1 Available online at Applied Nursing Research 21 (2008) Effect of telephone follow-up on surgical orthopedic recovery Marilyn J. Hodgins, RN, PhD a, 4, Louiselle L. Ouellet, RN, MN a, Sandra Pond, RN, BN b, Shelley Knorr, RN, BN b, Geri Geldart, RN, MHSA c a Faculty of Nursing, University of New Brunswick, Fredericton, New Brunswick, Canada E3B 5A3 b Orthopaedic Division, Dr. Everett Chalmers Hospital, Fredericton, New Brunswick, Canada E3B 5N5 c V.P. Hospital Care, River Valley Health Authority, Fredericton, NB, Canada E3B 5N5 Received 1 September 2006; revised 15 January 2007; accepted 19 January 2007 Abstract We examined the effect of telephone follow-up on surgical orthopedic patients postdischarge recovery. The sample consisted of 438 patients randomly assigned to receive routine care with or without telephone follow-up 24 to 72 hours after discharge (intervention). During the intervention, the nurse caller assessed each patient s status, identified problems, and provided needed follow-up care. Structured telephone interviews were conducted with all participants during the third week after their discharge. Key outcomes were self-reports of problems, progress, and unanticipated contact with the health care system. The primary self-reported problems were mood changes, constipation, pain, and swelling. Women and younger participants tended to report more problems. Availability of help was positively associated with progress. Although telephone follow-up did not affect the first two outcomes, it was associated with increased occurrence of health care contacts, as was living farther from the hospital. The study findings highlight the need to clearly explicate the requirements and outcomes for nurse-initiated telephone follow-up programs. D 2008 Elsevier Inc. All rights reserved. 1. Introduction The transition from hospital to home has long been recognized as a period of uncertainty and risk for many patients. Problems occurring during this period may adversely affect an individual s progress and sense of well-being. An intervention introduced by nursing staff to help ease the transition from hospital to home for surgical orthopedic patients was a postdischarge telephone call made by a registered nurse who was knowledgeable on each patient s in-hospital progress as well as the norms of recovery and potential complications. The perceived benefit of this intervention was the use of a relatively inexpensive technology (i.e., telephone) to which most people have access. However, this intervention was not without costs in that it temporarily removed a nurse from the care of inpatients. Given this, an investigation of the effects of this intervention was deemed necessary before its adoption as routine practice. A research team with representation from 4 Corresponding author. Tel.: ; fax: address: (M.J. Hodgins). the orthopedic service (program and unit manager plus a senior orthopedic nurse clinician) and the local university s faculty of nursing was established. A search of the CINAHL, MEDLINE, and PsycINFO databases was conducted using the search terms telephone, follow-up, transition, discharge, after care, and recovery. The search was limited to articles written in English and those dealing with the postdischarge experience of surgical patients. Twenty-three research articles that addressed the effectiveness of nurse-initiated telephone follow-up programs based on findings from descriptive (n = 11;Dewar, Scott, & Muir, 2004; Hartford, 2005; Heseltine & Edlington, 1998; Johnson, 2000; Jonas, 2003; Kleinpell, 1997; Lee, Wasson, Anderson, Stone, & Gittings, 1998; O Brien, Dennison, Breslin, & Beverland, 1999; Pidd, McGrory, & Payne, 2000; Savage & Grap, 1999; Thomson, Fletcher, Briggs, Barthram, & Cato, 2003), comparative (n = 5; Emerson, Gibbs, Harper, & Woodruff, 2000; Fallis & Scurrah, 2001; Harkness et al., 2005; Roebuck, 1999; Uppal et al., 2003), and quasi-experimental (n = 7; Bostrom, Caldwell, McGuire, & Everson, 1996; Boter, Mistiaen, & Groenewegen, 2000; Dewar, Craig, Muir, & Cole, 2003; /$ see front matter D 2008 Elsevier Inc. All rights reserved. doi: /j.apnr
2 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) Hartford et al., 2002; Middleton, Donnelly, Harris, & Ward, 2005; Phillips, 1993) studies were found. Although the focus of the descriptive studies was generally on the type and frequency of problems encountered after discharge, various outcomes were investigated in the remaining studies. These outcomes were grouped into the following themes: (a) problems or complications; (b) activity level or functional status; (c) emotional status (e.g., anxiety and depression); (d) unexpected contact with the health care system; (e) quality of life; (f) compliance with prescribed regimens; and (g) satisfaction with care. None of these outcomes was consistently affected by telephone follow-up. For example, satisfaction with care was observed to be higher among participants in the follow-up group in three of the five studies that investigated this outcome (significant difference: Fallis & Scurrah, 2001; Phillips, 2003; Uppal et al., 2003; nonsignificant difference: Bostrom et al., 1996; Weaver & Doran, 2001). Such inconsistencies hampered attempts to synthesize these studies. Various explanations have been postulated for the inconsistent findings regarding the effectiveness of telephone follow-up, including lack of a comparison group, insensitivity of measurement instruments (Boter et al., 2000; Hagopian & Rubenstein, 1990; Roebuck, 1999), problems with the dose (strength) or timing of the intervention (Boter et al. 2000; Roebuck, 1999), sample homogeneity (Boter et al., 2000; Phillips, 1993), and low statistical power (Hagopian & Rubenstein, 1990). Only one descriptive study examined the postdischarge experience of surgical orthopedic patients as reported during telephone follow-up (O Brien et al., 1999) despite the fact that this diverse patient population is at high risk for problems during the transition from hospital to home many of them are discharged with surgical incisions, medications with potentially serious side effects (e.g., anticoagulants), and orthopedic devices (e.g., casts and splints) that may impair their mobility and functional status. The team concluded that further research was warranted to evaluate the effectiveness of telephone follow-up in this population. 