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Thursday, December 22, 2005

In order to counsel the surgical patient, the nurse needs to have a clear picture of home recovery based on the patient's biophysiologic health problems. The purpose of this study was to examine short-stay surgery patients' experiences of pain, nausea, vomiting, fatigue, and problems with elimination and wound healing during a 1-week recovery phase at home.

Advances in medical technology and the drive to cost-effectiveness in health care have provided a major boost to short-stay surgery. In Finland, the goal was to have 50% of all elective surgeries done on an ambulatory basis by 2003. Elective surgery includes surgical procedures which are planned and organized beforehand; those procedures coming via emergency room are excluded. This figure currently varies in different hospitals from 28% to 59% (Punnonen, 2001). In many countries, however, outpatient services and follow-up procedures have failed to keep up with the rapid development in ambulatory surgery (Bruce, Russell, Mollison, & Krukowski, 2001). During recovery at home, the short-stay patient has to manage alone or rely on help from significant others. To provide support for the patient returning home, the nurse needs a clear picture of the patient's condition and possible health problems. The patient also needs to know what to expect, and how long any biophysiologic health problems will continue. Furthermore, the patient needs concrete advice on how to prevent and manage these problems in everyday life.

This study was concerned with the biophysiologic health problems of two groups of short-stay patients: day surgery patients (24 hours), and patients hospitalized for no more than 3 days. Its aim was to increase awareness of the biophysiologic health problems that short-stay patients may experience at home. With this knowledge and understanding, the nurse will be able to provide better counseling services and appropriate interventions. Ultimately this will help to raise the quality standards of patient care and nursing, both in the hospital and in home nursing contexts.

Review of the Literature

Earlier nursing and medical studies of pain, nausea and vomiting, fatigue, and problems with elimination and wound healing in short-stay surgery patients have different philosophical underpinnings and have been conducted in different cultural environments. They also vary widely in terms of their sample sizes, methods of data collection, anesthetic techniques, and surgical procedures. However, all these studies have shown that short-stay patients have difficulties managing their biophysiologic health problems sufficiently during recovery time at home. These problems should be studied in the Finnish context as well.

Pain

In the current study, acute postoperative pain was measured on the single dimension of intensity with five items on a 5-point Likert scale as described by the individual patient. The measurement of chronic pain was excluded in this study by asking patients to evaluate contemporary acute postoperative pain caused by the surgical procedure. Measurements of pain experienced by short-stay patients on the first day at home have yielded different results depending on the surgical procedures and the methods of measurement. Cason, Seidel, and Bushmaier (1996) reported that 81% of patients who underwent laparoscopic cholecystectomy had pain on the 2nd day at home. However, by the 7th postoperative day, 50% of the patients still had pain and 31% used pain medication. Other studies have also seen a progressive decrease in experiences of pain (Keulemans, Eshuis, de Haes, de Wit, & Gouma, 1998; Young & O'Connell, 2001). Some patients undergoing different kinds of surgical procedures have complained that pain relief was inadequate (Aasboe, Raeder, & Grogaard, 1998; McHugh & Thoms, 2002; Rawal, Hylander, Nydahl, & Gupta, 1997; Waterman, Leatherbarrow, Slater, & Waterman, 1999), and that instructions about pain control were unclear or nonexistent during the recovery phase at home (Beauregard, Pomp, & Choiniere, 1998; Young & O'Connell, 2001).

Upper Gastrointestinal Distress

In the current study, upper gastrointestinal distress included nausea and vomiting. The proportion of short-stay patients who vomit or feel nauseated after surgery varies considerably, even when the operations and anesthetic techniques are very similar (McQuay & Moore, 1998). According to some studies, general anesthesia is associated more with higher rates of nausea and vomiting than face-mask anesthesia or regional blocks (Thompson 1999). Patients undergoing orthopedic and certain other operations, such as hemorrhoidectomy, have reported nausea and vomiting at home during the first day (Claxton, McGuire, Chung, & Cruise, 1997) and the first week (Aasboe et al., 1998) after their operation. Rawal et al. (1997) found that 20% (n=1,035) of patients from various operations suffered from nausea during the first 48 hours after surgery. According to Cason et al. (1996), 17% of laparoscopic cholecystectomy patients had nausea even on the 7th postoperative day. These biophysiologic health problems decreased considerably in different patient groups during the first week (Hunt, Luck, Rudkin, & Hewett, 1999; Young & O'Connell, 2001). Very few patients suffered from vomiting, particularly for extended periods after the operation (Ashworth & Smith, 1998).

