Abstract
Few studies have focussed on patients’ experiences of and suffering due to mediastinitis following Coronary Artery by-pass Graft (CABG). Mediastinitis creates a complex and invasive experience for the patient with prolonged hospitalisation, and would be expected to be a significant stressor. The aim of the present study was to capture patients’ experiences of the medical and nursing care they received for mediastinitis following CABG. Content analysis revealed three themes with regard to how the patients coped with the stress and threats of mediastinitis and its treatment and how they thought it would influence their future life. A first theme centred on physical and psychological discomfort and impact on autonomy. The staff's medical knowledge and the quality of nursing care as well as the patients’ understanding of the situation influenced their experience. A second theme was how patients dealt with perceived danger and stress. Coping strategies such as problem solving, information seeking, dissociation, distraction, minimisation and expression of emotion were used to handle the situations. The third theme comprised the patients’ belief that the mediastinitis would not affect the outcome of the CABG procedure, even though their confidence in this was influenced by uncertainty about the rehabilitation process.
Many studies have investigated the incidence of and risk factors for mediastinitis Citation1, Citation2 following CABG, although few have focussed on the patients’ experiences of and suffering due to a postoperative surgical wound infection (SWI). Mediastinitis creates a complex and invasive experience for the patient with prolonged hospitalisation, and would be expected to be a significant stressor.
Physical, psychological and social well being are dependent on how a person can cope with illness, stress and threats to everyday life Citation3. Strategies to handle stress and threats are mainly of two types. Problem-focussed coping refers to problem-management by active coping, problem solving and information seeking, whereas an emotion-focussed coping strategy involves attempts to change the way one thinks or feels about stressful situations. Problem-focussed coping strategies will be most effective for stressors that can be changed whereas emotion-focussed strategies are most useful when the stressors are unchangeable Citation3. In this context it is important to note that the degree of stress depends on the individual experience of stress, not only on the stressors as such.
Psychological well-being was found to be influenced in patients with impaired wound healing and osteomyelitis in leg fracture, but the hope of cure enabled them to cope with medical and surgical treatment Citation4, Citation5. No similar study has been performed on patients’ experiences and coping in SWI or osteomyelitis of the sternum following CABG. The aim of the present study was to capture patients’ experiences of the medical and nursing care they received for post-CABG mediastinitis. How they coped with the stress and threats posed by the mediastinitis and its treatment and how they thought it would influence their future life were evaluated.
Methods
Informants
Patients with mediastinitis following CABG were identified through their hospital records at the Department of Cardiothoracic Surgery, Uppsala University Hospital. Eighteen patients diagnosed with mediastinitis during October 2003, March 2004, December 2004–April 2005 and July–December 2005 were identified. The patients were informed of the study by mail and were contacted by telephone one week later to ascertain whether they were willing to participate. The first author (CLS) phoned the patients and carried out all the interviews. Thirteen of the patients, six men and seven women agreed to participate. Treatment has been successful for all 13 patients, in that the mediastinitis had healed. The participants were 64±5.6 (mean±SD, range 56–74) years of age. Three men and two women declined participation. They were aged 73±3.0 (range 69–77). Two of the patients who declined participation said that their experiences were so unpleasant that they did not wish to talk about them, one patient felt too weak to participate and two patients did not give any particular reasons for not participating. All participants except one had had symptoms of angina pectoris for several years before the CABG procedure. Their daily life had been physically restricted and their psychological well being had been influenced before the operation. All the present patients were treated with vacuum assisted closure (VAC) therapy. VAC therapy is a novel, successful technique for managing postoperative sternal wound infection Citation6. The VAC therapy produces negative pressure by controlled suction through a polyurethane foam dressing (PFD). The application of sub-atmospheric pressure causes epithelial cells to multiply rapidly and enhances new granulation tissue, stimulates growth of new blood vessels which carry oxygen to the wound, draws fluid from the surrounding tissues and decreases the bacterial count in the wound. The duration between the CABG procedure and start of VAC therapy was 25±20.7 (range 10–74 days) days.
