Danish Medical Bulletin - No. 4. November 2004. Vol. 51 Pages 418-21.

ORIGINAL ARTICLE

Patient and staff (doctors and nurses) experiences of
abdominal hysterectomy in accelerated recovery programme

A qualitative study

Lis Wagner 1 , RN, DrPH, Anne Mette Carlslund 2 ,
MSc Soc, Charlotte Møller 3 & Bent Ottesen 4

PDF

1) Department of Nursing Science, University of Aarhus, Denmark. 2) National Institute of Social Education, Denmark. 3) Department of Obstetrics and Gynaecology, H:S Hvidovre Hospital, Denmark. 4) Juliane Marie Centre, University of Copenhagen, Denmark.

Correspondence: Lis Wagner, Department of Nursing Science, Faculty of Health Sciences, University of Aarhus, Høegh-Guldbergsgade 6A, 8000 Aarhus C, Denmark.

Abstract

Introduction: The accelerated recovery programme (ARP) is becoming commonplace in surgical specialties and has also been introduced to hysterectomy patients. Diagnostic, prognostic and other clinical indicators are well described. The aim of this article is to relay knowledge about the ARP, through the experiences of the women operated and the staff involved.

Material and methods: The study is exploratory and descriptive, using qualitative methods. Seventeen women, with good health status, were consecutively selected from August to September 2001. The women were observed and ten were interviewed twice, at discharge and one month following their return home. The staff (n=15) were interviewed individually and/or participated in focus group interviews before (February 2001) and following (November 2001) the introduction of the ARP.

Results: The women experienced little difficulty with the ARP. They defined themselves as being good girls but expressed that when the hospital's ARP had expired the attention from the staff declined. The staff continued to be concerned about whether the women received the information and psychological care they needed but claimed that the ARP proved better for the women than they had expected.

Conclusion: The ARP did not appear to be a burden for the women involved in the study; however, it did not consider individual needs for psychological care. Future efforts should ensure a thorough introduction of the ARP to new staff as well as illustrative material for purposes of information relay and dialogue between staff and patients/family members. A nursing care ambulatory unit is recommended to support with information for women prior to and following hysterectomy in the ARP.

Dan Med Bull 2004;51:418-21.

The accelerated recovery programme (ARP) is becoming commonplace in surgical specialties (1, 2), such as gynaecology, in which hysterectomy is one of the most frequent operations performed on non-pregnant women (3). Diagnostic, prognostic and other clinical indicators are well known and described in the literature (2, 4, 5). However, documentation is sparse regarding the social science perspectives in which the experiences of the actors in the ARP are included. The ARP is based on: 1) the woman's knowledge base about the regime; 2) a reduction in "surgical stress response"; 3) appropriate pain management; 4) early mobilization and 5) early resumption of normal diet. In principle, these aspects should lead to a minimized illness episode and accelerated restitution (2). The ARP requires revision of traditions, and to ensure that the patients receive the best possible care standardized care plans have been introduced. Could it be possible, however, that neither the women nor the staff have time to thoroughly discuss the situation and that the women may experience doubt, frustration, autonomy loss, stress and uncertainty or simply feel tired?

The aim of this article is to relay knowledge about the ARP, which was carried out in the Gynaecological Department of Hvidovre Hospital, Denmark, through the experiences of the women operated and the staff involved.

It describes the experiences of women undergoing abdominal hysterectomy and staff who are novices at working with the ARP in their daily clinical practice.

material and Methods

In the study an exploratory and descriptive design was chosen in order to investigate the ARP from a women and staff point of view. The qualitative methods used were observations in the ward, individual- and focus group interviews, with the participants, and written material as case records and information folder (6-8). Observation is an expression of the researchers' understanding and experience of the situation, while the interviews encompass the different participants' understanding and experience of the same situation. The written material is an expression of, what the staff focuses on in the intern communication about the situation. Together the different data sources provide a shared social experience between the researchers and the participants.

To refine the research guides for observation and interview, a pilot study was carried out. The researchers spent a week in the ward observing and testing guidelines and informal conversations with women and staff were conducted. In the data-collecting period the researchers were acting as part of the staff.

Participants

Seventeen women requiring abdominal hysterectomies were recruited consecutively from 7 August to 1 September 2001. Inclusion criteria: generally healthy; spoke Danish; not participating in other studies; written consent based on written and oral information. The average age of the women was 47.2 years (42-54 years) and they experienced postoperative stays of between one and three hospital days (median 2.4). One woman was readmitted four days after hospital discharge. Fifteen staff members, i.e. doctors, nurses and assistant nurses, were included in the study. Inclusion criteria: participation in the ARP.

