impact of the enhanced recovery after surgery (ERAS) programme on community nursing

Early discharge from hospital as a result of enhanced recovery after surgery (ERAS) programmes can be both positive and frightening experiences for surgical patients. In a recently published article by the authors in the British Journal of Nursing, participants described mixed reactions to the ERAS programme, highlighting the period of home convalescence as being particularly challenging. In this article the concept of ERAS is explained, followed by an overview of the research study which led to the authors highlighting the issue of home convalescence. The interventions that have already been established locally as a result of this research are explored, as is the potential impact that both these short hospital stays and further necessary interventions might have on community nursing. The article examines whether health professionals are sufficiently easing the pressures of self-recoveryto fill the apparent'void' that the study participants described as existing between hospital care and community follow-up.

Reducing anxiety in elective surgical patients

Effective communication is the cornerstone of good healthcare. Poor communication can have serious consequences for patients and damage the nurse-patient relationship. This article explores how nurses can use communication tools with surgical patients to help relieve anxiety.

Patient-reported outcome measures: implications for nursing

The Patient Reported Outcome Measures (PROMs) Programme, which was implemented by the NHS in 2009, gives prominence to patients' views about their health. Self-reported measures of health are now being sought from all patients before and after four elective procedures--hip and knee replacement surgery, hernia repair and varicose veins surgery. This information will be used to assess changes in health and provides routine information on NHS patients' health outcomes for the first time. The information will be used to identify and reward good performance by providers; help patients to make choices and clinicians to monitor and improve quality; and inform commissioners' decisions about which services to prioritise. The aim of this article is to inform nurses about PROMs and encourage them to engage with it.

Documented causes of unneCesareans

A recently coined term, unneCesareans, concisely describes the mode of delivery for 25% of low-risk first births in most Western countries. Evaluation of Cesarean Delivery, published by the American College of Obstetricians and Gynecologists (ACOG) in 2000, showed a lack of evidence of improved medical outcomes with the widespread use of cesareans for low-risk, full-term primiparas. Therefore, the term "unnecessary" is appropriate in the sense of medical outcomes. Although the complete causality of this phenomenon has probably not been elucidated, eighteen causes for this common practice have been documented in published research.

CONCLUSIONS

UnneCesareans have multiple causes and therefore, a reverse in current trends is unlikely.

Airway management of an elective surgical patient

Airway management is a skill that all healthcare professionals need to learn. This skill is used in two specific areas. First, in emergency situations such as cardiac arrest or respiratory arrest. Second, and the subject of this article, the postanaesthetic patient. This article explores not only the anatomy of the respiratory system but the different techniques and methods employed to manage a patient's airway. Airway management can be divided into three distinct phases. The first phase deals with the management of the airway while the patient undergoes an operation; this is managed by the anaesthetist. While the second phase deals with the patient's airway in the immediate recovery period, it usually occurs in a recover room and is managed by a recovery nurse. The third phase is when the patient returns to the ward, and for the first 24-48 hours after a general anaesthetic. It is only by recognizing the signs and symptoms of respiratory distress and initiating effective treatment that serious consequences can be avoided.

Improving outcomes following elective percutaneous coronary intervention: the key role of exercise and the advanced practice nurse

Percutaneous coronary intervention (PCI) is a safe, effective, non-surgical treatment for coronary artery disease (CAD). The demand for PCI has increased exponentially since the 1980s and it has become the treatment of choice for many individuals with CAD. Since PCI is not a cure, secondary prevention strategies are critical to prevent disease progression. Unfortunately, current strategies ignore the specific needs of the elective PCI population. In this article, the authors highlight the unique characteristics of these patients, which may contribute to their lack of engagement in healthy lifestyles. Elective PCI patients are vulnerable due to limited knowledge and follow-up, and lack of enrolment in secondary prevention programs. Exercise is a central component of any cardiac prevention strategy. Individualized exercise programs that incorporate physical activity and counselling can potentially improve the clinical outcomes of these patients. Advanced practice cardiovascular nurses play a key role in developing, implementing, and evaluating exercise programs in this population.

