Evaluation of patient preparation for hospital discharge after gastrectomy

INTRODUCTION

Gastric cancer is one of the leading causes of cancer deaths worldwide [1] and is considered one of the most com-mon malignant tumours of the gastrointestinal tract [2]. Studies indicate that this type of cancer is most often diagnosed in people between the ages of 60 and 70 years, and more often in men than in women [3, 4]. In Poland, the incidence of gastric cancer is at an average level; unfortunately, its advanced course at the time of diagnosis prevents surgical treat-ment leading to recovery [5]. The disease affects about 5000 people a year, and 90% of them die [3, 4]. The 2021 can-cer data for Poland indicate that 3230 men (3.8%) and 1870 women (2.2%) developed gastric cancer in 2019 [5].
Gastric cancer is a challenge for modern medicine due to the implementation of combined treatment in the form of radiotherapy or chemotherapy with surgical treatment and a high mortality rate [3, 4]. Surgical treatment and chemo-therapy are among the standard treatments for gastric cancer [6]. Therapeutic management of patients with gastric cancer is aimed at rapid recovery, which is also possible through preoperative patient education [7]. Therefore, it is im-portant to prepare patients for self-care by providing them with the knowledge of proper management [8].
The patient education in the provision of medical care shapes their attitudes that build responsibility for their own health [9], allows mitigation of the effects of the disease, and reduces complications [9]. Patient education emphasizes the patient’s active participation and the principle of partnership, resulting in effective treatment [9], as well as the need to include not only the patient, but also his/her family [10, 11]. Education provided by nurses follows from the princi-ples of nursing care and is aimed at imparting knowledge in relation to the patient’s resources, improving his/her func-tioning in the new situation caused by disease and surgery [9]. Providing education as defined by law is the responsibil-ity of health care professionals [12]. Nowadays, increasing importance is attributed to educational issues in the course of training future nursing students, which is reflected in educational standards [13].
The aim of this study was to evaluate the preparation of patients for discharge from the hospital after total gastrec-tomy.

MATERIAL AND METHODS

The study was conducted in 2021 among 71 patients of the University Hospital and the Stefan Żeromski Specialized Hospital in Cracow, after obtaining written consent from the directors of both institutions. Criteria for patients in the study included status after total gastrectomy for cancer, female and male gender, majority, and receipt of hospital dis-charge. The study planning did not divide the subjects according to the method of surgical treatment (open or laparo-scopic), but open laparotomy was preferred due to the cancer stage and the need for total gastrectomy.
were informed before participating in the study about its purpose and conduct, how to complete the survey instruments, the use of data, as well as anonymity and the possibility of opting out at any stage of the study without giving a reason. Patients’ participation in the study (on the day of discharge from the hospital) was preceded by their verbal, informed, and voluntary consent.
The method used in the study was a diagnostic survey. The tools used are the author’s survey questionnaire and the ISEL-40 v. GP, GSES, and AIS scales. The author’s survey questionnaire, in addition to questions on sociodemographic data, included questions about the disease, knowledge of postoperative management, and health education. Questions on subjective evaluation of knowledge allowed respondents to indicate an answer of either “yes”, “no”, or “I don’t know.” Objective assessment of knowledge was carried out by selecting all correct answers indicated by the respondents. Sub-jective and objective assessment included knowledge of complications after gastrectomy, diet, postoperative wound care, treatment, and follow-up examinations.
The Cohen’s Social Support Evaluation Scale (ISEL 40 v. GP; Polish adaptation by Zarzycka et al.) evaluates the po-tential perceived possibility of receiving social support. The scale consists of 4 subscales, allowing a score from 0 to 40, with individual scales ranging from 0 to 10 [14]. The Generalized Self-Efficacy Scale (GSES) measures an individual’s sense of effective coping in difficult situations. The overall score is between 10 and 40 points. Scores can be assessed on the basis of sten scores. The authors of the Polish version are Schwarzer et al. [15]. The Acceptance of Illness Scale (AIS) (developed by Felton et al., Polish adaptation by Juczyński) assesses the acceptance level of the disease. The total score ranges from 8 to 40 points: 20 points – poor acceptance of the disease, 20-30 points – medium acceptance of the dis-ease, above 30 points – high acceptance of the disease [15]. Statistical analysis was carried out using the Statistica 13.1 package. Tests were used to analyse variables: W Shapiro-Wilk, Mann-Whitney, and Pearson’s χ² . The statistical signifi-cance level was adopted as p < 0.05

