Patient satisfaction following mastectomy: Comparing the standard postoperative bra and a novel medical recovery bra : Nursing Management

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Patient satisfaction following mastectomy

Comparing the standard postoperative bra and a novel medical recovery bra

Wheeler, Peggy BS, RN, OCN, CBCN; Yackzan, Susan PhD, MSN, APRN, AOCN; Monroe, Martha PhD, RN; Davies, Claire C. PhD, PT

Author Information
Nursing Management (Springhouse) 54(1):p 40-47, January 2023. | DOI: 10.1097/01.NUMA.0000905004.49586.a7
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In Brief

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Figure

According to American Cancer Society, approximately one in eight women in the US will develop invasive breast cancer in their lifetime.1 In 2022, it's estimated that 287,850 new cases of breast cancer will be reported in the US.2 Treatment for breast cancer can include a unilateral or bilateral mastectomy with or without reconstruction.

Following a mastectomy, a postoperative bra or compression bandage is frequently prescribed. This garment is placed on the individual in the OR or postanesthesia care unit. The purpose of a postoperative bra or compression bandage can include holding dressings in place, preventing excessive blood loss, decreasing the risk of hematoma or seroma formation, and relieving tension on surgical skin closure by supporting the weight of breasts.3-8

During mastectomy, drains are placed in the chest to allow fluid that accumulates under the mastectomy flap to escape and prevent seroma formation.9 A postoperative drain is usually made up of a drain tube that empties into a bulb. As fluid collects, the bulb fills with fluid and must be emptied regularly. These drains remain in place for 10 days to 3 weeks until drainage decreases to 20 mL per day or less. Patients report that drains can be painful, uncomfortable, and challenging to manage.10 In order to diminish discomfort, nurses and patients anchor the drains in many ways. Securing and supporting drains is one reason to use a postoperative bra.9 Anchoring the drain using a supportive device such as a postoperative bra can increase comfort.

There's considerable anecdotal evidence at the authors' institution to suggest that patients aren't satisfied with the presently used postoperative bra (EMS Surgical, Selinsgrove, Pa.). At a postmastectomy follow-up visit, patients often discuss their concerns about their bra. They convey to nurse navigators, nurse managers, and physicians their difficulty with this garment and its ability to secure drains. Patients' concerns focus on the under-chest elastic position and constriction (which puts the drain exit at a more acute angle), skin irritation from seams on the bra, a general lack of satisfaction with the garment, and challenges with heavy drains and drain securement. In this facility, central supply often chooses products, and the sizes available are limited. This lack of available correct sizing often leads nurses in the postanesthesia care and medical-surgical units to cut the bra to size because patients complain about it.

An equestrian eventer who underwent a mastectomy at this hospital discussed with a nurse navigator and her nurse manager the possibility that the bra worn by female equestrian eventers might have some components that could help patients who had mastectomies. Equestrian eventers have reported issues associated with breast pain, pulling on their shoulder and neck, and back fatigue because of the repetitive bouncing of the breasts when riding. Therefore, the CHEATA sports bra (CHEATA Equestrian, Scranton, Pa.) has been designed to provide extra support. Because the equestrian sports bra doesn't have pockets designed to hold the drains that patients need following a mastectomy, a drain belt with hook-and-loop cloth pockets was added, and the CHEATA medical recovery bra was developed.11 This drain belt differed from the traditional method for securing drains in that it's separate from the bra.

The purpose of this pilot study was to examine the difference in patient satisfaction between the standard postoperative surgical bra presently used at this institution and the medical recovery bra among patients in the immediate postoperative phase following a mastectomy.

Methods

Sample and setting

The pilot study was conducted at a 434-bed Magnet® recognized hospital in the southeastern US and was approved by the hospital's Institutional Review Board. Participants (N = 24) were recruited by the breast cancer nurse navigator and surgeons in a surgical provider's office. All patients scheduled for mastectomy seen by the surgical provider were offered the opportunity to participate in the study. Inclusion criteria were women over 18 diagnosed with breast cancer and undergoing unilateral or bilateral mastectomy at this facility who could read and understand English. Those with a previous diagnosis of breast cancer and those undergoing latissimus dorsi flap reconstruction or nipple-sparing mastectomies were excluded.

Design

A quasi-experimental study design was used to test the difference between two postsurgical bras.

Procedure

Using a computer-generated random number assignment table, participants (N = 24) were randomly assigned to one of two groups to receive either the standard postoperative bra or medical recovery bra. The standard postoperative surgical bra (see Figure 1) is made of soft cotton, excluding the trim around the edges. Uncovered seams make the bra somewhat rough in spots. This garment has a zipper closure at the front. Hook-and-loop closure on the top of the shoulder strap is adjustable to size and is also used inside the front of the bra to attach and hold the drains within the drain pockets.

