Due to advances in surgical and anesthetic techniques, day surgery has become a common practice worldwide.1-3 Day surgery, also known as ambulatory surgery, is defined as “an operation or procedure where the patient is discharged on the same working day”.4 (p.6) It is considered a safe and cost-effective approach to surgery.5 A survey of 18 countries showed that the United States and Canada performed 80% of procedures as day surgery, which was followed closely by Scandinavian countries.1 In Australia, just over 50% of operative procedures performed from 2010 to 2011 were day surgery.6 Along with improvements in surgical and anesthetic techniques, advances in pain management have also increased the range of operations available as day surgery. These include ophthalmic, ear, nose and throat, orthopedic, gynecologic, gastrointestinal, urology, plastic and even trauma surgery.7
Day surgery offers a range of benefits to both patients and the healthcare system. There is a wealth of literature suggesting high levels of satisfaction among patients who have undergone day surgery.8-11 Day surgery allows patients to recover at home in a familiar environment, minimizing the separation from family and friends.9 Patients have also reported that it is less disruptive and time consuming12 compared to surgeries that require hospitalization. Day surgery offers convenience not only to mothers with small children but also individuals who are employed.13 For the healthcare system, day surgery increases throughput,14 decreases the waiting list15 and reduces the overall cost of care.14 The hospital cost for day surgery is 25% to 68% less than what would be required for an inpatient stay.15 In addition, the incidence of hospital-acquired infections, complications and rate of mortality is low.15
While there are advantages associated with day surgery, it also presents challenges that mainly revolve around discharge and recovery of patients at home.16 Following surgery, care is transferred to patients and their carers, which means that they do not have the advantage of healthcare professionals monitoring and facilitating their recovery.17 Misconceptions also exist where the term “day surgery” is perceived as synonymous to “same day recovery”, which may lead to unrealistic expectations of recovery among patients and their carers.18 Although major complications are rare, symptoms such as postoperative pain, nausea and vomiting, drowsiness, fatigue and headache are common,3,15,17-23 which often pose physical restrictions. If not effectively managed, these symptoms can persist and recovery from day surgery can be problematic and delayed, or cause unnecessary hospital admissions. A study found that symptoms such as pain and wound problems (e.g. bleeding and swelling) were present for up to three months following day surgery.20 Patients reported restricted mobility, impaired sleep and inability to live normally because of their lingering postoperative symptoms.20 In another study, patients who underwent general surgery and urologic surgery had bruising, swelling and skin discoloration which affected their self-image.19 Some patients described coping with such symptoms as stressful. Feelings of uncertainty are also common in day surgery patients. A qualitative study examined the postoperative experiences of women following gynecological surgery and found that majority of patients felt uncertain about what was “normal” in regards to the symptoms they were experiencing.24 Another study found similar results and reported that patients and carers felt uncertain of how to manage symptoms and who to turn to for support.18
Day surgery patients require support to help them manage their own care and feel confident in themselves and others who will be involved in their care (i.e. their carers). They need sufficient information to be able to manage postoperative symptoms and potential complications, and feel prepared for their recovery at home. However, there is evidence to suggest that patients and carers do not receive adequate information and support to prepare for discharge and recovery at home. A study involving women who underwent day surgery found that access to support was not sufficient.25 Another study showed that information given to patients postoperatively did not always address patient's needs and often was based on what nurses perceived as important for the patient to know.24 For example, women post-gynecological surgery, although they were provided information about pain management, were not given specific information on when they could resume sexual activities which was a source of distress for many younger and middle-aged women.25 There are also other factors in the day surgery setting which preclude the delivery of good quality information and effective support to patients and their carers. For instance, patient turnover is rapid and the quality of nurse-patient and carer interaction is often challenged by time constraints.10,18 The provision of written and verbal discharge education is also challenged by patient anxiety and forgetfulness brought about by anesthesia. It is therefore important for healthcare practitioners including nurses to understand these factors and the individual patient needs so they can provide a tailored approach that can facilitate safe and effective transition of care.17 A systematic review demonstrated that a tailored discharge plan which includes education and various forms of healthcare support can increase patient satisfaction and reduce the risk of hospital readmission in medical and surgical patients.26 While this systematic review does not specifically relate to the discharge and recovery of day surgery patients, it underscores the importance of education and support in preparing patients’ transition to their home environment.
