Understanding the Meaning of Recovery to Patients Undergoing Abdominal Surgery

This qualitative study elucidates the meaning of recovery from the perspective of patients undergoing abdominal surgery in 4 countries.

Key Points

Question

What does recovery mean to patients undergoing abdominal surgery?

Findings

In this international qualitative study of 30 patients undergoing abdominal surgery, the meaning of recovery was found to go beyond traditional clinical parameters. The elements of recovery identified (returning to habits and routines, resolution of symptoms, overcoming mental strains, regaining independence, and enjoying life) should be taken into account when developing patient-centered strategies to measure and improve recovery after abdominal surgery.

Meaning

Findings from this study reinforce the need to acknowledge, embrace, and incorporate patients’ perspective in surgical care.

Abstract

Importance

Postoperative recovery is difficult to define or measure. Research addressing interventions aimed to improve recovery after abdominal surgery often focuses on measures such as duration of hospital stay and complication rates. Although these clinical parameters are relevant, understanding patients’ perspectives regarding postoperative recovery is fundamental to guiding patient-centered care.

Objective

To elucidate the meaning of recovery from the perspective of patients undergoing abdominal surgery.

Design, Setting, and Participants

This international qualitative study involved semistructured interviews with patients recovering from abdominal surgery from October 2016 to November 2018 in tertiary hospitals in 4 countries (Canada, Italy, Brazil, and Japan). A purposive maximal variation sampling method was used to ensure the recruitment of patients with varying demographic, clinical, and surgical characteristics. Data on race were not collected. Each interview lasted between 1 and 2 hours. Interviews were recorded and then transcribed verbatim. Transcripts were then analyzed using an inductive thematic analysis approach. Data analysis was conducted from July 2019 to September 2019.

Main Outcomes and Measures

The qualitative analysis revealed themes reflecting the meaning of recovery from the perspective of patients undergoing abdominal surgery.

Results

Thirty patients recovering from abdominal surgery were interviewed (15 [50%] female; mean [SD] age, 57 [18] years; 10 [33%] underwent major surgery; 16 [53%] underwent laparoscopic surgery). The interviews revealed that for patients undergoing abdominal surgery, the meaning of recovery embodied 5 overarching themes: (1) returning to habits and routines, (2) resolution of symptoms, (3) overcoming mental strains, (4) regaining independence, and (5) enjoying life. Themes associating the meaning of recovery to traditional parameters, such as earlier hospital discharge or absence of complications, were not identified in the interviews.

Conclusions and Relevance

This qualitative study suggests that the meaning of recovery from the perspective of patients undergoing abdominal surgery goes beyond traditional clinical parameters. The elements of recovery identified in this study should be taken into account in patient-surgeon discussions about recovery and when developing patient-centered strategies to improve postoperative outcomes.

Introduction

Patient-centered care is defined as the delivery of care that is “respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”¹ This approach is recognized as an essential component of high-quality health care¹ and emphasizes the importance of patients and clinicians working together to produce the best possible treatment outcome.^2,3 As surgery is generally an overwhelming, disruptive, and often life-changing event for patients, surgical care can greatly benefit from a patient-centered approach. Patient centeredness should be considered in the context of discussions about the value of a surgical treatment to the patient and expectations regarding the process of postoperative recovery, specifically, considering the patient’s definition of a successful outcome.⁴

Abdominal surgery is the most common type of inpatient operating room procedure conducted in North America.^5,6 As with any major procedure, patients undergoing abdominal surgery actively seek information from their clinicians and/or other sources about how long it will take to recover postoperatively (ie, get back to normal).⁷ To address this concern, the meaning of recovery itself must first be understood. However, this meaning may vary between different stakeholders involved in surgery, including patients, surgeons, anesthetists, nurses, hospital administrators, payers, and policy makers.⁷ Studies addressing strategies aimed to improve recovery, such as minimally invasive surgery⁸ and enhanced recovery pathways,⁹ commonly focus on measures such as duration of hospital stay, complication rates, or biological/physiological variables (ie, inflammatory markers, gastrointestinal activity, and physical function).^10,11,12 Although these parameters are relevant to clinicians and system-level stakeholders, they do not reflect the complexity of the recovery process or fully capture the perspective of patients.¹³

Given that the effect of abdominal surgery on postoperative health and well-being is primarily experienced by patients themselves,^7,13 understanding the patients’ perspectives on postoperative recovery is fundamental to guiding patient-centered surgical care. Therefore, the aim of the present study was to gain an in-depth understanding of the meaning of recovery from the viewpoint of patients undergoing abdominal surgery.

