Is this a report of a single research study? A Randomized…

Question Answered step-by-step Is this a report of a single research study? A Randomized… Is this a report of a single research study?    A Randomized Controlled Trial of an Individualized Preoperative Education Intervention for Symptom Management After Total Knee Arthroplasty  RESEARCHPain and nausea limit recovery after total knee arthroplasty (TKA) patients. The aim of this study was to determinethe effect of a preoperative educational intervention on postsurgical pain-related interference in activities, pain,and nausea. Participants (n = 143) were randomized to intervention or standard care. The standard care group received the usual teaching. The intervention group received the usual teaching, a booklet containing symptom man- agement after TKA, an individual teaching session, and a follow-up support call. Outcome measures assessed pain, pain interference, and nausea. There were no differences between groups in patient outcomes. There were no group differences for pain at any time point. Respondents had severe postoperative pain and nausea and received inad- equate doses of analgesia and antiemetics. Individualizing education content was insufficient to produce a changein symptoms for patients. Further research involving the modification of system factors affecting the provision of symptom management interventions is warranted.IntroductionIn Canada, more than 42,000 total knee arthroplasty (TKA) surgeries were performed from 2012 from 2013 (Canadian Institute for Health Information, 2014). TKA is a common, successfully performed joint re- placement procedure for pain and immobility associ- ated with knee joint compromise. Arthritis is the most common preoperative diagnosis (95.4% osteoarthritis and 2.2% rheumatoid arthritis). The purpose of joint replacement for these patients is to reduce pain and knee joint stiffness, and thereby increase mobility and function.Pain and nausea are common symptoms for patients after this procedure. Moderate to severe pain on move- ment and at rest has been documented during the first 3 postoperative days (Brander et al., 2003; Salmon, Hall, Perrbhoy, Shenkin, & Parker, 2001; Strassels, Chen, & Carr, 2002; Wu et al., 2003). Similarly, nausea has been found to be worse on postoperative day 1, but has the greatest impact on patients on day 2 (Wu et al., 2003).Previous research (Beaupre, Lier, Davies, & Johnston, 2004; Bondy, Sims, Schroeder, Offord, & Narr, 1999; Lin, Lin, & Lin, 1997; McDonald, Freeland, Thomas, & Moore, 2001; McDonald & Molony, 2004; McDonald, Thomas, Livingston, & Severson, 2005; Roach, Tremblay, & Bowers, 1995; Sjoling, Nordahl, Olofsson, & Asplunf, 2003) has explored education interventions for pain prevention and treatment in the TKA popula- tion. These trials used a variety of delivery methods for the intervention including video, pamphlets, and class- room sessions, and the impact on pain outcomes was variable. Three studies reported that the education in- tervention resulted in moderately lower pain scores (McDonald & Molony, 2004, McDonald et al., 2001, Sjoling et al., 2003). Despite the relationship between pain and nausea and their prevalence after TKA, none of the studies addressed analgesic pain management or antiemetic therapy. An individualized preoperative education approach has been used successfully to reduce symptoms in pa- tients with cancer (Benor, Delbar, & Krulik, 1998; DeWit et al., 2001; Sherwood et al., 2005; Velji, 2006; Yateset al., 2004). Further, systematic reviews have recom- mended individualization of preoperative educational content (Johansson, Nuutila, Virtanen, Katajisto, & Salantera, 2005; McDonald, Page, Beringer, Wasiak, & Sprowson, 2014). However, no studies were found that used an individualized approach to preoperative patient education for patients with TKA.Therefore, the intervention used in this trial was de- signed to be an individualized, preoperative approach to patient education and was informed by an adaptation of Wilson and Cleary’s (1995) conceptual model of patient outcomes (Figure 1). The intervention focused on patient communication for pain management, analgesic use, and antiemetic use (see Table 1). This study aimed to investi- gate the impact of an individually delivered preoperative education intervention on pain-related interference, pain, and nausea for patients undergoing unilateral TKA.Research Questions• Primary research question: What is the effect of an individualized preoperative education intervention for patients with TKA on pain-related interference with usual activities on postoperative day 3?