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

R E S E A R C H P A P E R

A comparison of nurses’ perceptions of electivelaparoscopic or elective open colorectal resectionsijn_1979 621..627

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

Ian Whiteley BN, GradCertSTN, GradCertNursEd, GradDip (Acute Care), MCNClinical Nurse Consultant, Stomal Therapy Level 1 West, Concord Repatriation Hospital, Concord, New South Wales, Australia

Accepted for publication May 2011

Richardson G, Whiteley I. International Journal of Nursing Practice 2011; 17: 621–627A comparison of nurses’ perceptions of elective laparoscopic or elective open colorectal resections

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

Key words: colorectal surgery, laparoscopic, nurse, perceptions, postoperative care.

INTRODUCTIONThe purpose of this study was to develop an instrument todetermine if nurses perceive differences in postoperativeoutcomes for patients who had undergone elective laparo-scopic colorectal resections (LAP) vs. those who hadundergone a traditional elective open colorectal resection(OPEN) by laparotomy. Secondly, to determine if thenurse participants consider there are benefits for patientshaving laparoscopic colorectal surgery, and if there wasless time and effort required by these nurses to look after

them. Lastly, to identify whether these nurses considerLAP surgery preferable to open surgery.

The participants in this study were nurses currentlyworking in this specialized colorectal unit who voluntarilycompleted the survey. Therefore, as no patients wereinvolved, there was no risk of harm to patients or poten-tial breeches of confidentiality, and ethics approval wasnot required.

Laparoscopic colorectal surgery has been described inthe literature since 1991;1,2 however, there are few, ifany, papers describing patient outcomes or any variationin care required from a nursing perspective in the post-operative period. Between 1991 and 2000, there was arelatively slow uptake of laparoscopic colorectal surgeryby surgeons. Reasons identified for the delayed introduc-tion included the complexity of the surgery requiring

Correspondence: Gillian Richardson, Ground Floor West, ConcordRepatriation Hospital, Hospital Road, Concord, NSW 2139, Austra-lia. Email: [email protected]

International Journal of Nursing Practice 2011; 17: 621–627

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

training and a long learning curve and also because opera-tions were complex and challenging due to the inadequacyof equipment available at the time. Over the past 3 years,however, there has been an increase in the numbers oflaparoscopic colorectal surgical procedures being per-formed because of improvement and availability of equip-ment required.1

Despite these findings, LAP colorectal surgery is prac-tised expertly within our facility. This was one of theforemost reasons for developing the instrument to assessnursing perceptions of the benefits to patient outcomesand for nursing workload. Between January 2006 andDecember 2008, 39.5% of colorectal cancer resectionsat our institution were performed using LAP techniques.From January 2009 to December 2010, there wasa noteworthy shift at our institution with 50.7% ofcolorectal cancer resections performed using LAPtechniques.

Laparoscopy has revolutionized colorectal resectionsand has been associated with decreased overall morbidityand better postoperative outcomes than open resec-tions.2,3 Minimally invasive (laparoscopic) colorectalsurgery has the potential to enhance patient outcomethrough decreasing postoperative pain, shortening lengthof stay, enabling early resumption of pre-surgical lifestyleand earlier return to work.1–6 Other suggested benefits tolaparoscopy include: smaller incisions, a decreased risk ofadhesion formation because of less physical injury to intra-abdominal structures and a shorter postoperativeileus.2,4,6,7 Smaller incisions lead to better cosmesis forpatients.2,6 LAP have been associated with a betterimmune and inflammatory response leading to improvedpostoperative outcomes.2,3 Furthermore, reduced bloodloss has been identified as a benefit.1 Fewer wound infec-tions have been noted as a benefit of laparoscopic colorec-tal surgery.2,5

It is well documented that early concerns regardingoncological safety due to the risk of port-site tumourrecurrence after laparoscopy are unfounded, and the rateof cancer recurrence in an open wound is similar.2–4,6–8

Baker et al.2 compared laparoscopic vs. open abdomino-perineal resection (APR) and found no difference inthe mean length of overall survival and no difference inoverall recurrence rate and concluded laparoscopic APRdoes not compromise cancer specific survival outcomes.2

Delay in discharge was attributed to larger abdominalwounds in patients who had undergone an open APR.2

Eighty-three per cent of nurse respondents in this percep-

tion survey felt that patients having an OPEN resectionhad a longer length of stay. The learning of stoma careand organization of social placements increased length ofstay in patients who have undergone LAP and OPENresections.2

METHODA survey was developed for the specific purpose of thisinvestigation as the literature review failed to locate aprior study. The first 20 questions were grouped into 10sets of paired questions to assess for perceived differencesbetween LAP and OPEN surgery. The paired questionsreflected each other to avoid the perception of bias on thepart of the authors towards either laparoscopic or opensurgery. This method of questioning allowed the respon-dents a free range of responses; thus, it was possible thatwhichever surgery had been performed, the respondentsmight find the patients either equally easy or equally dif-ficult on any question. Statistical comparison of the resultswas performed using a paired t-test as the responses had anormal distribution.

The questionnaire is a subjective paired comparisonproblem where the nurse respondents were asked to use aseven-point modified visual analogue Likert scale to ratetheir responses. The range was selected as the authorsbelieved this allowed both a range of possible responsesand a ‘midpoint’ for ease of analysis. The final three ques-tions had nurses circle the response they felt was mostappropriate.

Within the questionnaire, each respondent was askedto compare the same activity between two differentpatient groups—those who have undergone LAP resec-tions in comparison with those who have undergoneOPEN resections.

The survey was exclusively targeted at nurses workingin the specialist acute care colorectal unit. The question-naire was distributed by attaching it to the nurses’ fort-nightly payslips with a letter of explanation and invitingtheir participation. Respondents were asked to place thecompleted survey in a box placed at the nurses’ station.

Definitions of the questions asked within the question-naire are included in Table 1.

Although this was a pilot study, considerable effort wasundertaken to ensure the results were as reliable as pos-sible. Stability is derived when measurements are takenunder identical conditions.9 The authors would needto undertake further studies to confirm the instrument’sreliability and stability.

622 G Richardson and I Whiteley

© 2011 Blackwell Publishing Asia Pty Ltd

When developing the questionnaire, there wereseveral shorter trials to assess the questions being askedand their wording. Prior to distributing the survey, it wasreviewed by a series of individuals with expert knowledgeincluding two colorectal surgeons, the colorectal nurseunit manager and colorectal cancer care coordinator.However, the authors acknowledge it was not possibleto use a concurrent assessment against a ‘gold standard’instrument as none existed.

RESULTSSurveys were distributed to 23 specialist colorectal nursesat a tertiary referral hospital. We had a response rate of 19of the 23 surveys distributed (82.6%). This high responserate was achieved by attaching the survey to the nurses’payslips and having a ‘return’ box located at the nurses’station. The nurses surveyed had a range of experiencefrom 1.5 to 32 years (Mean 16.13 years). The years ofcolorectal nursing experience ranged from 1.5 to 22 years(Mean of 8.97 years). The nursing classification includedenrolled nurses (n = 2), clinical nurse consultants(n = 2), with the majority being registered nurses (n = 9)and clinical nurses specialists (n = 6). The results reflect

the perceptions of nurses with a broad range of colorectalexperience, many who have witnessed the introduction oflaparoscopic colorectal surgical procedures in our facilitythat ideally positions them to make comparisons withtraditional open colorectal surgery.

The results of the questions using the Likert scale aresummarized in a graph format (Fig. 1). Within this graph,the questions are displayed in successive pairs. Our Likertscale had a range from 1 to 7 with 1 representing the mostfavourable (affirmative) response and 7 the least favour-able (negative) response. Therefore, an assumption wasmade that the mid-point or number 4 on the Likert scalewas a neutral response and was not included in thesummarized data. All responses from the nurses less than4 were considered affirmative responses, and all greaterthan 4 were considered negative responses. The highestpossible affirmative or negative response is 19, based onthe number of nurses who returned the questionnaires.

Statistical analysis of the nurses’ perceptions revealedstatistical significant P-values in the following questions:transferring; showering; mobility; diet; removal of surgi-cal drains, catheters and lines; wounds; pain; stoma careand nursing effort. The only exception where statistical

Table 1 Definitions of ‘paired’ questions included in the survey

Question Definition

1. Transfer patient from bed to chair 1. Nursing effort required to transfer a patient from bed to chair following LAP or OPEN

colorectal surgery2. Showering of patient 2. Nursing effort required to shower patients following LAP or OPEN colorectal surgery3. Independent mobilization 3. Speed at which patients regain their ability to mobilize independently following LAP or

OPEN colorectal surgery4. Tolerate full ward diet 4. Speed at which patients regain the ability to tolerate a full diet following LAP or OPEN

colorectal surgery5. Time to removal of drains,

catheters, lines

5. Length of time before surgical drains, indwelling urinary catheters and intravenous lines

were removed following LAP or OPEN colorectal surgery6. Wound complication 6. Frequency of the development of wound complications following LAP or OPEN colorectal

surgery7. Pain 7. Degree of pain experienced by patients following LAP or OPEN colorectal surgery8. Self-care of stoma 8. Speed with which patients become independent with stoma care following LAP or OPEN

colorectal surgery9. Overall postoperative

complications

9. Frequency with which patients develop general complications following LAP or OPEN

colorectal surgery10. Nursing effort required 10. Overall nursing effort required to care for a patient following LAP or OPEN colorectal

surgery

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

Nurse views of lap vs open bowel surgery 623


significance was not found was the question regard-ing overall complications (Table 2). These findings areexpanded further in the Discussion section.

