Day surgery in Australia Qualitative research report

Milica Markovic, Mridula Bandyopadhyay, Lenore Manderson,

Pascale Allotey, Sally Murray and Trang VuKey Centre for Women’s Health in Society, The University of Melbourne

AbstractThe article explores the experiences of patients undergoing day surgery in anAustralian public hospital for women. We draw primarily on interviews withthese patients to identify the factors arising from the specific context whichcompromised their well-being.

Keywords: anxiety, discharge, health care, hospitals, patients, support

Day surgery patients are admitted and discharged on the same day for aplanned non-resident investigation or operation (CDHAC, 1999; Otte,1996). This type of surgery has become increasingly prevalent worldwide(Sanares-Ousley et al., 1999), and by the mid-1990s, between 50 percentand 60 percent of all elective procedures in Canada, the UK and the USwere day surgeries (CDHAC, 1999; Millar, 1997; Mitchell, 2000). InAustralia, day surgery as a percentage of all surgical procedures hasincreased from 7 percent in the 1980s to about 41 percent in 1997–8(AHOL, 2001; CDHAC, 1999). In the late 1990s, 39 percent and 44 per-cent of all surgeries were performed as day surgery in public and privatehospitals respectively (CDHAC, 1999: 4–5). By 2001, 55 percent of allsurgeries were performed as day procedures (AHOL, 2001). The latter isclose to the Australian Federal Government target of 60 percent (CDHAC,1999: 8). In Victoria, the study site, 38.71 percent of surgeries were per-formed as day surgery in 1997/8 (CDHAC, 1999: 35). There are multiplereasons for the increase in day surgery, including improved anaesthetics(Moran and Kent, 1995; Stephenson, 1990), technological advances(Mitchell, 2000; Moran and Kent, 1995; Otte, 1996), the need to reducepatients’ waiting lists (Edwards, 1996; Friend, 1999; Sierra et al., 1995),

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government funding policies (Callanan, 2002; DHS, 2001), and cost-effectiveness (AHOL, 2001; Roberts, 1996).

While increasing numbers of patients are now undergoing surgery as out-patients, we have a limited understanding of their expectations and experi-ences, particularly in Australia. Most research on day surgery has beenquantitative, including regular data collection at discharge which surveyspatient satisfaction with hospitalization. Although day surgery is neither‘care-free’ for the patients or their families following discharge, nor pain-free (Beauregard et al., 1998; Jenkins et al., 2001; Joshi et al., 2000), quan-titative research suggests it is generally well accepted by the patients(O’Connor et al., 1991). They favour it as less disruptive and less time-consuming. The employed, who increasingly require after-hours and week-end surgery, and mothers of small children and other carers find it veryconvenient (Kerin, 2001; Read, 1990; Stephenson, 1990). Quantitativeresearch also proposed patient information provision (de Jesus et al., 1996;Mitchell, 1997) and anxiety management guidelines (Wicklin and Forster,1994) to meet the health care needs of day surgery patients.

Qualitative research has revealed that patients’ experience of day surgerymay be improved through adequate information provision, effective com-munication, educational support and continuity of care. These measuresensure that anxiety and fear prior to surgery are reduced, and the prepara-tion for self-care post-surgery and patients’ overall satisfaction with daysurgery are improved (Donoghue et al., 1995, 1997; Otte, 1996; Stevens etal., 2001; Vogelsang, 1990; Wiens, 1998). Our study aimed at addressingthe paucity of research on day surgery in Australia (Donoghue et al., 1995,1997), particularly in terms of patients’ experience of hospitalization.

Aims and objectivesOur interest in a qualitative component to our study was determined byseveral factors. First, qualitative research explores the given social phe-nomena in context, and can give an answer to the question of why thatphenomenon differs under different circumstances (see Pope and Mays,2000). We therefore aimed at analysing how day surgery patients’ hospitali-zation experience is different from the experience of residential surgerypatients, notwithstanding that there will be some commonalities. Second,the qualitative approach provided us with information of patients’ ownperspectives, allowing us to explore the meanings, ideas, concepts and inter-pretations of the interactions and processes experienced by the study par-ticipants. Third, the complexities of day surgery-related anxiety arerevealed by this approach (see Mitchell, 1997; Wiens, 1998). The appro-priateness of studying surgery-associated anxiety via a qualitative approachbecame apparent during the pilot study when the majority of participants

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did not want to complete a short pre-operative questionnaire on theirexpectations of the surgery.

In this report, we focus on exploring the attributions patients madeabout the processes to which they were exposed, as this provides an under-standing of the day surgery phenomenon from the patients’ pers-pective. Specifically, we aim to: (1) explore anxiety in the context of daysurgery, and (2) identify the issues pertinent to the experiences of day surgery patients.

