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Journal of Clinical Nursing, 23, 279–287, doi: 10.1111/jocn.12466. 279 ... patients who underwent orthopaedic surgery (Wong et al. 2010, Parker 2011).
ORIGINAL ARTICLE

The effect of educational intervention on the pain and rehabilitation performance of patients who undergo a total knee replacement Su-Ru Chen, Chyang-Shiong Chen and Pi-Chu Lin

Aims and objectives. To determine the effects of health education on postoperative pain, the practice of rehabilitative exercises and functional recovery of total knee-replacement patients. Background. Most total knee-replacement patients experience pain and limited physical activities during recovery and rehabilitation. Many patients fail to implement an effective rehabilitation plan because of the pain and a lack of practical knowledge regarding the rehabilitation process. Design. Quasi-experimental design. Methods. We recruited 92 total knee-replacement patients for our study. The experimental group (n = 42) received a health-educational intervention. The control group (n = 50) received routine care. Results. The experimental group reported lower levels of postoperative pain than the control group. The stair-climbing ability of the experimental group was superior to that of the control group. The experimental group also had superior scores for regular straight-leg raises and muscle power of the affected leg, compared with the control group. Conclusion. The preoperative health-educational intervention reduced the level of postoperative pain experience by total knee-replacement patients, increased the regularity with which they performed rehabilitative exercises and accelerated the recovery of their physical functioning. Relevance to clinical practice. The health-educational model can be included in regular clinical management and care of total knee-replacement patients.

What does this paper contribute to the wider global clinical community?

• A



preoperative health-educational intervention with an education pamphlet and compact disc can reduce the level of postoperative pain experienced by total knee-replacement patients. A preoperative health-educational intervention with an education pamphlet and CD can increase the regularity of rehabilitative exercises and muscle power of the affected leg.

Key words: functional recovery, functional status, health education, knee movement, muscle power, pain, quadriceps setting, rehabilitation exercise, straight-leg raises, total knee replacement Accepted for publication: 4 August 2013

Authors: Su-Ru Chen, PhD, RN, Assistant Professor, School of Nursing, College of Nursing, Taipei Medical University, Taipei; Chyang-Shiong Chen, BSN, RN, Head Nurse, Department of Nursing, Taipei Veterans General Hospital, Taipei; Pi-Chu Lin, EdD, RN, Associate Professor, School of Nursing, Master program

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287, doi: 10.1111/jocn.12466

in Long-term care, College of Nursing, Taipei Medical University, Taipei, Taiwan Correspondence: Pi-Chu Lin, Associate Professor, School of Nursing, College of Nursing, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan. Telephone: +886 2 27361661. E-mail: [email protected]

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Introduction Total knee-replacement (TKR) surgery can improve joint function and alleviate joint pain in patients with severe arthritis. In 2006, over 500,000 patients underwent TKR surgery in the USA. The number of TKR patients is increasing annually and is expected to reach 15 million by 2015. In Taiwan, approximately 20,000 patients undergo TKR annually (Kim 2008). Most TKR patients experience pain, joint stiffness, insufficient muscle strength and limited physical activity following surgery; therefore, postoperative care primarily focuses on pain management because pain affects patients’ ability to walk, exercise and engage in general activities (Akyol et al. 2009). When pain is managed, patients’ participation in rehabilitation increases (Duellman et al. 2009). A previous study showed that a lack of pain education impeded postoperative pain management (Grinstein-Cohen et al. 2009), and another study showed that health education reduced postoperative pain levels of patients who underwent orthopaedic surgery (Wong et al. 2010, Parker 2011). The early performance of rehabilitative exercises and outof-bed activities is important for TKR patients because it can prevent deep-vein thromboses and shorten recovery times. However, such activities can be extremely difficult because of postoperative pain. After surgery, patients should engage in rehabilitative exercises to restore their muscle strength and joint function of the affected leg, but one study showed that numerous TKR patients failed to implement an effective rehabilitation plan because of a lack of practical knowledge regarding the rehabilitation process (Parker 2011).