The study was approved by the Research Ethics Committee of Uppsala University (Dnr-2005:210).
Data collection
The participants were interviewed within 4 months after discharge from the hospital. The interview was conducted at a place convenient to the patient. It was considered important that the patient was interviewed alone. However, in the two first interviews the wives of the participants were present. The interviews lasted for 20–90 min and were tape-recorded. An interview manual with semi-structured, open-ended questions was used. The first author was supportive and follow-up questions were sometimes asked in order to let the participants expound their answers. The open-ended questions covered three areas:
How the patient experienced the medical and nursing care for the mediastinitis. The question was followed up with four questions concerning the period between the CABG procedure and the diagnosis of mediastinitis, the readmission to the hospital, the occasion of the diagnosis, the hospital stay, the discharge and the period immediately after in-patient treatment were covered.
How the patient coped with the mediastinitis, its treatment and care. The question was followed up with two questions concerning the period between the CABG procedure and the diagnosis of mediastinitis, the readmission to the hospital, the occasion of the diagnosis, the hospital stay, the discharge and the period immediately after in-patient treatment were covered.
How the patient thought the mediastinitis would influence his/her future life. The question was followed up with two questions concerning both the immediate future and the long-term perspectives were considered.
Clinical setting
Patients with mediastinitis were readmitted to the Department of Cardiothoracic Surgery in Uppsala for treatment. They were treated with VAC therapy and the PFD dressings are changed and the sternal wound inspected every 48 h under aseptic conditions in an operating theatre, requiring local or general anaesthesia Citation6–8. The patient must be connected to the suction pump at all times. The participants underwent 4±2.1 (range 1–9) such reoperations. The sternal wound was packed with PFD dressing and sealed with a self-adhesive drape or, alternatively, a final reconstruction was performed. On a day of general anaesthesia the patients had breakfast and subsequently fasted until the procedure was performed. This was usually in the late afternoon or early evening since patients with infections are not admitted to the operation theatre until all planned surgery of uninfected patients has been completed. The patients were offered soup and sandwiches in the evening after the procedure. During the study period there were no fixed routines for parenteral nutrition during such procedures. All patients with mediastinitis had a single room on the ward. They were not allowed to have meals or watch television in the dining room but had access to television and telephone in their rooms.
Data analysis
Interviews were analysed utilising a qualitative content analysis methodology Citation9, Citation10. The procedure and concepts used followed the suggestions of Graneheim and Lundman Citation11. In the manifest content analysis, the written words are used as a base for the analysis. In the latent content analysis, the aim is to find underlying meanings in the text Citation12. All tape-recorded interviews were transcribed verbatim. Each transcript was read and re-read several times and relevant statements referring to the interview questions was identified (CLS). Words and phrases comprising “meaning units”, which referred to similar topics, were grouped together in order to categorise the answers (CLS). A discussion of the categorisation and descriptions of the central characteristics of each category were performed (CLS and the second author BS). The analysis of the text first describes these visible, obvious components, the manifest content Citation9, Citation10. An example of how meaning units were condensed into categories is given in Citation11. A category answers the question “what?” Citation11. The underlying meaning of the categories, the latent content, are then described in themes. A theme answers the question “how?”. A theme is a common underlying meaning of categories on an interpretative level Citation11. Extensive discussions among the co-authors (BS and the forth author MC) concerning the logic and consistency of the classification contributed to a broad agreement on the relevance of the coding system and the stability of the emerging themes.
Table I. Examples of a meaning unit, condensed meaning unit, code and category.
