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Effects of Urinary Catheter

Education for Patients Undergoing
Diane M. Inman, Therese M. Jacobson, Pamela M. Maxson,
Huey Wang, and Christine M. Lohse

rostate cancer is the second leading cause of cancer death for U.S. men
(American Cancer Society,
2013). In a 2012 medical review,
the American Cancer Society estimated that approximately 238,590
new cases of prostate cancer will
occur in the U.S. in 2013. Radical
prostatectomy (RP) by retropubic
or robotic approach is a surgical
option used to treat localized
prostate cancer. Hospital length
of stay (LOS) after RP has decreased. In the University
HealthSystem Consortium Clinical database, the mean LOS
between 2003 and the second
quarter of 2007 for centers with
the highest case volume of RP
was 2.09 days (Mitchell et al.,
2009). Patients undergoing RP at
the study site are routinely dismissed within 1.5 days. After dismissal, their indwelling urinary
catheter remains in place for one

Diane M. Inman, RN, is a Nurse Manager

in Urology, Department of Nursing, Mayo
Clinic, Rochester, MN.
Therese M. Jacobson, RN, CNS, is a
Clinical Nurse Specialist, Department of
Nursing, Mayo Clinic, Rochester, MN.
Pamela M. Maxson, RN, CNS, is a Nurse
Manager, Department of Nursing, Mayo
Clinic, Rochester, MN.
Huey Wang, RN, is a Nursing Education
Specialist, Department of Nursing, Mayo
Clinic, Rochester, MN.
Christine M. Lohse, MS, is a Statistician,
Division of Biomedical Statistics and
Informatics, Mayo Clinic, Rochester, MN.

2013 Society of Urologic Nurses and Associates

Inman, D.M., Jacobson, T.M., Maxson, P.M., Wang, H., & Lohse, C.M. (2013).
Effects of urinary catheter education for patients undergoing prostatectomy.
Urologic Nursing, 33(6), 289-298. doi:10.7257/1053-816X.2013.33.6.289
In a nonrandomized prospective study, significant decreases in patient anxiety
with home urinary catheter management and in length of stay were reported
when patients attended the preoperative prostatectomy class with standard postoperative education versus standard postoperative education.
Key Words:

Patient anxiety, patient education, preoperative urinary

catheter care, stress.

to three weeks. Thus, these

patients need to know how to
manage their urinary catheter and
drainage bags. Previous research
has demonstrated that patients
and their significant others often
experience catheter-associated
anxiety (Burt, Caelli, Moore, &
Anderson, 2005; Davison, Moore,
MacMillan, Bisaillon, & Wiens,
2004; Moore & Estey, 1999;
Vickers-Douglas, Hathaway, Wang,
& Judy, 2007). Anecdotal reports
from staff nurses at the study site
indicate that patients and their
significant others who participate
in a preoperative education class
were less anxious, had fewer
questions, and mastered urinary
catheter management skills more
quickly than patients who did not
participate in the class.
The purpose of this study
was to determine the effect of preoperative urinary catheter management education on self-reported anxiety (State-Trait Anxiety
Inventory [STAI] score) among
patients undergoing RP. Aims

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

were to also identify patients

confidence level, frequency of
follow-up calls to physicians after
hospital dismissal, and nursing
time spent in providing postoperative education to determine how
the anxiety level impacted these
Literature Review

Historical Overview of Early

Research on Effects of
Preoperative Education
A meta-analysis of 49 studies
published between 1964 and 1982
evaluated the effects of psychoeducational interventions on hospital LOS for surgical patients
(Devine & Cook, 1983). Interventions included providing information about what to expect, skills
training, or emotional support
through verbal, written, or taped
modes of delivery or a combination. Results of the meta-analysis
showed the LOS was shorter for
the intervention group.

