Features

Surgery school speeds up cancer patients’ recovery

Promoting healthier lifestyles lifts general mood and prepares people for surgery

Cancer patients take on board surgery school's message about healthier lifestyles, thereby improving their mood, preparing them for surgery and ultimately resulting in shorter hospital stays

  • One part of surgery school focuses on patients being active, nutrition, smoking and alcohol
  • Another part looks at what they can expect during their stay and planning their discharge
  • A healthier patient prepared for surgery can expect a shorter hospital stay

Having an operation is a daunting prospect for most people, but a surgery school is empowering patients to make changes that reduce risks and speed up recovery.

Before they come along, patients are a little bit unsure of what its about, says Portsmouth Hospitals NHS Trust perioperative medicine nurse Charlotte Bellis. But afterwards 100% say they would recommend it to their family and friends.

The school was launched

...

Cancer patients take on board surgery school's message about healthier lifestyles, thereby improving their mood, preparing them for surgery and ultimately resulting in shorter hospital stays

  • One part of surgery school focuses on patients being active, nutrition, smoking and alcohol
  • Another part looks at what they can expect during their stay and planning their discharge
  • A healthier patient prepared for surgery can expect a shorter hospital stay
Picture shows a nutritionist holding a brochure title Eat Well, talking to a middle-aged man. Lessons for patients on improving fitness before surgery lift their mood and mean shorter hospital stays.
Picture: Alamy

Having an operation is a daunting prospect for most people, but a ‘surgery school’ is empowering patients to make changes that reduce risks and speed up recovery.

‘Before they come along, patients are a little bit unsure of what it’s about,’ says Portsmouth Hospitals NHS Trust perioperative medicine nurse Charlotte Bellis. ‘But afterwards 100% say they would recommend it to their family and friends.’

The school was launched in March 2018 at the trust’s Queen Alexandra Hospital, after Ms Bellis and colleagues had successfully applied for funding from Macmillan Cancer Support to run a two-year pilot.

Patients are encouraged to adopt healthier lifestyles before their operation

It offers multidisciplinary education to patients scheduled to have abdominal surgery, encouraging them to adopt healthier lifestyles before their operation.

This follows in the footsteps of similar initiatives set up a couple of years earlier at Manchester University NHS Foundation Trust and the University Hospital Southampton NHS Foundation Trust.

‘We took our inspiration from them,’ says anaesthetist Yousra Ahmad, who has been involved since the beginning, helping to get the school off the ground. ‘As a concept, prehabilitation was beginning to become widespread from around 2013. When we approached Macmillan, the idea fitted with their own work streams.’

‘We reinforce the point that they will be in hospital for less time – and I think that’s why we get such good attendance’

Charlotte Bellis, perioperative medicine nurse

As they had limited funding, they decided to invite patients undergoing one of five procedures: bowel resections, oesophagectomies, gastrectomies, nephrectomies and hysterectomies.

What is prehabilitation?

According to Macmillan, prehabilitation supports people living with cancer to prepare for treatment by promoting healthy behaviours, exercise, nutrition and psychological interventions, based on individual needs. Ideally, implementation should happen in the early stages of the patient pathway, soon after diagnosis and well in advance of treatment. The aim is to maximise resilience, improving long-term health, with benefits seen in as little as two weeks

(Macmillan Cancer Support – Principles and guidance for prehabilitation)

Most, but not all, have a cancer diagnosis. Annually the trust carries out around 550 of these kinds of operations each year, with the surgery school running once a week, with places for ten participants.

Of those who are invited around 10% are avoidable non-attendees. ‘They either don’t turn up or phone and say, “It’s not for me”,’ says Ms Bellis.

A further 5-10% are unavoidable non-attendees either because of operation dates or treatment clashes.

Patients are encouraged to bring a friend or family member along

‘We tell patients that it’s part of their treatment and will make a real difference to their outcomes,’ she says.

‘We reinforce the point that they will be in hospital for less time – and I think that’s why we get such good attendance.’

Good buy-in from surgeons also helps, says Dr Ahmad.