RESULTS

Most of the subjects were men (60.6%), and the percentage of women was 39.4%. The youngest person was 42 years old, and the oldest was 76 (mean age 62.32). Most of the respondents lived in a city with a population of more than 500,000 (22.5%), were married (42.3%), and had a university education (33.8%). The majority of people (49.3%) had been diagnosed with gastric cancer 6 to 12 months before participating in the study. In 49.3%, up to 5 months had elapsed between diagnosis and gastrectomy. The high percentage of people awaiting surgery for more than 5 months was due to the SARS-CoV-2 pandemic. In 2020, surgical wards reduced the number of places by up to a half, which was related to patients having a longer wait for hospitalization, treatment, and changes in treatment plans com-pared to the primary arrangements. Chemotherapy was implemented before surgery in 62.0% of the subjects. Com-plementary treatment after surgery was planned in 62.0% of the subjects, most often as chemotherapy (39.4%). The time from gastrectomy to hospital discharge was 10–14 days for 50.7% of the subjects, and 7-9 days for 19.7%. No patient stayed in the hospital for less than 6 days.

SUBJECTIVE AND OBJECTIVE EVALUATION OF THE SUBJECTS’ KNOWLEDGE IN TERMS OF MANAGEMENT AFTER GASTRECTOMY

SUBJECTIVE EVALUATION OF THE SUBJECTS’ KNOWLEDGE
The respondents made an evaluation of their knowledge of post-gastrectomy management. Patients declared their knowledge of possible complications after gastrectomy (50.7%), management of gastric dumping syndrome (59.2%), diet (71.8%), postoperative wound care (84.5%), knowledge of check-ups (52.1%), effects of medications (74.6%), complementary treatment (60.6%), as well as awareness of regular check-ups (84.5%) and taking medications (88.7%). The answers given by the respondents showed that 38.0% rated their knowledge as “good”, 33.8% as “suffi-cient”, 15.5% as “very good”, and 12.7% as “insufficient”. The study attempted to determine whether patients had knowledge of selected issues regarding the management after gastrectomy and how they rated it themselves. The pro-posed scale from “very good” to “insufficient”, where very good meant a high level of knowledge and insufficient meant a poor level of knowledge, was intended to facilitate their subjective assessment of this knowledge.
OBJECTIVE EVALUATION OF THE SUBJECTS’ KNOWLEDGE
In order to objectively evaluate the subjects’ knowledge, 3 thresholds were assumed depending on the number of correctly answered questions: < 50.0% – low level, 50.0-75.0% – medium level, and > 75% – high level. The following are the results indicating correct answers, categorized as medium and high level of knowledge:
• complications after gastrectomy: gastric dumping syndrome (83.1%), anaemia (64.8%), weight loss (62.0%), reflux oesophagitis (63.4%);
• symptoms of gastric dumping syndrome: onset 10-15 minutes after a meal (87.3%), abdominal pain and a feeling of fullness in the epigastrium (80.3%), nausea and vomiting (78.9%), diarrhoea (71.8%). Symptoms of late gastric dumping syndrome: 1.5-2 hours after a meal (93.0%), symptoms of hypoglycaemia (64.8%). Management of the syndrome means: eating frequent small meals (91.5%) and protein (84.5%), and limiting fats (88.7%), carbohy-drates (83.1%), and liquids while eating (76.1%);
• postoperative, uncomplicated wound management: daily use of sterile dressings, observation for pain, redness, warming, disinfection, showering (77.5%);
• diet: about 5-6 small meals with a thick texture (97.2%), easily digestible fats about 50-70 g/day (84.5%), protein about 1.5-2 g/kg/day (69.0%), dish processing (84.5%), mild condiments (78.9%), limiting liquids during meals (73.2%), and fibre (70.4%);
• pharmacotherapy: regular use of the drug (93.0%), consultation in case of withdrawal (73.2%), and reporting of side effects (73.2%);
• follow-up visits: respecting the physician’s recommendations (97.2%), regardless of well-being (73.2%), visits every few months during the first year and according to later recommendations (70.4%) and in case of worrisome symp-toms (76.1%);
• complementary treatment: a form of chemotherapy and radiotherapy or a combination thereof (93.0%), is an adjunct to surgery (93.0%), the goal of chemotherapy (100.0%) and radiotherapy (93.0%);
• impaired absorption of vitamins: vitamin B12 (73.2%).
The overall knowledge of the subjects on management after gastrectomy varied: a high level was presented by 66.2% of the subjects, a medium level by 12.7%, and a low level by 21.1%.