Research Summary
After prostatectomy surgery, a urinary catheter may be
in place for one to three weeks. Anxiety with catheter management has been reported by patients and observed by
nurses. Hospital length of stay has decreased to 1.5 days,
resulting in less time for education. Although preoperative
classes are offered, the majority of patients do not attend.
The primary purpose was to describe the effect of preoperative urinary catheter management education on the
patients level of anxiety following prostatectomy. Aims were
to measure the patients confidence level, with follow-up calls
to physicians after hospital dismissal and with nurses perceptions of the ease of providing postoperative education.
Data from a nonrandomized prospective study of 100
men were compared to determine the effect a specific preoperative prostatectomy class and the standard postoperative education had on postoperative anxiety and level of confidence with management of home catheter care. Data were
also collected of nurses perception of patients anxiety at

Hathaway (1986) completed

a separate meta-analysis of 68
studies published between 1963
and 1983 and reported that postoperative outcomes were positively affected by preoperative
education. Patient anxiety and
fear were identified as factors
that need to be considered when
providing patient education,
along with tailoring procedural
and psychological aspects of care
to best meet the needs of individual patients.

Preoperative Education
A literature search using the
search terms education, knowledge, teach, learn, and systematic reviews between 2005 and
2012 yielded a list of 43
Cochrane reviews. Only one of
the 43 results was related to preoperative education. The majority targeted educational efforts in
chronic disease management.
McDonald, Hetrick, and Green
(2004) analyzed the results of
nine randomized studies conducted between 1994 and 2003,
to determine the impact of preoperative education on patients
having surgery to replace a hip or
knee. Outcome variables included anxiety, LOS, pain, time to
standing and climbing stairs, and


dismissal and time needed for teaching about home management.

The patients in the intervention group experienced significantly less anxiety and significantly higher levels of confidence in their ability to secure the catheter, maintain cleanliness, and switch between bags. No statistical difference in
time spent providing postoperative education was observed
between the two groups.
This study supports the value of having all prostatectomy patients attend the preoperative class on urinary
catheter management.
Recommendations for Improvement
Strategies for improvement include exploring follow-up
phone calls and providing information on when and who to
call with questions.
Level of Evidence II
(Polit & Beck, 2012)

satisfaction with educational

information. The type and timing
of the educational interventions
varied among the studies, including a video, booklet, demonstration, or face-to-face teaching session either at home or in the clinic or the hospital. Findings
showed no significant difference
in LOS or in postoperative anxiety between the preoperative
education and control groups.
The result of education before
surgery on preoperative anxiety
was mixed, with three studies
citing less anxiety and two other
studies showing no difference.
Johansson, Nuutila, Virtanen,
Katajisto, and Salantera (2005)
conducted a systematic review of
the literature to identify the types
of interventions and outcomes
related to preoperative patient
education. The 11 studies reviewed focused on the adult
patient undergoing orthopedic
surgery. The measured outcomes
related to pain, knowledge, anxiety, exercises, and length of
stay (Johansson et al., 2005, p.
212). Self-efficacy and empowerment were assessed less frequently. Johansson et al. (2005)
also concluded that patients
anxiety levels and knowledge
were affected by educational

interventions, but the direction

of the effects was mixed, and further research is warranted.
Limitations included the small
number of studies and the variation in measurement methods.
Various educational strategies have been studied, contributing to difficulty in comparing outcomes. Ways in which
interventions have differed
include 1) timing of the education, whether preadmission or
postadmission (Davison et al.,
2004; Lookinland & Pool, 1998);
2) media type, such as video
(Bondy, Sims, Schroeder, Offord,
& Narr, 1999; Luck, Pearson,
Maddern, & Hewett, 1999; Ong,
Miller, Appleby, Allegretto, &
Gawlinski, 2009; Pager, 2005;
Yeh, Chen, & Liu, 2005), pamphlet (Bondy et al., 1999;
McGregor, Rylands, Owen, Dore,
& Hughes, 2004), or a Web-based
instruction module (Hering,
Harvan, Dangelo, & Jasinski,
2005); 3) multidisciplinary approach (Giraudet-Le Quintrec et
al., 2003; Prouty et al., 2006;
Thomas & Sethares, 2008); 4)
structured versus unstructured
educational programs (Coslow &
Eddy, 1998); 5) a preoperative
program based on an empowerment model (Pellino et al., 1998);