2. Study framework Demonstrating the impact of nursing interventions is essential within the current health care context of dwindling resources, increasing demands, and soaring costs. Intervention studies have three conceptual components: the intervention, outcome(s), and extraneous factors that may confound the results. During the planning stage, consideration was given to these components to (a) maximize the intervention effect, (b) select appropriate and sensitive outcomes, and (c) identify relevant extraneous factors Maximizing the intervention effect Efforts to maximize the intervention effect were hampered by the lack of an explicit framework outlining the mechanism by which telephone follow-up impacts recovery. The follow-up telephone call was conceptualized as providing the nurse caller with an opportunity to assess a patient s postdischarge status, identify actual or potential problems, and provide follow-up information, support, and/ or referral if warranted. Based on the results of the pilot study (Ouellet, Hodgins, Pond, Knorr, & Geldart, 2003), strategies were implemented to maximize the strength of the intervention. A standardized Follow-up Telephone Call form that addressed potential problems consistent with those included in the outcome questionnaire was developed. This form guided the sequencing of the telephone interaction and was used to document the nurse caller s assessment and any follow-up care provided Identifying outcome measures Attempts to articulate outcomes sensitive to nursing interventions have been ongoing for more than two decades (Griffiths, 1995). Hegyvary (1991) noted that the selection and measurement of relevant outcomes are not simple tasks and may vary greatly depending on the clinical situation. Despite this, few guidelines are available to assist in the selection of relevant outcomes or to determine their relative weighting in situations in which multiple outcomes are used. Because our review of the literature revealed that no outcome has consistently been affected by telephone followup, three outcome measures were selected to represent different aspects of the postdischarge experience: number of problems experienced, self-rating of progress, and unexpected contact with the health care system Recognizing relevant extraneous factors The postdischarge experience is affected by factors stemming from an individual s personal characteristics, underlying medical condition, and social situation (Mistiaen, Duijnhouwer, Wijkel, de Bont, & Veeger, 1997). Although Hegyvary (1991) emphasized the importance of accounting for factors that may confound the evaluation of nursing outcomes, Houston (1996) asserted that insufficient attention has been given to this task. For this study, possible factors that might confound the study findings were grouped into two categories: personal and situational Personal characteristics Personal characteristics, including age and prior health status, may impact individuals transition from hospital to home. The postdischarge problems experienced by elderly patients have been described by several authors (Jackson, 1994; Kain, 2000; Mistiaen et al., 1997; Naylor et al., 1999; Naylor et al., 1994). Jones et al. (2003) reported poorer outcomes for women and those with a poorer preoperative health status based on an investigation of the determinants of functioning after total knee arthroplasty Situational factors Situational factors impacting the postdischarge experience may arise directly from the surgical experience and from an individual s community; however, limited attention
3 220 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) has been given to these factors. Recent health care reforms have resulted in the amalgamation of health care services in larger communities. Although such restructuring may affect people s perceptions of access to health care, limited research has been conducted to determine its impact on the recovery process. In addition, given the seasonal extremes of Canada, perceptions of access to services and social support may vary depending on the time of year. Previous research suggested that social support plays an important function in health and well-being (Callaghan & Morrissey, 1993). Although support is conceptualized in various ways, instrumental support refers to the tangible services (i.e., help) received from family and friends. Availability of help may be extremely important for surgical orthopedic patients, especially for those discharged with devices that impede mobility and functional status. 3. Study design and objectives In this descriptive comparative study with random assignment to the intervention and control groups, the following research questions were posed: 1. What is the postdischarge experience of surgical orthopedic patients? 2. What personal and situational factors influence the transition from hospital to home? 3. What is the effect of a postdischarge telephone follow-up program on the postdischarge experience as measured by number of postdischarge problems, self-rated progress, and unanticipated contact with the health care system? 