The Effectiveness of Health Education on Maternal Anxiety, Circumcision Knowledge, and Nursing Hours: A Quasi-Experimental Study

Abstract

Background: 

Many studies have shown that providing health education before surgery may significantly increase health knowledge and decrease anxiety in both patients and their family members. However, few studies have compared the effects on pediatric outpatient surgery outcomes of different health education instruction modes.

Purpose: 

This study compares the effects of two health education delivery modes on maternal knowledge and anxiety, the number of unexpected early hospital follow-up visits, and the time spent by nurses on health education.

Method: 

A quasi-experimental design with pretest and posttest was used to compare the effect on the outcomes of pediatric circumcision of a multimedia compact disc (CD) and a printed material.

Seventy mothers of children who underwent Plastibell circumcision participated in this study.

Results: 

Both the printed material and the multimedia CD significantly increased the knowledge and reduced the anxiety levels of the participants. However, no significant differences in unscheduled early hospital follow-up visits postsurgery were found between the two modes of instruction. Furthermore, we found that significantly fewer hours were spent by nurses on health education for the multimedia CD group in comparison with the printed material group.

Conclusions/Implications for Practice: 

In the current clinical environment of common staffing shortages, information tools may be used to cost-effectively assist and simplify nursing work. The findings of this study may provide a reference to medical centers that are working to reduce the time spent by nurses on health education for outpatient surgery patients. Furthermore, audiovisual health education tools are recommended to increase nursing effectiveness and save nursing time.

Introduction

Over the past few decades, the tightening of healthcare budgets worldwide has led to significantly higher levels of cost-effective outpatient surgery (^{Manchikanti & Boswell, 2007}). Outpatient surgery decreases the number of hospitalization days and eliminates the costs of hospitalization (^{Park, Kim, & Lee, 2011}). Patients attend the hospital on the day of their surgery and have the surgery performed immediately. After the surgery, patients return home as soon as they recover from the anesthesia. According to Taiwan national statistics, the proportion of the total number of outpatient surgical operations increased by 12.34% in 2004 and 2.79% in 2014 (^{Ministry of Health and Welfare, 2015}).

In Taiwan, circumcision is performed as an outpatient procedure and may be done on infants and older male children. Circumcision using the Plastibell technique is an easy, quick, and safe surgical technique that does not require hospitalization (^{Weiss, Larke, Halperin, & Schenker, 2010}). The Plastibell circumcision device (a ring) generally falls off within 10 days postsurgery as the wound heals. Among older children, the ring usually falls off during the third week postsurgery (^{Bastos Netto et al., 2010}). During the wound healing process, patients normally experience localized swelling and yellow secretion, which families often mistake as a wound infection, resulting in unscheduled visits to the hospital before the standard 1-week follow-up appointment.

For most mothers who are frequently a child’s primary caregiver, having surgery performed on their child is an extremely stressful experience (^{Franck, McQuillan, Wray, Grocott, & Goldman, 2010}). ^{Salgado et al. (2011)} found that many family members fear the sudden death of their child during surgery. Anxiety levels have been reported as higher during surgery than during presurgery (^{Utens et al., 2000}). These findings suggest that knowledge and information, including a detailed explanation of the surgical process and treatment options as well as psychological support, should be provided to all caregivers (^{Franck et al., 2010}).

Thus, the performance of minor operations as outpatient surgery appears to increase the need for accurate, practical, and open-ended postoperative health education. Health education has the potential to decrease parental anxiety caused by a child undergoing surgery (^{Berghmans et al., 2012}; ^{Fincher, Shaw, & Ramelet, 2012}; ^{Sutters, Savedra, & Miaskowski, 2011}). It may also increase parental understanding of the situation and enable children to participate actively in their care plan and early adaptation (^{Lancaster, 1997}; ^{Sikorova & Hrazdilova, 2011}). For many outpatient surgeries, patients and family members need to be instructed on hospital and surgical procedures, including check-in, surgery preparation, and checkout procedures (^{O’Shea, Cummins, & Kelleher, 2010}). ^{Heikkinen, Salanterä, Suomi, Lindblom, and Leino-Kilpi (2011)} noted that providing information in a structured manner before surgery saves time for nurses and reduces medical fees.

