Patients’ experiences of having an underwater seal chest drain: a replication study

Patients' experiences of having an underwater seal chest drain: a

replication study

VALERIEVALERIE FOXFOX BSc, RGN, RM

Senior Staff Nurse, Cardiothoracic Theatre, St Thomas Hospital, 2 Lambeth Palace Road, London

SE1, UK

DINAHDINAH GOULDGOULD BSc, MPhil , PhD, RGN, RNT, Cert Ed, Dip Nurs

Professor of Nursing, Faculty of Health, South Bank University, London SE1 0AA, UK

NIGELNIGEL DAVIESDAVIES BSc, MSc, RGN, Cert Ed

Senior Lecturer, Faculty of Health, South Bank University, London SE1 0AA, UK

SUZANNESUZANNE OWENOWEN BSc, MSc, RGN, RNT

Lecturer, King's College London, Cornwall House, Waterloo Bridge Road, London SE1 8WA, UK

Accepted for publication 28 December 1998

Summary

· The nursing management of patients who have a chest drain in situ has

received little attention.

· The ®ndings of a single small-scale study previously indicated that such

patients' needs for information are not always fully met and pain control is

inadequate.

· This small-scale study was replicated to produce broadly similar ®ndings in a

second hospital 2 years later.

· Despite some differences in the approach to management it was apparent that

patients were still not well prepared pre-operatively and there was scope for

improving pain control.

· All the patients reported considerable discomfort and pain of moderate to

severe intensity. The type of pain described is typical of deep somatic/visceral

pain.

Keywords: pain control, pain, replication as a research approach, underwater seal

chest drain.

Background

Chest drains are routinely inserted during thoracotomy to

remove air and ¯uid from the pleural space and media-

stinum, to restore negative pressure when the pleural

membranes have been breached and to maintain theCorrespondence to: Dinah Gould, Professor of Nursing, Faculty ofHealth, South Bank University, London SE1 0AA, UK.

Journal of Clinical Nursing 1999; 8: 684±692

684 Ó 1999 Blackwell Science Ltd

function of the affected lung (Scott-Miller & Sahn, 1987;

Gross, 1993). Much has been written about the medical

management of thoracotomy patients. In contrast, the

nursing literature is scant. Authors have tended to focus

on the technical aspects of managing the equipment,

dismissing the patient's perspective in a few sentences

(Cohen & Stack, 1980; Mumford, 1986; Gross, 1993;

Macey & Landstrom, 1993). Insights into the patient's

experience appear to be based on opinion and anecdotal

evidence, with few empirical references cited. This lack of

interest is surprising considering the burgeoning nursing

literature concerned with pre-operative teaching and

reducing pain and anxiety during recovery (see, for

example, Hayward, 1975; Boore, 1978; Carr, 1990;

Brum®eld et al., 1996).

Within the literature relating to pre-operative prepara-

tion and recovery from surgery, only two studies address-

ing the experiences of patients who had a chest drain

in situ could be located. In the ®rst study, undertaken in

the USA, 36 patients were asked about their sensations

when the chest drain was removed (Gift et al., 1991). The

intensity of each sensation was recorded on a visual

analogue scale from 0 to 100 mm. Sensations reported

were: pain (n� 7), burning (n� 6) and pulling (n� 4).

The pain (mean 65 mm) and sensation of burning (mean

63 mm) were both moderately intense. Fifteen minutes

later 5 patients reported soreness in the chest, with a mean

intensity of 27 mm. Only eight patients had received

analgesia, a number too small to determine statistically

whether pain relief had been effective. On a more positive

note, however, the patients thought that being told that

the chest drain was to be removed provided suf®cient

information to meet their needs.

The second study was undertaken in the UK (Owen &

Gould, 1997). Its aims were to describe the patients'

experiences from the ®rst post-operative day until dis-

charge, including removal of the chest drain, and to

identify the information required by patients who have a

chest drain in situ. A longitudinal design was employed.

