Telephone Follow-Up for Day Surgery Patients:Patient Perceptions and Nurses’ Experiences

Anne Dewar, RN, PhDJan Scott, RN, BScN

Janice Muir, RN, MSN

This article is an analysis of qualitative data collected from telephoneinterviews by a nurse researcher with patients recovering from daysurgery. The nurse researcher used a standard protocol to telephone238 recovering day surgery patients. While answering their questionsand providing advice, the researcher found that patients held manybiases and misconceptions about pain and pain management. Manyof these misconceptions were not apparent preoperatively nor atdischarge because patients are anxious, still recovering from thesurgical experience, and not always able to absorb information oranticipate future issues. This article discusses those misconceptionsand the necessity that follow-up occurs over a time period, as thepatient’s need for advice and support changes throughout the recov-ery process.

© 2004 by American Society of PeriAnesthesia Nurses.

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THE ADVANTAGES OF ambulatory surgeryare well documented.1 There are indicationsthat the numbers of surgical procedures per-formed in this setting will continue to increaseas surgical and anesthetic techniques advance.Despite the positive benefits of day surgery,some patients do suffer from postoperativecomplications that require ongoing treatment,teaching, and support. Patients often reportproblems such as pain, drowsiness, nausea,vomiting, fever, and dizziness during their re-covery.2 Pain is repeatedly reported to be amajor concern following discharge.3,4 Estimatesof the number of patients who suffer pain fol-lowing day surgery are as high as 50%.2

Anne Dewar, RN, PhD, is an Assistant Professor of Nursingand Jan Scott, RN, BScN, is a Clinical Associate, School ofNursing at the University of British Columbia, VancouverBC; and Janice Muir, RN, MSN, is a Clinical Nurse Specialistin Pain Management, Nursing Administration, at St. Paul’sHospital, Vancouver, BC, Canada.

Address correspondence to Anne Dewar, RN, PhD, T254-2211 Wesbrook Mall, University of British Columbia, Van-couver, BC V5X 4M9, Canada; e-mail address: dewar@nursing.ubc.ca.

© 2004 by American Society of PeriAnesthesia Nurses.1089-9472/04/1904-0003$30.00/0

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here is evidence from a growing body of liter-ture that the telephone follow-up after dayurgery is an effective means of gathering datand providing support. Studies have been con-ucted to establish patients’ perceptions of dayurgery,1 identify common postoperative com-lications, and determine when patients feltble to resume normal activities.5-14 The pa-ients in these studies were telephoned at timesanging from 24 hours to 3 months after theirurgeries.

ew studies, though, have described the com-on misconceptions that ambulatory patientsold despite being given written and verbal

nformation in the hospital. Fox15 found thatatients want to be provided with very detailed

nstructions following surgery. This includes ex-licit information about managing pain andther aspects of recovery. However, many fac-ors can interfere with patients’ abilities to ac-uire the information they need, and theireeds may change during their recovery pro-ess.

his study is a qualitative analysis of phone calls

ade after discharge to the patients by a nurse

urnal of PeriAnesthesia Nursing, Vol 19, No 4 (August), 2004: pp 234-241

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TELEPHONE FOLLOW-UP FOR DAY SURGERY PATIENTS 235

researcher as a second component of a study ofpatients’ pain following day surgery.16 It high-lights the experiences and misconceptions thatpatients hold and supports the need for specificfollow-up information. The purpose of this re-search is to describe the nurse’s experience ofusing the telephone to follow up with patientsand to advise patients how to manage their painand also manage the side effects of pain-reliev-ing medications.

Methods

The research was reviewed and received ethicalapproval from the participating university andfrom the associated hospital. Patients with fourselected types of surgeries were approachedimmediately prior to day surgery and invited totake part in the study. The research protocolwas explained to the patients prior to surgeryand an informed consent was obtained. Theselected surgical types were anal surgeries, her-nias, arthroscopies, and mammary reductionsand enhancements. These surgeries were se-lected because these procedures are associatedwith more pain during recovery, and pain man-agement would be a major consideration. Pa-tients were assigned to either an intervention ora control group by using block randomizationto ensure an equal number of control and inter-vention participants for each of the four surgicaltypes. Both groups were given pain diaries tocomplete at home and return by mail. Theintervention group received preoperative teach-ing about postoperative pain management strat-egies from the nurse researcher. Prior to dis-charge, both control and intervention groupswere given the usual postoperative teachingabout pain management and surgical care bynurses in the day care surgery. The methods aredescribed in more detail elsewhere.16