A successful nurse-led model in the elective orthopaedic admissions process

AIM

To document a nurse-led admissions process for same day orthopaedic surgery, on relatively fit patients under 70 years of age.

METHODS

Patients undergoing minor surgery, under 70 years of age, and with a body mass index (BMI) of <35, were selected from the total of patients being admitted for elective orthopaedic surgery under the Accident Compensation Commission (ACC) contract. The nurse-led project relied primarily on an admission questionnaire, on physician consultation notes, and on previous clinical records.

RESULTS

During the 6-month study, 331 patients with a median age of 38 years were categorised into 3 streams. 252 patients (76%) underwent a nursing-admission process without the need for further consultation with a junior medical officer or an anaesthetist. The remaining patients not included in the study were admitted and clerked by a house officer. No safety issues arose and the surgeons and anaesthetists were satisfied with the process. The junior medical officers described improved job satisfaction by being able to attend theatre, other educational opportunities, and working more closely with the consultant.

SUMMARY

The process was safe; it improved the patient journey and job satisfaction among house surgeons; and it extended the skill base and job satisfaction of the nurses. It also allowed the hospital to cope better with the reduced number of house surgeons available. The process has now been incorporated into elective orthopaedic admissions at Burwood Hospital.

Nursing students' perceptions of clients undergoing elective cosmetic surgery

Aesthetic obsession is commonplace in current society. Supermarket a isles dedicated to beauty products, makeup, and anti-aging creams seem to expand daily. Television and publications flood the public with messages of what constitutes beauty and how to achieve the ideal. Surgical alteration of the body is swiftly becoming a form of self-care technique along with other heath-promoting behavior. Since 2003, the general acceptance of plastic surgery among all Americans surpassed 50% (American Society for Aesthetic Plastic Surgery, 2003). Elective cosmetic surgical procedures have increased by an astounding 444% since 1997 (American Society of Plastic Surgeons, 2006). This quest for body satisfaction based on modern cultural norms increases the public's need for accurate information and understanding from those in the healthcare profession. Despite a transformation in the general population's conception of cosmetic surgery and its clients, stigma still lies in many individuals, including those in the healthcare profession. As this progressively growing patient population emerges, many in healthcare question their attitudes toward plastic surgery and the patients receiving aesthetic operations. With clients undergoing plastic surgery becoming increasingly visible within the healthcare system, some unique aspects of patient care must be addressed.

At your convenience: preoperative assessment by telephone

This article describes how practitioners in one trust have worked in partnership with colleagues at NHS Direct to develop a telephone preoperative assessment service for elective day case surgery patients. The service has improved theatre utilisation by reducing the numbers of 'did not attends' (DNAs) and ensures the safe preparation of appropriately selected patients for day case surgery. It has reduced the number of trips to hospital patients need to make and, more recently, the length of time spent there.

A new vision for day surgery

The premise that underlines this article (based on a presentation delivered at AfPP's Annual Congress in October 2006) is that all elective surgery performed in this country should be day surgery. This should eventually include patients undergoing hip replacements, radical prostatectomies, aortic aneurysm repair and hepatectomies, to name a few. All of these procedures we should perform, safely and well, under the British definition of day surgery as 'going home at the end of the day'.

Governing time in operating rooms

AIM

This paper examines how time is controlled and governed in operating rooms through interpersonal communication between nurses and doctors.

BACKGROUND

Time is a valuable commodity in organizations with improvements often directed towards maximizing efficiencies. As a consequence, time can be a source of tension and interpersonal conflict as individuals compete for control of its use.

METHODS

The data in this paper emanate from an ethnographic study that explored a range of communication practices in operating room nursing. Participants comprised 11 operating room nurses. Data were collected over two years in three different institutional settings and involved participant observation, interviews and the keeping of a personal diary. A deconstructive analysis of the data was undertaken.

RESULTS

Results are discussed in terms of the practices, in which clinicians are engaged in, to govern and control their use of time. The four practices presented in this paper include; questioning judgment and timing, controlling speed, estimating surgeons' use of time and coping with different perceptions of time.

