ABSTRACT

Objective

Quality monitoring is a necessity in ambulatory surgery and is increasingly common. Since nurses are the health professionals that patients encounter most during the short time they spend in the hospital, the effect of their quality of care on patient outcomes should be determined. This study aimed to evaluate the relationship between ambulatory surgery patients’ perceptions of readiness for discharge and the quality of perioperative nursing care.

Methods

This descriptive and correlational study included 124 patients who underwent ambulatory surgery at a training and research hospital in İstanbul between October 2023 and March 2024. Data were collected using the Good Perioperative Nursing Care scale (GPNCS) and Readiness for Hospital Discharge scale (RHDS) before patients were discharged.

Results

The mean age of the patients in the study was 43.14±15.88 years, of which 56.5% were male and 62.1% were married. The mean total GPNCS and RHDS scores of the patients were 117.48±20.79 and 7.26±1.48, respectively. It was determined that 50.8% of the patients were not ready for discharge, and there was a significant relationship between not being ready for discharge and the adequacy of discharge education. A statistically significant, positive, and moderate relationship was found between the GPNCS and RHDS total score averages (r=0.633, p<0.001).

Conclusion

Findings showed that patients after ambulatory surgery, and the quality of perioperative nursing care affected the perception of readiness for discharge. In this regard, to facilitate patient recovery, nurses should plan appropriate interventions to improve the quality of perioperative care.

INTRODUCTION

The primary objective of healthcare systems is to deliver safe, high-quality care. Care lies at the core of nursing knowledge, skills, and practices, making it a fundamental component of healthcare services (1). Nurses are the primary caregivers patients interact with during hospital stay, and nursing care is a significant determinant of overall satisfaction with healthcare quality (2). Defining and evaluating nursing care quality can be challenging despite its widespread conceptual use. Nursing care quality, as perceived by patients, encompasses meeting physical and emotional needs, responding to their wishes, ensuring comfort and convenience, providing accurate information, and maintaining a pleasant environment. Patients’ experiences and satisfaction are often used when evaluating the quality of nursing care (2, 3). The significance of assessing the quality of care in the field of surgery is underscored by its status as a primary treatment option, associated costs, and potential for serious morbidity and mortality (4).

Surgical intervention is a major event that can evoke various care needs, emotions, and fears in patients. The perioperative period encompasses three distinct phases: preoperative, intraoperative, and postoperative, with nursing care directly affecting surgical and patient outcomes (5). Perioperative nurses are tasked with prioritizing patient safety, which entails creating and maintaining a sterile surgical environment, providing perioperative education to patients, monitoring their physical and emotional well-being, and coordinating care throughout the surgical process (6).

During the perioperative period, patients may find it challenging to articulate their needs due to their vulnerability and reliance on the surgical team. To enhance the quality of nursing care, patients should be encouraged to evaluate the care they receive and express their needs freely. Studies indicate that patients often require support in managing symptoms such as pain and nausea during this period, as well as access to information and respectful treatment after surgery (5). Furthermore, research highlights the impact of factors such as inadequate surgical information, fear of adverse outcomes, poor communication between surgical teams and patients, and the manner in which patients are approached, all of which influence patient satisfaction (7). Despite reports of low satisfaction regarding patient involvement in the surgical process and information provision, patients generally perceive the quality of perioperative care to be satisfactory (8).

Perioperative care has undergone significant transformations in recent years, marked by advancements in surgical and anesthesia techniques, as well as the adoption of accelerated postsurgical recovery protocols aimed at minimizing complications and shortening hospital stays. These developments have facilitated the shift of surgical interventions from traditional inpatient to ambulatory surgery settings (9). Ambulatory surgery entails the discharge of patients from the hospital within 24 hours of the procedure, allowing them to recuperate at home with minimal disruption to their daily routines while mitigating the risks associated with prolonged hospitalization. The growing preference for ambulatory surgery is driven by its low incidence of major adverse events and mortality rates, coupled with high levels of patient satisfaction, even for more complex surgical procedures. However, this increasing demand necessitates ongoing monitoring of care quality and evaluation of patient outcomes to ensure optimal outcomes (4, 10).