Results
Content analysis revealed three themes with regard to the patient's experiences, how they coped with the mediastinitis and its treatment and how they thought it would influence their future life. A first theme centred around the physical and psychological discomfort and the impact on autonomy. The staff's medical knowledge and the quality of nursing care as well as the patients’ understanding of the situation influenced their experiences (). A second theme was how perceived danger and stress affected how patients dealt with their situation. The patients used active coping, such as problem solving and information seeking to deal with their situation. They also attempted change their way of thinking by dissociation, distraction and minimising the problems or by expressions of emotion. The third theme covered the patients’ belief that the mediastinitis would not affect the outcome of the CABG procedure, although their confidence in this was influenced by uncertainties about the rehabilitation process. One category remained at the category level; the patients’ feelings towards their local hospital were influenced by experiences during the period before the mediastinitis was diagnosed.
Table II. Themes, categories and category contents.
Physical and psychological discomfort and autonomy were influenced by the staff's medical knowledge, the quality of nursing care and the patients’ understanding of their situation
The importance of knowledge
Knowledge is key to the patients’ experience of the situation. The patients described how they comprehended the doctors’, nurses’ and enrolled nurses’ medical and nursing knowledge. Understanding the process was important for feeling secure with treatment and care. If the medical staff could not explain a plan for treatment, if they were perceived as being vague about procedures or if they did not inform about potentially unpleasant aspects of procedures, insecurity and the risk for negative experiences increased.
“I refused to go to B. In A they never came in without disinfecting their hands with alcohol and they never left without washing their hands. I asked why they didn't have disinfectant in B. They said it was because the alcoholics drank it. I thought that was terrible.” (Woman, aged 65)
“When a patient is lying there crying and they don't even come in, they just walk past … I think … you're so vulnerable when you get back. The thoughts just spin through your head when they say this and that. They prescribe lots of medications. Then you know that something's not good. I think that's unfortunate. Maybe they could have come in and explained.” (Woman, aged 61)
The importance of nursing care
Patients described the importance of the ability of the nursing staff to show respect for the individual and acknowledge their physical and psychological needs in a professional way.
“I admire the people who work on the intensive care ward. I wasn't able to do anything myself, they even had to help we to the toilet, wipe my behind and things like that. I almost thought it was a little embarrassing to have to ask for help, but they did it with a little smile and it wasn't a problem at all. I must say that it worked very well.” (Man, aged 67)
“We also had a little fun, it was a combination … I was always a part of the team. They constantly asked me how I felt, how things were going; how I was … I thought they were wonderful in the operating theatre. They've been terrific.” (Woman, aged 61)
“But I have actually realised that a psychologist, someone to talk to, would have been good. Especially with everything going on around me at home and … this. … Someone who is knowledgeable, who knows how to start talking with you … do you know what I mean? … Because when a new person comes like this, you're not exactly an open book. Someone who can start talking a little, so you kind of start a little conversation. Once or twice maybe … and when you're back for the second time, then someone should definitely come and talk to you and ask how you feel.” (Woman, aged 59)
Physical and psychological limitations during the treatment
The patients described being tired and had little recollection of the VAC therapy. For example, they could not recall how many times they had undergone a procedure in the operating theatre. They also described physical limitations caused by the VAC therapy. They had to bring the VAC pump with them everywhere and found it difficult to perform everyday activities such as going to the toilet. They stressed the importance of being independent.
“I know there's a tube that goes to the VAC pump at the foot of the bed … It's a bit of a hassle, you know I even had it with me when I went to the toilet. You want to do things yourself as much as you can.” (Woman, aged 73)
Physical and psychological discomfort during the treatment
“Feelings of low priority” were described. Patients felt neglected or unfavorably treated by the medical and nursing staff compared to patients without mediastinitis. The feeling of having done nothing wrong but of having been mistreated physically and psychologically by the health care system emerged from the interviews. Patients felt discontent because of increased expenses for hospital care and bandaging. They wanted to be given high priority and for everything to be re-established to the expected outcome of a CABG procedure.