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Figure 1::
A picture of the traditional postoperative bra and drain securement

The medical recovery bra (see Figure 2) is made of a soft, stretchy material and closes with a hook and eye, as well as a zipper. There are no exposed seams or scratchy fabric. Drain pockets are attached to an adjustable stretch belt. Hook-and-loop fasteners on both sides of the drain pocket allow patients to comfortably position the drains. The medical recovery bra was modified based on the nurse navigator's clinical expertise and input prior to initiating the study. One modification was to add a zipper to the front of the bra because in the postoperative mastectomy phase, individuals have limited range of motion and pain from their surgery. The garment was also lengthened so the drains weren't trapped or jutting out at an acute angle as with the standard postoperative surgical bra. There was also an adjustment to lower the neckline.

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Figure 2::
A picture of the medical recovery bra and drain securement

The principal investigator, a breast cancer nurse navigator with 15 years of oncology experience, trained a team of certified oncology, postanesthesia care, preadmission testing, direct care, and OR nurses on study procedures via multiple in-service sessions.

A research team member met with participants in preadmission testing, postoperatively in the postanesthesia care unit, during hospital admission, and in the surgeon's office at follow-up. Potential participants provided informed consent in preadmission testing. Questions were addressed and a signature obtained from those individuals interested in participating. Preoperative bra sizes were reported by individuals verbally and collected by the nurse navigator and team to assess their postoperative sizes.

Based on random assignment, nurses applied either the medical recovery bra or standard postoperative surgical bra to the participant in the postanesthesia care unit. The day after surgery, a direct care nurse on the unit visited each participant to answer any questions, examine the bra for fit, and address any alterations as needed. The principal investigator met with participants at their postoperative surgical follow-up visit. At this time, they were given the satisfaction questionnaire and asked to return it using a postage-paid, self-addressed envelope.

Instrument

Items for the investigator-designed patient satisfaction questionnaire were based on a comprehensive review of the literature as well as input from five experts in oncology, including a nurse navigator, a nurse manager, and clinical nurses. Three consultants experienced in psychometrics and five oncology experts with knowledge of postoperative mastectomy care established content validity. The pencil-and-paper questionnaire took approximately 5-10 minutes to complete (see Table 1).

Table 1. - Patient satisfaction questionnaire on the postoperative bra and method for securing the drains
Postmastectomy bra Item Likert scale
Function and activity Wearing this bra, I am able to... Strongly disagree Disagree Agree Strongly agree
Move my arms freely.
Accomplish my daily activities.
Stand up.
Maintain posture.
Put on and remove with ease.
Move around easily.
Feel that my surgical wounds and drains are protected and secure.
Sleep.
Comfort Wearing this bra, I am comfortable...
Wearing the clothes I want to wear.
With the amount of support.
With the amount of back support.
With the fabric.
With the design.
With the fit.
With no skin irritation.
With the thought of going out in public.
With the fabric not digging into my shoulders, underarms, or bra line.
Wearing my seat belt in the car.
Overall, I am pleased with this garment.
Method for securing drain(s) Item Strongly disagree Disagree Agree Strongly agree
Function, activity, and comfort With this method of securing my drain(s), I am able to...
Allow the drain tubing to be in a comfortable position.
Access my drains easily.
Feel that the drains are protected and secure.
Walk freely without worry.
Overall, I am pleased with this method of securing my drain(s).
Comments:

Using this questionnaire, satisfaction is assessed on two variables: the bra and the method used to secure the drains. Bra satisfaction items are presented in two subscales: 1) function and activity (8 items); 2) comfort (10 items); and one item on overall satisfaction. One subscale addresses the method of securing drains in relation to function, activity, and comfort (4 items). One item relates to overall satisfaction with the method of securing drains.

A four-point Likert scale was used to assess satisfaction (1 = strongly disagree, 4 = strongly agree). The range of subscale scores are as follows: bra function and activity (8-24), comfort (10-40), overall garment satisfaction (0-4), method used to secure drains (4-16), overall satisfaction (0-4). At the end of the questionnaire, there was an open-ended question asking for participants to comment on their satisfaction with their garments.

Researchers analyzed the data using SPSS version 25 (IBM Corp, Armonk, N.Y.) and calculated descriptive statistics using frequencies, percentages, means, and standard deviations to describe the sample characteristics. Data from two participants, one from each group, were incomplete.

Responses to the open-ended question on bra satisfaction were reviewed for themes. Study investigators (n = 4) read and categorized comments independently. Following their analysis, they met and identified themes.

Results

Given the pilot nature of this study, sample size based on a power analysis (alpha = 0.05, power 0.85) wasn't sufficient to reach significance. However, t tests for both the medical recovery bra and standard postoperative surgical bra were calculated for the following variables: function, comfort, bra overall, drain total, and drain overall (see Table 2). In addition, means and standard deviations were calculated and reported. Participants in this small sample were satisfied to some extent overall with both garments (see Table 2).

Table 2: - Participants' satisfaction scores for both bras
Type of bra Standard postoperative surgical bra group (n = 11) Medical recovery bra group (n = 11) Dependent t-tests
Items n Mean SD n Mean SD t P
Function and activity 9 24.67 7.07 9 25.67 5.77 t (16) = - .33 P = .75
Comfort 10 27.5 6.65 10 30.2 6.9 t (18) = - .89 P = .39
Drain maintenance 9 11.11 4.51 10 10.4 3.9 t (17) = .369 P = .72
Drain overall 9 3 1.12 10 2.4 1.07 t (17) = 1.2 P = .25
Bra overall 10 2.8 1.03 9 2.89 1.17 t (17) = - .18 P = .86
There were no data on one questionnaire returned in both groups.

