Blackwell Science, LtdOxford, UKEJCCEuropean Journal of Cancer Care0961-5423Blackwell Publishing Ltd, 2005144310318Original ArticleNursing care for breast cancer

patients undergoing IBRHOLTZMANN & TIMM

Original article

The experiences of and the nursing care for breast cancer

patients undergoing immediate breast reconstruction
J. HOLTZMANN, rn, sd, ma, Development Consultant, Copenhagen University Hospital at Glostrup, County of
Copenhagen, & H. TIMM, ph.d, msc.cult.soc., Senior Researcher at the University Hospitals Centre for Nursing
and Care Research (UCSF), Copenhagen University Hospital, Rigshospitalet, Denmark

HOLTZMANN J.S. & TIMM H. (2005) European Journal of Cancer Care 14, 310–318
The experiences of and the nursing care for breast cancer patients undergoing immediate breast reconstruction

This study explores the experiences of and the nursing care for nine women with breast cancer undergoing
immediate breast reconstruction (IBR) with a TRAM-flap. The study was prospective and descriptive and
source and method triangulation was used. Source triangulation consisted of the patients’ and nurses’ per-
spectives, whilst method triangulation combined interviews, questionnaires and medical records. One result
is that the meaning of IBR for the women operated is related to feelings of hope, normality and ‘wholeness’.
Another result is that not all the needs of the patients are assessed and met; the nursing care during admission
is mainly focused on the physical care and after dismissal the patients are left in a situation characterized by
vulnerability and a sense of emptiness. The study points to some implications in the means of quality
development and rehabilitation.

Keywords: immediate breast reconstruction, patients’ experiences, nursing care, documentation.

BAC KG RO U N D reconstruction method is the transverse rectus abdominis

myocutaneous (TRAM) flap reconstruction, in which a
Breast cancer is the most common cancer disease among
portion of the abdominal muscle is used to create a new
women in Denmark. Three thousand seven hundred
breast.
women out of a population of 5.4 million people are diag-
Quite a lot of studies describe women’s perception of
nosed yearly (Blichert-Toft 2002). The main surgical pro-
body image, psychosocial accounts and the cosmetic
cedure is modified mastectomy, and due to surgical
results regarding the reconstruction (Schain et al. 1984,
progress it has been possible for decades to reconstruct the
1985; Stevens et al. 1984; Knobf & Stahl 1991; Vaziri &
breast either immediately or by delayed reconstruction
Agre 1996). These articles focus on the reasons why
often years after the mastectomy. Until recent years the
women want a reconstruction and on the degree of satis-
majority of reconstructive operations in Denmark have
faction with the result that the women feel.
been performed as delayed breast reconstructions, but dur-
The experiences of and the nursing care for patients
ing the last 5 years it has become more common to offer
admitted to immediate breast reconstruction have
women the opportunity for immediate breast reconstruc-
scarcely been described in the literature. The English lit-
tion. This procedure can be done with either breast
erature consists of descriptions based on case studies and
implants or tissue flap technique. In the current study the
personal accounts (Harden & Girard 1994; Buyske et al.
1996; Parker & Scullion 1996), although studies regarding
Correspondence address: Jette S. Holtzmann, Ordrupvej 4 2tv. 2920 Char- the decision-making process (Neill et al. 1998) and the per-
lottenlund, Denmark (e-mail: holtz@vip.cybercity.dk). ception of the body (Cohen et al. 1998) have been made.
Accepted 4 April 2005 Nissen et al. (2002) did a focus group study with 17 women
DOI: 10.1111/j.1365-2354.2005.00578.x undergoing mastectomies with immediate breast recon-
European Journal of Cancer Care, 2005, 14, 310–318 struction (IBR) and concluded that recovery can be difficult