Common quality indicators in ambulatory surgery include pain management, nausea and vomiting control, fatigue alleviation, physical comfort, emotional well-being, patient satisfaction levels, complication development, waiting times before and after surgery, discharge timing, readiness for hospital discharge, and the occurrence of unplanned hospital readmissions (10).

Readiness for hospital discharge entails assessment of readiness to leave the hospital and manage their condition at home (11, 12). Evaluating patients’ readiness for discharge helps prevent premature discharge, reduces post-discharge complications, alleviates strain on medical resources, and reduces costs (13). Nurses predominantly oversee essential discharge preparation tasks, such as assessing and planning for needs, providing education, and coordinating post-discharge care. Factors influencing readiness for discharge include individual characteristics like age, gender, education, and marital status, as well as nursing-related factors, such as nurse availability, interaction time, and communication quality (14, 15). Research indicates that patients under the care of experienced nurses often exhibit higher readiness for discharge (11) and that the quality of nursing care processes is correlated with satisfaction levels and discharge readiness (16, 17).

There is limited literature exploring the readiness of patients undergoing ambulatory surgery for discharge and the factors influencing this readiness. Although studies have indicated the impact of discharge education provided by nurses and surgical teams on discharge readiness (13, 18), its correlation with the quality of perioperative nursing care remains unexplored. Given the abbreviated postoperative care duration in ambulatory surgery, patients may have greater physical and emotional needs upon discharge than anticipated. Understanding the influence of nursing care quality on discharge readiness is crucial for identifying areas for improvement in the perioperative care process and planning patient-centered care.

This study aimed to investigate the relationship between patient perceptions of readiness for hospital discharge and the quality of perioperative nursing care during ambulatory surgery.

METHODS

Study Design

This research adopted a descriptive and correlational approach.

Sample and Settings

The study population comprised patients who underwent ambulatory surgery at a training and research hospital in İstanbul between October 2023 and March 2024. During the previous year, 370 patients underwent ambulatory surgery at our hospital. The inclusion criteria of the sample were age >18 years, undergoing ambulatory surgery with an operating room stay of >1 h, and a hospital stay of 24 h. Patients undergoing general surgery and urologic procedures met the criteria described above at the hospital where the study was conducted. Patients who did not consent to participate, were illiterate, or remained in the hospital for more than 24 h despite being scheduled for ambulatory surgery were excluded. The result of Turan et al.’s (19) study (2021) was applied to estimate the sample size using power analysis, with an effect size of 0.41, significance level of 5%, effect size of 0.5, and power of the study at (1-b) 80%. The total sample size required was 124 patients.

Data Collection Tools

Data collection involved the use of a descriptive information form, “Good Perioperative Nursing Care scale”, (GPNCS) and “Readiness for Hospital Discharge scale”. Patients, who were monitored in relevant clinics after ambulatory surgery, were briefed about the study before discharge and requested to complete the data collection forms.

Descriptive Information Form: This form, developed by the researchers in line with the literature (1, 3, 14, 15), encompasses sociodemographic characteristics, as well as inquiries regarding receipt and adequacy of discharge education, and availability of post-discharge care support, comprising 15 questions.

GPNCS: This 34-item, 5-point Likert scale evaluates the quality of perioperative nursing care. Dönmez and Özbayır (20) performed adaptation of the scale to Turkish society. The following expert suggestions, the scale was refined from 34 to 32 items. The score is derived by summing responses, with seven sub-dimensions indicating quality of perioperative nursing care: physical care, providing information, supporting, respect, personnel characteristics, environment, and nursing process. Scores ranged from 32 to 160, with higher scores denoting superior nursing care quality. In a previous study, Dönmez and Özbayır (20) reported a Cronbach’s alpha reliability coefficient of 0.92 for GPNCS. In the current study, the Cronbach’s alpha reliability coefficient of the scale was 0.97, and its sub-dimensions were determined as 0.86 for physical care, 0.83 for providing information, 0.73 for support, 0.86 for respect, 0.79 for personnel characteristics, 0.85 for environment, and 0.83 for nursing process sub-dimensions.

Readiness for Hospital Discharge Scale Short Form (RHDS): The scale, developed by Weiss et al. (2014) (21), assesses patients’ readiness for discharge and was subjected to a Turkish validity and reliability study conducted by Kaya et al. (2018) (22). Comprising eight items in four dimensions, the scale assesses personal status, knowledge, coping ability and expected support. Patients scoring ≥7 in each dimension are considered ready for discharge, whereas those scoring <7 are deemed unready. Additionally, patients were categorized based on their scores as having very high (9-10), high (8-8.9), medium (7-7.9), or low (<7) readiness levels. The scale exhibits a Cronbach’s alpha reliability coefficient of 0.74 and employs a 10-point Likert scale (22). In the current study, the scale demonstrated high internal consistency, with a Cronbach’s alpha coefficient of 0.95.

Ethical Permissions

Approval for this research was obtained from the University of Health Sciences Türkiye, Bakırköy Dr. Sadi Konuk Training and Research Hospital Clinical Research Ethics Committee (decision no: 2023-19-03, date: 02.10.2023). Institutional permission was obtained from the hospital where the research was conducted. Patients were briefed on the study objectives and procedures and provided written informed consent.

Statistical Analysis

Data analysis was performed using Statistical Package for the Social Sciences 21.0. Descriptive statistics, such as mean, standard deviation, frequency, percentage, minimum, and maximum, were used. The Kolmogorov-Smirnov test was used to assess the normal distribution of continuous variables. Intergroup comparisons of continuous variables used the Mann-Whitney U test for two groups and the Kruskal-Wallis test for multiple groups. Spearman’s correlation tests determined relationships between scales, with correlation coefficients classified as very weak (0.00-0.25), weak (0.26-0.49), moderate (0.50-0.69), strong (0.70-0.89), or very strong (0.90-1.00). A significance level of p<0.05 was considered statistically significant.

RESULTS

The results indicate that the average age of the patients enrolled in the study was 43.14±15.88 years. Among the included patients, 56.5% were male, 62.1% were married, 36.3% were high school graduates, 66.1% did not have a chronic disease, and 20.2% had hypertension. The predominant type of surgical intervention in the current study was general surgery, accounting for 89.5% of cases, with laparoscopic appendectomy surgery being the most common procedure performed (46.8%). The average operating time was 62.17±16.35 minutes, and patients spent an average of 86.53±18.66 minutes in the operating room. Regarding post-discharge care, 90.3% of patients reported having someone available to assist with home care. All patients reported receiving discharge education, with 89.5% finding it adequate. However, 61.3% of the patients expressed feeling somewhat prepared for discharge (Table 1).

When examining the mean total and sub-dimensions scores of the patients on the GPNCS, the mean score for the physical care sub-dimension was 37.23±6.83, for giving information it was 18.23±4.07, for supporting it was 13.90±3.27, for respect it was 11.27±2.02, for personnel characteristics it was 14.54±2.85, for environment it was 14.82±2.91, and for nursing process it was 7.48±1.55, while the mean total score was 117.48±20.79. Regarding the RHDS, the mean total score was 7.26±1.48, with the personal status sub-dimension scoring a mean of 7.27±1.44, the knowledge sub-dimension scoring a mean of 7.30±1.73, the coping ability sub-dimension scoring a mean of 7.19±1.72, and the expected support sub-dimension scoring a mean of 7.27±1.76 (Table 2).

There was a positive and moderate correlation between the mean total score of the GPNCS and the RHDS (r=0.633, p<0.001). A similar correlation was also found between all sub-dimensions of both scales. Additionally, among patients who scored 7 points or higher on the RHDS, 49.2% were deemed ready for discharge, whereas 50.8% of those scoring below 7 points were considered not ready for discharge. Furthermore, a moderate and positive correlation was identified between the mean total score of the GPNCS and the RHDS in patients ready for discharge (r=0.455, p=0.000). Moreover, a low to moderate positive correlation was observed among all sub-dimensions of the scales, as well as between their mean total scores and all sub-dimensions (p<0.05) (Table 3).

Although no relationship was discerned between the mean total scores of the GPNCS and the RHDS in patients who were not deemed ready for discharge, a relationship was observed between several sub-dimensions. Specifically, correlations were found between giving information and knowledge (r=0.271, p=0.032), personnel characteristics and knowledge (r=0.339, p=0.006), environment and personal status (r=0.310, p=0.014), environment and knowledge (r=0.441, p=0.001), nursing process and personal status (r=0.288, p=0.022), and nursing process and knowledge (r=0.365, p=0.003) sub-dimensions. Additionally, a correlation was noted between the mean total score of the GPNCS and the knowledge sub-dimension of the RHDS (r=0.343, p=0.006) (Table 4).

There were no significant relationships between the sociodemographic characteristics of the patients and the scales, as well as the variables associated with the surgical process and the scales (p>0.05). However, a notable correlation was observed only between patients who were not deemed ready for discharge and the adequacy of discharge education (Z=-2.676, p=0.007).

DISCUSSION

Evaluating patients’ readiness for discharge is a pivotal aspect of the discharge planning process (11). Nurses, being the primary point of contact for patients, play a crucial role in facilitating the discharge process. In ambulatory surgery, where patients have short hospital stays, nurses are tasked with efficiently preparing patients for discharge within a limited timeframe. Patients who are not adequately prepared for discharge are at increased risk of complications. Perioperative nursing care practices significantly contribute to preventing complications and ensuring favorable patient outcomes (6). This study aimed to assess the impact of the quality of perioperative nursing care among patients undergoing ambulatory surgery on their readiness for discharge. The results of the study revealed a positive and moderate correlation between the quality of perioperative nursing care and readiness for discharge, indicating that patients with higher evaluations of care quality were more ready for discharge.

The average score for perioperative nursing care quality among patients was 117.48±20.79. A comparison with existing literature utilizing the GPNCS revealed noteworthy differences. For instance, Özkan et al. (2023) (23) reported a mean score close to the scale maximum in their study involving patients undergoing general or orthopedic surgery, with an average score of 140.0±16.9. Similarly, higher score averages compared to this study were observed in a study by Şahin and Başak (2018) (24), with averages of 129.49±13.84. Notably, this study’s sub-dimension mean scores for physical care, personnel characteristics, and environment were comparatively lower. This variance may be attributed to the busy nature of the operating room in the study institution, and healthcare professionals believe that ambulatory surgery patients have fewer needs due to undergoing minor surgical interventions. Although no prior studies have assessed the quality of perioperative nursing care specifically in ambulatory surgery patients, Gezer and Arslan (2021) (9) reported above-average satisfaction levels among such patients with nursing care. Similarly, Jun and Oh (2016) (10) found a comparable satisfaction level, particularly regarding trust and technical professionalism. The relatively lower perception of perioperative nursing care quality in the current study compared with that of inpatient surgical procedures may be due to nurses having less interaction time with patients in the ambulatory surgery setting.

In this study, the mean score of the RHDS was determined as 7.26±1.48, indicating that patients felt moderately ready for discharge following ambulatory surgery. This finding is consistent with the results of Nurhayati et al. (2019) (25) study (7.11±0.59) involving inpatients who underwent general surgery. Similarly, Baksi et al. (2020) (26) and Zhao et al. (2020) (27) found that patients who underwent various surgical procedures, such as laryngectomy and craniotomy, were moderately discharged. However, other studies have reported varying levels of readiness for discharge, ranging from low to high (12, 19). In the current study, patients were observed to have a moderate level of readiness across the sub-dimensions of the scale. Although not significant, the average score for the coping ability dimension was slightly lower than the other dimensions. This dimension encompasses questions regarding patients’ preparedness for managing home demands and personal care post-discharge. The patients’ relatively lower perception of readiness for coping highlights a significant finding that the ambulatory surgery team should consider because it poses a potential risk for readmission or hospitalization (15).

In the current study, 49.2% of the patients were deemed ready for discharge based on the RHDS. When comparing this finding with the limited literature available, it is consistent with Mabire et al. (2019) (11), who observed that 47.8% of patients in both internal and surgical clinics were ready for discharge. However, when examining the relevant literature concerning patients undergoing ambulatory surgery, our results are notably lower than previous findings. Qiu et al. (2019) (13) reported a readiness rate for discharge of 95.36%, whereas You et al. (18) found it to be 98.8% after ambulatory surgery. This discrepancy in comparison with other studies could be attributed to differences in the composition of the study groups, as the participants in the current study may have undergone less complex surgical procedures, such as cataract surgery.

Although this study did not reveal a significant relationship between patients’ sociodemographic characteristics and their readiness for discharge, previous research has indicated that factors such as age, literacy, availability of support for home care, previous hospitalization experiences, and length of hospital stay can influence readiness for discharge (12, 17, 28). However, in the current study, a correlation was only found between patients who were not ready for discharge and the adequacy of the discharge education provided. This finding aligns with the results of Durmaz and Özbaş (2023) (14).

In this study, a positive relationship was observed between the quality of perioperative nursing care among patients undergoing ambulatory surgery and their readiness for discharge. This particular finding lacks comparison in the existing literature. Discharge education is a crucial nursing intervention during the discharge preparation process, addressing a significant need among ambulatory surgery patients and significantly affecting patient satisfaction. The quality of education is a key determinant of patient readiness for discharge (15). Qiu et al. (2019) (13) and You et al. (2019) (18) examined the correlation between the quality of discharge education and readiness for discharge among ambulatory surgery patients, both reporting a positive correlation. Similarly, findings from studies including inpatients undergoing surgical interventions echo these results (27). Another study involving patients from internal and surgical clinics concluded that the content and nurses’ skills in delivering discharge education were associated with patients’ readiness for discharge (28). Additionally, this study revealed a positive relationship between the giving information sub-dimension of the GPNCS and the knowledge sub-dimension of the RHDS, further supporting these findings. This underscores the significance of education for patients undergoing ambulatory surgery, emphasizing the importance of adequately informing patients during the perioperative period to enhance their readiness for discharge and subsequent self-care at home.

Determining patient satisfaction with nursing care is crucial for meeting patients’ needs and assessing the quality of care. When patients’ expectations regarding nursing care are fulfilled, their participation in treatment and care practices becomes smoother (29). Therefore, the association between patient satisfaction with nursing care and readiness for discharge has been investigated in various studies. Baksi et al. (2021) (17) identified a positive correlation between nursing care satisfaction and readiness for discharge among surgical patients, whereas Schmocker et al. (2015) (30) found that patient satisfaction in areas such as the communication with physicians and nurses and overall hospital experience influenced their readiness for discharge. Additionally, a study observed that patients under the care of nurses with greater professional experience were more ready for discharge, suggesting that experienced nurses provided higher-quality care during the discharge preparation process (11). In this regard, the current study is in line with the existing literature.

A moderate correlation was observed between the personnel characteristic sub-dimension of the GPNCS and the knowledge sub-dimension of the RHDS among patients who were not ready for discharge. Although patients may not feel ready for discharge, positive interactions with healthcare professionals during the perioperative period can positively influence their knowledge. Healthcare professionals who demonstrate expertise, strong communication, and interpersonal skills, allocate sufficient time for patient care, and provide reassurance typically yield better patient outcomes (3, 8).

Although no comparable studies exist in the literature, a positive association was identified between the environment sub-dimension of the GPNCS and the personal status and knowledge sub-dimensions of the RHDS. Similarly, a positive correlation was found between the nursing process sub-dimension of the GPNCS and the personal status and knowledge sub-dimensions of the RHDS. A clean and orderly clinic environment and comfortable patients are considered indicators of quality care (3, 5). Moreover, an environment free from distractions is crucial for effective patient education. Therefore, a relationship between patients’ positive environmental perceptions during the perioperative period and their personal status and knowledge at discharge is expected.

In addition to the relationship between patients’ readiness for discharge and the quality of discharge education and nursing care satisfaction, a few studies have suggested that nursing practices, such as care coordination and one-on-one time with patients, contribute to patients’ overall readiness for discharge, although their impact on specific sub-dimensions remains unclear (16, 28). The role of nurses in discharge management for patients undergoing ambulatory surgery, as highlighted by the effect of the nursing process observed in this study, is vital for ensuring smooth transitions for both patients ready for discharge and those who are not.

Study Limitations

This study is the first in the literature to explore the relationship between perioperative care quality and readiness for discharge after ambulatory surgery. Moreover, it is confined to data from patients who underwent general and urologic surgery at a single center.

CONCLUSION

The findings of this study indicate that patients undergoing ambulatory surgery exhibit moderate readiness for discharge, with their perception of perioperative care quality significantly influencing this readiness. Given that patients who are unprepared for discharge may face heightened risks and adaptation challenges that impede recovery, enhancing the quality of care provided by nurses to ambulatory surgery patients can foster readiness for discharge and positive patient outcomes.