The intervention group patients were tele-phoned daily for the first 3 postoperative days(days 1-3). These phone calls were primarily togive patients advice about managing their post-operative pain. During the phone call the pa-

tients were reminded to complete their pain w

iaries. The pain diaries were straightforwardnd required the patients to circle a numberhat corresponded to the level of pain and thempact of pain on their daily activities, emo-ions, and sleep. The patients were also asked toecord the amount of medication they had con-umed in the last 24 hours. A standardizedrotocol was used by the nurse researcher todvise patients regarding their pain and symp-om management. Both groups of patients (in-ervention and control) were telephoned on theth postoperative day to determine their levelf pain and how much pain-relieving medica-ions they were using.

ata Collection

he protocol included telephoning patients theorning of their first postoperative day to de-

ect any problems and, if necessary, to advisehe patients with difficulties to contact theirhysicians. Some patients were difficult to con-act the first postoperative day despite beingdvised preoperatively that they would receive

telephone call from the nurse researcher.any patients either chose to have their mes-

age machine take telephone calls or discon-ected their telephones to prevent friends fromelephoning to inquire about their recovery.ome patients later indicated that they did notnswer their telephones because they did noteel well enough to speak to anyone. Late after-oon or early evening was the best time toontact patients. The follow-up telephone callsere extremely time-consuming because re-eat telephone calls were made until there wasn answer. The average length of telephonealls was 5 minutes, but occasionally the callsook 20 to 25 minutes if the patient needed helpr advice.

he hospital provided all patients with writtenischarge instructions, tailored to the prefer-nces of the physicians. The day surgery nurseslso gave verbal discharge instructions. Manyatients did not recall the information that theyad been given at the time of discharge whenelephoned on day 1. Patients claimed that they

ere too groggy or sleepy, had not been feeling

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DEWAR, SCOTT, AND MUIR236

well enough to be discharged, and conse-quently were not able to absorb discharge in-structions. On day 2, many patients did notrecall the instructions that the nurse researcherhad given on day 1. Information had to berepeated and reenforced. A rapport had beenestablished by the 3rd day. Patients were antic-ipating the telephone calls and had specificquestions to ask.

Often patients ventilated anger about the hospi-tal, the surgeon, and their displeasure aboutbeing discharged from day surgery when theyperceived they were not well enough. Althoughthis was time-consuming, it was important toallow the patients the opportunity to debrief tofollow the research protocol. The nurse re-searcher acknowledged the patients’ commentsand encouraged them to report their concernsto the hospital or directly to the surgeon.

Population

There were 254 patients enrolled in the study.Sixteen patients became protocol failures be-cause they were too sick to be discharged andremained overnight in the hospital, left theirpain diaries at the hospital, or were admitted toanother facility. Of the remaining 238 patients,222 completed pain diaries and returned thediaries as instructed. Table 1 represents thenumbers of patients in each surgical group.

Data Analysis

The data are from the notes that the nurseresearcher kept as she reviewed the teachingprotocol with the patients postoperatively. Thetelephone notes were searched for broad

Table 1. Types of Surgeries

Type Percent (N)

Hernia 14.4 (32)Mammary reductions and enhancements 16.2 (36)Arthroscopies 31.1 (69)Anal surgeries 38.3 (85)Total 100 (222)

themes that represented the patients’ concerns c

nd beliefs about pain and analgesia. The com-ents from the diaries were not correlated with

he patients’ telephone comments becauseost of the written comments focused on their

ratitude at receiving advice and support byelephone.

esults

eliefs and Misconceptions in Relation to Painnd Pain Management

everal beliefs and misconceptions about painnd pain management were identified from theelephone calls. The misconceptions with sup-orting patient responses and nursing interven-ions are summarized in Table 2 and representoth direct quotes and paraphrases when sev-ral comments were similar.

ain and Activity. A number of patientshought they should experience some pain.ne expressed belief was that the amount ofain experienced helped patients gauge their

evel of activity. These individuals were reluc-ant to take medication because they believedf they were pain-free they might be temptedo “overdo it.” One patient commented thateing relatively free of pain led him to beore active than he should have been and, inis opinion, this delayed healing. Being pain-ree was a disadvantage for one patient whoad a marcaine block following knee surgery.ecause he had no pain, he walked for severallocks immediately following discharge. Laterhat evening, he was in considerable pain andad to return to the hospital emergency de-artment.

hen the nurse researcher gave advice aboutain management, this led to questions aboutther activities. For example, many patientsere afraid of actions that would open their

ncisions such as going up and down stairs.ome patients did not understand why theyould not drive their cars. They required clar-fication that effects of both medications andain associated with their incisions, might

ontribute to slower reaction times.

