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Introduction
With the increase in average life expectancy comes the need to reorganise healthcare and, specifically, nursing care in order to respond to the emergence of chronic diseases, such as eye pathologies (Costa, et al, 2021).
One of the most frequent and incapacitating alterations is the cataract, characterised by the opacification of the crystalline lens. It is responsible for 50% of cases of total loss of sight in people aged 80 or over, and 85% of cataracts are senile, which means that recovery of visual capacity is only possible through surgery (Almança, et al, 2018).
Cataract treatment is mostly performed using the phacoemulsification technique, which is performed on an outpatient basis, and is characterised by a quick visual recovery and low occurrence of intraoperative complications. Taking into account the ageing of the population, which is intended to be healthy, autonomous and independent, it becomes necessary to adapt care to meet the real needs of the elderly person in their life context (Costa, et al, 2021).
The preoperative nursing consultation for cataract surgery allows planning the entire surgical process with the multidisciplinary team and, in relation to the client, providing the involvement and knowledge of the entire surgical process inherent to their situation. This consultation makes it possible to reduce the degree of anxiety, fears and concerns associated to the surgery, to reinforce postoperative care and to promote the potential for autonomy inherent to the surgery. All the information given to the patient is extremely important, both preoperatively and postoperatively, to ensure the success of the surgery and to contribute to patient satisfaction (Balona, 2016).
The caregivers' availability has a considerable implication on the degree of client satisfaction (Mota, 2018).
In general, satisfaction is understood as an indicator of better health outcomes, contributing to therapeutic adherence and is seen as a predictor of health behavior (Santana, et al, 2020).
According to Timóteo (2017), as satisfaction is an important indicator of service quality, it should be used as a guide for nursing care, since there is a proportional relationship between client satisfaction and the assessment of the quality of care.
This study was designed to identify customer satisfaction with the preoperative outpatient cataract surgery nursing consultation.
1. Theoretical foundation
Aging is a natural part of the life cycle, so it is desirable to promote a healthy and independent life as long as possible.
Elderly care is a challenge, taking into account the changes resulting from the aging process and the variety of associated pathologies (Costa, et al, 2020).
In this context, nurses see their care provision increased in terms of complexity. Therefore, the care provided to cataract surgery patients is demanding, since this degenerative process is prevalent in advanced age groups. Cataract is a chronic and irreversible disease that results in the progressive installation of the loss of transparency of the lens, which can evolve from mild vision loss to blindness. In the most developed countries, it is the cause of avoidable blindness (in Portugal, it has an incidence rate of 8% of clients with decreased visual acuity) (Direção Geral de Saúde, 2018). Factors such as age, diabetes, genetic factors, smoking habits, trauma, among others, are risk factors for this pathology, which can only be treated surgically (Direção Geral de Saúde, 2018). According to statistical results presented in the same document, in Portugal, where there is an aging population, this pathology is increasingly frequent, which is verified by the number of cataract surgeries that increased from 14226 in 1993 to 146958 in 2015 (last year with available data) (Direção Geral de Saúde, 2018). With this procedure, clients see an improvement in their daily life activities and consequent quality of life. Cataract surgery is mostly performed on an outpatient basis, which translates into multiple social, family, economic, and psychological advantages (Timóteo, 2017). It is essential to invest in differentiated nursing care in the perioperative period of outpatient surgery, taking into account the nurses' role in ensuring the safety and continuity of care (Timóteo, 2017).
A preoperative nursing consultation is performed which, according to Balona (2016), allows facilitating the client's preparation for surgery, creating a relationship of empathy and help with the client and caregiver. It is already at this stage that the potential for autonomy begins to be promoted, focusing on the preparation for discharge.
In this context, the preoperative nursing consultation is of great importance, given the relevance of the information both preoperatively and postoperatively, making the discharge process more responsible and participatory by clients and caregivers.
It is also important to emphasize the uniqueness of this moment to promote care oriented according to the client's needs and being appropriate to clarify doubts, provide clear information, establish a relationship of empathy and trust with the operating room team.