The use of multimedia compact discs (CDs) to deliver health education has grown in popularity in recent years (^{Stegeman & Zydney, 2010}). Audiovisual presentations are able to convey significant amounts of simple to more complex information, and patients and family members are not restricted to a specific time for learning the material (^{Ribbons, 1998}). Although the initial investment cost is high, there are many advantages to providing health education using computers and multimedia as part of the instruction process (^{Klein-Fedyshin, Burda, Epstein, & Lawrence, 2005}; ^{Lo, Hayter, Hsu, Lin, & Lin, 2010}). Health educators may use audiovisual CDs to explain surgical procedures, thereby reducing the need for nurses to repeat explanations of surgical procedures and postoperational information (^{Mank & Molenaar, 2008}). Not only may multimedia CDs help enhance the effectiveness of postsurgery education, they may also save nurses and families a great deal of time. Indeed, it has been shown that the learning effects of information provided in this format may last as long as 6 weeks (^{Cornoiu, Beischer, Donnan, Graves, & de Steiger, 2011}).

Many studies have shown that providing health education before surgery significantly increases the health knowledge and decreases the anxiety of both patients and their family members (^{Lo, Wang, et al., 2010}; ^{Muldoon, Cheng, Vish, Dejong, & Adams, 2011}). However, few studies have compared the effects of different health education instruction modes on the outcomes of pediatric outpatient surgery. Thus, the aim of this study was to compare the effects of two health education delivery modes on maternal knowledge and anxiety, the number of early hospital follow-up visits, and the time spent by nurses on health education in the context of pediatric circumcision procedures.

Methods

Design

A quasi-experimental design with pretest and posttest was used to compare the effects of two health education delivery modes (a multimedia CD and a printed material) on the related knowledge of mothers and their anxiety levels, early hospital follow-up visits, and the number of hours nurses spent on health education.

Participants

We recruited mothers of children who were scheduled to undergo Plastibell circumcision at a medical center in southern Taiwan; whose child had received outpatient circumcision under general anesthesia; who were the main caregivers, at least 20 years old, and a resident of Taiwan; and who could communicate in Mandarin Chinese or Taiwanese. A sample size of 52 was estimated using G-Power Version 3.1 statistical software and based on a two-way repeated measures analysis of variance (ANOVA; repeated measures, within–between interaction), with an effect size of 0.20, an α of .05, and a power setting of 0.8. Allowing for an attrition rate of 30%, the minimum total number of required participants was determined to be 68.

Participants were assigned to either the multimedia CD (experimental) group or the printed material (control) group. Seventy mothers were enrolled as participants, with 35 assigned to the experimental group and 35 assigned to the control group. Health education with the multimedia CD for the experimental group was conducted after health education with a printed material for the control group to prevent treatment diffusion.

Instruments

Two questionnaires, including the 20-item Caregiver’s Circumcision Knowledge Scale and the 10-point Visual Analogue Scale for Anxiety (VAS-A); a table for recording health education hours; and a timetable for recording the dates of follow-up hospital visits were used to record study data. The Caregiver’s Circumcision Knowledge Scale was developed by the authors and was used to measure caregiver knowledge. The content validity index was 1.0, indicating that each item was rated either 3 or 4 based on a maximum score of 4. Internal consistency with Cronbach’s alpha coefficient was .70 in the pretest and .75 in the posttest. This scale includes 20 items; incorrect answers or responses of “unknown” were assigned 0 point, and correct answers were assigned 1 point. The sum of all points was the total score, with a maximum possible score of 20.

The VAS-A ranges from “not anxious at all” to “extremely anxious” and is a robust, sensitive, and reproducible way of evaluating subjective phenomena such as feelings, emotions, and reactions (^{Williams, Morlock, & Feltner, 2010}). The VAS-A is a quick and easy method for respondents to report their subjective pain, nausea, fatigue, breathing difficulty, and anxiety (^{Cella & Perry, 1986}; ^{Wewers & Lowe, 1990}). It is a simple, reliable, and valid measurement scale (^{Williams et al., 2010}). ^{Facco et al. (2013)} confirmed the VAS-A as a reliable indicator of anxiety. This study used this scale to measure the perceived level of anxiety of participants before and after the health education intervention. Scoring for questions on the VAS-A ranges from 0 = no anxiety to 10 = extreme anxiety.

The table that was used to record the health education hours documented the total time that nurses spent on health-education-related tasks, including the time spent dealing with participants’ inquiries (both face-to-face and over the telephone) during the 7-day postsurgery period and the time spent explaining and reading the printed material on health education to the participants. Whereas the time that nurses spent setting up the multimedia CD was included, the time that the participants spent watching the program on the CD was not.

The timetable that was used to record the participants’ hospital visits documented whether the participants visited the hospital before the originally scheduled follow-up appointment. The data for the timetable were obtained from the official medical record. The timetable noted that each of the participants was scheduled for a regular hospital visit within 1 week of the surgery. If the hospital follow-up visits occurred earlier than scheduled, an “early hospital visit” was recorded.