Background Previous studies showed that preoperative health education can effectively improve patients’ functional activities, reduce the length of stay (LOS) in hospital (Yeh et al. 2005), reduce the length of rehabilitation (Lin et al. 1997) and promote earlier standing ability (Giraudet-Le Quintrec et al. 2003). Yeh et al. (2005) used a multimedia compact disc (CD) with printed nursing guides for hip-replacement patient education and found that patients who received the educational intervention displayed significant improvements in self-efficacy, functional activities and LOS compared with control patients. Lin et al. (1997) used a preoperative instructional booklet and videotape to educate TKR patients and found that the experimental group performed exercises more frequently than the control group. In addi-

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tion, Wong et al. (2010) used a 30-min preoperative educational intervention for patients undergoing surgery for limb fractures and found that the experimental group had a significantly lower pain barrier and a lower intensity of pain. Johansson et al. (2005) reviewed 11 articles involving the preoperative education of adult orthopaedic patients and found that preoperative education impacted patients’ anxiety and knowledge levels. They concluded that although educational interventions considerably varied, the majority were based on the use of written materials alone or on written materials used in combination with other teaching methods. Other studies reported that educational interventions eliminate barriers to effective pain management (Carr 2007) and reduce analgesics use (Daltroy et al. 1998). In contrast, Kearney et al. (2011) found that patients who attended a preoperative education class showed no significant differences in LOS, ambulation distance, pain level or complication rates compared with those who did not attend the class. McDonald et al. (2004) searched multiple databases for randomised controlled trials of preoperative educational approaches, including verbal, written and audiovisual, that were used for patients undergoing a knee or hip replacement. In nine studies totalling 782 patients, the authors found no significant differences in LOS (four studies), mobility (four studies), postoperative pain (five studies), patient satisfaction (two studies) or complications (two studies) between patients who received preoperative education and those who did not. Therefore, McDonald et al. concluded that there was insufficient evidence to support or refute the use of preoperative education to improve the outcomes of patients undergoing total hip replacement (THP) or TKR. The findings of McDonald et al. (2004) clearly highlight the need for methodologically sound study designs for investigating the effects of patient education on clinical outcomes in TKR patients. A widely used technique was multimedia presentations that were shown to maintain users’ attention and enhance learning effectiveness (Yeh 2000). Therefore, we proposed that the use of a multimedia CD, combined with pamphlets for health education, would be effective for improving patients’ regularity of rehabilitation exercise, functional activities and pain management.

Study aims The aims of this study were to determine the effectiveness of cognitive-behavioural educational interventions for improving postoperative pain management, the recovery of physical functions and the performance of rehabilitative exercises by TKR patients.

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

Original article

Methods Study design We used a quasi-experimental design for our study. To avoid contamination between the experimental and control groups, we first enrolled patients in the control group, and the number of experimental patients recruited was based on the results of a power analysis. After the assessment of the control group was completed, treatment and assessment of the experimental group began. The experimental group received a cognitive-behavioural intervention that provided relevant health information and instructions on performing TKR rehabilitation treatment and pain management plans. Experimental patients were provided a health-educational CD and pamphlet, oral instructions were provided by the assigned nursing staff before undergoing TKR surgery, and enhanced instruction was given on postoperative day 1. The control group received routine care, and preoperative instructions were provided orally to the patients and their family members by the nursing staff responsible for the specific patients.

Ethical considerations This study was approved by the institutional review board of the hospital where the study was conducted. The researchers explained the research objectives and procedures for the study to patients who met the inclusion criteria. Written informed consent was obtained from all patients before their participation in the study.

Participants We enrolled 92 patients for our study from a single orthopaedic ward of a regional teaching hospital in Taipei City from September 2011–August 2012. Although patients were cared for by different surgeons, they received the same analgesic regime. The experimental group contained 42 patients, and 50 patients were assigned to the control group. A sample size of 42 participants per group was determined to be sufficient using G power software (Grant Devilly, Vic., Australia). We set a to 005, the effect size for pain to 055 (medium) and a power of 08 for our statistical analysis of the two study groups. Patients who met the following criteria were included in our study: (1) having received TKR for the first time, (2) being 18 years of age or older, (3) exhibiting ambulation and the ability to perform out-of-bed activities preoperatively and (4) being free of postoperative complications. Exclusion criteria were as follows: (1) being nonambulatory © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

Educational intervention for total knee-replacement patients

before surgery, (2) exhibiting symptoms of delirium after surgery, (3) bring restricted from postoperative out-of-bed activities or (4) presenting unstable vital signs necessitating intensive care after surgery.