© 2005 Blackwell Publishing Ltd


and that reconstruction does not neutralize the fear of
recurrence. In another recent study, Harcourt and Rumsey
(2001) did a review of the literature concerning the psy-
chological aspects of breast reconstruction, both immedi-
ate and delayed. Their findings reveal ‘a lack of
theoretically based studies . . . especially in relation to
coping and decision-making’ (p. 477). Furthermore they
conclude that ‘little attention has been given to how breast
care nurses can most effectively and beneficially support
women facing the option of breast reconstruction’ (p. 482).
Harcourt et al. (2003) have followed up on this with a mul-
ticentre, prospective study, where they examine the psy-
chological implications of women’s decisions for and
against breast reconstruction. Some of the results from
this study challenge some of the common assumptions
regarding the benefits of IBR and suggest that the role of
specialist breast reconstruction nurses should be investi-
gated further. A problem regarding studies of breast recon-
struction is that the majority originates from USA, where
the socio-economical and cultural attitudes towards plas-
tic and reconstructive surgery are different from Europe. In
fact in Denmark only about 10% of women having a mas-
tectomy choose a reconstruction (Elberg et al. 1995), com-
pared with 30% in USA (Harcourt & Rumsey 2001).
The Danish research literature consists only of descrip-
tions of nursing care regarding delayed reconstruction
(Thomsen 1993; Scherrebeck 1996; Scherrebeck & Munk
1998).
An investigation of the experiences of and the care for
patients undergoing immediate breast reconstruction has
never been carried out in Denmark. It is our experience
that nursing care for these women differs a lot from nurs-
ing care for women undergoing delayed breast reconstruc-
tion. Whilst coping with a recent cancer diagnosis these
women have to make a decision concerning reconstruc-
tion possibilities and once they have made the decision,
they are to undergo a major surgical procedure. Our
assumptions, based on the scarce literature, our experi-
ences and common knowledge, are that the patients have
little knowledge regarding the aspects of recovery, that all
the needs of the patients are not assessed and met and
finally, that the nursing care during admission is focused
on the psychical care.
AIM O F TH E ST U D Y
Our aim is to investigate the experiences of and the nurs-
ing care for patients admitted to immediate breast recon-
struction on the basis of the following two perspectives:
• The patients’ perspectives on IBR, including their needs
for and the nursing care received during admission.
© 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318
Nursing care for breast cancer patients undergoing IBR
• The nurses’ assessment and documentation of the
needs of the patients and the care for the patients dur-
ing admission.
DESI GN AND MET HOD
The study is prospective and descriptive and uses both
source and method triangulation. Source triangulation
consists of the patients’ and the nurses’ perspectives,
whilst method triangulation in this study combines inter-
views (telephone and personal), questionnaires and medi-
cal records. See Table 1 for the design of the study.
An interview guide and the questionnaires were
designed on the basis of the written literature and in col-
laboration with an expert group consisting of experienced
nurses within plastic reconstruction surgery and oncology
and one of the plastic reconstruction surgeons. To further
asses the feasibility of the tools a trial study was con-
ducted with two patients. As no subsequent changes were
made results from this trial were incorporated in the main
study.
ET HI CAL APPR OVAL AND SAMPLE
The study took place at the Department of Plastic Surgery
& Burn Unit, Copenhagen University Hospital, Rigshos-
pitalet 1998–2000. The scientific ethical committees of
Copenhagen and Frederiksberg Municipalities had no
objection to the study. All the respondents gave an oral
and written consent to the participation.
On the basis of the aim of the study and the expected
amount of patients (estimated 25 in 1999), it was planned
that 10 patients should participate. The patients were
enrolled in the study consecutively. Inclusion criteria
were: to have been diagnosed with operable cancer
mamma with tumour < 5 cm without growth into skin or
fascia and without palpable regional glands and awaiting
reconstruction immediately with a TRAM-flap; the
patients should be able to understand and speak Danish.
Two patients withdrew during the study: one due to geo-
graphical relocation and one due to cancelled operation.
By the ninth patient saturation of information was
reached, i.e. nothing new appeared.
The patients were between 36 and 59 years old with an
average of 50 years of age. Seven of the patients were mar-
ried whilst two were living alone. Seven had children,
whilst two did not. Two had a university degree, four a
college degree and three a vocational education. Seven
were working, whilst two were without jobs. The material
therefore consisted of a heterogeneous group regarding
level of education, span of age and marital status.
311
HOLTZMANN & TIMM