Data

The women and staff were studied as outlined in Table 1.

Observation guides were used to systematise the notes made by the researchers during the observation. Due to procedure and planning in the ward six of the seventeen women were only observed at their preliminary examination (Table 1) and one woman only at her admission day. The remaining ten women were further observed in the following situations: 1) On the admission day in dialogue with nurse and doctor; 2) on the operation day at first time out of bed, after operation; 3) at discharge in dialogue with nurse and doctor. Furthermore they were interviewed on the day of discharge and one month later in their own home using semi-structured interview guides about their experiences with ARP and their situation at home after discharge.

The staff members participating in ARP were interviewed individually once during the study, also by using semi-structured interview guides concerning their view on the standard care plan used in ARP and their own experiences working in ARP. The two focus group interviews were conducted, before and after the ARP introduction, to see possible changes in attitudes toward the programme. Eight participated in the first focus group interview and six in the second, of whom four also participated in the first interview.

All interviews were tape-recorded and later fully transcribed. The final analysis approaches the following research question: Does the ARP ensure that the patients receive the best possible care, or is it possible that neither the women nor the staff have time to thoroughly discuss the situation and that the women must experience doubt, frustration, autonomy loss, stress and uncertainty or simply feel tired? How did the staff experience the change to ARP?

The observation notes and transcribed interviews were read several times with the aim of summarizing parts which related to the issues and themes under study. Different data on the same situation were compared. Furthermore new themes that had surfaced during the interview were registered. The result of the analysis is in short form presented in this article and interpretations are highlighted by few interview citations marked by letters covering names known by researchers.

Ethical considerations

The project was carried out in accordance with the Helsinki Declaration and was approved by the local ethics committee and registered with the Data Inspectorate. The women received the study report, and the staff was invited to a presentation and discussion of its results.

Results

The women's experiences

From a physical perspective, the women successfully underwent hysterectomies and the ARP with no significant problems. They reflected on their role during their hospital stay and defined themselves as assuming a good girl role. They participated in dialogue with the staff in order to satisfy expectations which were inherent in the concept of the ARP, and become compliant patients. One said:
"I use the available resources to get a grip on myself." (A)

The ARP, including dialogue with the staff, was generally perceived positively, but the women experienced the standard care plan as being a manual which did not consider individuality. One said: "Caring stopped the day I got out of bed." (B)

The women's perception of the hospital discharge showed that there was an expectation for them to be discharged two days after the operation. One said: "Seen in retrospect, I should have stayed an extra day, but who is the professional in this situation?" (H)

During an interview one month following discharge, several of the women expressed concern about the surgery's impact on their sexual life. They had not discussed this issue with the staff during their hospital stay. The follow-up interviews at home indicated that they did not experience any change when resuming sexual activity. However, they had been harbouring this concern before taking the step. Only the question of when they could resume sexual activity was included in the information folder.

It was not a requirement that the women experience a bowel movement prior to their hospital discharge. The women were alert to their bowel function during the first week following discharge and experienced that it was not easy or painless, as they had anticipated from the information received. The women also appeared to be concerned about the appearance of their scars, bloating effects and they felt fatigue for a long period of time, two to four weeks.

The Staff's experiences with change
in care practice

The staff's experiences, collected through individual and focus group interviews, showed that the ARP was better for the women than they had anticipated prior to its implementation. However, the staff continued to be sceptical and uncertain whether the women were provided with the necessary information and psychological support. One nurse said: "From a psychological perspective, I think that it takes some time for people to get used to the fact that something has happened to their bodies."

The standard care plan is a tool to allow the nurses' tasks to be transparent and structured and there is no similar tool developed for the doctors, therefore procedures for specific areas are developed to structure and secure the doctors' procedures and to ensure that all information is provided. Psychological care, however, is toned down in the standard care plan. One other nurse said: "I believe that care has become more goal oriented, but we wrote more personal remarks about the patient in our previous practice, and information transmitted orally will never be replaced by the written word."

The staff expressed that implementing the ARP was based on savings and organizational goals and the implementation was not followed up by the promised and expected team formations.