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

and 6) preadmission education

with a follow-up telephone call
before surgery (Lamarche, Taddeo,
& Pepler, 1998). Different combinations of interventions have
also been used.
There is a paucity of research
focused on the effect of preoperative education on a patients ability to perform a skill. In a pilot
study, McGregor et al. (2004) randomly assigned patients to the
intervention group that attended
a class where exercises, gait aid
use, and adaptations to the home
environment were taught. The
intervention group required less
occupational therapy and was
able to be dismissed from the
hospital three days earlier compared with the control group.
Thus, a financial and labor cost
savings occurred.
Chaudhri, Brown, Hassan,
and Horgan (2005), in a randomized controlled study, compared
the effects of an intensive preoperative ostomy skill-based education program with the effects of
conventional postoperative teaching. The investigators determined that median time to skill
proficiency in managing the
stoma was 5.5 days for the study
group compared with nine days
for the control group (p = 0.0005;
Mann-Whitney U test). Hospital
LOS was eight days for the study
group and 10 days for the control
group (p = 0.029; Mann-Whitney
U test). Unplanned visits after
dismissals per patient in the
study group were 0, while in the
control group, they were 0.5 (p =
0.0309; Mann-Whitney U test).
Guruge and Sidani (2002)
performed a meta-analysis of 20
studies focused on preoperative
education between 1970 and
1996 and specifically examined
the demographic variables of the
participants to determine the
generalizability of the findings.
The sample was composed mainly of educated white women
between the ages of 41 and 60
years (Guruge & Sidani, 2002).
They stressed the importance of
controlling for demographic variables, including age, race, level of
education, and gender.

Effects of Preoperative
Education on Anxiety
The investigators of numerous
studies used STAI (Spielberger,
Gorsuch, & Lushene, 1970) to
measure the effects of preoperative education on pre- and postoperative anxiety (Asilioglu &
Celik, 2004; Bondy et al., 1999;
Giraudet-Le Quintrec et al., 2003;
Hering et al., 2005; Luck et al.,
1999; Mott, 1999; SchwartzBarcott, Fortin, & Kim, 1994).
The effects on postoperative anxiety were mixed, with some studies showing less anxiety (Luck et
al., 1999; Mott, 1999; SchwartzBarcott et al., 1994), and others reporting no difference (Giraudet-Le
Quintrec et al., 2003; Hering et
al., 2005).
Callaghan, Cheung, Yao, and
Chan (1998) used the Chinese
STAI to study the effect of preoperative education for Chinese men
having transurethral resection of
the prostate. The study concluded
the men, having received education, were considerably less anxious postoperatively and reported
higher levels of satisfaction
(Callaghan et al., 1998).

Educational Needs for Men

After Urologic Surgery
Prostate surgery is specific to
the male population (Burt et al.,
2005; Callaghan et al., 1998;
Davison et al., 2004; Moore &
Estey, 1999). Moore and Estey
(1999) reported patient concerns
about catheter care, pain, incontinence, and sexual function after
prostatectomy surgery. A repeated concern was the lack of
knowledge about the postoperative recovery period, with many
knowledge gaps related to
catheter care, such as cleaning
the night bag, bladder spasms,
rectal pain, hematuria, and leakage around the catheter. Some
men reported anxiety that interfered with retention of instructions, and others stated that written material was not clear.
Results of a descriptive study
performed by Davison et al. (2004)
show that community resources
were used inappropriately by
25% of the study population (N =
100) after receiving preoperative