Table 1. Design of the study: the two perspectives

Time line
Prior (app. 5–7 days before During admission (app. 6th
Perspectives and topics admission) day post-operation) After admission (app. 8 weeks)
Patients’ perspectives Semi-structured telephone Questionnaire containing questions Semi-structured interview
interview containing the within the following topics: pain, in their private homes
following topics: information, nutrition, fluids, GI, personal care, containing the following
reconstruction, sources of respiration, immobilization, surgical topics: information and
support complications, psychosocial, sleep communication, reconstruction,
and rest sources of support, nursing care
All in all 9 interviews of app. 9 questionnaires 9 interviews of app. 90 min each
40 min each
Nursing care – the nurses’ Quantitative questionnaire
perspectives. The nursing containing questions within the
staff at work, (1–4 following topics: pain, nutrition,
participants), who had fluids, GI, personal care, respiration,
taken care of the patient immobilization, surgical
during admission. complications, psychosocial, sleep
and rest
The medical record Was analysed according to the
topics above.
All in all 9 questionnaires and 9 medical
records
App. approximately; GI, gastro-intestinal.

DAT A A N A L YSIS
The interviews were tape recorded and selective tran-
scribed verbatim. In this study we chose only to transcribe
the patient remarks and in the chosen quotes removed the
‘hmms’ and ‘ahs’.
A transcription represents a transformation from the
verbal interview to a written text. Such a transformation
is necessary in order to obtain data, which is ready for fur-
ther analysis, but a complete transcription often gets the
enigma of ‘the truth’ and the material is therefore often
overwhelming (Kvale 1996). If you write down everything
as correctly as possible, more often you end up with a rid-
dle rather than with a communicative material, while in
the other hand in the same instant you begin to put in dots
and commas you’re already editing the data. Therefore,
every verbatim transcription is a choice (Callewaert 1998).
In the process of analysing the data, Giorgis psychological
phenomenological method was used. This method con-
sists of four steps, through which the whole of the inter-
view is being condensed into ‘meaning units’ (Giorgi
1985). In the current study, this process was carried out as
follows:
1 The patients’ remarks were read through several times
to grasp a sense of the whole.
2 The tape was listened through once more whilst reading
the transcripts. The quotes followed the interview
guide. This was done with each interview.
3 This data material was then read again and a pattern
with general themes and meaning units emerged.
4 The interview was read again and ‘broken up’ and the
quotes related to the meaning units.
The quantifiable data from the questionnaires were
entered and treated using the Word and Excel software
programs. The data were analysed regarding the amount
and type of problem. Results from the different perspec-
tives were compared and described.
R EFLEXI VI T Y R EGAR DI NG AUT HOR
POSI T I ON
The first author was, at the time of the study, a clinical
nurse specialist at The Department of Plastic Surgery and
Burn Unit, Copenhagen, where the study took place, a
position that meant that she was not directly involved in
the care of these patients. The patients were informed
about this. The staff knew about the study and any even-
tual problems regarding the patients were not discussed
with the clinical nurse specialist. Another issue regarding
position occurred at the interview in the homes of the
patients. As it is later shown many of the women had spe-
cific unanswered questions, which it would be unethical
not to respond to. Therefore, the author agreed with the
patients that she would answer questions if possible after
the research interview. This change of context did not give
any problems and diminished any potential bias between