The same researcher visited the patients every day from

the ®rst post-operative day until after the chest drain was

removed. A daily account of each patient's experiences

was developed using a semistructured interview with

standard probes. The main issues covered were: patients'

knowledge and expectations concerning the chest drain;

the sensation of having the chest drain in situ; any

restrictions on posture; movement in bed; and mobility.

The interview schedule included open-ended questions

and incorporated verbal pain descriptors from the Short

Form McGill Pain Questionnaire (Melzack, 1987) and a

pain intensity scale (Gracely et al., 1978). Both provide

valid and reliable measurements of the pain experienced

by patients (Holroyd et al., 1992; Gracely, 1992).

The ®ndings of this small-scale, exploratory study were

a cause for concern, especially in relation to the informa-

tion that the patients had received to prepare them for the

experience of having a chest drain in situ and pain control.

All the data were collected in the same Regional Thoracic

Unit over a period of three months. Throughout this time

it was possible to follow up 18 patients who had never had

a chest drain before. Sociodemographic details were

obtained from the casenotes. All patients admitted to the

unit were given a lea¯et about thoracic surgery which made

speci®c reference to chest drains and, although no formal

pre-operative teaching programme existed, all received a

full nursing assessment before surgery and were seen by

the doctor and physiotherapist, with opportunities to ask

questions individually. Patients undergoing major thoracic

surgery received patient controlled analgesia (PCA) and

were seen by the pain control nurse specialist.

The chest drain remained in situ for between 2 and

6 days. From patients' responses to the open-ended

questions at interview it was clear that their sensations

were of pain and discomfort. Moreover, they were able to

distinguish between discomfort caused by the drainage

tubing (restrictions on posture and movement) and pain in

the incisions. The degree of discomfort experienced was

variable but the existence of a common pattern of pain

experience was discernible for all patients. All experienced

pain if they inadvertently lay on the drainage tubes and

were most comfortable in an upright position, either in

bed supported by pillows or in a chair. Six of the 18

patients could move easily in bed on the ®rst post-

operative day. The remainder experienced restricted

mobility, either through pain or fear of dislodging the

drainage tubing, a situation which resolved slowly as they

recovered. Pain was also experienced during mobility. It

was most marked when the patient tried to get out of bed

or had physiotherapy. Mobility was restricted all the time

that the chest drain was in situ because the drainage tubing

was attached to a wall suction unit. Ten of the 18 patients

experienced dif®culties sleeping through pain and dis-

comfort, especially if they rolled on to the drainage tubing.

Seventeen of the 18 patients reported pain from the

insertion site of the chest drain. They did not, however,

report the main wound as the primary source of pain and

generally seemed unaware of the size or location of the

incision. Daily records of pain intensity measured on the

Short Form McGill Pain Questionnaire allowed an

individual pain pro®le to be constructed for each patient.

While the chest drain was in situ most patients reported a

moderate degree of pain (score 8 out of 15). Sensory

Experiences of care Underwater seal chest drain 685

Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 684±692

descriptors from the McGill Pain Questionnaire were

chosen more often than affective descriptors to indicate

the nature of the pain. Moreover, these descriptors

suggested that the patients were describing either deep

somatic or visceral pain, as all these adjectives are typical

of pain emanating from the deeper tissues (Procacci &

Massima, 1994; Campbell, 1995), a ®nding not commented

upon by Owen & Gould (1997) in their discussion. The

individual descriptors most often selected were `throb-

bing', `stabbing' and `aching'. It was also apparent that for

most patients there was scope for improvement of their

knowledge in relation to analgesia. Of the 10 using PCA,

only six mentioned the equipment or indicated it in

relation to questions about pain relief. Knowledge about

the chest drain and its probable effect on early mobility

and posture was also lacking. Six patients could not recall

any pre-operative information at all and a further eight

could at best be considered to have been poorly informed.

Removal of the chest drain was the most distressing and

intensely painful experience of all.