4. Methods The study population consisted of adult patients admitted for either elective or emergent orthopedic surgery to a regional referral hospital in Eastern Canada between January and December The selection and inclusion criteria required that the patients be (a) English speaking, (b) able to communicate by telephone, (c) free of mental confusion, and (d) discharged to a private residence. The required sample size was estimated based on a desired power of.80, a preset a of.05, 11 predictor variables, and an anticipated weak intervention effect (i.e., incremental change to R 2 of.02 in the multiple regression analysis as defined by Cohen, 1988). Using these criteria, we estimated that a minimum of 390 participants would be required to detect a difference in the number of postdischarge problems experienced by the intervention and control groups (Power and Precision Software, Release 2.1, Biostat Software Products, Englewood, NJ) Study protocol Approval for this study was obtained from the research ethics boards of the university and regional hospital corporation. Potential participants were approached before their discharge by a research assistant who explained the study purpose and requirements of participation. Patients were informed that factors influencing their postdischarge progress were to be investigated. They were not told that one aspect of the study involved investigating the effectiveness of a follow-up telephone call. This concealment was required to eliminate a potential source of response bias. If the patients were aware of this aspect, they might have altered their responses based on what they believed the nurses wanted to hear. After providing their written consent, the participants were randomly assigned to either the intervention group or the control group using presealed envelopes containing a label indicating group assignment (equal numbers per group). Participants in the control group received routine discharge instructions and care, whereas participants in the intervention group received routine discharge instructions and care plus a follow-up telephone call by a senior orthopedic nurse. The purpose of this intervention was to assess postdischarge recovery and provide follow-up care if needed. This call was completed 24 to 72 hours after the patients discharge. During the third week after their discharge (i.e., days), all participants were contacted by telephone to collect outcome data. This time frame was selected because it was believed that the most difficult period of the recovery process would have passed but still be easily recalled within this period. The calls were made by a research assistant who was blind to group assignment and trained in interviewing techniques. Before beginning the interview, each patient s willingness to participate was reestablished. The outcome questionnaire developed for this study was composed of the following sections: (a) presence and severity of 11 predefined problems (pain; activities of daily living; bowel habits; eating and meal preparation; swelling; emotional/ mood changes; social interactions; ability to perform prescribed exercises; use of orthopedic devices; wound care; and problems with blood [e.g., anticoagulation therapy or anemia]); (b) self-care practices (those who had experienced a particular problem were asked to describe actions taken, whereas those who had not were asked to describe what they would have done if a problem had occurred); (c) help systems (professional and nonprofessional) used since discharge; (d) perceived progress and satisfaction with the recovery process; and (e) demographic information. The questionnaire format consisted of a combination of Likert-type scales, numeric rating scales, fixed categorical options, and a few open-ended questions. During the development of the survey questionnaire, care was taken to ensure that descriptors used in items were appropriate for the diverse patient population. For example, items dealing with work were phrased to encompass paid employment, work within the home, and/or volunteer activities. Changes were made to the questionnaire based on the results of the pilot study (Ouellet et al., 2003). Finally, the questionnaire was loaded onto SUMQUEST Survey Software (SUMQUEST, Toronto, ON, Canada),
4 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) which enabled computer-assisted interviewing, to reduce coding errors and simplify completion of the interview. The average time consumed to complete the questionnaire was 29 minutes (SD = 13.2 minutes) Outcome measures Number of postdischarge problems A summative score was computed from participants reports of the presence or absence of the 11 predefined problems. Possible scores for this computed variable ranged from 0 to 11, with higher scores signifying more problems. It was assumed that multiplicity of problems would have a negative effect on the postdischarge experience Self-rating of progress Perceptions of progress since discharge were determined based on participants responses to three items on an 11- point numeric rating scale dealing with their physical, emotional, and general progress. Because Cronbach s a (.79) indicated an acceptable level of internal consistency for the three items, a variable was computed by summing participants scores for the three items. Possible scores for the computed variable ranged from 0 to 30, with higher scores indicating a higher level of progress. Because the distribution of scores for this variable was negatively skewed, scores were squared to obtain a distribution that more closely approximated a normal curve Unexpected contact with the health care system The final outcome measure was the proportion of participants who accessed health care services after discharge as a result of an unexpected problem related to their surgery (as opposed to a problem unrelated to surgery or a planned checkup). This contact included (a) telephone contacts, (b) home visits, (c) visits to physicians offices, clinics, or emergency departments, and (d) hospital readmissions Predictor variables Personal characteristics The effects of four personal characteristics were investigated in this study. These characteristics included age in years, sex (female sex was assigned a higher value), highest level of education (1 = lower than high school; 11 = university graduate degree), and