Experimental intervention Education pamphlet and CD Educational pamphlets were compiled by researchers based on current literature and existing health-educational manuals and pamphlets from various research institutions. After the first draft, the pamphlets were reviewed by orthopaedic specialists and senior orthopaedic nurses for revision. Pamphlets consisted of information regarding preoperative and postoperative care, pain control, rehabilitative exercise practices, methods for safely rising from a bed and the use of walking aids. The health-educational CD contained videos that were based on the contents of the pamphlets and offered clear examples for patients. The videos were reviewed by experts in the field to ensure clarity and appropriateness of the content. Intervention process Experimental patients received the described cognitivebehavioural health-educational intervention. The purpose of the educational intervention was to enhance patients’ knowledge of pain control, postoperative rehabilitation and postoperative physical activities, thereby assisting them in acquiring the relevant skills by viewing the videos on the CD and listening to the information presented by the research staff. After hospitalisation, patients were given one-on-one health instruction using the educational CD and pamphlets. The educational intervention was performed by two trained senior ward nurses using identical methods. The researchers made arrangements for patients and their family members to watch the 10-minutes educational CD. Afterwards, a five-minutes discussion of the pamphlet was led by the research staff. The intervention was repeated one day after surgery to enhance effectiveness. Contents of the pamphlet included pre- and postoperative care, expected postoperative pain, pain assessment methods, pain management, cryotherapy, postoperative rehabilitative exercise (sports activities, methods, frequency and timing), methods for safely rising from a bed and the use of walking aids. Subsequently, a skill-teaching session that focused on demonstrations and drills was conducted, which lasted until the patient had learned to perform the movements correctly (approximately 10 minutes). Control patients received routine care, and all instructions were delivered orally to individual patients by the assigned nursing staff.

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Data collection Data collection was performed by a trained research assistant. The collection methods were as follows: (1) demographic characteristics and medical histories of patients were obtained from medical records, (2) an assessment of the patients’ physical function prior to hospitalisation was self-reported, (3) an assessment of actual physical function was conducted before discharge, (4) during the first five days after surgery, patients were questioned on a daily basis regarding the frequency of their rehabilitative exercises and (5) during the first five days after surgery, the muscle power of the affected leg and each patient’s pain index were assessed daily.

Instruments The study tools included the patients’ demographic characteristics and medical history, a numerical pain-rating scale, a functional status assessment and an exercise performance checklist. Basic information The patients’ basic information included age, gender, marital status, educational level, occupation and medical history. Numerical Pain-Rating Scale A verbal numerical rating scale (VNRS) was used to measure pain. Similar VNRSs are commonly used to assess pain and the effects of pain management. Such scales have the advantages of being quick and simple, requiring no equipment, being easy to understand and being independent of intact motor skills (Hartrick et al. 2003). Patients were instructed on the use of the VNRS before completing the assessment. Patients indicated the degree of pain they experienced on a scale of 0–10, with 0 representing no pain and 10 representing the worst pain possible. Using the scale, the patient indicated the worst pain experienced in the previous 24 hours, the average pain level experienced in the previous 24 hours and the level of pain experienced at the time the VNRS was completed. Functional status assessment A Chinese version of a functional status subscale was adapted from the Multidimensional Functional Assessment Questionnaire that was developed as part of the Older Americans Resources and Services programme (Williams et al. 1994). The original inventory assessed the recovery of patients with hip fractures after hospital discharge and

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comprised nine specific components, including eating, dressing/undressing, personal hygiene, bathing, getting into/out of bed, walking on level ground, using the toilet, rising from/sitting down on a chair and walking up/ down stairs. Each item was scored from 0–2 for a total score ranging 0–18. An internal reliability of 085–090 (Lin & Lu 2007, Lin et al. 2009) and an inter-rater reliability of 912% (Lin et al. 2009) were reported in studies on hip-fracture patients. The scale was also used in a study of postoperative pain in TKR patients (Lin et al. 2013). Exercise performance checklist The exercise checklist was used to assess the regularity of performing ankle pumping, quadriceps setting, straight-leg raises and knee flexion and extension exercises. Daily scores ranged 0–2, with a score of 0 indicating that the exercise was not performed, a score of 1 indicating that the exercise was performed occasionally and a score of 2 (routinely executed) indicating that the exercise was performed two or more times per day for five minutes or longer per session. The agreement of inter-rater reliability ranged from 83–100%, and the total mean agreement was 94%, according to the methods by Lin et al. (1997).

Results Basic information of study participants Among the 92 study participants, 29 respondents were men (315%) and 63 were women (685%). Participant ages ranged from 46–88 years, with a mean age of 6926  9025 years. Seventy-four participants were married (804%), and 16 were widowed (174%). Forty participants (435%) had an elementary school education. Eighty-three (902%) participants were unemployed, and 80 (87%) had a medical history other than TKR-related conditions, among whom 51 (638%) had hypertension. The demographic characteristics of the two study groups were compared using a chi-square test, and excluding gender (p > 005), no significant statistical differences between the two groups were identified, indicating that the data of the 2 groups were homogeneous (Table 1). The mean LOSs were 639  2407 days for the experimental group and 714  2248 days for the control group. These data indicated that there was no significant difference in the LOS between the study groups (t = 1257, p = 0213). However, the experimental group exhibited a trend towards a shorter LOS. All patients returned to their homes after discharge. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

Original article

Educational intervention for total knee-replacement patients

Table 1 Participants’ basic information

Variable Gender Male Female Mean age (years) Mean  SD (years) Marital status Married Widowed Unmarried Educational level Literate Elementary school Junior high school High school University Occupation No Yes

Exp group n (%)

Control group n (%)

Total (n = 92) n (%)

8 (190) 34 (810)

21 (420) 29 (580)

29 (315) 63 (685)

6890  8590

6956  9451

6926  9025

37 (881) 5 (119) 0 (0)

37 (740) 11 (220) 2 (40)

5 19 6 7 5

10 21 9 8 2

(119) (452) (143) (167) (119)

40 (952) 2 (48)

(200) (420) (180) (160) (40)

43 (860) 7 (140)

v2

p

5571

0018

74 (804) 16 (174) 2 (22)

3581

0310

15 40 15 15 7

(163) (435) (163) (163) (76)

5700

0337

83 (902) 9 (98)

2207

0137

Exp, experimental; SD, standard deviation of the mean.

Pain level Pain levels of experimental patients within the first 1–5 days after surgery were compared with those of the control group using t-tests. In general, pain levels reported by experimental patients were significantly lower than those of control patients during the first two days following surgery (Table 2). During the first day following surgery, average VNRS scores of the experimental group were lower for the worst pain experienced (t = 2427, p = 0017), average level of pain experienced (t = 2894, p = 0005) and current level of pain (t = 2461, p = 0016), compared with those of the control group. On the second day following surgery, average VNRS scores were lower in the experimental group for the worst pain experienced (t = 4958, p = 0000), average level of pain (t = 2829, p = 0006) and current level of pain (t = 2300, p = 0024), compared with those of the control group. On the third day, the average VNRS score for the worst pain experienced was lower (t = 3510, p = 0001) for the experimental group than for the control group.

Table 2 Pain indices reported by the two patient groups following total knee-replacement surgery Variable

Exp group

Worst pain experienced Postop day 1 812  Postop day 2 589  Postop day 3 545  Postop day 4 539  Postop day 5 557  Average pain level Postop day 1 455  Postop day 2 326  Postop day 3 295  Postop day 4 271  Postop day 5 243  Current pain level Postop day 1 400  Postop day 2 331  Postop day 3 269  Postop day 4 271  Postop day 5 257 

Control group

t

p

237 207 218 279 284

908 796 712 614 489

    

136 176 233 271 282

2427 4958 3510 1249 1027

0017* 0000* 0001* 0215 0308

253 213 192 231 203

592 442 300 286 238

    

200 179 175 188 197

2894 2829 0124 0342 0106

0005* 0006* 0901 0733 0916

257 206 234 231 226

542 456 244 236 246

    

290 297 242 275 231

246 2300 0501 1274 0207

0016* 0024* 0618 0206 0836

Exp, experimental; Postop, postoperative. *p < 005.

Functional status The overall ratings of the nine physical function items before discharge were 1205  3682 for the experimental group and 1238  2806 for the control group, with no significant difference observed between the study groups © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

(t = 0491, p = 0625; Table 3). Subsequently, a repeatedmeasures analysis of variance (ANOVA) was conducted to further analyse variances of the pretest and post-test and differences between study groups. The ANOVA results

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S-R Chen et al. Table 3 Physical functional status of participants

Variable

Experimental group Mean  SD

Control group Mean  SD

Physical function before hospitalisation Physical function before discharge

1780  0639 1238  2806

1710  1511 1205  3682

Repeated measures Within group F/p

Between groups F/p

22074/0000*

196/0165

SD, standard deviation of the mean. *p < 005.

showed that significant differences occurred between pretest and post-test performances (F = 220737, p = 0000), but no significant differences occurred between the 2 groups (F = 1962, p = 0165). Performances for eating (t = 3084, p = 0003) and walking up/down stairs (t = 3104, p = 0000) of the experimental group were superior to those of the control group.