Literature searches undertaken with MEDLINE and

CINAHL employing the key words `thoracotomy', `chest

drain' and `underwater seal drain' con®rmed that patients'

experiences of early recovery with a chest drain in situ have

apparently attracted no other research attention. Further

investigations concerning recovery from the patients'

perspective are thus justi®ed. Thoracotomy is considered

to be a very painful procedure (Mulder, 1993) and

observation of patients during early recovery suggests that

the presence of the chest drain inevitably restricts

movement and interferes with activities such as bending

and stretching, as Owen & Gould (1997) con®rmed.

Replication was therefore undertaken to determine whether

the ®ndings by Owen & Gould (1997) were unique to the

unit where the study was undertaken or could be

considered to give an indication of wider problems in

the nursing management of thoracotomy patients.

Method

Replication is the duplication of a research procedure in a

second investigation (Polit & Hungler, 1995). It is of

particular value when clarifying and re®ning the ®ndings

of original work, especially when they are unexpected or

ambiguous (Sellitz et al., 1976). Thus replication can

successfully demonstrate similarity of ®ndings and

strengthen con®dence in the results obtained from an

original but small-scale study, extend generalizability

when the sample is drawn from a different population

and when undertaken in the clinical stituation, and will

reduce the risk of spurious ®ndings in¯uencing practice

(Connelly, 1986; Blomquist, 1986).

Aims

The overall aim of the study was to replicate the original

work by Owen & Gould (1997). Speci®c objectives were

to:

1 Establish whether patients' experiences of pain and

discomfort reported in the original study were the same

in another centre.

2 Identify the information that patients received about the

chest drain and the management of their pain, and

compare these ®ndings to those of the original study.

Study design

Connelly (1986) has identi®ed three strategies that may be

used in replication (see Table 1). The study reported here

was not a literal replication, as the aim was to determine

whether the ®ndings of the original study pertained

elsewhere. Operational replication was not possible be-

cause staff in the second unit considered that the daily

visits employed to collect data in the original study would

be too tiring for the patients. Instead a constructive

replication approach was employed, and each patient was

visited once only. A single structured interview was

undertaken with each patient (see Appendix 1). Cross-

sectional rather than longitudinal data were therefore

obtained. The opportunity was also taken to re®ne the

original interview schedule. In the original study patients

did not report the wound as the primary source of pain

and generally seemed unaware of the size or location of the

incision. In the replication study these questions were

Table 1 Replication strategies (Connelly, 1986)

Literal replication The precise duplication of the original study, employing the same sampling procedures, conditions of data

collection and analysis

Operational replication Employs exactly the same sampling procedures and conditions of data collection as the original investigation

but utilizes a different method of analysis in order to determine their reliability and validity

Constructive replication Avoids direct imitation of the methodology of the original investigators in order to test the empirical facts which

they purport to have established. This approach implies that if a genuine relationship exists between variables

then it will be demonstrable regardless of the approach to sampling or data collection


686 V. Fox et al.

re®ned so that patients were asked directly about pain

relating to the chest drain as distinct from the wound.

Additional questions about discomfort relating to the

sutures and wound dressing were also asked. Removal of

the chest drain was not addressed in the replication study.

It was considered that as the ®ndings of the study by Gift

et al. (1991) and Owen & Gould (1997) had yielded similar

®ndings, it could be assumed that this procedure was

painful. The criteria necessary for successful replication

are presented in Table 2.

PAIN ASSESSMENTPAIN ASSESSMENT

As the method of constructive replication required the use

of data collection instruments different from those used in

the original study, alternative methods of pain assessment

had to be identi®ed. The scale developed by Gracely et al.

(1978) was replaced by a visual analogue scale (VAS) to

measure pain intensity. The VAS has been used to assess

the intensity of pain in many research studies because it is

easy to administer, patients readily grasp what is required

(Cline et al., 1992) and it is recognized as a valid and

reliable method of assessment (Carson et al., 1994). For

the replication study a vertical VAS was employed because

this format is reported to be easier for patients to use

(Cline et al., 1992). Sixteen points were used because it

was considered that this increased range would allow

greater sensitivity in interpretation of the data than a scale

with fewer points. Patients were asked to complete the

VAS twice: ®rstly to record the pain they were experi-

encing at the time of interview; and secondly to document

the most intense pain they had experienced since the

insertion of the chest drain.

The VAS shares the same disadvantage as the pain

intensity scale developed by Gracely et al. (1978) in that it

fails to capture the affective nature of the pain experience

(Duncan et al., 1989). A search of the literature failed to

secure any instrument comparable to the Short Form

McGill Pain Questionnaire (Melzack, 1987) used in the

original study, so the same instrument was employed for

replication. This was not ideal, as the use of the same

method of data collection is against the spirit of construc-

tive replication. However, the Short Form McGill Pain

Questionnaire is considered to be valid and has been used

widely in clinical practice (Holroyd et al., 1992). It

consists of 11 sensory descriptors (e.g. `burning', `heavy',

`shooting') and four affective descriptors (`sickening',

`fearful', `punishing/cruel', `tiring/exhausting'). The sen-

sory dimension describes pain in terms of time, space,

pressure and heat while the affective dimension describes

pain in terms of tension, fear and autonomic properties

(Carol & Bowsher, 1993). Patients were shown the

descriptors and asked to choose those that best described

their pain. No overall score is obtained with this

instrument. The purpose of the descriptors is to compare

the pain experiences of individual patients.

OTHER DATAOTHER DATA

As in the original study, knowledge of analgesia and the

chest drain acquired through pre-operative teaching and

the information booklets routinely provided by the unit

were explored. Sociodemographic data and details con-

cerning surgery were collected from the patients' notes.

The pilot study

A pilot study undertaken with four patients on the same

unit con®rmed that the new interview schedule and

methods of pain assessment were feasible and would

obtain the required data.

Sample

All data were collected in a regional cardiothoracic unit in

the UK. Consecutive patients were recruited to meet the

planned target of 20 subjects. This small sample size was

inevitable because thoracotomy is not among the most

commonly performed surgical procedures, and thus a

protracted period of data collection would be required to

Table 2 Criteria for replicating an original study (after Connelly, 1986)

· The research question (of the original study) should be signi®cant and contribute to the body of nursing knowledge

· Current literature relating to the topic should support the continuing relevance of the research question to nursing

· Replication should have the potential to empirically support the original study ®ndings, either by extending their generalizability

or by clarifying and explaining issues raised by the original ®ndings

· The researcher should have expertise in the area and be aware of the speci®c details relating to the manner in which the original study was

conducted

· Any modi®cations or extensions to the original study should be based on current knowledge of existing research in the same ®eld

· It should be possible to plan and undertake replication with the same rigour as that employed with the original study



interview suf®cient patients. The selection criteria were:

that the patient would require the insertion of a pleural

chest drain; that the drain would remain in situ for a

minimum of 24 hours; and that the patient could under-

stand and speak English, and would be willing and able to

sign a written consent form.

Ethical approval

The study was approved by the trust's Research Ethics

Committee.

Analysis

Open-ended questions were analysed by content. The

results of closed-ended questions and of data from the

VAS and McGill Pain Questionnaire were tabulated to

illustrate frequency distributions and ranges. Both types of

data were then compared to the original ®ndings of Owen

& Gould (1997).

Results

Nineteen patients were approached over 3 months to

participate in the study and 15 agreed. Fourteen patients

were interviewed within the ®rst 3 post-operative days.

The remaining patient was interviewed on the tenth day,

with the chest drain still in situ. From the case notes there

appeared to be no major differences between those who

agreed and did not agree to participate. Their ages ranged

from 30 to 75 and all but two were male.

The analgesic regime

Twelve patients were using PCA and of these ®ve also had

a paravertebral block (PVB) for the ®rst 2 post-operative

days. Three patients had neither PCA or a PVB but all

were receiving other analgesia (paracetamol, dihydroco-

deine, diclofenac, ibuprofen and diamorphine). During

interview one patient said they disliked the PCA because it

induced nausea and three said they could not use it

because they were not sure how to operate the equipment.

A pain control nurse specialist was not employed but

lea¯ets giving information about PCA were available

within the unit.

Discomfort

All patients reported considerable discomfort, lasting as

long as the chest drain remained in situ. All experienced

pain if they lay on the drainage tubes and were most

comfortable in an upright position, either upright in bed

(n� 10) or supported by pillows in a chair (n� 13).

Movement in bed

Nine of the 15 patients claimed that discomfort interfered

with movement and two were anxious in case the drainage

tubing became disturbed.

Mobility

Pain was most marked when the patient tried to get out of

bed or had physiotherapy. In this unit the drainage tubing

was connected to portable suction equipment and not a

major restriction on mobility.

Sleep

Thirteen of the 15 patients experienced dif®culties

sleeping because of pain and discomfort, especially if they

inadvertently rolled onto the drainage tubing.

Distinguishing between sensations in the chest drain

and the incision

Because patients in the original study had speci®cally

mentioned discomfort arising from the site of the chest

drain, patients in the replication study were asked to

describe any sensations they felt speci®cally in relation to

this. Six were unable to suggest any suitable adjective, but

the remainder used words typically associated with

visceral or deep somatic pain: `stabbing', `packed',

`bruised', `dull ache' and `tender'.

Other sources of discomfort

Two patients reported discomfort because the dressing

was soiled but the sutures were not reported to cause

particular pain or discomfort.

PAINPAIN

Data relating to the experience of pain were elicited by

open-ended questions from the interviews and on two

measurement scales: a VAS and the Short Form McGill

Pain Questionnaire (Melzack, 1987).

Open-ended questions concerned with pain

Five of the 15 patients could clearly distinguish between

pain in the chest drain and the main incision. Seven


688 V. Fox et al.

patients reported pain at rest and all experienced consid-

erable pain if they coughed or moved inadvertently.

Pain intensity

Eleven of the 15 patients scored between 3 and 8 (out of

16) on the VAS used to measure pain intensity. This was

inferred to describe pain of moderate severity. Two

patients reported scores below 3 (inferred as mild pain)

and two had no pain at rest. However, intense pain (8±15)

was reported by all patients in relation to sudden

movements such as coughing or getting out of bed.

The Short Form McGill Pain Questionnaire

The 15 patients used 33 descriptors to indicate the nature

of the pain they were experiencing. The most common

were; `sharp' (n� 6), `tiring/exhausting' (n� 7), `heavy'

(n� 5) and `aching' (n� 7). These could all be considered

indicative of deep somatic or visceral pain.

Type of pain in relation to pain intensity

Inspection of the data revealed that patients who selected

two or more descriptors of deep somatic/visceral pain had

higher levels of pain on the VAS (score 10±16) whereas

those selecting only one indicator of deep somatic/visceral

pain did not. The sample was not large enough for valid

statistical analysis to be undertaken.

Type of pain and analgesic regime

Inspection of the data revealed that the ®ve patients using

a PVB exhibited lower levels of pain on the VAS than the

others: the two patients reporting no pain were both

using a PVB. Numbers were too small for statistical

analysis.

Knowledge of analgesia

Three of the 10 patients with PCA said they were not sure

how to use it and the remainder made little comment

concerning their analgesic regimes.

Knowledge of the chest drain

Eleven patients could remember being given information

about the chest drain pre-operatively, mainly of a

procedural nature (e.g. the length of time it would remain

in situ, its site and its function) and for six this was

considered suf®cient. The remaining four patients could

not remember any pre-operative information and one had

not known about the chest drain at all.

Discussion

The discussion will compare the ®ndings of the replication

study to those of Owen & Gould (1997). Consideration

will then be given to some of the practical dif®culties of

undertaking replication in clinical nursing research.

DISCUSSION OF THE STUDY FINDINGSDISCUSSION OF THE STUDY FINDINGS

Overall the ®ndings of this study corroborated the results

of Owen & Gould (1997) collecting data in another unit

although the methods of data collection were not the same

(see Table 3). The patient populations were broadly

similar but there were some differences in their manage-

Table 3 Summary of ®ndings comparing the original and replication studies

Original study

Owen & Gould (1997)

n = 18

Replication study

n = 15

Pain intensity Moderate Weak/moderate at rest

VAS score 3±8

Moderate/severe on exertion

VAS score 8±15

Pain descriptors Throbbing (non visceral) Sharp (visceral)

Stabbing (non visceral) Aching (visceral)

Aching (visceral) Tiring/exhausting (affector)

Most comfortable position In bed In chair

Sleep Disturbed by rolling on Disturbed by rolling on affected side

Information remembered Procedural from doctors, nurses and physiotherapists Procedural from doctors



ment between the two units, mainly in terms of the

policies used to control pain. Nevertheless, it was clear

from both studies that there is scope for improving the

strategies used to inform patients about what to expect

following thoracic surgery (that a chest drain will be in situ

and the sensations it will produce) and for ensuring

effective pain relief. From the descriptors selected from

the Short Form McGill Pain Questionnaire by patients in

both studies it was apparent that most of the pain was

originating from the very deep tissues, a ®nding supported

by the lack of discomfort related to the dressing or wound

in the replication study. Pain of this nature, at this

location, is acknowledged by surgeons and anaesthestists

to be considerable (Gross, 1993). In view of this literature

it was disturbing to ®nd that there was still scope for

improving pain management in both the original and the

replication study. PCA did not appear to be used to best

effect by patients in either of the studies. This is

unfortunate, as it has been considered a major break-

through in pain relief because it eliminates judgements

made by staff on appropriate dose and timing, thus

supposedly overcoming the administration of ineffective

amounts of pain relief through lack of appreciation of

individual pain tolerance (Melzack & Wall, 1988). The

method, however, depends on patients' ability and

willingness to use the equipment, factors which in turn

may be in¯uenced by psychological attributes such as

coping style and cognitive ability as well opportunities to

learn how to use the equipment (Thomas & Rose, 1993).

In both the original study and the replication study it was

apparent that insuf®cient attention had been paid to

preparing the patients for the pain and attendant discom-

fort that their major surgical intervention would engender,

and no consideration had been given to the extent to

which they would be able or even wish to participate in

their own care. As Caress (1997) has recently pointed out,

participation by patients in making decisions about their

treatment has become widely encouraged and in the UK

recent government initiatives have provided considerable

impetus towards a participative and user-led health

service. Such initiatives have been based on the assump-

tion that patient participation must always be possible,

valuable and welcomed by patients themselves. The

results of numerous research studies support this view

but Caress (1997) challenged their ®ndings as not

universally true of all patient groups, establishing that in

a sample requiring renal replacement therapy, many

patients preferred to leave important decisions regarding

their care to medical staff. From her data it appeared that

poor physical condition diminished desire to participate in

decision-making.

The same situation may prevail in relation to patients'

willingness and ability to make decisions about the use of

self-delivery pain relief systems following very major

surgical interventions. As Thomas & Rose (1993) discuss,

some patients may under-use PCA because they are

worried about addiction or may harbour traditional

attitudes concerning pain relief, preferring the nurse to

take responsibility, especially if they are particularly

anxious or feeling acutely unwell, as may be the case in

the early stages of recovery from major surgery.

THE PROBLEMS OF CONDUCTING REPLICATIONTHE PROBLEMS OF CONDUCTING REPLICATION

STUDIES IN THE CLINICAL SETTINGSTUDIES IN THE CLINICAL SETTING

Carrying out the study highlighted the practical dif®cul-

ties of undertaking replication in clinical nursing research.