• Secondary research question: What is the effect of an individualized preoperative education inter- vention for patients with TKA on nausea, pain, and analgesic and antiemetic administration on postoperative days 1, 2, and 3?MethodsTRIAL DESIGNAn RCT design was used to evaluate outcomes on the first, second, and third days after TKA surgery (see Figure 2). This trial was conducted at an academic health sciences center in Southeastern Ontario. Ethics approval was obtained from the associated university’s Research Ethics Board and the Trial Site Hospital’s Research Ethics Board.TABLE 1. PRE-KNEE SYMPTOM EDUCATION INTERVENTION CONTENT TopicSupporting EvidencePain, importance of pain managementImportance of pain management to promote activity Communicating pain to health professionalsAsking for analgesicsAsking for antiemeticsPreventing dehydration (fluids) Misbeliefs about taking medicationNonpharmacological measures FIGURE 1. Conceptual framework: adaptation of Wilson and Cleary’s (1995) model.STUDY PARTICIPANTSPatients were included if they were scheduled for elec- tive unilateral primary TKA using planned intrathecal (spinal) anesthetic technique; had grade I-II American Society of Anesthesiologists Physical Status Classification (Larson, 1996); were able to speak and understand English; were able to be reached by telephone; were planned for home discharge; and consented to partici- pate in this trial. Patients were excluded if they were not expected to be discharged home, or were booked for hemi, revision, or bilateral knee arthroplasty.Recruitment took place at the weekly outpatient or- thopaedic preadmission testing clinic at a facility affili- ated with the trial center. Potential participants were identified by clinic staff, and eligible patients were asked for their permission by hospital staff to release their names to the investigator using a standardized script. The trial research assistant gave all willing patients a detailed verbal and written explanation of the trial dur- ing their preadmission appointment. Before randomi- zation, written consent was gained by the trial research assistant, who then collected baseline demographic characteristics and clinical information.InterventionsINTERVENTION: THE PRE-KNEE SYMPTOM EDUCATION INTERVENTIONThe Pre-Knee Symptom Education intervention was composed of three components: the booklet, an indi- vidual teaching session, and a follow-up support tele- phone call. Content used in this intervention was drawn from trials of preoperative education programs in surgi- cal patients (McDonald et al., 2001; McDonald & Molony., 2004; Sjoling et al., 2003; Watt-Watson et al., 2004) and supported by focus groups’ findings of indi-vidual areas of concern for patients with TKA (Chang et al., 2005). To ensure concerns, found in the literature, were consistent with those of patients with TKA at the trial site, pilot interviews of 10 patients were conducted on day 2 or 3 post-TKA surgery. The Pre-Knee Symptom Education Booklet was reviewed with each consenting participant in an individualized, private teaching ses- sion during the preoperative patient visit to the Pre- Surgical Screening (PSS) Centre. This component was adapted from an educational tool used by Watt-Watson and colleagues (2004) for relevance to TKA postopera- tive recovery and the result of the pilot interviews done with local patients. The booklet was 12 pages long and included the content provided in Table 1 in addition to diagrams, pictures, and a space for recording questions for the investigator during the telephone follow-up call. The teaching session and booklet review were provided in a quiet examination room. The principal investigator delivered all intervention components during the PSS clinic appointment within 4 weeks of surgery. New con- cerns identified by trial participants as well as strategies presented were recorded on the Individualized Education Content Tool and reinforced during the fol- low-up support telephone call along with discussion of any questions raised by participants in the intervening time. The follow-up support telephone call occurred during the week before the scheduled surgical date.FIGURE 2. Schema of trial design. Questions asked by participants focused on (a) use of the intravenous patient-controlled analgesia (PCA-IV) pump, (b) concerns about the adverse effects of opioid analgesics, (c) physiotherapy timing, (d) home dis- charge analgesia, and (e) presurgical fasting guidelines and information regarding oral fluid intake.STANDARD CAREParticipants in both groups received standard care, in- cluding an educational session provided by a physio- therapist outlining physiotherapy activities, a 30-min- ute video explaining the surgical procedure and postoperative orthopaedic routines, and a brief review of the use of PCA-IV by clinic nursing staff.OUTCOMESBaseline demographic data were