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TELEPHONE FOLLOW-UP FOR DAY SURGERY PATIENTS 237

Patients with hernias were told not to lift, butthey required more specific informationabout which activities of daily living involvedlifting. These patients were surprised to learnthat grocery shopping, caring for children,and doing laundry were considered lifting.Teaching was provided about how to avoidsuch activities or to minimize the strain whenit was unavoidable.

Pain Is to be Avoided. Patients who hadanal surgeries had been prescribed a laxativeto take at home during the days prior to theirsurgery. These patients needed reassurancethat their bowels would not move for a day orso after surgery and they should not be un-duly alarmed. Many of the individuals whohad hemorrhoidectomies commented thatthey dreaded their first bowel movements,because they were anticipating pain. Onesuch patient used the term “howling pain” to

Table 2. Paraphrases

Problems Identified Patient Commen

Pain and activity. Pain helps gauge the leactivity.

Some pain should beexperienced.

Pain can be avoided. Don’t eat so that yourdon’t move.

Don’t mobilize.

Pain is to be endured. Don’t report pain—donphysician/surgeon.

Don’t take anything founless it is really bad

Pain and analgesicmedications.

“Testing the reality ofFear surrounding takin

medications.

Pain and side effectsof pain-relievingmedications.

Discrepancies betweenmedications reportednumber consumed.

describe the pain following bowel movements. t

hese patients had to be encouraged to eat,ecause they believed if they did not eat, theirowels would not move, and thus they woulde spared agonizing pain. They were advisedo take their prescribed stool softeners andulk laxatives and to eat a normal diet thatrovided enough roughage so their bowelovements would be soft.

ain Is to be Endured. Despite reportingigh levels of pain, some patients were reluc-ant to phone their physicians, particularlyheir surgeons. Several patients expressed dis-greement with the advice to take medica-ions to keep the pain in control. A frequentomment was that no matter how severe theain, the patient did not believe in taking a lotf pain medication. In the follow-up tele-hone calls these patients appeared to haveore difficulties with activities of daily living

ollowing surgery but remained reluctant to

Multiple Comments

Nursing Intervention

Assess for knowledge about therelation between pain and activity.

Outline strategies to reduce pain (ie,limiting lifting).

s Explain the relationship between eating,bowel movements, and post-oprecovery.

Clarify the importance of exercise.uble Encourage reporting severe pain.

Reenforce instructions aboutalternative treatments (ie, sitz baths).

Assess for knowledge level aboutmedications.

Reinforce the purpose of medications.Acknowledge and support any anxiety

regarding medications.er of Assess for embarrassment about the

surgical procedure.Identify less common side effects of

NSAIDs.Explain prevention of constipation

associated with analgesia.

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DEWAR, SCOTT, AND MUIR238

one man insisted on driving himself to hishome, which was approximately a 12-hourtrip from the hospital, on the day after hishemorrhoidectomy. His wife, who did notdrive, accompanied him. On the trip, he re-fused to take pain medication because he wasconcerned about being drowsy despite beingadvised that his prescribed NSAIDs would notmake him drowsy if they had never made himdrowsy in the past. This patient reportedconsiderable pain after he got home.

Pain and Analgesic Medication. Some pa-tients experimented by decreasing their painmedications to see if they were actually effec-tive and, as a result, developed severe pain.One patient used the phrase, “I wanted tocheck out the reality of how much pain I washaving.”

Two patients, one in the intervention and onein the control group, admitted to exceedingtheir prescribed analgesic doses, despite clearinstructions on the pharmacy labels. Both re-quired follow-up hospital care. One patientfrom the control group had to be admitted forobservation. He insisted that when he wasdischarged, the nurses had advised him thathe could exceed the prescribed dose of anal-gesia. The other patient initially told the nurseresearcher he had been taking the medicationas prescribed, but in a later phone call admit-ted that he had doubled his dose to preventpain.