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

education that consisted of a

booklet, a kit of supplies (including drainage bags and incontinence pads), a community resource list, and two follow-up
phone calls. The nurses developed a checklist of discharge
patient education topics as a
guide when providing education.
Results indicated that community
resources were used due to concerns about wound care, catheter
care, or urine retention (Davison
et al., 2004, p. 483).
Using qualitative, descriptive
research methods, Burt and associates (2005) explored the experience of living with a postoperative indwelling urinary catheter.
Anger, frustration, and embarrassment in dealing with the
catheter and its associated pain
and leakage were commonly
expressed emotions (Burt et al.,
2005). These participants did not
believe their preoperative education adequately prepared them
for the catheter-related discomfort they experienced. Researchers reported their strong impression that sexuality and erectile
function provided severe challenges and distress for the participants, although not expressed as
vehemently as their distress with
the catheter (Burt et al., 2005, p.
888). The study participants
identified that the reassurance
provided by the investigators
during the multiple methods of
interviews helped them cope
with the catheter. Receipt of comprehensive information preoperatively was not sufficient to reassure the patients on all the
aspects of recovery causing concern and that the impact of
stress on the recall and processing of information (Burt et al.,
2005, p. 889) has to be considered when providing patient
Vickers-Douglas et al. (2007)
conducted a qualitative study of
18 patients having RP to determine the effectiveness of a structured preoperative education
class on the patients perceived
self-efficacy in managing postoperative care and their satisfaction
with the instruction. The investigators identified the following


key findings: 1) the information

provided in class about the surgery reduced anxiety for some
patients, 2) many men specifically
mentioned the catheter and its
management as an area of concern, 3) some participants thought
the class increased their recognition of the complex aspects of
self-care, 4) the video and the
class instructor were important to
the effectiveness of urinary catheter teaching because they provided both visual learning and
hands-on experience, and 5)
many men made general positive
comments about the class.
In summary, the available literature shows that educational
methods and individual learning
styles, limited time in the hospital after surgery, effects of anesthesia and analgesia, and anxiety
about a cancer diagnosis may
impair patients ability to retain
information and to comprehend
or apply the material. Generally,
a multifaceted, structured approach for delivery of preoperative education before hospital
admission was more effective.
According to Hodgkinson, Evans,
and ONeill (2000), the combined
use of pamphlets and instructions delivered pre- and postadmission enhanced skill performance, with pre-admission
written instructions influencing
more rapid acquisition of skills.
Gaps and inconclusive results on
the effects of self-care management and nursing workload have
existed in past studies with the
prostatectomy population. Yet,
few preoperative education studies have focused on the prostatectomy patient population. On the
basis of these findings, a study
was needed to examine the
effects of preoperative urinary
catheter education on patient
anxiety, self-care management,
and ease of teaching for nurses
following RP.

The purpose of the present
study was to determine the effect
that standardized preoperative


urinary catheter management

education has on anxiety, as selfreported by patients undergoing
RP as treatment for localized
prostate cancer.

Variables of the study were 1)
level of anxiety, 2) self-reported
confidence to manage home
catheter care, 3) frequency of follow-up calls to physicians after
hospital discharge, and 4) time
spent by nurses in delivering
postoperative urinary catheter

Study Design
A single-site, non-randomized, two-group, pre-survey and
post-survey study was conducted
between December 23, 2009, and
January 11, 2011. A randomized
controlled study with an enrollment of 200 patients was initially
considered but was deemed not
feasible because of competing
requests for patients participation in other prostate cancer
studies. Mayo Clinic Institutional
Review Board approval was
secured before the initiation of
any study activity.

Sample and Setting

The study sample consisted
of patients who had received a
diagnosis of localized prostate
cancer, were planning to undergo
RP surgery, and would receive
their postoperative care on the
urology inpatient units at a large
midwestern academic medical
center. The preoperative appointment registry for prostate surgery
triggered the study coordinators
face-to-face meeting with patients to discuss the study and
obtain consent from those interested in participating in the
study. Age was the pertinent
demographic data collected.
Patients excluded from providing consent were men who previously had a urinary catheter at
home, had attended a general
preoperative class, were nonEnglish speaking, or were unable
to give informed consent. A total
of 180 patients were approached,
but 53 patients declined to participate. Throughout the data col-

lection, 27 patients who had consented were excluded for the following reasons: prior catheter
experience (n = 1), surgery cancelled (n = 2), LOS greater than 3
days (n = 10), incomplete final
paperwork (n = 6), postoperative
education not provided by a urology nurse or admission to an
intensive care unit or both (n =
4), readmission (n = 1), and reason not identified (n = 3). The
study coordinator continued to
enroll patients until a total of 100
patients had completed the
Registered nurses (RNs) on
the two urology nursing units
were invited to participate in this
study for the purpose of providing the standardized postoperative catheter management education. Fifty-one RNs consented,
provided demographic information, and identified their perception of patients anxiety and ability to care for themselves and the
time spent in postoperative education.

