The emotional toll of day-of-surgery cancellations on patients - a qualitative study using participant observation and interviews

ABSTRACT

Objectives

To explore patients’ experiences of day-of-surgery cancellation and the initial days of the extended waiting period.

Methods

A qualitative explorative design inspired by Ricoeur’s phenomenological-hermeneutic approach was used. Participant observation of day-of-surgery cancellations and semi-structured follow-up interviews with patients were conducted. Transcribed data were analysed using a Ricoeur-inspired analysis.

Results

Five themes emerged from the analysis and interpretation, including “an unexpected and shocking message–triggering reactions ranging from crying to unclear thinking”, “shattered mental strength–an emotional rollercoaster marked by exhaustion and concerns”, “a fragile situation–the need for early, informative and caring management of surgery cancellation”, “prolonged waiting–feeling stuck and mentally distressed, caught in limbo with one’s disease” and “known and unknown consequences–a butterfly effect”.

Conclusions

Surgery cancellation could be explained as a “butterfly effect” causing known and unknown consequences triggered by the initial shock. Various emotional reactions followed the event and patients’ mental strength was shattered. Provision of empathic care and information during cancellation notification was essential. The prolonged waiting period subjected patients to a sense of being stuck in limbo, unable to move forward with their lives. Multiple new practical preparations had to be made, and trust in the healthcare sector might be compromised.

Introduction

Surgery cancellations represent a major and continuing challenge for the global healthcare sector (Abate et al., 2020). These unintentional events lead to wasted healthcare resources, and increased costs and may negatively impact the patients involved (Koh et al., 2021). Surgery cancellation can occur due to patient-related factors (non-attendance), medical factors (unexpected health issues or incomplete preoperative preparations) or organizational factors (staff shortages, lack of intensive care unit (ICU) beds or urgent admissions, etc.) (Ivarsson et al., 2004). In recent years, organizational factors have been the most frequent cause of day-of-surgical cancellations (DOSC) (Abate et al., 2020; Al Talalwah & McIltrot, 2019; Tayeb, 2024). Patients react more negatively to cancellations due to organizational issues, especially when the cancellation occurs on the day of surgery (Drake-Brockman et al., 2021; Ivarsson et al., 2004). Further research is needed to understand better the experience and impact of same-day cancellations due to organizational issues.

Background

Each year, approximately 250 million major surgical procedures are performed globally, corresponding to about one operation for every 25 people (Weiser et al., 2008). The global cancellation rate on the scheduled day of surgery is estimated at 18% across various specialities (Abate et al., 2020). This rate was further exacerbated by approx. 28.4 million additional cancellations during the peak of the COVID-19 pandemic (Nepogodiev, 2020), resulting in a significant increase in the number of patients affected by surgery cancellations.

The literature presents varied outcomes regarding the implications of surgery cancellations. A study of 256,836 patients found significantly higher odds of reporting a negative impact on quality of life among those who experienced surgery cancellation than among those whose surgeries proceeded as planned. Moreover, a higher prevalence of worry, anxiety, stress, pain and problems with activities of daily life was seen (Sommer et al., 2020). Another study, based on interviews (n = 10) with patients who had experienced cancellation of knee or hip replacement, found that patients perceived the cancellation as unfair, expressing feelings of rejection, being treated as a “number on a list” and lacking dignity (Caesar et al., 2022). Additionally, a scoping review investigating the nature and extent of social and economic harm resulting from postponed surgery identified negative effects on patients’ employment status, finances and social life (Jack et al., 2022). This included a reduced likelihood of returning to work, a need to adjust work conditions or increased expenses related to travel for hospital appointments (Jack et al., 2022). Inversely, a recent study where patients completed a questionnaire on psychological measures the day before their surgery showed no significant difference in anxiety and depression levels between those who had previously experienced postponement of cardiac surgery and those who underwent cardiac surgery as scheduled (Spindler et al., 2023). A Canadian study retrospectively analysed all elective surgery cancellations from 2012 to 2016 and conducted standardized personal communication with a subset of patients (n = 72) between 12–18 months after cancellation. Using a set of developed questions to assess patients’ perspectives on a 5-point Likert scale, the study found that although patients experienced inconvenience, they were generally satisfied with the availability and quality of their healthcare (Koh et al., 2021). Moreover, research has highlighted the importance of exploring patients’ experiences of cancellations to develop supportive interventions and mitigate potential negative consequences (Sommer et al., 2020).

To our knowledge, no studies have combined observations of DOSC and subsequent qualitative interviews with patients to gain in-depth knowledge of the phenomenon from patients’ perspectives.

Hence, this study explores patients’ experiences of DOSC, including the event itself and the initial days of the extended waiting period at home, among patients who were outpatients preoperatively and arrived at the hospital on the intended day of surgery.

Aim

To explore patients’ experiences of day-of-surgery cancellation and the initial days of the extended waiting period.

Materials and methods

Design and theoretical framework

This study is the second in a series of four studies within a larger project aiming to develop a complex intervention to manage DOSC. The project is structured in accordance with the Medical Research Council’s (MRC) framework for developing and evaluating complex interventions (Skivington et al., 2021). Understanding patients’ perspectives is essential for co-creating such interventions (Hawkins et al., 2017). A qualitative explorative design consisting of participant observation and semi-structured interviews was chosen to study patients’ experience of the phenomenon of surgery cancellation. This study draws inspiration from the French philosopher Ricoeur, who integrated a phenomenological-hermeneutic approach in his interpretation theory (Ricoeur, 1976). Ricoeur's hermeneutical function of distanciation enables the researcher to move beyond the author’s meaning or intention of narration to gain a new and deeper understanding of the lived experiences studied (Dreyer & Pedersen, 2009). Participant observation was combined with qualitative interviews as the use of both methods offers complementary advantages and provides richer data (Simonÿ et al., 2018). The phenomenon of cancellation is a complex experience, commencing at the hospital and continuing with a subsequent waiting period at home. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Study setting and participants

The study was conducted across three surgical departments at a university hospital in Denmark, where approximately 85,000 surgical procedures are performed annually. The three departments were considered a single, coherent study setting. Patients admitted to one of the departments for surgery underwent preoperative preparations, including checking biochemistry, changing into hospital clothes and measuring temperature and blood pressure, among others. They then waited in the ward’s waiting area or bed rooms. Patients were included if they were ≥18 years of age and experienced cancellation of planned surgery due to organizational reasons at the hospital on the intended day of surgery. To ensure sampling variation, we included patients of different genders, ages and diseases (Table I).

Table I.

Characteristics of included patients.

Gender, (n): Female Male	14 15
Age (years): Median (range)	61 (29–82)
Surgical speciality (n): Orthopaedic Vascular Otolaryngology Neurological Gynaecological Spine Cardiac	5 4 1 4 7 2 6
Previously experienced surgery cancellation (n): Yes No	3 26
Duration of prolonged waiting period (days): Mean (range)	15 (1–38)

Data collection

Data was collected over a 10-month period in 2022 and 2023 by the first author (AV) and consisted of participant observation (n = 21) of the event of surgery cancellation and informal interviews with patients. Furthermore, qualitative individual interviews were completed with patients (n = 28). A total of 11.4 hours of participant observation were conducted. Interviews with patients lasted 12–42 minutes and was conducted 1–14 days following surgery cancellation.

Participant observations and informal interviews

Inspired by ethnography and Spradley’s description of participant observation, the event of surgery cancellation was chosen as the social situation for learning (Spradley, 1980). The first author (AV) was notified by a nurse from the department whenever a patient was to be informed about a cancellation, allowing AV to arrive in time to observe the cancellation event. Initially, the level of participation during the cancellation conversation was passive, followed by a more moderate and active level. This included engaging in context-appropriate activities, such as finding patients’ clothes or providing drinks. A few phrases or essential statements were noted immediately after the cancellation, and detailed field notes were recorded later the same day to ensure accurate recall. Fewer participant observations (n = 21) than interviews (n = 28) were conducted, as AV was occasionally unable to reach the department before the patient was notified about the cancellation.

Qualitative individual interviews

After the conversation about surgery cancellation, patients were invited to participate in individual semi-structured personal communication The interviews were planned to occur in the new waiting period at home before the new scheduled surgery date, and patients were therefore contacted at different time points (1–14 days). Inspired by (Brinkmann & Kvale, 2015), a semi-structured interview guide was used to support the interviews and capture patients’ narratives (Brinkmann & Kvale, 2015). The guide consisted of open questions such as, “Please tell me about your experience of having the surgery cancelled?” or “How did you experience the waiting period at home after the cancellation?” If, for instance, the data from the observation and interviews were contradictory, clarifying questions were asked to validate the interpretation. The duration of the personal communication ranged from 11 to 42 minutes. The interviews were recorded and transcribed verbatim by two nursing students, a project nurse and AV. Most patients had no previous cancellation experience, and the prolonged waiting following surgery cancellation was between 1 and 38 days (Table I).

Data analysis

A Ricoeur-inspired analysis and interpretation of data was conducted (Dreyer & Pedersen, 2009). Field notes and interview text were combined into a single text for analysis and interpretation. This unified text captures both patients’ experiences and their context, consistent with Ricoeur’s interpretation theory (Simonÿ et al., 2018):

Because we are in a world, because we are affected by situations, and because we orient ourselves comprehensively in those situations, we have something to say, we have experience to bring to language. (Ricoeur, 1976, pp. 20–21)

According to (Dreyer & Pedersen, 2009), a Ricoeur-inspired analysis and critical interpretation involve three distinct stages: naïve reading, structural analysis, and critical interpretation and discussion (Dreyer & Pedersen, 2009). Naïve reading encompasses listening to the recording of the interviews and reading the text (interviews and field notes) to get a first impression of the text and what the substantial meaning of the text touches upon (Dreyer & Pedersen, 2009). This approach can be exemplified as a “first guess” within the narrative of what it means to experience surgery cancellation.

In the structural analysis, the researcher systematically examines the text to gain a deeper understanding of “what the text speaks about” or “what the observation represents” (significance-bearing units) beyond “what was said or observed” (meaning-bearing unit, including quotations) (Table II). The third level of creating themes is thereby accomplished. The software programme NVivo (QRS International Pty Ltd., Victoria, Australia) was used to manage the full text. The critical interpretation stage involves discussing the results at a general level, incorporating other theories and research. A dialectical interplay between the three stages occurs, resembling the movements between part and the whole in a hermeneutic spiral, to achieve a new, deeper understanding of the phenomenon under investigation (Dreyer & Pedersen, 2009).

Table II.

Example of the structural analysis.

Units of meaning “What is said/What is observed”	Units of significance: ‘What is being talked about/What the observation is about	Theme
“The next day, I was back in normal ‘limbo land’.” “I just want to get it over with.” “It affects my daily life as we cannot do anything.” “On days when I have several things to do, if I’m active at home in the morning, I usually can’t accomplish anything in the afternoon.” “It is a long process that has lasted ten months, and it’s always in the back of your mind. That is probably what has been the hardest for me.” “To function as a person, having a highly structured life is essential. When things go wrong, like the cancellation, I need to re-establish that structure to maintain my mental stability”	After surgery cancellation, patients faced a new prolonged waiting period, which was often characterized as being in limbo, unable to move forward with their lives as they desired. During this prolonged wait, patients experienced varying physical symptoms and limitations, depending on their specific condition. They also reported persistent thoughts about the surgery while waiting at home, which added to their mental burden. The cancellation led to a sense of lost control and disrupted life structure, adversely affecting their mental state/stability.	Prolonged waiting–feeling stuck and mentally distressed, caught in limbo with one’s disease.

Ethical considerations

The study was reported to the regional data protection agency (1-16-02-102-22). According to Danish law, ethical approval was not required (Danish Legislation-LBKnr.1338, 2020). The heads of the surgical departments at the University Hospital approved the study. Participants, including patients and healthcare professionals, gave informed oral and written consent to participate in the study. Healthcare professionals gave informed consent before the observation of cancellation. Patients were invited to participate after their surgery was cancelled, as it was not feasible to inform them beforehand. If a patient declined participation, the corresponding observation was excluded from the study.

Rigor and reflexivity

To ensure data quality, an open atmosphere was fostered during personal communication, encouraging patients to freely share their experiences. This openness was facilitated by AV’s previous encounter with patients during or immediately after the cancellation. Ongoing discussions among the authors enabled a deeper understanding and interpretation of patients’ experiences and ensured the study’s credibility.

Findings

Five themes were revealed in the Ricoeur-inspired analysis. Participant observation was limited to include the event of surgery cancellation and not the subsequent waiting period at home. Hence, data from observations are not represented in all of the themes.

An unexpected and shocking message—triggering reactions ranging from crying to unclear thinking

Receiving the message of cancellation caused a state of shock in patients. Metaphors such as “getting a cold bucket of water dumped on the head” or “being slapped in the face” were used to describe the event as a hurting and unpleasant realization. Even though patients had heard about surgery cancellation in the news, they did not imagine that it could happen after their hospital admission: “I was completely shocked because I hadn’t expected it” (P28). “That simply should not happen, as heart surgery is something you really prepare yourself mentally for” (P1). The shock of the cancellation was followed by immediate reactions such as frustration, disappointment, crying or quiet acceptance. Some patients reacted instantly as shown in the following field note:

The woman rose from the chair, her voice thick with frustration, saying that she no longer had the strength to go on. Tears were rolling down her cheeks while she, visibly upset, explained that she was supposed to be the first to have surgery that morning. (field note P18)

Another field note showed how the notification caused feelings of sadness and powerlessness: “The woman, clearly overwhelmed, had tears in her eyes, saying over and over ‘what can I do’. The atmosphere was heavy as we sat in silence” (field note P26). Furthermore, the shock could also manifest physically, as a patient experienced temporarily impaired vision following the notification. In contrast, some patients initially expressed acceptance during the notification but often reacted emotionally when the surgeon had left the room or after discharge: “I must admit, afterwards I reacted emotionally. I was sad and tired that everything had failed, and I was forced to continue to handle the pain for another period of time—I must admit, I was quite sad” (P7). Other patients express a desire to leave the hospital quickly, possibly to avoid losing their composure during the notification: “After getting the news, she quickly said she wanted her clothes so she could go home. It was almost as if she just wanted to get away—out of there” (field note P9).

Experiencing shock impaired patients’ ability to listen and remember information about the cancellation, such as when to begin medication or when to expect a new appointment: “It was difficult for me, and I could not fully process what was happening. When I got the news, I struggled to think clearly—obviously, you get shocked” (P17). This meant that patients had to contact the hospital after discharge, which they described as troublesome and time-consuming. Instead, patients contacted their general practitioner or the emergency department for information about their medication. This situation caused frustration, and some patients felt burdened by the responsibility of coordinating their own continuity of care: “I feel that I must be the coordinator of my pathway, which I find frustrating” (P18). After surgery cancellation, patients expressed a crucial need for accessible contact with the hospital.

Shattered mental strength—an emotional rollercoaster marked by exhaustion and concerns

Preoperatively, most patients underwent an extended series of examinations and hospital visits, which they described as exhausting. At the same time, they mentally prepared for the upcoming surgery, building the strength and courage needed to transition into a different state of being and a new reality: ‘Before going in for surgery, you have to be mentally prepared for the fact that you’re about to transition into another type of existence”’ (P12). This reality was described as lacking self-determination and decisiveness, requiring patients to entrust control to the healthcare professionals and accept a postoperative period possibly involving pain, fatigue and limited energy for making plans. The mental preparation before admission helped patients navigate this transition and remain emotionally calm in a frightening situation: “I have prepared for the surgery and am ready to get over it, even though I worry about it” (P17). When patients experienced surgery cancellation, their mental strength was shattered, requiring them to rebuild their courage during a new waiting period to face the challenge of returning to the hospital. This was described as a demanding task: “It is extremely demanding to get mentally prepared, and when it doesn’t go as planned, then I know I have to go through this once again, which is really hard. … It is an emotional rollercoaster—oh, I feel overwhelmed now (silently crying)” (P21). “But, then, when you finally reach the date and you’re ready, it hurts to be told that you have to go back home” (P13). Hence, the cancellation caused feelings of distress as patients were forced to leave the transcendental state, they had mentally prepared for. As one patient described, he felt “out of place” (P12) when not being in the hospital for surgery.

When returning home following the cancellation, patients found themselves physically exhausted due to preoperative worries and their mental upheaval: “When I came home, I slept the rest of the day. I was mentally drained, and it really affected me. I can feel it again as we speak” (P13). Patients also described cancellation in terms of “feeling lost” or that the “world fell apart”. Other patients described that they lost hope in their situation. These statements reflected concerns about extended waiting time, including fears of disease progression or a poorer surgical outcome. This was especially evident among patients requiring major surgery or those with severe diseases: “Every day, I am thinking about how serious it is—Three of the coronary arteries are calcified. I am concerned if I will make it in time—or something could happen” (P17). “I have been feeling down, I must say, I have really had a rough time in the extended waiting, because the sooner things get started, the better” (patient in need of cancer surgery) (P23). A field note documented a patient’s distress while awaiting urgent hip surgery, which was exacerbated by worries about an additional disease: “The patient looked visibly distressed and said that he was scared shitless” (field note P8). However, other patients with similar types of surgery, expressed being less affected by the cancellation once they returned home, adapting to the situation without mental distress: “I am not particularly affected mentally by anything. I am not afraid or nervous about the surgery at all” (patient in need of an open-heart surgery) (P20). “You cannot say that it was a good experience … but we would get through it” (patient in need of aortic aneurysm repair) (P25).

A fragile situation—the need for early, informative and caring management of surgery cancellation

Professional communication was found to be important to patients experiencing surgery cancellation, particularly regarding where, when and how the message was delivered. Most patients were notified by the surgeon and a nurse in an examination room or a ward bedroom. However, some patients received the notification in the waiting room or corridor, as described in the following field note:

The patient was on her way out of the door (the surgeon had informed her about cancellation in the waiting area), and the nurse invited her back into the office … . The patient broke down and started to cry when entering the office. (field note P13).

This revealed the need to deliver the information personally and in private surroundings.

Early and continuous information about a possible cancellation was also important to the patient. Patients, particularly those with longer travel distances, preferred to be informed about cancellations before arriving at the hospital. Patients who waited for several hours after arrival reported frustration and increased nervousness: “I just felt so sad, frustrated and angry. Why couldn’t they have sent me home sooner if they had even the slightest idea about it (the surgery cancellation)” (P23). A longer wait often meant extended fasting, contributing to a sense of illness: “It is hard when you start feeling sick just because you haven’t had anything to drink” (P23). Waiting on the day of surgery was described as being in a vacuum—caught between two events with minimal information: “Information is so extremely important when you are sitting there, waiting, feeling like you’ve lost all control. It would have been helpful if I had received an update every couple of hours; ‘now this and this had happened’” (P12).

Participant observation revealed variation in the duration of surgery cancellation notifications. A very brief notification could result in insufficient information, leading to uncertainty about how to prepare for and handle the new waiting period: “In some way, I felt insecure because you think … Did I miss something important along the way” (P10). Patients needed information about their prognosis during the prolonged waiting period and whether this was a cause for concern, what symptoms to watch for at home, how to manage their medication and when they could expect a new appointment: “I would have preferred more information before being sent home—or at least someone telling me not to worry about the disease” (P17). “I was not informed about anything or what to do. I am taking a blood-thinning medication, and I had to figure out myself subsequently, what to do” (P8). Patients also requested an honest and thorough explanation of the reason for the cancellation: “What I really needed was to understand why the surgery was cancelled. I find transparency important” (P3). Moreover, patients valued empathy and care from healthcare professionals, such as being comforted, provided with food and drink or assisted with transportation: “He was present and human” (P24). “It mattered that they didn’t just walk away but showed they cared for you somehow” (P13).

Patients had mixed feelings regarding whether a surgeon or a nurse should deliver the cancellation notice. Some found it crucial for the surgeon to provide the information due to their comprehensive knowledge of the disease. Other patients did not mind receiving the message from the nurse if it meant that they could leave the hospital sooner.

Prolonged waiting—feeling stuck and mentally distressed, caught in limbo with one’s disease

It was evident that patients had persistent thoughts about the surgery while waiting at home. Some tried to distract themselves, while others experienced negative effects from mental stress, such as new-onset sleep problems or increased tension: “I have some frustrations, and I get easily irritated. I’m not very pleasant to live with” (P28). It was therefore crucial for patients that a new surgical appointment was scheduled shortly after the cancellation: “It means everything to me not to have to wait for another month or two because I feel I’ve waited long enough” (P13). As most patients did not receive a new surgery date at the time of cancellation, they worried about being “forgotten” in the hospital’s booking system. The unpredictable nature of waiting without a scheduled appointment made it more difficult: “I am not sure when I’ll get the surgery, but knowing the exact date would ease the stress” (P16). Thus, patients’ sense of uncertainty was reduced when they received a new appointment.

Waiting at home after a cancellation left patients in limbo, unable to move forward with their lives:

The next day, I was back in “limboland” … I cross my fingers that it will work out next time so I can get it out of my system and move on with my life‘ (P21). In general, patients were eager to resume normal life by getting through the surgery, often expressing this sentiment with phrases like: “I just want to get it over with”. Thus, patients found it difficult to fully live their lives while waiting. This limitation was also linked to their physical condition, as the disease often caused pain or compelled them to take precautions to avoid physical strain: “It affects my daily life because we can’t do anything. We’re stuck at home as my mobility is impaired” (P8). ‘I cannot take part in larger social gatherings. (P15)

Furthermore, being in limbo disrupted some patients’ sense of structure in their lives: “I have had depression … When things go wrong, like the cancellation, I need to re-establish a routine to maintain my mental stability” (P13). Conversely, patients without physical symptoms were able to continue their normal activities while waiting after the cancellation: “I got home and just carried on as usual” (P19). The extent and severity of negative consequences experienced while waiting in limbo varied among patients, with vulnerable patients being most at risk of severe impacts. Alongside these accounts, some patients expressed an understanding of the cancellation, particularly when it was due to others needing acute surgery: “I would understand if someone came in with a life-threatening or acute condition” (P3).

Known and unknown consequences – a butterfly effect

New practical preparations after surgery cancellation were varied and unpredictable, including tasks such as shopping for the post-discharge period, arranging new blood tests or organizing transportation to the hospital. These tasks were time-consuming and required significant efforts from patients already in a mentally stressful situation: “There has been a lot to do … It’s always planning, planning, planning, and it’s demanding’ (P21). Beyond the new practical preparations, surgery cancellations often led to additional negative effects, such as increased transportation costs, lost holiday plans and repeatedly pausing prescribed medications.

When the surgery date was uncertain, patients found it difficult to make plans with their workplace:

I am a teacher, and we’ve already arranged substitutes for me. It’s a mess when the appointment is undetermined’ (P16). For some, an indefinite date risked job dismissal due to extended sick leave without a clear end: “There is also a financial aspect—could I lose my job? I have so many thoughts”. (P13)

Cancellation was also found to affect patients’ relatives and other people around the patient:

The daughter asked the surgeon if he knew that she had taken a week off and should pay herself. She explained how she had arranged for colleagues to take over her watch at work in order to be present during her mother’s hospitalisation. (field note P28).

Relatives often had to set aside their own plans to support the patient: “It doesn’t just affect us. It affects everyone else stepping in for you. Our daughter even postponed her own surgery to help us’ (P1). Thus, the unpredictable consequences of cancellation could be likened to a “butterfly effect”. Even if the event seems immediately insignificant compared to other major potentially fatal events in life, it had several far-reaching consequences.

Patients’ sense of justice and trust in the healthcare system could also be influenced. Some patients had difficulties understanding the organization of the surgical program: “I think—I expect that when you have an appointment, then you have an appointment’ (P14). Doubt in the healthcare system was also seen, as patients feared another cancellation: “Now I have to mentally prepare for surgery again and plan everything around it, but there is still the fear—will it be cancelled again” (P13). This frustration was exacerbated when cancellation happened repeatedly: “I had already been cancelled once—actually twice. So I thought, okay, at least I’m admitted to the hospital, and hopefully it will happen this time—but then the surgery was cancelled again” (P3). Generally, the mistrust patients expressed was targeted at the healthcare system rather than individual healthcare professionals, meaning their confidence in the treatment and care itself remained intact. Nevertheless, the cancellations led to feelings of hopelessness and powerlessness.

Discussion

Patients’ experiences of the phenomenon of surgery cancellation throughout their care trajectory resembled a “butterfly effect”, where a seemingly small event triggered numerous known and unforeseen consequences. These consequences included immediate emotional impacts, weakened mental resilience and a prolonged waiting period in a state of “limbo” with their condition. Additionally, other unforeseen practical consequences emerged.

Our study revealed that the surgery cancellation notification was often a shocking experience, described with metaphors like, “getting a cold bucket of water dumped on the head”. When individuals are under pressure or face situations involving tension, conflict, fear or other negative stimuli, their emotional response systems are activated (Fitzduff, 2021). The system is regulated by amygdala, a brain structure in the limbic system, and triggers an instinctive “fight, flight or freeze” response (Fitzduff, 2021). Thus, the cancellation notification can be a stimulus that activates patients’ instinctive reactions and feelings, such as frustration/anger, resignation, insecurity and sadness. Immediate reactions such as anger, disappointment and bitterness were also observed in a study of patients following knee or hip replacement surgery cancellation (Caesar et al., 2022). Moreover, negative reactions, including being angry and/or frustrated, disappointed, upset and/or sad, were reported among families who experienced cancellation of planned paediatric surgery close to the appointment (Drake-Brockman et al., 2021). In addition to the emergency and primitive response system, the brain includes a cognitive system involving the thalamus and prefrontal cortex, which generates more conscious and logical responses. During a shocking experience, however, this system is often bypassed by the amygdala (Fitzduff, 2021). In our study, we found that some patients were able to suppress their immediate emotions and remained calm until the surgeon left the room. This could be explained by the human capacity to activate the prefrontal cortex to control our behaviour even though feelings are present (Fitzduff, 2021). Our results also revealed that a few patients hastened out of the hospital after receiving the cancellation notice, which could be interpreted as a “flight” response and an attempt to remain composed while in the hospital. For most patients, the experience of surgery cancellation was a significant mental upheaval regardless of surgical speciality. In our study, patients were comforted by healthcare professionals’ empathy and care during the cancellation conversation. Empathic care includes understanding the patient’s perspective, emotions and situation, among others (Byrne et al., 2024). Thus, incorporating empathic care during the cancellation notification may help patients regain emotional composure and enhance their sense of being understood and supported. Moreover, providing a private setting for delivering the cancellation notice could create an environment where patients feel comfortable expressing their reactions.

The primary question patients asked during the cancellation was when their surgery would be rescheduled, as knowing this helped reduce their stress. A review similarly found that patients wished to receive a new surgery date at the time of cancellation (Viftrup et al., 2021). Hence, providing information about a new appointment at the time of or shortly after the cancellation notice could reduce feelings of uncertainty and stress during the subsequent waiting period. Furthermore, patients valued honest explanations for the cancellation. When the cancellation was due to other patients requiring emergency acute surgery, patients were more likely to express understanding. Caesar et al. found similar results, highlighting the importance of honest communication regarding the reason for the cancellation, which helped the patient better cope with the situation (Caesar et al., 2022). Conversely, insufficient explanations for the cancellation could make it more difficult for patients to cope with the cancellation. This study also revealed that sparse information while waiting could result in feelings of frustration and increased nervousness. Additionally, the timing of the cancellation notification, relative to the proximity of the scheduled surgery, was found to be important. An earlier study by Thomas et al. (2013) similarly found that patients preferred to be informed promptly when possible changes to the surgical schedule arose (Thomas et al., 2013). Thus, transparency and involving patients on the day of surgery, along with early notification of cancellations, are crucial.

Our results revealed patients’ need for information about disease progression to alleviate their concerns about the prolonged waiting time. However, the data showed that patients often had difficulty absorbing information during the cancellation, likely due to the shock of the notification. Aston et al. also emphasized the importance of providing comprehensive information, including clear guidance on danger signals related to the condition that patients should monitor at home (Ashton et al., 2017). Hence, to ensure that patients receive important information, healthcare professionals could provide it later in the conversation, convey it to relatives or offer alternative formats such as written materials. These strategies are crucial because many patients become aware of missing information only once they are back home, which underscores their need for easy access to hospital contacts after a cancellation

Moreover, we found that relatives played a significant role in supporting patients throughout their care journey. This correlates with findings that show a growing dependence on relatives/friends among patients who experienced cancellation compared to those who did not (Sommer et al., 2020). Further research is needed on how relatives support patients during surgery cancellation and on the relatives’ own experience of surgery cancellation.

When leaving the hospital following cancellation patients experienced conflicting realities, as they felt that they were in the wrong place when they were not at the hospital as expected. The same result was found by Caesar et al., showing that cancellation was an unexpected and surreal experience. Patients felt a lack of correspondence between their inner reality and their actual external reality (Caesar et al., 2022). The feeling of conflicting realities could be linked to patients’ efforts to mentally prepare for surgery, as our results revealed that patients worked to build up mental strength and courage to face the planned procedure. Preoperative anxiety has been well-documented in several studies and is often associated with perceived threats related to the surgery (Friedrich et al., 2022; Gamst-Jensen et al., 2024). Hence, admission to the hospital represented a “transition” into another world, requiring patients to muster significant mental strength to overcome their anxiety. This is consistent with findings showing that hospitalization often leads to increased anxiety, stress and powerlessness (Alzahrani, 2021). These insights could also help explain why patients preferred to receive the cancellation information before arriving at the hospital as this could help them avoid the heightened anxiety associated with hospitalization.

Patients awaiting surgery, even without experiencing cancellation, expressed concerns about worsening health and poorer surgical outcomes due to the wait (Gagliardi et al., 2021). However, Sommer et al. also reported a higher incidence of stress and anxiety among patients who experienced surgery cancellations than among those who did not. Thus, the experience of DOSC was perceived to exacerbate its negative influence on patients. We found that patients exhibited varying mental states following day-of-surgery cancellations. Our results seem to show that an extended waiting period after DOSC imposes a greater emotional burden on patients requiring major surgeries, particularly those with severe diseases or complex conditions. Most interviewed patients reported difficulties at home, including either persistent thoughts about the upcoming surgery or concerns about disease progression and poorer outcomes. Similar findings by Caesar et al. showed that patients often worried about potential deterioration (Caesar et al., 2022). Conversely, our results revealed that some patients facing the same need for major surgery (e.g., open-heart surgery and aortic aneurysm repair) adapted to the situation without experiencing mental distress. This aligns with a study on postponement of cardiac surgery during COVID-19, found that patients felt reassured knowing that they could endure a longer wait for surgery, using this confidence to reduce their fear and anxiety. In contrast, patients experiencing prolonged severe illness were less likely to accept the cancellation (Thorup et al., 2021). Moreover, Spindler et al. found that patients whose surgeries were postponed 0–14 days experienced greater anxiety and depression than those waiting more than 14 days, suggesting that initial postponement may elevate anxiety, but that its impact lessens over time (Spindler et al., 2023). Hence, further research is needed to identify predictors of patients’ psychological states during the entire waiting period after cancellation and to determine how to ensure comfort and safety for these patients.

DOSC had several consequences for patients, including new practical preparations which were described as demanding. Standardized interviews assessing the impact of cancellations found similar results, with 62.5% reporting moderate to severe inconvenience for themselves or their families (Koh et al., 2021). This included transportation costs and lost workdays (about half of respondents lost at least one day). In our study we found similar consequences of long transportation and wasted time, along with more severe effects, such as a risk of job dismissal, relatives postponing their planned surgery to assist the patient, and the need to arrange substitutes.

Koh et al. (2021), also found that repeated cancellations contributed to a more negative perception of the healthcare system. Our study similarly showed that doubts about the system were linked to fears of further cancellations. Concerns about repeated surgery cancellations were additionally associated with a loss of hope. Hopelessness tends to emerge when patients’ belief in recovery and returning to a normal life fades after a cancellation (Caesar et al., 2022). Our findings also showed that patients longed to return to their normal lives but felt stuck in limbo with their illness at home after a cancellation. Another study found that patients waiting for surgery managed to cope with negative emotions during the waiting period by holding on to hope for regaining their health (Svensson et al., 2016). Therefore, to help patients retain hope and trust in the healthcare system, it is crucial to prevent surgery cancellations, especially repeated cancellations.

Strengths and limitations

Given that the experience of surgery cancellation is multifaceted, using triangulation for data collection—combining participant observation with qualitative interviews—enabled us to gather comprehensive and rich data. We believe that this is a strength because we generated insights through the dynamic interaction between patients’ behavioural expressions, the atmosphere and their verbal descriptions of the experience. Furthermore, it proved beneficial for the personal communication that AV had previously met the patients during the cancellation event, as a relationship had already been established. Some patients had even prepared for the call by making written notes about their experience.

We strove to capture diverse lived experiences of surgery cancellation by including patients from various specialities, age groups, genders and differing waiting times. Through a Ricoeur-inspired analysis and critical interpretation of texts and actions, we sought to meticulously work with data to ensure transparency and credibility. Additionally, the use of NVivo facilitated a systematic approach to moving between individual parts of the data and the broader context.

Conclusion

This study provided in-depth insights into the experience of surgery cancellation as faced by patients in a Danish context. The phenomenon of surgery cancellation can be likened to a “butterfly effect”, leading to both known and unknown consequences initiated by the initial shock. Day-of-surgery cancellations at the hospital were particularly distressing, causing significant emotional upheaval. Patients exhibited various immediate reactions, including quiet acceptance, frustration, anger, sadness and disappointment, even though some later expressed acceptance of the situation. The experience of cancellation required renewed psychological adjustment, often experienced as a burdensome struggle. Provision of empathic care and information during cancellation notification was essential. A new waiting period at home subjected patients to ongoing mental stress and constant worry, as they were unable to find peace of mind until the surgery was completed. Surgery cancellation also left patients feeling hopeless and stuck in limbo, unable to move forward with their lives. Other negative and unexpected consequences included numerous new practical preparations that patients had to manage. Furthermore, trust in the healthcare system could be undermined by the experience of DOSC.

Biographies

Anette Viftrup (RN, MScN) is currently PhD-student at Aarhus University. She is employed as Clinical Nurse Specialist at the Department of Anaesthesiology and Surgery, and conducts research focused on the perioperative area.

Lone Nikolajsen (MD, PhD, DMSc, Professor) is Clinical Professor, Professor and chair of Anaesthesiology and Intensive Care at Aarhus University Hospital and Aarhus University. She has an extensive career as a researcher and has served as the primary supervisor for a substantial number of PhD students. Her research primarily focuses on pain and pain management, contributing significantly to advancements in these areas.

Sussie Laustsen (RN, MSc, PhD, Associated Professor) is a skilled researcher and teacher. Her primary research focus is Cardiac rehabilitation, and she has successfully carried out research projects within this area of expertise. She demonstrates expertise in both quantitative and qualitative methodological approaches.

Pia Dreyer (RN, PhD, Professor in Nursing) is Professor in nursing at Aarhus University Hospital and Aarhus University. She is a highly esteemed researcher specializing in cognitive impairment among intensive care patients. Her work employs a rigorous methodological approach rooted in phenomenology and hermeneutics, drawing inspiration from Paul Ricoeur’s theory of interpretation.

Funding Statement

This work was supported by Novo Nordisk Foundation under grant number: [NNF21OC0072570].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available from the corresponding author, AV, upon reasonable request. The data are not publicly available.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17482631.2025.2502193