Discharge teaching, patient-reported discharge readiness and postsurgical outcomes in gynecologic patients undergoing day surgery: a generalized estimating equation

We conducted a longitudinal survey from January 2021 to June 2021 in a women and children’s medical center in western China serving over 5 provinces. Convenience sampling was used. According to Kendall’s experience and methods, the sample size can be 5 to 10 times the number of independent variables [32]. Our study examined a total of 19 independent variables (9 social demographic data points, 5 questions from the Quality of Discharge Teaching Scale, 5 from the Readiness for Hospital Discharge Scale). Our sample size was calculated as 85 to 190.

Patients were eligible if they (1) were diagnosed with gynecological disease, (2) were underwent day surgery, (3) were over 18 years old, (4) were able to read and write Chinese, and (5) had normal cognitive function and intelligence. Patients were excluded if they (1) had gynecologic cancer, (2) had other severe organic diseases, or (3) had a history of mental illness.

A self-designed questionnaire was used to collect sociodemographic information, reproductive history and gynecological surgery history.

Quality of Discharge Teaching Scale was developed by Weiss et al. [18] and consisted of 24 items, including 3 dimensions: Content needed (6 items), Content received (6 items), and Delivery (12 items). The Quality of Discharge Teaching Scale is a patient self-reported measure that uses an 11-point (0 to 10) scale. The total score is calculated by adding the scores of “Content received” and “Delivery”. The total possible score ranges from 0 to 180. Higher scores indicate a greater amount of discharge-related information received and a higher-quality teaching approach [33]. The “Delivery” dimension measures participants’ perception of the skills of doctors and nurses as health educators. In a previous study, the Cronbach’s α coefficient for the Quality of Discharge Teaching Scale was 0.92, and for the 3 dimensions, it ranged from 0.85 to 0.93 [18, 25]. The Cronbach’s α coefficient of the Chinese version was 0.91, and the range of the 3 dimensions was from 0.882 to 0.935. The Chinese version was authorized by the original authors [34].

The Readiness for Hospital Discharge Scale was developed by Weiss et al. [18] and consists of 22 items, including 4 dimensions: Physical condition (6 items), Knowledge (8 items), Coping ability (3 items), and Expected support (4 items). The Readiness for Hospital Discharge Scale is a self-reported scale with items scored on an 11-point scale (0–10). The total possible score ranges from 0 to 220. Higher scores indicate greater readiness. The Cronbach’s α coefficient for the Readiness for Hospital Discharge Scale was 0.93 [18]. The Cronbach’s α coefficient of the Chinese version was 0.97 [35] and 0.89, 0.92, 0.90, and 0.85 for the 4 dimensions [24]. The Chinese version was authorized by the original authors [35].

The postsurgical outcomes form is a self-designed tool to record problems on postoperative Day 1, postoperative Day 7, and postoperative Day 28. The postsurgical problems included surgical site infection, pain, body temperature, bowel dysfunction, urinary tract dysfunction and vaginal bleeding.

On the day of discharge, patients received the general information questionnaire, Quality of Discharge Teaching Scale, and Readiness for Hospital Discharge Scale. On postoperative Day 1, postoperative Day 7, and postoperative Day 28, patients received the postsurgical outcomes forms through a follow-up system on a smartphone app. The trained investigators checked the data and then telephoned and interviewed the patients who needed medical intervention. Readmissions and deaths were also recorded.

SPSS 21.0 (SPSS Inc, Chicago, IL) was used for statistical analysis. Median, standardized median, interquartile range (IQR), number (N) and percentage (%) were used to describe the demographic and clinical variables. Spearman correlations were conducted to explore the correlation between the Quality of Discharge Teaching Scale and Readiness for Hospital Discharge Scale. Generalized estimating equations were used to explore the determinants of postsurgical outcomes. Odds ratios (ORs) were calculated in generalized estimating equations. In all analyses, a P value of < 0.05 indicated statistical significance.

Our study was approved by the ethics committee. After providing written informed consent, participants received the questionnaires.

A total of 168 gynecological patients who underwent day surgery were recruited. The participants’ demographic and clinical characteristics are shown in Table 1.

The scores of the Quality of Discharge Teaching Scale and Readiness for Hospital Discharge Scale are shown in Table 2. Responses to the first item of the Readiness for Hospital Discharge Scale indicated that 98.8% of the participants stated they were ready for discharge.

No readmissions and no deaths were recorded on postoperative Day 1, postoperative Day 7 or postoperative Day 28. The incidence of postsurgical outcomes on postoperative Day 1, postoperative Day 7 and postoperative Day 28 are shown in Table 3.

Scores of “Content needed”, “Content received”, “Delivery” and total score of Quality of Discharge Teaching Scale showed strong positive correlations with scores on all dimensions of Readiness for Hospital Discharge Scale (P < 0.001). More details are shown in Table 4.

“Delivery”, “Physical conditions” and “Social support” of the Readiness for Hospital Discharge Scale were protective factors for postsurgical outcomes. More details are shown in Table 5.