self-reported rating of presurgery health on an 11-point numeric rating scale (0 = very poor; 10=excellent) Situational factors Data for three surgery-related factors were obtained from each patient s medical record. Elective versus emergency surgery was dichotomously coded, with emergency cases being assigned the higher value. Length of stay was measured in days. Type of procedure was also included as a predictor variable because clinicians on the research team proposed that patients undergoing arthroplasty receive the most standardized care because of the use of formalized postoperative care plans. They hypothesized that these care plans help streamline the recovery process. A dichotomous variable was therefore created, with arthroplasty coded as one and other procedures coded as zero. Data on three community factors were also collected. Distance from the referral hospital was measured in miles. Owing to a few extreme scores that skewed the distribution of scores, the maximum value was set at 250. Season of discharge was coded as a dichotomous variable, with months of more adverse conditions (i.e., October April) assigned the higher value. Availability of help was measured using a single item with a six-point scale (1 = more help than needed; 6 = no help available). This variable was reverse coded such that higher scores for all variables indicated more of the underlying concept Group assignment Participants assigned group was the final predictor variable. This variable was analyzed based on initial group allocation. The intervention group was assigned the higher value Data analyses Data analyses were conducted using SPSS version 12 (SPSS, Chicago, IL). Preliminary descriptive statistics were examined to evaluate data accuracy, identify potential outliers, and assess for violations in assumptions underlying regression analysis. Descriptive statistics were also run to provide a general description of the sample characteristics and to describe the nature and frequency of problems encountered by surgical orthopedic patients after discharge. Next, bivariate correlations were generated to examine the relationships among study variables and to detect potential collinearity problems among the predictor variables. Three hierarchical regression analyses were conducted (i.e., two multiple regressions and one logistic regression) to explain differences in participants postdischarge experiences. The same sequence was used for all analyses. In the first block, four variables pertaining to personal characteristics were entered. The six situational variables were entered in the second block after partialling out the effects of the personal characteristics. Variables entered in the first and second steps were viewed as relevant to the recovery process but not amenable to the intervention. Finally, participants assigned group was entered into the analysis to determine if telephone follow-up affected recovery outcomes beyond those attributable to the individual and situational characteristics. After each regression analysis, an examination of the residuals was conducted to assess for outliers and any evidence to suggest that the errors of prediction were caused by systematic variation rather than random error. 5. Results The final sample consisted of 438 participants. Of the 511 patients enrolled, 73 were lost to follow-up, resulting in an overall retention rate of 85.5%. Reasons for loss to
5 222 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) follow-up included the following: unable to be contacted for the outcome interview, n = 38; transferred to another unit, n = 20; declined to participate at the time of the outcome interview; n = 8; death, n = 2; problem with data entry, n = 1; and unspecified, n = 4. A number of the recruited cases (n = 22) were lost before their random group assignment, which was done immediately before the telephone follow-up. The sample consisted of 197 men (45%) and 241 women (55%) at a mean age of 59 years (range = years; Table 1). Approximately one third (37%) of the participants reported some postsecondary education. Three quarters (78%) had undergone elective surgery. Arthroplasty of a hip or knee was the most common surgical procedure (49%). The average length of hospital stay was 5.8 days (range = 1 28 days). No statistically significant difference was evident in the demographic characteristics of the participants based on group assignment using v 2 analysis, t test, or Mann Whitney U test. Table 1 Demographic characteristics of the sample (N = 438) by group Characteristic Intervention group (n = 216) Control group (n = 222) Age [years, M (SD)] 59.3 (15.4) 58.9 (15.7) Male [n (%)] 91 (42.1) 106 (47.7) Education, some 73 (34.2) 87 (39.9) postsecondary [n (%)] Prior health status, 11-point 7.4 (2.4) 6.8 (2.7) numeric rating scale [M (SD)] Distance from hospital 15.0 (0 to 250+) 19.0 (0.5 to 250+) [miles, Mdn (range)] Elective procedure [n (%)] 167 (77.7) 173 (77.9) Procedure, arthroplasty 102 (47.2) 98 (44.1) [hip/knee, n (%)] Length of stay [days, M (SD)] 5.8 (3.5) 5.5 (4.1) Season [May September, n (%)] 115 (53.0) 107 (48.2) Adequate help available [n (%)] 164 (76.4) 169 (76.1) With problems postdischarge 3.8 (1.9) 3.6 (2.0) [M (SD)] Problems reported (%) Average pain N3/10 in the past week Performing activities of daily living Bowel management Eating or meal preparation Swelling Emotional/mood change Doing prescribed exercises Orthopedic devices Wound care Blood (coagulation or anemia) Social interaction Progress [higher/better 24.2 (4.1) 24.3 (4.5) progress, M (SD)] Unexpected contact with the health care system (%) Intervention Two hundred sixteen patients were assigned to the intervention group. The postdischarge intervention telephone calls were conducted by seven senior orthopedic nurses, with most calls (78%) made by two members of the research team (SP and SK). Most of the calls were local (80%) and completed on the first or second postdischarge