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International Journal of Nursing Practice 2011; 17: 621627

RESEARCH PAPER

A comparison of nurses perceptions of elective


laparoscopic or elective open colorectal resections ijn_1979 621..627

Gillian Richardson BN
Registered Nurse, Ground Floor West, Concord Repatriation Hospital, Concord, New South Wales, Australia

Ian Whiteley BN, GradCertSTN, GradCertNursEd, GradDip (Acute Care), MCN


Clinical Nurse Consultant, Stomal Therapy Level 1 West, Concord Repatriation Hospital, Concord, New South Wales, Australia

Accepted for publication May 2011

Richardson G, Whiteley I. International Journal of Nursing Practice 2011; 17: 621627


A comparison of nurses perceptions of elective laparoscopic or elective open colorectal resections

The purpose of this study was to develop an instrument to measure the perceived benefits nurses observe in the recovery
of patients who have undergone elective laparoscopic colorectal resections vs. traditional open elective colorectal
resections. Secondly, to determine if there are perceived differences in the intensity of nursing required to care for these
patients. A twenty-three-point questionnaire was developed and distributed to 23 colorectal nurses working in a single
tertiary referral hospital. There was an 83.6% response rate. The findings demonstrate that the participants believe there
are significantly better outcomes for the laparoscopic patients in the postoperative period. These benefits include more
rapid resumption of independence, decreased pain and fewer complications. The nurses also perceived less time and effort
was required when caring for these patients.
Key words: colorectal surgery, laparoscopic, nurse, perceptions, postoperative care.

INTRODUCTION them. Lastly, to identify whether these nurses consider


The purpose of this study was to develop an instrument to LAP surgery preferable to open surgery.
determine if nurses perceive differences in postoperative The participants in this study were nurses currently
outcomes for patients who had undergone elective laparo- working in this specialized colorectal unit who voluntarily
scopic colorectal resections (LAP) vs. those who had completed the survey. Therefore, as no patients were
undergone a traditional elective open colorectal resection involved, there was no risk of harm to patients or poten-
(OPEN) by laparotomy. Secondly, to determine if the tial breeches of confidentiality, and ethics approval was
nurse participants consider there are benefits for patients not required.
having laparoscopic colorectal surgery, and if there was Laparoscopic colorectal surgery has been described in
less time and effort required by these nurses to look after the literature since 1991;1,2 however, there are few, if
any, papers describing patient outcomes or any variation
in care required from a nursing perspective in the post-
operative period. Between 1991 and 2000, there was a
Correspondence: Gillian Richardson, Ground Floor West, Concord relatively slow uptake of laparoscopic colorectal surgery
Repatriation Hospital, Hospital Road, Concord, NSW 2139, Austra- by surgeons. Reasons identified for the delayed introduc-
lia. Email: gillydolan@hotmail.com tion included the complexity of the surgery requiring