collected using the self-reported Baseline Demographic Questionnaire be- fore the intervention.The primary outcome, pain interference, was meas- ured using the Brief Pain Inventory, Interference (BPI-I) subscale on postoperative day 3 (Cleeland & Ryan, 1994). Pain-related interference, as measured by the BPI-I, re- fers to the extent to which pain interferes with general activities, sleep, mood, walking, movement from bed to chair, and relationships with others. This measure has well-established construct validity (Mendoza et al., 2004b, 2004a; Tan, Jensen, Thornby, & Shanti, 2004; Watt-Watson et al., 2004). Psychometric testing of post- operative use of the BPI-I demonstrates a consistent sub- scale structure between acute and chronic pain states (Mendoza et al., 2004a, 2004b; Watt-Watson et al., 2004; Zalon, 1999) as well as sensitivity to change (Mendoza et al., 2004a) and sex differences (Watt-Watson et al., 2004). The use of the BPI-I in the immediate postopera- tive period (Zalon, 1997) and beyond postoperative day 3 has been demonstrated (Mendoza et al., 2004a; Watt- Watson et al., 2004). Two items were deleted: “normal work” and “enjoyment of life” as these items were not relevant to the early postoperative period. The addition of one item addressing the activity of transferring from bed to chair was added, and the modified tool was pilot tested on the third postoperative day in a group of TKA patients (n = 14). The additional item, transferring from bed to chair, was easily answered by all participants and similarly judged to be an appropriate item for the ad- ministration time. Similar adaptation of the BPI-I items took place in a study by Watt-Watson et al. (2004) where both “normal work” and “enjoyment of life” were deleted and “deep breathing and coughing” was inserted for use in a postoperative patient population. Cronbach’s α for this change was reported as .71.Secondary outcomes included levels of pain and nau- sea, and analgesic and antiemetic use. Pain and pain quality were measured using the Short Form McGill Pain Questionnaire (MPQ-SF) (Melzack, 1987; Melzack et al., 1987). Nausea was measured using the Overall Nausea Index (ONI), one component of the Nausea Questionnaire (Melzack, 1989), used previously by Parlow et al. (2004) in a trial of postoperative anti-ematic therapies.Antiemetic and opioid administration data were re- corded from the chart for each of postoperative days 1 to 3.SAMPLE SIZESample size for this trial was based on group means from another study (n = 406) using the BPI-I as a pri- mary outcome (Watt-Watson et al., 2004). Using a mod- erate effect size of .5 based on between standard devia- tion and within standard deviation (Cohen, 1988), the sample size required was 64 per arm (α = .05, power = 80%). A reduction of half the standard deviation of the general population, as reported by Watt-Watson et al. (2004), is a reasonable estimate of the clinically impor- tant effect of this intervention. Minimal trial attrition was expected as all measurements were taken during the inpatient hospital stay. A conservative estimate of 10% was used. As a result the sample size required for this trial was 140 in total, with an α level of .05 and- power of 80%.RANDOMIZATION AND BLINDINGParticipants were randomly assigned to the interven- tion plus standard care group or the standard care group using a randomization service provided by a re- search program not connected to this trial. Personnel at the research office used a computer-generated block randomization table provided by statistical services. The research assistant called the research office num- ber, provided the participant number, and received group assignment information. Group assignment was recorded on the Baseline Demographics Questionnaire and was stored in a location separate from all postop- erative data collection forms.The intervention was initiated immediately after ran- domization for participants in the experimental group in a private room in the presurgical screening area. Although participants could not be unaware of group allocation, the research assistants collecting postopera- tive outcome data were blinded to group allocation, re- ducing the potential for cointervention or the introduc- tion of bias by trial personnel during data collection.STATISTICAL ANALYSISResults were analyzed using an intention-to-treat ap- proach. Baseline data were analyzed using descriptive statistics. A two-tailed level of significance of .05 was used for all analyses. Data were analyzed using the SPSS/PASW software package, version 18.Independent samples t test was used to determine differences in pain-related interference with activity be- tween the intervention and standard care groups on postoperative day 3 on total and component scores. Repeated measures-analysis of covariance was used to determine differences between groups and over the measurement periods in pain scores (MPQ-SF, Numeric Rating Scale [NRS] questions), nausea scores (ONI), and total 24-hour analgesic administration. Differences in antiemetic administration between the two groups were determined using χ2. Linear-by-linear χ2 was also used to detect differences in frequency of postoperative activities completed (TKA-AQ). Separate analyses were conducted using participants, rating moderate to severe worst pain and nausea—scores of 4 to 10 (Jones et al., 2005)—in the last 24 hours with antiemetic and analge- sic administration. ResultsA total of 337 patients were screened for participation in this trial (see Figure 3). Of these, 162 were eligible and only 19 of these declined to participate.Therefore, 143 were randomized after baseline de- mographic data collection in the preadmission phase of surgery preparation. One participant in the standard care group did not meet eligibility criteria at the time of surgery as a result of a change of procedure type (bilat- eral vs. unilateral TKA), and one participant in each group had the procedure cancelled indefinitely. As a re- sult, the total number for the analysis of baseline char- acteristics was 143 and 140 for postoperative outcomes. No participants withdrew from the trial during data col- lection. Baseline demographic data are included in Table 2.Baseline characteristics were similar between groups with a mean age of 67 ± 8 years in the intervention group and 66 ± 8 years in the standard care group, con- sistent with many studies of patients with TKA and na- tional TKA data. The primary diagnosis requiring sur- gery was osteoarthritis in both groups, with approximately one third of participants requiring opi- oid analgesics for arthritic pain preoperatively.PRIMARY RESEARCH QUESTIONDay 3 measurements of the BPI-I are presented in Table 3. Total scores for the standard care group (22.4 ± 15.1) and the intervention group (24.4 ± 14.4) were not significantly different (p = .45). Independent sample t tests were nonsignificant for all BPI-I items. Highest in- terference scores for both groups at day 3 were in the moderate range and included general activity (standard care: 5.6 ± 3.2; intervention: 5.8 ± 3.2) and transfer from bed to chair (standard care: 5.0 ± 3.4; interven- tion: 4.6 ± 2.9). It is important to note that these pain- related interference scores were measured on the third postoperative day, 1 day before the expected discharge date for this group of patients.SECONDARY RESEARCH QUESTIONSPainPostoperative pain was measured using the MPQ-SF on each of postoperative days 1, 2, and 3 (see Table 4). There were no significant group differences on any of the three postoperative days in either pain right now at rest, pain now with movement, or worst pain in last 24 hours. There was, however, a significant effect for time in painFIGURE 3. Flow of participants through the trial. aPrimary outcome. TABLE 2. BASELINE DEMOGRAPHICS OF PARTICIPANTSTABLE 4. PAIN ON POSTOPERATIVE DAYS 1, 2, AND 3DemographicsSex FemaleHome status Live aloneHighest education level Less than high school PostsecondaryHome pain medication NoneOpioidNonopioid Preoperative diagnosisOsteoarthritis Rheumatoid arthritisIntervention (n = 73) n (%)46 (63) 13 (18)34 (47) 39 (53)13 (18) 21 (29) 39 (53)70 (96) 3 (4)Standard Care (n = 70)n (%)43 (61) 15 (21)36 (51) 34 (49)18 (26) 24 (34) 28 (40)67 (96) 3 (4)NRS (0-10)Pain right now at resta Postoperative day 1 Postoperative day 2 Postoperative day 3Intervention (n = 62) M (SD)4.1 (2.9) 3.3 (3.0) 2.8 (2.5)6.4 (2.6) 6.2 (2.8) 5.4 (3.0)7.5 (2.5) 7.7 (2.4) 7.0 (2.4)Standard Care (n = 55)M (SD)3.7 (2.8) 2.9 (2.2) 2.8 (2.7)6.4 (2.7) 5.9 (2.4) 6.1 (2.5)7.2 (2.8) 7.5 (2.1) 7.0 (2.3)   right now at rest (p = .0002) and worst pain last 24 hours (p = .013), with pain decreasing over time but not for the item, pain right now when moving (p = .06). Similarly, there was a significant effect for time in the Present Pain Intensity (PPI) global pain rating (0-5) (p = .001) but no group difference across time (p = .70). As with the NRS and PPI, there was a significant effect of time for both the PRI-S (p = .02), the PRI-A (p = .05) and the PRI-T (p = .02), but there were no significant group differences across the three measurement times. Across both groups, the average rating of worst pain in the last 24 hours was 7 ± 2.4, in the severe range on each of the three postop- erative days. Seventy-three percent of the total sample reported moderate to severe pain on movement on day 3, whereas 81% of the sample reported having experienced moderate to severe pain in the last 24 hours.Pain right now when movingb Postoperative day 1 Postoperative day 2Postoperative day 3 Worst pain last 24 hoursc Postoperative day 1Postoperative day 2 Postoperative day 3NAUSEATABLE 3. PAIN-RELATED INTERFERENCE WITH ACTIVITY ON POSTOPERATIVE DAY 3Interference Scores BPI-ITotal (scores 0-60)a Subscales (scores 0-10)General activityWalkingMoodTransfer from bed to chair SleepRelationships with othersIntervention (n = 70) M (SD)24.4 (14.4)5.6 (3.2) 4.8 (3.0) 3.3 (3.2) 4.8 (2.9) 3.8 (3.5) 1.9 (2.9)Standard Care (n = 65)M (SD)22.4 (15.1)5.8 (3.2) 4.4 (3.5) 2.4 (3.2) 5.0 (3.4) 3.3 (3.1) 1.6 (2.7)The impact of the intervention on nausea was measured using the six-point ONI. There was no difference be- tween groups in nausea scores (previous 24 hours) over time (F = 0.02; p = .88); however, there was a difference within groups in nausea scores (previous 24 hours) over time (F = 50.9; p < .01) with nausea decreasing over the 3-day period.ANALGESIC AND ANTIEMETIC ADMINISTRATIONPCA-IV opioids prescribed for participants postopera- tively during the 3-day study period were morphine (82%) and hydromorphone (18%). Oral opioids prescribed on day 3 were morphine, hydromorphone, or oxycodone (67%, 14%, and 18% of participants, respectively) and one participant received oral codeine. Repeated-measures analysis of variance demonstrated no difference between groups in daily 24-hour opioid administration, but for the total sample there was a significant main effect for time as analgesic administration in both groups declined over the 3 postoperative days (F = 36.1; p = .000). For patients consistently reporting moderate to severe pain on each day, opioid analgesic administration also de- clined over their hospital stay (see Table 5). Overall, 7 par- ticipants did not receive any opioid analgesic doses on postoperative day 3, two of whom did not receive any doses on postoperative day 2. One participant did not re- ceive any opioid over the 3-day period.The routine dosing protocol ordered for all patients with TKA reporting even mild nausea was three doses of a prescribed antiemetic (ondansetron). Overall, 79 (56%) participants were administered at least one dose of antiemetic over the 3-day trial period. However, for those reporting moderate to severe nausea on the first postoperative day, 29% in the intervention group and 25% in the standard care group received no antiemeticsNote. NRS = Numeric Rating Scale. aF = 0.36, p = .70.bF = 1.61, p = .20.cF = 0.14, p = .87.  Note. BPI-I = Brief Pain Inventory, Interference. at = −0.76: p = .45. TABLE 5. TOTAL OPIOID ANALGESIC ADMINISTRATION FOR ALL PARTICIPANTS IN MILLIGRAMS OF ORAL MORPHINE EQUIVALENTS FOR 24 HOURS ON EACH OF THE 3-DAYTRIAL PERIOD Postoperative day 1 Postoperative day 2 Postoperative day 3Intervention (n = 72) Median (Interquartile Range)78 (69) 62 (65) 40 (45)Standard Care (n = 68) Median (Interquartile Range)78 (87) 56 (55) 40 (42)were intended to maximize pain relief and improve mo- bility to prevent further complications, but the interven- tion focused on the patients and ignored the roles of the care providers. Additionally, data were not collected that discriminated between surgical pain and other pain. Wittig-Wells, Shapiro, and Higgins (2013) found that other or nonsurgical pain, present in 37% of their sample, interfered with walking, mood, sleep, and rela- tionships with other people. Kearney et al. (2011) re- ported a similar lack of effect on postoperative pain or activity in a trial of structured preoperative information in joint replacement patients.Opioid analgesic administration (see Table 5) de- clined over the 3-day study period (F = 36.1; p = .000), whereas pain ratings on movement stayed in the moder- ate range in both groups across all 3 postoperative days. It is important to note that the median oral morphine equivalent administration was 40 mg for patients in both trial groups, only one third of the opioid doses that were prescribed. This finding is similar to the 33% of prescribed doses administered in the study by Watt- Watson and colleagues (2004).Unrelieved pain and stress response as a result of acute, surgical injury can have psychological and physiological consequences for patients (Apkarian, Bushnell, Treede, & Zubieta, 2005; Carr & Thomas, 1997; Kehlet, 1997). The phenomenon of central sensitization of dorsal horn neu- rons by prolonged and repetitive nociceptive input can create the physiology for a longer-term pain problem (Bausbaum & Jessell, 2000) predisposing patients to re- lated comorbidities. Patients with TKA with persistent, unrelieved pain are less likely to do specific physiotherapy activities (i.e., range of motion and weight bearing) that may result in delayed rehabilitation and knee stiffness.Concomitant moderate to severe nausea rates in this trial may reflect the established interrelationship be- tween pain and nausea. Twenty-eight percent of the in- tervention and 24% of the standard care groups reported experiencing moderate to severe nausea in the previous 24 hours on postoperative day 3. The attenuation of the pain experience by the presence of nausea and the pro- duction of nausea by the pain experience (Fields, 1999; Julius & Bausbaum, 2001; Kandel, Schwartz, & Jessell, 2000) reinforces the need to address both of these symp- toms simultaneously.This trial presents clear evidence that there are signifi- cant system issues influencing postoperative symptom management after TKA. Participants in both groups who were reporting moderate to severe nausea or pain fre- quently did not receive the antiemetic therapy or analge- sics ordered. Evidenced-based protocols for nausea man- agement were in place at the trial site, but data show that they were not followed consistently and in some cases, not at all. Antiemetic agents used in these protocols, on- dansetron and prochlorperazine, are effective for postop- erative nausea when given appropriately (Dzwonczyk, Weaver, Puente, & Bergese, 2012). In this trial, 25% of participants who reported moderate to severe nausea had no antiemetics administered at all. Similarly, partici- pants who reported moderate to severe pain received ap- proximately one third of the prescribed doses of oral an- algesic on postoperative day 3 despite hospital-wide programs that support the need for effective painin the previous 24-hour period. For those reporting ei- ther no or mild nausea in each group, 17% received at least one dose of antiemetic during the same period.DiscussionThere were no significant group differences in any of the outcomes in this trial. However, the results of the total sample are important to highlight. There were no differ- ences in total or component scores for pain-related in- terference with activity as measured by the BPI-I Interference with general activity, walking, and transfer from bed to chair were in the moderate to severe range and consistent with results reported by Akyol, Karayurt, and Salmond (2009). A major emphasis of the education content within all three components of intervention de- livery was the importance of appropriately timed analge- sic use to increase opioid administration and improve pain and pain-related interference with activity. In the context of similar opioid use on postoperative day 3 in both groups—median daily oral morphine equivalents: intervention 40 mg (interquartile range = 45 mg), stand- ard care 40 mg (interquartile range = 42 mg)—moderate to severe BPI-I scores in the intervention group illustrate that placing the focus on the patient alone to ensure pre- activity analgesia administration is not sufficient to im- prove pain-related interference. Watt-Watson and col- leagues (2004) reported that only 33% of prescribed analgesics were administered in 53% of patients report- ing moderate to severe pain in their study of 406 patients with cardiac surgery. These authors identified a lack of understanding of opioid analgesia among health profes- sionals, and recommended future trials include focus groups with nursing staff in particular to discuss issues affecting pain management in the postoperative setting.The education provided by all three components of the intervention that focused on strategies to prevent resting pain and pain on movement, including appro- priate communication of pain to healthcare providers, failed to produce a difference in pain ratings and quali- tative aspects of pain description. Moderate to severe pain, in the context of declining and inadequate opioid analgesic administration, is troubling and raises impor- tant questions about the postoperative environment in terms of clinical care. Components of the intervention that reinforced analgesic use before movement in an in- terval appropriate to the type of analgesic administered management (e.g., Pain, the 5th Vital Sign). Other re- search has suggested that this is not an unusual finding; nursing staff education and attitude may be contributing factors. Gordon and colleagues (2008), in a study of prac- tice-associated pro re nata (PRN) administration of opi- oids in 602 registered nurses, found that comfort with dose titration was directly and positively related to years of practice experience.At the trial site, the pain management service is avail- able for consultation by the nursing staff at all times to modify or increase analgesic doses. Although patients reporting scores in the moderate to severe range on pain assessment should, by institutional policy, be reviewed either by the attending service or the pain service, they were not. Although an inadequate explanation