Fatigue

Fatigue is used by patients themselves to assess their postoperative recovery (Kleinbeck, 2000). In the current study, fatigue as well as pain were measured with five items on the single dimension of intensity as described by the individual patient on a 5-point Likert scale. Short-stay patients undergoing different surgical procedures are usually fatigued to some extent (Rawal et al., 1997). Fatigue may last longer than expected, and it may also hinder normal daily activities (Young & O'Connel, 2001). In some cases patients needed to contact a health care provider or significant others to get help (Ruuth-Setala, LeinoKilpi, & Suominen, 2000).

Problems in Elimination

Problems include both bladder and bowel elimination. Patients who undergo spinal or epidural anesthesia and pelvic surgery may be unable to control their bladder (Korttila, 1991, 1995; Rawal et al., 1997) and bowel function (Campanelli et al., 1998). Some patients undergoing hydrocelectomy and varicocelectomy have reported difficulties in urinating (Twersky, Fishman, & Homel, 1997). Opioid analgesics can decrease the motility of the alimentary tract (Pasero, Paice, & McCaffery, 1999). On the other hand, pain itself can make it difficult to urinate and defecate after a surgical procedure. Furthermore, patients may avoid moving because of pain, and refrain from drinking and eating to avoid nausea and vomiting (Waterman et al., 1999). This increases the risk of constipation. Campanelli et al. (1998) found that 90% of patients had normal bowel peristalsis within 24 hours of laparoscopic cholecystectomy. Young and O'Connell (2001) indicated that by day 4 after laparoscopic cholecystectomy, most patients had returned to normal bowel habits.

Problems in Wound Healing

Wound healing can be divided into three distinct phases--inflammation, proliferation, and maturation--each showing its own characteristic biophysiologic features. The common features of a healing wound in the first few days after surgery are redness, swelling, incision pain, and localized heat (Dealey, 1994). Other complications include incision ache, swelling, bleeding, serous exudate, bruises, wound hematoma, and wound disruption. Surgical wound infection can cause scar tissue to develop and further give rise to scar pain (Stotts, 1993). Evaluation of surgical wound healing is problematic because the normal phases show the exact same symptoms as complications: ache, swelling, and redness.

In Finland, no records are kept of the exact rate of wound complications. Studies in other countries have shown that wound infection rates vary from 3.5% to 15.9% (Twersky et al., 1997; Zoutman, Pearce, McKenzie, & Taylor, 1990). In a study comprising gastroenterologic, orthopedic, vascular, plastic, and urologic day surgery, Grogaard, Kimsas, and Raeder (2001) reported a wound infection rate of 3.5%. Direct comparison of these wound infection results is not, however, possible because of the culture, definitions, and methods of measurement (Bruce et al., 2001), and their nature, sample sizes, surgical procedures, and methods of data collection. In the current study, problems in wound healing included redness, swelling, ache, bleeding, discharge and odor of the pus, disruption of the incision wound, and wound infection, which is considered if antibiotics were prescribed for the infection of the incision wound.

Purpose of the Study and Research Questions

The purpose of this study was to describe short-stay surgery patients' perceptions at home after discharge, of pain, nausea, vomiting, fatigue, and problems in elimination and wound healing caused by surgical procedure. The authors had three specific interests: (a) the incidence; (b) intensity of the experiences of pain, nausea, vomiting, fatigue, and problems in elimination and wound healing in the recovery phase at home; and (c) the change in the incidence and intensity of these biophysiologic health problems during the first week of recovery.