Left to right: perioperative medicine nurse Charlotte Bellis, doctors Sarah Marston and Yousra Ahmad, and ​​the team's original physiotherapist Erin Williams at Queen Alexandra Hospital, Portsmouth

The two-hour sessions are held in a wellness centre separate from the hospital, and patients are encouraged to bring a friend or family member along with them.

‘We give out so much information, it’s useful to have another person listening too,’ says Ms Bellis.

They can also act as a coach, offering encouragement and support at all stages of the patient’s treatment, including immediately post-surgery, motivating them to become active as soon as possible.

From the outset patients are met by a volunteer who is a retired ward sister

‘We had one patient who came along with his wife and he told us that not only had he increased the amount of exercise he did, but they had begun doing all kinds of activities together they would never have done before, including visiting the local open-air museum.

‘It’s about emotional well-being too,’ says Ms Bellis, who qualified in 1999 and worked in surgery and acute pain before taking on her current role, which became full-time last August.

At the outset patients are met by a volunteer, who is a retired ward sister. They are weighed, their body mass index (BMI) calculated, and asked about smoking.

‘This isn’t waiting time for surgery, it’s preparation’

The session is divided into two, with the first part about the benefits of prehabilitation, focusing on activity, nutrition, smoking and alcohol.

What surgery school covers

Run every week with ten participants and lasting for two hours, surgery school begins with a brief explanation of perioperative medicine and its benefits for patients. This includes improved personal health, reduced surgical complications and less time spent in hospital. The emphasis is on how the school can help individuals improve their own health before surgery, reducing the risks of complications and supporting them to make positive changes.

Afterwards patients learn about:

  • The risks of major surgery, including blood clots, chest infection, kidney problems, slow gut function, confusion, slow wound healing or infection, pressure sores and reactions to anaesthetic
  • Key benefits of increasing activity before surgery, emphasising that the fitter someone is beforehand the less risk there is of complications afterwards
  • The importance of nutrition, healthy eating and keeping up fluid intake
  • Risks of alcohol, with those drinking four units a day 50% more likely to get post-operative complications, which can be significantly reduced by abstinence for 3-8 weeks before surgery
  • The risks of smoking (non-smokers spend two days less in hospital than smokers) with signposting to local advice and support on quitting

Patients also learn about ICOUGH, an acronym for simple strategies to reduce post-operative respiratory complications:

I - incentive spirometry

C - coughing and deep breathing exercises

O - oral care, including brushing teeth and using mouthwash

U - understanding, including patient and family education

G - getting out of bed at least three times a day

H - head of bed elevation

Patients talk about what to expect before surgery, on the day itself and how enhanced recovery helps individuals get better sooner post-surgery. As well as pain relief, this covers the patient journey including the different units where patients may be treated – such as critical care and surgical high care – and then a ward, before discharge home. Patients are also advised where to go for help and advice, including emotional and financial support.

After a short break, in which patients can ask the team questions, the second half looks at what they can expect during their stay and planning their discharge home. Patients leave with a tote bag full of tips and tools, including an incentive spirometer, pedometer, exercise DVD, gym subscription and various leaflets.

‘This isn’t waiting time for surgery, it’s preparation,’ says Ms Bellis. ‘They can get themselves into an optimal position so they are not in hospital for any longer than they need to be.’

Goodie bag produced by Portsmouth Hospitals NHS Trust. Lessons for patients on improving fitness before surgery lift their mood and mean shorter hospital stays.
Patients receive a tote bag full of tips and tools

Nurses can tell who’s been to the school and who hasn’t

The multidisciplinary team delivering the sessions includes a physiotherapist, a role now performed by Sarah Johns, who offers specific advice and tips on exercising. ‘We tell them that increasing activity reduces the risks of cancer returning,’ says Ms Johns. Suggestions include vigorous housework, gardening, swimming, cycling, running, getting off the bus a stop before your destination and walking upstairs rather than using a lift.

Afterwards, Ms Johns is often stopped by patients on the wards who tell her how well they’re doing. ‘They’re proud to say they’re walking, doing their breathing exercises and going home sooner than expected,’ she says.