“I asked them, why should I wait? They said others were scheduled … I was supposed to wait patiently, if they had time I would be taken on. That's how it felt.” (Man, aged 59)
“I went to surgery five times. I wasn't allowed to eat lunch. I was supposed to go to the operating theatre when the day's operations were done. Then I got back to the ward and I couldn't remember if I was supposed to eat or not, I was a little groggy. I didn't get much to eat. I was hungry.” (Man, aged 74)
“The whole experience of the anaesthesia was unpleasant, that you had to be put under every other day. It was no pleasure to think about. I think everybody wonders “Will I wake up again?”. The uneasy feeling returns, will I come back?” (Man, aged 59)
“I also had a bad cough all the time; I coughed up phlegm every ten minutes. That was the pain I had then, when I had the incision, it was terrible.” (Man, aged 74)
“I was drugged. Sometimes the wallpaper waved just like curtains, bugs flew around and I saw birds. It was probably the morphine; I thought it was because of the tablets. But I didn't tell anyone. I cried once in a while. I stopped taking the tablets.” (Woman, aged 65)
“The vacuum pump sucks a little bit … I felt it more and more each time they changed the dressing … It really hurt on the last day. It hurt a lot, then there was no more I could take, I don't know.” (Woman, aged 59)
“I never felt it was disgusting. I think it was the fear. Mostly you're afraid. Where is it now, what's in there, how much is in there? When he used the suction and I saw how the tube … I thought, oh my god this can't be true. They really took out a lot.” (Woman, aged 61)
“Something was wrong with the bladder catheter, it overflowed. My scrotum was like a sponge when I got home. The last week I was in hospital they helped me. There were also sores on my bottom because they didn't wash me well enough. My wife noticed immediately that I smelled bad.” (Man, aged 60)
Perceived danger and stress influenced how patients handled their situation
Struggling to take control of the situation
Patients used previous experience of their reactions to stressful situations in order to cope with the present distress. For example, one woman knew that having to pass urine was a sign of being nervous. They used knowledge from their own professions, and some patients had knowledge of medical and heath care routines. They also used information from other individuals about their own personal experiences of similar situations to cope with distress. They sought information from the medical and nursing staff by asking repeated questions in order to understand and cope.
“They didn't come and explain automatically. The problem was that there were so many different people. I got an answer when I asked stubbornly enough.” (Woman, aged 69)
“I got hold of a nurse on the medical service who helped me. Then the doctor called and sent me to B and then onward. I told him how it was. ”Well, that's awful” he said. They don't give a damn about this, to be honest. “Of course you can be honest” he said … well, this is ridiculous.” (Woman, aged 59)
“I was obsessed that if it wasn't clean I would get more. I lay and watched the staff. I always had a mirror with me, I wouldn't let it go. I wanted to be in control and have a good view of the wound.” (Woman, aged 65)
“I didn't have the patience to read. The TV was on but I only watched a little. But I liked to play our recording from “The Winter War”, a play I was in, when a few of us sang. I laid there and listened to it sometimes. Then I felt like I was home. ”I'm going back there” I thought when I listened to it.” (Woman, aged 65)
Avoiding problems by changing the way one thinks or feels about the situation
Some patients dissociated themselves from the situation and decided not to take action in order to cope. They accepted the situation as it was on the occasion of their diagnosis, did not ask questions and avoided situations that could upset them. They slept or rested, withdrew from other people, focussed on other things and did not listen to information given to help them.
“They had talked to me earlier, I was a bit prepared that I had an infection, but I didn't understand how it would feel. When they talked to me about it I still had my friends around. We got to know each other well. I actually made several new friends that I still talk to over the phone.” (Man, aged 59)
“I had an open dialog with the doctor. I think we've had a mutual feeling of respect for each other. Despite the seriousness we allowed ourselves to joke a little and make light of the situation.” (Man, aged 67)
Emotional reactions based on feelings
Patients also used emotional reactions as a coping strategy. They cried, were disappointed, asked themselves “why me?” and isolated themselves.
“When I was home I stopped answering the telephone. I couldn't stand explaining to everyone once again. It made me sad when people started to ask questions. Well, you know, how are you, you understand … so I isolated myself a lot.” (Woman, aged 69)
The patients believed that the mediastinitis did not affect the final outcome of the CABG procedure, although their confidence was influenced by uncertainties about the rehabilitation process.
No effect on the Coronary Artery By-pass Graft procedure
The patients were optimistic about the future. They had had symptoms of angina pectoris for several years before surgery and were satisfied because they did not feel such symptoms any more. They hoped to put the experience behind them.
“Despite all the difficulties I would do the same again. Even if I knew I would get an infection I would go through it again. Now I can see how bad it's been during the last few years.” (Woman, 56)
Uncertainties of successful rehabilitation
For some patients the infection constituted far-reaching threats to complete long-term recovery of health. For example, there were worries concerning whether the infection would recur. One patient did not believe she was cured from the infection even though her wound had healed at the time of the interview. The patients did not realise the extent of rehabilitation necessary to recover their physical capacity.
“I wondered how long the pressure in my chest would remain. They told me that it would be just as strong as if I still had my breastbone. I talked to the doctor; she said it might take up to a year for med to get full mobility back. That was a bit of a shock, I hadn't expected that.” (Man, aged 62)
Influence on the relationship with the local hospital
Several patients made statements about negative feelings towards their local hospitals. These had to do with a feeling of being neglected and not being listened to before the diagnosis of the mediastinitis and a perceived inability to correctly diagnose the condition.
“I have to hope that the negative feelings about B are gone, otherwise it would be a disaster. Right now I have no desire to go there. I went there with a woman, I pushed her wheelchair. I told her, “We'll get this done and then get out.”” (Woman, aged 59)
Discussion
Patients with a newly diagnosed nosocomial wound infection exist in an indeterminate state in between health and illness, cure and disease. Although patients with mediastinitis have been successfully treated for a heart condition by CABG they are still sick and in need of treatment and care. The SWI is a complication not in line with the curative focus and outcome orientation of the health care environment. The patients are therefore without a clear designation or in a state of liminality Citation13 when the mediastinitis has been diagnosed. The mediastinitis my be considered a failure by the care providers since it is not the expected outcome of a CABG procedure which in turn could influence how the patients are treated. The patients themselves do not understand their illness or its severity but are aware that they have not yet gained the expected return to a new and improved state of health. They are considered contagious, a danger to other patients and are kept in isolation on the ward. The wound discharge is a constant material evidence of this liminal state. There may thus be a combination of a change in attitude from the care providers and an uncertainty of the situation on the patients’ part. As presently demonstrated the patients are then very sensitive to how medical and nursing care is performed and prone to negative feelings and interpretations. The state of liminality would be relieved if the patients’ new state was recognised by the care providers and the patients themselves were kept well informed. This would require routines for information and care of the patients and attitudinal changes among the care providers. In this context, it is important to emphasise the present finding of how information and professional skill highly improved the psychological well-being of the patients.
Stress during recovery from surgery may also impair wound healing. Laboratory studies have shown that stressed mice produce higher levels of glucocorticoids and display less inflammatory response, impaired bacterial clearance and slower healing than non-stressed control mice Citation16. Psychological stress impairs the inflammatory response and matrix formation process in the wound immediately following surgery in humans Citation17. This impact of stress on wound healing further emphasises the importance of reducing physical and psychological discomfort during the immediate postoperative period.
