Interference of Postoperative Pain on Women's Daily Life after Early Discharge from Cardiac Surgery

Design 

A combination of interviews, established questionnaires in the pain field, and a self-developed pain diary was chosen to capture the various aspects of women's postoperative pain experiences.

Ethical Considerations 

Ethical approval was obtained from the Regional Committee for Medical Research Ethics and the Ombudsman for Privacy in Research, Norway. Each woman received verbal and written information about the study that included her right to refuse participation or to withdraw at any point in the study. After written informed consent was obtained and before discharge, each woman received a folder containing the pain diary with instructions. The consent was confirmed by telephone when they were contacted after discharge, and their right to refuse participation was repeated when the researcher met them at home.

Participants 

Inclusion criteria were women able to understand, read, and write Norwegian, admitted to their first elective cardiac surgery, and able to take care of themselves after discharge. Suitable women were consecutively approached for recruitment in the study by staff nurses at two thoracic surgical departments at a large university hospital in Norway from September 2004 to September 2005.

Two days after discharge, consenting women were contacted by the first author, and appointments were made for interviews in the women's homes. Altogether 30 women were approached while hospitalized, 21 women agreed to participate before discharge, and 10 gave their final consent by telephone.

Data Collection 

Interviews lasting 40-90 minutes were conducted in the women's homes 8-14 days after discharge. The research questions of the large study guided the development of the open-ended questions for the semistructured interview. The interview guide covered the following themes: daily activity and rest, need for help, use of analgesics, pain alleviation, and pain experiences in the hospital. During the interviews, the women were encouraged to talk freely about their experiences.

Principles from established self-reporting instruments to measure pain were used to develop a structured pain diary (Klepstad et al., 2002; Schumacher et al., 2002). Women used the pain diary to record the levels of pain as “worst,” “least,” “average,” and “pain now” using a 0-10 numeric rating scale (NRS). Descriptive words for the range of pain were also included on the NRS (no pain, mild, moderate, severe, and worst pain). The women were instructed to fill in the diary before bedtime every day after returning home from the hospital. The women also recorded the sites of pain and the pain medication used and its dosage and effectiveness. They assessed this information five times each day. The diaries were completed for 8-14 days. The first two women included in the study pretested the diary and found it simple to use. The only change was to include the night as a time for pain assessment.

The Brief Pain Inventory–Short Form (BPI-SF) is an established multidimensional instrument used with diverse populations of people experiencing pain (Cleeland & Ryan, 1994; Daut, Cleeland, & Flanery, 1983). The instrument was developed primarily to measure cancer-related pain, but it has also proved to be useful as a measure of postoperative pain experiences and the impact of pain on daily functions (Zalon, 1999). In the present study, we used the Norwegian version of the BPI-SF (Klepstad et al., 2002). This instrument measures pain intensity, pain location, pain relief, and pain interference. Only data about pain intensity now (at the time of interview) and pain interference are shown in the present study. Pain interference is measured by seven items that measure how much the pain interferes with daily functions related to general activity, mood, walking ability, normal work (including housework), relations with others, sleep, and enjoyment of life. Pain intensity scores (pain now) were obtained using an NRS from 0 (no pain) to 10 (worst pain imaginable). Pain interference with seven functions was measured using an NRS from 0 (does not interfere) to 10 (completely interferes).

After an introduction and before the interview started, the women filled in the BPI-SF. Demographic data were obtained when closing the interview.

Data Analysis 

The transcribed interview data were analyzed qualitatively (Kvale, 1996; Malterud, 2001). Transcripts were compared with the tapes for accuracy. The first readings were done before analyzing the pain diaries and the BPI-SF to avoid data contamination. The following analysis describes only the development of themes addressing the research questions for this article.

The women's experiences of postoperative pain and descriptions of their daily life guided the first reading of transcripts. After the text had been copied into a new document, the two research questions guided the analysis in uncovering the main categories within each substantive area. These categories were combined in a second document to give an overall picture of each woman's experience of pain and daily life after cardiac surgery. The final themes and subthemes were identified through this thematic content analysis. The third author reviewed these analytic steps to verify the final themes and subthemes.

A total of 109 single pain diary entries were obtained, representing each postoperative day before the day of interview. The number of single entries from each woman varied between eight and fourteen. Data from the entries in the diaries were transfered and displayed in one matrix for each woman. This included four different pain scores, the types and amount of pain medication, and its effectiveness at five times each day. The procedure was verified by a colleague, who independently recounted 20% of the randomly selected single pain entries; only minor corrections were made. Further information about how the pain diaries were analyzed is given elsewhere (Leegaard & Fagermoen, 2008b).

Pain intensity now and the interference scores from the BPI-SF were recorded. Microsoft Office Excel (version 2003) and GraphPad Prism (version 4.03) were used for simple statistical calculations and graphic representations of data from the pain diaries and the BPI-SF.

Setting the Stage 

Demographics of the ten included women are presented in Table 1. The age range was 52 to 82 years, with three women >70 years of age. All had easy access to close family members if assistance was needed after discharge. Two women lived alone.

Table 1. Demographic Characteristics (n = 10)

	Age in years, mean (range)	61.4 (52-82)
	Marital status
	Married or live-in partner	7
	Divorced	1
	Widow	1
	Unmarried	1
	Living arrangements
	With spouse or other close relative	8
	Alone	2
	Years with known heart disease
	<6 months	4
	≥6 months and <2 years	1
	≥2 years	5
	Type of cardiac surgery
	CABG	6
	Valve surgery	2
	CABG and valve surgery	2
	Length of hospital stay in days, mean (range)	9.4 (6-17)
	Days at home after discharge, mean (range)	13.3 (8-15)

CABG = coronary artery bypass grafting.

Four women were aware of having heart disease for <6 months, indicating that they had received urgent surgery. The length of hospital stay (LOS) represents the total number of days hospitalized before discharge and returning home. The normal procedure is to undergo surgery the day after hospital admission, and some women were sent to a local hospital before returning home. Two women needed >11 days in the hospital, and the others returned home 6-9 days after surgery. Two women undergoing valve surgery had a shorter LOS than the others: 6 and 8 days. The number of postdischarge days at home before the woman met the researcher is recorded as days at home after discharge. The variation was due to the women's schedule when agreeing on a time for the interview.

All patients received written instructions from the hospital's physiotherapist about how to perform daily exercises after discharge. Patients were advised to find a good balance between rest and activity, and to try to return to normal activity as quickly as possible. The instructions were very specific regarding different kinds of physical exercises to prevent stiffness and aching in the neck and shoulders. It was strongly recommended to patients to take three short walks every day and to gradually increase exercise duration gradually. They were also advised to follow specific restrictions for the first 2-3 months after surgery, e.g., avoid lifting >5 kg (2.5 kg with each hand), driving a car, and movements that might strain the sternum.

In Norway, all patients are offered, free of charge, 1-3 weeks at a convalescence center after discharge from cardiac surgery. The women in this study had different reasons for not accepting this offer, such as having no experience with convalescence homes, feeling more comfortable returning home, being tired of hospitalization, and having had negative experiences with health institutions. However, two women commented that without their spouse, they would not have dared to go straight home.

For pain medication, patients were advised to use one or two tablets of acetaminophen (500 mg) two to four times a day for the first weeks at home. They were also given a prescription of a stronger analgesic to use “as required” when experiencing their worst pain: 20 tablets of acetaminophen (500 mg) combined with codeine (30 mg). This information was given in a booklet to take home, usually supplemented with oral information given by the surgeon on duty.

BPI-SF and Pain Interference 

The women filled in the BPI-SF immediately before the interview took place 9-15 days after discharge. Scores for pain interference with different aspects of daily life and activity are given in Figure 1. One woman declined to answer the BPI-SF, because she did not like to fill in self-reports.

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Figure 1 The level of interference with daily life from BPI-SF. The median score is indicated by a horizontal rule for each variable. The dots indicate each woman's score on the interference scale.

Four of nine patients reported that pain affected their general activity, normal work (including housework), and sleep (Table 2). Three women reported the maximum score of 10 on how pain affected general activity. These areas had the highest intensity scores, i.e., were most affected (Fig. 1). Walking ability was the least affected, whereas the effects on mood, relations with others, and enjoyment of life varied from “no interference” to “all the time.” The median scores for the different areas confirmed these results.

Table 2. Sum Scores on Interference Scales from BPI-SF, Areas Most Affected, Pain Intensity Now, and Number of Days at Home

	ID∗	Sum Score (0-10)†	Areas Most Affected	No. of Days at Home	Pain Intensity Now (0-10)‡
	Evy	8.9	General activity	14	3
			Normal work
			Sleep
	Carol	7.3	General activity	9	3
			Normal work
	Kate	6.6	Enjoyment of life	15	2
	Sharon	6.0	Relations with others	10	4
			Sleep
	Grace	3.7	General activity	15	2
	Emma	3.4	Normal work	15	3
	Anna	2.4	Normal work	13	2
			Sleep
	Mia	2.1	Sleep	13	1
	Judy	1.6	General activity	15	0
			Mood

∗ ID names are pseudonyms assigned to each woman to maintain confidentiality. † Sum of total interference score divided by 7 (seven variables). ‡ Score on numeric rating scale immediately before interview.

The individual sum scores of pain's interference in the different areas varied from 1.6 to 8.9 (Table 2). The number of days at home after surgery were also studied to see whether this affected interference, but no clear pattern was found. Women with the lowest pain interference sum score also reported low “pain intensity now.”

Self-Medication after Discharge 

The pain diaries showed that few women consumed the maximum amount of pain medication (eight tablets per day of acetaminophen with or without codeine) in the first weeks after discharge. The consumption varied: Two women used pain medication regularly four times a day, one woman used nearly no pain medication, and the others used one to eight tablets of acetaminophen a day. Consumption of codeine was minimal. One woman did not use codeine at all and another consumed only 30 mg of codeine twice during the first week.

Daily Rhythm 

Cardiac surgery is expected to interfere with the patient's ability to return to usual daily activities within the first 2 weeks after discharge. The pain diaries provided data on pain intensity and pain sites during the day and night after discharge. During the interview, each woman was asked to describe in detail one typical day from morning to late at night.

Housework 

All of the women had ready access to help with household activities after discharge. The hospital recommended restrictions on physical activities to avoid strain on the chest wound, which limited their performance of housework.

I tried to put some laundry in the washing machine yesterday, but pain in my chest and arms made it impossible. I can imagine how painful it would be to take the laundry out again. (Anna)

I tried to vacuum once despite knowing this was forbidden, and I had so much pain. (Evy)

Not being allowed to lift more than 2.5 kilos makes housework almost impossible, but the sternum split should be handled like another broken leg. (Judy)

The most commented upon activities were doing the laundry and keeping the house clean, but not being able to lift more than 2.5 kg in each hand also restricted domestic activities such as shopping and making dinner.

Their need for help depended on how they felt each day, or as Grace described: “If I'm in good shape I still want to do most of the housework myself.” The women commented that male partners do not “see” the dust or have other opinions about what a clean house is. As Sharon expressed it: “I have decided to be generous toward my husband even when the dust bunnies keep running after me.” The women accepted help for housework such as vacuuming and taking the laundry in and out, but wanted to organize the activities, e.g., to avoid damaging the clothes. Another option was to not care too much:

I had to place restrictions on myself about cleaning the house because this is something that preoccupies me. So, I have told myself this is not alpha and omega—don't bother (Mia).

The two women without a live-in partner found that asking for help was more difficult, because they did not want to bother their family with unnecessary housework such as dusting. Feeling tired all the time was in general described as a major reason for not doing housework, or they described not yet having enough energy.

General Activity 

The general activity theme includes both physical and social activity after discharge. All women tried to follow the advice to take three short walks each day. The best time was around noon, but only two were able to do this more than twice a day, as Anna described: “Three times is too much, I don't have the energy yet.”

The women tried to follow instructions about physical exercises such as moving their arms and neck at least once a day. Some saw it as a duty: “I do as the doctor has told me” (Jenny). Others did exercises to avoid complications and described positive experiences such as less shortness of breath when walking hills and steps. Four women described problems because they had been too optimistic about their physical capacity after discharge.

Maybe I was too tough with myself after discharge from hospital. I went out walking and pushed myself to continue walking until it was almost impossible to walk back home and my husband encouraged me to try even harder. (Judy)

Another option was to take life more casually, and their favorite position was to sit down and rest in their armchair during most of the day. Evy described: “I do things in slow motion—that feels okay.” No woman talked about the importance of physical activity to avoid thromboembolic complications after surgery, but all used the elastic stocking as recommended.

Not being allowed to drive a car for the first 6 weeks after surgery inhibited their social activity. Two women confessed during the interview that they had broken this rule after 1 week because of family obligations or feeling isolated and needing to see some people at the shopping mall. Kate followed the rules, but “not being allowed and able to drive a car has restricted my freedom because my husband doesn't drive anymore.”

The women limited visits by family and friends because of their lack of energy and to avoid becoming exhausted. Usually, only the closest family members were allowed to visit, and the women used phone calls to maintain other relations. Jenny expressed it this way: “I am lucky and have a lot of friends, but you can't pull the string too far regarding social activity.” Social activity was also dependent on how they had organized their lives and contacts with friends and neighbors before the surgery.

Limitations 

The small sample size and the demographic characteristics of the present sample limit the ability to draw general conclusions from the data. One limitation is that almost 50% of the women dropped out of the study from the first consent at the hospital to the second consent by telephone after returning home. There are several possible reasons for this, and the most likely reasons relate to the women's personal problems or the researcher's difficulty in reaching the patients by telephone. The inclusion only of women who could take care of themselves after discharge also restricted recruitment. The final sample had a lower mean age (55.7 years) than the typical female heart patient in Norway (68 years) (European Association for Cardiothoracic Surgery, 2005). Because the sample only included women who could take care of themselves, with the result that women of a younger age than most female heart surgery patients were included, the sample was healthier than most women after heart surgery in Norway.

To understand more about the participants’ complex and many-faceted postoperative pain experiences, we used a combination of semistructured interviews and self-reports. Therefore, the data are inherently different, and findings cannot be compared directly or used to confirm or validate each other.