312 © 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318

the role of a research interviewer and that of a clinical
nurse specialist.
PRE SE N TA TIO N OF P AT I E N T S
No. 1. 58 years old. Married, with two children. Has a
college degree within the commerce and ser-
vice sector.
No. 2. 36 years old. Married, no children. Has a college
degree within the commerce and service sector.
No. 3. 41 years old. Lives alone, with a child of school
age. Has a university degree within health care.
No. 4. 48 years old. Lives alone, no children. Has a
vocational degree within commerce. Is not
employed.
No. 5. 55 years old. Married, with two grown-up chil-
dren. Has a vocational degree within com-
merce. Is not employed.
No. 6. 59 years old. Married, with three grown-up
children. Has a college degree within the edu-
cational system.
No. 7. 39 years old. Married, with one child in shool
age. Has a vocational degree within the com-
merce and service sector.
No. 8. 57 years old. Married, with one grown-up child.
Has a university degree within building and
engineering.
No. 9. 59 years old. Married, with three grown-up
children. Has a college degree within health
care.
RESU L TS
The meaning of immediate breast reconstruction – from
the patient perspective
Two major themes were identified in the interviews with
the patients. One theme consisted of the experiences with
having a cancer diagnosis and the role of reconstruction in
relation to this. The other theme consisted of the experi-
enced needs for nursing care and how these needs were
met.
To regain hope after cancer and the wish for normality
and wholeness
The women reacted differently in their ways of dealing
with the cancer diagnosis, but all of them verbally
expressed vulnerability and to a certain degree a sense of
despair. In this situation the possibility of a reconstruc-
tion helped the women gain a bit of control over their
lives.
© 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318
Nursing care for breast cancer patients undergoing IBR
It is very positive and a fantastic offer to get. I think
it is quite good. So it is a positive thing in the middle
of it all and somewhere I think that with such a major
thing – you wouldn’t expect them to reconstruct it, if
they expected that I had something again within
20 minutes’. (No. 7)
In this context, the reconstruction helped the women
gain feeling of hope and future. The offer of a reconstruc-
tion was perceived by many as a signal saying ‘you’re
worth betting on’. Several of the patients felt fine when
the plastic surgeon told them that they were well suited
for the operation.
I was well suited – that’s the first time in my life, that
a good belly is an advantage. (No. 9)
I was told, that it would be tough, but he said that I
was very well suited – that made me feel really good
– well I was still useful. (No. 5)
The reconstruction also helped the women to feel a
degree of normality and a sense of being ‘whole’.
I actually feel that I still have my breast. It feels intact
and it doesn’t bother me, that the nipple is not there.
(No. 6)
It is important to look fairly normal – that I’m not
ugly and not reminded of it the whole time. (No. 3)
I feel that I still have my breast and I do not sense
that I have lost something – and I guess that’s the fine
thing with this type of surgery – that you get a sense
of wholeness. (No. 8)
But one thing is the cosmetic result of the operation,
another the understanding of the impact on the body. Lack
of sensitivity was one of the areas where the patients felt
uninformed:
I would have liked to have some information about
the physiology. What is muscle, what is fat-tissue and
so on? You lack information about how the tissue
reacts. (No. 9)
The lack of sensitivity in the reconstructed breast
shows a conflict between what Bob Price calls body ideal
and body reality (Price 1990).
I perceive it as mine – I do – I touch it, I massage it,
so I feel it’s mine – but there is no sense in it – not at
all. (No. 7)
Price describes the body-image-care-model as consist-
ing of three dimensions: body reality – the body as it
really exists, body ideal – the picture of how one would
like the body to look, and body presentation – how the
313
HOLTZMANN & TIMM