How the patients coped with the mediastinitis depended on both the perception of stress and threats and on the personal coping strategy Citation3. To the burden of the mediastinitis is added the limitations of daily life and discomfort associated with its management. Repeated anaesthesia, hallucinations and pain may be frightening and make coping difficult. It is, however, evident from the present data that perceiving care providers as knowledgeable, feeling well informed, feeling that the nursing care is good, being seen as an individual and having emotional support from family and friends are associated with the use of problem-focused coping strategies. In a situation in which constructive changes are possible, information may advance the process of forming problem-focused coping strategies Citation14 which are known to be associated with a better outcome of the rehabilitation process Citation3. Some patients used emotion-focused coping strategies, such as avoiding problems by changing the way of thinking or feeling about the situation or by allowing strong emotional reactions. Such alternative strategies are important when the situation was perceived as impossible to change or if problem-focused strategies had been tried without success. Distancing oneself from the problems may then be used as a temporary adaptive mechanism until one is ready to address the stressors in a problem-focused manner. This was evident in the present study in the patients’ descriptions of how they surrendered themselves to care when they were informed of the diagnosis of mediastinitis. Such situations that have to be accepted generate higher levels of emotion-focused coping Citation15, a strategy, which can be effective in that it allows a rest or pause from the situation. However, dissociation, distraction and minimisation of the problem are not adequate for long-term understanding or for handling the recovery of mediastinitis Citation3. The care provider must acknowledge this and provide information and reassurance to help the patient to address the problem in a problem-focussed manner.
Donabedians model could be used to understand the importance of interpersonal interactions between patient’ and caring staff. Donabedian analysed quality of health care in a triad of elements in a conceptual framework for evaluation Citation18, Citation19. The three elements were structure, process and outcome of care. Structure refers to facilities and equipment as well as human resources including the qualifications and experience of healthcare professionals and the services available to the patients Citation20. Process refers to how care is provided, under what circumstances and how patients are moved into, through and out of the system Citation20. Outcome refers to the results of care and includes biological, functional, emotional and social dimensions. In this model structure affects process, which in turn affects outcome Citation21. This conceptual framework can be used to understand the central characteristics of the themes in the present study. The structure constitutes the technical and medical care available to the patients with mediastinitis including care providers, the VAC technique, operating theatres, antibiotics etc. How nursing and medical care is performed and how information is given represent the process. The outcome in the present study is not only the curative effect of the CABG and the healing of the mediastinitis but also the patients’ experiences of the process and their physical and psychological well-being. In an organisation tuned to perform a large number of CABG procedures the curative focus of the process is highly emphasised. Good outcome is equated with successful treatment of coronary artery disease. In Donabedian's framework outcome should, however, also include emotional experiences and psychological well-being. The present findings would therefore indicate that there is considerable room for improvement of the process of treatment and care of patients with mediastinitis. The patients’ feelings of low priority and helplessness must be acknowledged and routines for information improved in order to reduce perceived stress and improve coping. The observation that the patients’ experiences did not effect the final outcome of the CABG procedure should not allow the conclusion to be made that these experiences are acceptable or of minor importance. The significance of such negative experiences may be overlooked since an anticipation of a final outcome may reduce stress in an otherwise difficult situation Citation15. Indeed, the full impact of negative experiences may not be revealed in view of the patients who declined participation were older, weaker and not ready or willing to talk about what they have been through. They may have had difficulties with expression of feelings, which in combination with unpleasant experiences and physical weakens prompted them to decline participation.
The trustworthiness of the material was established in that all patients were asked the same three open-ended questions and the followed up questions for each area. Inter-coder reliability is necessary for the reproducibility of the analysis. This was achieved through discussions among the co-authors on the logic of the classification Citation22, Citation23. The transferability was established by a documented sampling procedure, a clearly described context of patients with mediastinis and an extensive documentation of the analysis Citation12. The first author has several years of experience of patients with mediastinitis following CABG. This may help to develop an understanding of these patients’ experiences Citation12. However, that two participants had their wives nearby during the interview may be seen as a weakness. The age distribution of the sample is representative for patients undergoing CABG procedures in Sweden. However, women were overrepresented in the sample since only 22% of CABG procedures are performed on women Citation24.
This study shows the value of evaluating the patients’ perspectives by semi-structured interviews with open-ended questions analysed with qualitative content methodology. This deeper understanding of the patients’ experiences may not have been reached with questionnaires with standardised questions assessing patients’ views on quality of care. The present observations are thus important for understanding the patients’ situation and hence for the care providers in their medical and nursing care of patients with an unexpected mediastinitis.
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