According to Matzenbacher, et al, (2021), the arrival to the operating room is always preceded by a feeling of discomfort due to the increased sensitivity to the noises and noises of the environment.
At this juncture, fear of visual impairment are concerns that trigger major anxiety symptoms, and preoperative information is an essential contribution to reducing them. Aspects of great relevance contributing to the collaboration of the client (who is awake) and consequently hemodynamic improvement, namely hypertension (which causes increased ocular hypertension) and tachycardia that predisposes to agitation.
Anxiety and stress are common in the experience of clients who will undergo a surgical procedure, which reinforces the idea that any surgical procedure, even the simplest, generates a degree of anxiety on the part of the client and caregiver. The fear of the unknown, doubts and uncertainties related to the recovery process and the surgical procedure are aspects that should be taken into consideration.
The preoperative nursing consultation represents a key autonomous activity to prepare the client for the intervention and their postoperative recovery (Breda & Cerejo, 2021).
These aspects support the need for a preoperative nursing consultation, which is a fundamental contribution to ensuring the efficiency and safety of cataract surgery care in outpatient settings. As the quality of the information transmitted to both the client and the caregiver is of great importance, it should be adapted to the capacity of understanding of those involved so that all the information transmitted is assimilated. The high age range in this type of surgery, as previously mentioned, sometimes makes the information transmission a challenge. In this context, information must be transmitted in a clear and consistent way, enabling all the intervenients to have all the essential information. A good transmission of information has a great weight in this whole process and actively contributes to customer satisfaction.
Balona (2016) mentions that outpatient surgery aims to increase customer satisfaction and provide a better response in terms of community health, by reducing the number of hospitalized patients, reducing the rate of healthcare-associated infections, reducing waiting lists, reducing hospital costs, and freeing up beds for hospitalizations needed for other pathologies. Satisfaction is also associated with the quality of care (Breda & Cerejo, 2021).
This theme is increasingly relevant because one of the challenges in the current health area is to assess customer satisfaction regarding the care provided, which is an extremely important health indicator for possible reorganizations of the health service (Oliveira, et al, 2018). In view of the above, the surgical procedure should be previously considered by the health professional as a quality procedure to provide customer satisfaction.
In this context, the preoperative nursing consultation is a key factor for the success of outpatient cataract surgery, both by involving the patient in the whole surgical process and by reducing anxiety, facilitating the return to daily life and care adequacy, as well as minimizing postoperative complications and, consequently, quality of care and client satisfaction.
2. Methods
Quantitative, descriptive and exploratory study developed in a hospital in central Portugal. The sample of the study is non-probabilistic and of convenience having been included in the study the clients who have participated in the preoperative nursing consultation of cataract surgery and who have performed this intervention in this institution, in the period between 1 January 2019 and 31 December 2019. Data collection was performed using a highly structured interview (via telephone) using a form. This form, which was designed by the authors of the study, is composed of questions focused on the study objective related to the identification of client satisfaction, as well as the relevance of the preoperative nursing consultation from the client's perspective. The variables of the instrument were operationalized on a Likert scale with semantic fields ranging from 0 to 4: relevance of the information transmitted (not at all relevant to extremely relevant); clarification regarding postoperative care (not clarified at all to extremely clarified); satisfaction with the consultation and quality of service provided (not satisfied at all to extremely satisfied).
The form includes questions of sociodemographic characterization and includes space for suggestions for improvement and recording of appropriate notes.
Out of a total of 2075 surgeries performed, 1594 were performed in an outpatient regime in 2019. Of these, 783 had a preoperative nursing consultation.
Exclusion criteria for the sample were: clients who died, duplicate patients (both eyes were operated), those who could not be contacted and those who refused to participate in the study. We obtained a final sample of 348 clients. Data collection took place between October 1 and December 15, 2020.
Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 22 software.
The procedures ensuring ethical conduct were carried out, namely data confidentiality and voluntary participation with the possibility of withdrawing from the study without any prejudice. The study was authorized by the Administration of the hospital unit under study and a favorable opinion was obtained from the Ethics Committee (Doc.noº CA-192/2020-ot_MP/AC of July 13, 2020).