Sample and Questionnaire

The study was conducted on six surgical wards of four district hospitals performing short-stay surgery in southern Finland. The country has a total of 26 district hospitals; the four selected for this study were chosen because they perform identical surgical operations with the same types of patient groups. The study protocol was approved by the institutional review board of each participating hospital. The convenience sample of 200 voluntary informants recruited for the first measurement (1-2 days postoperatively) included short-stay patients who had undergone an orthopedic, general surgical, or urologic procedure at the time of data collection, who were at least 16 years of age, who were Finnish-speaking, and who were independently able to complete the questionnaire. Gynecologic patients were excluded to avoid gender bias; ear, nose, and throat surgical patients were excluded because they were mainly under 16. The cover letter attached to the questionnaire informed the respondents of the purpose of the study and stressed that participation was voluntary.

Fifty questionnaires were distributed at each of the four hospitals (N=200). The sample for the second measurement (1 week after the operation) consisted of those patients (n=73) who in the first measurement indicated they were willing to take part in the second stage and who gave their contact address for the next questionnaire. The response rate in the first measurement was 54%, with 107 patients returning the questionnaire; the corresponding figure for the second measurement was 32% (64).

Instruments

No tools are available for measuring all the previously mentioned biophysiologic health problems. Most existing tools are not suited for measuring the intensity of biophysiologic health problems unidimensionally (Frank-Stromborg & Olsen, 1997) and subjectively from the patients' point of view. The authors therefore designed a new 27-item, structured questionnaire for purposes of collecting the required data. The main items concerning biophysiologic health problems were identical in questionnaires 1 (1 to 2 days postoperatively) and 2 (1 week after the operation). The development of questionnaires was based on the literature and earlier studies in medicine and nursing science. Pain and fatigue were measured with five items, upper gastrointestinal distress with four, and problems in elimination with three items on a 5-point Likert scale. Five items to address problems in wound healing were measured with a dichotomic scale (yes--no). The biophysiologic health problems measured in this study varied in terms of the extent; therefore, the operationalization and number of items measuring these problems varied as well. Before pilot-testing, the questionnaires were reviewed by lay people (2), nurses (2) working in a short-stay surgery ward, and an expert panel that included professors (2) and students (10) of nursing science. The questionnaires were pilot-tested with six patients on a surgical ward. Only a few minor adjustments were made on the basis of the feedback.

The demographic data showed that most respondents to questionnaire 1 were ages 30 to 60 and had completed upper secondary school or less. In this population, the majority of patients had been hospitalized for more than 1 day but no more than 3 days. Daysurgery patients accounted for 35% of all subjects. The recruited patients had been admitted for orthopedic surgery, general surgery, or urologic procedures. The majority underwent the operation under local anesthesia and had prior surgical experience (see Table 1).

Analysis

Statistical data analysis was conducted using Statistica software 5.1. Descriptions of pain, upper gastrointestinal distress, and fatigue, as well as problems in elimination and wound healing, were based on frequency and percentage distributions. In addition, sum variables were constructed on the basis of the responses to statements concerning pain, fatigue, and problems in elimination. If at least half of the respondents had answered the items, the sum variables were constructed by adding up the response scores. The nonrespondents were coded by using zero. In the case of upper gastrointestinal distress, only 44 of the 107 respondents answered the question concerning the amount of emesis in conformity with the instructions; therefore, it was not possible to construct a sum variable. Problems in wound healing were addressed by a number of different items and therefore could not be reduced into a sum variable. Cronbach's alpha values of 0.70 or higher were considered desirable in pain and fatigue items (Polit & Hungler, 1997). Items which considerably reduced the Cronbach's alpha were excluded from the sum variable, but not from the questionnaire. Lower Cronbach's alpha levels were accepted in the measurement of problems in elimination, which included two different items (urinating and constipation) (see Table 2).

In the items measuring pain, nausea and vomiting, and problems in elimination, the lowest scores were recorded for the no/not at all response options and the highest scores for the other extreme of to a great extent (1 = no/not at all, 2 = to some extent, 3 = don't know, 4 = to a great extent, 5 = to a very great extent). All fatigue items were translated into positive items for the sum variable, which made a high score indicative of a nonsignificant problem. The items measuring wound healing were dichotomic. Results reflecting no problems got a value of zero, and those reflecting problems got a value of one.