Rehabilitation exercise performance Rehabilitation exercises included ankle pumping, quadriceps setting, knee flexion/extension and straight-leg raises. Performance of rehabilitation exercises within the first five days after surgery was examined. The regularity of the performance of straight-leg raises within the first five days after surgery significantly differed between the two groups (t = 4754, p = 0000; Table 4), whereas no significant differences occurred for the remaining exercises (p > 005). The experimental group scored higher on muscle power of the affected leg than the control group (p < 005). The mean muscle strength of the affected leg on the first day following surgery for the experimental group was 198  0869, whereas in the control group, it was

144  0644 (p = 0001). On the fifth day after surgery, the mean muscle strength of the affected leg of the experimental group was 371  0622, while that of the control group was 308  1090 (p = 0004).

Discussion Our results indicate that during the first two days after surgery, levels of pain experienced by the experimental group were lower than those reported by the control group. These findings are consistent with those of previous studies (Johansson et al. 2005, Wong et al. 2010). Educational interventions were proposed to reduce barriers to effective pain management (Johansson et al. 2005, Carr 2007) and pain levels (Wong et al. 2010). No significant differences in pain levels were observed between the study groups from day 3 onwards, especially regarding the average level of pain and current level of pain. It is possible that pain levels of the two groups decreased after the third day following surgery, but the sensitivity of the instrument was insufficient to demonstrate a statistically significant difference. Although patients’ functional activities improved, increased compliance with the exercise routine may have subse-

Table 4 Performance regularity of various rehabilitation exercises and muscle power of the affected leg (MPOAL)

Variable

Experimental group Mean  SD

Rehabilitation exercises (score range, 0–2) Ankle pumping 155 Quadriceps setting 017 Knee flexion/extension 044 Straight-leg raises 122 MPOAL (score range, 0–5) Postop day 1 198 Postop day 2 260 Postop day 3 298 Postop day 4 339 Postop day 5 371

Control group Mean  SD

t

p

   

039 039 053 258

154 023 069 064

   

044 043 066 056

009 064 189 475

0927 0518 0062 0000*

    

0869 0885 0780 0780 0622

144 198 250 295 308

    

0644 0892 0995 1033 1090

3393 3307 2518 2075 3005

0001* 0001* 0014* 0041* 0004*

Postop, postoperative. *p < 005.

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© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

Original article

quently increased pain. In clinical practice, TKR patients must begin rehabilitation exercises on the first day following surgery. As exercise is initiated, patients feel greater pain, and the pain subsides as they gradually adapt to the movements. Because the preoperative health education provided information regarding postoperative pain management, patients developed accurate concepts of pain control. Having an appropriate understanding of patient-controlled analgesia enabled patients to effectively manage pain, rather than merely tolerate it. Thus, superior pain management was achieved. This result is consistent with the findings of other studies (Johansson et al. 2005, Carr 2007, Cheng & Lu 2007, Wong et al. 2010, Papanastassious et al. 2011). Cheng and Lu (2007) examined the effects of pain-related health education for patients who had undergone spinal surgeries and found that the education effectively alleviated patients’ postoperative pain. Papanastassious et al. (2011) also confirmed that participants who attended preoperative patient education classes were more satisfied with the efficacy of pain management. However, other studies proposed that preoperative health education had no effect on postoperative pain control for joint-replacement patients (McDonald et al. 2004, Kearney et al. 2011). In their review of five independent studies, McDonald et al. (2004) found no significant differences between the levels of postoperative pain experienced by patients who received preoperative education and those who did not. Furthermore, Kearney et al. (2011) found that preoperative education had no significant effect on patients’ pain levels following joint-replacement surgery. These findings may be attributed to the additional guidance provided after surgery, as well as the educational invention prior to surgery. Our experimental group received a preoperative cognitive-behavioural educational intervention, in addition to routine care offered on the ward. The control group received only routine care. Results of our study indicate that although no significant differences between the study groups were observed for the total score of functional activities, the experimental group significantly outperformed the control group in terms of eating and walking up/down stairs. These results indicate that the health-educational intervention partially enhanced patients’ self-care skills, thereby contributing to recovery of their physical functions after surgery. These findings are consistent with the results reported by Yeh et al. (2005) regarding enhancement of patients’ functional activities through the use of multimedia-based health education. However, inconsistencies exist between our findings and those of 9 other studies on the © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