3. Results
The study participants have an average age of 73.74±8.44 years, ranging from 44 to 98 years of age.
The majority of the participants are female 59.5% (n=207). In this sample, 60.9% (n=212) of the individuals reside in an urban area and only 39.1% (n=136) reside in a rural setting. Regarding marital status, 64.6% (n=225) of clients are married, 27.3% (n=95) are widowed, 4.9% (n=17) are divorced and the remaining 3.2%, (n=11) are single.
When asked about their level of education, the majority of respondents 74.7% (n=260) have completed the first cycle of schooling (i.e., 4th grade). Only 16% (n=56) respondents have a higher level of schooling than the previous one. It should also be noted that 9.2% (n=32) of the people who make up this sample have not attended elementary school.
In relation to profession, 85.1% (n=296) are retired, and only 9.5% (n=33) of the respondents are active workers.
Almost all of the clients live at home 99.7% (n=347). Thus, the variable of people living in institutions, becomes insignificant for the study in question, since it represents only 0.3% (n=1) of the clients surveyed.
With regard to the question of who they live with, most clients live with a spouse or partner 45.1% (n=125); they live with a spouse and/or children 21.0% (n=73) and 14.9% (n=52) children only, respectively. It should also be noted that 13.5% (n=47) of people are living alone.
The cognitive capacity to retain the information transmitted in these consultations is present in almost all the respondents 95.7% (n=333). When questioned about the existence of an informal caregiver, only 6.9% (n=24) affirmed the existence of one.
About 99.1%, (n=345) were operated in an outpatient regime. Practically all the respondents, 98.9% (n=344) had only one preoperative nursing consultation. In all respondents, no readmissions were recorded during the period of data collection. We verify high levels of satisfaction in all variables (table1).
Using the T-test, which is a hypothesis test that allows us to compare averages, we verified that there are no statistically significant differences regarding the satisfaction of the participants according to their gender, as well as their cognitive ability. There are significant differences between participants who live in their own homes or institutionalized (in nursing homes) regarding the need for a companion/caregiver for the first 24 hours, t(346) = 1.973, p =0.05. Participants living in their own home reported greater need for companionship than those institutionalized. Participants living in their own home report greater relevance of preoperative information than institutionalized participants, t(346) = 1.970, p =0.05. Participants living in their own homes show greater relevance of clarification regarding effort-centered postoperative care during the first week, t(346) = 1.985, p =0.05. Participants living in their homes show greater relevance to the enlightenment that the video on postoperative care provided them, t(346) = 2.165, p =0.03. Participants living in their own homes showed greater agreement between the information provided to them preoperatively and their actual experiences at the time of surgery, t(346) = 2.498, p =0.01.
4. Discussion
From the analysis of the interviews we conducted, we can conclude that on a global indicator, the clients present quite high levels of satisfaction. The study shows an overall average in the questions asked that is 3.73, which represents a degree of satisfaction of 93.73%. According to Oliveira, et al, (2018), with the aging of the population, there is a need to change the focus of the evaluation of the quality of services, meaning, to stop focusing this evaluation on the care provider and start evaluating customer satisfaction.
It has become evident that the level of satisfaction in general does not depend on the variable under study, as we have shown with this study, the place of residence between urban or rural, in which its behavior remains homogeneous between the two distinct groups.
We can verify that there is an added value of the preoperative nursing consultation for the client, given their feedback transmitted in the surveys carried out. This case can be verified by analyzing the averages of the answers obtained to the different groups of questions. Since the average of the answers to questions Q1 to Q5 is 3.72, the information transmitted in the preoperative nursing consultation is extremely relevant. This fact is corroborated by Breda & Cerejo (2021) when they state that the consultation is the crucial moment to assess the client's information needs and the ideal time to transmit important verbal and written information. Similarly, given that the average of questions Q6 and Q7 was equal to 3.73, this fact leads to the inference that the information transmitted in this consultation is extremely pertinent. The consultation allows for proper preparation for surgery, as well as compliance with postoperative care and suggested treatments (Breda & Cerejo, 2021). This fact is substantiated by (Loureiro, 2018) when he states that there is a consensus that nurses are the factor that most influences satisfaction as a whole, related with the hospital experience.
