Environmental Needs,Barriers,and Facilitators for Optimal Healing in the Postoperative Process: A Qualitative Study of Patients’ Lived Experiences and Perceptions

Ability to influence treatment and recovery

Patients expressed that they were well-informed by their care providers about their health situation. They also felt involved in decisions regarding the treatment process. This involvement gave patients a sense of being able to influence their recovery. In addition, the support and encouragement received from care providers to learn self-care activities were valued as these activities increased levels of independence. “I want to do the stoma care myself. I know some people [other patients] don’t want that, but I insisted on doing it myself, because I want to be in control. I don’t want to depend too much on others” (SSI08). They expressed a preference for greater involvement in the planning of medical checkups and medication rounds to reduce the level of stress. Unexpected visits and treatments often left patients surprised and induced stress. Patients noted that more clarity in the timing and purpose of activities and in the estimated duration of visits and checkups probably would have made their recovery more comfortable.

Control over ambient features

The recovery of patients was positively and negatively influenced by several ambient factors such as light, sound, and temperature. The appreciation of ambient factors varied based on interviewees’ personal preferences and state of recovery. For example, hearing constant sounds from the hallway could give a sense of safety, whereas the sounds of medical devices (e.g., the beeping of an infusion pump running low), conversations, or footsteps could as well create irritation. Furthermore, sunlight entering the patient rooms could give energy to patients, while it could also disturb patients’ rest. “Sensing the presence of staff in the evening and night, because you hear them talking and working. This reassures me and gives me a comfortable feeling” (SSI01). Patients felt that they had limited possibilities to regulate or modify important ambient factors in their room in accordance with their preferences. Patients described depending on an automatic sunblind system and on the assistance of nurses to adjust the lights or room temperature or to close the door. The constant need for help from nurses and the preferences of roommates in shared rooms made patients reluctant to seek assistance and discouraged them from proactively changing ambient factors.

The illogical placement of light switches and devices hindered control, for example, managing the temperature or illumination. Switches or control devices in patient rooms were often perceived as difficult to access, especially when patients were confined to bed. Therefore, suggestions were made on alternative locations for switches and control devices closer to the bed and the use of a comprehensive and portable device (e.g., a mobile tablet device) to increase control over the ambient environment.

Control over privacy

Patients perceived privacy as an important aspect of recovery. Those who were hospitalized in a private room described the comfort of having their own bathroom and being able to do certain activities without worrying about being overheard or seen by others. They also felt in control of deciding when to isolate themselves from others. On the contrary, all interviewees who stayed in a four-bed bay experienced limited to no privacy, both in audio and visual privacy. They mentioned that their personal information could be easily overheard by others. This poor level of privacy could induce stress. “It’s like you are in the worst student dorm ever. No privacy and you are bothered all day long. But it’s part of the game, and after a couple of days you adapt” (NI04). Patients described isolating themselves from roommates, if needed, with the limited means they possessed in a four-bed bay. For instance, they closed the curtain to create privacy around their bed. Despite more visual privacy, this did not prevent them from possibly being overheard by others and created a feeling of being “locked up.” The lack of privacy, however, did not withhold patients from sharing personal information with care providers if needed.

Control over nutrition

It was felt that recovery benefited from the ability to make own choices about when and what to eat and drink. Patients liked the fact that they could select their preferred meal from a large variety of options and that food and drinks were offered multiple times per day. “The food service system is great. Food tastes good, it looks good (…) but also showing what is offered to you is fantastic” (NI10).

Control over help request

The nurse call button nearby was valued as important for control. Being able to quickly call the nurse for help provided them with a sense of safety. However, frustration was expressed on the “single-option” feature of the device which made patients sometimes hesitate to ask for help. Due to the device’s design and functionality, a nurse cannot distinguish between a life-threatening event and a simple question from the patient. Being able to indicate the urgency level of their help request could improve the use of such a device (Figure 2). “I would prefer an additional button. One for urgent matters and another one for help requests such as: ‘I’m hungry and I would like something to eat’” (NI03).

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Figure 2.

Impractical nurse call button—NI05: “The nurse call button is not practical for me.”

Personalized room

The need was expressed for positive distractions during hospitalization to be less focused on pain, worries, and stress. For example, it was much appreciated that patients could decorate their own room with presents or postcards received from friends and family. However, as the pinboard was positioned behind the bed, patients could not see the decorations and kind messages themselves. Therefore, the wall or door opposite of their beds was sometimes decorated (Figure 3).

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Figure 3.

Personalized door—SSI05: “A pinboard would have been nice.”

Patients expressed needs to personalize their room or personal space. Rooms were often negatively described as sterile, monotone, and white. A room with a warm ambience was preferred with a feeling being at home. This could be facilitated by artworks, for example, particularly intriguing ones that are worth looking at for a longer period. “I think you’ll go slightly mad when you have to stare at a white wall for 6, 7, 8 days or longer” (SSI09).

Connection with the external environment

Patients expressed their preferences concerning the window and the outside view. In general, they prefer to be better connected with the external environment. Without an outside view, the natural view was missed, which was perceived as missing a potential powerful distraction. Moreover, the current window size and covering style were mentioned to contribute to even more isolation. Large (panorama) windows were suggested as a better connection to the outside environment. Windows larger than the current ones would give patients a more comprehensive view of the outside world. Nevertheless, patients often accepted and understood that the size and shape of the hospital building made it impossible to answer to the view preferences of all patients (Figure 4).

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Figure 4.

The outside view (A) SSI06: “I can see over the trees (…) The view is good and calming.” (B) SSI05: “The outside view can be better (…) looks like a prison room.”

When a natural view from the window is not possible, it was suggested to use images or dynamic projections of natural scenes on the wall as an alternative to providing distraction. “Opposed to the bed there should be a depth effect, allowing you to look away. Something peaceful. A sea, forest, or mountains (…) allowing you to relate to nature and the outside world” (NI02).

Undertaking activities

To improve recovery and as a form of distraction, patients also expressed the need to undertake activities. This need was mostly expressed by patients during later phases of recovery in contrast to patients immediately after surgery. These patients mentioned needs for activities such as going for a walk to mobilize, getting some fresh air, and finding social distractions, either by talking to other people or just by observing people in the corridor. Although the hospital provides several opportunities to distract patients, each was considered to have its own flaws. For example, activities outside the hospital were difficult to undertake due to the large distance patients had to cover between the hospital ward and its nearest exit and the poor direction signing of the hospital. One patient, for example, mentioned being afraid to get lost, which discouraged him from leaving the ward. “You have to take the main hospital exit and cross a crowded square to find a few benches. And first, you have to get through a curtain of smoke because many people are smoking outside of the hospital” (NI10).

Moreover, patients expressed the need for a room to undertake social activities as having lunch with other patients or playing games (e.g., board games, jigsaw puzzles). Although such a “dayroom” already exists within the hospital, patients describe the room as monotone and uninviting (Figure 5).

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Figure 5.

Design of the dayroom—SSI10: “The dayroom looks rather sterile. Could be cozier and look like home.”

Finally, where the hospital offers a multipurpose device with TV, radio, and Internet access to facilitate entertainment and distraction from pain and worries, the technology was not always functioning well which could be frustrating for patients.

Contacts with care providers

Patients perceived the contact with care providers as very important for their well-being and healing. They indicated that a caring attitude and the motivating words of providers helped to relieve stress, anxiety, and pain. Contact with physicians mostly helped to gain medical information and guidance to obtain a better understanding of and more confidence in one’s own health, medical treatment, and recovery. Contact with nurses was considered a very important first contact offering practical, informative, and emotional support. Furthermore, having contact with a constant group of familiar care providers helped patients to trust providers and know what they could expect from them. Interestingly, it was mentioned that more personal attention was perceived in a private room compared to that in a four-bed bay.

Where patients experienced benefits from the contacts with care providers, they also mentioned several factors that hinder healing support. First, due to the high workload of care providers, the providers were sometimes not able to quickly respond to a help request. Not knowing when they would receive support after requesting help was experienced as stressful. Patients also mentioned that seeing their care providers in a rather stressed state made them refrain from seeking help or care when needed. “I had to get used to how things work here. Super structured. (…) I noticed that because of the high administrative burden, there is less time for people in beds.” (SSI03).

Second, it was felt that care providers were inattentive to their changed supportive needs during the recovery process. While the need for functional support decreased during recovery, patients indicated that they could have benefited from an increase in emotional support by care providers. Patients mentioned that it took a while for them to realize what had happened and how their illness/surgery affected them physically and emotionally. They indicated that they had to bring better specific needs to the attention of their care providers.

Third, constant changes in medical or nursing personnel turned out to be confusing and worrisome for patients. For example, patients felt insecure about whom to address with their problems and complaints. They sometimes did not know whom to turn to in case of questions or whom they had spoken to after a visit. It was also found hard to discern the different types and roles of care providers, for example, due to the lack of identification badges or specific provider uniforms. Furthermore, it was felt irritating to repeat the same information to different care providers. “You have to find out yourself who is doing what. Who will bring you towels in the morning? (…) stuff like that. We see so many new faces. For us [patients] all faces are new when we wake up” (SSI09).

Finally, patients were confused by the inaccurate and outdated information on their whiteboard (e.g., describing today’s on-duty staff, patient’s nutrition status, special remarks).

Contacts with other patients

The need for contact with other patients seemed to depend on the phase of recovery and personality of a patient. Especially during the initial postoperative phase—when they felt sick and in need of rest—patients did not experience a need to have contact with other patients. There were also patients who wanted minimal contact because they disliked listening to other people’s problems or stories.

Other patients—often referring to their later phase of recovery—preferred communication with peers. They pointed out the benefits of staying with multiple patients in a hospital room: being able to support each other emotionally and practically, sharing experiences, and keeping an eye on each other. The possibility to interact with fellow patients or relatives was also seen as a positive distraction from their current health situation and a helpful way to pass time. These positive experiences, however, largely depended on the personality, health condition, and preferences of the people the patients had to share their room with. Patients described that more involvement in the allocation or relocation from or to a private or four-bed bay could reduce stress and fasten recovery. “I do not want to exaggerate but I think that being in a four-bed bay resulted in three to four days of extra recovery. It takes so much energy, all the stimuli” (NI07).

Contacts with relatives

The contacts with family and friends during hospitalization were valued. Aside from being a positive distraction from pain, anxiety, and boredom, talking with relatives helped patients to cope with their health situation. Patients who stayed in a private room appreciated having autonomy in deciding when to receive visitors. In their view, the flexible visiting hours at the ward allowed visitors to come from distant places, and it allowed patients to plan their rest moments themselves. On the other hand, patients in a four-bed bay mentioned that the flexible visiting hours induced stress and fatigue because visits were allowed the whole day. They indicated not having the courage to ask visitors from other roommates to leave even when they needed to rest (Figure 6).

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Figure 6.

Crowded room by patient visits—NI08: “It’s often very crowded, while I really need more rest.”