A systematic review of patient experiences of discharge and recovery following day surgery is important in determining their needs and support requirements. A literature review by Mitchell in 201310 summarized the findings of 25 studies which examined the nursing support required by day surgery patients to facilitate their recovery at home. Common themes identified from included studies were related to pain management, information provision and post-discharge anxiety. While this review provided useful information, it did not critically appraise the literature and more studies pertaining to discharge and recovery from day surgery have been published since the review. A search of the Cochrane Database of Systematic Reviews, PROSPERO and the JBI Database of Systematic Reviews and Implementation Reports failed to identify a systematic review on adult patients’ experiences of discharge and recovery from day surgery. A systematic review investigating patients’ experiences can help identify important information about discharge and recovery at home which will be useful for healthcare professionals, specifically nurses, in understanding how to best prepare patients and their carers postoperatively.
This review will consider studies that include adult patients aged 18 years and over who have been discharged from day surgery. This review will include any type of day surgery procedure including, but not limited to: ear, nose and throat, general, gynecology, ophthalmic, oral and maxillofacial, orthopedic, plastic, urology and vascular surgeries.
Phenomena of interest
This review will consider studies that explore adult patients’ experiences of discharge and recovery following day surgery. These experiences can include those related to discharge process and preparation, physical and/or psychosocial recovery (e.g. symptoms such as pain, nausea and fatigue), psychological reactions (e.g. anxiety), complications and their ability to manage, return to normal activities, support requirements from healthcare professionals and/or carers/family, and met and unmet needs.
This review will consider studies on day surgery.
Types of studies
This review will consider qualitative studies including, but not limited to, designs such as phenomenology, grounded theory, ethnography and action research. Descriptive qualitative studies that describe the experience or the effects of the experience will also be considered. Only studies published in English will be considered for inclusion in this review.
The search strategy aims to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL will be conducted, followed by an analysis of text words contained in the title and abstract, and of the index terms used to describe the article. This will inform the development of a search strategy which will be tailored for each information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
The databases to be searched will include CINAHL, MEDLINE, Embase, PsycINFO and Web of Science. The search for unpublished studies will include ProQuest Dissertations and Theses, Google Scholar and WorldWideScience.org. The organization webpage of the International Association of Ambulatory Surgery will also be searched for relevant studies. A date limit will not be set in the search strategy.
A proposed CINAHL search strategy is included in Appendix I.
Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Two independent reviewers will then screen titles and abstracts for assessment against the inclusion criteria of the review. Studies that meet the inclusion criteria will be retrieved in full and their details imported into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Assessment of methodological quality
Selected studies will be critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist for Qualitative Research.27 Any disagreements that arise between reviewers will be resolved through discussion or with a third reviewer. The results of the critical appraisal will be reported in narrative form and in a table.
All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis. The quality of included studies will be considered in the analysis and will therefore be reflected in the findings and conclusion of the systematic review.
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool28 from JBI SUMARI by two independent reviewers. The data extracted will include specific details about the populations, context, culture, geographical location, study methods, the phenomena of interest (i.e. adult patients’ experience of discharge and recovery following day surgery) and other information that may be relevant to the review question and specific objectives. Findings and their illustrations will be extracted and assigned a level of credibility. Authors of primary studies will be contacted for clarification or missing information.
Qualitative findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.27 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing certainty in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.29 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the table is the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review is then presented along with the type of research informing it, a score of dependability, credibility and the overall ConQual score.
Appendix I: CINAHL search strategy
1. Toftgaard C. Worldwide day surgery
activity 2003 IAAS survey of ambulatory surgery. Ambul Surg
2007; 13 1:4–11.