Five different tests were used in the statistical analyses. The Mann-Whitney U-test was used in analyzing the association of background variables (gender, basic education, day surgery, and short-stay surgery patients) with sum variables. Kruskall-Wallis ANOVA and the Median test respectively were used in analyzing the association of vocational education background variables (no vocational education, school-level vocational education, postsecondary vocational education, academic degree) with sum variables. Spearman rank correlation test and Analysis of Variance were used for analyzing the association with age. The associations of background variables with other individual items remaining outside the sum variables were examined by cross-tabulation. The statistical significance of differences between groups was measured by Pearson's Chi Square Test. P-values of 0.05 or less were interpreted as statistically significant. Differences in the incidence and intensity of biophysiologic health problems between the two measurements were determined on the basis of sum variables by using the Wilcoxon Signed-Rank Test.

Results

Pain. Pain was the most common health problem among the short-stay surgery patients in this study. One or 2 days after discharge (questionnaire 1), more than half of the respondents reported some pain with movement (57%) and also at rest (52%). Almost one-fifth had pain while moving (19%) and sitting (19%). Most of the respondents used analgesics (63%) and noted that they reduced pain. However, 13% were of the opinion that analgesics had little effect (see Table 3).

Comparison of the sum variables for patients who took part in both measurements indicated a clear decrease in the intensity of experiences of pain during the first week after discharge (Wilcoxon Signed-Rank Test, p=0.000). Nonetheless, 63% of the respondents still had at least some pain while moving, and about 40% while sitting and resting. No one reported severe pain at this stage. The use of analgesia was reduced by more than one-third. Five respondents stated that analgesics gave them no relief at all. In these two measurements, no statistical significant differences existed (Kruskal-Wallis ANOVA) among the general surgical, orthopedic, and urologic patients groups, which may be due to the small sample sizes.

Upper gastrointestinal distress (nausea and vomiting). The clear majority of respondents (82%) had not vomited during their first days at home, and vomiting had not prevented them from doing daily activities. Less than one in five (17%) reported some nausea, and five stated nausea had to some extent prevented them from doing daily activities. One week after discharge (questionnaire 2), one respondent reported having vomited and four (6.5%) still had nausea. Type of anesthesia correlated with upper gastrointestinal distress; 1 to 2 days after surgery, those who had undergone general anesthesia suffered from nausea more often than those who required local or regional anesthesia (Kruskal-Wallis test, p=0.003). Upper gastrointestinal distress was not a major problem for the short-stay patients in this study.

Fatigue. Almost all informants reported experiences of fatigue, but very few said that it had been severe. One to 2 days postoperatively, most respondents (77%) had to rest during the daytime, but the majority could still cope with their daily activities (97%). Experiences of fatigue decreased considerably between the two points of measurement (p=0.000). However, the proportion actually increased of those who were too tired to cope with daily activities and who felt that resting did not help to reduce fatigue. Over half of the respondents (53%) felt very or extremely energetic, and 56% reported that they could cope with their daily activities to a great extent. Four respondents (6.5%) could not cope with their daily activities at all, while 54% still had to rest during the daytime. For five respondents (9.6%), resting did not help to reduce the feeling of fatigue.

Problems in elimination. Constipation was the main concern (27%), and it decreased between the two points of measurement (14%). At the first point of measurement, some respondents had difficulties in getting urine to flow (11%) or in controlling the flow of urine (9%) (see Table 3). At the second point of measurement, the percents were the same.

Problems in wound healing. More than half of the respondents (54%) experienced aching in the incision wound, and 7% also reported bleeding. Four percent received an antibiotic prescription for the surgical wound infection. The problems of redness, swelling, and bleeding did not change to any significant extent during 1 week at home. The incision wound caused less aching, hut the incidence of aching was still 33% (see Table 4).