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use of health education prior to TKR surgery (McDonald et al. 2004), in the latter of which preoperative health education was found to have no effect on patient mobility. However, such inconsistencies may also be attributable to the guidance we provided to patients after surgery. One strength of our study was that we were able to more accurately identify the effects of our intervention on outcomes of the specific surgical group, TKR patients, which may account for conflicting results compared with previous intervention research that included both hip- and kneereplacement patients in the sample. Our results showed that among postoperative leg rehabilitative exercises assessed in our study, the regularity of the straight-leg raises for the experimental group was significantly better than that of the control group, and the muscle power of the affected leg in the experimental group was significantly greater than that of the control group. However, no significant differences were observed between the two groups for ankle pumping, quadriceps setting or knee flexion/extension exercises. Straight-leg raises are vital for rehabilitation after TKR surgery because they improve patients’ recovery of muscle strength in the lower limbs, enabling them to get out of bed and ambulate. These findings were similar to previous studies (Wong & Wong 1985, Lin et al. 1997). Preoperative education was proposed to enhance the regularity of exercise (including quadriceps setting, straight-leg raising, and knee flexion and extension) performance for TKR (Lin et al. 1997) and THR patients (Wong & Wong 1985). Although the experimental group exhibited improvements in recovering physical functioning and the regularity of rehabilitation exercise compared with the control group, no significant difference in the hospital LOS was observed between the study groups, consistent with the findings of Kearney et al. (2011) and McDonald et al. (2004). However, such results differ from the findings by Yeh et al. (2005). Thus, additional studies on the effects of educational interventions on the hospital LOS are warranted to resolve these inconsistencies. Furthermore, in the present study, the LOS for the experimental group was 075 days shorter (639 vs. 714) than the control group, which might be reflected in medical costs. In future studies, in addition to comparing the number of hospital days, medical costs could be another explored variable. Considering the time and space constraints that impinge on applying health education in clinical settings, CD-based materials represent a valuable medium because they can be viewed repeatedly and are more cost-effective than nurseled health education. The use of digital and printed media also ensures the consistency of the content of materials for

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health education designed to improve patients’ self-care abilities and behaviours. In addition, due to the general low educational level of our study participants, the use of a CD may be more suitable for these patients compared with written information. Therefore, the use of electronic material should be promoted as long as patients have access to the technology. In this study, we followed the outcomes of patients only for the first five days after surgery; future research could conduct a longer follow-up, to compare longer-term effects of differences between the two groups. Lastly, our study used a quasi-experimental design. The participants’ group assignments were not randomised. Future randomised studies are warranted to confirm our findings and resolve inconsistencies in the current knowledge base.

compliance and restore the muscle strength of the affected leg. The National Health Insurance system of Taiwan currently provides coverage for TKR surgery, but the LOS is reduced as much as possible, which may limit the use of health-educational programmes. The results of our study can be used as a reference for clinical practice, and the health-educational model can be included in the regular management and care of TKR patients. Specifically, our health-educational pamphlet and CD can be used by clinical nursing staff to improve the quality of TKR care.

Acknowledgement The authors thank all the patients who participated in this research for their cooperation.

Conclusions

Disclosure

Our results showed that TKR patients who received a cognitive-behavioural educational intervention performed significantly better than control patients in terms of their eating and stair-climbing abilities before discharge. The regularity of performing straight-leg raises following surgery was also improved following the pre- and postoperative use of health education, and the level of pain experienced by patients who received health education was lower than that of the control group during the first two days after surgery.

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Relevance to clinical practice Based on the results of our study, we propose the following recommendations. By highlighting postoperative cognitive and behavioural training, CD- and pamphlet-based health education can promote the recovery of physical functions, reduce pain levels, enhance the regularity of exercise

Funding This project was financially sponsored by the National Science Council (Grant No.: NSC 98-2314-B-038 -017 -MY3).

Conflict of interest The authors declare that no conflict of interest exists.

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© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 279–287

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The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.

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