EDUCATION OF SUBJECTS UNDERGOING TOTAL GASTRECTOMY

Respondents indicated important areas of education: diet (93.0%), wound care (91.5%), complementary treatment (70.4%), and pharmacotherapy (69.0%). Education was provided in the following areas: diet – nutritionists (52.1%), physicians (21.1%), and nurses (18.3%); wound care – nurses (62.0%), physicians (35.2%); pharmacotherapy and complementary treatment – physicians (66.2% and 78.9%) and nurses (31.0% and 18.3%); and in the area of preven-tion of complications – physicians (59.2%) and nurses (40.8%).
Respondents confirmed the opportunity to ask questions during education (84.5%), the comprehensibility of con-tent (70.4%) and adaptation to their needs (84.5%), good pace (55.0%) and timing of education (69.0%) as well as meeting expectations in this area (67.6%), and the patience and understanding of the educator (65.4%). Education was most often conducted daily from the day of surgery (40.8%) or daily from admission to the ward (33.8%). Education used instruction (90.1%), informative lecture (73.2%), talks (67.6%), leaflets, brochures (57.7%), and videos (22.5%). No one indicated any other means or methods that may have been used. 21.1% of the respondents’ relatives actively participated in the education (due to the pandemic).
The respondents evaluated their health education. The most indications, 40.8%, were given “good”, “very good” comprised 25.4%, “sufficient” 22.5%, and “insufficient” 11.3%. Low evaluation was most often due to insufficient time (23.9%), incomprehensibility of content (21.1%), fast pace of work (19.7%), lack of the educator’s patience (15.5%), and selection of adequate content (15.5%). Despite the education provided, patients expected additional information, which included complications of the disease (33.8%), diet (35.2%), postoperative wound care (22.5%), complemen-tary treatment (38.0%), and pharmacotherapy after hospitalization (36.6%).

SOCIAL SUPPORT OF THE SUBJECTS BASED ON THE ISEL 40 V. GP SCALE

Respondents in each subscale could score from 0 to 10 points. In our study, respondents scored an average of 6.34 to 7.07 (moderate score); the average total for all subscales was 26.93, which can be assumed as a moderate score for the whole scale (Table 1).

THE SUBJECTS’ SENSE OF GENERALIZED SELF-EFFICACY BASED ON THE GSES SCALE

Based on the results obtained (mean 27.94 points; 5 sten), the subjects’ sense of generalized self-efficacy was mod-erate (Table 2).

ACCEPTANCE LEVEL OF THE DISEASE BY THE SUBJECTS BASED ON THE AIS

On the disease acceptance scale, the subjects scored an average of 22.06 points. The respondents’ level of disease ac-ceptance can be described as average (Table 3).

ANALYSIS OF THE RELATIONSHIPS BETWEEN VARIABLES/h5> The relationship between subjective evaluation of the subjects’ preparation for hospital discharge and the level of social support they received was not confirmed (p = 0.261). Respondents objectively as better evaluated for discharge obtained a higher index of social support than those evaluated less poorly in this regard (p < 0.001) (Table 4).
Subjects who rated their own preparation for discharge as good, and individuals objectively rated good in this re-gard, had a higher generalized sense of self-efficacy compared to patients rated moderately or poorly on their own preparation for discharge from the hospital. Similar results can be noted for those objectively rated moderately or poor-ly in this regard (p = 0.006 and p < 0.001, respectively) (Table 5).
Individuals who rated good in terms of their own preparation for discharge, and subjects rated good objectively, had a higher acceptance level of their own illness than those who rated moderately or poorly in terms of their own prepara-tion for discharge from the hospital. Similar findings apply to those objectively rated moderately or poorly in this re-gard (p = 0.031 and p < 0.001, respectively) (Table 6).
Subjective evaluation of preparation for discharge was higher among patients who had been ill for more than a year (p = 0.044). No such difference was found in the subjects’ objective evaluation of their preparation (Table 7).
Subjects aged up to 60 years were better prepared for discharge than older patients on objective evaluation (p < 0.001). No such relationship was shown for subjective evaluation. Women subjectively assessed their own prepa-ration for hospital discharge better than men (p = 0.003). The same conclusions were drawn on the basis of objective evaluation (p < 0.001). Subjective evaluation of the subjects’ preparation for discharge was unrelated to marital status (p = 0.156). Married subjects had a higher level of knowledge about hospital discharge preparation than unmarried persons (p < 0.001). Subjective evaluation of discharge preparation was not dependent on education level (p = 0.112). In objective evaluation, patients with higher education had a higher level of knowledge on hospital discharge prepara-tion compared to those with other education (p < 0.001).

DISCUSSION

The diagnosis of cancer forces the sick person to assume the role of a patient, submit to the treatment process, and prepare for self-care after hospitalization. Preparing the patient to function in a situation changed by the disease is con-ditioned by the support and education provided to them, which in addition to the essential content, would also meet their individual needs and expectations. The patient’s preparation for self-care should be preceded by an evaluation of their cognitive and emotional resources by professionals.
An important part of professional patient care is good preparation for discharge from the hospital and functioning at a satisfactory level after hospitalization, which is possible through reliable health education [3]. Our study addressed the evaluation of patients’ preparation for hospital discharge after gastrectomy and selected factors determining this preparation.
The mean age in the present study was 62.32 years, compared, for example, with in the studies of Religioni et al. – 59.98 years [16], Medak et al. – 61.60 years [17], and Choi et al. – 58.8 years [18]. Most often, perioperative chemo-therapy or adjunctive chemo-radiotherapy is recommended if chemotherapy was not implemented before surgery [19]. The results of this study showed the implementation of preoperative chemotherapy in more than half of the sub-jects. Studies emphasize the importance of perioperative chemotherapy in the management of disease [11, 20]. Chemo-therapy combined with surgery can significantly prolong the survival of patients, including those with advanced dis-ease [21].
Future in-depth studies on a wider group of patients can take into account the division of subjects by the method of surgical treatment, and they can analyse whether it was related to preparation for self-care and the need for education in the hospital. The duration of hospitalization after surgery was conditioned by the patients’ preparation for discharge. In the first few days, patients were fed through an enteral tube (industrial diet), and on day 5-6 a mixed diet was intro-duced, followed by a complete diet. Hospitalizations of more than 14 days were due to, among others, postoperative wound infection or wound dehiscence, or anastomotic leakage and bleeding, requiring surgical re-intervention. An in-depth study could also answer the question of what determines the treatment duration and whether, and to what ex-tent, postoperative complications prolong hospitalization.
Participants in our study confirmed the provision of education by various professionals during hospitalization. Phy-sicians educated on pharmacotherapy, complementary treatment, and prevention of complications, while nurses edu-cated on wound care. It is noteworthy that nurses provided information on pharmacological treatment (31.0%), which may indicate that patients were not provided with comprehensive information during the drug administration. A study conducted by Tokdemir et al. showed that education on oral pharmacotherapy increased the subjects’ sense of self-efficacy in this area [22]. The results of the study by Medak et al. in a group of patients after gastrectomy for cancer dif-fered from our study. Nurses educated about lifestyle after surgery, and nearly half of the respondents reported receiv-ing information from nurses about diet and physical activity [17]. A study by Grabowska et al. found that over 41% patients expected education after surgery by a nurse as well as a physician [23], and the quality of this education pro-vided by nurses was rated better than the education in this study. The role of education for gastric cancer patients is undeniable in building their knowledge and shaping their behaviour toward self-care. The study by Hu et al. showed that nurse-led preoperative and postoperative education, based on the establishment of an individualized care plan according to needs, helped to alleviate surgical tension and negative emotions, motivate a positive attitude, and teach respiratory gymnastics and postoperative improvement, diet management, or postoperative pain relief. These measures resulted in improved patient self-care and increased patient responsibility in this area, as well as shorter hos-pitalization times and lower rates of postoperative complications [24]. In another study, Davoodi et al. showed im-provements in patients in the areas of overall health scale evaluation, pain, constipation, and experience of dysphagia. Despite these benefits, the authors of the study considered the self-care education program insufficient to significantly improve the quality of life of gastric cancer patients after surgery [25]. A study conducted by Zhao et al. showed that health education can have an impact on improving the overall condition of gastric cancer patients undergoing surgery. Its effectiveness is also evident in better cognitive, emotional, and social functioning of patients, thus improving their quality of life [2]. Gao et al. in their study proved that an intervention in the form of health education, in terms of in-creased awareness of the disease, lifestyle, rehabilitation, and mental health counselling, has been shown to be effective in improving quality of life [26].