Pain and Side Effects. The research alsofound that some patients experienced lesscommon side effects from medications, suchas insomnia (from ketorolac) and dizziness(from ibuprophen). Patients required assis-tance to confirm that these were side effectsof medications and to find an alternative med-ication.

With the exception of one, all of the physi-cians in the study prescribed acetaminophenwith 30 mg codeine for postoperative pain

relief. Many patients were concerned about a

onstipation and required reassurance as wells information about prevention. Patientsho commented that they were never consti-ated were told that the combination of fast-

ng for 24 hours and receiving anesthetics andodeine along with decreased activity mightredispose them to constipation, and theyhould take proactive measures to preventhis from occurring. The patients who wereaving rectal procedures had been prescribed

axatives preoperatively and required addi-ional reassurance and education about post-perative bowel management. Even on thend postoperative day, many patients weretill eating light meals, such as soup, andeeded to have their diet and laxative instruc-ions reenforced.

ther Findings and Comments

atients required reassurance that they weredoing the right thing” or caring for themselvesorrectly. To assist them, it was important toive very specific instructions. For example, itas not helpful to advise patients to “drinklenty of water”; the nurse had to say “take 3lasses of water and/or fruit juice with youraxatives.” Information from the diaries indi-ated that some patients did not read any writ-en instructions. Some patients also claimedhey had not received any written instructions,ne of whom was in the intervention group.

he largest group (38.3% or 85 patients) of theour different surgical types was anal proce-ures. Specific problems were identified in re-

ation to recovery in this group of patients. Aisconception of this surgical group was about

he importance of sitz baths in promoting heal-ng. Some patients believed that the baths wereor cleanliness only, as one patient stated, “but Io not need a bath; I am not dirty.” Once thisisconception was discovered, and the re-

earchers described the value of warm salt wa-er to promote healing and to relieve pain, manyf the patients were then positive about theomfort of sitz baths. The patients having hem-rrhoidectomies were surprised when the pain

nd bleeding increased over the 3 postoperative

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TELEPHONE FOLLOW-UP FOR DAY SURGERY PATIENTS 239

days. Most of the patients who had hemorrhoid-ectomies were experiencing severe pain on theday 5 phone calls and were advised to phonetheir physicians for pain relief.

Discussion

This research reports on patients’ experiencesand nurses’ interactions in telephone follow-upfor day surgery patients. It demonstrates thatpatients still have many misconceptions regard-ing pain and pain management and requirefollow-up support following day surgery. Manypatients had concerns that needed to be ad-dressed when they were more alert. It is under-standable that patients find it difficult to absorbinformation prior to discharge from day sur-gery. However, some patients stated they wereunable to fully absorb postoperative informa-tion into the 1st and even 2nd postoperativedays. This finding suggests that the time periodto absorb information is longer than one wouldexpect.

Written instructions are helpful, but not every-one reads them or even remembers receivingthem. Therefore, some individuals need differ-ent types of educational support. In contrast,some people have a preference for written in-structions. Follow-up and reassurance are valu-able to reenforce and clarify instructions and toprovide encouragement and emotional support.

This research illustrates that it is very difficult toanticipate all of the situations that may occur(e.g., the patient who had the marcaine blockand did not realize that he should not walk sofar immediately after discharge). This result sug-gests the importance of reviewing protocols asincidents occur. Providing limited or uncleardischarge instruction to patients has beenlinked to increased use of health facilities post-operatively.17

An important finding of this research is thatquestions may develop over time as the patientrecovers and experiences problems in relation

to the surgery, pain, and side effects of pain p

elieving medications. The examples of the twoatients who exceeded their prescribed doses

ndicate the need for reenforcement of patienteaching and highlight the importance of docu-enting patient teaching. Postoperative pa-

ients are not necessarily cognizant of the ad-ice that has been given, and nurses need toemonstrate that protocols have been followed.

ome patients were reluctant to take pain med-cation. This has been identified in previoustudies, notably patients with cancer.18 Beau-egard et al3 also reported that day surgeryatients hold attitudes and beliefs similar toospitalized patients about pain relieving med-

cations, such as fears of addiction and concernsbout side effects. These attitudes and beliefsre strongly entrenched in the general public.19

urses should be aware that they need to ex-lore these attitudes and beliefs because pa-ients may not understand the important rolehat analgesia plays in pain relief and postoper-tive recovery.