Methods

Study Design and Patients

This qualitative study is in accordance with the Standards for Reporting Qualitative Research (SRQR) reporting guideline (eTable 1 in the Supplement).¹⁴ We followed an inductive thematic analysis approach as described by Braun and Clarke.¹⁵ Data were collected as part of an international research program aimed at developing a patient-reported outcome measure (PROM) of recovery after abdominal surgery.^16,17 Potential participants were identified via operating room booking lists and invited to participate via telephone or in person at the hospital. The study protocol was approved by the ethics committees of all participating centers, and written informed consent was obtained before each interview.

To account for potential crosscultural differences in recovery experiences, we recruited patients in 4 different countries (Canada, Italy, Brazil, and Japan) with varying demographic, socioeconomic, and health care setting characteristics. Countries were chosen by convenience, based on our research collaboration network. We targeted the inclusion of adult patients (older than 18 years) who underwent abdominal surgery within 3 days to 3 months before recruitment and were fluent in the local language. We excluded patients with documented mental impairment, in palliative care, had organ transplantation or cesarean delivery, and with preoperative comorbidities that may affect postoperative recovery (eg, musculoskeletal, neurological, pulmonary, or cardiac disorders). Data on race were not collected.

The initial targeted sample size was 30 patients, but interviews were planned to continue until thematic saturation was reached (ie, point after which no new concepts/themes were identified).¹⁸ To account for the diverse characteristics of patients undergoing abdominal surgery, participants were recruited using a purposive maximal variation sampling method.¹⁹ This method aims to capture common themes emerging from heterogeneous samples, thereby constructing a holistic understanding of the topic of interest.¹⁹ To achieve maximal variation, we used a priori recruitment quotas targeting diversity in patient (ie, physical status, education level) and surgery characteristics (ie, extent and approach), as detailed in eTable 2 in the Supplement.

Data Collection

Data collection took place from October 2016 to November 2018. An interview guide was collectively and iteratively produced by our multidisciplinary research team.²⁰ Questions were open ended to allow for an in-depth description of patients’ perspectives about postoperative recovery; follow-up questions were asked when appropriate. Our analysis focused on questions regarding the meaning of recovery after abdominal surgery, including: What does recovery from surgery mean to you? Do you feel that you are already completely recovered? What made you consider yourself to be completely recovered? When will you consider yourself to be completely recovered? What do you think was the most challenging issue that you faced during your recovery? What was the aspect of your life that was most affected during your recovery? What is the most important sign of recovery for you? In addition to these questions, patients were asked about topics (ie, domains of health) to be covered in a PROM aimed to assess postoperative recovery (analysis reported elsewhere¹⁶). Each interview lasted between 1 to 2 hours and took place at the local hospital or at the patient’s home, depending on their preference.

Interviewers were familiar with the subject matter (postoperative recovery) and received specialized training in qualitative interviewing from a senior qualitative researcher (J.M.). Canadian interviewers received training in person and interviewers from international centers received training via video conferencing. All interviewers engaged in at least 1 mock interview before interviewing patients. In international centers, interviewers were fluent in English and the local language. Patients were interviewed in the language of their preference. All interviews were audio recorded, anonymized, and transcribed verbatim by an International Organization for Standardization–certified transcription company, which also provided translations of the interviews to English. The translations were verified by the bilingual interviewers who conducted the interviews.

Data Analysis

Our thematic analysis was conducted from July 2019 to September 2019. The analysis was inductive because there was no intent to confirm an existing theory or hypothesis.¹⁵ Coding was done at a latent level, going beyond the semantic content of the data to identify underlying ideas expressed by patients.¹⁵ Two analysts were primarily responsible for the thematic analysis: a postdoctoral researcher (F.R.; familiar with the subject and has PhD experience in qualitative research) and a medical student (A.P.; experienced with the subject and trained in qualitative research). Disagreements in the assignment of codes and themes were resolved by consensus arbitrated by a senior researcher (J.F.F.; experienced with the subject and has PhD experience in qualitative research). A reflexive approach was used, acknowledging that the researchers’ views and past experiences are reflected in the analysis.²¹ Our thematic analysis followed the steps proposed by Braun and Clark.¹⁵ In step 1, the 2 analysts read the interview transcripts and took initial notes. In step 2, they reviewed the first 5 transcripts line by line and identified prominent codes to generate a codebook, which was subsequently applied to the remaining interviews. The codes were compared for agreement after every 5 interviews, with iterative refinement of the codebook until reaching a final version (eTable 3 in the Supplement). The software MAXQDA 2020 (VERBI Software, 2019) was used to facilitate the process of coding. In step 3, the analysts systematically grouped codes into candidate themes, and in step 4, these themes were compared and refined. In step 5, the coded data were advanced into a thematic map and other researchers in the team contributed input to further refine the themes to best represent the codes included. Assessment of thematic saturation was done with a saturation table that documented the themes identified in each interview.¹⁸ Finally, in step 6, a report of our findings was produced.

Results

From a total of 40 eligible patients invited to participate, 6 refused, 3 agreed but canceled, and 1 did not show up to the interview. Ultimately, 30 patients recovering from abdominal surgery were interviewed (15 in Canada [10 English speaking and 5 French speaking], 5 in Italy, 5 in Brazil, and 5 in Japan). All the recruitment quotas were met, resulting in a patient sample with diverse characteristics (Table 1^22,23). In summary, our sample comprised a wide range of abdominal surgical procedures, including appendectomy and pancreatic resection, 15 patients (50%) were female, the mean (SD) age was 57 (18) years, and 16 (53%) had laparoscopic surgery. Five overarching themes concerning the meaning of postoperative recovery emerged from the thematic analysis: (1) returning to habits and routines, (2) resolution of symptoms, (3) overcoming mental strains, (4) regaining independence, and (5) enjoying life (Figure). Table 2 provides illustrative patient quotes within each of the themes identified. Thematic saturation was reached after analyzing 17 interviews.

Table 1. Characteristics of Interviewed Patients.

Characteristic	No. (%)
Total No.	30
Age, mean (SD), y	57 (18)
Age, y
≤45	8 (27)
≥65	15 (50)
Female	15 (50)
Male	15 (50)
Surgery extensiona
Moderate	10 (33)
Major extended	10 (33)
Major	10 (33)
Surgical approach
Laparoscopic	16 (53)
Open	14 (47)
Previous abdominal surgery	17 (57)
Physical status
ASA I	6 (20)
ASA II	16 (53)
ASA III	8 (27)
Education level
<High school	6 (20)
High school and college	12 (40)
University degree	12 (40)
Official employment status
Unemployed	4 (13)
Working or studying	16 (53)
Retired	10 (33)
Occupation typeb
Physical (ISCO skill level = 1 or 2)	10 (33)
Nonphysical (ISCO skill level = 3 or 4)	9 (30)
BMI
Low (<20)	7 (23)
Obese (≥30)	6 (20)
30-d Complications	12 (40)
Time from surgery, wk
<1	6 (20)
1-4	12 (40)
5-12	10 (33)
Hospital status at time of interview
Inpatient	9 (30)
Outpatient	21 (70)

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); ISCO, International Standard Classification of Occupations.

^aClassified according to Copeland.²² Moderate surgical procedures included hernia repair (n = 5), cholecystectomy (n = 2), appendectomy (n = 1), enucleation of duodenal gastrointestinal stromal tumor (n = 1), and omental patch repair (n = 1). Major surgical procedures included colectomy (n = 3), nephrectomy (n = 2), distal pancreatectomy (n = 2), hysterectomy (n = 1), splenectomy (n = 1), and Heller myotomy with fundoplication (n = 1). Extended major surgeries included left hepatectomy (n = 4), pancreaticoduodenectomy (n = 3), anterior resection (n = 2), and bilio-pancreatic diversion with duodenal switch (n = 1).

^bClassified according to International Labour Office.²³

Figure. Themes and Subthemes Concerning the Meaning of Recovery After Abdominal Surgery.

Table 2. Themes and Representative Quotes on the Meaning of Recovery After Abdominal Surgery.

Theme	Representative quote
Returning to habits and routines	“When I can do all the activities. When I get back to normal, go back to doing all the activities, I will think I’m recovered, I think.”
	“After I spend my time outside and I sweat with activities, I would find no problems with that. I would become also normal when I join dinner parties or drinking parties.”
Resolution of symptoms	“I’m still not fully recovered. Because I’m feeling some pain, some burning sensation like I told you. When it disappears then I’ll be fully recovered.”
	“I could not say it now. I will have to see when I’m at home, when finally, the appetite will come back, I will have bowel movement normally, OK then I can say recovery is 100%. For now, can’t say so.”
Overcoming mental strains	“Like, I didn’t believe that I was able to recover. So that is the most challenging thing. I had to tell myself you’re going to be back to normal, don’t worry.”
	“Well, after surgery [I am] little bit… sensitive when my husband talks to me and he says something wrong and I was crying. Before that I’m not like this. Maybe I’m tired because it’s long time I’m at the hospital.”
Regaining independence	“I’ll feel like I’m totally recovered when I can do things on my own, without needing help, to put on my shoes, to put on my socks or to drive… and do all that by my own. That’s when I’ll feel recovered.”
	“To recover means to… I mean here becoming able to be autonomous, do things by myself, without the assistance of any person.”
Enjoying life	“I couldn’t smile before the operation but gradually I can smile.”
	“I have to keep paying attention to recover more, to slowly start… having fun.”

Returning to Habits and Routines

Many patients defined recovery as returning to the habits and routines that they had before surgery. Depending on their lifestyle, patients listed various activities that they considered as part of their everyday life preoperatively. For example, some patients valued going back to work or being able to partake in household responsibilities, such as cleaning. Others considered themselves fully recovered when they were able to return to their physical exercise routine or practice their favorite sports, such as playing tennis. Other patients valued resuming activities with and caring for their children or grandchildren. Resuming preoperative eating and drinking habits was also mentioned as an indicator of full recovery. Lastly, some patients perceived recovery as resuming social interactions, such as joining family gatherings and spending time with friends.

Resolution of Symptoms

The resolution of symptoms experienced postoperatively was another important aspect of recovery according to patients. The symptoms described were widely variable. Most of the patients stated that they would not consider themselves to be fully recovered until the cessation of postoperative pain. Numbness, swelling, and burning sensation around the incision(s) were also reminders that they were not completely recovered. Overcoming digestive issues was another indicator of recovery, with patients awaiting the return of their preoperative appetite and ability to eat solid food. Some patients mentioned that having normal bowel movements was an indicator of recovery. Feeling weak and fatigued were also common symptoms experienced by patients, and recovery was associated with feeling stronger and energetic again. Lastly, the resolution of sleep-related issues (ie, not being able to sleep) was also described as an indicator of recovery.

Overcoming Mental Strains

Some patients reported that they would consider themselves fully recovered after overcoming the mental strains experienced because of the surgical procedure. These mental strains, which encompassed any worry and tension caused by the surgery, presented differently for each patient. Some expressed worries about long-term surgical outcomes, such as the possibility of needing another surgical procedure in the future. Another concern was about whether the pain would ever go away. Other worries were related to not achieving full recovery; for example, one patient expressed “worry of not having healed completely.” Some patients expressed the sentiment of impatience during recovery, for example, feeling tired of staying in bed or being hospitalized. Furthermore, some patients reported feeling depressed, lonely, emotionally sensitive, and frightened of the changes experienced after the surgery; for these patients, overcoming these mental strains was considered a sign of full recovery.

Regaining Independence

Regaining independence was a recurring definition of recovery as patients looked forward to being able to complete everyday tasks without assistance, as they could preoperatively. Experiencing pain, feeling discomfort around the incisions, and not being able to move easily made it difficult for patients to do many activities on their own. Patients felt dependent on their family members or friends, requiring assistance for completing everyday activities such as walking, getting in and out of bed, getting dressed, and maintaining personal hygiene. Some patients also attributed full recovery to the ability to complete more complex activities independently, such as driving and getting around their neighborhood.

Enjoying Life

Patients expressed that recovery means being able to enjoy life as much as they did preoperatively. Some patients considered themselves fully recovered when they were able to smile, dance, and have fun. One patient attributed recovery to being as adventurous as before the surgery. Another patient associated surgical recovery with regaining the ability to travel and enjoy activities while traveling.

Discussion

In this international qualitative study, patients undergoing abdominal surgery attributed postoperative recovery to returning to previous habits and routines, resolving symptoms and mental strains caused by surgery, regaining independence in daily tasks, and enjoying life. Although different definitions of recovery were expressed based on personal lifestyles and values, our findings support that to patients, the meaning of recovery goes beyond traditional clinical parameters. The recurring themes identified in this study comprise an interplay of physical, psychological, and social factors that should be addressed in patient-surgeon discussions about recovery expectations and when setting recovery goals. These findings should also inform the development of patient-centered strategies to measure and improve postoperative recovery.

Outcomes traditionally measured postoperatively are relevant to health care professionals and system-level stakeholders, such as hospital administrators and funders, but fail to fully capture the perspective of patients. Surgeons and other perioperative care clinicians are understandably interested in clinical outcomes such as development of complications and biomarkers that signal potential complications. System-level stakeholders are also interested in postoperative complications because they lead to increased health care costs,²⁴ but they are also motivated to prevent costs associated with prolonged hospital length of stay, intensive care admissions, emergency visits, and hospital readmissions. Although the outcomes mentioned above are the most commonly reported in the literature addressing interventions to improve postoperative recovery,^10,11,12 none of the patients interviewed in our study attributed a successful recovery to these outcomes. This finding supports that traditional outcome parameters do not fully capture what matters to patients recovering from an abdominal surgery. As such, our study suggests that to patients, the most meaningful aspect of traditional postoperative outcome measures is their downstream effect on physical and mental well-being and ability to resume regular activities independently after hospital discharge. In other words, while outcomes such as length of stay and complication rates may serve as indirect (proxy) measures of recovery, they cannot replace a robust patient-centered recovery assessment.

Recent literature has advocated that postoperative recovery be measured using PROMs^25,26,27,28 (ie, measurements of health status coming directly from the patient without interpretation by others²⁹). Findings from the present study support this approach given that the recovery themes identified in this study can be best assessed and reported by patients themselves. The main advantage of using PROMs in the context of surgical recovery is that they allow a broad, patient-centered, assessment of postoperative health status across various domains, hence capturing the multidimensionality of the recovery process.¹⁶ Additionally, PROMs generally take the form of questionnaires that can be completed at different times, allowing a better understanding of the recovery trajectory.¹⁶ However, a recent comprehensive systematic review revealed that PROMs currently used in the context of recovery after abdominal surgery lack adequate measurement properties as they were not rigorously developed according to optimal scientific standards.³⁰ The lack of robust PROMs to assess recovery after abdominal surgery is a major knowledge gap that strains patient-clinician communication about recovery expectations and limits patient-centered research focused on quality-of-care improvement. Findings from the present study will inform a novel multidimensional PROM to assess recovery after abdominal surgery. The research steps taken toward the development of this questionnaire have been reported elsewhere.^16,17

Strengths and Limitations

A major strength of this study is the use of an international, multicenter approach to uncover patients’ views about postoperative recovery across different cultures and health care systems. Also, we used a maximal variation sampling method³¹ to account for potential differences in recovery perspectives according to patient and surgery characteristics. The interviews were conducted 1 on 1, allowing patients to openly share their thoughts and experiences without the influence of others.³² An additional strength was the use of an inductive approach to identify themes rather than limiting the breadth of our analysis to predetermined recovery concepts (deductive approach).³³ Previous qualitative literature in this field were limited to single-center, deductive studies^34,35 confirming theoretical frameworks,³⁶ and were focused on specific procedures^37,38 and contexts of care (eg, day surgery^34,37,38).

While our study was designed to explore internationally diverse viewpoints about postoperative recovery, the countries where patients were interviewed were chosen by convenience, based on a research collaboration network involving academic hospitals in North America, South America, Europe, and Asia. Early achievement of thematic saturation (after 17 interviews) supports that patients attribute similar meanings to recovery despite differences in perioperative care culture³⁹; however, we cannot exclude that perspectives may be different in other practice settings and environments. Although we followed strict methodological standards including an iterative analytical process with dual coding of transcripts, latent thematic analysis is inherently interpretative⁴⁰ and thus subject to researcher bias.⁴¹ The questions addressed in the present study (focused on the meaning of recovery) were part of a comprehensive interview that also captured specific domains of health to be covered in a PROM.¹⁶ To address both a priori study aims and facilitate analyses, the interviews were divided into 2 parts. As the interviews were long (1-2 hours), interviewee fatigue cannot be excluded. As our study targeted common and shared patterns in how abdominal surgery patients define recovery, comparison between different patient subgroups (eg, open vs laparoscopic procedures, older vs younger, higher vs lower risk) was beyond our scope. The number of patients in each subgroup would likely have been insufficient to ensure within-group thematic saturation, therefore preventing meaningful comparisons. Patients with major comorbidities were excluded from the study, so our findings may not reflect their perspectives of postoperative recovery. As with any qualitative study, the rigor of our findings should be judged by their resonance and plausibility rather than generalizability.⁴¹ In line with this principle, we used a maximal variation sampling method with sample size targeting thematic saturation rather than statistical power.⁴¹

Conclusions

This qualitative study supports that from the perspective of patients undergoing abdominal surgery, the meaning of recovery goes beyond traditional clinical parameters. Overall, patients defined recovery as returning to previous habits and routines, resolving symptoms and mental strains caused by surgery, regaining independence in daily tasks, and enjoying life. These themes should be addressed in patient-surgeon discussions about recovery and shared decision-making. Furthermore, findings from this study must be taken into account when developing patient-centered strategies to measure and improve recovery after abdominal surgery.

Supplement.

eTable 1. Standards for Reporting Qualitative Research (SRQR) Checklist

eTable 2. Targeted sampling quotas

eTable 3. Code book