In the final three questions, the nurses were askedto circle the response they felt was most appropriate.Eighty-three per cent (83%) of nurse respondents feltpatients who had undergone a LAP resection had ashorter length of stay than patients who had undergonean OPEN resection.

Seventy-two per cent (72%) of nurses surveyed wouldprefer to look after a patient who had undergone LAPrather than OPEN resections.

Finally, nurses were asked to imagine they had a closefriend or relative requiring an elective colorectal resectionand to identify which procedure they would advocate.Eighty-three per cent (83%) of nurses reported they

would advocate LAP surgery, although 11% of nurseswould advocate an OPEN procedure. This clearly indi-cates these specialist nurses perceive there are benefits tohaving LAP resections. The remaining 6% of respondentsfelt there was no difference or had no opinion.

DISCUSSIONWith the increasing interest in LAP worldwide, there is aneed to examine the benefits for patients and the impacton the nursing care required. The primary finding was thata patient who has had a LAP resection compared with anOPEN resection had improved outcomes in terms of aquicker and less complicated postoperative course. Therewas also a general consensus from the cohort of nursessurveyed that it takes less effort to care for a patientwho has had a LAP resection compared with an OPEN

Number of responses

-20

-15

-10 -5 0 5

10

15

20

Transfer - LAP

Transfer - OPEN

Showering - LAP

Showering - OPEN

Mobilizing - LAP

Mobilizing - OPEN

Full diet - LAP

Full diet - OPEN

Removal drains & tubes - LAP

Removal drains & tubes - OPEN

Wound complications - LAP

Wound complications - OPEN

Pain - LAP

Pain - OPEN

Care of stoma - LAP

Care of stoma - OPEN

Overall complications - LAP

Overall complications - OPEN

Nursing effort - LAP

Nursing effort - OPEN

Ne

ga

tive

Affirm

ativ

e

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



resection. However, there have been few, if any, nursingstudies conducted to compare our findings.

The respondents’ scores for the two paired patientgroups are correlated as they are naturally linked.10

During data analysis, this became evident in the cross-tabulations and also in the correlation coefficients in thet-test results.

The Wilcoxon matched-pairs signed-rank test and thepaired t-test gave virtually identical P-values identifyingconsistency and statistical significance in the nurses’ per-ceptions favouring LAP over traditional OPEN surgeryin the majority of questions. The one exception was thequestion pertaining to overall postoperative complica-tions. The authors believe the results from this questionwere inconsistent with all others as the Likert scale wasinadvertently reversed for this set of paired questions. Forall other questions, a lower score represented a morefavourable or affirmative response. For the paired ques-tions regarding overall complications, the reversed direc-tion of the Likert scale meant a lower score representedmore frequent complications or a negative response. Webelieve the respondents did not detect this change indirection of the scale, thus skewing the results.

Baker et al.2 and Hageman et al.6 report LAP patientshave smaller incisions so it is not surprising that our resultsconfirm patients have less pain, are able to shower moreeasily, mobilize more quickly and tolerate a diet sooner.Mobilizing earlier and tolerating a diet allows for indwell-ing urinary catheters and intravenous lines to be removedearlier. It was also noted that surgical drains were also

removed sooner following LAP surgery.2,6 This is a directcomparison of the positive responses that the nurses gavein regards to perceived favourable postoperative outcomesfor the patient but also to the nurses looking after thosepatients. Nurses felt that LAP patients were easier totransfer, shower, mobilize, tolerated their diet, experi-enced less pain and were generally easier to care for.

In our colorectal unit, it has become common practicefor LAP patients to be showered on day 1 postoperatively,and the OPEN patients are sponged. This practice hasbeen adopted due to the perception that LAP patientshave less pain and are more mobile and therefore showerwith greater ease, and this is reflected in the graphed data(Fig. 1). This is variable and based on individual patientassessment.