ome patients used pain as a guide to level ofctivity. The belief that pain helps gauge levelsf activity has been identified by Turk et al.20

everal authors have encouraged assessment ofatients’ beliefs about pain as an important

ndicator of a patient’s compliance with treat-ent regimens.14,20-22 Knowledge of patients’

eliefs may also enable the nurse to encouragehese patients not to tolerate pain above a levelhat is acceptable for them. This research usedain scales in the telephone follow-up. Paincales could be included as a standard part ofhe discharge information. Thus, patients canse the scales to describe their pain and toauge their progress when having conversa-ions with health professionals.

atient comments suggest that many still seeain as something to be endured. Of concernre those patients who, despite increasing levelsf pain, were reluctant to phone their familyhysicians and even more reluctant to tele-

hone their surgeons. These comments are

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DEWAR, SCOTT, AND MUIR240

similar to findings by Payne et al23 that of 18.5%of patients reporting severe pain, only 7.9%called their physicians regarding pain manage-ment.

The majority of patients were prescribed ace-taminophen with 30 mg of codeine. These med-ications were easily affordable, and none of thepatients in this study reported that they stoppedtaking pain-relieving medications because theywere not available or they could not affordthem. This finding contrasts with findings byMarquardt and Razis24 who provided patientswith prepackaged analgesics and concludedthat having available medication reduced thepatients’ levels of pain.

This study is unique because of the number ofpatients who had anal surgery. This group hadparticular concerns about the postoperative re-covery of the surgical area and the importanceof sitz baths; they expressed anxiety about painsurrounding their bowel movements. The re-searcher also found that some patients werereluctant and embarrassed to discuss their prob-lems. It was one of these patients who did notaccurately report how many medications hehad been consuming and had to be admitted tothe hospital. It is not clear why he did not admitthat he was doubling his dose of medication; itmay be a desire to be seen as a good patient.Ward et al18 identified the desire to be a “good”patient as a barrier to pain relief. More preop-erative preparation and follow-up is recom-mended for this group of patients to reducetheir anxiety and assist with their recoverywhile being sensitive to any possible embarrass-ment.

Limitations

For the most part, the nurse who gave thepreoperative teaching instructions telephonedthe patients at home, so a rapport was estab-lished. In practice, this may not be realistic,because a nurse’s schedule does not mean thatthe nurse who gave care in the day surgery

would make the follow-up telephone call. d

he intervention focused on the patient, and mostf the families were not present during the initial

nterviews with the nurse researcher. The re-earcher did not see the patients during theirecovery period in the hospital; therefore, it is notnown if postoperative instructions were given tohe patient alone or the patient and family.

ecommendations and Conclusions

atient teaching should be reenforced whenatients actually have problems. Given that pa-ients still suffer pain postoperatively, it is rec-mmended that pain assessment should also

nclude a component about attitudes to painnd pain management. These attitudes shoulde explored preoperatively if possible as well as

n the postoperative recovery period. Patientshould be strongly encouraged to advocate forhemselves if their pain-relieving prescriptionsre inadequate. Nurses can play an importantole by increasing patients’ awareness that pains not something that they must endure. In thisesearch it was not possible to track the patientsho were readmitted or sought medical advice

fter the 5-day follow-up. This would be theubject of future research in the area. Futuretudies could also include information aboutow patients are coping on the day of dis-harge.

ummary

eadmission of the patient is an additional costo the health care system as well as troublesomeor the patient. Access to follow-up informationnd support is essential to providing pain man-gement for the ambulatory patient. As ambula-ory surgery becomes more common, overcom-ng patient barriers to pain relief may be part ofhe solution to the persistence of postoperativeain. Perianesthesia nurses will have a key role

n implementing this solution for these patients.

cknowledgments

he authors thank the British Columbia Medical Services Foun-ation for their generous support of this research; the nursingtaff of the Day Surgery St. Paul’s Hospital, Vancouver, BC; andr. Margaret Osborne for her helpful comments on earlier

rafts of this article.

TELEPHONE FOLLOW-UP FOR DAY SURGERY PATIENTS 241

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