The most immediate problem facing the research team

was the availability of alternative data collection instru-

ments to assess pain that are valid, reliable and straight-

forward to use. An alternative method of assessing pain

intensity was identi®ed in the verbal pain intensity scale

developed by Gracely et al. (1978). This was successfully

replaced by a VAS to measure the same phenomenon.

However, no suitable alternative could be found to capture

the same type of data measured by the Short Form McGill

Pain Questionnaire (Melzack, 1987) in order to undertake

constructive replication. This lack of appropriate methods

of measuring clinical phenomena is a major problem for

nursing research. Other problems in the research design

and methods of data collection are also apparent and could

have in¯uenced the ®ndings.

In the replication study a cross-sectional approach to

data collection replaced the longitudinal approach taken in

the study by Owen & Gould (1997). This meant that the

data were based on patients' recollections rather than their

perceptions of pain and discomfort at the actual time of

data collection.

In addition, there were genuine differences in the two

centres where data were collected. Proponents of the

constructive replication approach, such as Blomquist

(1986), argue that if a relationship between two or more

variables is genuine then it will hold good irrespective of

the methods used to obtain the data. This belief may be

reasonable when data are collected under stable conditions

but ignores the variations in local practice which inevitably

exist in healthcare settings (Connelly, 1986). Such local

variations rapidly became apparent here. For example,

although patients in both studies encountered dif®culties

using PCA, this was most marked in the second study, a

situation that could be attributed to the lack of a pain

control specialist nurse, even though some of the patients


690 V. Fox et al.

in the original study did not seem to have derived maximal

bene®t from her intervention. In the second study patients

with a PVB enjoyed greater pain relief than any patient in

the original study, where this technique was not used at the

time of data collection. Data collection for the replication

study took place 2 years after data collection for the

original investigation, introducing another factor which

could confound replication ± changes in clinical practice.

Conclusion

The original small-scale study by Owen & Gould (1997)

raised more questions about the effective nursing man-

agement of patients who have a chest drain in situ than it

answered. Replication of this study has now con®rmed

that the issues of patient information and adequate pain

control that emerged were not local phenomena, support-

ing the use of replication as recommended by Sellitz et al.

(1976), Connelly (1986) and Blomquist (1986). Moreover,

the replication strategy employed ful®lled all the criteria

considered essential for meaningful replication suggested

by Connelly (1986). Thus it has become apparent that

intervention studies are required to determine the most

effective approaches to informing these patients about the

immediate effects of surgery and exploring the optimal

time for information-giving. In view of the painful nature

of thoracotomy, it is clear that patients need careful

instruction and monitoring in the use of complicated self-

administration analgesic schemes. If for any reason PCA is

not effective its de®ciencies should be identi®ed and

alternative methods of pain relief provided as a priority.

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Appendix 1

THE INTERVIEW SCHEDULETHE INTERVIEW SCHEDULE

Patient number:

Number of days post surgery:

1 Were you given any information about the chest drain before your operation?

Yes/No

Please specify

2 Can you feel the drain in your chest now?

Yes/No

3 Are there any words which you could use to describe how it feels?

4 Can you feel any difference between the chest drain and the wound?

Yes/No

Please specify

5 Is the dressing comfortable?

Yes/No

Please specify

6 Do you have any discomfort from the sutures?

Yes/No

Please specify

7 What is the most comfortable position for you now?

Prompt:

In a bed sitting upright

In a chair

Standing

Lying ¯at in bed

Lying ¯at on the side where the drain is

Lying ¯at on the other side, away from the drain

Other

8 Are there any times/activities when the pain/discomfort is worse?

9 Does your pain/discomfort interfere with any activity?

10 Does the chest drain affect your sleep?

11 Do you feel any pain speci®cally related to the chest drain?

12 Is it painful to cough?

13 Is it painful to move?

14 Do you know what type of pain relief you are using?

15 Do you ®nd this effective?

The patients were then asked to use the pain assessment instruments (as explained in the text).


692 V. Fox et al.

Patients’ experiences of having an underwater seal chest drain: a replication study

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