The average obtained in Q11 suggests a significant relevance concerning the viewing of the video during the preoperative consultation. This fact is supported by Costa et al. (2020), when he mentions that nurses are responsible for collaborating and communicating in an efficient way, guiding the client's return home. In this context, the information conveyed, either through audiovisual films (including an explanation of what cataract is, the phacoemulsification removal technique, the route from the entrance to the operating room, the respective admission care, preparation, surgery and discharge, explaining all the inherent postoperative care) or through the reinforcement of the pamphlet with important preoperative aspects, is of great relevance.
On the other, the analysis of the groups of questions Q13 to Q15 and Q8 to Q12 shows that the preoperative nursing consultation was extremely enlightening and that clients were extremely clear about postoperative care (since the average answers obtained to these questions were 3.69 and 3.76, respectively).
Finally, since the average of the answers given to questions Q16 to Q17 is equal to 3.78, we conclude that clients were extremely satisfied with the existence of the preoperative nursing consultation. These results reveal the extreme importance of the preoperative nursing consultation for the unfolding of the entire surgical process and preparation for a responsible, informed and participatory discharge. The surgical process performed in outpatient settings, characterized by a short stay in the health care institution, compromises the nurse-client relationship, which further values the preoperative consultation as an autonomous activity essential for preoperative preparation and subsequent surgical recovery (Breda & Cerejo, 2021).
Outpatient surgery implies mandatory criteria for its performance. If these criteria are not met, the surgery will be postponed, resulting in all costs and losses for both the client and the hospital. Information should be simple, clear and focused on the essential, adapted to the capacity of understanding of those involved, enabling the assimilation of all the information transmitted.
The communication skills of professionals are crucial, because effective communication has a direct impact on client satisfaction. On the other, high levels of satisfaction associated with the preoperative nursing consultation and all the information provided therein can confirm that the preoperative nursing consultation has a direct impact on the type of information received by clients and greater adherence to care (Oliveira, et al, 2018).
Conclusion
The preoperative nursing consultation, as previously mentioned, represents a fundamental contribution that ensures efficiency and safety in the outpatient cataract surgery care. All information transmitted to the client/caregiver should be adapted to the capacity of understanding of those involved, allowing for the assimilation of all the information transmitted.
All the information approached in order to prepare the client and his/her family is an aspect of great importance. The explanation of the technical procedures, as well as all the steps to be taken on the day of the surgery, aims to prepare the patient as well as possible for the surgical experience, providing success for the satisfaction of the whole treatment.
The information provided should be simple, if possible, using audiovisual means, transmitting safety and involving the client in the whole process. As is well known, effective information improves communication, provides satisfaction and reduces anxiety related to the experience of surgery.
We recognise that client satisfaction with nursing care is an essential indicator of the quality of care provided.
As a result of this study, we reflect on the great importance of the quality of information transmitted to the client, family and/or caregiver, adapted to the clients's capacity of understanding and clearly and objectively assimilated.
It is essential and necessary to select the information in advance, empowering clients with relevant information, participating in an active and enlightened way, thus contributing to a high level of client satisfaction.
Our study reflects the opportunity for us to get to know the opinion of our clients regarding the quality of our service provision, in relation to their satisfaction.
By continuing this service, we intend to optimise resources, promoting client satisfaction and to reduce the effects of hospitalisation.
Thus, it is of paramount importance that institutions promote and increase preoperative outpatient cataract surgery nursing consultations and reflect on the decisive importance of the provision of nursing care associated with satisfaction and quality, thus promoting excellence in care focused on clients' needs.
As a limitation of this study, we were faced with a very long delay in obtaining the necessary data, which limited the time for form application and data processing.
In the future, a comparative study between clients undergoing cataract surgery with and without preoperative nursing consultation would be essential to assess the added value of the existence of this consultation.