Health Education Delivery Modes

Two health education delivery modes (a multimedia CD and a printed material) were used in this study. We devised the multimedia health education CD to address circumcision using the Plastibell method, including the check-in procedure on the day of surgery and the surgical procedure itself. The CD also introduced the recovery room, outlined the key points for wound care, explained the application of medicine to the wound, and gave advice regarding water intake, food intake, and urination during recovery from the anesthesia. Furthermore, the CD provided an advice regarding the use of medicine for pain relief after surgery, provided the appropriate time for a follow-up visit to the hospital, and provided the telephone number for the recovery room. The CD contained 13 minutes of material.

A printed material was the standard approach that was used in the medical center where this study was conducted for health education on Plastibell circumcision. This material included 11 items that mothers were likely to be concerned about after their child’s surgery. These items included “If my child is running a fever, should I bring him in early for a follow-up visit to the hospital?”, “If my child feels pain after surgery, how often can my child take pain relief medication?”, “What should be done if my child feels pain or discomfort because of a loosened Plastibell?”, “If my child feels pain after the surgery, can I administer pain relief medication?”, “What type of post-surgical wound around the Plastibell is considered normal?”, “How many days after the surgery will the Plastibell start to fall off?”, “What types of pants should be worn after the surgery?”, “After returning home, when should warm water be used to wash the skin around the Plastibell?”, “After surgery, if the Plastibell has not fallen off after two weeks, what should I not do?”, “When should the child return to the hospital for a follow-up checkup after surgery?”, and “After returning home, what department should be contacted if I have further questions?”

Data Collection

When a mother brought her child to the operating room, the study’s purpose and procedure were explained to her. If she agreed to participate, she was taken to the family lounge, which was close to the recovery room. After signing the consent form, she completed the Caregiver’s Circumcision Knowledge Scale and the 10-point VAS-A. The health education with a multimedia CD was administered after the health education session that used the printed material. Participants were assigned to either the multimedia CD group or the printed material group. After receiving the health education intervention, the participant completed the Caregiver’s Circumcision Knowledge Scale and the VAS-A again, and a follow-up visit to the hospital 1 week postsurgery was scheduled. The time that nurses spent providing health education to the mother was calculated with a brand-new timer, and the date of the first follow-up visit was documented (Figure 1).

Figure 1.: Data collection.

The institutional review board at the researcher’s university approved the protocol (KMUH-IRB-960224) for this study. Prospective mothers were given both oral and written information about the study. Their participation was wholly voluntary, and they were informed that their choice to participate or not would not influence the treatment and care of their child in the hospital.

Data Analysis

Valid data were coded, and statistical analyses were conducted using t test, chi-square test, paired t test, and two-way repeated measures ANOVA. They were performed using Statistical Product and Service Solutions Version 17.0 (SPSS, Inc., Chicago, IL, USA) for Windows.

Results

The results of this study included (a) the participants’ demographic characteristics, (b) the knowledge and anxiety levels of participants at both pre and post health education time points, and (c) the amounts of time spent on health education and early hospital follow-up visits by the two groups.

Participants’ Demographic Characteristics

The demographic characteristics of participants are summarized in Table 1. The average scores for knowledge were 12.60 (SD = 3.07) and 17.00 (SD = 1.99), respectively, before and after the health education in the comparison group. By comparison, the average knowledge scores were 12.03 (SD = 3.59) and 15.89 (SD = 2.00), respectively, before and after the health education in the experimental group. The paired t test indicated that the knowledge scores of the mothers in both groups increased significantly after the health education (p < .001; Table 2).

TABLE 1.: Demographic Characteristics, by Group (N = 70)

TABLE 2.: Participants’ Knowledge and Anxiety Levels Pre and Post Health Education, Time Spent on Health Education, and Early Hospital Follow-Up Visits for the Two Groups (N = 70)

The average scores for the participants’ anxiety level were 5.37 (SD = 2.10) and 4.34 (SD = 1.98), respectively, before and after the health education in the comparison group. By comparison, these scores were 5.80 (SD = 1.98) and 4.37 (SD = 2.39), respectively, before and after the health education in the experimental group. The paired t test indicated that the anxiety levels of both groups decreased significantly after they received heath education (p < .01 and p < .001, respectively; Table 2).

No significant differences were found between the two groups for participants’ knowledge and anxiety levels in either the pretest or posttest, with the exception that the level of knowledge was significantly different between the experimental and control groups after receiving the health education (p < .02; Table 2). In this study, however, we used a mixed design with between- and within-subject measures. The experimental and comparison groups constituted the between-study group measures. The within-study group measures involved the two groups’ pretest and posttest results. Two-way repeated measures ANOVA indicated no interaction between the study group and time for either the knowledge (p = .51) or anxiety (p = .39) of participants (Table 3).