Compliance between the staff's
and the women's experiences

Dialogue in the ARP, with its compressed and information-filled approach, was evaluated as the most difficult turning point for both the women and the staff. Both parties made an effort to fulfil the other's expectations in the situation, but from different perspectives and different understandings of the same situation. The women showed willingness to meet the staff's expectations of achieving normal reactions to the procedure while the staff sought to satisfy management's expectations regarding the standard care plan and fulfilment of the ARP as planned.

The women stated that they had been informed about a short hospital stay prior to hospitalisation, both at the out-patient clinic and by reading the information folder and that their view of the hospital stay was influenced by this previous knowledge. This complied with the staff's understanding as well. The staff tried to create a comfortable and relaxed atmosphere in the ward. Collaboration was seen when following the standard care plan regarding early mobilization and intake of food and fluids. The staff was aware of these requirements and worked to motivate and support the women so that they could meet the desired goals by means of relieving inconveniences such as nausea and pain.

The women also experienced having received optimal attention and help on return to the ward following their surgeries, but saw these actions as means to satisfy the mobilization requirement. In this context, the women described how the staff, through use of humour, provided a relaxed atmosphere for them.

Built into the standard care plan were the expectations of what the women were able to accomplish directly following their operation and while in hospital. The women experienced that the standard care plan could have a limiting and confining effect. In an effort to be "good patients" and to follow the prescribed expectations, they saw the nonverbal expectation of the staff regarding time for discharge. The decision to discharge took place during ward rounds, by means of a dialogue between the woman, the doctor and the nurse, and the staff placed importance on the fact that the woman should not feel pressured at discharge. There were women who admitted that they did not benefit from this dialogue because they felt dizzy from the painkiller medicine and had used all of their energy to act in order to meet the standard care plan. The women lastly expressed in the interview at home to have to be able to estimate and decide when to return to work, irrespective of the duration of the sick leave given by the hospital doctors at discharge.

Implementation of the ARP
- the staff's perspectives

The focus group interviews with the staff before and after the implementation of the ARP showed that the earlier scepticism about the regime was resolved by the fact that the women experienced the process as successful. During the first focus group interview there was a clear objection to the fact that the women were pressed through a speedy process without being able to be "sick". A nurse said: "I don't know if they get a chance to discuss the process with anyone, but perhaps there is additional pressure placed on the general practitioners." The second focus group interview showed that a positive change in attitude did occur after carrying out practical work in the ARP. The staff had become comfortable with the new routines and claimed that the women were able to and wanted to follow the standard care plan. A doctor said: "The patients are very satisfied and would almost be disappointed if they were not allowed to go home as they anticipated."

However, the staff did not believe that they were trained enough in the ARP.

Discussion

The ARP had the main aim to reduce morbidity and risks associated with the surgical intervention by optimising the pre-, intra- and postoperative care. The above evaluation shows that the women who participated in the study were prepared for the short hospital stay; however, it became apparent that information was dependant on each woman's unique entry point into dialogue with the staff. The qualitative methods were appropriate for this type of research based on women's and staff's subjectivity data. In the interpretation process, this type of research makes demands on the researchers' theoretic skills, insight ability and sensitivity. The selected data sources supplement each other and create overall strengthening of the data's reliability. The strength of the study is the close and thorough form of knowledge it obtains about this group of women and staff, and their experience with the ARP. The weakness is that the results cannot be generalized to women with other diagnoses or surgical interventions.

Observation of different dialogue situations showed that the staff was generally good at establishing a secure and comfortable atmosphere. Debra Otte (9) has in her study pointed out four important areas: communication between the patient and the professional, patient preparedness, nursing competence and precise information at discharge, which was also found to be of central value in this study. Eight out of the ten women described their hospital stay in positive terms and expressed an understanding of the mobilization aim and requirement for early mobilization and early intake of normal food. They stated that the expectations and standard care plan became a type of manual or norm brought forward by the staff, a norm, which they tried to attain whereas a few of the women felt that the staff's attention towards them was reduced when mobilization had been achieved. Wom Eigen (10), through her study, pointed to the importance of drawing family members into as social and emotional support during short hospital stays and that this could also become an additional support to the staff. This should be a future challenge for the staff.

At the follow-up interview one month after discharge, the women reported some uncertainties to which degree their sex lives would be affected. Studies have shown that hysterectomy has no negative effect on sex life (11). However, no one has addressed the form and character of the identified concern or how to alleviate it. To what extent sexual activity would be affected by a hysterectomy is a general concern, not specific to the ARP, but seems to be an area that both parties avoid (12).