day (74%). One hundred eighty-one of the intervention calls were completed. For the remaining cases (n = 35), the nurse caller was unable to contact the patient or opted to leave a voice message. In 80% of the completed calls, the nurse spoke directly with the patient as opposed to a family member or caregiver. The median duration of these calls was 4 minutes (range = 1 30 minutes), with 96% completed within 10 minutes or less. Based on the nurses documentation, swelling (36%), pain (27%), and constipation (25%) were the most commonly reported problems. The primary nursing interventions were teaching (45% of cases) and reinforcement of current practices (38% of cases) Postdischarge experience Descriptive statistics for the three outcome measures suggest that the transition from hospital to home was relatively uneventful for most participants, although variability in responses was evident (Table 1). For example, using 11-point numeric rating scales, with higher scores indicating better progress, participants tended to rate their postdischarge physical (M = 8.0, SD = 1.7), emotional (M = 8.2, SD = 1.7), and general (M = 8.1, SD = 1.7) progress highly. Despite this, most reported an occurrence of problems. Only 12 participants (2.7%) reported not having encountered any problem. Emotional or mood change was the problem with the highest percentage of occurrence for the intervention and control groups (53.2% and 55.9%, respectively). Other problems experienced by more than 40% of the participants in both groups were in relation to bowel management, pain, swelling, and performing activities of daily living. In addition, 134 (30.6%) participants reported a total of 184 unexpected contacts with health care professionals as a result of a surgery-related problem. The observed rate of hospital readmission was 3.4% (n = 15). Reasons for readmission included the following: unable to manage; uncontrolled pain; dehydration; pneumonia; blood clot; and need for follow-up surgery. Statistically significant correlations were observed among the three outcome variables. The strongest correlation was between number of problems and rating of progress (r =.42, p b.001), suggesting that participants with more problems tended to report poorer progress Factors influencing the transition from hospital to home Results of the two hierarchical multiple regressions are presented in Table 2. Despite the number of predictor variables investigated, less than 10% of the variance in either outcome variable was explained. In the first step, sex
6 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) Table 2 Hierarchical regression of factors associated with participants rating of postdischarge outcomes Variable No. of problems Overall progress B weight (SE) t ( p) B weight (SE) t ( p) Step 1 Age 0.02 (0.01) 2.56 (.011) 1.07 (0.64) 1.66 (.098) Sex 0.61 (0.19) 3.17 (.002) 1.35 (19.53) 0.07 (.945) Education 0.03 (0.05) 0.71 (.478) 5.48 (4.53) 1.21 (.227) Prior health 0.07 (0.04) 1.91 (.057) 6.80 (3.77) 1.80 (.072) R F (df), p 4.69 (4, 416), (4, 413),.091 Step 2 Elective surgery 0.10 (0.26) 0.40 (.688) (25.45) 1.01 (.313) Arthroplasty 0.46 (0.24) 1.88 (.062) (24.02) 1.10 (.274) Length of hospital stay 0.07 (0.03) 2.25 (.025) 8.16 (3.12) 2.61 (.009) Poorer season 0.25 (0.19) 1.32 (.187) (18.62) 1.49 (.136) Distance from hospital 0.00 (0.00) 0.08 (.937) 0.30 (0.21) 1.47 (.142) Help postdischarge 0.15 (0.10) 1.44 (.150) (10.05) 4.43 ( b.001) R F (df), p 2.19 (6, 410), (6, 407), b.001 Step 3 Intervention group 0.20 (0.19) 1.07 (.287) ( 18.51) 0.90 (.376) R F (df), p 1.14 (1, 409), (1, 406),.376 Overall Total adjusted R F (df), p 3.03 (11, 409), b (11, 406), b.001 and age made significant contributions to predicting number of problems. Women and younger participants tended to report more problems after their discharge. Two variables played significant roles in the second set of predictors. Length of hospital stay was a significant predictor in both analyses. Longer hospital stays were associated with poorer postdischarge reports more problems and less progress. The availability of help after discharge was a predictor of better self-rated progress. The assigned intervention group did not help explain the variance in either of these outcome measures. Logistic regression was conducted to predict those who accessed health care services after their discharge as a result of an unexpected surgery-related problem. The results of the three-step hierarchical regression are presented in Table 3. None of the personal characteristics entered in the first block made a statistically significant contribution. After partialling out the effects of these variables, the six situational variables were entered. The addition of these variables resulted in a statistically significant improvement in the predictive capabilities, v 2 (6) = 13.45, p =.036, with one variable making a significant contribution. Participants who lived farther from the hospital had a higher-than-expected likelihood of accessing health care services. In the final block, intervention group assignment was entered. Inclusion of this variable made a significant contribution, with participants in the intervention group almost two times (1.8) more likely to report contact with the health care system. Table 3 Factors associated with unanticipated contact with the health care system using logistic regression Variable B weight Wald statistic ( p) Odds ratio (95% confidence interval) v 2 (df), p Step 1 Sex (.145) 1.38 ( ) 6.53 (4),.163 Age (.122) 0.99 ( ) Education (.235) 1.06 ( ) Prior health (.866) 0.99 ( ) Step 2 Elective/Emergency (.174) 0.66 ( ) (6),.036 Arthroplasty (.368) 0.78 ( ) Length of stay (.130) 1.06 ( ) Season discharged (.055) 1.53 ( ) Distance from hospital (.022) 1.01 ( ) Help received (.707) 1.05 ( ) Step 3 Intervention group (.007) 1.83 ( ) 7.51 (1),.006 Nagelkerke R 2 for the entire model =.089; Hosmer Lemeshow goodness of fit = 3.13, df =8,p =.926.