The majority of the nurses who are experienced in thecolorectal field would advocate laparoscopic surgery totheir close friend or family member requiring an electivecolorectal resection. The rationale behind this questionwas to determine which type of operation nurses per-ceived delivered better patient outcomes. This is not tosuggest that nurses have any influence or decision-makingover what operation is available to patients. This surveywas conducted at an institution where LAP surgery is acommon practice and nurses are aware that LAP surgeryis offered to patients considered appropriate by theirsurgeon.

We speculate from this result that nurses feel stronglythat the postoperative outcome for a patient during theirstay in hospital is positive.

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

and laparoscopic colorectal operations

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

1. Transfer patient from bed to chair 4.6 2.6 < 0.0012. Showering of patient 4.4 2.9 < 0.0013. Independent mobilization 4.7 2.6 < 0.0014. Tolerate full ward diet 4.7 3.5 < 0.0015. Time to removal of drains, catheters, lines 4.2 2.6 < 0.0016. Wound complication 3.8 2.6 < 0.0047. Pain 5.3 3.1 < 0.0018. Self-care of stoma 4.7 4.0 < 0.0059. Overall postoperative complications 4.8 4.7 < 0.889

10. Nursing effort required 4.7 3.3 < 0.001

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



The perceived benefits in the reduced nursing effortrequired to care for patients undergoing LAP resectionsraises the question of what can be done with the potentialnursing time saved. From the findings, it is believed theLAP patients require less nursing hours of care. There areseveral assumptions that can be drawn from these find-ings; fewer nursing hours spent caring for LAP patientsfrees up nursing time to care for patients with morecomplex nursing care requirements. LAP patients couldpotentially be discharged earlier allowing earlier access tohospital beds and ultimately a higher throughput ofpatients. It is not envisaged that there would be anydecrease in the number of full-time equivalent nursesrequired on the colorectal unit. Any decrease in patientacuity related to LAP resections will be compensated forby higher turnover of patients, the fact that not all patientsare suitable candidates for LAP surgery and increasedopportunities for continued improvement strategies.Any time savings that might result from caring forLAP patients could potentially be redirected to provideongoing education to current staff and the support andeducation to newer members of the nursing team andstudents. Therefore, we can conclude that there are per-ceived benefits for both nurses and patients followinglaparoscopic colorectal surgery in the postoperativeperiod.

Nursing dissatisfaction is linked to high rates of nursesleaving the profession, poor morale, poor patient out-comes and increased financial expenditure. Understand-ing factors that contribute to job dissatisfaction couldincrease nurse retention.11 Murrells et al. reported a dra-matic increase in both dissatisfaction and burnout wasassociated with poorer staffing levels and that mortalityincreased by 7% for every patient added to the averagenurses’ workload.12 Decreased patient acuity mightperhaps lead to less ‘burnout’ of nursing staff, better staffretention rates, educational opportunities and increasedjob satisfaction. There is no evidence in the literaturereviewed to support or dispute our findings, althoughwhen higher levels of nurse job satisfaction are experi-enced, there is an increase in morale and commitmentthat makes it more likely that a nurse will stay in theprofession.11

It is well documented that there is a global shortage ofnurses,13 and if a more supportive, cohesive and satisfyingwork environment can be created, then retention ratesmight be higher. This can be supported by our preliminaryfindings of reduced nursing effort to care for LAP patients.

We acknowledge a limitation of this study arises fromthe actuality that it was conducted at a single site andthe nurses’ perceptions might not be generalized to othercentres. Other centres could use our method and instru-ment to conduct comparison studies.

CONCLUSIONOur study reports on the findings of a survey from acohort of nurses working in a specialist colorectal unit ina major teaching hospital, comparing LAP with OPENcolorectal surgery. This demonstrates that there is a defi-nite perception that, overall, the LAP patients return to apreoperative level of function faster, experience less painand have fewer wound complications. Secondly, lesseffort is required to care for patients who have had a LAPsurgery compared with the effort to look after a patientwho has had an OPEN surgery. We can also surmise fromthese results that the future of nursing care required onthe ward will be quite different to how it is currently,with more surgeons taking on the technique. A futurestudy looking at nursing acuity will assist to determinethis.

From these data, we instigated a plan to create avalidated nursing acuity score for acute care colorectalnursing. Due to the global nursing shortage, we hope thatif LAP surgery can lead to a less intensive workload,nurses can be attracted and retained.

ACKNOWLEDGEMENTSThe authors would like to thank the following individualsfor their support and assistance: Dr Scott MacKenzie foraiding in the development and design of the survey tool,Dr Owen Dent (Statistician) for assisting with statisticalanalysis and Dr Anil Keshava for his continued encourage-ment for reviewing the manuscript.

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

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