body is presented to the outside world. Throughout our
lives we tend to maintain a balance between these three
dimensions. The reconstruction helps the women to
maintain this balance, but it is also a major surgical pro-
cedure, which is physically and emotionally strainful for
them. Two of the nine patients experienced disturbed
body image: a condition where you avoid looking at or
touching the body and where you hide it and express anx-
iety of rejection. One of these women regretted undergo-
ing the whole procedure.
The worst experience was coming home and you can’t
do a damn thing and you do not get any help – I
haven’t received any help at all. I felt abandoned. And
the breast and my tummy are ugly. I wouldn’t have
gone through with it, if I had known this. (No. 4)
Whilst the other found support from a good friend and
her husband, and still would recommend the procedure to
other women.
I have lacked information regarding problems in the
recovery period and my appearance. It means a lot for
me to look normal, preferably perfect. I’m the type,
who prefers to forget, I cover the scars. (No. 1)
The reconstruction does not reduce the thoughts regard-
ing the cancer diagnosis, but it helps in dealing with the
situation. The patients avoid being scarred by a mastec-
tomy and avoid having problems with an external pros-
thesis, but they do not avoid the feeling that their body
has changed.
The experienced needs for nursing care
The most common care problems from the patients view
during admission were nutrition – specifically nausea, per-
sonal care, problems with sleep and rest and problems
from being bedridden (neck and back pain). The nutri-
tional problem only lasted for the first couple of days
whereas the problems regarding neck and back pain and
sleep and rest persisted throughout the duration of the
admission and were not solved. Seven of the patients still
had the problems after dismissal from the hospital. The
interventions by the staff in form of different positioning,
massage, pain killers and physiotherapy show that they
posses the knowledge to solve or relieve the problems, but
this knowledge is not used systematically or in a prophy-
lactic way.
Staff are described by several of the patients as nice,
sweet, kind, helpful and attentive.
They have all been unique and very attentive, sweet,
nice and helpful. (No. 1)
They have been very nice and sweet, open-minded
and available. I have met kindness everywhere. (No. 5)
It is positive that the staff show social competences that
makes them easy to address, but there are indications that
some of the women felt neglected if they had problems
that did not involve the primary diagnosis. One of the
women complained about head and neck pain for several
days. This was diagnosed as a headache and treated with
pain killers. Several days later the back of the head was
inspected and it turned out that the woman had a stage 2
decubitus ulcer due to a gel cushion used during surgery.
One woman felt that the care was fragmented:
I had my own sources of support, which meant that
I had someone to talk to about all this, but if I hadn’t
had that, I think I would have felt like a piece of meat,
because they only focused on the physical aspect. (No.
2)
Another example is seen when the women are no longer
bedridden.
It is as if they put a red cross over you – well now she
can take care of herself – no one came into the room
– not a single one. (No. 7)
Interestingly enough two of the patients did not feel this
change. Their explanation was that they had had the same
nurse during the whole admission.
It was apparent that all women felt very well informed
prior to the procedure and therefore confident, but lacked
quite a lot of information especially when they were no
longer hospitalized. The overall impression was that the
time after dismissal was very difficult. The women felt
left alone, they were vulnerable and unsafe and they
lacked professional contact. Vacuum, emptiness and the
feeling of being lost was apparent with all the women.
I felt that the information was good until the time of
dismissal. Thereafter I experienced a vacuum and I’m
still lacking information about how much I’m
allowed to do. (No. 2)
It has something to do with the fact that you come
from this much protected hospital environment,
where they check you every half hour and all of a
sudden you’re by yourself. (No. 8)
It would have been nice with a professional to call
after discharge – you are a little bit lost. (No. 6)
It would be a good idea with telephone hours after
discharge – you don’t know who to call – the hospital
seems big, when you’re away from it. (No. 3)

314 © 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318
 Nursing care for breast cancer patients undergoing IBR

The nurses’ assessment and documentation focused on the physical care, and after admission the
patients are left in a situation characterized by vulnerabil-
The aim in this part of the investigation was to explore to
ity and a sense of vacuum.
which degree the needs of the patients were assessed, met
Nissen et al. conclude among other results, that the
and finally documented in the medical documents during
recovery period is more difficult than expected (Nissen
the admission. It is shown that there is not complete
et al. 2002). This study also confirms the finding regarding
accordance between the problems perceived by the
lack of information especially concerning the sensation in
patients, the nurse staffs’ identification of problems and
the reconstructed breast and the loss of feeling. In a study
the documentation in the nursing journal. There are areas
exploring women’s experience of breast conserving treat-
where the patients have problems the nursing staff do not
ment the issue regarding finish of treatment is explored
identify and areas, where the nursing staff identify prob-
(McPhail & Wilson 2000). Some of the women in their
lems, which the patients do not perceive. Table 2 shows
study suggested an ‘end of treatment’ consultation to help
the problems as perceived by the patient, by the nursing
the transition period and the explanation of ‘what happens
staff and documented in the medical document. In all but
next’. A metaphor used by some of the women were feel-
one case the patients perceive more problems than the
ing ‘left out in the cold’. A metaphor similar to the major-
nurses identify and document in the journal. It is inter-
ity of the women’s feelings in the current study. In a more
esting to note that five patients express psychosocial prob-
recent study the benefits of immediate reconstruction
lems and three of these are identified by the staff. Two of
over either mastectomy alone or delayed reconstruction
these patients had disturbed body image. This indicates
have been challenged (Harcourt et al. 2003). One of the
that the staff possess knowledge regarding these issues,
main results, of this multicentre prospective study includ-
but lack systematic assessment, intervention and follow-
ing 103 patients, indicate ‘that breast reconstruction is
up. This is seen in the fact that although four of the
not a universal panacea for the emotional and psycholog-
patients do not express having psychosocial issues, you
ical consequences of mastectomy’ (Harcourt et al. 2003, p.
would still expect the issue to be documented in the med-
1060). Regarding women who chose immediate recon-
ical journal, given the fact that these women within a very
struction the study indicates that the women would have
short period of time have been diagnosed with breast can-
liked more time regarding the decision making process.
cer, have made an important decision regarding option for
Another finding that is similar to our results is that the
treatment and have recently undergone a major surgical
information should meet individual requirements and
procedure.
address both the physical and the psychological conse-
As written at the beginning of this article, nursing care
quences. This would also allow the more vulnerable
for women undergoing immediate breast reconstruction
women a more informed choice.
is assumed to differ from nursing care for women under-
The problems with assessing and documenting needs
going delayed breast reconstruction. It seems, however,
are not unique or new. Adamsen and Tewes (2000) have
that the nursing staff in this study do not recognize this
shown that there is a remarkable degree of underscoring
difference and it seems that they do not take the recent
regarding assessment of needs. In their study only 31% of
cancer diagnosis and the vulnerability of the patients into
the patients problems were documented in the medical
consideration in their nursing care. They are ‘nice’ and
journal and the staff knew about 68% of the problems.
‘sweet’, but tend to focus on the physical care, which,
The underscoring of needs have not been related to the
due to the major surgical procedure and the relatively
model of care delivery, but focused on the documentation
short time of admission, tends to take up all of their
system. The model of care delivery at the ward in the cur-
time. No correlation was found between seniority,
rent study could best be described as ‘The Team Nursing
assessment of needs or amount of care time spent with
Care Delivery Model’ (Tiedeman & Lookinland 2004).
the patients.
This model consists of a team leader and a small group of
nurses working together to care for a certain amount of
patients. In this study only two of the patients had the
DI SC U SSIO N A ND CONCL US I ON
same nurse during admission. This may indicate the rea-
The study shows that the reconstruction helps the women son for lack of continuity amongst the other patients and
obtain a sense of normality and helps provide hope after the unsystematical assessment of nursing problems. Tide-
cancer, but the study also confirmed to a great extent our mann & Lookinland show that there is a general lack of
assumptions. All the needs of the patients are not assessed evidence in determination of which care delivery model is
and met, the nursing care during admission is mainly most effective. They show that the different care delivery

© 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318 315
316
Table 2. Problems during admission. The different perspectives compared – during admission the women were questioned about their nursing problems. These data were compared
HOLTZMANN & TIMM

with the nurses’ assessment and documentation in the medical record. The X’s mark a perceived and an identified problem
Questions regarding Pain Nutrition Fluids GI Personal care Respiration Immobilization Surgical complications Psychosocial Sleep/rest
Participant no. 1 X X X X X X X
Nursing staff X X X X X X
Medical record X X X X X X X
Participant no. 2 X X X X X X X
Nursing staff X X X X X
Medical record X X X
Participant no. 3 X X X X X X X
Nursing staff X X X X
Medical record X X X
Participant no. 4 X X X X X X X X
Nursing staff X X X X X X X
Medical record X X X X X X
Participant no. 5 X
Nursing staff X
Medical record X X X
Participant no. 6 X X X X X X
Nursing staff X X X X X X
Medical record X X X
Participant no. 7 X X X X X X X
Nursing staff X X X
Medical record X X X X
Participant no. 8 X X X X X X
Nursing staff X X X X X X X X
Medical record X X X X X X
Participant no. 9 X X X X X X
Nursing staff X X X X X X X
Medical record X X X X X
GI, gastro-intestinal.