2. Mitchell M. Home recovery
following day surgery
: A patient perspective. J Clin Nur
2014; 24 (3/4):415–427.
3. Dewar A, Scott J, Muir J. Telephone follow-up for day surgery
patients: Patient perceptions and nurses’ experiences. J Perianesth Nurs
2004; 19 4:234–241.
5. Manners JL, May D, Bailey IS, Anderson J. Utilising ‘theme’ day surgery
to improve efficiency and reduce costs. Journal of One Day Surgery
2010; 20 1:17–19.
8. Lemos P, Pinto A, Morais G, Pereira J, Loureiro R, Teixeira S, et al. Patient satisfaction following day surgery
. J Clin Anesth
2009; 21 3:200–205.
9. Jun E, Oh H. Patient needs and satisfaction with nursing care after day surgery
based on a patient-centred care framework. Clin Nurs Res
2016; 26 3:1–7.
10. Mitchell M. Literature review: Home recovery
following day surgery
. Ambul Surg
2013; 19 1:13–27.
11. Lau H, Poon J, Lee F. Patient satisfaction after ambulatory inguinal hernia repair in Hong Kong. Ambul Surg
2000; 8 3:115–118.
12. Mottram A. Like a trip to McDonalds”: A grounded theory study of patient experiences of day surgery
. Int J Nurs Stud
2011; 48 2:165–174.
13. Markovic M, Bandyopadhyay M, Manderson L, Allotey P, Murray S, Vu T. Day surgery
in Australia: Qualitative research report. J Sociol (Melb)
2004; 40 1:74–84.
14. Fabricant PD, Seeley M, Rozell JC, Fieldston E, Flynn JM, Wells LM, et al. Cost savings from utlization of an ambulatory surgery center for orthopaedic day surgery
. J Am Acad Orthop Surg
2016; 24 12:865–871.
16. Majholm B, Esbensen B, Thomsen T, Engbaek J, Moller A. Partner's experiences of the discharge
period after day surgery
- a qualitative study. J Clin Nurs
2012; 21 (17/18):2518–2527.
17. Berg K, Arestedt K, Kjellgren K. Postoperative recovery
from the perspective of day surgery
patients: A phenomenographic study. Int J Nurs Stud
2013; 50 12:1630–1638.
18. Mottram A. ‘They are marvellous with you whilst you are in but the aftercare is rubbish’: A grounded theory study of patients’ and their carers’ experiences after discharge
following day surgery
. J Clin Nurs
2011; 20 (21/22):3143–3151.
19. Gilmartin J. Contemporary day surgery
: Patients’ experience of discharge
. J Clin Nurs
2007; 16 6:1109–1117.
20. Rosen HI, Bergh IHE, Lundman BM, Martensson LB. Patients’ experiences and perceived causes of persisting discomfort following day surgery
. BMC Nurs
2010; 9 16:1–8.
21. Fitzpatrick JM, Selby T, While AE. Patients’ experiences of varicose vein and arthroscopy day surgery
. Br J Nurs
1998; 7 18:1107–1115.
22. Erkal S. Patients’ experiences at home after day case cystoscopy. J Clin Nurs
2007; 16 6:1118–1124.
23. Barthelsson C, Lutzen K, Anderberg B, Nordstrom G. Patients’ experiences of laparoscopic cholecystectomy in day surgery
. J Clin Nurs
2003; 12 2:253–259.
24. Cox H, O’Connell B. Recovery
from gynaecological day surgery
: Are we underestimating the process. Ambul Surg
2003; 10 3:114–121.
25. Markovic M, Bandyopadhyay M, Vu T, Manderson L. Gynaecological day surgery
and quality of care. Aust Health Rev
2002; 25 3:52–59.
27. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilising meta-aggregation. Int J Evid Healthc
2015; 13 3:179–187.
29. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol
2014; 14 108: