International Journal of Orthopaedic and Trauma Nursing (2012) 16, 1320

www.elsevier.com/locate/ijotn

Ambulatory orthopaedic surgery patients symptoms with two different patient education methods
Katja Heikkinen MNSc, RN a,*, Helena Leino-Kilpi PhD, RN (Professor and Head of Department/Nurse Manager) b, Tero Vahlberg MSc (Biostatistian) c, Sanna Salantera PhD, b RN (Professor/Nurse Manager)
a b c

University of Turku, Department of Nursing Science, FIN-20014 Turku, Finland University of Turku, Department of Nursing Science, Hospital District of Southwest Finland, Finland University of Turku, Department of Biostatistics, Finland

KEYWORDS
Patient education; Internet; Ambulatory surgery; Symptom

Summary Aim: To evaluate changes in ambulatory orthopaedic surgery patients symptoms during the surgical process and to compare whether the two different patient education methods had an effect on patients symptoms during the ambulatory surgical process. Design: A randomised controlled trial was used. Ambulatory orthopaedic surgery patients in one university hospital in Finland participated in the study. Methods: Patients were randomised to either an experiment group (n = 72) that received Internet-based patient education or to a control group (n = 75) that received face-to-face education with a nurse. Data were collected at seven different time points during the surgical process. A structured instrument called The Symptoms with a visual analogue scale was used. Results were statistically analyzed. Results: Ambulatory orthopaedic surgery patients had few severe symptoms during the surgical process. Severity of symptoms changed during the surgical process. The severity of symptoms did not decrease after the patient education, and they were highest on the rst post-operative day. There were no differences in the symptoms of patients in the two groups. Conclusion: Patients symptoms were dependent of the surgical process and were strongest right after the surgery. Thus, both education methods can be recommended equally when working with ambulatory orthopaedic surgery patients. c 2011 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +358 50 401 9999; fax: +358 2 333 8400. E-mail addresses: katheik@utu., katja.heikkinen@utu. (K. Heikkinen). 1878-1241/$ - see front matter c 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijotn.2011.04.004

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K. Heikkinen et al.

Editors comment This article compares two methods used to educate patients which is then assessed to see what impact it has on a number of variables over a given length of time. Trying to cover all aspects of education in relation to the patients orthopaedic experience, and attempting to guage its affect on problems such as pain, is always difcult. This study uses previous literature and builds upon it to give us a little more insight to the care of ambulatory orthopaedic patients. BS surgery. McHugh and Thoms (2002) studied patients pain expressions using Verbal Descriptor Scale (VDS scale; none, mild, moderate, severe pain). Severe pain presented as a problem for approximately 20% of patients (n = 120) on the second post-operative day and continued to present as a problem for a few of the patients on the fourth post-operative day. Furthermore, on the fourth post-operative day, approximately 20% of patients reported that their pain had not improved. Apfelbaum et al. (2003) reported that approximately 80% (n = 250) of patients in their study experienced acute pain after surgery. Half of these patients experienced moderate pain and almost 40% experienced severe to extreme pain at some time during their post-surgical recovery period. Overall, 82% of patients reported that they had experienced some pain until the second week after their discharge. Education supports patients to manage their symptoms and recovery (Wong et al., 2010). Several researchers have studied the benets of preoperative education on post-operative symptoms, using meta-analyses and reviews (Devine, 1992; Shuldham, 1999; Coll et al., 2004a; Johansson et al., 2004, 2005; Wofford et al., 2005). Some researchers found that pre-operative patient education is effective in reducing the following postoperative complications: pain (Devine,1992; Shuldham, 1999; Lewis, 2003), nausea, vomiting, and fatigue (Johansson et al., 2004). There are, however, conicting results concerning pain reduction (Johansson et al., 2004, 2005; Wofford et al., 2005). There are a limited number of studies focusing on ambulatory orthopaedic surgery patients education or the evaluation of different education methods. Goldsmith and Safran (1999) studied the use of Internet-based education for reducing ambulatory surgery patients post-operative pain. Patients receiving extra information about pain from a website evaluated their post-operative pain as lower than patients receiving information that only related to the surgical process. It is typical that educational interventions focus on one, or very few areas of knowledge, such as the bio-physiological e.g. pain, whilst also measuring pain severity as an outcome (Goldsmith and Safran, 1999).