7 224 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) Participants perceptions of the value of the follow-up telephone call One of the last items on the questionnaire specifically asked whether the participant had received a telephone call from a nurse in the orthopedic unit. This item was added as a prompt for those who may have received but forgotten the follow-up call. Those who indicated that they had received a call were also asked to rate how helpful the call had been. More than 80% of the participants in the intervention group rated the call as helpful or extremely helpful. Midway through data collection, we realized that a relevant question had been omitted. After participants rated the helpfulness of the follow-up call, it was useful to ascertain their rationale for this rating. This item was subsequently added and completed by 135 participants in the intervention group. Responses were thematically coded into one of five categories: (a) social value or public relations (28%; e.g., bnice for them to call,q beven my car dealer calls to see how things are goingq); (b) utility value (25%; e.g., bopportunity to ask questions,q bget adviceq); (c) supportive value (25%; e.g., breassuring,q bboost confidenceq); (d) multiple source value (11%; i.e., combination of utility, supportive, and social values); and (e) no value. Only 11% of the participants (n = 15) who had received a follow-up call perceived that it had no value. 6. Discussion 6.1. Postdischarge experience The study findings highlight the multiplicity of problems experienced by surgical orthopedic patients after their discharge from the hospital. Although it is reassuring that most participants rated their postdischarge experience positively, the findings suggest that more can be done to improve the postdischarge experience. For example, the finding that more than 40% of the participants reported problems with swelling, bowel management, and/or pain needs to be interpreted in light of the fact that these problems are generally predictable and largely preventable. Although the predictor variables included in the regression analyses were selected because they were believed to affect surgical orthopedic patients postdischarge experience, the proportion of variance actually explained by these variables was extremely limited. Personal nonmodifiable characteristics made a small but statistically significant contribution to explaining differences in outcomes. Women appeared to have poorer experiences after discharge. Various explanations may be put forward to explain this finding. The simplest explanation would be to attribute findings to a bias in participants willingness to admit difficulty: Men may be more stoic than women. An alternative explanation may point to differences in the roles assumed by men and women within the home and as informal caregivers. Because women still assume primary responsibility for housekeeping duties and child care within the home (Meleis & Lindgren, 2001, 2002), they may feel pressured to resume these roles. As one woman reported, bi needed a wife when I first went home.q Although age-related differences were anticipated, the direction of the observed association was unexpected. Generally, younger participants reported more difficulty during the postdischarge period. Once again, various explanations can be offered for this finding. One explanation is that an age bias exists in willingness to admit difficulty: Older people are more stoic or have lower expectations for their recovery than younger people. An alternative explanation may relate to the roles assumed by older and younger people within the community. Younger patients may have more pressure and impatience to hasten their recovery because of work and family responsibilities. This explanation is supported by the comment of one young woman who stated, bi have three young children. We couldn t afford for my husband to stay home or to hire help.q The six situational variables included in the regression also had limited predictive capabilities. Distance from the hospital was associated with unexpected use of health care services. Because of the recent trend to amalgamate services in larger centers, the implication of this finding for health care use patterns warrants further investigation. Participants who reported inadequate help also tended to rate their progress as poorer as compared with those who had adequate help. Mandy, Pearman, and Ross (2000) observed that patients without adequate support were more vulnerable in the early postdischarge period in a longitudinal study on 29 patients who underwent elective hip arthroplasty. Such findings warrant consideration especially when dealing with an older patient population whose primary source of help may be a spouse who may also have health problems. For example, the primary source of help for one participant was a family member who had undergone arthroplasty the previous month Implications for clinical practice The findings from this study provide a systematic description of the postdischarge experience of surgical orthopedic patients that may assist nurses involved in the care of these patients to help ensure their readiness for discharge. Nurses play a pivotal role in the assessment and management of symptoms, such as pain, constipation, and swelling, during patients hospital stay. However, given the reality of shorter hospital stays, patients are assuming responsibility for their care much earlier in the recovery process. If patients are to effectively take on this role, they must be equipped with the requisite knowledge and skills to proactively manage their condition. Patients need to understand that symptoms, such as pain, constipation, and swelling, negatively affect their recovery as well as know when and how to intervene to prevent problems. Equipping patients to proactively manage their symptoms may not be feasible during the acute postoperative period. A more appropriate time, at least for those undergoing elective procedures, may be during the preadmission clinic visit. The