Intervention and Control

Participants in the intervention group attended a preoperative educational class and received the standard postoperative education. Participants in
the control group received only
the standard postoperative education. An RN in the outpatient
education center taught content
of the one-hour preoperative
class (see Figure 1). The standard
postoperative education was provided to both groups by a staff
RN responsible for inpatient
urology care and included verbal
review of the same content presented in the preoperative class.

Measurement Methods
The STAI consists of 20 statements that describe how a
patient feels (e.g., I feel calm, I
am tense) (Spielberger, 2012).
Responses are selected on a scale
in which 1 = not at all; 2 = somewhat; 3 = moderately so; and 4 =
very much so. Using test-retest
methods, Quek, Low, Razack,
Loh, and Chua (2004) determined the reliability of the STAI

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

when administered to urologic

patients. Internal consistency for
the STAI was calculated using
Cronbach alphas. Preoperative
score versus postoperative intervention score in additional patients with lower urinary tract
symptoms who underwent transurethral resection of the prostate
was noted to be sensitive to
change, with internal consistency reported as excellent by the
investigators. The Cronbach
alpha value ranged from 0.38 to
0.89, whereas the Cronbach alpha
for the total scores was 0.86,
reflecting a high degree of internal consistency. Similar important results occurred with the
test-retest correlation coefficients.
Intraclass correlation coefficient
ranged from 0.39 to 0.89. High
degrees were reported of both
sensitivity and specificity to the
effects of treatment. The STAI
form is identified as the definitive
instrument for measuring anxiety
in adults (Spielberger, 2012). The
STAI clearly differentiates between the temporary condition of
state anxiety and the more general and long-standing quality of
trait anxiety. The Spielberger
STAI survey was purchased and
administered to patients preoperatively and postoperatively by the
study coordinator. Other checklists developed by clinical staff
from the urology surgical care
areas included a patient survey

(Figure 2), staff nurse survey

(Figure 3), and a checklist for the
preoperative class (Figure 4).

Data Collection Process

The study coordinator, based
in the outpatient clinic, generated an appointment list daily to
identify patients scheduled for
RP surgery the following day.
Preoperatively, the study coordinator was responsible for recruiting and enrolling patients, collecting baseline data, administering the STAI, and notifying the
unit charge nurse, clinical nurse
specialist (CNS), and unit nurse
manager (NM) of study patients
scheduled surgery. Patient attendance at the preoperative class
was nonrandomized and occurred by natural group assignment.
The urology unit CNS or NM
made sure the assigned RN had

the data collection form and was

aware the patient was a study
participant. RNs on the inpatient
urology units were instructed on
the use of the data collection
tool. To reduce the chance of
bias, they were specifically
instructed not to ask patients
whether they had attended a
class, although they could not
control whether a patient or family member volunteered that
information. The RNs provided
usual postoperative education to
all patients, recording time spent,
years of nursing experience, and
their perception of the patients
anxiety upon discharge. The unit
CNS or NM tracked the data collection forms to ensure completion, followed up with RNs as
necessary, and hand-delivered
the completed forms to the study
coordinator. The study coordina-

Figure 1.
Contents of Prostate Education Packet
Indwelling Catheter Care With Drainage Bag Instructions Mayo Clinic
Prostate Cancer Support Group Mayo Clinic
Hematuria Scale Mayo Clinic
Emergency Care after Your Prostatectomy Mayo Clinic
Catheter Care for Men after Urologic Surgery (video) Mayo Clinic
Exercises for Men with Urinary Leakage Mayo Clinic
Causes and Treatment of Erectile Dysfunction Mayo Clinic
What You Need to Know about Prostate Cancer National Cancer Institute
Sexuality for the Man With Cancer American Cancer Society

Figure 2.
Postoperative Patient Survey

1. How confident are you in managing the catheter, leg bag, and overnight bag?
2. How confident do you feel in maintaining the cleanliness of the catheter/bags?
3. How confident are you in your ability to clean the leg bag and overnight bag?
4. How confident are you in switching between the leg bag and the overnight bag?
5. How confident are you in securing the catheter?
6. How confident are you in knowing when and whom to call for any trouble with the catheter?
7. How confident are you in knowing what to do about bladder spasms?
1. Have you called your surgeon or other health care provider since you have been home?
If yes, how many times and for what reason?


2. Did you have the opportunity to watch the video before surgery on home catheter care?
If so, did watching the catheter care video first help you in understanding the nurses
further instructions on how to care for your catheter?


*Likert-type scale in which 1 = not at all confident; 2 = somewhat confident; 3 = confident; and 4 = very confident.
UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6


Figure 3.
Staff Nurse Survey
As the survey is completed, please try to separate out time and focus on only the
aspects of dismissal teaching for home management of the urinary catheter.
Patient identification number ___________________________
Number of minutes you spent in
demonstrations on your shift

Number of years of experience

as a urology RN


Dismissal Nurse

Perception Ratings*

9 10

Perception of patients
anxiety level about
home urinary catheter
Note: RN = registered nurse.
*Ratings range from not anxious (0) to very anxious (10).

Figure 4.
Objectives and Checklist Related to Leg Bag Instruction:
Preoperative Leg Bag Class

The patient and spouse or significant other will be able to demonstrate

care for the indwelling catheter at home.
The patient and spouse or significant other will be able to demonstrate
changing between the urinary night bag and the leg bag and cleaning.
The patient and spouse or significant other will be able to identify
management issues (spasms, hematuria).
The patient and spouse or significant other will be able to identify
strategies for prevention and/or management of constipation.





Refer to the Prostate Surgery Packet (MIC 231638)

Reference the DVD, written catheter instructions, Emergency Care
card, hematuria scale
Exercise for Men with Urinary Leakage, and Managing Constipation
View Catheter Care for Men After Urologic Surgery (MIC 230818)
Hands-on practice/switching between bags/emptying the bags
Discuss bag cleaning procedure
Discuss the placement of the catheter bags
No tension on the catheter tubing/slack in the catheter
Securing the tubing
Cleaning the catheter/applying ointment
Discuss bladder spasms
May leak around the catheter with bladder spasms
Avoid straining when having a bowel movement
Do not lift the bag above the level of the bladder Can cause backflow
of urine and cause spasms
Keep slack in the catheter Pulling/tension on the catheter can cause

tor contacted the patients by

phone three to five days after
hospital dismissal, administering
the STAI and the survey measuring patient confidence on urinary
catheter management. The study
coordinator entered the data into
an Excel spreadsheet. The files
were kept in a locked file cabinet.

Statistical Methods
Patient anxiety was measured preoperatively and postoperatively using the STAI. A total
STAI score was obtained by calculating individual items in
accordance with the STAI scoring grid (Spielberger, 2012).
According to Spielberger (2012),
higher STAI scores are correlated
with (or are indicative of) greater
Continuous features were
summarized with means, standard deviations, medians, and
ranges; categorical features were
summarized with frequency
counts and percentages. Comparisons of features among patients
who did and did not attend the
preoperative class and among
patients who did and did not call
their surgeon were evaluated
using Wilcoxon rank sum, 2,
and Fisher exact tests. Associations of features with the difference (postoperative preoperative) in STAI scores were evaluated using Spearman rank correlation coefficients and KruskalWallis and Wilcoxon rank sum
tests. Statistical analyses were
performed using the SAS software package (SAS Institute Inc,
Cary, North Carolina). All tests
were two-sided, and p-values
less than 0.05 were considered
statistically significant.
The purpose of the study was
to describe the effect of preoperative urinary catheter management
education on patients level of
anxiety following RP. In Table 1,
the median LOS for participants
who did not attend the class was
36.6 hours; median LOS for participants who attended the class
was 29.8 hours (p < 0.001). No
statistical difference was ob-