© 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318

models are very well described but it is much less docu-
mented how effective they are regarding nurse and patient
satisfaction and quality of care. Their study also includes
primary nursing care. It is therefore difficult to conclude
which care delivery model system would minimize the
above mentioned problems; however, our study indicates
that a primary care person could reduce some of the anx-
iety and the feeling of being lost.
The results from these previous studies support our
findings, but also indicate that the literature concerning
the benefits of immediate breast reconstruction is incon-
clusive and there is a need to examine how breast care
nurses can help and support women undergoing breast
reconstruction most effectively.
MET H O D D ISC US S I ON AND F UR T HE R
RESE A RC H
A bias in this study was the design of the questionnaire
used during admission. The focus was on the basic nursing
problems and therefore the physical issues might have
been more in focus than the psychosocial.
The authors also acknowledge that due to the chosen
design the study sample is small. The relative small num-
ber of patients electing reconstruction is an issue, which
has to cause methodological concerns especially if you
want to combine qualitative research with quantitative
methods and for instance want to include a control group.
In these cases and for further studies we would recom-
mend a multicentre approach. Further research into our
findings is necessary in order to validate and explore the
issues raised. An area for further investigation could be an
intervention study combining a structured dismissal con-
sultation and follow up telephone contact to reduce the
anxiety in the recovery period. Another area could be to
examine the relation between a care delivery model and
the quality of care.
IMPL IC A TIO N S F OR P R ACT I CE
We find that the current study has shed light on problems,
which probably exist more generally and therefore we find
that the following implications for practice could be: (1)
continuity in the care given – either by primary nurse care
organization or by specialist breast reconstruction nurses;
(2) development of clinical guidelines according to both
physical and psychological care; (3) systematical dismissal
consultation; (4) follow-up telephone contact; (5) educa-
tion and competence development of the nursing staff;
and (6) cooperation between oncology nurses and plastic
reconstructive nurses.
© 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318
Nursing care for breast cancer patients undergoing IBR
ACK NOWLEDGEMENT S
The authors wish to thank the nine patients who partic-
ipated in the study and wish them the best in their reha-
bilitation. We also thank the staff at the ward, who so
willingly put their nursing care up for discussion. Also
thanks to the Department of Plastic Surgery and Burn
Unit, Copenhagen University Hospital, Rigshospitalet and
the head of the department and the expert reference group.
The research was funded by the Lundbeck Foundation.
R EFER ENCES
Adamsen L. & Tewes M. (2000) Discrepancy between patients’
perspectives, staff’s documentation and reflections on basic
nursing care. Scandinavian Journal of Caring Sciences 14, 120–
129.
Blichert-Toft M. (2002) Brystkræft (Breast Cancer). NetDok-
tor.dk, Copenhagen, Denmark. [updated 2002 May 24; cited
2004 December 8]. Available at http://www.netdoktor.dk/
sygdomme/fakta/brystkraeft.htm
Buyske J., Mackarem G., Ulmer B.C. & Hughes K.S. (1996) Breast
cancer in the nineties. AORN Journal 64, 64–72.
