THR patient is defined as one who is admitted for received an elective surgery hospitalized 5 - 7 days but requires several months’ rehabilitation for recovery. Under this surgical treatment and then is the main purpose is to decrease joint pain and improve joint function [3] . Patients’ diagnosis with hip osteoarthritis, rheumatoid arthritis and femoral head osteonecrosis will receive THR. Following new analgesics developed and arthritis patients’ pain could get more relieved. However, THR surgery is still the terminal step to solve their pain. Although the successful rate of operation is more than 90%, patients still need to face problem including operative risk, complications, post-operative care and rehabilitation. Therefore, patients need to know more about the operation and its influence to the future [4] .

Studies showed patients who just hospitalized will feel stress because of the change of living environment, threated by uncertainty of the disease, unknown to medical terminology, endured pain from examination and treatment, and worried about family or friends’ response. They were even high anxiety before the operation [5] [6] . Scholar indicated that patients’ fear of pre-operation and disease could induce high anxiety. Lue, Chang, Liu, Chen and Lu [7] investigated knee and hip replacement patients’ anxiety degree and found that 31.33% of the patients have mild anxiety; 10.84% of the patients have moderate to high anxiety. Patients worried about including safety of anesthesia, success rate of the operation, complications, mortality, how long can awake after operation, wound pain, discomfort, post-operation physical function, rehabilitation time, when can walk and independent self-care, and recover level etc. If they adjusted inadequately, it will cause negative impact on their health [8] .

Meanwhile, every patient had different anxiety level. Peoples’ anxiety level will influence by their past experience and preconceptions experience. Non-experienced and negative-previous experience patients had higher pre-operative anxiety. Younger, female and lower education level had higher anxiety [9] . Female patients worry about postanesthesia can not awake, and male patients worry about pain [6] . Every patient has its individuality and different afraid item. Therefore, individual assessment is necessary before operation. As what is concluded from the above, nurses need to face many challenges when provide emotional care for pre-operative patients.

Not only based on the medical treatment but also humanity caring, nurses hope to help patient recovered from operation fast and safe. Joint replacement patients need to actively participate in pain control, rehabilitation and daily care [10] . The pre-operative education is an important part of operation; it can enhance patient’s knowledge about operation and their compliance. Pre-operative patients with psychologically distress will have more pain complaint and lower satisfaction level [9] . So be careful to manage patients’ psychological distress is very important.

Recently, inform pre-operative patient that they have the right to know is taken seriously. Under the pressure of hospital administrator, nurses explain the purpose and risk of the operation, routine process, the situation they may face and future management at a day before operation or the operation day. Let patient receive huge information in one time [11] . According to American Association of Orthopedic Surgeons (AAOS), patients’ education should include knowledge about operation and rehabilitation, sign of pulmonary embolism (such as shorten breath, tachycardia, anxiety, chest pain, hemoptysis, hypotension and dizziness) and deep vein thrombosis [4] . Taiwan scholars suggested hip replacement education should include operating leg correct positioning, turning, ambulation, rehabilitation, walker or crutches using, self-care and home care [12] [13] .

Data were analyzed using qualitative content analysis as described by scholars [15] . First, the recorded tapes were repeatedly listened to and all the interview records were read through in order to get an overall sense of the patients’ views. Next, the verbatim data were read line-by-line in order to identify statements related to THR. These statements were marked, and tentative codes were written in the margin for the detection of emerging patterns. Differences and similarities among codes were compared, and codes that were similar in content were subsequently grouped and classified into various categories.

To validate the results, responses to questions were further probed several times during the interview, to gain deeper understanding. Coding and development of the categories were done by the first author. The third author read all the condensed units of meaning and also questioned the preliminary analysis. After 11 interviews, no new categories or subcategories were developed, and then stop collected. The third author has been working as an orthopedics nursing clinical supervisor for about 20 years and the first author is a senior researcher in nursing.

Ethical considerations were observed according to the recommendations of Helsinki declaration, as suggested by Wilkie [16] . This study has been approved by the Institutional Review Board of the hospital where the study was conducted (IRB No: 93-11-08A).

Patients afraid that physical activity will be affected after operation. In addition, they worry about lose job and not qualified the job requirement they used to be.

The depth of educational content depends on personal demand. Somebody felt scared if the image was too realistic; somebody wanted to know more, but somebody thought they won’t understand so just asked their children to be educated. As a case said (C7): “Handout is better because I forget the contents soon after I watched the education video.” Another said (C9): “I have an operation before and the THR educational content is similar.” Despite repeat THR information provided, patients confirmed and accepted the education. As a case (C6) said: “I knew more about it after I watched the video. I won’t know it if I didn’t watch it. This video can help me to be well prepared.” Another said (C5): “I think the education was clearly with that video. My family would also know how to take care of me if they watched it together.” The other said (C8): “Could you tell us whether the operation have some risks? Is it dangerous? What should I do before the operation? Could you please tell me more details after the operation?” And case C8 said he refuse to watch the video because he scared blooded and realistic images. “I thought I would see some operative images in the video.”

We found that the patients admire the hospital workers’ authority with which it was not possible to argue or disagree. The patients believe the superior knowledge of health care professionals especially the doctor is a health team leader, which enhances patients’ confidence. Edwards, Davies and Edwards [17] used meta-study approach to synthesis 7 studies. There were three themes of information exchange were found including non- empowered who non-user of information relies on doctor as ultimate information source; disempowered who healthcare practitioner regulated information, and empowered who patient-regulated information. Patients’ motivation to seek information, the management of that information and its risks and information exchange in consultations can lead to empowerment. Our results are not quite the same with Edwards et al. [17] study. In present study, we found that patients only passively accept authoritative advice, they did not feel participation―but did not want to either. It may be patient with older age and the traditional Chinese character with more docile. However, patient empowerment is still the future direction to improve information exchange between patients with professionals.

After THR surgery, patients worry about mobility changed, similar as Japanese Scholar’s study osteoarthritis patients after THR experience. In their study found that participants’ anxiety was heightened around the time of discharge because of worries about dislocation and living at home with prosthesis [18] . The result of this study was similar with the previous results [19] [20] . Gustafsson, Ekman, Ponzer and Heikkilä [21] use phenomenology to interview 16 knee or hip replacement elderly people (above 65 years old). One of them said: “When I was young, I had been in hospital for a long time because of hip fracture. Maybe that’s why now I feel more afraid of this hip replacement operation.” Another also questioned about post-op life type: “Will I have more quality of life after THR? Can I do everything just like before?” It told that they worried whether they could have a regular life like before.

Most of the participants of this study were middle age and early elderly; this age group generation had lower learning motivation than younger. Thus, it seems possible that the preference of patients belongs to non-partic- ipant in THR education learning process. Little of patients can express preference of THR education. The study has investigated THR patients’ perspectives of pre-operation THR education. It showed they did not clearly express their THR education needs. They want to be informed and listened to; they wanted to enjoy top-down communication with their health education providers. The result is similar with the previous study. Loft, Mc William, and Ward-Griffin [22] found five themes emerged centering on a strong desire to maintain independence through data analogist. Overall, participants experienced disempowered relationships with professional in-home care providers and a more equitable empowered relationship with nonprofessional care providers.