The effectiveness of education can also be affected by the choice of means and methods. Participants in this study did not indicate any means and methods other than those given in the research tool that could be used in the course of knowledge transfer. Due to progress and the possibility of access to numerous tools, including software, their use in education is being considered. Interesting results were presented in the study of Yazdanian et al. The authors ad-dressed the subject related to determining the requirements of an app used in the self-care of patients with gastric can-cer. Information in the areas of diet, emotional support, coping with chemotherapy, and postoperative wound care, as well as reminders about medications and doctor’s appointments were found to be important for patients. The apps can be used when properly designed to meet the expectations of use [8].
This study also focused on patients’ acceptance of the disease, and their sense of generalized efficacy and social sup-port. Park et al. showed in their study that people with cancer have different needs and expectations, including the need for support. Most of the gastric cancer patients surveyed expected support from other patients with the same di-agnosis by providing information, sharing experiences and motivation to fight the disease [27]. Self-efficacy affects the quality of life of gastric cancer survivors, and it is one of the resources that should be assessed in patients before imple-menting interventions to improve the quality of life of gastric cancer survivors [18]. A study by He and He showed the positive importance of nursing interventions for perioperative gastric cancer patients based on education, psychological support taking into account the individuality of perioperative gastric cancer patients for improving their sense of self-efficacy, self-care ability, and quality of life [28]. In this study, the respondents obtained a score indicating an average level of disease acceptance. The results of a study among oncology patients led by Smoleń et al. showed a moderate level of disease acceptance [29], while a study conducted by Dryhinicz et al. showed a lower acceptance level [30]. In com-parison, Juczyński obtained higher results in a group of women with breast and uterine cancer [15], and the mean val-ue of disease acceptance for gastric cancer patients in a study by Religioni et al. indicated a moderate level of acceptance [16].
Our own research showed that patients’ preparation for hospital discharge after gastrectomy was mostly at a high level, especially in terms of complementary treatment and wound care. The same subject was studied by Andruszkie-wicz et al., but in a group of patients with stoma due to cancer. It turned out that patients rated the preparation for self-care at a low level due to a lack of information about further treatment, complications, and necessary lifestyle changes [31]. The negative evaluation of education in our study was due to a sense of lack of time, incomprehensible content, lack of patience on the part of the educator, and selection of content that was adequate in the patients’ opinion. Compli-cations and follow-up treatment were areas that needed to be further explored according to the respondents in the compared studies. A study conducted by Kapusta et al. among post-mastectomy women also found that lack of educa-tion contributes to patients’ low level of knowledge [32].
The results of our own study confirmed that respondents who had better knowledge in objective evaluation ob-tained a higher index of social support, and good evaluation of knowledge in subjective and objective terms was related to a higher generalized sense of self-efficacy. Similarly, good subjective and objective evaluation of knowledge generated a higher acceptance level of self-disease. The analysis also confirmed that subjective evaluation of discharge preparation was higher in patients who had been ill for more than a year. The subjects under 60 years of age had better preparation for discharge. Women subjectively and objectively rated their own preparation for discharge from the hospital better. Married people had a higher level of knowledge about preparation for hospital discharge. In the objective evaluation, individuals with higher education had a higher level of knowledge about preparation for hospital discharge. Analysis of these results suggest that evaluation of patients’ preparation for discharge after gastrectomy should be made in subjec-tive and objective views depending on a number of factors, including demographics, disease course, social support, self-efficacy, and acceptance of the disease.

CONCLUSIONS

Despite the required re-education in self-care and self-nursing, the preparation for discharge of the surveyed pa-tients after gastrectomy due to cancer is at a good level.
Preparation for discharge of patients requires not only an assessment of their knowledge, but also the acceptance level of the disease, self-efficacy, and social support.
Patient health education is an essential component of care that prepares patients for self-care and determines their quality of life.

Disclosure

The authors declare no conflict of interest.

References