The Patient Experience of an Inadequate Quality Bowel Preparation during the Colonoscopy Process: A Qualitative Study

Abstract

Background:

As many as 35% of patients may experience an inadequate quality bowel preparation for colonoscopy, which may require a repeated colonoscopy without insurance coverage. To the knowledge of the authors, there have been no qualitative studies that have performed an in-depth exploration of patient experiences of this outcome.

Purpose:

This study aimed to explore patients’ perceptions of experiencing an inadequate preparation compared to those with only an adequate quality bowel preparation history.

Methods:

Quantitative analyses were conducted for three one-item questions (e.g., anxiety rating) with ordinal scales. Qualitative data were collected from audio-recorded and transcribed telephone interviews (N=20) and anonymous online surveys (N=59). An inductive/deductive coding system was constructed, and themes were generated to form a conceptual framework.

Findings:

Brief quantitative results are provided. Themes of the colonoscopy process included context, pre-preparation, implementation, outcomes, response, and decision to repeat.

Discussion:

This novel study underscored the emotional experience of patients with inadequate preparation and its influence on decisions to repeat the procedure. Focus is brought to prevention with appropriate screening and tailored instructions; and compassionate intervention following inadequate preparation. Limitations: include cross-sectional interviews/surveys and a highly educated sample. Recommendations are given for research, policy, and practice.

Colonoscopies are the gold standard of colorectal cancer (CRC) screening; however, successful visualization depends on complete bowel evacuation prior to the procedure (Mahmood et al., 2018). Adequate bowel preparation (AP) for colonoscopy is the capacity to identify adenomas that are five mm in size or larger (Mahmood et al., 2018). Inadequate quality bowel preparation (IP) often results in an incomplete procedure and a repeated colonoscopy with a more extensive bowel preparation that may not be covered by insurance (Kingsley et al., 2016). IP has been studied quantitatively, yet a qualitative knowledge gap remains. (Clarke et al., 2014; Gkolfakis et al., 2019; Mahmood et al., 2018; McLachlan et al, 2012).

Background

As many as 35% of patients experience IP outcomes – excess stool in the colon that cannot be flushed or suctioned (Kang et al., 2016; Mahmood et al., 2018; Ness et al., 2001; Vanner et al., 1990). This outcome leads to increased costs, high rates of missed adenomas, and reduced patient satisfaction (Lebwohl et al., 2011). While it is known that factors such as Tricyclic Antidepressants, male sex, and diabetes contribute to IP, the experiences of those with IP have not been extensively explored (Yee at al., 2015).

Existing qualitative literature has focused on reasons patients complete or avoid colonoscopy screenings or patients’ experiences of the colonoscopy process regardless of the quality of bowel preparation. There is consensus that the preparation phase is the most unpleasant and anxiety-provoking aspect of the colonoscopy experience (Bhise et al., 2016; McLachlan et al., 2012; Mikocka-Walus et al., 2012). Participants identified the overall time commitment and laxative as most burdensome (Martindale et al., 2014). Patients described additional barriers to completing test appointments: sickness; no driver; commute; inconvenient timing; and forgotten appointment (Bhise et al., 2016; Mahmood et al., 2018). Considering known barriers for all patients undergoing colonoscopy, it is important to understand how these difficulties may be compounded by IP to promote patient-centered clinical processes.

Specific Aims

The specific aims were to explore patients’ experiences of:

• Inadequate quality bowel preparation for a colonoscopy.

• Pre-endoscopy education and scheduling.

• Colonoscopy preparation.

• The setting for their procedure.

• Emotional responses to the process.

• Being told that the procedure and preparation will need to be repeated.

Research Team and Reflexivity

Personal Characteristics

The first author (CCK) worked as a pre-endoscopy nurse for four years and completed this study to investigate patient outcomes. The first author identifies as female and was a PhD student at the Vanderbilt University School of Nursing. This project was completed under the mentorship of Elizabeth Card, an Advance Practice Registered Nurse employed at Vanderbilt University Medical Center as a Research Consultant.

Relationship with Participants

Participants were not familiar with the research team prior to enrollment. Research purpose and procedures were described to participants in initial emails, during the consent process, and the consent form with the first author’s information. Further information was disclosed upon request.

Methods

Study Design and Procedures

This qualitative descriptive study was approved by the Vanderbilt University Medical Center (VUMC) institutional review board (IRB 180477). Consolidated Criteria for Reporting Qualitative research (COREQ) Publication Guidelines were followed (Tong, Sainsbury, & Craig, 2007).

Enrolled participants submitted responses, by survey or during interviews for demographic data (i.e., age), ratings of anxiety, and clarity of instructions (i.e., verbal, written), and amount of laxative consumed. Quantitative analysis was performed with the anxiety and instruction clarity questions, which consisted of individual, one-item questions for a total of three questions, asking the participant to rate on a scale of 0 to 100. For instance, “please rate from 0–100, the level of anxiety you experienced with this colonoscopy, 0=no anxiety at all, 50=moderate anxiety, and 100, the worst anxiety you’ve ever experienced.” These items were developed for this study and have not been previously used elsewhere. The survey/interview guide questions were pilot-tested and iteratively refined by the study team, including members of the Vanderbilt University Qualitative Research Core (DGS, KB). The number of questions was determined by type of bowel preparation history: 32-items for IP history and 24-items for AP history. Semi-structured, one-on-one, telephone interviews were conducted with an interview guide (CCK, KB).

Interview questions were derived from a literature review and content expertise (CCK). Each participant was asked the same set of questions regarding the colonoscopy process with prompts and probes to expound upon unique aspects of each experience and previous colonoscopies if applicable. Telephone interviews were conducted in quiet and private, home settings. Each included interview was audio-recorded, transcribed by rev.com, and de-identified.

Recruitment, Inclusion, and Exclusion

A purposive sample of volunteers were selected from the following recruitment methods: 1) general and targeted emails, 2) ResearchMatch messages; or 3) recruitment posters displayed in the gastroenterological clinics and endoscopy lab waiting rooms. ResearchMatch, a national health volunteer registry that was created by several academic institutions and supported by the U.S. National Institutes of Health as part of the Clinical Translational Science Award (CTSA) program. ResearchMatch has a large population of volunteers who have consented to be contacted by researchers about health studies for which they may be eligible (https://https://www.researchmatch.org/) (“Welcome / Researchers / Frequently Asked Questions,” 2020). Voluntary, informed consent was obtained prior to each interview. Some study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at VUMC (Harris et al., 2019). REDCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources. Enrollment and data collection persisted until the point of data saturation, when no new themes were identified. Participants were not compensated for taking part in the study.

Candidates were screened for inclusion by the following criteria confirmed by self-report: 1) history of an IP for an outpatient colonoscopy, defined as needing a second procedure due to not being completely cleared of stool or an AP not requiring repetition; 2) English-speaking; 3) reliable access to phone and computer; and 4) 18 years of age or older. Capacity to voluntarily consent to participation was required for all interviews. Survey respondents submitted anonymously, and submission was accepted as voluntary consent.

Analysis

Quantitative: Descriptive statistics for close-ended questions were conducted in IBM 25 SPSS (CCK). Descriptive statistics were computed as follows: mean and standard deviation (SD) for normally distributed, continuous variables; median, interquartile range (IQR), and minimum and maximum values to represent ordinal data; and numbers and percentages for nominal data. IP and AP group differences were statistically tested as follows: independent samples t-test for normally distributed continuous data; Mann-Whitney tests for ordinal data; and Chi-Square Tests of Independence for nominal data.

Qualitative: Data were coded and analyzed by the Vanderbilt Qualitative Research Core team, headed by a PhD-prepared psychologist (DS). An inductive/deductive approach was taken to iteratively develop a hierarchical coding system (Fereday & Muir-Cochrane, 2006). The coding schema was structured by major phases of the colonoscopy process, mirroring the interview guide, clinical expertise, and the collected data. Initial transcripts were analyzed with a recursive process for primary categories, which were then broken into subcategories to capture further thematic detail (Fereday & Muir-Cochrane, 2006). The coding system consisted of eight major categories: 1) Knowledge of the procedure; 2) Logistics of prep and procedure; 3) Quality of instructions; 4) Quality of experience; 5) Impacts of double prep/extended prep; 6) Emotions/feelings; 7) Point of view of participant; and 8) Areas that need change and/or improvement. Each speaking term in the interview was treated as a quotation and each quotation could be given up to five codes.

Coding was performed by two trained coders. Each transcript was independently coded twice and reviewed by coders to reach consensus for any disagreements. Coded transcripts were imported into a single file and sorted by coding category. During this phase of analysis, groupings of quotes by code were interpreted and higher-level themes were generated and relationships between themes were identified. Management of transcripts, quotations, and codes was done using Microsoft Excel 2016 and SPSS version 26.0.

Results

Participants and Quantitative Results

From June of 2018 to June of 2019, 39 respondents completed anonymous online surveys and twenty participants completed telephone interviews. Purposive sampling and anonymous surveys prevented detailed tracking of non-respondents. Of 338 ResearchMatch volunteers, 52 responded with interest for telephone interviews. The first 34 of 52 participants were contacted consecutively due to budgetary and eligibility constraints. Nonparticipation reasons included nonresponse to scheduling emails (n=6), cancellation due to data saturation (n=3), no show (n=2), never rescheduling (n=2), and lack of interest (n=1). Data were excluded for one interview about an emergent colonoscopy. Interviews lasted an average of 42 minutes. Forty-four women and fifteen men contributed data (mean age=58.2 years; SD=11.8, range: 29–82). Thirty-three participants reported a history of IP while twenty-eight participants reported AP for all previous colonoscopies. There were no statistically significant differences between preparation history groups in terms of age or gender (p>.05). Additional descriptive statistics are presented in Table 1.

Table 1.

Descriptive Characteristics of Sample (N=59)

	Preparation Status
Characteristic	Inadequate (N=33) Mean (SD, min-max)	Adequate (N=26) Mean (SD, min-max)	Overall (N=59) Mean (SD, min-max)
Age (N=58)	58.3 (12.3, 29–81)	58.0 (11.7, 32–82)	58.2 (11.8, 29–82)
	Median (IQR, min-max)	Median (IQR, min-max)	Median (IQR, min-max)
Experience of Anxiety (0–100) (N=57) *	50 (22–70, 0–92)	23 (13.8–52.5, 0–100)	40 (20–58.5, 0–100)
Clarity of Verbal Instructions (0–100) (N=52) *	92.5 (52.3–100, 0–100)	100 (95–100, 64–100)	98 (83.5–100, 3–100)
Clarity of Written Instructions (0–100) (N=56)	91 (85–100, 0–100)	99 (95.5–100, 50–100)	97 (90–100, 0–100)
Amount of Laxative Consumed (0–100%) (N=57)	100 (100–100, 27–100)	100 (93.75–100, 60–100)	100 (100–100, 27–100)
Gender	N (%)	N (%)	N (%)
Male	9 (27.3)	6 (23.1)	15 (25.4)
Female	24 (72.7)	20 (76.9)	44 (74.6)
Data Source
Survey	21 (63.6)	18 (69.2)	39 (66.1)
Interview	12 (36.4)	8 (30.8)	20 (33.9)
First Colonoscopy
Yes	11 (33.3)	8 (30.8)	19 (32.2)
No	22 (66.7)	18 (69.2)	40 (67.8)
Length of time since Colonoscopy
<1 month	1 (3.0)	3 (11.5)	4 (6.8)
(6.8)	6 (18.2)	3 (11.5)	9 (15.3)
7–12 months	2 (6.0)	3 (11.5)	5 (8.5)
1–2 years	7 (21.2)	8 (30.8)	15 (25.4)
3–5 years	8 (24.2)	6 (23.1)	14 (23.7)
>=6 years	9 (27.3)	3 (11.5)	12 (20.3)
Met proceduralist before the procedure (N=58)
Yes	13 (39.4)	15 (57.7)	28 (48.3)
No	18 (54.5)	11(42.3)	29 (50)
Repeat Status (N=58) **
Yes	10 (30.3)	-	-
I’ve already repeated	17 (51.5)	-	-
Not sure	3 (9.0)	-	-
Not necessary (adequate)	-	26 (100)	-
Other	2 (6)	-	-

^*Statistically significant difference (p<.05), otherwise no statistically significant differences between groups

^**This variable applied only to those with inadequate bowel preparation history

Caption: N: Number, SD: Standard Deviation, IQR: Interquartile Range, Min: Minimum value in range; Max: Maximum value in range

The median anxiety rating for the sample was 40 (median=40; IQR=20–58.5). Those describing an experience of IP reported statistically significantly higher anxiety ratings (median=50; IQR=22–70) than those without IP (z=−2.14, p=.032, median=23; IQR=13.8–52.5).

Participants also rated clarity of instructions from zero (not at all clear) to 100 (completely clear). Clarity ratings for verbal instructions were statistically significantly lower for those with history of IP than those without (z=−2.49, p=.013). Both median written and verbal instruction clarity scores (written: median=91; IQR= 85–100; verbal: median=92.5, IQR=52.3–100) for those describing an IP were slightly lower than those with only AP (written: median=99; IQR= 95.5–100; verbal: median=100, IQR=95–100). Among 59 participants, eight participants reported that they did not receive any kind of verbal instructions for the colonoscopy preparation (IP: n= 6, 18.2%; AP: n=2; 7.7%). No other statistically significant differences were found.

Themes

A conceptual framework (Figure 1) was constructed through an iterative inductive-deductive qualitative analysis of quotes from all participant interviews (Fereday & Muir-Cochrane, 2006). Deductively the analysis relied on clinical knowledge of colonoscopy protocols and social cognitive theory (Mischel & Shoda, 1995). Analysis of quotes exhibited both depth and detail and will be summarized in the text and Table 2.

Figure 1. Patient Perceptions of the Experience of an Inadequate Quality Colonoscopy Preparation: Themes and Sub-themes.

This conceptual framework organizes the key experiential themes (i.e., title of each box, e.g., Pre-preparation) and sub-themes (i.e., bulleted list, e.g., Ease of scheduling) of the colonoscopy process: Context influences every step of the process that begins with pre-preparation and continues through implementation, and outcomes. Those with unsuccessful outcomes go through additional stages of response (e.g., anger, determination, attributions) that influence and challenge the decision to repeat.

Table 2.

Codes and Quotes

	Preparation History
Code	Adequate	Inadequate
1.1 General Purpose of a Colonoscopy 1.1.1 Cancer Screening	“A colonoscopy, from my understanding, is to check the health of your colon specifically looking to see if there's any polyps or cancerous or pre-cancerous formations.” (P19 Adequate)	“A colonoscopy is to look at the inside lining of the rectum and colon. For me iťs to see if there's any polyps or other bad cells forming so that they can screen for cancer.” (P20 Inadequate)
1.1.2 Remove Polyps	“And then, I guess if polyps are found, they can typically be removed. If cancer is found, I donť know what they do. I'm sure they have something, some procedure that they deal with.” (P19 Adequate)	“Thaťs what [the doctor] told me. Iťs so slow growing. Thaťs the beauty of it. You catch it early, like in my case, I'm good to go. Every time I go, I have less polyps. The less polyps you have, the better off you are. One of my doctors told me that. They say if you have polyps, of course, naturally, thaťs how they begin, so if you donť have polyps thaťs always a better sign.” (P2 Inadequate)
1.1.3 Other	“Well, they could also detect some diverticulitis or irritable bowel or other things they can diagnose, not just cancer.” (P16 Adequate)	“I did mention to my doctor that as well as screening for polyps, family history… I have been having some constipation, and then you wipe so hard that you have a little blood on the tissue. Oh, so the doctor said I was full of stool this most recent one, I'm like, "How could I have been?" Full of stool and I had taken extra MiraLax, didnť eat… Have a thing of [laxative] and she said I was full of stool, that I was going for constipation. She said I didnť have cancer though, so iťs like, "Wow." It was pretty disappointing.” (P20 Inadequate)
1.2 Reason for Specific Procedure 1.2.1 Family History of Colon-Related Diseases	“… iťs very prominent precancerous polyps are common in the family. So after my mother passed away, I had to do it. I didnť want to go through what she went through.” (P15 Adequate)	“It’s a necessary thing. My mother died of colon cancer, so I'm gonna do everything I can to avoid having that happen again…” (P3 Inadequate)
1.2.2 Risk Factors	“Yeah. So I went in, and I had the colonoscopy done. They found two or three polyps, which put me on a five-year plan. So when I turned 55, I got a letter from the GI specialist, who said, ‘Guess what? Time for another one.’” (P5 1 Adequate)	“Well, in my case, it was the CT scan picked up some stuff going through whatever it does. They were looking for cancer actually, and they discovered … I donť know the technical term, something in there, and said, "You probably ought to get a colon scan." So, okay, well I get a colon scan. I'd had one about 10 years before, but thaťs what I did and they go in there with their little scope and look for things and take the out if they find them.” (P1 Inadequate)
1.2.3 Age Appropriate	“The first one because I turned 50, and my gynecologist said, "Oh, congratulations, you just turned 50." I said, ‘Thank you.’ She said, ‘We're going to set up a colonoscopy.’ I said, ‘Oh, thank you.’ (P5 Adequate)	“My doctor just felt it was a good idea, I think I was [in my early 50s]. I had a doctor that was very thorough.” (P6 Inadequate)
1.3 Peer Experiences and Reports 1.3.1 Positive	N/A	“So having my family and friends are really… Because they knew my issues, they were really behind me on it, and we talked about it. Like I said, my family and I, different members, talked about it and everything. But because I've had serious issues as far as like my digestion and stuff, they're like, ‘Well, hopefully they'll find whaťs wrong with you.’ I'm like, ‘Well, yeah, that would be nice.’” (P17 Inadequate)
1.3.2 Negative	N/A	“Oh yeah, there's nothing to the procedure. Iťs simple, but the prep, yeah, iťs the prep. Iťs all prep.” (P1 Inadequate)
1.3.3 Did not discuss with peers	N/A	“I donť remember talking to anybody about what it was going to be like. Although I did read up on it and try to understand what the process was going to be like.” (P9 Inadequate)
1.4 Difference between successful and unsuccessful colonoscopy		“Then on [the night] they had me take a bottle of Mag Citrate, and then I didnť get too much sleep on [that] night into [the next day]. Then on [the second day]… And I couldnť eat [for three days], so [two days earlier] I only had a bowl of soup, then I didnť eat all day [the first day], didnť eat all day [the second day] after I had the bottle of Mag Citrate [the first night], then I started drinking the GoLytely, and I would be drinking it and then I'd start to get really nauseous. I got the first jug down, but oh my gosh, I was pretty nauseous. Then I had to wake up in the morning, at one o' clock in the morning. And I just took one glass of it and then I just started throwing up. I just threw up, and so now it’s …the morning that I go, I couldnť finish the other half…and I continued to have the heaves and throwing up bile, green bile…” (P2 Inadequate)
2. Logistics of Prep and Procedure 2.1 Percentage of Laxative Consumed 2.1.1 All of it	“I did. I didnť want to have to redo it.” (P5 Adequate)	“Every bit of it. Yes I did.” (Ss1 Inadequate)
2.1.2 Most of It	“I made the executive decision that I was clear enough.”(P7 Adequate)	“Well, the liquid I drank this time seemed to be a lot more distasteful than the other. This one, I actually threw up after like the fourth or fifth glass. I didnť have that problem with the other ones. Also, the other ones, I was able to drink a lot more of it and it only generally only takes me about half the jug because I get diarrhea really easy. It doesnť take much to get me going. I thought I'd drunk enough with this one, but not according to the nurse.” (P10 Inadequate)
2.2 Time Consumed 2.2.1 Late Afternoon	“No, actually it went later than that. I had to take the … You know what? I'm not sure. I think I did a … Somehow it looks like at 4:00 pm ….” (P7 Adequate)	“I started drinking at 4:00 PM and was supposed to drink a glass every 15 minutes over an hour period. And I think I may have been off by a half an hour at the most. Thaťs when you pay attention the most I think right there when you're trying to drink every 15 minutes to get it all down.” (P12 Inadequate)
2.2.2 During the Night	“And then, so the doctor had me take the first dose … when did he? … start the first dose the evening before the colonoscopy at 6:00 PM. So, I was right on the button. And then, exactly every 10 minutes I would take another eight ounces or whatever and really tried to force it down. And then, take the second dose four to five hours before your scheduled procedure time. So, he said, "Which would be 5:00 AM." So, I started right at 5:00 AM. I think. 5:00–6:00, 6:00–7:00. I was supposed to check-in at 7:30.”(P19 Adequate)	“Yeah, after the first gallon, it wasnť completely cleared. It wasnť like it was supposed to be, I remember, but after that … and I was starting to worry because I almost called them and said, "This ainť working. Iťs not cleared out." I have to finish my gallon. And it was early in the morning before … Actually, I did try to call them that morning to tell them that iťs still brown, you know. This stuff's not the color iťs supposed to be. But I couldnť get anybody because they werenť open.” (P1 Inadequate)
2.2.3 Other	“So, iťs likely I did do it exactly at 5:00 AM. But I was worried that … I think I kind of remember being worried that thaťs going to be too late. I hope iťs not too late because I donť want to be having diarrhea while we're trying to drive there.” (P19 1 Adequate)	N/A
2.3 Reason for Inadequate Prep 2.3.1 Incomplete Laxative Consumption	N/A	“What had happened was, I started drinking it, and I was getting it down. Then, iťs like if you're drinking something and it just comes right back up on you. It wasnť like I would drink it and I would just throw it up. I just had that gag reflex. I would drink a big gulp, and I would be there in the sink and I would throw it back up into it. Probably a full glass or so, I probably did that. At that point, you canť get it back. What was I going to do? I actually started to tell him, but I was hoping that maybe it would be clear, but it wasnť.” (P2 Inadequate)
2.3.2 Interactions with other Prescribed Medications	N/A	“I'm going to remind him of the first and second experiences. And remind him of the fact that I take medications that constipate me and that we need a more thorough prep for me.” (P21 Inadequate)
2.3.3 Lack of Understanding Concerning steps of Prep	N/A	“Well I mean, they give you the instructions and then they tell you if you have any problems to call. So I followed the instructions and I had problems. I was gagging. I was just not feeling good at all. So I did call the doctor. He said I could do an enema. Well, I donť know anything about enemas, so I sent someone to the store to get one. I attempted to do it. And I guess I didnť do it. It wasnť the right kind of enema. I didnť know there were different kinds, but apparently it wasnť the right kind, 'cause it only cleared the lower colon, not the upper colon, which is I guess why they could not do the colonoscopy.” (P8 Inadequate)
2.3.4 Other	N/A	“Yes. Because I'm diabetic, I've been diabetic for [over two decades], my digestive system has slowed down. And before it was discovered that I was having problems, I would get these massive cramps and I went to the hospital one time, and then, it was diagnosed that spastic colon that just gets blocked up and slowed down. And the cramps develop and then what I have to do is take MiraLAX every night to keep a soft stool. But otherwise, if I donť do that, then I pay for it.” (P12 Inadequate)
3. Quality of Instructions 3.1 Nursing Instructions 3.1.1 Clear	“Well, it was in person to person, which was good. Before I left my doctor's office for my routine checkup, both he and the nurse went through the prep. I was pretty knowledgeable of it because this was not my first one, so I knew what to expect. They were there to answer questions and explained medications and what kinds of things I would have to do and what I could experience and kind of a timetable of when I would experience different things. The guidelines were really very adequate.” (P16 Adequate)	“They were very good. They gave me all the instructions. Thaťs one thing about it. I knew exactly what I needed to do. There was no confusion about that. I made sure I got the right prep and all that. They were very good. They explained, have somebody drive you there because you're going to be woozy when you leave.” (P2 Inadequate)
3.1.2 Unclear	“Well, sometimes if you are hearing something without having a chance to process it, you may not ask all the specific questions. There may have been some things that could be been explained more clearly, but it was very minimal.” (P16 1 Adequate)	“I was not very impressed that thaťs all they had to offer.” (P3 Inadequate)
3.2 Written Instructions 3.2.1 Comprehensive	“Okay. Well, I think they even had it broken down what you do two days prior to the clear liquids, and then it brought it down to the day… two days before, day before, and then hour to hour, so it was very specific and very easy to understand. If you followed the directions, there was no reason not to have a really well-prepped colon prior to.” (P16 1 Adequate)	“Oh, they were great. They give you a very detail sheet telling you what to eat when and what to cut out of your diet five days before donť eat any nuts and seeds and things like that. So, everything is carefully described. And the medicine is discussed with you. Any medicines you take, they discuss with you what to take and what not to take. So, very good instructions.” (P12 Inadequate)
3.2.2 Non-comprehensive	“They were generic, if that makes sense. Each doctor has their own formula for how they want you to do it timing-wise, so they were more generic with the medications.” (P5 Adequate)	“They did not really prepare me. Since I was going into this with very little idea since I'd never had one and I hadnť really discussed it with anybody I didnť know what preparation was really needed. I didnť know really how to do it. It said how to do it but I donť think they were as good as … I thought afterwards that I wished I'd had better explanations.” (P6 Inadequate)
4. Quality of Experience 4.1 Scheduling	“My doctor recommended I do a colonoscopy when I turned 50. And she called and sent me text reminders several times over the next three years. Finally, they had the clinic call me and thaťs how it finally got scheduled. Any time I would think about I need to schedule that, I would get that anxiety and just wasnť able to follow through.” (P19 Adequate)	“As far as the scheduling for it goes, I really didnť a problem with it. I mean, when I had to wait the first two weeks or so, I was like, "All right, guys, hurry up," you know? I want to get this done. So I would have preferred that the scheduling had been sooner, like maybe three or four days after they told me I was going to have to have one, as opposed to me waiting two weeks. You know, I get a little stressed out. I'm anxious, I want to get it over with. If I'm taking tests, a medical test, I want it done. Just get it over with, you know? So when I had to wait the two weeks or so, I was just like, "You know what? …this better hurry up. The day better get here," type deal. So earlier scheduling would have been fantastic.” (P17 Inadequate)
4.1.1 Easy	“It was great, it was very, very easy, and they were very accommodating.”( P14 Adequate)	“No. They were good. They always want to do you early, and I'm not a morning person, but what the hell? I figured, leťs get in and over with and get back home and get something to eat. I was okay with that.” (P2 Inadequate)
4.1.2 Stressful	“Well the very first time I had to wait about three or four months to get an appointment. In fact, I find thaťs common that you have to wait months for this appointment. And iťs kind of hassle, because back then I was still working, I wasnť retired yet. And you have to arrange for rides, and people I know were still working, and iťs difficult. That was a major headache to me getting a ride back and forth to these things. Now that I'm retired thaťs not a problem because most of the people I know are retired, and there's always someone available now. But when I'm working, that was a problem. And they, leťs see, what was your other part of the question?” (P15 Adequate)	“So they had some problems from the department where I was having it done and the first one they said they will let me know. And I said, "Well, I'm gonna need to arrange transportation. We're arenť going to negotiate this?" "No, we'll just send you a letter." I'm like, "Okay." So they sent me a letter and I said, "Well, that didnť work." Well, now you can call and change the date. Okay. So they had kind of tidied that up a bit after that first one.” (P3 Inadequate)
4.2 Prep Experience	“…. So I think I ate a little more than I should have, and I found the cleansing out process a lot worse. The next few times I did it, I ate lighter for a couple of days, and that was much easier then when you have to do that cleansing procedure. So I find it easier to go light instead of trying to not miss any meals.” (P15 Adequate Prep)	“The day before a colonoscopy, I only drank chicken broth and I ate a lot of yellow jello. Then at the time that the paperwork told me to start the cleanse, I did it, and like I said, I did everything else it told me to do, but I didnť feel like I was cleaned out, like I told them. I only had to go to the bathroom twice, so when I was doing it, I was just like, "This doesnť seem right," you know?” (P17 2 Inadequate)
4.3 Day of Procedure	“Gosh. You know, like you said, just the time thing is the only … I mean, other than that, it was a very comfortable office. Even when you go in there, the bathrooms or restrooms were very handy. The waiting area is very … Gosh, they even had wifi. It was very comfortable and clean. Very comfortable, clean, colorful. They have nice colors. They really try to make the environment … A lot of glass, a lot of sunlight. It was all good.” (P7 Adequate)	“The reality of it is that a lot of procedures, iťs like a tooth. There's no easy way to go in and pull a tooth or whatever. There's going to be some pain, discomfort. I think some patients go in expecting, "I'm just going to lay here and nothing is ever going to hurt." It just doesnť work that way, unfortunately. None of us want to have to go through that stuff, but to go in and just think, "This is going to be a perfectly happy, lovely experience," it probably ainť going to be that way. In a way, you got to, "Do I want to suffer through this procedure, or do I want to die of colon cancer?" Between the two, I'll take the lesser of those two evils.” (P2 2 Inadequate)
4.4 Follow-Up	“I have never once gotten a letter of results from them. I've called them a couple times to ask them, and I even called a couple times and said, "You told me you were sending me something, I never got it." They said, "We'll send it." I still never got it….” (P15 Adequate)	“No, I've actually been surprised that no one's contacted me about making another go at this.” (P10 Inadequate)
4.6 Clinicians 4.6.1 Nurse	“Yes, it was very shiny and very pink. Yes. No, this is what they do every day, all day. The nurses in recovery were wonderful….” (P5 Adequate)	“I mean they didnť blame the patient. I'm sure they know that this stuff happens occasionally. You just have to redo it. But yeah, they were very nice about it.” (P11 Inadequate)
4.6.2 Physician	“I must say, when you say "comfort," the first thought that comes to my mind is that I did have a lot of confidence in the physician that did the procedure…(P7 Adequate)	“Yeah. I've had him for years. He seems to be a good guy. When he says iťs good, I trust him.” (P10 Inadequate)
4.6.3 Other	“And the person that came out, she … I donť know what her job was but she escorted us up to the proper area where we were supposed to actually check-in…So, that was a little bit confusing. So, clearer instructions on specifically where to go would have been helpful.” (P19 Adequate)	N/A
5. Impacts of Double-Prep/Extended Prep 5.1 Work	N/A	“Well, I've worked for a long time. I have a lot of sick time, but nobody covers me when I'm not there, so that means more work when I come back.” (P3 Inadequate)
5.2 Financial	N/A	“… If they could come up with a way to make that other stuff more affordable, because it was [over 100 dollars]. It wasnť outrageous, but still, not everybody is going to be able to afford [over 100 dollars out-of-pocket]. I just think insurance companies ought to include that, just because more people would get it done, and naturally, if you're getting it done ahead of the game, you're not going to have cancer, which would cost the system a whole lot more if you've got cancer.” (P2 Inadequate)
5.3 Nutrition	N/A	“And wanted me to come back the next day and I couldnť really face … that was going to be 12 meals I missed. And I was like, "No.” (P3 Inadequate)
5.4 Sleep	N/A	“… So I didnť get… I was up during the night [the first] night with the Mag Citrate, I think I worked on [the second day] the day shift, and then…And then I probably felt weaker and maybe just walked home from work but didnť exercise on [the second day].” (P20 Inadequate)
5.5 Complications	N/A	“I was very sick, the extended prep really made me sick.”( P20 Inadequate)
5.6 Other	N/A	“Nauseous, feeling not that I could just bounce back and go, go out to dinner, go for a walk. I was on the couch not really feeling very well until the next morning.” (P3 Inadequate)
6. Emotions/Feelings 6.1 Anxiety/Dread	“Well, iťs more the sedation anxiety because you never know what can happen…that was a little bit disconcerting. But not to the point where I wouldnť do anything, so it was very minor.” (P16 Adequate)	“I was frustrated. I was a little embarrassed. I almost felt like it was my own fault for a minute. And I resented knowing I was going to have to do it all over again. I did not look forward to that.” (P21 Inadequate)
6.2 Nonchalance	N/A	“Just that there isnť any point in getting upset about something that canť be controlled or changed. The next time, making sure I had as much information and I could to make it … not to let this happen again.” (P3 Inadequate)
6.3 Disappointment	N/A	“I was really disappointed, because it was really … It was not a typical, the prep wasnť anything that I could have said was typical, because I was restricted from … Well, not doing so many things, but at least eating and having to stay close to the bathroom. So it was really restrictive. So, I was really disappointed, because it was an uncomfortable prep day, and then they couldnť even do it. So I was disappointed.” (P9 Inadequate)
6.4 Anger	N/A	“I wasted a whole day of work and a whole long trip and wasted my wife's time. She was driving me. So, I just felt angry…I was angry because I'd taken off all day from work and we'd driven … It was going be [close to 100 miles] round trip.” (P10 Inadequate)
6.5 Confusion/Shock	N/A	“I was a little questioning and then miffed at the doctor that she said I was full of stool. Now how could I have been, I didnť eat… She said, "Oh you donť have cancer, but you're going to have to come back, because I wasnť able to check for polyps." I've gotten through this before but the extended prep was just too much for me.” (P20 Inadequate)
6.6 Determination/Resilience	“Oh, no. I mean, as I said, iťs not a pleasant experience, but iťs something that I feel is very important to do for my health and to be there for my family, so I had no hesitation…..” (P16 Adequate)	“…There's a lot of things, I donť get … My attitude is I've got to get it done, I canť do anything about it, worrying about the future, I just got to deal with this and do my next step.” (P6 Inadequate)
6.8 General Dislike/Unhappiness	“Uncomfortable, I mean, especially initially because you are constrained. You obviously have to stay home in order to evacuate all that. Iťs uncomfortable. Iťs not a pleasant experience, but iťs nothing that is not able to be handled.” (P16 Adequate)	“Yeah, bladder cancer's pretty awful, but any of those procedures I've had the past year for cancer, still, there's not anything like a double prep. It is by far the worst of everything I've ever had.” (P1 Inadequate)
6.9 Other		“I donť think it really affected so much, it was just… For me, it was just uncomfortable and a little bit embarrassing, but I have a really good relationship with my GI doctor and her staff, so when I went in for the next one, I was fine….” (P17 Inadequate)
7. Point of View of the Participant 7.1 Opinion on Colonoscopies in General 7.1.1 Necessary	“I think they're critically important, especially if there is a family history…” (P16 Adequate)	“I think that they are a needed resource. I actually know someone who had it where they discovered that that person had some problems. They were very early, and hey were able to intervene, and he's doing really great now.” (P9 Inadequate)
7.1.2 Life Saver	“I know that they save lives. I had a friend who did not have one until [several years after it is recommended], and when he had it, he had colon cancer…Luckily, they were able to go in and take a third of his colon out..” (P5 Adequate)	“I think they're life savers. If my grandmother had the ability to have one, she wouldnť have died at the age that she did.” (P3 Inadequate)
7.2 Likelihood of Scheduling another Colonoscopy 7.2.1 Very Likely	“Oh yeah. If I'm still alive in nine more years, I will go in and get my colonoscopy…” (P14 Adequate)	“Make a funny face and say, "Oh, all right, Doc. I'll do it, but canť you find something to make it taste better?" (P10 Inadequate)
7.2.2 Unlikely	N/A	“I donť know. They told me I should get one every five to 10 years because of the nature of the polyps that they took out, so she put me on a high risk group. Right now of course, I wouldnť. I would never take another one. That was just awful.” (P1 Inadequate) Only 1 quote for both history types
7.2.4 Other	N/A	“I guess the plan was to do it again. I had to do it again, because I'm supposed to be doing this every five years. It was unpleasant. The next time I was supposed to do it in another five years, I didnť do it. I waited a little longer. I think I waited like seven, seven and a half years to do it.” (P8 Inadequate)
8. Areas that need Change and/or Improvement 8.1 Improved Explanation of Adequate Prep	“I think if I get written instructions first, then I can read those and then if I have questions, then thaťs a good idea to do it that way.” (P14 Adequate)	“Make sure the instructions in the protocol are as clear as possible. Probably for a fifth-grade education, eighth grade education, so that everybody can understand whaťs entailed. Tell people to make sure they're well hydrated before they start the prep.” (P11 Inadequate)
8.2 Logistics of Preparation Process	“So not knowing the medical process of the whole thing, I'm not sure. At least for me, I think it would have been better if it was possible, if it was medically acceptable, if I could have done eight ounces every 20 minutes or something like that. And probably on the one where he says, "Start at 5:00 AM," which literally was two and a half hours before my scheduled arrival time, maybe if that one could have been started [earlier].” (P19 Adequate)	“Mm-hmm (affirmative). My family physician should have noticed it too. You know? But they're busy too and donť go, "Oh, she's on MiraLAX every night." But thaťs something a family physician can bring up with patients if he says, "You've got to have a colonoscopy again. Go sign up." And okay, fine. Give me a hint that thaťs what happens when you go on MiraLAX treatment. So, I think iťs almost more the responsibility of the family physician who knows you and sees you every month almost for them to be alert to this issue. Like put a little article in American Family Physician Magazine or something.” (P12 Inadequate)
8.3 Procedure	“Well, let me think, well this wouldnť concern what you're doing I donť think. But I was a little irritated at this last time I went where this younger woman was filling out some forms, and I was ready to get dressed. And she refused to leave while I got dressed, and she stood there staring at me…?” (P15 Adequate)	“What could have been different? I think the doctor could have been more compassionate to see how hard I tried, and I thought her expression, "You're full of stool," was a little… I didnť understand that because, how could I have been full of stool? I mean, did she say that too casually, or was I really full of stool? Then there's something wrong and I didnť get an explanation of that.” (P20 Inadequate)
8.4 Improved Interpersonal Communication	“I have never once gotten a letter of results from them…” (P15 Adequate)	Knowledge of how to contact after hours if there is a problem: “Yeah, after the first gallon, it wasnť completely cleared. It wasnť like it was supposed to be, I remember, but after that … and I was starting to worry because I almost called them and said, "This ainť working. Iťs not cleared out." I have to finish my gallon. And it was early in the morning before … Actually, I did try to call them that morning to tell them that iťs still brown, you know. This stuff's not the color iťs supposed to be. But I couldnť get anybody because they werenť open.” (P1 Inadequate)
8.6 No Change/Improvement	“Nothing, really. The nurses were wonderful, they're so good at putting in IVs, and needles donť bother me. And when I woke up, they said I'd been chatting. Which there's nothing I can do about that. I was comfortable, and they asked what I wanted to drink, and asked if I felt well, and after I had been awake and drinking, I think it was about an hour, then I was able to be taken home.” (P14 Adequate Prep)	“Nothing really. Everything was all right. It was just me. They tried to do it, and they werenť able to. They did … there's another less invasive kind of test, I forget what they call it. They were able to do that, which I think that must just do the lower colon. I'm not really sure. But I donť remember. But they did that, but they said they couldnť do the colonoscopy. So I would be back for that.” (P8 Inadequate)

Caption: Quotes are presented for each code for each preparation history type. N/A or Not applicable indicates that there was not a quotation for the preparation history type. Some of the questions in the interview guide were asked of those with inadequate bowel preparation history only to further explicate their unique experiences.

Context

The colonoscopy experience was influenced by the contextual factors that were unique to each participant such as understanding the purpose of the colonoscopy: “A colonoscopy is to look at the inside lining of the rectum and colon…see if there’s any polyps or other bad cells forming so that they can screen for cancer.” (P20, IP). For those with IP, family history of colon cancer and discussions with loved ones may have primed attitudes and expectations for the difficulty or ease of preparation. Anxious anticipation permeated experiences of the colonoscopy process: “…I was really anxious about this colonoscopy the next day. I don’t think I slept very well” (P8, IP).

Pre-preparation

Prior to the preparation phase, sub-themes consisted of ease of scheduling, instruction clarity, and evaluation for extended preparation. Scheduling could be a straightforward process: “…they were very accommodating,” (P14, AP) but could be frustrating: “… If I’m taking…a medical test, I want it done…I had to wait the two weeks [for scheduling]…” (P17, IP).

Participants from both preparation backgrounds noted the helpfulness of either spoken or written instructions. Effective instructions made a difference: “… they answered all my questions [and]…were very patient… [the instructions were on] brightly colored paper so you couldn’t mix them up with anything else…” (P12, IP). Another participant with IP history acknowledged the instructions were not to blame for the IP outcome: “…they were completely clear…And I’ve followed that protocol before and not had a problem, it was just this time” (P11, IP).

Implementation

The implementation theme entailed sub-themes of preparation type, adherence to the preparation, tolerance of the preparation, and unpleasantness of the experience. One participant with an AP history was surprised by the laxative effect: “…I wasn’t prepared for the explosive diarrhea” (P18, AP). Respondents described the laxative consumption schedule as too inflexible: “… If I knew we need you to do at least 80%…then I wouldn’t have been so forcing myself into the really painful discomfort of drinking so much so fast” (P19, AP).

Adherence to laxative consumption was influenced by tolerance of taste, physical responses of vomiting or diarrhea, and of the prescribed pace. Those with IP experienced additional stress: “…I did everything else it told me to do, but I didn’t feel like I was cleaned out…I only had to go to the bathroom twice…” (P17, IP). One participant with IP noted wanting to keep the appointment despite doubts: “I never could finish the other half of the [laxative] and…I was so weak that my husband says, ‘We really shouldn’t go…’” (P20, IP).

Outcomes

Those with AP history typically had little trouble after the implementation phase, but were concerned with privacy, safety, and hunger. One participant recalled frustration: “…[the nurse] refused to leave while I got dressed…I think I deserve some privacy when I’m putting my clothes on…” (P15, AP). Another participant described safety around discharge: “…[It would have been] better to have stayed in the recovery area a little bit longer so that I had a little bit more coherence…” (P19, AP). A participant discussed staff skill and support: “… [Before] The nurses were wonderful, they’re so good at putting in IVs…[After]… they asked what I wanted to drink and asked if I felt well…” (P14, AP).

Response

Several emotions accompanied the discovery of an unsuccessful outcome. Participants consistently described experiencing anger with perceived waste and inconvenience, anger toward self, preparation, the process, or anger with staff. One participant described frustration: “…the fact that I was alert and could actually see the gunk, I think that was the part that was humiliating. Like, “…I did everything according to the instructions…I was frustrated because I did my best, but it wasn’t good enough…” (P12, IP). A participant described the reaction to the news: “…I was definitely embarrassed when they woke me up and told me that the prep wasn’t complete…I went through a lot of ups and downs.” (P17, IP). Anxiety persisted as participants processed the implications: “Knowing that I would have to do it again was … after I had such a struggle with that prep….” (P8, IP).

Other participants with CRC family history described resolve and determination to succeed: “It didn’t really bother me. Knowing what my mom went through and everything, I certainly didn’t want to have to go down that path” (P2, IP). Another participant was determined to share positive views despite bad experiences: “… My daughter had to go through one…. I talked to her about like I wished that they had talked to me, explaining…how important it is to have that clean…” (P6, IP).

Participants reported that clinicians were pleasant and supportive. One participant described non-judgmental staff: “I mean they didn’t blame the patient. I’m sure they know that this stuff happens occasionally…” (P11, IP). Alternatively, one participant was frustrated that the procedure was performed despite warning: “… when I went under and it proved that I wasn’t [clean], I was very angry about them…not paying attention to what I was saying…” (P17, IP). However, patient-physician trust was a consistent theme: “… I’ve had him for years…When he says it’s good, I trust him.” (P10, IP).

Some of the participants attributed the outcome to different causes. One participant described vomiting as a barrier to finishing: “…I would drink a big gulp, and I would be there in the sink and I would throw it back up…” (P2, IP). Others reported medication side effects: “…the cancer treatment I take… it’s notorious for creating constipation” (P1, IP). Reasons also included misunderstanding instructions, diabetes-associated dysmotility, and dehydration from exercise.

Decision to Repeat

Most participants reported that they either planned to or had already repeated their colonoscopies. One participant shared how provider and staff rapport influenced the experience: “I have a really good relationship with my GI doctor and her staff, so when I went in for the next one, I was fine…” (P17, IP). Participants with IP described various contextual reasons for continued colonoscopy. They discussed experience with CRC, the influence of family history on decisions, and accepting responsibility. One participant described a personal relation with CRC: “I actually know someone who had it where they discovered that that person had some problems. They were very early, and they were able to intervene….” (P9, IP). Participants ultimately accepted the responsibility: “…although I did everything I was supposed to, but you can’t really blame anybody except yourself” (P11, IP).

Participants discussed contextual considerations of repeating the process. The repeat procedure and extended preparation burdened participants with unanticipated costs, time off work, and potential health risks of losing sleep and meals. One participant described work demands: “…nobody covers me when I’m not there, so that means more work when I come back.” (P3, IP). Two participants described complications during and after performing an extended preparation: “…I had an extended prep and the extended prep really made me sick.”(P20 IP) and “My biggest complaint about this whole process is the way it’s left me [with constipation]…” (P1, IP).

Discussion

Colonoscopy preparation occurs within the context of personal experience and quality of preparation. There are clear differences in the quality of experience when we compare those with AP and IP. While most see colonoscopy preparation as an invasive and unpleasant experience, participants who were informed of their IP had additional negative experiences. These experiences informed their decision to undergo a repeat preparation. A better understanding of patient response to an IP may lead to improvements in screening for IP risk factors and communicating preparation instructions. Understanding the subjective experience of a failed colonoscopy may enable providers to develop strategies for better supporting these patients.

Although a recent qualitative study explored general patient experiences of colonoscopy, to our knowledge, this is the first study to explore how patient experiences compare at every stage of the colonoscopy process related to this outcome (Restall et al., 2019). The personal context in which a colonoscopy is performed includes elements such as prior experience, peer influences, understanding of indications for colonoscopy, and anxious anticipation. Anxiety is a well-documented experience among patients that undergo colonoscopy (McLachlan et al., 2012; Mikocka-Walus et al., 2012; Shafer et al., 2018). We found that those with IP reported higher levels of overall anxiety than those without such a history. Preparation and procedure phase anxiety may have been exacerbated by trouble with the laxative, the prospect of extended preparation, and the uncertainty of future outcomes.

In addition to anxiety, we learned that participants with IP had other emotional experiences including disappointment and embarrassment and that these experiences differ from those with only AP history. Other studies have found similar patterns among patients undergoing colonoscopy (McLachlan et al., 2012; Mikocka-Walus et al., 2012). We found that unpleasant staff interactions may make the experience of IP even more unpleasant. A separate study found that participants also relayed positive experiences and identified the importance of staff support (Restall et al., 2019). Patients with IP often engage in self-blame and providers may lack time and resources to support them appropriately.

Provider recommendations are instrumental to colonoscopy screening adherence (McLachlan et al., 2012). Patients with IP may not view colonoscopies as worthwhile preventative care. Trust in the colonoscopy provider was essential in the setting of an IP. Furthermore, we found that most of those with a history of IP reported that they either planned to repeat the colonoscopy or had already completed it. Providers and staff may provide additional support as patients struggle with the decision to follow through and repeat the procedure.

These findings may be used to develop preventative measures and interventions that have clinical significance for nursing. Prior to endoscopy, standardized screening methods may be used to identify those at highest risk for IP. Based on the literature and study findings, risk factors may include constipating medications such as certain types of chemotherapy, narcotics, and Tricyclic Antidepressants; and diabetes, intestinal dysmotility, or constipation (Mahmood et al., 2018; Yee et al., 2015). Additionally, higher risk patients may need more intensive, tailored instructions. Nurse navigators have an important role in promoting bowel preparation quality by guiding patients through each step of the process, providing clear instructions, and screening patients for risk factors (Yee et al., 2015).

In this study, more of those with IP history reported having no verbal instructions and gave lower ratings for verbal instruction clarity than those with AP. The teach-back method should be used to confirm understanding and assess need for alternative educational strategies. Providers can use the teach-back method after providing education by encouraging patients to verbalize key education concepts in their own words (Tamura-Lis, 2013). Facilities that only employ one type of educational method (e.g., written only) may benefit from integrating additional educational strategies for all learning types (Boyde & Peters, 2014). Verbal instructions and instructional videos have been associated with improved quality of bowel preparation (Hsueh et al., 2014; Lee et al., 2015).

When prevention fails, endoscopy nurses may focus on intervention. This may include training endoscopy personnel and establishing algorithms for appropriate response. Staff should address specific emotional and practical barriers that may prevent a patient from repeating the procedure. The patient may also be supported with timely and efficient communication regarding plan of care. For instance, staff may facilitate the rescheduling process for the next day to reduce inconvenience and reinforce determination to have a successful outcome (Lebwohl et al., 2011). Advising patients on a repeat colonoscopy should emphasize health consequences and a thorough, tailored approach to identify preparation steps that could be improved.

Limitations

This study did not include the methods of member checking, audit trails, and field notes that promote trustworthiness in qualitative data (Morse et al., 2002). However, themes were compared across preparation type, transcripts were checked multiple times to verify findings, and quantitative data were triangulated with qualitative data. The study integrity was enhanced through collaboration with an established, professional Qualitative Research Core.

The majority of participants were women. Themes from this study may not transfer to all genders; however, several findings are consistent with previous findings. Data were not collected regarding race/ethnicity, income, educational attainment, or occupation. The majority of respondents correctly identified key components of the colonoscopy purpose reflecting higher health literacy (King-Marshall et al., 2016). Those with lower health literacy may have different experiences of the colonoscopy process relative. Many participants shared occupational information that suggested educational attainment beyond a high school degree. Their experiences may differ from those with lower educational attainment.

Interviews and completed surveys were completed cross-sectionally without follow-up, which may have limited the detail of the description. Most participants confirmed bowel preparation quality by self-report for feasibility but may differ from provider documentation and procedure imaging. The majority of participants may have had some difficulty recalling some details as most participants described procedures from one year or more before the interview or survey encounter with 20% overall reporting a time lapse of equal to or greater than six years. Purposive sampling was utilized for this study due to time constraints. This method is weaker, because it is less representative of the general population (Trochim & Donnelly, 2008). Given the purpose of this exploratory study, preliminary themes were identified. Lastly, many interview participants were recruited from ResearchMatch. Those on this platform may be more motivated than the general population, which may also account for the reports of the high repeat colonoscopy rate.

Conclusion

Our findings indicate an interplay of patient context, instruction clarity, staff support, and the burden of extended bowel preparation. Future studies may explore the influence of cultural attitudes, health literacy levels, variations in family and personal medical history, and experiences of different degrees of bowel preparation (Hennelly et al., 2015; Kiviniemi et al., 2014). Themes may differ among those with lower awareness, self-efficacy, or understanding of the colonoscopy process and outcomes (Hester et al., 2015; King-Marshall et al., 2016). Interventional studies are necessary to test emotional support strategies, IP screening tools, and interdisciplinary collaboration with nutritionists, psychologists, and social workers to customize preparation protocols and instructions, and address financial and logistical barriers.

Patient-centeredness may be promoted with adequate staffing to support patients during different stages of the colonoscopy process. Staff and provider education may be necessary to discuss prevalence, predictors, and prevention of IP (Gkolfakis et al., 2019). While lack of adherence to preparation instructions are a factor of this outcome, there are a myriad of other influences that must be considered (Mahmood et al., 2018). Processes for checking insurance should include review of coverage for repeat procedures and laxative solution prior to initiating the colonoscopy process. Insurance companies should be encouraged to cover the costs of repeat preparations.