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

Table 1.
Comparison of Patients Who Did and Did Not Attend the Preoperative Class STAI
Patients (N = 100)
Did Not Attend, Mean
(Median) (n = 53)

Age in years
Preoperative STAI
Postoperative STAI
Postoperative STAIpreoperative STAI
Total nurse teaching time, min
Discharge anxiety scale (n = 99)



Attended, Mean
(Median) (n = 47)


< 0.001
< 0.020

Notes: LOS = length of stay; STAI = State-Trait Anxiety Inventory.

served in the ease of teaching

between the intervention and the
control groups. Median differences (postoperative-preoperative) in STAI scores for patients
who did not and did attend the
class were -4.9 and -9.6, respectively (p < 0.02), indicating a
greater reduction in anxiety for
patients who attended the class
than for those who did not.
Table 2 shows that in the 47
patients who attended the class,
34 (72%) were very confident in
their ability to secure the catheter,
compared with 26 (49%) of the 53
patients who did not attend the
class (p < 0.02). The following
items were statistically significant with the difference in STAI
scores: type of RP, attendance in
the preoperative class, watching
the video, and self-reported confidence in catheter management,
maintaining cleanliness, ability
to clean the leg and overnight
bags, and switching between the
leg and overnight bags.
Data related to the variables
of self-confidence and patient
follow-up calls are outlined in
Table 3. LOS, postoperative STAI
scores, difference between the
preoperative and postoperative
STAI scores, surgeon, patient
confidence in securing the catheter, patient confidence in
switching the leg and overnight
bag, and watching the video
were associated in a statistically
significant manner with attendance in the preoperative class.
Of the 47 patients who attended
the class, 34 (72%) were very

confident in their ability to secure

the catheter compared with 26
(49%) of the 53 patients who did
not attend the class (p = 0.01).
A comparison of features
among patients who did and did
not call their surgeon is shown in
Table 3. The mean and median
frequency of phone calls to the
physician after discharge from
the hospital was associated with
shorter LOS (p < 0.05). For example, median postoperative STAI
scores for patients who did and
did not call their surgeon were 28
and 24, respectively (p < 0.05).
The mean and median postoperative STAI scores were significantly higher (p < 0.05; indicating less anxiety) for those
patients who made follow-up
phone calls to the surgeon.
The results of this study
demonstrate that a structured,
preoperative educational program, with content specifically
aimed at the indwelling catheter
care requirements of patients
who undergo RP for treatment of
localized prostate cancer, decreases postoperative anxiety
and increases self-confidence in
urinary catheter management. In
addition, patients who received
preoperative education had reduced hospital LOS. Even though
preoperative education reduced
patient anxiety and increased
confidence in urinary catheter
management, nurses did not perceive a difference in the ease of

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

delivering postoperative education among patients who received preoperative education

versus those who did not.
One major concern of patients undergoing RP surgery is
their ability to live with their
urinary catheter at home (Burt et
al., 2005, p. 886). Given the
decreasing length of hospital
stays, nurses are challenged to
identify effective strategies to
educate patients within a shorter
time frame. Results of our study
found preoperative education
reduced patient anxiety and
increased confidence in management of a urinary catheter. This
result is consistent with qualitative research by Vickers-Douglas
et al. (2007), who found that a
structured, preoperative education class for patients undergoing
RP surgery reduced anxiety and
increased recognition of complex
aspects of self-care.
Preoperative education has
been shown to reduce hospital
LOS (Chaudhri et al., 2005;
McGregor et al., 2004). Even
though the hospital LOS for
patients undergoing RP surgery
at the research site is already
shorter than the national average
of 2.09 days (Mitchell et al.,
2009), our study found that
patients attending a structured
preoperative education class had
an even shorter LOS. This reduction may be the result of patients
enhanced confidence in the
skills needed to manage their urinary catheter. Consistent with
the results from our study,

Table 2.
Comparison of Self-Confidence Levels
Patients, Number (%)
Did Not Attend
Preoperative Class
(n = 53)

Securing catheter
All other responses
Very confident
Switching leg, overnight bag
All other responses
Very confident
Maintaining cleanliness
All other responses
Very confident
Knowledge of bladder spasms