‘It’s that kind of attitude that comes with the surgery school. We’ve had feedback from senior nurses who can clearly tell the difference between those who’ve come to the school and those who haven’t. Attendees want to get up and go, and be as independent as possible.’

Surgery school patients spend one less day in hospital

So far they have seen around 350 patients, with just three giving negative feedback. ‘The biggest challenge is being able to get referrals in a timely way, with dates for surgery not changing,’ says Ms Bellis.

‘Two of the patients said the school was too close to their operation, while a third said it was too far away. In an ideal world, six weeks beforehand would give time to make meaningful changes, but that’s not always possible.’

‘We say you wouldn’t run a marathon without doing any training, and that’s how patients should view their upcoming surgery’

Yousra Ahmad, anaesthetist

Their evaluation shows that patients who attend surgery school spend one less day in hospital than those who don’t. Meanwhile almost three quarters increase their activity before surgery, while almost four out of ten stop drinking alcohol before their operation and 39% of smokers quit.

The team wants to extend it to other groups of patients

The school has been so successful that when the pilot ends the trust has decided to continue funding it. The announcement follows a recent Care Quality Commission (CQC) inspection, published in January, which cited the initiative as an example of ‘outstanding practice’.

Looking ahead, the team would like to be able to extend it to other groups of patients, with head and neck as well as breast surgery and reconstruction both interested.

Dr Ahmad says: ‘We say you wouldn’t run a marathon without doing any training, and that’s how patients should view their upcoming surgery.’

‘You’re encouraged to be up and about as soon as possible’

For patient Ivy Green, who had a right hemicolectomy in March, surgery school improved her knowledge and understanding of what happens after an operation and the part she could play in boosting her own recovery. ‘The last operation I had was 35 years ago and it was nothing like my current experience,’ says Ms Green.

Picture shows a carer and an older woman walking together. Lessons for patients on improving fitness before surgery lift their mood and mean shorter hospital stays.
Picture: iStock

‘Back then you stayed in bed for almost a week and were in hospital for another week or so afterwards. You had to use a horrible bedpan, be bed-bathed and wear a hospital gown.

‘Now you’re encouraged to be up and about as soon as possible, get dressed in your own clothes, have a shower and walk around if you can. It makes you feel so much better. No one wants to lie in bed all day.’

‘Not many people know what happens when you have surgery’

She was invited to attend the school during a consultation with the anaesthetist. ‘I’d never heard of anything like it before and wondered what they might tell us,’ Ms Green recalls. ‘But I thought it was a good idea, because not many people know what happens when you have surgery and I was interested to find out more.’

At the beginning of her two-hour session in January 2020 she was weighed and her body mass index calculated. ‘Then they talked to all of us about how to get fit before surgery,’ says Ms Green. ‘They emphasised its importance, increasing the amount you already did. Usually I attend keep fit and line dancing, so I do get some exercise.’

Picture of a pedometer. Lessons for patients on improving fitness before surgery lift their mood and mean shorter hospital stays.
Picture: Alamy

‘The school refreshes your mind about how important it is to exercise and eat well’

Other topics included having a healthy diet, drinking more fluids, and stopping smoking and drinking alcohol. Each of the participants was also given an incentive spirometer, which measures how deeply someone inhales, teaching them to take slow deep breaths. It’s particularly useful after surgery, helping to keep lungs healthy.

‘We were told how important it is to do breathing exercises, doing them several times a day at home even before our operations,’ says Ms Green. ‘We got to practise and they checked to see if we were doing it properly. I’m happy using mine and I try to do it as much as I can.’

She feels that the information is helping her recover well and quickly. ‘Although my operation was only a few days ago, I’m making a good recovery so far,’ she says. ‘The school refreshes your mind about how important it is to exercise and eat well. I’d definitely recommend it.’

Note: The patient’s name was changed at her request. 


Lynne Pearce is a health journalist


Find out more

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to cancernursingpractice.com
  • Bi-monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs