Corresponding author : Mona Choi, PhD College of Nursing · Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea INTRODUCTION
Lung cancer has the fourth-highest incidence rate among cancer types in Korea [1]. Cancer was the leading cause of death in Korea in 2018, and lung cancer, which had the highest mortality rate, accounted for 22.5% [2]. Surgery is a core method for treating lung cancer patients; however, lung resections can lead to pulmonary complications such as atelectasis, prolonged air leak, pneumonia, and acute respiratory distress syndrome [3,4]. It can also result in other complications such as atrial fibrillation, acute myocardial ischemia, cardiac infarction, pneumothorax, hemothorax, and bronchopulmonary fistula [3]. Furthermore, thoracic surgery carries higher risks of postoperative pulmonary complications (PPCs) than do other surgeries [5]. PPCs could increase early postoperative mortality and admission rates to intensive care units (ICUs) and prolong the length of stay in the ICU and hospital [6], which eventually delays patients' postoperative recovery.
Postoperative recovery is a process that requires energy to recover to normal health by regaining physical, psychological, social, and habitual functions and returning to the levels of patients’ independence and psychological well-being before surgery [7]. It includes not only the physical but also emotional and social domains. Therefore, healthcare providers need to help improve patients' postoperative recovery process to enable them to return to their daily lives as soon as possible [8].
As a way to promote postoperative recovery, Enhanced Recovery After Surgery (ERAS) protocols, including treatment and nursing, are the leading example of interventions provided by a multidisciplinary team [9]. Interest in ERAS has been increasing, as studies have demonstrated its effectiveness in reducing lengths of hospital stay, patients’ complications, and medical costs [10]. The ERAS 2018 guidelines for lung surgery consist of 45 items in the pre-admission, admission, intraoperative, and postoperative phases to improve patients’ recovery [11]. Among the ERAS items, early mobilization in the postoperative phase is associated with reducing immobilization-related complications and the length of stay in hospital [11]. It was found that early mobilization was effective in reducing the incidence of PPCs such as atelectasis and pleural effusion at postoperative day (POD) 2-3 [12].
Early walking exercise also facilitates patients’ recovery by improving their functional status in an effective, safe, and feasible manner and has a critical role in reducing postoperative complications and improving quality of life after discharge [13]. When patients participated in exercise intervention, it was determined that self-efficacy among the various psychological variables increased walking ability and physical activity [14]. Additionally, self-efficacy triggers changes in health promotion behavior, maintaining exercise, and engaging in self-care for postoperative patients [15]. In other words, self-efficacy can increase physical activity for functional state recovery, which may eventually facilitate postoperative recovery [16].
Although postoperative recovery is an essential part of returning to daily life, to our knowledge, there have been few studies examining factors associated with postoperative recovery from the patients' perspective, especially lung cancer patients. Identifying factors associated with postoperative recovery would help develop strategies to promote recovery in lung cancer patients. Therefore, using a sample of 90 Korean patients, this study aimed to 1) identify the characteristics of lung cancer patients after lung resection, including the performance of walking exercises in an ICU and 2) explore the factors associated with lung resection patients’ postoperative recovery before discharge.
METHODS
1. Study design
This study used a cross-sectional study to identify factors associated with postoperative recovery among patients who underwent lung resection for lung cancer and performed walking exercises while in the ICU.
2. Study setting and participants
Postoperative walking exercise is part of the standard care for thoracic surgery patients in the hospital. Lung resection patients should perform walking exercises at least once to transfer to general wards. If patients had no problems, they performed walking exercises in the order of bedside sitting, standing, and walking around the ICU (about 30 m) with the assigned nurse's help on POD 1. While a patient was walking, the nurse monitored their symptoms, heart rate (HR), and saturation of percutaneous oxygen (SpO2) via a portable monitor and documented them.
This study used convenience sampling. Participants performed walking exercises in a thoracic surgery ICU after lung resection for lung cancer in a tertiary hospital in Seoul, Korea. The selection criteria included 1) those over 19 years of age, 2) who had been diagnosed with primary lung cancer, and 3) who had had a lung resection. The sample size was calculated using G*Power software 3.1.9.2 (Heinrich-Heine University, Düsseldorf, Germany) for multiple linear regression, with an effect size of 0.2, α (significance level) of 0.05, a power of 0.8, and nine predictors. The minimum number of participants required was 88. Initially, 91 participants were recruited, but data from only 90 participants were analyzed because one was excluded due to missing data.
3. Measurement
1) Participants’ characteristics
(1) General and clinical characteristics
Data were collected regarding participants' general characteristics: age, gender, religion, marital status, main caregiver, education level, employment status, and monthly income. Clinical characteristics were the history of preoperative chemotherapy and radiotherapy, smoking history, American Society of Anesthesiologists' Classification, cancer history, operation history, stage of lung cancer, type of surgical approach, the extent of resection, and length of ICU and postoperative hospital stay.
(2) ICU walking-related characteristics
ICU walking-related characteristics consisted of variables related to walking exercises in POD 1. Walking distance, maximum HR, and minimum SpO2 recorded during the walking exercise in POD 1 were collected from electronic medical records. Symptoms included pain, fatigue, dizziness, shortness of breath, and nausea and vomiting (N&V) experienced by patients during walking exercises. These were measured on an 11-point numeral rating scale (0=none; 10=very severe). The Category Ratio 10 scale (0=nothing at all; 10=extremely strong) was used to measure perceived exertion during walking [17]; the modified Borg Scale (0=nothing at all; 10=maximal) was also used to measure dyspnea during walking [18]. Through questionnaires, participants selected a number on a vertical scale to indicate their subjective degree of difficulty and dyspnea during walking exercises, respectively.
2) Postoperative recovery
Postoperative Recovery Profile (PRP) was used to measmeasure postoperative recovery as perceived by patients on the day before discharge [19]. The Korean version of the PRP has well-established reliability and validity [20]. It included 17 problems across five dimensions: physical symptoms (five items), physical functions (four items), psychological problems (four items), social problems (two items), and activity problems (two items) [20]. Each item was rated on a 4-point scale from 0 (none) to 3 (severe) according to the participant's experience within 24 hours. Higher scores indicate lower levels of postoperative recovery. The Cronbach’s α was 0.80-0.88 for the Korean version20) and 0.84 for this study.
4. Data collection
This study was approved by the Institutional Review Board of a tertiary hospital in Seoul, Korea (SMC 2019-03-137-002). Data were collected using self-reported questionnaires from April to June 2019. The researcher visited patients in the general thoracic surgery wards on the day before discharge and explained the study's purpose and procedure. Subsequently, written informed consent was obtained from patients who agreed to participate in the study voluntarily. If participants had difficulty reading the questionnaire, the researcher read it aloud and obtained answers from them. Some elements of clinical and ICU walking-related characteristics were extracted from electronic medical records by the researcher.
5. Statistical analysis
Statistical analyses were performed using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). This study used descriptive statistics to analyze frequencies, percentages, means, and standard deviations of collected data. T-tests and analyses of variance were performed to analyze differences in postoperative recovery according to participants’ characteristics. Pearson’s correlation was performed to explore the relationships among perceived postoperative recovery and other variables. Finally, a multiple regression analysis was performed to identify the factors associated with postoperative recovery.
RESULTS
1. General, clinical, and ICU walking-related characteristics of the participants
The mean age of participants was 63.23±8.12 years, ranging from 37 to 79 years. Half of them were male, and 54% were unemployed. A quarter of the participants were current smokers; about one-third had no previous operation history, and nearly two-thirds were diagnosed with the first stage of lung cancer. The mean length of ICU stay was 1.12±0.42 days, and the mean postoperative hospital stay was 6.44±5.50 days. The mean walking distance was 61.69±44.97 m, based on an analysis of the data from 62 participants because records of the other participants were missing from the electronic medical record. Among the symptoms experienced during walking exercises, participants reported pain as the most severe, while N&V was the weakest. The mean score for perceived exertion during walking was 3.47, indicating moderate to strong exertion. The mean score for dyspnea during walking was 1.57, indicating slight dyspnea (Table 1).
2. Postoperative recovery and self-efficacy of the participants
Table 2 shows participants’ scores for postoperative recovery and self-efficacy. As to postoperative recovery, higher scores reflect lower levels of recovery. The mean score for postoperative recovery was 0.70±0.41 out of 3, indicating a high level of perceived recovery. Among the five dimensions, the physical symptoms indicated the lowest, and the psychological dimension indicated the highest recovery level. Among the problems, the pain ranked at the lowest recovery level, followed by appetite changes and gastrointestinal function, whereas bladder function was ranked highest, followed by nausea and personal hygiene. The mean self-efficacy score of the participants was 3.06±0.42 out of 5.
3. Postoperative recovery according to the characteristics of the participants
There was no significant difference in postoperative recovery according to age, gender, marital status, stage of lung cancer, and extent of resection (Table 3). However, there were significant differences in postoperative recovery according to employment status (t=-2.689, P=0.009) and operation history (t=2.008, P=0.048).
4. Correlation among postoperative recovery, self-efficacy, and ICU walking-related characteristics
Postoperative recovery and self-efficacy had a negative correlation (r=-0.230, P=0.029), which indicates that the higher the self-efficacy, the higher the level of recovery. In addition, postoperative recovery was positively correlated to pain during walking (r=0.296, P=0.005), dizziness during walking (r=0.355, P=0.001), fatigue during walking (r=0.352, P=0.001), N&V during walking (r=0.424, P<0.001), perceived exertion during walking (r=0.428, P<0.001), and dyspnea during walking (r=0.232, P=0.028). This indicates that the more severe the symptoms, the lower the level of postoperative recovery. On the other hand, postoperative recovery and self-efficacy had a negative correlation (r=-0.230, P=0.029), which indicates that the higher the self-efficacy, the higher the level of recovery (Table 4).
5. Factors associated with postoperative recovery
The results of the multiple regression model found that unemployment (β=4.353, P=0.005), more N&V during walking (β=0.596, P=0.043), and severe perceived exertion during walking (β=1.105, P=0.007) influenced postoperative recovery (F=4.692, P<0.001). The adjusted R2 indicated that this regression model explained their perception of postoperative recovery before discharge by 31.3% (Table 5).
DISCUSSION
The study was conducted to examine the factors associated with perceived postoperative recovery in lung cancer patients after lung resection. In this study, the level of postoperative recovery before discharge was relatively high, and results showed higher levels of postoperative recovery among lung resection patients compared to gastrectomy [23], gastrointestinal surgery [20], and cardiac surgery [24] patients. The patients analyzed actively performed walking exercises to promote postoperative recovery as a part of the ERAS, emphasizing the postoperative phase [9,25]. According to the ERAS guideline, exercising within 24 hours after surgery can help improve postoperative recovery despite several obstacles such as chest tube, foley catheter, and pain [11]. As exercise has positive effects on patients’ physical and psychological aspects [9,11], the study participants who participated in walking exercises early on also showed positive postoperative recovery levels.
Among the five dimensions of postoperative recovery perceived by participants before discharge, the psychological dimension had the highest recovery level, while physical symptoms had the lowest level. Previous studies also reported psychological recovery as having the highest level [23,24], which can be attributed to the belief that patients can be treated by surgery and return to their daily lives after discharge [24].
In this study, 70% of the participants underwent surgery through VATS, a minimally invasive method, and their extent of resection was mostly below lobectomy. Compared to thoracotomy, patients who had lung resection through VATS showed relatively lower pain in a previous study [26]. Despite the high percentage of the VATS method, the results of this study indicated that the recovery level for physical symptoms was the lowest, of which pain was the lowest among all problems. In the process of lung resection, surgeons cut or retract muscles, fracture or sever ribs, and insert chest tubes that irritate or damage the pleura or intercostal muscles, which may cause more pain than other operations [11]. Pain is a common physical symptom that patients frequently experience after lung resection, and this pain can be further aggravated by walking exercises. Other symptoms with lower recovery levels, such as appetite changes and gastrointestinal function, also did not meet the patients' expectation of recovery during the postoperative phase. Therefore, nursing interventions to alleviate and control these symptoms need to be implemented to enhance postoperative recovery.
In the multiple regression analysis, employed participants reported significantly higher postoperative recovery levels than unemployed ones. Jeon et al. [23] found that stomach cancer patients who were employed showed higher postoperative recovery levels. The reason might be that employed patients make more effort to recover to return to daily life quickly after discharge compared to unemployed ones [27]. Moreover, it was identified that females, older adults, and those who had poor health status had difficulty returning to work after the treatment [28]. Consequently, multidisciplinary, patient-tailored interventions should be provided at discharge or in outpatient clinics to assist those who are less likely to return to work after surgery [29,30].
Furthermore, those who felt less N&V during the walking exercises reported higher levels of postoperative recovery. Postoperative nausea and vomiting are one of the most frequent complications, with negative effects on the early stages of recovery after surgery [11]. Controlling these symptoms could also make early exercise more plausible [25]. When nurses care for patients who perform walking exercises, they need to alleviate N&V to affect postoperative recovery positively.
This study is the first in Korea to investigate subjective postoperative recovery and the associated factors using patients’ reports and objective data on walking exercises in an ICU after lung resection. However, this study has several limitations. As convenience sampling was used to recruit patients in a specific ICU after surgery, it is difficult to generalize the results to all post-surgical lung cancer patients. Furthermore, given that more than a 2-day interval passed between the actual walking exercises in the ICU and data collection, a patient’s recollection might not reflect their real condition. Another limitation is that this study did not compare results with those who did not engage in walking exercises in ICU. However, such a comparison was impossible because all patients performed walking exercises based on physicians' order in this study site.
In conclusion, our study revealed that unemployed patients, patients who experienced severe N&V during walking, or had high levels of perceived exertion during walking reported lower levels of perceived postoperative recovery. Multidisciplinary, patient-centered interventions should be implemented to support patients who plan to return to work. To enhance patients’ recovery following lung resection surgery, nursing interventions should be applied to alleviate physical symptoms and patients also need to exercise at an appropriate level of perceived exertion. These findings can contribute to promoting postoperative recovery among lung resection patients, which can ultimately improve their quality of life.
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