Using a large sample of Chinese TKA patients, this study investigated the relationship between the quality of discharge teaching and RHD, focusing on the mediating role of patients' depression and self-efficacy for rehabilitation. With the use of enhanced recovery after surgery, the length of stay for TKA patients has been reduced and their self-reported RHD needs to be considered. It took several months to recover after TKA, and the patient's self-reported RHD was important for their compliance behaviors and symptom recovery[15, 31]. In the clinic, doctors based the discharge time on the exam indicators and the patient's degree of functional recovery, while paying less attention to the patient's true inner feelings. In fact, we paid attention to the physical condition of the patients and less to their psychological problems. The psychological status of TKA patients was also important to their health outcomes[32, 33]. The results of this study provided relevant data support.
Some TKA patients do experience some psychological problems, such as depression and low self-confidence[34, 35], which not only delays the recovery but also increases the incidence of complications[36, 37]. The results of this study showed that depression and self-efficacy for recovery partially mediated the relationship between quality of discharge teaching and RHD in patients with TKA. That is, nurses can intervene in patients' depression and self-efficacy through discharge teaching to improve their RHD. The results of this study were important in improving patient readiness for discharge, and there was a need to include psychological status in the nursing assessment. The quality of discharge teaching had a strong positive correlation with RHD, which was consistent with the results of previous studies[31, 38, 39]. The direct effect accounted for 37.3% of the total effect. Doctor and nurse discharge teaching was the main method to improve patients' disease awareness, reduce their uncertainty and improve their RHD. In addition to this, there was an indirect effect of discharge teaching through depression and self-efficacy for rehabilitation, accounting for 62.7% of the total effect. When doing discharge teaching, it was important to pay attention to the presence of depression in post-TKA patients and their level of recovery self-efficacy.
There is a growing concern among researchers about the psychological symptoms of patients because when the disease is combined with depression, the prognosis is generally poor. Due to the fear of the unknowable and postoperative knee pain, TKA patients were prone to depression[35, 40]. Depression had a negative impact on both health outcomes and postoperative satisfaction in patients with TKA[40, 41]. Studies showed that depression and pain often coexist and interact with each other, influenced by molecular neurobiology and that pain can further lead to functional limitations, creating a vicious cycle. Besides, patients with depression were often reluctant to communicate with others, unable to communicate effectively with doctors or nurses, resulting in a lack of disease knowledge and a low willingness to be discharged from the hospital. As a major means of communication between healthcare professionals and patients, discharge teaching was the best time to provide psychological interventions to alleviate their depression. Normally, playing some soothing music in the ward was also an important measure to relieve patients' depression[43, 44].
Self-efficacy for rehabilitation could effectively reduce the time to first bed activity after surgery in TKA patients, which was an important predictor of their postoperative ability to live and long-term rehabilitation outcomes[45, 46]. The primary goal of postoperative rehabilitation for patients was to improve quadriceps strength and increase joint range of motion, which could reduce the incidence of postoperative complications and shorten the length of hospital stay, improving RHD. The results of Wylde et al showed that the outcome of postoperative rehabilitation of TKA patients was closely related to self-efficacy. Rehabilitation self-efficacy as a modifiable variable could be improved by medical staff through cognitive-behavioral interventions, parallel family education, and "teach-back" during discharge teaching.
Of course, this study also had some limitations. First, the subjects in this study were from Grade 3 A hospitals, which had a higher level of caregiving, so the data values for the results were higher and couldn’t be representative of the average hospital. Second, the use of one-on-one questions and answers to obtain relevant information may have some reporting bias. Therefore, the extrapolation of the results may be limited.