The women felt tired following discharge and also during the first period in which they resumed their work. Several women informed, however, that their workplaces showed them consideration. A few of the women felt a sense of hopelessness or frustration about not living up to the norm of returning to work after two to three weeks. They needed a longer sick leave period. Sick leave, feeling ill and recreation time are still not highlighted in the literature, and no evidence-based guidelines exist for convalescence following hysterectomy (13, 14). Pelliono (15) documented that structured patient counselling in a "learning centre" prior to admission had a positive correlation with the patient's ability to carry out necessary pre- and postoperative care. These results supplement those of Lookinland and Pool (16) where preoperative counselling also had a positive effect on the postoperative process.

In conclusion the study shows that the women successfully underwent abdominal hysterectomy and the ARP without significant problems, considering that the women did their best to follow the standard care plan for ARP, but at the same time there was a need for improvement such as securing appropriate psychological support. Comparison of two focus group interviews with the staff, at the start of the study and eight months later, showed a positive change in the staff's opinion and an understanding of the ARP. The staff felt comfortable with the new routines when they experienced that the women were able to and more motivated to follow the standard care plans. The study resulted in recommendations for clinical adjustments: 1) A thorough introduction should be given to new staff about the principles of the ARP; 2) a pleasant consultation room in the ward with access to illustrative material should be established and 3) a permanent nursing outpatient clinic, which could provide information to the women before and after the operation, should be established.

Financing

The project was supported by Copenhagen Hospital Cooperation (grant number 10/01) as well as Hvidovre Hospital and The University Hospitals Centre for Nursing and Care Research.

REFERENCES

  1. Hessov I. Fewer complications - earlier discharge - shorter convalescence. Ugeskr Laeger 2001; 163: 415.
  2. Kehlet H. Accelerated surgical stay programs: a professional and administrative challenge. Ugeskr Laeger 2001; 163: 420-4.
  3. Møller C, Kehlet H, Ottesen BS. Hospitalization and convalescence after hysterectomy: open or laparoscopic surgery? Ugeskr Laeger 1999; 161: 4620-4.
  4. Møller C, Kehlet H, Friland SG, Schouenborg LO, Lund C, Ottesen B. Fast track hysterectomy. Eur J Obstet Gynecol Reprod Biol 2001; 98: 18-22.
  5. Basse L, Hjort Jakobsen D, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232: 51-7.
  6. Krogstrup HK, Kristiansen S. Participating observation: introduction to a research method. Copenhagen: Hans Reitzel, 1999.
  7. Kvale S. Interview: an introduction to qualitative research interviewing. Thousand Oaks: Sage, 1996.
  8. Bojlén NS, Lunde IM. Focus group interview as a qualitative research method. Ugeskr Laeger 1995; 157: 3315-8.
  9. Otte DI. Patients' perspectives and experiences of day case surgery. J Adv Nurs 1996; 23: 1228-37.
  10. Vom Eigen KA, Walker JD, Edgman-Levitan S, Cleary PD, Delbanco TL. Carepartner experiences with hospital care. Med Care 2001; 37: 33-8.
  11. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM. Hysterectomy and sexual functioning. JAMA 1999; 282: 1934-41.
  12. MacQuenn A. Gynaecological Nusing. J Adv Nurs 1997; 25: 767-74
  13. Rasmussen KL, Hansen V, Madzak F, Ljungstrøm B, Lauszus FF. Feeling of illness after hysterectomy: women's own assessment. Ugeskr Laeger 2001; 163: 7040-7.
  14. Møller C, Ottesen M, Kehlet H, Ottesen BS. Convalescence recommendations after hysterectomy: a study of opinions among Danish physicians. Ugeskr Laeger 2001; 163: 7043-7.
  15. Pellino T, Tluczek A, Collins M, Trimborn S, Norwick H, Engelke ZK et al. Increasing self-efficacy through empowerment: preoperative education for orthopaedic patients. Orthop Nurs 1998; 17: 48-51, 54-9.
  16. Lookinland S, Pool M. Study on effect of methods of preoperative education in women. AORN J 1998; 67: 203-8, 210-3.

Return

DANISH MEDICAL BULLETIN
The Danish Medical Bulletin reserves the right to store and publish articles (texts and illustra-tions), electronically too, eg on CD-ROM and the Internet. All rights reserved, ie prohibition against publication of texts and illustrations from the Danish Medical Bulletin. Rights can only be obtained by written acceptance from the author and editors and by quoting the Danish Medical Bulletin as source. Quotations of information from the Danish Medical Bulletin may not be published until after the publication of the issue in question and quotation of the source.