for defi- ciencies in care, staffing resources and patient acuity may have contributed to fewer pain and nausea assess- ments, placing the onus on the patient to report symp- toms requiring treatment.It appears that the current postoperative environ- ment does not support best practice for nursing staff in terms of symptom management regardless of the meas- ures put in place. This finding is not unique to orthopae- dic patient care. In a systematic review of 16 trials of labor support during childbirth in institutional settings, Hodnett, Gates, Hofmeyr, and Sakala (2009) concluded that the effectiveness of labor support interventions was mediated by the environment in which the interventions were provided. Although this clinical group has different requirements than patients with TKA, findings of the re- view in terms of environmental factors were similar. The ability of interventions with patients to overcome barri- ers present in the environment is limited if strategies to address these barriers are not also included.Limitations of this trial are primarily related to sup- port for the implementation of the educational material in the postoperative setting. As the intervention for this trial was directed only at the participants with no com- ponent for staff education or protocol development or monitoring, the influence of the healthcare environment on the ability of the participants to engage in the associ- ated behaviors was not reinforcing. Systems issues such as staff lack of adherence to established protocols for symptom management may have resulted in more pain and nausea and greater functional interference.Institutional accountability reflecting hospital ac- creditation standards in the clinical environment for the provision of symptom management and early identifica- tion and investigation of activity and mobility concerns needs to be established. A consistent approach used by disciplines involved in the care of patients with TKA needs to span from initial assessment for surgery to postoperative care and includes all points of contact be- tween. In the preoperative setting, nursing staff caring for orthopaedic patients must take the lead in ensuring surgical preparation, which includes education that is reinforced by all team members, regardless of their role. Postoperatively, orthopaedic nursing staff must attend to the need for temporally appropriate symptom assess- ment and pharmacologic and nonpharmacologic inter- ventions for patients. As this trial demonstrates that the delivery of individualized educational content with re- inforcement provided by booklet and telephone follow-up was not sufficient to impact postoperative symptoms after TKA surgery, the nursing role as a symptom management provider and patient advocate is essential to the recovery after TKA. Further trials that also in- clude standardized information provided to patients by preadmission, surgical scheduling and postoperative nursing and medical staff would be beneficial in sup- porting learned behaviors and knowledge uptake. Consistent with the recommendations of Watt-Watson and colleagues (2004), a qualitative research approach using focus groups of orthopaedic nursing, medical, and physiotherapy staff could be undertaken to deter- mine the environmental and patient-related character- istics, affecting the provision of analgesics and an- tiemetics and the relationship to postoperative activity.ConclusionThe numbers of Canadians requiring primary TKA has increased 140% over the last 10 years (CIHI, 2013). The highest rate of TKA surgery is in the 75- to 84-year-age range (65%). There are no published guidelines for the preoperative preparation or postoperative care of these relatively older aged patients. Inadequate management of symptoms such as pain and nausea in the early post- operative period may result in increased morbidity for patients and increased costs for the healthcare system. The purpose of the trial was to examine the impact of individualizing preoperative patient education as a means to address postoperative symptoms affecting re- covery from TKA.Providing information to patients alone was not suf- ficient to address the need for postoperative symptom prevention and management after TKA. A broader, con- sistent approach that includes healthcare providers at all levels of patient contact is required to support recov- ery and rehabilitation after this type of surgery. Further research is required to delineate the barriers in the healthcare environment to appropriate pain and nausea management and to provide more evidence for the rela- tionship between pain and nausea and functional out- comes for patients who have had TKA. Health Science Science Nursing NURS 6207 Share QuestionEmailCopy link Comments (0)