8 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) value of such clinics could be enhanced by expanding their mandate so that they prepare patients not only for their hospitalization but also for their subsequent discharge. The limited explanatory power of the predictor variables examined in this study suggests that most patients might benefit from such preparation Effectiveness of the telephone intervention The absence of a statistically significant intervention effect on postdischarge outcomes was disappointing. One explanation for this finding was the lack of resources specifically targeted to support implementation of this intervention. These calls were added to nurses regular work. Other factors warranting consideration are the timing and duration of the calls. Most calls were completed on the day after the patients discharge. This could have been too early as participants may not have settled into their home environment or thought sufficiently about how they would manage. However, based on the finding by Chewitt, Fallis, and Suski (1997) that almost 50% of the 356 calls received by their surgical call-in line were within 48 hours of discharge, follow-up calls should occur relatively early in the postdischarge period. Finally, the short duration of the follow-up calls may have contributed to the lack of a significant intervention effect (i.e., low dose of intervention). Although these calls were conducted by senior orthopedic nurses who were knowledgeable on the patients inhospital progress, 4 minutes is a short interval in which to outline the purpose of the call, conduct a comprehensive assessment, and initiate appropriate follow-up care. Few recommendations have been made regarding the time required to conduct telephone follow-up. Of 11 studies that investigated surgical patients postdischarge experience and that which provided information on the duration of the calls (Bostrom et al., 1996; Dewar et al., 2004; Hartford, 2005; Hartford et al., 2002; Heseltine & Edlington, 1998; Lee et al., 1998; O Brien et al., 1999; Phillips, 1993; Pidd et al., 2000; Roebuck, 1999; Weaver & Doran, 2001), 6 reported durations of 10 minutes or less. Requirements for the duration of contact as well as the qualifications of the caller may vary depending on the desired goals of a telephone follow-up program. In this study, participants perceived the follow-up telephone call in different ways. If the desired program goal is to improve public relations (social), then limited contact is probably sufficient. However, if the desired goal is utilitarian and/or supportive to prevent or reduce the severity of postdischarge complications and unnecessary use of costly health care services (e.g., emergency department or readmission), then adequate time must be allocated for a thorough assessment of a patient s postdischarge status and the delivery of required interventions. The observed rate of hospital readmission and the statistically significant effect of the intervention on health care service use are noteworthy. Interpreting the significance of a readmission rate of 3.4% is difficult because of the absence of established norms what is the expected rate of readmission for surgical orthopedic patients within the first 2 weeks of discharge? In this study, the actual number of readmissions was too low to permit analysis of the factors related to it. However, given the cost of a hospital stay, each readmission should be evaluated to determine whether it was preventable. Various explanations may be offered for the statistically significant effect of the intervention on participants postdischarge contact with health care services as a result of a surgery-related problem. One possible explanation is simply that the telephone follow-up program increased patterns of health care use. However, it is important to note that this outcome referred to all forms of contact and not merely hospital readmissions. An alternative explanation is that hospital readmissions may have been prevented by the use of alternative contacts, such as a telephone call and/or an office visit. Many participants may have perceived the follow-up call as dealing with a problem although the nurse caller particularly stated that the purpose of the call was to check on each patient s progress. It is also possible that this early contact prevented the development of more serious problems requiring hospitalization Implications for clinical practice Despite or perhaps because of the study findings, the postdischarge telephone follow-up program continues. The rationale for the continuation of this program is that most study participants rated the call as helpful and nurse callers continue to document problems. Continuation of this program also demonstrates the value placed by the orthopedic nurses on these telephone calls. However, this situation does raise questions as to the actual impact of research on clinicians practice. Staff on the unit did not perceive study findings to be clinically significant at least to the extent of affecting a change in current practice. A recommendation for the planning stage of future intervention studies is to ensure that discussions take place not only to maximize the intervention effect, select appropriate and sensitive outcomes, and identify relevant extraneous factors but also to define the conditions in which the intervention would be adopted/rejected. Nurses directly involved in the delivery of the intervention need to assume a lead role in defining these conditions to promote the integration of research into practice. 7. Conclusions The study findings highlight factors influencing the postdischarge experience of surgical orthopedic patients. Although most participants reported a high level of progress since their discharge, they also reported a number of problems. Work is needed to explicate the critical requirements of a telephone follow-up program when, how, what, and to whom should this nursing intervention be administered. Such work would be facilitated by the establishment
