Elsevier

Australian Critical Care

Volume 29, Issue 1, February 2016, Pages 35-40
Australian Critical Care

Research paper
Patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery

https://doi.org/10.1016/j.aucc.2015.04.001Get rights and content

Abstract

Background

Clinical interventions aimed at reducing the incidence of postoperative pulmonary complications necessitate patient engagement and participation in care. Patients’ ability and willingness to participate in care to reduce postoperative complications is unclear. Further, nurses’ facilitation of patient participation in pulmonary interventions has not been explored.

Objective

To explore patients’ ability and willingness to participate in pulmonary interventions and nurses’ facilitation of pulmonary interventions.

Design

Single institution, case study design. Multiple methods of data collection were used including preadmission (n = 130) and pre-discharge (n = 98) patient interviews, naturalistic observations (n = 48) and nursing focus group interviews (n = 2).

Setting

A cardiac surgical ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia.

Participants

One hundred and thirty patients admitted for cardiac surgery via the preadmission clinic during a 1-year period and 40 registered nurses who were part of the permanent workforce on the cardiac surgical ward.

Outcome measures

Patients’ understanding of their role in pulmonary interventions and patients’ preference for and reported involvement in pulmonary management. Nurses’ facilitation of patients to participate in pulmonary interventions.

Results

Patients displayed a greater understanding of their role in pulmonary interventions after their surgical admission than they did at preadmission. While 55% of patients preferred to make decisions about deep breathing and coughing exercises, three-quarters of patients (75%) reported they made decisions about deep breathing and coughing during their surgical admission. Nurses missed opportunities to engage patients in this aspect of pulmonary management.

Conclusions

Patients appear willing to take responsibility for pulmonary management in the postoperative period. Nurses could enhance patient participation in pulmonary interventions by ensuring adequate information and education is provided. Facilitation of patients’ participation in their recovery is a fundamental aspect of care delivery in this context.

Introduction

Worldwide, the notion of patient participation has been integrated into health care policy1 and is proposed to play a role in improving the quality and safety of health care.2 One aspect of acute care where patient participation is likely to impact on many patient and organisational outcomes is in the context of post-cardiac surgical recovery. Cardiac surgery, that requires cardiopulmonary bypass, is associated with decreased pulmonary residual capacity, diaphragmatic dysfunction, impaired gas exchange and alteration in pulmonary defence mechanisms exposing patients to an increased risk of pulmonary complications.3 Pulmonary complications include atelectasis and pneumonia and account for a substantial increase to length of stay, associated cost and morbidity and mortality4 and have been reported to occur in 8–79% of patients following cardiac surgery.5 Pulmonary complications are considered modifiable adverse events and the incidence of pulmonary complications is used as a measure of the quality and safety of care.

Various interventions have been recommended to decrease the risk of pulmonary complications following surgery.4, 6 One intervention is patient-performed pulmonary exercises in the form of deep breathing and coughing where the goals are the improvement of pulmonary function via lung expansion and enhanced mucous clearance.7 In recent years, the benefit of performing prophylactic, voluntary, pulmonary exercises has been questioned from a physiological perspective,8, 9, 10 however deep breathing and coughing exercises remain a common respiratory intervention following cardiac surgery.11, 12, 13

Findings of a recent study suggest use of a standardised postoperative care program emphasising patient education, early mobilisation and pulmonary interventions, reduced the incidence of postoperative pneumonia and unplanned intubation of patients.14 The performance of pulmonary interventions including deep breathing and coughing exercises requires patient participation yet patients’ ability and willingness to participate in pulmonary interventions is unclear. Further it is not known how nurses facilitate deep breathing and coughing exercises though it is clear that explaining their importance, ensuring correct technique, and providing adequate pain relief11, 12, 13 are vital related activities.

The study reported in this paper is situated within a large mixed methods exploration of the enactment of patient participation following cardiac surgery. Patient participation in medication and pain management has been reported previously.15, 16 The aim of this paper was to explore patients’ ability and willingness to participate in pulmonary interventions and nurses’ facilitation of participation in pulmonary interventions.

The specific research questions were:

  • 1.

    Do patients know the importance of deep breathing exercises and coughing, the technique for performing deep breathing exercises and coughing, and the need for adequate pre-exercise analgesia?

  • 2.

    What is patients’ preference for participation in deep breathing and coughing exercises?

  • 3.

    Is patients’ experience of participation in deep breathing and coughing exercises commensurate with their preferred participation in deep breathing and coughing exercises?

  • 4.

    How do nurses facilitate patient participation in deep breathing exercises and coughing?

Section snippets

Methods

To explore patient participation in pulmonary interventions to reduce postoperative pulmonary complications following cardiac surgery, a mixed-method approach was used in a single institution, case study design. Case study is “the study of the particularity and complexity of a single case, coming to understand its activity within important circumstances”17 and is the method of choice when a contemporary phenomenon, such as patient participation, is located within a real-life context.18, 19

Results

Table 1 depicts patients’ characteristics. The average age of patients was 65.5 (SD = 12.2) years. Thirty-seven per cent (n = 36) of patients had an education level equivalent to or greater than successful completion of high school. For the majority of patients (86%), the main language spoken at home was English. Characteristics of the patients who participated in the naturalistic observations and patients who did not, were similar except for the sex distribution in the observed patient group due

Discussion

In general, patients displayed a greater understanding of their role in deep breathing and coughing exercises following their surgical admission in terms of the technique, their importance in avoiding complications and the requirement for adequate pain relief in order to deep breathe and cough effectively. However, clear deficits in patients’ knowledge remained following surgical intervention. Specifically only 64% of patients were able to state the importance of deep breathing and coughing

Conclusion

Most patients’ preferred and reported making decisions about deep breathing and coughing exercises during their hospital admission. Overall patients’ understanding of deep breathing and coughing exercises improved as a function of surgical admission but there were gaps relating to the importance of managing pain in order to deep breathe and cough effectively.

The majority of patients felt confident to take control of their deep breathing and coughing exercises without input from nurses.

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