TABLE 3.: Participants’ Knowledge and Anxiety Levels With Two-Way Repeated Measures Analysis of Variance

We found a significant difference in participants’ levels of knowledge (p = .00) and anxiety (p = .00) before and after the health education (time effect), with levels of knowledge higher and levels of anxiety lower after receiving health education for both groups. However, there was no statistical difference between the groups in terms of either the knowledge (p = .11) or anxiety (p = .61) of participants. In other words, levels of knowledge and anxiety for the participants were not significantly different between the experimental and control groups despite the time effect (Table 3).

There were no significant differences between the two groups in terms of early follow-up visits to the hospital (p = .74). There was, however, a significant difference in the nursing time spent on delivering health education between the two groups (p = .00; Table 2).

Discussion

This study compared the effect of different modes for delivering healthcare information (multimedia CDs and printed materials) on the mothers’ anxiety levels and knowledge of Plastibell circumcision, the time spent by nurses on health education activities, and the incidence of early follow-up visits to the hospital. The results indicate that both the printed material and multimedia CD significantly increased the knowledge of participant mothers and reduced their anxiety levels. However, no significant differences in unscheduled early hospital follow-up visits postsurgery were found between these two modes of instruction. Significantly, we found that the time that nurses spent on health education was 6 minutes less per patient when the multimedia CD was used for health education.

This study showed that knowledge increased and anxiety levels decreased in both groups after the health education interventions. ^{Dexter and Epstein (2001)} found that family members’ anxiety would suddenly increase during the waiting period while their children were receiving surgery. Thus, providing relevant surgery knowledge and psychological support to parents is very important to help them increase their knowledge and reduce their anxiety (^{Adams, 2011}; ^{McEwen, Moorthy, Quantock, Rose, & Kavanagh, 2007}). Moreover, ^{Lo, Wang, et al. (2010)} and ^{Luck, Pearson, Maddern, and Hewett (1999)} found the disease knowledge of patients who received health education to be significantly greater and their anxiety level to be significantly less than patients who did not receive this education. In our study, there were no significant differences in the levels of either knowledge or anxiety between the two groups. In other words, the health education was effective for both of these different modes of health education instruction.

Furthermore, no significant difference between the two groups was found in terms of making early follow-up visits. Clinically, the most common causes for early follow-up hospital visits after circumcision included wound bleeding, frequent pain-related crying by the patient, parents’ concerns about their child’s urination behavior, and the appearance of localized swelling during the first 3–5 postsurgical days (^{Jonas, 2003}; ^{Palit et al., 2007}; ^{Weiss et al., 2010}). Thus, detailed health education to increase parents’ knowledge of these issues is necessary to reduce unnecessary early follow-up visits to the hospital. We found that six participants (17.1%) in the comparison group and five (14.3%) in the experimental group made early hospital follow-up visits. In the future, the CD and printed materials should include information on wound care, pain management, and urination care to further reduce the incidence of early hospital visits.

In terms of nursing time, the experimental group spent 6 minutes less time per patient than the comparison group on health education activities. In the medical center where this study was conducted, about 250–300 children per year receive a general anesthetic for Plastibell circumcision. This means that about 25–30 nursing hours (1500–1800 minutes) could be saved per year by introducing an appropriately designed multimedia CD as the medium for delivering health education. The results of this study are consistent with those of ^{Lo, Wang, et al. (2010)}, who found that using a multimedia learning educational program rather than a conventional education service program reduced healthcare costs.

Conclusions

In the context of the current clinical environment in which staff shortages are a common problem, the use of information tools holds the potential to cost-effectively assist and simplify nursing work. ^{Zboril-Benson (2002)} identified that overwork may easily lead nursing staff to become fatigued and, in some cases, show symptoms of nurse burnout such as absenteeism and stress. Thus, there seems to be a strong case for encouraging medical unit administrators to use audio and visual health education tools to reduce labor costs, increase the morale of clinical nurses, increase time efficiency, and increase nursing effectiveness.

In this study, only the mothers of children who received Plastibell circumcision surgery were recruited as participants. We recommend that future studies explore the comparative efficacy of different health education modes on other family member caregivers to assess whether our findings are generalizable to fathers and grandparents.

The findings of this study offer a reference for current medical centers that are working to reduce the number of nursing hours spent on health education for outpatient surgery patients. Audiovisual health education tools have the potential to increase nursing effectiveness and save nursing time. When health education is provided using a multimedia presentation, nurses may focus their attention on addressing the questions of patients and family members after the presentation. Multimedia instruction modes allow patients’ questions to be answered online or through a single-contact window. Moreover, information that is provided through multimedia offers patients and family members the opportunity to access educational programs online after completing the hospital registration procedure and again at home by CD after the procedure has been completed.