doi:10.1111/j.1440-172X.2011.01979.x 2011 Blackwell Publishing Asia Pty Ltd


622 G Richardson and I Whiteley

training and a long learning curve and also because opera- tion survey felt that patients having an OPEN resection
tions were complex and challenging due to the inadequacy had a longer length of stay. The learning of stoma care
of equipment available at the time. Over the past 3 years, and organization of social placements increased length of
however, there has been an increase in the numbers of stay in patients who have undergone LAP and OPEN
laparoscopic colorectal surgical procedures being per- resections.2
formed because of improvement and availability of equip-
ment required.1 METHOD
Despite these findings, LAP colorectal surgery is prac- A survey was developed for the specific purpose of this
tised expertly within our facility. This was one of the investigation as the literature review failed to locate a
foremost reasons for developing the instrument to assess prior study. The first 20 questions were grouped into 10
nursing perceptions of the benefits to patient outcomes sets of paired questions to assess for perceived differences
and for nursing workload. Between January 2006 and between LAP and OPEN surgery. The paired questions
December 2008, 39.5% of colorectal cancer resections reflected each other to avoid the perception of bias on the
at our institution were performed using LAP techniques. part of the authors towards either laparoscopic or open
From January 2009 to December 2010, there was surgery. This method of questioning allowed the respon-
a noteworthy shift at our institution with 50.7% of dents a free range of responses; thus, it was possible that
colorectal cancer resections performed using LAP whichever surgery had been performed, the respondents
techniques. might find the patients either equally easy or equally dif-
Laparoscopy has revolutionized colorectal resections ficult on any question. Statistical comparison of the results
and has been associated with decreased overall morbidity was performed using a paired t-test as the responses had a
and better postoperative outcomes than open resec- normal distribution.
tions.2,3 Minimally invasive (laparoscopic) colorectal The questionnaire is a subjective paired comparison
surgery has the potential to enhance patient outcome problem where the nurse respondents were asked to use a
through decreasing postoperative pain, shortening length seven-point modified visual analogue Likert scale to rate
of stay, enabling early resumption of pre-surgical lifestyle their responses. The range was selected as the authors
and earlier return to work.16 Other suggested benefits to believed this allowed both a range of possible responses
laparoscopy include: smaller incisions, a decreased risk of and a midpoint for ease of analysis. The final three ques-
adhesion formation because of less physical injury to intra- tions had nurses circle the response they felt was most
abdominal structures and a shorter postoperative appropriate.
ileus.2,4,6,7 Smaller incisions lead to better cosmesis for Within the questionnaire, each respondent was asked
patients.2,6 LAP have been associated with a better to compare the same activity between two different
immune and inflammatory response leading to improved patient groupsthose who have undergone LAP resec-
postoperative outcomes.2,3 Furthermore, reduced blood tions in comparison with those who have undergone
loss has been identified as a benefit.1 Fewer wound infec- OPEN resections.
tions have been noted as a benefit of laparoscopic colorec- The survey was exclusively targeted at nurses working
tal surgery.2,5 in the specialist acute care colorectal unit. The question-
It is well documented that early concerns regarding naire was distributed by attaching it to the nurses fort-
oncological safety due to the risk of port-site tumour nightly payslips with a letter of explanation and inviting
recurrence after laparoscopy are unfounded, and the rate their participation. Respondents were asked to place the
of cancer recurrence in an open wound is similar.24,68 completed survey in a box placed at the nurses station.
Baker et al.2 compared laparoscopic vs. open abdomino- Definitions of the questions asked within the question-
perineal resection (APR) and found no difference in naire are included in Table 1.
the mean length of overall survival and no difference in Although this was a pilot study, considerable effort was
overall recurrence rate and concluded laparoscopic APR undertaken to ensure the results were as reliable as pos-
does not compromise cancer specific survival outcomes.2 sible. Stability is derived when measurements are taken
Delay in discharge was attributed to larger abdominal under identical conditions.9 The authors would need
wounds in patients who had undergone an open APR.2 to undertake further studies to confirm the instruments
Eighty-three per cent of nurse respondents in this percep- reliability and stability.

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Nurse views of lap vs open bowel surgery 623

Table 1 Definitions of paired questions included in the survey

Question Definition

1. Transfer patient from bed to chair 1. Nursing effort required to transfer a patient from bed to chair following LAP or OPEN
colorectal surgery
2. Showering of patient 2. Nursing effort required to shower patients following LAP or OPEN colorectal surgery
3. Independent mobilization 3. Speed at which patients regain their ability to mobilize independently following LAP or
OPEN colorectal surgery
4. Tolerate full ward diet 4. Speed at which patients regain the ability to tolerate a full diet following LAP or OPEN
colorectal surgery
5. Time to removal of drains, 5. Length of time before surgical drains, indwelling urinary catheters and intravenous lines
catheters, lines were removed following LAP or OPEN colorectal surgery
6. Wound complication 6. Frequency of the development of wound complications following LAP or OPEN colorectal
surgery
7. Pain 7. Degree of pain experienced by patients following LAP or OPEN colorectal surgery
8. Self-care of stoma 8. Speed with which patients become independent with stoma care following LAP or OPEN
colorectal surgery
9. Overall postoperative 9. Frequency with which patients develop general complications following LAP or OPEN
complications colorectal surgery
10. Nursing effort required 10. Overall nursing effort required to care for a patient following LAP or OPEN colorectal
surgery

LAP, laparoscopic colorectal resections; OPEN, open colorectal resection.

When developing the questionnaire, there were the perceptions of nurses with a broad range of colorectal
several shorter trials to assess the questions being asked experience, many who have witnessed the introduction of
and their wording. Prior to distributing the survey, it was laparoscopic colorectal surgical procedures in our facility
reviewed by a series of individuals with expert knowledge that ideally positions them to make comparisons with
including two colorectal surgeons, the colorectal nurse traditional open colorectal surgery.
unit manager and colorectal cancer care coordinator. The results of the questions using the Likert scale are
However, the authors acknowledge it was not possible summarized in a graph format (Fig. 1). Within this graph,
to use a concurrent assessment against a gold standard the questions are displayed in successive pairs. Our Likert
instrument as none existed. scale had a range from 1 to 7 with 1 representing the most
favourable (affirmative) response and 7 the least favour-
RESULTS able (negative) response. Therefore, an assumption was
Surveys were distributed to 23 specialist colorectal nurses made that the mid-point or number 4 on the Likert scale
at a tertiary referral hospital. We had a response rate of 19 was a neutral response and was not included in the
of the 23 surveys distributed (82.6%). This high response summarized data. All responses from the nurses less than
rate was achieved by attaching the survey to the nurses 4 were considered affirmative responses, and all greater
payslips and having a return box located at the nurses than 4 were considered negative responses. The highest
station. The nurses surveyed had a range of experience possible affirmative or negative response is 19, based on
from 1.5 to 32 years (Mean 16.13 years). The years of the number of nurses who returned the questionnaires.
colorectal nursing experience ranged from 1.5 to 22 years Statistical analysis of the nurses perceptions revealed
(Mean of 8.97 years). The nursing classification included statistical significant P-values in the following questions:
enrolled nurses (n = 2), clinical nurse consultants transferring; showering; mobility; diet; removal of surgi-
(n = 2), with the majority being registered nurses (n = 9) cal drains, catheters and lines; wounds; pain; stoma care
and clinical nurses specialists (n = 6). The results reflect and nursing effort. The only exception where statistical

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624 G Richardson and I Whiteley

Number of responses

-20

-15

-10

10

15

20
-5

5
Transfer - LAP

Transfer - OPEN

Showering - LAP

Showering - OPEN

Mobilizing - LAP

Mobilizing - OPEN

Full diet - LAP

Full diet - OPEN

Removal drains & tubes - LAP

Removal drains & tubes - OPEN

Wound complications - LAP

Wound complications - OPEN

Pain - LAP

Pain - OPEN

Care of stoma - LAP

Care of stoma - OPEN

Overall complications - LAP

Overall complications - OPEN

Nursing effort - LAP

Nursing effort - OPEN


Affirmative

Negative

Figure 1. Summary of nurses responses from Likert scale. LAP, laparoscopic colorectal resections; OPEN, open colorectal resection.

significance was not found was the question regard- would advocate LAP surgery, although 11% of nurses
ing overall complications (Table 2). These findings are would advocate an OPEN procedure. This clearly indi-
expanded further in the Discussion section. cates these specialist nurses perceive there are benefits to
In the final three questions, the nurses were asked having LAP resections. The remaining 6% of respondents
to circle the response they felt was most appropriate. felt there was no difference or had no opinion.
Eighty-three per cent (83%) of nurse respondents felt
patients who had undergone a LAP resection had a DISCUSSION
shorter length of stay than patients who had undergone With the increasing interest in LAP worldwide, there is a
an OPEN resection. need to examine the benefits for patients and the impact
Seventy-two per cent (72%) of nurses surveyed would on the nursing care required. The primary finding was that
prefer to look after a patient who had undergone LAP a patient who has had a LAP resection compared with an
rather than OPEN resections. OPEN resection had improved outcomes in terms of a
Finally, nurses were asked to imagine they had a close quicker and less complicated postoperative course. There
friend or relative requiring an elective colorectal resection was also a general consensus from the cohort of nurses
and to identify which procedure they would advocate. surveyed that it takes less effort to care for a patient
Eighty-three per cent (83%) of nurses reported they who has had a LAP resection compared with an OPEN

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Nurse views of lap vs open bowel surgery 625

Table 2 Mean visual analogue scale scores for respondents ratings of various activities and characteristics compared between elective open
and laparoscopic colorectal operations

Activity or characteristic OPEN (Mean) LAP (Mean) P (paired t-test)

1. Transfer patient from bed to chair 4.6 2.6 < 0.001


2. Showering of patient 4.4 2.9 < 0.001
3. Independent mobilization 4.7 2.6 < 0.001
4. Tolerate full ward diet 4.7 3.5 < 0.001
5. Time to removal of drains, catheters, lines 4.2 2.6 < 0.001
6. Wound complication 3.8 2.6 < 0.004
7. Pain 5.3 3.1 < 0.001
8. Self-care of stoma 4.7 4.0 < 0.005
9. Overall postoperative complications 4.8 4.7 < 0.889
10. Nursing effort required 4.7 3.3 < 0.001

LAP, laparoscopic colorectal resections; OPEN, open colorectal resection.

resection. However, there have been few, if any, nursing removed sooner following LAP surgery.2,6 This is a direct
studies conducted to compare our findings. comparison of the positive responses that the nurses gave
The respondents scores for the two paired patient in regards to perceived favourable postoperative outcomes
groups are correlated as they are naturally linked.10 for the patient but also to the nurses looking after those
During data analysis, this became evident in the cross- patients. Nurses felt that LAP patients were easier to
tabulations and also in the correlation coefficients in the transfer, shower, mobilize, tolerated their diet, experi-
t-test results. enced less pain and were generally easier to care for.
The Wilcoxon matched-pairs signed-rank test and the In our colorectal unit, it has become common practice
paired t-test gave virtually identical P-values identifying for LAP patients to be showered on day 1 postoperatively,
consistency and statistical significance in the nurses per- and the OPEN patients are sponged. This practice has
ceptions favouring LAP over traditional OPEN surgery been adopted due to the perception that LAP patients
in the majority of questions. The one exception was the have less pain and are more mobile and therefore shower
question pertaining to overall postoperative complica- with greater ease, and this is reflected in the graphed data
tions. The authors believe the results from this question (Fig. 1). This is variable and based on individual patient
were inconsistent with all others as the Likert scale was assessment.
inadvertently reversed for this set of paired questions. For The majority of the nurses who are experienced in the
all other questions, a lower score represented a more colorectal field would advocate laparoscopic surgery to
favourable or affirmative response. For the paired ques- their close friend or family member requiring an elective
tions regarding overall complications, the reversed direc- colorectal resection. The rationale behind this question
tion of the Likert scale meant a lower score represented was to determine which type of operation nurses per-
more frequent complications or a negative response. We ceived delivered better patient outcomes. This is not to
believe the respondents did not detect this change in suggest that nurses have any influence or decision-making
direction of the scale, thus skewing the results. over what operation is available to patients. This survey
Baker et al.2 and Hageman et al.6 report LAP patients was conducted at an institution where LAP surgery is a
have smaller incisions so it is not surprising that our results common practice and nurses are aware that LAP surgery
confirm patients have less pain, are able to shower more is offered to patients considered appropriate by their
easily, mobilize more quickly and tolerate a diet sooner. surgeon.
Mobilizing earlier and tolerating a diet allows for indwell- We speculate from this result that nurses feel strongly
ing urinary catheters and intravenous lines to be removed that the postoperative outcome for a patient during their
earlier. It was also noted that surgical drains were also stay in hospital is positive.

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626 G Richardson and I Whiteley

The perceived benefits in the reduced nursing effort We acknowledge a limitation of this study arises from
required to care for patients undergoing LAP resections the actuality that it was conducted at a single site and
raises the question of what can be done with the potential the nurses perceptions might not be generalized to other
nursing time saved. From the findings, it is believed the centres. Other centres could use our method and instru-
LAP patients require less nursing hours of care. There are ment to conduct comparison studies.
several assumptions that can be drawn from these find-
ings; fewer nursing hours spent caring for LAP patients CONCLUSION
frees up nursing time to care for patients with more Our study reports on the findings of a survey from a
complex nursing care requirements. LAP patients could cohort of nurses working in a specialist colorectal unit in
potentially be discharged earlier allowing earlier access to a major teaching hospital, comparing LAP with OPEN
hospital beds and ultimately a higher throughput of colorectal surgery. This demonstrates that there is a defi-
patients. It is not envisaged that there would be any nite perception that, overall, the LAP patients return to a
decrease in the number of full-time equivalent nurses preoperative level of function faster, experience less pain
required on the colorectal unit. Any decrease in patient and have fewer wound complications. Secondly, less
acuity related to LAP resections will be compensated for effort is required to care for patients who have had a LAP
by higher turnover of patients, the fact that not all patients surgery compared with the effort to look after a patient
are suitable candidates for LAP surgery and increased who has had an OPEN surgery. We can also surmise from
opportunities for continued improvement strategies. these results that the future of nursing care required on
Any time savings that might result from caring for the ward will be quite different to how it is currently,
LAP patients could potentially be redirected to provide with more surgeons taking on the technique. A future
ongoing education to current staff and the support and study looking at nursing acuity will assist to determine
education to newer members of the nursing team and this.
students. Therefore, we can conclude that there are per- From these data, we instigated a plan to create a
ceived benefits for both nurses and patients following validated nursing acuity score for acute care colorectal
laparoscopic colorectal surgery in the postoperative nursing. Due to the global nursing shortage, we hope that
period. if LAP surgery can lead to a less intensive workload,
Nursing dissatisfaction is linked to high rates of nurses nurses can be attracted and retained.
leaving the profession, poor morale, poor patient out-
comes and increased financial expenditure. Understand-
ing factors that contribute to job dissatisfaction could ACKNOWLEDGEMENTS
increase nurse retention.11 Murrells et al. reported a dra- The authors would like to thank the following individuals
matic increase in both dissatisfaction and burnout was for their support and assistance: Dr Scott MacKenzie for
associated with poorer staffing levels and that mortality aiding in the development and design of the survey tool,
increased by 7% for every patient added to the average Dr Owen Dent (Statistician) for assisting with statistical
nurses workload.12 Decreased patient acuity might analysis and Dr Anil Keshava for his continued encourage-
perhaps lead to less burnout of nursing staff, better staff ment for reviewing the manuscript.
retention rates, educational opportunities and increased
job satisfaction. There is no evidence in the literature REFERENCES
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2011 Blackwell Publishing Asia Pty Ltd