The item median score of the Quality of Discharge Teaching Scale for gynecological patients who underwent day surgery was 9.81, higher than previous studies on parents of hospitalized children, postpartum women, cataract patients and general surgical patients [14, 15, 22, 25, 36]. The score of “Content needed” was slightly higher than the score of “Content received”, but the difference in these two variables was not statistically significant (P > 0.05), which was inconsistent with previous studies of postpartum women and cataract patients [24, 25]. These results reflected that the content that participants received about discharge almost met their needs. Moreover, doctors and nurses provided good quality discharge teaching for these patients despite their decreased length of hospital stay. For the “Delivery” dimension, the item median score was relatively higher than previous studies [14, 15, 22, 25, 36], which indicated that the discharge teaching skills and effects of doctors and nurses were acceptable for gynecological patients who underwent day surgery.

Interestingly, for the Readiness for Hospital Discharge Scale, the item median score was 8.82, and 98.8% of the participants stated they were ready for discharge, which was higher than that in previous studies of other populations [24, 25, 36, 37]. One reason might be the relatively young age of our participants. As reported, the older patients were, the more likely they were to be not ready for discharge [38]. Another reason might be the preoperative assessments, which screened the patients’ physical condition, as mentioned above, the physical conditions is the dimension of the Readiness for Hospital Discharge Scale [18]. Moreover, day surgery was only recommended for patients with milder conditions and no comorbidities. Therefore, a variety of reasons caused this difference and we must acknowledge the differences. The score of “Social support” was rated highest, followed by “Coping ability” and “Knowledge”. The score of “Physical conditions” was rated lowest. We inferred that the reason might be the decreased length of hospital stay. Because gynecological patients who underwent day surgery were discharged in an intermediate stage of recovery, we recommend that doctors and nurses be more concerned about their physical condition, ensure their comfort and teach them how to manage postsurgical problems effectively.

As expected, the Quality of Discharge Teaching Scale was verified to be positively correlated with Readiness for Hospital Discharge Scale, and each dimension of the Quality of Discharge Teaching Scale and Readiness for Hospital Discharge Scale showed strong positive correlations. These results were consistent with previous studies on cataract patients, parents of hospitalized children, general surgical patients and psychiatric patients [22, 23, 36, 39]. The findings support the structure and relationships proposed by Meleis’ middle-range theory of transitions. Discharge teaching as a medical therapeutic process was verified to be a predictor of readiness for hospital discharge. As mentioned above, the decreased length of hospital stay of gynecological patients undergoing day surgery might make it challenging for doctors and nurses to deliver high-quality discharge teaching. Considering that patients’ readiness for hospital discharge was affected by the discharge teaching, we recommend that human resource managers ensure the number of doctors and nurses to avoid compromising the quality of discharge teaching due to workload. Future research could explore how doctors and nurses can effectively deliver discharge teaching during limited hospital stays.

Most patient-reported problems after minimally invasive gynecologic surgery include pain, vaginal bleeding, urinary tract infection and surgical site infection [26‐28]. This study showed that the most common postsurgical problems of minimally invasive gynecologic surgery were vaginal bleeding, followed by mild pain. In the generalized estimating equations of postsurgical outcomes, “Delivery” of Quality of Discharge Teaching Scale, “Physical conditions” and “Social support” of Readiness for Hospital Discharge Scale were protective factors for postsurgical outcomes. No demographic or clinical characteristics of participants were statistically significant in generalized estimating equations. These findings were partly consistent with a previous study on cataract patients, in which “Content needed” and “Delivery” both affected the patient’s postsurgical outcomes through the mediating effect of Readiness for Hospital Discharge Scale [24]. These findings indicated that the higher the level of skills and effects of discharge teaching of doctors and nurses, the better the postsurgical outcomes in our patient population. Moreover, these findings support the structure and relationships of the theoretical framework based on Meleis’ middle-range theory of transitions. Discharge teaching as a medical therapeutic process was verified to be a predictor of postsurgical outcomes. Therefore, we recommend that human resource managers should train doctors and nurses in discharge teaching methods. Improving the health teaching skills and competencies of doctors and nurses is an important way for patients to improve postsurgical outcomes. Another prior study on patients diagnosed with anxiety disorders showed that a higher level of “Knowledge” of Readiness for Hospital Discharge Scale showed a lower risk of unscheduled clinic visits and readmission, and a higher level of “Social support” also showed a lower risk of unscheduled clinic visits. This study found that better physical conditions and a higher level of social support at hospital discharge were associated with better postsurgical outcomes. This finding suggests that doctors and nurses should assess patients’ physical conditions at discharge, including pain, strength and physical ability. Although doctors and nurses might not be able to change patients’ physical conditions through discharge teaching, they could teach them how to reduce stress and manage their pain via cognitive–behavioral therapy [39]. Moreover, social support, which is defined as informational, emotional, appraisal and practical support from partner, family or friends, should be valued [40, 41]. Previous studies also verified the positive relationship between social support and physical condition and quality of life [41‐44]. Therefore, for gynecological patients undergoing day surgery, we recommend that in addition to clinical care, doctors and nurses take every opportunity to give appropriate and personalized information and appraisals and emotional and practical support. In addition, facilitating the patients’ social support system is crucial.