A qualitative study of nurse‐patient communication and information provision during surgical pre‐admission clinics

Abstract Background Health‐care service users are often being described as ‘co‐producers’ with an active role in their care. However, there are challenges associated with this approach, including how standardization affects personalized care, and the ability of patients to retain high volumes of information. Objective Our study explores patient and nursing perspectives of information provision in the pre‐admission element of an Enhanced Recovery After Surgery programme, an evidence‐based approach implemented to improve the quality of surgical care. Our analysis has been informed by an evidence‐based model developed by Grande et al Patient Educ Couns. 2014;95:281. Design/Setting and participants This was a qualitative study including observations of pre‐admission clinics and semi‐structured interviews across three surgical wards. Patients (n = 21) and registered nurses (n = 21) were purposively selected for interviews. Results Patients welcomed the opportunity for active involvement in their care. However, we also identified informational boundaries and how illness and treatment‐related anxieties were barriers to patient engagement with the information provided. Discussion We recommend that to support a patient‐centred and individualized approach to patient involvement the ‘information (giving) + activation’ element of Grande et al Patient Educ Couns. 2014;95:281 model be reconfigured to allow for ‘information (giving) + exploration +activation’. Conclusion Nurses need to feel empowered to adopt strategies that allow for different informational needs, rather than adopting a one‐size‐fits‐all paternalistic approach. Patient contribution This study focused on patient involvement and we give thanks to all the patients who took part in interviews and those who allowed us to observe their care.


| INTRODUC TI ON
Historically, relationships between patients and health-care professionals have followed a paternalistic model in which patients are regarded as passive recipients of care. 1 Anderson and Funnel 2 describe an 'acute care paradigm' which has underpinned the approach to health care in hospitals, where patients surrender control to health-care professionals who are then relied on to use their expert skills and knowledge to solve patients' health problems. This paradigm closely reflects the notion of the 'sick role', 3 which positions an acutely ill person as temporarily passive, while being treated by an active doctor and other carers. However, more recent thinking has questioned the sick role as a useful explanatory concept, suggesting that it is more appropriate to view health-care service users as coproducers with an active role in their care. 4,5 Within health-care academia, practice and policy, this shift in focus has led to the development and use of strategies and interventions to actively involve patients in supporting safe practice and reducing harm. [6][7][8][9][10] A recent example is the Enhanced Recovery after Surgery (ERAS) programme, an evidence-based 'bundle' approach implemented internationally to improve the quality and safety of patient care for major surgery. 11 A prevalent aspect within ERAS is the active involvement of patients in the delivery of their care, 12 for example ensuring patient involvement during early and continuing postoperative mobilization, which can reduce the risk of postoperative complications including pulmonary and thromboembolic complications. 11,13,14 This is different to 'traditional' surgical care, as postoperative mobilization occurs much earlier and prioritizes direct patient involvement in this aspect of rehabilitation.
An overview of patient involvement in an ERAS programme is provided in Figure 1.
An important factor affecting the willingness and ability of patients to become involved in safety initiatives is that patients need to be aware of any requirements for involvement and what this will entail in terms of specific actions and behaviours that may be required by patients. 9 In line with this, patients who are familiar with their own care and treatment plans are more likely to become involved in safety-related initiatives. 15 Previous studies have also reported the importance of health professionals managing patients' expectations by clearly communicating what is expected of them during their care. For example, the provision of good quality information to patients can provide patients with a sense of control 16,17 and this can act as a key facilitator in making the shift from passive to active patient in the context of postoperative recovery. 18 The overall aim of this paper was to present findings from the analysis of qualitative interview and observational data to explore patient and nursing perspectives of information provision in an ERAS programme. Our analysis is informed by Grande et al 19 model, which posits that patient involvement initiatives are more likely to be achieved when they fit within existing workflows, require little additional human resources and proportional amounts of work by patients. Specifically, the model proposes a 'Information +Activation' approach where health professionals target patient involvement through encouragement, prompting, coaching, help and support to perform specific actions in the clinical encounter. In this sense, the facilitator role adopted by the health-care professional is critical during the encounter in finding a 'sweet spot', which generates improved knowledge in patients and, in turn, motivates active involvement. 19 However, potential tensions exist in that the 'help and support' offered by professionals is bounded and determined by the performance of specific behaviours expected of patients enrolled in ERAS. For example, early postoperative mobilization largely occurs as a pre-determined requirement of the ERAS specification, rather than unconditionally resulting from the exploration and planning of patient identified goals. Although clinical outcomes of the ERAS programme have been published internationally, 20 there is little research exploring the so-called 'sweet spot' and the 'information +activation' approach in practice. One exception is a recent qualitative study of health-care professionals' views of ERAS, 18 which identified a number of implementation challenges, including how standardization affected personalized patient care, and challenges associated with the high volume of information provision impacting on patients' ability to retain information.
The specific aims of the paper are to address gaps in existing understanding through exploration and critique of.
• the 'information +activation' model in the context of the preassessment element of an ERAS programme, by analysing nurses' attempts (and patients' reactions) to manage patient expectations and prepare patients for an 'active' postoperative role.
F I G U R E 1 An overview of patient involvement in an ERAS programme • the tensions between standardized programmes of care delivery, such as ERAS, and individualized patient needs and whether these tensions impact on the receptiveness of patients to the information +activation approach.
In doing so, we contribute to the better understanding of some of the theoretical constructs that abound in patient involvement, while also giving a better understanding of the 'inner workings' of the internationally implemented ERAS programme from a patient and nurse perspective.  Table 1 provides summary detail of interview participants. Observations, then interviews were undertaken by the first author across the three specialties, with interview participants split equally between patients and nurses. Potential participants were provided with written information about the study prior to agreeing to take part. All participants met the inclusion criteria that they were involved in an ERAS programme, were aged over 18 and able to provide informed consent.

| ME THODS
Assurances were provided to all participants about protection of anonymity and confidentiality. Interviews with nurses took place in offices and other private spaces on the respective wards. Patient interviews took place at their homes.
Semi-structured interviews were chosen as they are a widely used qualitative method that enabled the researchers to identify topics of interest, whilst also allowing for discussions directed by participants responses. 21 Structured observations were purposively sampled to include ERAS patients and data from these clinics were recorded by the first author based on a list of prompts developed by the researchers, which allowed interactions in pre-assessment appointments to be captured in a systematic way. 22 The use of multiple data collection methods can help add rigour, breadth and depth to a study. 23,24 Triangulation was a feature of data analysis, which involved the comparison of data relating to the same phenomenon but derived from different phases of fieldwork and the accounts of different participants. Triangulation is generally considered a process of using multiple perceptions to clarify meaning, allowing the researcher to verify the repeatability of an observation or interpretation. 21,25 Initial thematic analysis of the data was undertaken by the first author, guided by a six-step process 26 which entailed familiarization with the data and generating initial codes, which were subsequently used to produce a thematic 'map'. Ongoing analysis and discussion between the two authors resulted in further iterations and refinement of the map which proved useful in comparing our emergent findings to the extant literature, including Grande's model. 19

| Findings
The findings are presented in two sections. The first, 'exploring and critiquing information +activation', examines the pre-admission interactions that took place between nurses and patients. All wards in the study adhered to ERAS guidelines recommending the use of pre-operative patient information as a mechanism to encourage patients to become active participants in their postoperative recovery. 11,13,14 Here, we focus on hitherto unexplored strategies enacted by nursing staff to attempt to manage patients' expectations and to prepare patients to undertake this active role. The next findings section, 'informational boundaries', considers the tensions between the attempts of nurses to provide standardized information or elements of ERAS, alongside the specific needs and wants of some individual patients. We focus on how these perceived boundaries can influence patient receptiveness to the information and in turn impact on attempts to 'activate' patients.
The data included in this paper are selected to be illustrative of the sample population in relation to the themes and discussion presented. This is guided by Braun and Clarke's framework, 26 where

| Exploring 'information +activation'
In this first section, we show that the 'information +activation' process was, in many cases, an effective approach to raising patient awareness and managing patient expectations of their anticipated role within the ERAS programme. For example, prior to admission for surgery, patients meet with members of the multidisciplinary team, including a RN, who provide the information necessary to support and guide patients through the planned surgical process. RNs described how during this appointment they sought to manage patient expectations to help prepare them for an 'active' approach to postoperative care, in line with the 'information +activation' model. 19 Patients also described how information provided during the preadmission appointment was helpful in managing expectations and preparing them for the upcoming hospital care.
It's kind of getting rid of those preconceptions […] preassessment kind of busts those myths […] They're not surprised when we get them moving quicker. They're not surprised when they're going home a lot quicker. [Upper GI: Patient 5] Early postoperative mobilization and reduced length of hospital stay greatly reduce the risk of iatrogenic harm occurring to patients. 11,20 During pre-admission, patients were provided with information about how adopting an active role in their postoperative care could help manage these risks. In addition to providing information about early mobilization, ERAS guidelines also highlight the importance of providing pre-admission information to patients about discharge goals and predicted length of hospital stay. 11,13,14 Patients and nurses described how this information helped to manage expectations during subsequent hospital care, demonstrating a shared awareness and expectations of postoperative care.
Our aim is to get you in and out as quickly as possible. The 'information +activation' approach adopted by RNs during preassessment helped to raise patients' awareness of the expectations for an active role in postoperative care. Patients valued the information provided and were positively receptive to the prospect of early mobilization. Patients also mostly welcomed the enhanced awareness of potential risks and the advantages associated with shortened length of hospital stay. From this, it is possible to conclude that the 'information +activation' model was effective in terms of raising patient awareness and managing expectations of the ERAS programme.
However, deeper analysis of these initial surface-level conclusions demonstrates that, when analysed from an individual patient perspective, interactions during these pre-admission appointments can be more complicated. This is explored in the next theme in which we discuss 'informational boundaries' and how these can impact on and influence the nurse-patient interactions, adding more depth to these initial conclusions.

| Informational boundaries: Procedural and professional domains
Despite many patients describing the usefulness of the information provided, it was evident during pre-assessment observations that some patients were, understandably, distracted by their diagnosis and possible prognosis and required information beyond the defined scope of the ERAS protocol. For example, one patient was To summarize, the data show two boundaries or overlapping 'nogo' zones during the information provision, one about procedure and the other about prognosis. The common ground to both being uncertainty; that is, the nurse either does not know, or cannot share the information. The data also show there to be professional boundaries between nursing staff and medical staff -with each providing different information at different times during the patient journey, as shown when the nurse invoked some information as being in the medical domain to be dealt with during the consent process. Equally revealing is that patients' attempts to breach these boundaries demonstrate their lack of awareness or understanding about these boundaries and the purpose of the pre-assessment appointment -that it is about basic information provision, not treatment discussion or exploration.

| Informational boundaries: Patient anxiety
Patient anxiety and information overload were also identified as boundaries to the effective exchange of information. In some cases, patients were simply not receptive to the provision of information, irrespective of the nature of this information. This is demonstrated in the following example of observational data, in which a patient remarked there was 'too much information' and told the nurse 'I

| D ISCUSS I ON
Our findings show that patients were provided with information during a pre-admission appointment and that this information encouraged patients to prepare for an active role during their surgical recovery. In most cases, patients welcomed this information and the opportunity for active involvement in their hospital care. However, we also identified a variety of informational boundaries which shaped pre-admission appointments. Boundaries were identified by nurses which pre-determined which professional groups shared information with patients, and at the specific points in the patients' journey that this would occur. Boundaries were also identified by patients which demarcated their preferences for the amount and/or timing of information that should be delivered.
In most cases, a standardized 'scripted' information-giving approach was deployed by RNs during the pre-assessment appointment and nurses were unable, or unwilling, to deviate from this approach, even when patients requested specific information and despite nurses' apparent awareness of the perils of 'too much information' during the clinical appointment. Knowing and understanding the individual concerns and needs of patients are clearly important as they directly relate to how effectively patients are able to absorb and process new information. In this sense, the requirement to deliver standardized information in a way that also addressed individualized information needs is a key message from these findings. This implies that a step is required between 'information' and 'activation'

| Exploration as a possible way forward?
In Grande's model, 19 the onus is on the provider to effectively facilitate interaction. However, the current study findings indicate that facilitation was not a role that nurses in our study were willing (or able) to adopt. So, although attempts to encourage patients to take working together to identify necessary information, rather than passive information transmission from nurse to patient. 17 This approach is further reinforced by a study 28 which found that successful attempts to involve patients in their safety relied on the quality of the patient-clinician relationship. In addition, Sutton and colleagues 29 present evidence which shows health-care staff are supportive of approaches that encourage co-operation, with other studies reporting that the encouragement, approval and positive attitudes of health-care staff are crucial in preparing patients for an active role. 15,30,31 Further to this, studies report that to encourage patient involvement information should not be based on standardized procedures, but should consider patients' skills, knowledge, ability and specific needs, combined with appropriate explanations. [32][33][34] However, paradoxically, in the quest for an 'active' patient, it was sometimes the case in our findings that delivering information as a script was akin to a paternalistic approach to health-care care -'the patient needs to know this, even if they're not receptive' -the antithesis of patient involvement. What is clear and of importance from our findings is that some patients were not aware or did not understand the unidirectional flow of information in these interac- Establish paƟent's willingness and ability to engage with aƩempts to explore informaƟon relaƟng to their care.
Ensure that each paƟent is supported to integrate informaƟon with their exisƟng circumstances and informaƟon needs.
Ensure nurses (and other healthcare professionals) appreciate paƟent recepƟveness and potenƟal barriers.
Include opƟon for paƟent not to receive informaƟon if they feel overburdened.
Package informaƟon in such a way that paƟents can engage with at a Ɵme, place and rate that is more conducive to individual needs and preferences: Examples include electronically, via website / mulƟ-media, documenƟng their quesƟons in the ERAS session for later discussion with the surgeon and providing this summary back to the paƟent to use when they have their pre-operaƟve consultaƟon.
Within the clinic, in terms of Ɵme, this should not be an over-burdensome acƟvity for nurses or other professionals but a brief period of reflecƟon of the noƟng by paƟents of relevant quesƟons or reflecƟons to be addressed later.
Engaging with paƟents in this way may result in more meaningful and recepƟve interacƟons and generally a beƩer-quality informaƟon exchange rather than passive informaƟon transmission from nurse to paƟent.
of interaction, only to belatedly discover, for example, that this was not the place to explore treatment options or results. role to play in ensuring an effective balance between these seemingly competing priorities. The task is that of understanding when standardization is appropriate and when it is not and then being able and willing to act on this. However, in our findings, despite nursing staff identifying patient issues and acknowledging the limitations of the information-giving approach, most failed to react to this.

| Implications for research and clinical practice
To support our proposed model and associated approach to the provision of patient information, more clarity is needed about what is 'allowed' or expected in pre-operative appointments. Specifically, more clarity for the patient that the appointment is information giving and may involve lots of information delivery, rather than information exploration or exchange. However, the latter needs to be facilitated elsewhere in a different forum or in a different way. In addition, patients who feel overburdened with information can be provided with information to take home, or web-based information and links to consultations at a later stage, when they feel better disposed to take this information in. What is crucial is that nurses who engage with patients during these appointments are able to assess and react to the individual requirements of each patient and tailor their approach to information sharing in accordance with these requirements. This is no easy feat, as we have discussed, due to the volume of information and the drive for efficiency, particular in terms of human resources and time.
This paper is specifically focused on the interactional dynamics and accomplishment of the pre-assessment appointment rather than reflecting on educational delivery and accordingly, we have po-

| CON CLUS ION
Nurses must consistently be alert to the fact that humans are sensitive information processors and when bombarded with lots of potential or actual distractors, the information provision leading to information retention and subsequent activation is too linear and causal an approach to base the success of informational interventions on. What we have seen in our findings is that this approach does work most of the time, for most patients, but nurses need to feel empowered to adopt strategies that can allow for different informational needs and communication challenges, rather than a one-size-fits-all paternalistic approach. This further supports our proposal to adapt the model to include the opportunity for an exploration of patients' information needs.

ACK N OWLED G EM ENTS
The authors would like to acknowledge the support of Health and Care Research Wales, all those who participated in the doctoral study and Professor Davina Allen for her supervisory role during the main author's PhD candidature.

CO N FLI C T O F I NTE R E S T
Both authors declare that there is no conflict of interest either in this study or in this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.