Callewaert S. (1998) Bourdieu-Studier II (Bourdieu Studies II).
University of Copenhagen, Department of Philosophy, Educa-
tion, and Rhetoric, Copenhagen, Denmark.
Cohen M.Z., Kahn D.L. & Steeves R.H. (1998) Beyond body
image: the experience of breast cancer. Oncology Nursing
Forum 25, 835–841.
Elberg J.J., Blichert-Toft M. & Drzewiecki K.T. (1995) Primær
brystrekonstruktion efter mastektomi for cancer mammae (Pri-
mary breast reconstruction after mastectomy for breast cancer).
Ugeskrift for Laeger 157, 1013–1016.
Giorgi A., ed. (1985) Phenomenology and Psychological
Research. Duquesne University Press, Pittsburgh, PA, USA.
Harcourt D. & Rumsey N. (2001) Psychological aspects of breast
reconstruction: a review of the literature. Journal of Advanced
Nursing 35, 477–487.
Harcourt D.M., Rumsey N.J., Ambler N.R., Cawthorn S.J., Reid
C.D., Maddox P.R., Kenealy J.M., Rainsbury R.M. & Umpleby
H.C. (2003) The psychological effect of mastectomy with or
without breast reconstruction: a prospective multicenter
study. Plastic and Reconstructive Surgery 111, 1060–1068.
Harden J.T. & Girard N. (1994) Breast reconstruction using an
innovative flap procedure. AORN Journal 60, 184–192.
Knobf M.T. & Stahl R. (1991) Reconstructive surgery in primary
breast cancer treatment. Seminars in Oncology Nursing 7, 200–
206.
Kvale S. (1996) Interviews: An Introduction to Qualitative
Research Interviewing. Sage, Thousand Oaks, CA, USA.
McPhail G. & Wilson S. (2000) Women’s experience of breast
conserving treatment for breast cancer. European Journal of
Cancer Care 9, 144–150.
Neill K.M., Armstrong N. & Burnett C.B. (1998) Choosing recon-
struction after mastectomy: a qualitative analysis. Oncology
Nursing Forum 25, 743–750.
Nissen M.J., Swenson K.K. & Kind E.A. (2002) Quality of life after
postmastectomy breast reconstruction. Oncology Nursing
Forum 29, 547–553.
Parker J. & Scullion P. (1996) Susan’s breast reconstruction: a case
study and reflective analysis. British Journal of Nursing 5, 718–
723.
317
HOLTZMANN & TIMM
Price B. (1990) Body Image: Nursing Concepts and Care. Prentice
Hall, London, UK.
Schain W.S., Jacobs E. & Wellisch D.K. (1984) Psychosocial issues
in breast reconstruction. Clinics in Plastic Surgery 11, 237–
251.
Schain W.S., Wellisch D.K., Pasnau R.O. & Landsverk J.
(1985) The sooner the better: a study of psychological fac-
tors in women undergoing immediate versus delayed
breast reconstruction. American Journal of Psychiatry 142,
40–46.
Scherrebeck K. (1996) At miste et bryst: brystkræft, kropstab og
rekonstruktion (Losing a breast: breast cancer, body damage
and reconstruction). Klinisk Sygepleje 10, 8–14.
Scherrebeck K. & Munk M. (1998) At Miste et Bryst Og Få Lavet
Brystrekonstruktion (Loosing a Breast and Breast Reconstruc-
318 © 2005 Blackwell Publishing Ltd, European Journal of Cancer Care, 14, 310–318
tion). Department of Plastic Surgery, Aarhus University Hos-
pital, Aarhus, Denmark.
Stevens L.A., McGrath M.H., Druss R.G., Kister S.J., Gump F.E.
& Forde K.A. (1984) The psychological impact of immediate
breast reconstruction for women with early breast cancer. Plas-
tic and Reconstructive Surgery 73, 619–628.
Thomsen K. (1993) Brystrekonstruktion – bedre livskvalitet
(Breast reconstruction – a better quality of life). Sygeplejersken
5, 11–12.
Tiedeman M.E. & Lookinland S. (2004) Traditional models of care
delivery: what have we learned? Journal of Nursing Adminis-
tration 34, 291–297.
Vaziri N. & Agre P. (1996) What patients and their significant
others need to know about breast reconstruction. Plastic Sur-
gical Nursing 16, 193–196.