Study designStudy participants were recruited from day surgery patients in anAustralian public hospital for women. The study applied a combination ofquantitative and qualitative methodologies: a telephone survey conducted48 hours following discharge (315 participants), observations and in-depthinterviews. The results of the survey have been reported elsewhere(Markovic et al., 2002), and in this article we focus on the empirical findings arising from observations and in-depth interviews

Observations were made in the public waiting areas available to familymembers and day surgery patients, and of patients only, prior to surgery.On average, we spent two hours per day in direct contact with patients andstaff. Due to hospital infection control regulations, we did not have accessto the operating theatres and recovery rooms during the data collectionphase.

Patients who consented to in-depth interviews during the phone survey(about 50 percent) were subsequently contacted, and all those weapproached agreed to being interviewed. Ten in-depth interviews were con-ducted between December 2000 and June 2001. We applied purposive sam-pling to include patients from different socio-economic backgrounds whohad undergone a range of different surgical procedures. Most of the womeninterviewed were born in Australia, lived with family members, had sec-ondary schooling and were employed. Interviews were conducted byresearchers at places of interviewees’ choice, and on average lasted forabout 50 minutes. Study participants were invited to give their account ofbeing a day surgery patient, and the interviewer respected the disclosure of the events with minimal disruption.

Thematic analysis was performed to identify common patterns inpatients’ reports and all available data were triangulated, that is, the findings arising from different data sets were corroborated. As is commonin the presentation of qualitative research, excerpts from interview tran-scripts are used to describe and illustrate patients’ hospitalization experi-ence; while these are individual accounts, issues raised are indicative of allinterview transcripts, observation notes and responses to open-ended ques-tions. Confidentiality is maintained by the use of pseudonyms.

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As this was a small-scale exploratory study, the reported experience maynot be regarded as representative of the total day surgery patient popula-tion. However, this research provides personal and contextualized accountsand important insights into day surgery hospitalization experience in thecontext of the significant shift in provision of surgical services (see alsoO’Connor et al., 1991).

ResultsAnxiety and day surgery

Day surgery-related anxiety, commonly observed in other research (Codd,1991; James, 2000; Mitchell, 1997; Smith and Pittaway, 2002; Stevens etal., 2001; Vogelsang, 1990; Wicklin and Forster, 1994; Wiens, 1998) wasidentified in thematic analysis. In addition to coding the word ‘anxiety’, theoperational definition included the terms such as fear, uneasiness, restless-ness, nervousness, distress, discomfort and apprehension. In some respects,such as with regard to fear of death, anaesthetics, complications and hos-pitals in general, residential surgery patients and day surgery patients donot differ. Fears may have some grounding; for example, in Victoria,between 1993 and 1996, about 12 percent of deaths were wholly or partlyrelated to anaesthesia, and in 72 percent of the cases, death occurred in amajor metropolitan or regional hospital (these hospitals attract patientswith the highest risk factors) (Mackay, 1999: 11, 15). However, specificcontextual factors also contributed to patient distress. Patients reflected onthe expectation that patients walk to the theatre – a practice intended tonormalize the experience for patients:

... it was just weird, just sort of go [walk] down this long corridor... you see likeother operating theatres ... that sort of stuff.... I was like, trying to hold mybreath, and trying to calm myself down.... I just frankly lost it in my head.(Holly)

That’s [walking to the theatre] really scary, because like you go into the operat-ing theatre, and there’s lights and tools, and I mean of course it’s scary and myheart was pounding a hundred miles an hour. (Patricia)

I didn’t mind walking [into the theatre], perhaps if I was younger, you know thewhole thing would have been a lot more stressful.... I suppose walking into the actual room where, you know, where the surgery took place. It’s a bit strangehopping on the bed – actually being on a bed would have been a bit better.(Lydia)

In theory, walking allows the patient to be in control as much as possible,emphasizing her ‘wellness’. However, there are clear economic benefits fromreducing the need for trolleys and clean sheets. Some study participantsexpected to be wheeled in, which would have been the case if they were resi-dential surgery patients. Patient anxiety may have been heightened by the

Markovic et al.: Day surgery in Australia 77

incongruities of having changed into a theatre gown and being stripped oftheir belongings and being physically reminded of their patient role, butexpected to be independent. This incongruity may have impacted on theexpectation of some to be treated as patients, that is requiring assistance(Coser, 1962; Hyndman, 1986). In addition, walking gave patients aheightened awareness of the surgical environment; they could not detachby closing their eyes on the trolley or wheelchair, for example, therebyblocking out the medical setting.

A second factor that contributed to anxiety was that patients who pre-sented to the hospital with a partner or friend as their anxiety managementstrategy (see Wiens, 1998) were separated from their support person imme-diately prior to and after surgery. This contrasts with the experience of resi-dential patients. Sarah reflected on the effect of her lack of access tosignificant others:

Once I’d been admitted ... and all that sort of stuff, I think I was still feeling quiteteary at that point because Paul wasn’t with me.... I was just feeling really appre-hensive ... a bit upset ... there was nothing anyone could do about that, exceptme.... The thing I found hard was that once I did get up [in recovery], and I wentand sat in the lounge ... my partner couldn’t sit with me.

Post-surgery experience

Several contextual issues specific to day surgery were identified by respon-dents in the post-operative stage. These included lack of knowledge of andcontact with the surgeon who performed the operation and limited or noinformation about the results of surgery. Stephanie, for example, notes:

[Despite significant complications in recovery – patient on oxygen] I didn’t speakto a doctor once, I spoke to a nurse.... I was trying to get the lady to explain tome where the endometriosis was, was it going to come back, was it in an areathat I should be concerned about fertility-wise, and she was so vague, so vague,in the end I gave up.... I wouldn’t be able to recognize him [the surgeon] again,I wouldn’t have a clue who he was, I never saw him again afterwards ... it wasjust whoever was on duty. It’s pretty slack really.... I was disappointed that I didn’t get to see a doctor on the day, and that basically it took me three monthsto find out exactly what was wrong and where it was and what was done, andwhat my choices were from here on.

As the excerpts suggest, the lack of face-to-face contact with their surgeonwas not what patients expected, nor what they would have experienced hadthey been residential surgery patients. This was a particular issue forpatients undergoing investigative procedures who sometimes experiencedsignificant time gap between discharge and a follow-up appointment whenthey learned of the results. In contrast, residential surgery patients are toldtheir results as soon as they become available, that is while they are in-patients and usually by their treating surgeons.

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Patient management

In terms of patient management, thematic analysis identified the frequencyof comments such as ‘in and out’, ‘you feel like a number’, or ‘productionline’:

Especially sitting in that room with all those girls that kind of really felt like aproduction line and you know you put your clothes in this plastic box and it wasa bit like that. (Lisa)

It’s sort of, you go into the waiting room, and then you go to the admittanceclerk, and you go to the next room, and the nurse tells you to go in this cubicleand get into these things [hospital gowns], and then you sit in the waiting room,and then you walk down to the thing [theatre]. Yes it is a bit of a production line.(Belinda)

My biggest comment was that I really did feel a bit like a number, and that I wasbeing pushed through.... I was just being shuffled through basically.... I haven’thad the same nurse throughout the day ... certainly didn’t benefit me in any way,probably was a disadvantage.... I think that’s what I really liked about the re-covery section is because that’s where I ended up spending most of the day, andthe fact that I had two nurses in particular ... they were really good with me, letme stay in bed because I wanted to. (Sarah)

I felt like I was more a piece of paper work than an actual human person ...(Priscilla)

Here too, the concerns raised by the women arise predominantly from thespecific context of day surgery. Busy schedules imposed by the fundingarrangements and aim for profit, and associated brief patient–staff encoun-ters provide staff with little opportunity to give priority to individual needs.The trajectory of a day surgery patient and theatre lists are calculated onthe average time required for administrative admission, pre-operativeassessment, operation and post-surgery recovery, and any deviation jeopar-dizes the fulfilment of the plan. Consequently staff seek to minimize dis-ruption to the system and to conduct their work efficiently and effectively,as defined by organizational rules (see Weber, 1983) and the imperatives ofthe day’s surgery schedule. Due to case-mix funding, inpatient surgicalpatients are exposed to similar pressures, but their management is never-theless different as they meet their surgeons prior to and post-surgery, havetheir own rooms (even if shared), keep their possessions with them, and donot move swiftly through the system, all of which contributes to establish-ing patienthood rather than ‘numberhood’.

Patients expressed a preference to be cared for by a dedicated health pro-fessional throughout their day surgery admission. This request is not spe-cific to day surgery patients (see Curtin, 1997; Krogstad et al., 2002; vander Waal et al., 1996). Patients undergoing surgery exposed to continuity ofcare have better health outcomes post-operatively: they have lower painand a significantly better mental well-being (Boman et al., 1999). Study

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participants’ preference for continuity of care is not an isolated variable,but rather is interlinked with the other attributions day surgery patientsmake about their trajectory.

Waiting time

Long waiting time was discussed by women and contributed to patient dis-tress. There was little opportunity not to be affected by other patients in thewaiting area:

There was another older woman there who said she’d been waiting for ages andshe was carrying on and sort of making everybody else feel a bit stressed. So Ithought that that was, that was probably the worst part of it. (Lydia)

While minimizing waiting time may be a general patient concern, daysurgery patients who are admitted and discharged on the same day possiblyhave higher expectations of an efficient system. Further, day surgerypatients must be accompanied by someone at discharge (see Stephenson,1990). A patient may be restricted in finding an available carer who mayhave his/her own commitments, rendering the waiting additionally prob-lematic as Lydia explains:

... that was sort of another thing that was annoying about waiting, because Iknew that he [a friend who drove me home] had children waiting for him atcrèche and he was waiting for me.

DiscussionThe experiences of day surgery patients in Australia are similar to thosereported internationally (Fox, 1999; James, 2000; Wiens, 1998). Despitesome advantages, day surgery remains a challenging experience for somepatients. Patients’ individual needs for support from health professionalsand significant others as well as their need for access to information are notadequately met. Hospital regulations are created in response to the fundingprovided by the government and day surgery staff aim to ensure that thetime between admission and discharge for each patient is minimal. Withinthat framework, patient health care may not be individualized. Consistentwith the reports of our study participants, day surgery nurses in the UK alsofelt that they had to keep moving the patients as if they were on a produc-tion line (Fox, 1999).

Study participants’ assessments appear to be somewhat contradictory, asthey expected hospital staff to be efficient and not ‘waste’ time so thatwaiting is reduced, but at the same time felt pressure in moving from onestage to another. Under the current funding arrangements, this contradic-tion is possibly unavoidable. However, if patients experience continuity ofcare throughout their hospitalization, including access to their surgeon atleast at a follow-up appointment, they may be more likely to accept waiting

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and possibly negotiate the trajectory pace which suits them (see Sarah’squote above).

Walking to the operating theatre and lack of access to significant othersprior to and post-surgery were pertinent to the experiences of studied daysurgery patients. This hospital policy was identified as having an adverseeffect on patients’ well-being; patients would like to have been exposed tothe same protocol as residential surgery patients: other day surgery settingsapply the residential surgery patients protocol.

It takes some time to conduct the laboratory analysis to diagnose thehealth problem and the results may not be available on the day of surgery.This information should be conveyed to patients at the pre-admission stage.Further, hospitals should ensure that these patients have access to summaryinformation (i.e. what was done during the operation) while they are in therecovery room (see Perry, 1994). An information sheet could be completedby the responsible surgeon and provided to the patient by the nurse, prefer-ably one with whom the patient had established rapport if continuity ofcare is maintained. In addition, patients’ access to information about theirsurgery may be hastened through General Practitioners; this alternative wasnot used in the studied hospital.

As this study was conducted with patients of a women’s hospital, furtherquantitative and qualitative research is needed to delineate gender differ-ences as well as surgery-specific experiences. In addition, a comparativeanalysis of the experiences of patients in public hospitals, private hospitalsand day surgery free-standing facilities is required as contextual issuesdetermine the patients’ trajectory. Collaborative research with hospitals toensure the implementation of recommendations arising from the researchfindings is an important next step (see Draper and Hill, 1995).

AcknowledgementsThe study was approved by the relevant hospital and university committees. Weacknowledge the contribution of hospital staff to the design and execution of thestudy, and that of the research assistants. We thank the participants for their con-tribution. The funding body, the Victorian Health Promotion Foundation, is grate-fully acknowledged. We would also like to thank anonymous referees and MariaZadoroznyj for their insightful comments.

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Biographical notesMilica Markovic, PhD, is a Research Fellow at the Key Centre for Women’sHealth in Society at The University of Melbourne. Her main areas of inter-est are women’s health, provision of health care in a multicultural contextand hospital-based care. Address: Key Centre for Women’s Health inSociety, Department of Public Health, School of Population Health, The University of Melbourne, Victoria 3010, Australia. [email:milicam@unimelb.edu.au]

Mridula Bandyopadhyay, PhD, is a Lecturer at the Key Centre for Women’sHealth in Society at The University of Melbourne. She has extensive expe-rience working in maternal and child health projects in rural India, partic-ularly in reproductive health, family planning and determinants of health.

Lenore Manderson, PhD, is a senior medical anthropologist and social his-torian. She is Professor at the Key Centre for Women’s Health in Society,The University of Melbourne. As an inaugural Federation Fellow of theAustralian Research Council, she is conducting a five-year research pro-gramme on chronic illness, disability, social relationships and well-being.

Pascale Allotey, PhD, from the Key Centre for Women’s Health in Society,The University of Melbourne, is a Senior Research Fellow. She has beenawarded the VicHealth Public Health Fellowship to support her researchinto identifying the best policies to assist the settlement of refugees andasylum seekers in Australia

Sally Murray is a Program Coordinator of the Victorian Immigrant HealthProgram at the Department of Paediatrics of The University of Melbourne.At the time of the study, she was with the Key Centre for Women’s Healthin Society through the Victorian Public Health Training Scheme.

In addition to being a medical scientist, Trang Vu has qualifications in gen-der and reproductive health, counselling, and interpreting and translating.At the time of the study, Trang was a Public Health Fellow of the VictorianPublic Health Training Scheme at the Key Centre for Women’s Health inSociety, The University of Melbourne.

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