Attended Preoperative
Class (n = 47)






< 0.020





< 0.050






All other responses

Very confident
Managing leg bag, overnight bag
All other responses
Very confident
Ability to clean leg, overnight bag
All other responses














Very confident
Knowledge of when and whom to call
All other responses
Very confident
Called surgeon
Watched video preoperatively




















< 0.001

Table 3.
Patients Who Did Not and Did Call Their Surgeon STAI
Patients (N = 100)
Age, years
Length of stay (hours)
Preoperative STAI
Postoperative STAI
Postoperative STAI preoperative STAI
Total nurse time, minutes
Discharge anxiety scale (n = 99)

Did Not Call, Mean

(Median [Range]) (n = 82)
61.8 (61.5 [48 to 77])
(29 [18 to 55])
(34 [20 to 66])
(24 [20 to 65])
(-7 [-37 to 20])
56.6 (58 [15 to 160])
(2 [0 to 8])

Did Call, Mean (Median

[Range]) (n = 18)
(63 [54 to 76])
(23 [19 to 54])
(32 [20 to 50])
(28 [20 to 46])
-2.5 (-3.5 [-23 to 23])
52.3 (45 [20 to 125])
(2 [0 to 8])

< 0.05
< 0.05

Note: STAI = State-Trait Anxiety Inventory.


UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

Chaudhri et al. (2005) found that

an intensive preoperative ostomy
skill-based education program
resulted in increased skill proficiency, reduced hospital LOS,
and decreased number of unplanned home care visits.
Patient anxiety and fear are
factors that need to be considered
when looking at best ways to
educate patients to meet their
individual needs (Hathaway,
1986). Patients have reported
that anxiety interfered with their
ability to retain educational instructions (Moore & Estey, 1999).
When patients experience difficulty retaining self-care educational instructions, their use of
community and medical resources increases (Davison et al.,
2004; Inman, Maxson, Johnson,
Myers, & Holland, 2011). Our
study also found that patients
who attended a structured preoperative educational class made
fewer phone calls to their health
care provider after hospital discharge.
Participants in this study
were not randomized to the intervention or control group; thus,
there may be differences between
the study groups that affected
these results. Data collection from
one study site, a large midwestern health care facility, limits the
ability to generalize these results
to other health care settings or
other geographic areas. Application of these results needs to be
done with caution because specific demographic characteristics
of our study population may
influence the study results.
Another limitation of the
study may be that persons attending a class may be healthier,
which could impact the hospital
LOS. Because people attending
the class all have different knowledge levels and experiences, the
questions and concerns they
present at the class may differ.
The information that patients
receive from their individual surgical team may also vary. Despite
standardized education templates
for the preoperative education

classes, inherent limitations in

the educational sessions may
have been present, including
variability of the RN instructors
knowledge and experience, differences in class size, and questions that participants ask.
A significant decrease in
patient self-reported anxiety was
observed when participation in a
structured, preoperative educational class occurred. Patients in
the intervention group also
reported an increase in self-confidence in providing the catheter
care required after hospitalization. Recognition and confidence
in how to manage bladder
spasms also tended to increase.
Finally, a significantly decreased
LOS was observed in the intervention group.

Implications for Nursing

Incorporation of indwelling
catheter care should be included
in any preoperative education
activity for men scheduled to
undergo an RP as treatment of
localized prostate cancer.

For Further Research
Further study should explore
the implications of specialty
nurse teaching versus general surgical nurse teaching. Further
research or the next most logical step would be to alter the
teaching, perhaps providing this
education online or in a Webbased format to determine
whether the teaching method
makes a difference. The use of
follow-up phone calls by a nurse
after dismissal as an intervention
to reduce anxiety and improve
patient satisfaction is another
potential study. Identification of
the man at risk for the inability
to provide catheter care at home,
reasons for phone calls to the surgeon, and need for home health
care would be interesting to investigate further. Distress, identified
by the National Comprehensive
Cancer Network as a sixth (or seventh) vital sign, is another variable to consider for assessment.

UROLOGIC NURSING / November-December 2013 / Volume 33 Number 6

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