Reliability and Validity

The reliability of the instrument was tested for internal consistency by Cronbach's alpha. The alpha value for the sum variable measuring pain was 0.82 in questionnaire 1 and 0.86 in questionnaire 2; the corresponding figures for the sum variable measuring fatigue were 0.77 and 0.71, and measuring problems in elimination 0.56 and 0.51 (see Table 2). A coefficient of reliability in excess of 0.70 is considered desirable in a new instrument that has not been used before (Nunnally & Bernstein, 1994), especially when the researcher is interested in making group-level comparisons, as is the case in this study (Polit & Hungler, 1997).

The upper gastrointestinal distress item caused some problems due to missing responses to the question concerning the number of times the respondents had vomited ("I have vomited about ... times"). The informants were expected to indicate the appropriate number from 0 upward. However, three different methods were used in responding to this question. Another point that should be made clearer in the instructions is the time span that the measurement covers.

The validity of the instrument was assessed in terms of content validity and construct validity. Content validity was supported by the literature review (LoBiondo-Wood & Haber, 1994). Furthermore, content of the new instrument was assessed by a group of nurses (10) and patients (2) as well as by a specialist in statistical methods (1). The feedback received was used in further developing the instrument. Construct validity was also supported by Cronbach's alpha.

Limitations

The credibility of the research procedure can be assessed in terms of internal and external validity and in terms of statistical conclusion validity. The primary concern has to be with internal validity, because that will also determine external validity. One threat to internal validity is represented by selection bias (Polit & Hungler, 1997). In this study, the selection of respondents could have been influenced by the fact that the questionnaires were handed out on the wards by nurses. Their efforts to motivate all the patients similarly were guided and supervised personally by the researcher with verbal and written instructions. However, the researcher was not able to control how nurses actually distributed questionnaires and how they motivated patients to take part to the study.

The study was carried out in two phases, which itself may give rise to response fatigue (Burns & Grove, 2001). One indication of this is that, contrary to the instructions, some informants mentioned experiences of nausea outside the period of measurement; however, they always clearly indicated when this was the case. It is possible that response fatigue may have undermined the reliability of the results and reduced the response rate to some extent, which would affect external validity as well (Burns & Grove, 2001). Any generalizations beyond the study's population have to be made with extreme caution because the nonresponse rate 1 to 2 days postoperatively was relatively high at 46%. Reminders could not be used in this study because the names and addresses of the respondents were destroyed immediately after the questionnaires had been mailed. Analysis of nonresponse by demographic background variables revealed no systematic patterns.

The study has some limitations that need to be noted. The number of patients was relatively small, and the lack of significant differences between the patient groups (or other variables) may be due to low statistical power. The study has demonstrated to what extent short-stay patients who have had a surgical procedure in a district hospital in Finland suffer from pain, nausea and vomiting, fatigue, and problems in elimination and wound healing 1 to 2 days and about a week after the operation. These results do not indicate how patients manage these problems and what the problems mean to them. Because the patients' health conditions were not measured prior to the ambulatory surgical procedure, it is possible that some of these patients suffered from chronic pain, fatigue, or constipation. However, the instructions in the questionnaire did make it clear that the statements concerned biophysiologic health problems specifically caused by the surgical procedure.

Discussion

This study was concerned with the biophysiologic health problems experienced by short-stay surgery patients. In line with earlier findings (Beauregard et al., 1998; Waterman et al., 1999; Young & O'Connell, 2001), the most common reported problem in this study was pain. It is notable that 1 to 2 days after surgery, 36 out of 104 patients were not using analgesia; 1 week after surgery, the figures were 44 out of 64, respectively. Experiences of pain decreased during the first week, but some patients complained that their analgesic provided no real relief; Cason et al. (1996) made the same observation in their study. It seems that at least some of the patients who reported pain were not making proper use of the pain management methods available, but it was not possible within the confines of this study to look into this question in closer detail.

It is possible that patients are unaware of the adverse affects of inadequate pain control upon recovery after surgery. They should be taught that the physiologic stress response triggered by surgery and unrelieved pain can adversely affect circulation and suppress immune functions, while the use of analgesics even in advance can help to inhibit the stress response and so contribute to the healing process (Pasero et al., 1999; Pavlin, Chen, Penaloza, Polissar, & Buckley, 2002). Patient counseling should consider all these issues and additionally give patients the opportunity to ask questions (Beauregard et al., 1998; McHugh & Thoms, 2002). Patients also should be informed about the purpose and different types of analgesics, as well as the additional use of nonpharmacologic treatments such as cold packs and relaxation techniques (for example, music, massage) according to patients' preferences. These interventions may have benefits such as making pain more bearable, reducing distress and muscle tension, and providing a sense of control (McCaffery & Pasero 1999).