Introduction
An increasing number of patients are undergoing operations in ambulatory surgery settings (OECD Health Data, 2010). After spending short periods in hospital, ambulatory orthopaedic surgery patients might experience different levels of pain (Chung, 1995; Jenkins et al., 2001; Rawal, 2010; Apfelbaum et al., 2003; Coll et al., 2004a; Susilahti et al., 2004; Suhonen et al., 2007; McHugh and Thoms, 2002; Idvall et al., 2008); amounts of bleeding (Chung, 1995); vomiting (Chung, 1995; Stockdale and Bellman, 1998; Beauregard et al., 1998; Wu et al., 2002; Susilahti et al., 2004); nausea (Jenkins et al., 2001; Oberle et al., 1994; Chung, 1995; Beauregard et al., 1998; Wu et al., 2002; Susilahti et al., 2004); headache (Chung, 1995; Beauregard et al., 1998); sore throat (Chung, 1995; Beauregard et al., 1998); dizziness (Chung, 1995; Beauregard et al., 1998); fatigue (Oberle et al., 1994; Beauregard et al., 1998; Susilahti et al., 2004); drowsiness (Chung, 1995; Beauregard et al., 1998); and hoarseness (Chung, 1995; Beauregard et al., 1998). The main reasons for unplanned readmissions after ambulatory surgery are pain, urinary retention, wound bleeding, infection, and haematoma (Watson et al., 2004). Poorly managed pain may also interfere with wound healing, adding to a patients suffering, which can prolong his or her recovery (Bardiau et al., 2003). Despite the fact that ambulatory orthopaedic surgery patients experience different symptoms during the surgical process, the severity of symptoms other than pain is rarely measured. There seems to be variations in the intensity of symptoms, and comparing symptoms is problematic because researchers use different instruments (Coll et al., 2004a,b). It is known that patients experience of pain varies during the surgical process. Post-operative pain is usually the strongest during the rst and second day (Oberle et al., 1994; McHugh and Thoms, 2002; Apfelbaum et al., 2003; McGrath et al., 2004). Beauregard et al. (1998) found that almost half of patients (n = 89) reported moderate to severe pain during the rst 24 h after discharge. Pain decreased over time but was severe enough to interfere with daily activities, even seven days after

Ambulatory orthopaedic surgery patients symptoms with two different patient education methods In our study, an empowering Internet-based patient education method was used, meaning that the education used a multidimensional approach relating to the whole ambulatory surgical process (Leino-Kilpi et al., 1998, 1999). We hypothesized that this knowledge would cognitively empower patients to handle the severity of symptoms during their ambulatory surgical process (Leino-Kilpi et al., 1998, 1999; Heikkinen et al., 2008).

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Aim of the study

Our goal was to evaluate changes in ambulatory orthopaedic surgery patients symptoms during the surgical process and to compare whether the two different patient education methods had an effect on patients symptoms during the ambulatory surgical process. The experiment group received Internet-based patient education, and a control group received face-to-face education conducted by a nurse. Research questions: (1) How did the patients rate their symptoms at seven time points during the ambulatory surgical process? (2) Were the symptom scores associated with the phases of the surgical process? (3) Did either of the two different patient education methods have an effect on the patients symptom scores?

ria received an invitation to participate in our study along with the letter they received concerning the ambulatory surgery operation. The rst instrument (baseline) was included with the invitation. The response rate was 86% (149/173). Patients were randomized either to the experiment group (n = 72), which received patient education through the Internet, or to a control group receiving oral education by nurses (n = 77). Two patients in the control group were excluded from the study because they did not participate in the patient education. Randomization was stratied on: gender, age, and the location of the operation. Neither the patients nor the study co-ordinator were aware of the educational assignment until after the randomisation.

Experiment group
Patients in the experiment group participated in an Internet-based patient education program designed for this study. It was a structured programme and based on six areas of knowledge: bio-physiological, functional, experiential, ethical, social, and nancial (Leino-Kilpi et al., 1998, 1999), all of which are dened as being important in the cognitive empowerment process (Heikkinen et al., 2008). The website contained different topics related to the surgery: instructions for patients preparing for the operation, events that occur on operation day, follow-up care, and ethical and nancial aspects. Patients visited the website 1 121 days (mean = 14 days) before the operation. They used the website from one to six times and spent an average of 81 min using the site (ranged from 10 to 300 min). Patients were able to contact a nurse via email or phone. However, only a few patients used this option.

Methods
Study design and sample
Ambulatory orthopaedic surgery patients were randomly allocated to either an experiment or control group. All ambulatory orthopaedic surgery patients (n = 173) attending one of ve university hospitals in Finland during the period July 2005 to September 2006 were eligible for inclusion in this study. The inclusion criteria were: patients age over 18 years, Finnish-speaking, access to the Internet at home and able to use it, those with no cognitive disabilities, those capable of completing the instruments, and those who were able to give informed consent. The only exclusion criteria related to those patients who were rated at being above the American Society of Anesthesiologists (ASA) classication of II or above otherwise a normal healthy patient. These patients were excluded due to pre-operative education. All patients fullling the inclusion crite-

Control group
Patients in the control group participated in faceto-face sessions with a nurse (in total, eight nurses) that were held in a room in the ambulatory surgery unit. Patients were given a leaet about the content of the session. Education with a nurse had the same theoretical content as the Internet-based education. All participatory nurses were trained for this study. They knew the content of the website, and they had a printed version of the website contents available to them. The control education session lasted on average 22 min (range 10 40 min), and it took place on average 9 days before the operation (range 155 days).

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K. Heikkinen et al. make comparisons of the samples demographic characteristics among people in the groups. Each patients estimations of his or her symptoms (measured with the SPRE and SPOST) were grouped into three classes: low (0 6 29.9 mm), moderate (30.0 6 69.9 mm), and high (70.0 6 100 mm). The decision to use this range of scores was based on earlier studies about the use of VAS in the context of pain (Collins et al., 1997; Kelly, 2001). Usually scores over 30 is indicative of a patient needing special attention and support from the health professional (Ene et al., 2008). The estimations of symptoms were used as dependent variables in an ordinary logistic regression with generalized estimating equations, which accounts for an association between repeated measurements. Ordinary logistic regression included the effect of the method of patient education used, the measurement of time, and the interaction between the method of patient education and the measurement of time. All tests were conducted at the 5% signicance level (Burns and Grove, 2005).

Instruments and data collection

The data were collected using a structured instrument called The Symptoms, which comprised of two questionnaires (S), one a pre-operative (SPRE) and one a post-operative (SPOST) version. These were used in total seven times in order to see if there were any changes in patients evaluations of their symptoms during the ambulatory surgical process. The survey was used at the following times: (1) before pre-operative patient education (baseline); (2) after pre-operative patient education, but still pre-operatively; (3) on operation day before surgery; (4) one day after the operation; (5) three days after the operation; (6) two weeks after the operation; and (7) four weeks after the operation. The SPRE asked about ve symptoms that might occur pre-operatively: headache, pain in the area of planned surgery (pain in the operated area), pain elsewhere, sleeplessness, and difculties with movements. The SPOST asked about 16 items, including the ve symptoms in the SPRE and eleven symptoms that occur especially post-operatively: vomiting, nausea, dizziness, tiredness, problems with urination, problems with digestion (like constipation), problems with washing and with hygiene, swelling of the operation area, redness of the operation area, bleeding of the operation area, and fever. Both the SPRE and SPOST evaluation of symptoms were undertaken using a vertical Visual Analogue Scale (VAS; 100 mm). Scores on the left side (0) indicated low intensity or severity, and those on the right side (100) indicated intolerable intensity or severity of symptoms. The questions in SPRE and SPOST were based on theoretical literature (e.g., Oberle et al., 1994; Chung, 1995; Beauregard et al., 1998; Susilahti et al., 2004) and on statements by an expert panel (three nurses, two physicians, and three researchers). The instrument was piloted by 17 ambulatory surgery patients. Demographic characteristics obtained from the baseline included: age, gender, basic and vocational education, employment status, employment in social and health care, the number of ambulatory surgeries, and long-term illness.

Results
Description of patients
There were no statistically signicant differences between the groups (n = 147: 72 in the exp. group and 75 in cont. group) in the demographic variables (p = 0.1890.976). Fewer patients were women (46% exp. group/44% cont. group). Patients ages ranged from 18 to 69 years in the experiment group and 1867 in the control group (mean 44.2 years in the exp. group and 43.5 years in the cont. group). Most of the patients had no long-term illness (79% in both groups), and most of the patients in both groups were in the ASA I group (68% in the exp. group/76% in the cont. group). Most of the patients had undergone a shoulder arthroscopy operation; (62% in the exp. group/57% in control group). The rest had undergone a knee arthroscopy operation. More than half of the patients had experienced earlier ambulatory surgery (58% exp./57% cont. group).

Statistical analysis Patients evaluations of their symptoms

SPSS for Windows (version 16.0) was used to analyze the data. Continuous variables are presented as means and standard deviation, and categorical data are presented as frequencies and percentages. The Pearson Chi-Square test was used to Ambulatory orthopaedic surgery patients scored their symptoms low. Before the patient education (baseline), several patients in both groups rated their symptoms as moderate or high. More than

Ambulatory orthopaedic surgery patients symptoms with two different patient education methods half of the patients scored their pain at the operative area as moderate or high. A third of the patients (30%) scored their pain as being located elsewhere other than the operation area and rated difculties with movements to be moderate or high. After the patient education (2nd measurement), the scores relating to difculties with movements decreased and was statistically signicant (p = 0.018). After the operation (3rd measurement), many patients reported moderate or high scores of pain in the operated area and difculties with movement were common (4060%). Four weeks post-operatively (7th measurement), approximately 10% of patients in both groups scored their pain as being somewhere else with sleeplessness and difculties with movements rated as moderate. Approximately 30% of patients in the experiment group and approximately 10% of patients in the control group were experiencing moderate pain in the operated area (Table 1). Patients symptoms changed in a statistically signicant way during the surgical process (p 6 0.0010.043). After the patient education, patients scores related to difculties with movement decreased at a statistically signicant rate (p = 0.018). On the operation day, all symptom scores decreased (p 6 0.0010.013) compared to the baseline. Two weeks post-operatively, all patients symptom scores decreased statistically, signicantly (Table 1). The method of patient education (the experiment and control group) had no signicant effect on most symptom scores (p = 0.0840.589). However, this did impact on the scores in response to the questions regarding pain in relation to somewhere else other than the operated area (p = 0.033). Four weeks post-operatively patients in the experiment group scored their pain in a region somewhere else higher than patients in the control group. Interaction between the method of patient education and symptoms at different measurement times were tested (logistic regression), and no signicant interactions were found (p = 0.2580.903). This result indicates that the change in symptom scores was similar at different time points in both groups throughout the ambulatory surgical process. The symptoms that were measured only postoperatively were vomiting; nausea, dizziness, tiredness, problems with urination, problems with digestion (like constipation), problems with washing and with hygiene, swelling of the operation area, redness of the operation area, bleeding of the operation area, and fever. Patients gave these symptoms rather high ratings shortly after the operation. On the rst post-operative day, almost

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half of the patients in both groups scored their tiredness, problems with washing and hygiene, and swelling of the operation area as moderate or high. Four weeks after the operation (7th measurement), approximately 7% of patients in both groups gave moderate scores to tiredness but low scores to other symptoms (05.6%). Patients evaluations on post-operatively evaluated symptom scores changed signicantly during the ambulatory surgical process at different measurement times: dizziness (p 6 0.001), tiredness (p 6 0.001), problems with digestion (p = 0.001), problems with washing and with hygiene (p 6 0.001), swelling of the operation area (p 6 0.001), redness of the operation area (p = 0.038) and bleeding of the operation area (p = 0.033). On the third post-operative day, the scores on dizziness (COR = 0.13, p = 60.001), tiredness (COR = 0.37, p = 60.001), problems with washing and with hygiene (COR = 0.55, p = 60.001), swelling of the operation area (COR = 0.45, p = 60.001), redness of the operation area (COR = 0.31, p = 0.025), bleeding of the operation area (COR = 0.18, p = 0.033) decreased. Four weeks post-operatively, the decrease was statistically signicant on the following scores: tiredness (COR = 0.12, p = 60.001), problems with digestion (COR = 0.21, p = 60.001), washing and hygiene (COR = 0.03, p = 60.001), swelling of the operation area (COR = 0.05, p = 6 0.001), and redness of the operation area (COR = 0.23, p = 0.02). The method of patient education (the experiment and control group) had no signicant effect on post-operatively evaluated symptom scores (p = 0.2830.981). The interaction between the method of patient education and symptoms (measured only post-operatively) at different measurement times were tested with logistic regression, and no signicant interactions were found (p = 0.1590.959), indicating that the change in symptom scores was similar in both groups at different time points throughout the ambulatory surgical process.

Discussion
We evaluated the changes in ambulatory orthopaedic surgery patients reported symptoms during the surgical process and compared two different patient education methods: Internet-based patient education (experiment) and face-to-face education conducted by a nurse (control) to see whether they had an effect on patients symptoms during the ambulatory surgical process.

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Table 1 Patients symptom scores grouped into three classes: (1) low, (2) moderate, (3) high score in seven different measurement times in the experiment and control groups (patient education method) in percentages (%). The effects of the patient education method, measurement time, and interaction between the patient education method and measurement time were tested.
Symptom scores Before the patient education* Baseline exp./control N = 72/N = 75 Headache Low Moderate High COR (95% C1) p-Value Pain operated area Low Moderate High COR (95% C1) p-Value 100/100 / / After the patient education ** 2nd measurement exp./control N = 71/N = 73 88.6/94.4 8.6/5.6 2.9/ 1 Operation daypreoperatively 3rd measurement exp./control N = 72/N = 74 94.4/93.2 4.2/5.4 1.4/1.4 0.71 (0.311.65) 0.424 63.9/67.6 30.6/25.7 5.6/6.8 0.35 (0.240.51) 60.001 88.7/91.9 11.3/5.4 /2.7 0.49 (0.360.68) 60.001 81.7/81.7 15.5/18.3 2.8/ 0.56 (0.36089) 0.013 86.1/97.3 13.9/2.7 / 0.23 (0.13041) 60.001 First postoperative day 4th measurement exp./control N = 71/N = 74 97.1/98.6 1.4/1.4 1.4/ 0.23 (0.060.87) 0.030 35.2/35.1 43.7/51.4 21.1/13.5 1.25 (0.821.91) 0.302 87.1/95.9 10.0/4.1 2.9/ 0.45 (0.320.64) 60.001 76.1/82.2 18.3/15.1 5.6/2.7 0.68 (0.411.12) 0.132 61.4/60.8 25.7/29.7 12.9/9.5 1.78 (1.152.77) 0.010 Third postoperative day 5th measurement exp./control N = 71/N = 74 93.0/97.3 5.6/2.7 1.4/ 0.55 (0.241.25) 0.145 67.6/62.2 28.2/32.4 4.2/5.4 0.36 (0.240.55) 60.001 88.7/95.9 9.9/4.1 1.4/ 0.42 (0.300.60) 60.001 87.3/86.5 12.7/12.2 /1.4 0.38 (0.210.68) 60.001 75.7/76.7 20.0/20.5 4.3/2.7 0.81 (0.511.31) 0.397 Two weeks postoperatively 6th measurement exp./control N = 71/N = 73 100/98.6 /1.4 / Four weeks postoperatively 7th measurement exp./control N = 71/N = 72
**

94.4/100 2.8/ 2.8/

42.6/44.3 36.8/38.6 20.5/17.1 1

45.5/40.9 47.0/51.5 7.6/7.6 0.80 (0.591.09) 0.156 69.6/82.6 27.5/15.9 2.9/1.4 0.84 (0.671.06) 0.146 74.3/80.3 17.1/14.1 8.6/5.6 0.78 (0.551.12) 0.176 75.7/87.0 20.0/10.1 4.3/2.9 0.60 (0.400.92) 0.018

70.4/72.6 25.4/23.3 4.2/4.1 0.27 (0.180.41) 60.001 87.3/91.7 9.9/4.2 2.8/4.2 0.54 (0.390.75) 60.001 84.5/86.3 9.9/12.3 5.6/1.4 0.45 (0.27075) 0.002 78.6/79.5 21.4/17.8 /2.7 0.68 (0.441.04) 0.072

71.8/87.5 28.2/9.7 /2.8 0.17 (0.110.26) 60.001 84.3/93.1 10.0/5.6 5.7/1.4 0.56 (0.410.77) 60.001 87.3/93.1 9.9/5.6 2.8/1.4 0.28 (0.150.52) 60.001 84.5/88.9 12.7/11.1 2.8/ 0.40 (0.240.66) 60.001

Pain somewhere else Low 70.0/74.0 Moderate 21.4/23.3 High 8.6/2.7 COR (95% C1) 1 p-Value Sleeplessness Low Moderate High COR (95% C1) p-Value 67.6/77.0 23.9/17.6 8.5/5.4 1

Difculties with movement Low 70.8/73.2 Moderate 23.6/25.4 High 5.6/1.4 COR (95% C1) 1 p-Value

K. Heikkinen et al.

Ordinal logistic regression with generalized estimating equations. COR = cumulative odds ratio; COR > 1 indicates increase of symptom scores (moderate or high versus low scores). CI condence interval. * =on average37 days before operation. ** =on average 9 (control) 14 (experiment) days before operation.