CONCLUSIONS

Time and speed were hotly contested by nurses. They used their personal knowledge of individual surgeon's habits of time to govern and control practice. Nurses thought about surgeons in terms of time and developed commonly accepted understandings about the length of surgical procedures. They used this knowledge to manage the scheduling of operations in the departments and to control the workflow in individual operating rooms. Knowledge of individual surgeons was a source of power for operating room nurses.

RELEVANCE TO CLINICAL PRACTICE

Nurses have more power in the operating room than might be imagined but they exercise this power in subtle ways. If operating rooms are to work effectively, the operating room team must understand each others' work better.

Pre-operative fasting for elective surgical patients

AIM

To explore the knowledge, past experience, perceptions and opinions of nurses working in surgical units at a local hospital with regard to pre-operative fasting times.

METHOD

A qualitative research design, using a grounded theory approach, was adopted. Semi-structured interviews were undertaken with a sample of 15 staff nurses employed within five surgical units in one hospital.

FINDINGS

After thematic analysis, three core categories emerged from the data: knowledge, practice and systems. Nurses stated that there were significant barriers to an individual approach to pre-operative fasting within the organisation. These included lack of knowledge and skills, limited autonomy with regard to changing practice, and an operating room system that contributed to patients being fasted for a longer period than necessary.

CONCLUSION

Further research is required on how long patients should be fasted before theatre. In addition, all healthcare professionals require education pertaining to best practice, and organisations should have in place clear policies and guidelines to prevent variances in fasting procedures.

23-hour care centre: changing the culture of care

AIM

A 23-hour Care Centre was created at a principal referral hospital in Sydney in 2003. Its primary aim was to provide efficient and high quality care to patients requiring a brief stay in hospital for surgical or medical procedures, within one coordinated unit.

DESIGN

The features underlying the 23-hour Care Centre as an innovative model of care were the clinical guideline driven approach and nurse-initiated discharge. All patients, emergency and elective as well as surgical and medical, who fitted the following criteria were admitted as '23-hour patients' to the Centre. The criteria were: absolute expectation of discharge within 24 hours; pre-admission screening by a nurse screener (if elective admission); agreed clinical guideline in place; and, agreement to protocol-based, nurse-initiated discharge.

RESULTS

Following the first three months of the 23-hour Care Centre, 1601 patients utilised the 23-hour Care Centre as follows: 593 day only patients, 410 DOSA (day of surgery admission) patients and 598 23-hour patients. Excluding inappropriate admissions, overall discharge compliance was 83%.

CONCLUSION

From the results generated throughout the trial it has become evident that the new clinical area offers a workable system of health care delivery for patients who require a brief stay in hospital, as it promotes an efficient use of hospital beds and services without compromising patient outcomes. However, further research is required to compare the efficiency and outcomes of care directly with that provided by the traditional inpatient hospital system.

Children's accounts of their preoperative information needs

AIMS AND OBJECTIVES

To explore the information needs of children aged 7-11 years relating to planned admission for surgery. To identify the knowledge of a group of children prior to admission and their own identified information needs.

BACKGROUND

There is widespread agreement that children should be given information prior to surgery but continuing debate about the most appropriate form and content of preadmission preparation. There is little research evidence about children's concerns, fears and misconceptions about hospitals and surgery. Previous investigations have examined the views of parents/carers and health care professionals rather than the direct reports of children themselves. This study was designed to explore whether children could identify their own information needs prior to admission for elective surgery.

DESIGN

Qualitative.

METHOD

Nine children aged 7-11 years were interviewed using the write and draw technique to ascertain their preadmission information needs. Data collection occurred several weeks prior to the child's first admission to hospital for planned surgery.

RESULTS

Children reported that they had not received direct information from the hospital or from health professionals. They obtained information from a variety of sources including leaflets for parents, television and the experiences of relatives and friends. Some children knew very little about hospitals and their own planned operation. Children identified 61 questions about their forthcoming admissions, including questions about: getting information; procedures; anaesthesia; timing; hospital environment; family support; feelings/pain; their condition; and concerns.

CONCLUSIONS

Children aged 7-11 years can identify their own information needs and so contribute to the development of preadmission education.