9 226 M.J. Hodgins et al. / Applied Nursing Research 21 (2008) of a standardized set of outcome measures to promote the synthesis of findings and encourage meta-analysis across studies. To support the development and sustainability of an effective telephone follow-up program, adequate resources, including funding and staff, need to be secured before its implementation. The resources allocated to telephone follow-up should also reflect the articulated goals and desired outcomes of the program. Acknowledgments This research was supported by a grant from the Medical Research Fund of New Brunswick. We wish to acknowledge the contributions of Janice Arsenault, research assistant, and the staff of 4NE to the successful completion of this study. References Bostrom, J., Caldwell, J., McGuire, K., & Everson, D. (1996). Telephone follow-up after discharge from the hospital: Does it make a difference? Applied Nursing Research, 9, Boter, H., Mistiaen, P., & Groenewegen, I. (2000). A randomized trial of a telephone reassurance programme for patients recently discharged from an ophthalmic unit. Journal of Clinical Nursing, 9, Callaghan, P., & Morrissey, J. (1993). Social support and health: A review. Journal of Advanced Nursing, 18, Chewitt, M. D., Fallis, W. M., & Suski, M. C. (1997). The surgical hotline: Bridging the gap between hospital and home. Journal of Nursing Administration, 27(12): Cohen, J. (1988). Statistical power analysis for the behavioral sciences. (2nd ed). Hillsdale, NJ7 Lawrence Erlbaum. Dewar, A., Craig, K., Muir, J., & Cole, C. (2003). Testing the effectiveness of a nursing intervention in relieving pain following day surgery. Journal of Ambulatory Surgery, 10, Dewar, A., Scott, J., & Muir, J. (2004). Telephone follow-up for day surgery patients: Patient perceptions and nurses experiences. Journal of Perianesthesia Nursing, 19, Emerson, C., Gibbs, L., Harper, S., & Woodruff, C. (2000). Effect of telephone followups on post vasectomy office visits. Urologic Nursing, 20, Fallis, W. M., & Scurrah, D. (2001). Outpatient laparoscopic cholecystectomy: Home visit versus telephone follow-up. Canadian Journal of Surgery, 44, Griffiths, P. (1995). Progress in measuring nursing outcomes. Journal of Advanced Nursing, 21, Hagopian, G. A., & Rubenstein, J. H. (1990). Effects of telephone call interventions on patients well-being in a radiation therapy department. Cancer Nursing 13, Harkness, K., Smith, K. M., Tarabe, L., MacKenzie, C. L., Gunn, E., & Arthur, H. M. (2005). Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery. Heart & Lung, 34, Hartford, K. (2005). Telenursing and patients recovery from bypass surgery. Journal of Advanced Nursing, 50, Hartford, K., Wong, C., & Zakaria, D. (2002). Randomized control trial of a telephone intervention by nurses to provide information and support to patients and their partners after elective coronary artery bypass graft surgery: Effects of anxiety. Heart & Lung, 31, Hegyvary, S. T. (1991). Issues in outcomes research. Journal of Nursing Quality Assurance, 5, 1 6. Heseltine, K., & Edlington, F. (1998). A day surgery post-operative telephone call line. Nursing Standard, 13, Houston, S. (1996). Getting started in outcomes research. AACN Clinical Issues: Advanced Practice in Acute Critical-Care Nurses, 7, Jackson, M. F. (1994). Discharge planning: Issues and challenges for gerontological nursing. A critique of the literature. Journal of Advanced Nursing, 19, Johnson, K. (2000). Use of telephone follow-up for post-cardiac surgery patients. Intensive and Critical Care Nursing, 16, Jonas, D. A. (2003). ParentTs management of their child s pain in the home following day surgery. Journal of Child Health Care, 7, Jones, C. A., Voaklander, D. C., & Suarez-Almazor, M. E. (2003). Determinants of function after total knee arthroplasty. Physical Therapy, 83, Kain, H. B. (2000). Care of the older adult following hip fracture. Holistic Nursing Practice, 14, Kleinpell, R. M. (1997). Improving telephone follow-up after ambulatory surgery. Journal of Perianesthesia Nursing, 12, Lee, N. C., Wasson, D. R., Anderson, M. A., Stone, S., & Gittings, J. A. (1998). A survey of patient education postdischarge. Journal of Nursing Care Quality, 13, Mandy, A., Pearman, A., & Ross, K. (2000). Postdischarge support for elective hip arthroplasty patients. Physiotherapy Theory and Practice, 16, Meleis, A., & Lindgren, T. (2001). Show me a woman who does not work! Journal of Nursing Scholarship, 33, Meleis, A. I., & Lindgren, T. G. (2002). Man works from sun to sun, but women s work is never done: Insights on research and policy. Health Care for Women International, 23, Middleton, S., Donnelly, N., Harris, J., & Ward, J. (2005). Nursing intervention after carotid endarterectomy: a randomized trial of Co-ordinated Care Post-Discharge (CCPD). Journal of Advanced Nursing, 52, Mistiaen, P., Duijnhouwer, E., Wijkel, D., de Bont, M., & Veeger, A. (1997). The problems of elderly people at home one week after discharge from an acute care setting. Journal of Advanced Nursing, 25, Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M.D., Pauly, M. V., et al (1999). Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA, 281, Naylor, M. D., Brooten, D., Jones, R., Lavisso-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine, 120, O Brien, S., Dennison, J., Breslin, E., & Beverland, D. (1999). A review of an orthopaedic outcome assessment telephone follow-up helpline and nursing advice service. Journal of Orthopaedic Nursing, 3, Ouellet, L. L., Hodgins, M. H., Pond, S., Knorr, S., & Geldart, G. (2003). Post-discharge telephone follow-up for orthopaedic surgical patients: A pilot study. Journal of Orthopaedic Nursing, 7, Phillips, C. Y. (1993). Postdischarge follow-up care: Effect on patient outcomes. Journal of Nursing Care Quality, 7, Pidd, H., McGrory, K. J., & Payne, S. R. (2000). Telephone follow-up after urological surgery. Professional Nurse 15, Roebuck, A. (1999). Telephone support in the early post-discharge period following elective cardiac surgery: Does it reduce anxiety and depression levels? Intensive and Critical Care Nursing, 15, Savage, L. S., & Grap, M. J. (1999). Telephone monitoring after early discharge for cardiac surgery patients. American Journal of Critical Care, 8, Thomson, P. J., Fletcher, I. R., Briggs, S., Barthram, D., & Cato, G. (2003). Patient morbidity following oral day surgery Use of a post-operative telephone questionnaire. Journal of Ambulatory Surgery, 10, Uppal, S., Nadig, S., Mielcarek, M. W., Smith, L., Jose, J., & Coatesworth, A. P. (2003). Patient satisfaction with conventional and nurse-led telephone follow-up after nasal septal surgery. International Journal of Clinical Practice, 57, Weaver, L. A., & Doran, K. A. (2001). Telephone follow-up after cardiac surgery: Facilitating the transition from hospital to home. American Journal of Nursing, 101(5), Critical Care Extra, 24OO, 24QQ, 24SS passim.