Upper gastrointestinal distress was not a major problem for short-stay patients in this study. The severity and duration of upper gastrointestinal distress depends, among other things, on the type of anesthesia employed (Apfelbaum et al., 2002) and on the surgical procedure. The absence of severe nausea in this study is explained in part by the fact that most patients (approximately 80%) received regional anesthesia. Those who had their operation under general anesthesia suffered from nausea more often 1 to 2 days after the operation. Because regional anesthesia is generally favored for short-stay surgical procedures in Finland, this study's results on the incidence and intensity of upper gastrointestinal distress may reflect the national situation.

Although rarely severe, fatigue was a common health problem shared by almost all short-stay patients. Almost all patients were able to manage their daily activities, but they needed to rest. Most patients said they were feeling less fatigued by the 7th postoperative day, although some patients still had to rest during the daytime even when they felt energetic. Cason et al. (1996) and Kleinbeck and Hoffart (1994) reported similar results. Patients should know that they will need time to rest for at least 1 week after the operation. This may mean they will need to make special arrangements for housework and child care during recovery. Young and O'Connell (2001) made the same observation.

Almost one in three patients had constipation during the first days at home; this problem was more persistent than the other biophysiologic health problems. Pain can restrict patients' mobility and cause decreased bowel elimination. On the other hand, constipation may be due to the use of opioid analgesics, which decrease the motility of the bowel (Pasero et al., 1999). For proper prevention and management of constipation, patients need to be informed before surgery about the possible side effect of the use of opioids. This will allow them to plan their diet and the use of laxatives and stool softeners. Patients also need to be aware of the importance of physical activity after the operation.

This study found no threats to the healing process of the incision wound. However, every other patient (53 of 99) suffered from incision ache during the first days after the operation; by the 7th day, one-third still complained of aching. This result clearly underscores the need for improved pain management. Four patients out of 99 (4%) received an antibiotic prescription for surgical wound infection soon after the operation. This result reflects the findings of Zoutman et al. (1990), who reported an infection rate of 5.05%. This study was unable to produce final figures on surgical wound infection, which may take up to 30 days from the operation to develop (Fanning, Johnston, MacDonald, LeFort-Jost, & Docerty, 1995). Because many monitoring programs exclude patients undergoing day surgery, there is no evidence on the infection rate universally (Bruce et al., 2001).

How can nurses put these results to good use with the ambulatory surgery population? The findings clearly underline the importance of increasing efforts in patient counseling concerning the prevention and management of pain, fatigue, constipation, and incision wound aching. The timing of counseling is particularly crucial so that patients are aware of potential problems in advance and can make arrangements for the recovery phase at home. Before discharge, they need concrete advice on how to prevent and manage potential biophysiologic health problems in their everyday lives. Nurses may not have the tools they need to make sure that patients really understand and accept the instructions they are given; indeed, there is an urgent need to develop methods for assessing the effectiveness of counseling and for monitoring short-stay surgery patients' recovery at home.

Further research with larger sample sizes should look separately at the distinctive biophysiologic health problems of patients undergoing certain types of short-stay surgical procedures with certain anesthesia techniques. The results should provide important clues about targeting counseling efforts and developing their content and methods. By extending the time span to 1 month after the operation, studies could gain useful information about how long patients' biophysiologic health problems continue and how long the recovery phase lasts at home. Current literature does not identify the meaning of these biophysiologic health problems to short-stay patients or how they cope with them. Qualitative research is needed to fill in this gap.

Ethical Considerations

A basic requirement in any scientific research is that participation is genuinely voluntary. During the first measurement for this study, the patients were recovering at home and therefore were unlikely to feel any dependence on the hospital and its staff; this may have contributed to creating a genuine sense of voluntary participation. By contrast in the second stage, the respondents who volunteered to take part had to give their names and addresses to the researcher, which may create some sense of commitment (Thompson, Melia, & Boyd, 1994). The requirements of privacy and dignity are obviously easy to meet when the respondents can fill in the questionnaires at home (Burns & Grove, 2001).

A potential source of emotional discomfort is that the questionnaire required the participants to concentrate on unpleasant responses and to disclose personal feelings to the researcher. The decision by the respondents to return the questionnaire was regarded as a sign of their informed consent (Burns & Grove, 2001).

Conclusion

Given the rapid growth and expansion of short-stay surgery, especially day surgery, the nursing knowledge and practical care of these patients may need to be refocused. More research is needed into the knowledge of nurses taking care of day-surgery patients in hospitals as well as in home care settings.

Table 1. 
Demographic Data 1 to 2 Days (Q1)
and 1 week (Q2) after surgery

Demographic Variable Q1 Q2

n % n %
Gender
Male 53 50 32 50
Female 53 50 32 50

Basic education
Middle school/comprehensive school or less 85 82 49 78
Senior secondary school 19 18 14 22

Vocational education
No vocational education 35 35 19 32
School-level vocational education 39 39 20 34
Post-secondary vocational education 23 24 18 31
Academic degree 2 2 2 3

Duration of hospitalization
Over 1, but not more than 3 days 68 65 43 67
24 hours or less, no overnight (day surgery) 36 35 21 33

Surgical specialization
Orthopedic 51 52 32 52
General surgery 45 45 29 47
Urology 3 3 1 1

First procedure for patient
Yes 17 16 10 16
No 88 84 54 84

Type of anesthesia
Local or regional 87 83 50 78
General 18 17 14 22

Table 2.
Sum Variables and Statistical Measures of Biophysiologic
Health Problems 1 to 2 Days (Q1) and 1 Week (Q2) After
Surgery

Biophysiologic Items Included
Health in Sum SD M
Problem Variables Q1 Q2 Q1 Q2

Pain I feel pain 3.5 2.8 8.3 6.4
while moving.
I feel pain
while sitting.
I feel pain
while resting.
I use pain medication
to relieve
pain caused by
the operation.

Fatigue I feel energetic.
I feel I have 3.4 3.0 13.8 15.5
no energy left. *
I can cope with my
everyday chores.
I have to rest during
the daytime (because
I get so tired).
Problems in I have difficulties 1.3 1.2 3.7 3.5
elimination getting urine
to flow.
I have difficulties
controlling the
flow of urine.
I have constipation.

Biophysiologic Items Included
Health in Sum Alpha
Problem Variables Q1 Q2

Pain I feel pain 0.82 0.86
while moving.
I feel pain
while sitting.
I feel pain
while resting.
I use pain medication
to relieve
pain caused by
the operation.

Fatigue I feel energetic.
I feel I have 0.77 0.71
no energy left. *
I can cope with my
everyday chores.
I have to rest during
the daytime (because
I get so tired).
Problems in I have difficulties 0.56 0.51
elimination getting urine
to flow.
I have difficulties
controlling the
flow of urine.
I have constipation.

* The Likert-scale reversed (5-1) before statistical analysis
(SD = standard deviation, M = mean, Alpha = Cronbach's alpha)

Table 3.
Responses to Items Concerning Pain, Fatigue, Problems in Elimination
and Upper Gastrointestinal Distress 1 to 2 Days after the Operation
(Q1) (Numbers Rounded to the Nearest Whole Number)

No/Not To Some Don't
Items at All Extent Know

Pain

I feel pain while moving.
n=103 Freq 18 59 2
100% % 18 57 2

I feel pain while sitting.
n=102 Freq 42 39 2
100% % 41 38 2

I feel pain while resting.
n=102 Freq 36 53 0
100% % 35 52 0

I use pain medication to relieve
pain caused by the operation.
n=104 Freq 36 48 3
100% % 35 46 3

Pain medication alleviates pain. Freq 1 11 12
n=84 % 1 13 15
100%

Upper Gastrointestinal Distress

Vomiting prevents me from doing my
daily activities. 89 0 0
n=89 Freq 100 0 0
100% %

I feel nauseous (sick).
n=102 Freq 85 17 0
100% % 83 17 0

Nausea prevents me from doing my
daily activities.
n=99 Freq 94 5 0
100% % 95 5 0

Fatigue

I feel energetic.
n=101 Freq 22 42 9
100% % 22 41 9

I feel I have no energy left.
n=100 Freq 59 28 7
100% % 59 28 7

I can cope with my daily activities.
n=101 Freq 3 39 4
100% % 3 38 4

I have to rest during the daytime
(because I get so tired). *
n=98 Freq 22 52 6
100% % 23 53 6

Resting alleviates fatigue.
n=91 Freq 2 26 15
100% % 2 29 16

* Likert-scale reversed (5-1) before statistical analysis

Problem in Elimination

I have difficulties getting urine to flow.
n=104 Freq 93 10 0
100% % 89 10 0

I have difficulties controlling the flow
of urine.
n=104 Freq 95 6 1
100% % 91 6 1

I have constipation.
n=103 Freq 75 20 3
100% % 73 19 3

To a Very
Great Great
Items Extent Extent

Pain

I feel pain while moving.
n=103 Freq 20 4
100% % 19 4

I feel pain while sitting.
n=102 Freq 19 0
100% % 19 0

I feel pain while resting.
n=102 Freq 10 3
100% % 10 3

I use pain medication to relieve
pain caused by the operation.
n=104 Freq 14 3
100% % 13 3

Pain medication alleviates pain. Freq 44 16
n=84 % 52 19
100%

Upper Gastrointestinal Distress

Vomiting prevents me from doing my
daily activities. 0 0
n=89 Freq 0 0
100% %

I feel nauseous (sick).
n=102 Freq 0 0
100% % 0 0

Nausea prevents me from doing my
daily activities.
n=99 Freq 0 0
100% % 0 0

Fatigue

I feel energetic.
n=101 Freq 20 8
100% % 20 8

I feel I have no energy left.
n=100 Freq 4 2
100% % 4 2

I can cope with my daily activities.
n=101 Freq 44 11
100% % 44 11

I have to rest during the daytime
(because I get so tired). *
n=98 Freq 16 2
100% % 16 2

Resting alleviates fatigue.
n=91 Freq 32 16
100% % 35 18

* Likert-scale reversed (5-1) before statistical analysis

Problem in Elimination

I have difficulties getting urine to flow.
n=104 Freq 1 0
100% % 1 0

I have difficulties controlling the flow
of urine.
n=104 Freq 2 0
100% % 2 0

I have constipation.
n=103 Freq 4 1
100% % 4 1

Table 4.
Frequencies and Percentages of Responses to Items Concerning
Problems in Wound Healing 1 Week after the Operation (Q2)
(Numbers Rounded to the Nearest Whole Number)

Items Yes No

Is there any redness in the incisional
wound (operation area)?
n=63 Freq 10 53
100% % 16 84

Is there any swelling in the incisional
wound (operation area)?
n=63 Freq 22 42
100% % 33 67

Is there any ache in the incisional
wound (operation area)?
n=63 Freq 21 42
100% % 33 67

Is there any bleeding in the incisional
wound (operation area)?
n=63 Freq 2 61
100% % 3 97

Is there any discharge of pus in the
incisional wound (operation area)?
n=63 Freq 1 62
100% % 2 98

Does the pus have an odor?
n=60 Freq 1 59
100% % 2 98

Did the doctor prescribe antibiotics for
you for the infection of the incisional
wound (operation area)?
n=63 Freq 3 60
100% % 5 95

Has the incisional wound (operation
area) disrupted?
n=63 Freq 2 61
100% % 3 97

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Helena Susilahti, MNSe, RN, PhD(c), is a Clinical Nurse Specialist, District Hospital of Rauma, Rauma, Finland.

Tarja Suominen, PhD, RN, is a Professor, University of Turku, Department of Nursing, Finland.

Helena Leino-Kilpi, PhD, RN, is a Professor, University of Turku, Department of Nursing, Finland.

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