RELEVANCE TO CLINICAL PRACTICE

Patients attending a children's hospital can have little information provided prior to admission. Information about hospital should be presented directly to children in the most accessible and flexible form.

Obstetric "conveniences": elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions

Common obstetric interventions are often for "convenience" rather than for clinical indications. Before proceeding, it should be clear who is the beneficiary of the convenience. The primary healthcare provider must make sure that women and their partners have a full understanding of what is known about the associated risks, benefits, and alternative approaches of the proposed intervention. Thorough and accurate information allows women to choose what is best for them and their infant on the basis of the individual clinical situation. Ideally, this discussion takes place during the prenatal period when there is ample opportunity to ask questions, reflect on the potential implications, and confer with partners and family members. A review of common obstetric interventions is provided. While these interventions often are medically indicated for the well-being of mothers and infants, the evidence supporting their benefits when used electively is controversial.

The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery

This study was undertaken to determine the effect of music on elders undergoing elective hip and knee surgery who experience acute confusion and delirium postoperatively. Postoperative confusion and delirium in elders often cause complications that negatively effect recovery. Music listening was introduced as an intervention to an experimental group. Nurses documented episodes of acute confusion and delirium experienced by elders postsurgically. Scores from a readiness-to-ambulate profile to determine if patients were cognitively ready for postoperative therapy were evaluated. There was a significant decrease in the number of episodes of postoperative confusion among those in the experimental group compared with those in the non-listening control group. In addition, the experimental group had significantly higher scores on the readiness-to-ambulate profile than the control group. These findings indicate that music listening is an effective nursing intervention that can be used to decrease acute postoperative confusion and delirium in elders undergoing elective hip and knee surgery.

Methodological challenges in the study of psychological recovery from modern surgery

Most cases of elective surgery in the UK are now undertaken in day-case facilities, and the trend is set to increase. Surgical and anaesthetic health care is changing rapidly. Traditional pre- and post-operative nursing intervention, once commonly taught and practised, must now be re-evaluated as a result of such transformations. However, undertaking research in order to investigate the fresh challenges facing nursing in the modern surgical environment may present many difficulties. Methodological issues, such as the application of research approaches, time for adequate data collection, and the utilisation of patients as participants undergoing modern surgery, will present numerous barriers. In this article, Mark Mitchell identifies and discusses three problematic methodological issues that currently challenge the effective study of psychological recovery from modern surgery in the UK.

Anticoagulation in Elective Surgery

Several categories of patients may be receiving anticoagulation therapy and require surgery. Many patients take cardioprotective aspirin or warfarin for atrial fibrillation, the presence of a mechanical heart valve, prior thromboembolism, a documented left ventricular thrombus, or a history of venous thromboembolism with or without a pulmonary embolism. Inpatients may be receiving injectable forms of anticoagulation to reduce risk of deep venous thrombosis or for other conditions, such as atrial fibrillation. Patients receiving any type of anticoagulation present a problem when they require surgery because the interruption of anticoagulant therapy increases their risk of thromboembolism and stroke (Schanbacher & Bennett, 2000). Rational decisions regarding the appropriateness of perioperative anticoagulation depend on individual patient factors and can only be made when the risk of perioperative thromboembolism is balanced against the risk of perioperative bleeding.

Supplementary prescribing for the elective surgical patient

Supplementary prescribing is an exciting new development in nursing. After qualifying, the supplementary nurse prescriber may prescribe a range of medications as part of a clinical management plan. The rationale for the choice of medication for inclusion in a clinical management plan for use in elective surgery is described.

The reflective patient: intrapersonal care

AIM

To consider the relevance and potential role of patient reflection in their overall healthcare experience.

METHOD

In-depth, unstructured, qualitative interviews were conducted with 19 patients due to have elective orthopaedic surgery. A longitudinal study design was used, covering the period from a few weeks before to approximately three months after surgery. Forty five interviews were conducted in total.

RESULTS

The degree to which participants expressed evidence of reflection and the nature of their reflections varied. Much reflection focused on remaining unknowns and lingering queries. Participants seemed to be trying to work towards an acceptable interpretation of their experiences. This interpretation then fed into their experience of, and responses to, their care.

CONCLUSION

Intrapersonal care is suggested as a way of conceptualizing the patient's process of reflection. This complements interpersonal care given by nurses. Intrapersonal care must be well supported to realise its potential therapeutic effect.

The role of nurses in preoperative assessment

When patients elect to have surgery, it is vital that they are assessed systematically in the preoperative period. This article discusses the principles of preoperative assessment, the government perspective on assessment and the resources available to underpin patient empowerment, as well as the importance of early discharge planning.

Understanding incarcerated populations

Approximately 1.3 to 1.8 million people are incarcerated in the United States at any given time. When providing emergency or elective surgical intervention, perioperative nurses may encounter incarcerated individuals, including many who require treatment for traumatic injury. Nurses, therefore, need to educate themselves about this patient population and understand the specific clinical and educational needs of this group. This article explores key concepts involved in caring for incarcerated individuals, including their characteristics and assumptions others make about them. The article concludes with a discussion of educational and policy implications.

Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery

OBJECTIVES

(1) To determine whether pre-operative assessment carried out by an appropriately trained nurse (ATN) is equivalent in quality to that carried out by a pre-registration house officer (PRHO). (2) To assess whether pre-assessments carried out by ATNs and PRHOs are equivalent in terms of cost. (3) To determine whether assessments carried out by ATNs are acceptable to patients. (4) To investigate the quality of communication between senior medical staff and ATNs.

DESIGN

The study design was principally a prospective randomised equivalence trial but was accompanied by additional qualitative assessment of patient and staff perceptions, and an economic evaluation.

SETTING

The study was carried out at four NHS hospitals, three of which were teaching hospitals, in three NHS Trusts in Southampton, Sheffield and Doncaster.

SUBJECTS

All patients attending at one site for assessment prior to general anaesthetic for elective general, vascular, urological or breast surgery were potentially included in the study. Of 1907 patients who were randomised, 1874 completed the study with a full evaluation.

INTERVENTIONS

The intervention consisted of a pre-operative assessment carried out by either an ATN or a PRHO. Of the patients who completed the study with a full evaluation, 926 patients were randomised to the PRHO arm of the trial and 948 to the ATN arm. Three ATNs took part in the study, one from each centre, together with a total of 87 PRHOs.

MAIN OUTCOME MEASURES

Immediately following the initial assessment of a patient by a PRHO or an ATN, one of a number of clinical research fellows, all specialist registrars in anaesthetics, repeated the assessment and recorded it on a study form, together with a list of investigations required. The clinical research fellow then evaluated the competency of the initial assessor by comparing the quality of their assessment with their own. Any deficiencies in ordering of investigations and referral to other specialities were met in order to maximise patient care. Three areas of ATN and PRHO performance were judged separately, history taking, examination and ordering of tests, and each was graded into one of four categories, the most important of which was under-assessment, which would possibly have affected peri-operative management. In the case of ordering of tests, it was possible to have both over- and under-assessed a patient on different tests.

RESULTS

The pre-operative assessments carried out by the ATNs were essentially equivalent to those performed by the PRHOs in terms of under-assessment that might possibly have affected peri-operative management, although there was variation between the ATNs in terms of the quality of history taking. This may be related to the low number of patients seen at one study site. PRHOs ordered significantly more unnecessary tests than the ATNs. The substitution of ATNs for PRHOs was calculated to be cost neutral. The results of the qualitative assessment showed that the use of ATNs for pre-operative assessment was acceptable to patients; however, there was no evidence that communication between senior medical staff and those carrying out pre-operative assessments was improved by their introduction.

CONCLUSIONS

This study demonstrated no reason to inhibit the development of fully nurse-led pre-operative assessment, provided that the nurses are appropriately trained and maintain sufficient workload to retain skills. CONCLUSIONS--IMPLICATIONS FOR THE HEALTH SERVICE: ATNs provide an acceptable and efficient alternative to PRHOs for the purposes of routine pre-operative assessment. Consideration will have to be given, however, to the positions of these nurses within the surgical team, and also to their career structure. CONCLUSIONS--RECOMMENDATIONS FOR FUTURE RESEARCH: Further research is needed in the following areas: (1) the extent and type of training needed for nurses undertaking the pre-operative assessment role; (2) the use, costs and benefits of routine pre-operative testing.

Perioperative considerations for the child with an upper respiratory tract infection

The decision to cancel or proceed with elective surgery for the child with an upper respiratory tract infection (URI) has been a source of debate among pediatric anesthesiologists, nurse anesthetists, and perianesthesia nurses for many years. Although some studies suggest that anesthesia for the child with a URI increases the risk of perioperative respiratory complications, others suggest that these complications are easily managed and are not associated with any adverse sequelae. This article describes the pathogenesis of viral respiratory tract infections, reviews the literature regarding anesthesia and URIs, and discusses the assessment and management of the child who presents for elective surgery while harboring a URI. It is hoped that this information will be important to perianesthesia nurses and anesthesia providers in making decisions regarding proceeding or cancelling surgery for children with URIs and in optimizing their perioperative management.

Elective colostomy in the patient with a spinal cord injury: an ET nurse's perspective

The patient with a spinal cord injury presents significant challenges to the nurse seeking to promote an optimal state of physical wellness and maximum independence with self-care. This article describes the nature of spinal cord injuries and their long-term effects on the gastrointestinal system. The preoperative and postoperative needs that the WOC nurse must consider when designing a care plan for the patient with a spinal cord injury and a colostomy are discussed, as well as the indications and efficacy of elective colostomy surgery as a management alternative for the neuropathic bowel.

Transfusion-free surgery is a treatment plan for all patients

Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

Guided imagery as a coping strategy for perioperative patients

Patients who undergo surgery usually experience fear and apprehension about their surgical procedures. Guided imagery is a simple, low-cost therapeutic tool that can help counteract surgical patients' fear and anxiety. The authors randomly assigned 130 patients undergoing elective colorectal surgical procedures into two groups. Members of one group received routine perioperative care. Members of the other group listened to guided imagery tapes for three days before their surgical procedures, during anesthesia induction, intraoperatively, in the postanesthesia care unit, and for six days after surgery. The authors measured patients' anxiety levels, pain perceptions, and narcotic medication requirements. The patients in the guided imagery group experienced considerably less preoperative and postoperative anxiety and pain, and they required almost 50% less narcotic medications after their surgical procedures than patients in the control group.

Patients' perceptions of the pre-operative information they need about events they may experience in the intensive care unit

Through a descriptive survey, this study examined the pre-operative information which patients need about the events they may experience in intensive care, when they are admitted there following elective surgery. A subsidiary aim was to find out how they felt this information should be delivered. Questionnaires were posted to a convenience sample of 57 people who had been admitted post-operatively to one ICU in the past year. Forty-three (75%) of the questionnaires were returned and were analysed with the five returned in the pilot study. The results suggested that pre-operative information about ICU was perceived helpful by all respondents, particularly the management of pain and nausea, the likely site of pain, mouth care, the high nurse:patient ratio and having a urinary catheter. Information rated helpful less frequently, included noise levels, visiting times and men and women being nursed in the same room. The most popular method for receiving the information was via a pre-operative visit from a nurse working in ICU. In view of the sampling procedure and the validity of data collection methods, these findings cannot be generalized.

The practice of health education in acute care settings in Hong Kong: an exploratory study of the contribution of registered nurses

A multiple case study design was used to explore the practice of health education in acute care settings in Hong Kong. Two case studies, a medical ward and a surgical ward, were selected to reflect the real setting in which nurses carry out health education in acute care. Data collection methods involved the use of non-participant observation and semi-structured interviews. Seven nurses and eight patients were interviewed to explore their understanding of health education concepts, the use made in the wards of health education and the factors influencing such practice in the acute settings. Individual and cross-case analysis showed that respondents' understanding of the concept of health education was limited to patient information-giving. Although the importance of health education in acute patient care was acknowledged, the degree to which health education featured in nurses' practice was minimal. Many available opportunities for health education were missed and factors such as nurses' busy-ness and the associated lack of time and staff were identified as influencing health education practice in these acute care settings. Implications for practice and future studies were discussed in the light of these findings.