Following the independent review of items, it appears that participants were satisfied with specific components of the garments. Five participants (50%) believed the design and fit of the medical recovery bra wasn't comfortable. Two participants (40%) who wore the standard postoperative surgical bra reported discomfort mostly with the sizing and fit. Four participants (40%) who wore the drain belt and drain pockets didn't feel the drains were protected and secured. Three participants (30%) felt they couldn't walk around freely without worry.

The comments section of the instrument revealed a number of issues for consideration when designing a bra. For example, size was an issue for petite patients who didn't fit a standard size. The length of the garment was too short when the drains were attached. The participants liked the hook-and-loop fastener because they could apply the garment without help. Also, participants reported that they'd like to have two bras, so they could wear one and wash one.

In both groups, comments addressed the same needs after surgery. The bras need to be adjustable for different body shapes within each size. There's a need for a wider hole or lower material cut under the arm as the material seems to rub in the armpit. Securing the drains was a challenge. Participants wanted bulb holders on the bra to support the drains. Also, the bulb holders needed to be adjustable. There was a recommendation to have a tank top instead of a bra because of the longer length of the garment as bras seemed to be too short or tight. Zipper fastenings were preferred over hooks or hook-and-loop fasteners. Participants liked the fabric of the medical recovery bra because it was very soft.

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Purpose The purpose of this pilot study was to examine the difference in patient satisfaction between the bra presently used at this institution and a medical recovery bra among women in the immediate postoperative phase following a mastectomy regarding the following variables: function and activity, comfort, and drain maintenance.
Location 434-bed Magnet-recognized community hospital in the southeastern US
Time frame 2019-2020
Population Women diagnosed with unilateral or bilateral breast cancer, undergoing unilateral or bilateral mastectomy.
Collection tool Investigator-designed patient satisfaction questionnaire
Sample size N = 24

Discussion

This pilot study was designed by a nurse navigator, with oversight from her nurse manager, to focus on the difference in patients' satisfaction between the bra presently used in this institution and the medical recovery bra during the postoperative phase following mastectomy. The two bras were compared, and the findings demonstrated that although participants were somewhat satisfied with both bras, several issues were raised for consideration when modifying or developing a new bra.

In the case of the medical recovery bra, staff were challenged when applying the bra to the individual after surgery because of the hook-and-eye fastener followed by a zipper. Staff, therefore, didn't support use of the medical recovery bra in the immediate postoperative phase. In the case of the standard postoperative surgical bra, its application to the individual was easier but sometimes the staff had to use scissors to cut the bra to make it comfortable. In the postoperative time frame, both bras had their challenges, but comparing bras and the learning during the process can contribute to the evidence will help move the research toward a better solution.

Correct fit was considered extremely important to bra comfort. This finding supports a previous study conducted by LaBat et al., who asked survivors of breast cancer their needs and wants for wearable products.12 Study participants reported bra comfort was an important factor enabled by support provided and correct fit. A major finding from this study agrees with results from a small number of studies conducted regarding postmastectomy bras.3,12 Having bras that fit comfortably is an unmet need for these patients. The fabric used to construct the bra is one aspect of comfort emphasized by participants in this study. Participants also suggested a different overall garment design.

Nurse navigators, nurse managers, and clinical nurses had the opportunity to be innovators in helping design the bra used in this study. This role was new for nurse navigators who hadn't been involved in bra design previously. Nurse navigators develop a close relationship with patients as they go through the breast cancer journey. Nurse navigators should take these opportunities to be innovators because they understand patients' needs during mastectomy and can communicate the issues experienced.

Limitations

This quasi-experimental pilot study was limited to a single site and therefore this design may not be useful in other settings. Another limitation was that only two bras were tested although additional bras may be available. Based on this pilot study, recommendations for future studies are to modify the bra related to findings, obtain a sample size with sufficient power to reach significance, and include multiple hospital sites.

Nurse management implications

Nurse navigators have observed that using the bras in the postoperative phase following mastectomy is challenging in terms of fit and comfort. Investigators, with the support of their nurse leadership, are uniquely positioned to collaborate with a clothing designer to try and address a patient issue that still needs further research. Based on this study's findings, it's recommended that future garment designs include a softer fabric, a longer garment length, and a zipper fastener over hook-and-loop fastener. Securing the drains is an important issue following surgery and participants in this study preferred the drain holder attached to the bra rather than being separate. Nurse leaders are in a unique position to work with nurse navigators and direct care nurses to contact product company representatives and offer product modification suggestions to help with practical redesigning to meet patient needs.

Conclusions

This pilot project was conducted to test the efficacy of using quasi-experimental methods to establish differences between two bras following mastectomy. This design appears to be appropriate and the study revealed information to assist in conducting additional investigations. Recommendations regarding components of the two bras related to comfort could be used to further develop and test other garments.

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