Ambulatory orthopaedic surgery patients symptoms with two different patient education methods Patients experienced quite similar symptoms post-operatively compared to those in earlier studies (e.g., Chung, 1995; Jenkins et al., 2001; McHugh and Thoms, 2002; Susilahti et al., 2004; Coll et al., 2004a; Suhonen et al., 2007). Patients reports of symptoms were highest during the rst post-operative days. It is essential to identify those patients scoring their symptoms high and address the symptoms to prevent complications and ensure a smooth recovery process (Bardiau et al., 2003; Watson et al., 2004). Four weeks after surgery, patients scores on all these symptoms were signicantly lower than pre-operatively or on the rst post-operative day. However, four weeks after surgery, there were still approximately 10% of patients scoring moderate pain in the operated area, pain elsewhere, sleeplessness, or difculties with movements. These ndings of pain are consistent with the ndings reported in earlier studies (Beauregard et al., 1998; McHugh and Thoms, 2002; Apfelbaum et al., 2003). Our results revealed that these patients recovery process was longer than four weeks, which might be a period of time that is too short to evaluate patients symptoms. No matter which method of patient education was used, there were no differences in patients symptoms. The effect of different education methods relating to patients symptoms is unclear in the earlier studies (e.g., Devine, 1992; Shuldham, 1999; Johansson et al., 2004; Wofford et al., 2005). In addition, in some of the earlier studies, the education focused only on a few symptoms (Goldsmith and Safran, 1999). However, one can conclude that education that includes multidimensional knowledge is appropriate. This makes sense because patients will experience different symptoms during their surgical process, and their knowledge and expectations might vary. In summary, pre-operative patient education can be recommended as a standard method for all patients coming for ambulatory orthopaedic surgery. There were some limitations in this study concerning the instrument, analysis, sample and intervention used. We wanted to create a more comprehensive view of patients evaluations of different symptoms. That is why we included a wide spectrum of symptoms in the SPRE and SPOST surveys. In previous studies, symptoms were usually measured one by one, e.g., pain (McHugh and Thoms, 2002; Coll et al., 2004a; Suhonen et al., 2007). For that reason, it is not necessarily relevant to compare the results of this study with earlier studies. SPRE and SPOST instruments were designed for this study. The instruments were easy to use and the dropout rates were low (see Table 1). The VAS scale was classied into three classes based on earlier

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studies about the use of VAS in the evaluation of pain (Collins et al., 1997; Kelly, 2001). However, two classes might have been enough for some of the symptoms because of the small number of patients reporting the highest scores. On the other hand, the use of means of the symptom scores was not appropriate, because the means were so low. The study sample was drawn from one university hospital in Finland. The surgical procedures are quite similar in Finland and these results may be useful also in other countries due to the similarity of surgical procedures worldwide. Patients earlier experiences of surgery may have had an effect on results, because more than half of the patients had experienced earlier ambulatory surgery in both groups. However this effect was similar in both groups. In addition, the education intervention used may have affected the result. Although the patients surveyed were of a wide age range, this did not appear to be the case. All patients in both education groups managed well with their education. Also the patients in the experiment group could use the website without any problems and evaluated it as easy to use.

Conclusion
We found that ambulatory orthopaedic surgery patients did not report many severe symptoms. Patients evaluations of their symptoms varied during the surgical process and were not impacted by the education they received. Our ndings suggest that either Internet-based patient education or face-to-face education can be used with ambulatory orthopaedic surgery patients.

Conict of Interest Statement

None of the authors had any actual or potential conict of interest including any nancial, personal or other relationships with people or organizations within three years of beginning the work submitted that could inappropriately inuence their work.

Ethical Approval
All relevant permissions and ethical approval to conduct this study were obtained from the ethical research committee of the district hospital and from the organisation concerned. Patients participated in this study voluntarily and signed an informed consent form.

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K. Heikkinen et al.
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Funding Source
This study was supported by the South-Western Hospital District of Finland.

Contributions
Study design: KH, SS, HLK; data collection: KH, TL; data analysis: KH, TV; and manuscript preparation: KH, SS, TL, HLK.

References
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