WOMEN’S PERSPECTIVES OF PAIN FOLLOWING DAY SURGERY IN AUSTRALIA
Mridula Bandyopadhyay, BS, MSc, CPS, MPhil, PhD, Senior
Policy Officer, Department of Health and Community Services,
Northern Territory, Australia.
Dr Milica Markovic, BSoc, MSoc, PhD, Research Fellow,
Monash University, Victoria, Australia.
Lenore Manderson, BA(AsStud), PhD, FASSA, ARC Federation
Fellow and Professor, Monash University, Victoria, Australia.
Accepted for publication January 2007
Key words: day surgery, pain, gynaecological procedures
To investigate the incidence of pain following
discharge from reproductive day surgery.
Cross-sectional descriptive study.
A public hospital for women in Melbourne.
315 women participated in phone interviews and 10
in face-to-face interviews.
Main Outcome measure(s):
Self-reports of pain were assessed in relation to age,
English and non-English speaking background, prior
experience of day surgery, type of surgery, time in
recovery, information provision prior to surgery, and
access to significant others at home.
Older women were less likely to report having pain
immediately following discharge (regression coefficient
= -0.72, 95% CI, 0.58 to 0.88, p ≤0.01), or within 48
hours following discharge (regression coefficient = -
0.71, 95% CI, 0.57 to 0.88, p ≤ 0.05). Women with a
prior experience of day surgery were 1.9 times more
likely to be in pain within 48 hours following surgery
(regression co-efficient 1.88, 95% CI, 1.134 to 3.10, p
≤ 0.05). Women who understood information were less
likely to report that they experienced pain within 48
hours of discharge (regression co-efficient -0.74, 95%
CI, 0.24 - 0.95, p ≤ 0.05).
Younger patients, those who have had prior
experience of day surgery and those who received
inadequate information prior to surgery were most
likely to report pain. Adequate individual patient
assessment will ensure that patients’ experience of
pain following day surgery is minimised.
Day surgery has increased worldwide with changes
in medicine (eg laser), a need to improve the cost-
effectiveness of health services, and an emphasis on
reducing waiting times for elective surgery. By the late
1990s, 60% of elective procedures in the UK and the
US and 50% in Canada were conducted as day surgery.
In Australia, day surgery as a percentage of all surgical
procedures increased significantly from 7% in the 1980s
to about 41% in 1997/98 and 55% in 2001 (Millar 1997;
Australian Government Department of Health and Aged
Care 1999; Mitchell 2000).
in technological advances
Pain is documented as being the most intense and
disabling postoperative symptom experienced following
day surgery, immediately and after discharge when the
patient is expected to resume responsibility for his or her
own care (Carr and Thomas 1997). Some patients still
report pain a week after surgery (Agboola et al 1999).
Health professionals may underestimate patients’ pain and
prescribe inadequate analgesia (Callesan et al 1998; Watt-
Watson et al 2001) leading to hospital readmission (Tham
and Koh 2002). Limited research has been conducted
in Australia on day surgery (Donoghue et al 1995;
Roberts et al 1995); none in relation to the incidence and
management of pain immediately or on return home.
While both qualitative and quantitative research
studies have been conducted to explore pain associated
with surgery and day surgery, a universal day surgery
Australian Journal of Advanced Nursing 2007 Volume 24 Number 4
Australian Journal of Advanced Nursing 2007 Volume 24 Number 4
pain measurement tool does not exist (Coll et al 2004).
In quantitative studies, various methods, including a
Visual Analogue Scale (VAS), a verbal rating system,
and a structured questionnaire, have been used to
explore pain in the fields of orthopaedics, urology,
ophthalmology, otorhinolaryngology, gynecology and
general surgery (Roberts et al 1995; Gagliese et al 2000;
Taenzer et al 2000; Jakobsen et al 2003;). Qualitative
research has also been conducted on experiences
of postoperative pain in relation to ophthalmologic,
gastroenterologic, and gynaecologic surgery, with
patients in recovery or on the ward (de Beer and Ravalia
2001); immediately before discharge (Burumdayal and
MacGowan-Palmer 2002); within two days ( Stockdale
and Bellman 1998; Gagliese et al 2000;); five days
(Roberts et al 1995; Taenzer et al 2000); eight days
(Agboola et al 1999; Barthelsson et al 2003); and four
weeks following surgery (Callesan et al 1998).
Adequate information has been shown to reduce self-
reported pain and its intensity (Linden and Engberg
1996) and to ensure realistic patient expectations with
regard to resuming activities postoperatively (Jakobsen
et al 2003). Callesan and associates (1998) and Yellen and
Davis (2001) and have reported that with increased age
of patients, reporting of postoperative pain decreases. In
contrast, Gagliese and colleagues (2000) found that while
older patients expected less intense pain than younger
patients following surgery, there were no statistically
significant differences in the experience of pain by age.
Medical anthropological research (Lipton and Marbach
1984) points to cultural background as influencing
the communication, expression and responses to pain.
However this need not imply homogeneity in response,
since pain experience is also affected by life experiences,
coping mechanisms, social roles and relationships, and
socioeconomic and demographic circumstances such as
age, class and gender (Bates 1996). Studying the impact
of these factors, as well as culture, on the experience of
pain is important to avoid reinforcing cultural stereotypes
resulting in sanctioning stoicism.
Gender affects day patients’ ability to draw on personal
support following surgery. Mitchell (2003) suggests that
increased day surgery has led to greater lay caregiver
involvement postoperatively. Women fare worse; as
patients they cannot or are unable to rely on personal
networks in the way that men can. A study in Europe, for
example, demonstrated that women who had been under
a general anaesthetic resumed household chores (eg.
cooking, cleaning) and care giving (eg. childcare) within
24 hours of discharge, and this may have contributed to
their pain experience (Jakobsen et al 2003).
Women report high pain levels following day surgery
for reproductive health (Coll et al 2004). Previous studies
have focused on specific procedures, predominantly
laparoscopy ( Donoghue et al 1995; de Beer and Ravalia
2001) and laparoscopic sterilisation (Agboola et al 1999;
de Beer and Ravalia 2001; Burumdayal and MacGowan-
Palmer 2002; Jakobsen et al 2003), but also termination
of pregnancy (Hein et al 2001), tubal ligation (Fraser et al
1989), and breast surgery (Stockdale and Bellman 1998).
The exception is a study conducted by Roberts and
colleagues (1995) on various gynaecological surgeries
which compared the pain experiences of patients with
an open versus closed surgery rather than according
to procedure. Their focus, on type of surgery and pain
levels, overlooked social, demographic and economic
characteristics of the patients. The present study, by
contrast, examines pain experiences of women in relation
to their socio-demographic characteristics; this includes
by English or non-English speaking background as a
simple but feasible proxy of patients’ culture.
This descriptive correlational study aimed to explore
the experience of pain at, and within 48 hours, of
discharge from day surgery, and to investigate patients’
management of pain. The objectives were to explore the
impact of sociodemographic characteristics (age and
cultural background), surgery status (day surgery on
a previous occasion, type of surgery), informal support
(access to significant others at home), and quality of
care (time in recovery, adequate information provision)
on women’s perceptions of pain and pain management
strategies. Ethics approval for the study was granted by
the relevant hospital and university committees.
Study participants were women who had undergone
day surgery in an Australian women’s public hospital
and included both private and public patients. Between
August and October 2000, women were recruited on the
day of their surgical procedure in the area where they
were required to wait for surgery. A small number of
women (n=58, 11.4% of all women approached) declined
to participate. From 451 women who agreed to participate
(about 27% of total planned surgeries), 315 women were
followed up (70%; about 19% of total surgeries in the study
period). The remaining women were not followed up due
to inability to establish contact within 48 hours of surgery
(26%), overnight stays due to complications from surgery
or additional surgery indicated as a result of the day
procedure (2.6%), and withdrawals from the study (1.1%).
Quantitative and qualitative methods (telephone survey
and in-depth interviews) were used. The questionnaire,
comprised of open-ended and closed questions, was
piloted with 20 day surgery patients, born in Australia
(n=11) and overseas (n=9), prior to being administered.
Data were gathered on socioeconomic background,
general health (self-rated), information provision and its
adequacy prior to day surgery, support and help at home
following discharge, and advantages and disadvantages
of day surgery. Information was collected on whether
women had pain following discharge, management of
Australian Journal of Advanced Nursing 2007 Volume 24 Number 4
pain at home (pain killers, alternative remedies, nothing),
whether they were in pain at 48 hours of discharge, and
the level of pain. Women who reported being in pain
within 48 hours of discharge were asked to indicate its
level on a Likert scale (1-5), where one indicated that the
patient had little pain and five that the patient had the
worst pain imaginable. On average, a telephone interview
lasted for about 16 minutes. SPSS software was used for
data entry and descriptive, bivariate and multivariate
To complement and corroborate the survey data, face-
to-face in-depth interviews were conducted with ten
women recruited through purposive sampling to include
different socioeconomic backgrounds and different
surgical procedures. Interviews, lasting for about 60
minutes, were conducted at a woman’s home or another
place of her choice. Interviews explored women’s
pain management strategies and the experiences of
recovery at home. Qualitative data collection and data
analysis were conducted concurrently, allowing for the
refinement of interview guidelines and cessation of
interviews with data saturation.
Thematic analysis was conducted with the use of
ATLAS-ti software (Scientific Software Development
1991-2004) using a grounded-theory approach (Strauss
and Corbin 1990). This was an iterative process in which
all authors read the transcripts and developed the coding
book, identifying the themes within individual transcripts
and cross-checking them across narratives (Ryan and
Bernard 2003). To illustrate women’s experiences, we
use excerpts from interviews.
The majority of women in the sample were born in
Australia (62.5%). Most women were aged 26-45 years
(58.4%, mean age 36.68 years), and had completed
secondary schooling (56.8%). Almost 60% were married
or in a de facto relationship and about 80% lived with
their family. The majority (63.8%) was employed, but
almost a quarter was full-time homemakers (23.2%).
Nearly three quarters (n=234, 74.3%) were public
patients, the remainder private (n=81, 25.7%).
Overall, 69.5% of the women experienced pain
following discharge. There was a statistically significant
negative association between age and pain (see table 1):
with increased age, women were less likely to report
having pain immediately following discharge (regression
coefficient = -0.72, 95% CI, 0.58 to 0.88, p ≤ 0.01),
or within 48 hours following discharge (regression
coefficient = -0.71, 95% CI, 0.57 to 0.88, p ≤ 0.05).
Pain following discharge and within 48 hours of
hospital discharge and patients’ age
48 hours of
48 (84.2%) 9 (15.8%) 57 (18.1%) 33 (64.7%) 18 (35.3%) 51 (19.8%)
74 (74.0%)26 (26.0%)100 (31.7%) 52 (59.8%) 35 (40.2%) 87 (33.7%)
50 (59.5%)34 (40.5%) 84 (26.7%) 29 (46.8%) 33 (53.2%) 62(24.0%)
47 (63.5%)27 (36.5%) 74 (23.5%) 24 (41.4%) 34 (58.6%) 58 (22.5%)
219 (69.5%) 96 (30.5%)315 (100%) 138 (53.5%) 120 (46.5%) 258 (100%)
No statistically significant differences were observed
among women by country of birth or background: Australia-
born, English-speaking background overseas-born and
non-English speaking background overseas-born women
reported similar experiences of pain. Within 48 hours of
hospital discharge, 53.5% of women still experienced pain,
and again no statistically significant differences were noted.
The mean pain score was 2.6 (SD = 1.02), with no significant
differences between English speaking and non-English
speaking background women (2.7 and 2.5 respectively).
More than half of the respondents (57.1%) had previous
day surgery. These women were 1.9 times more likely to
report pain within 48 hours of surgery (regression co-
efficient 1.88, 95% CI, 1.134 - 3.10, p ≤ 0.05). Previous
day surgery however had no impact on experiencing pain
immediately following discharge.
Whether a woman had undergone a single procedure
or multiple procedures did not significantly alter pain
intensity levels. However specific procedures were
statistically significant in terms of experience of pain
following discharge and within 48 hours of discharge;
these were breast biopsy, dilation and curettage
combined with laparoscopy, hysteroscopy or pelviscopy,
and medical termination of pregnancy. For all surgeries
apart from breast surgery, most women reported pain
following discharge (see table 2).
Type of operation and pain following discharge and
within 48 hours of discharge
Type of operation Any pain following
curettage + LHPa(11.4%)
Any pain within 48
hours of discharge
a Note: LHP = laparoscopy, hysteroscopy, pelviscopy
Australian Journal of Advanced Nursing 2007 Volume 24 Number 4
Women who felt that the information provided
was easy to understand were less likely to report pain
following discharge from hospital (regression co-efficient
-0.334, 95% CI, 0.14 - 0.85, p ≤ 0.05), regardless of type
of surgery and within 48 hours of discharge (regression
co-efficient -0.74, 95% CI, 0.24 - 0.95, p ≤ 0.05). However
no statistically significant association was found between
understanding information and reporting pain levels on
the Likert scale.
Most women (83.8%) reported that it was easy to follow
the information provided. Private patients were about three
times more likely than public patients to find information
inadequate (X2 = 9.67; p ≤ 0.01). Based on information
received, most patients expected little pain associated with
day surgery, and persistent pain led them seek medical
advice and reassurance that their pain was ‘normal’.
Bivariate analysis indicated a statistically significant
association (X2= 13.25, p ≤ 0.001) between time spent
in recovery and reporting pain 48 hours following
discharge (see table 3). Continuity of nursing care in
recovery and rapport with the nurses influenced women’s
ability to negotiate the length of their stay in recovery,
and ultimately pain free recovery at home: ‘In recovery,
I had two nurses in particular… they were really good
with me, let me stay in bed because I wanted to… I only
had painkillers at hospital, not at home, not even the next
day; I didn’t take anything’ (23 years, Australia-born,
medical termination of pregnancy).
Time spent in recovery room and pain within 48 hours
Still in pain Time spent in the
100 (38.8%) 20 (7.8%)
258 (100%) 71 (27.5%)
Most respondents self-managed their pain (80.8%),
relying on analgesics (78.5%) or alternative remedies (eg.
massage and/or herbal medicine) (2.3%). About a fifth
of the sample (19.2%) did nothing to cope with the pain.
No statistical differences emerged in factors influencing
pain management and in-depth interviews revealed that
the pain management depended on a woman’s individual
preference. There was a statistically significant association
(X2= 9.33, p ≤ 0.05) between women reporting the
purchase of non-prescription analgesics (31.2%) and type
of procedure; women with dilation and curettage combined
with laparoscopy, pelviscopy or hysteroscopy (50%) were
most likely to self-medicate than those undergoing medical
termination of pregnancy (38.5%), multiple surgeries
(27.5%), and various single procedures (23%) such as cone
biopsy, laser treatment, or sterilisation.
In total, 86% of women received help at home. Women
who reported pain 48 hours following discharge were
about 2.3 times more likely to receive help at home from
significant others (regression co-efficient 2.34. 95% CI,
1.26-4.36, p ≤ 0.01). Women who reported that it was
inconvenient for their caregivers to take care of them
(1.9%) were more likely to resume their own caregiving
roles following discharge (X2 = 18.21; p ≤ 0.001), with
some respondents reporting difficulties in caring for
small children following day surgery, and identifying this
as a disadvantage of day surgery (see also Barthelsson et
al 2003). This was compounded for those who received
inadequate help, or for those whose caregivers were
unable or reluctant to be available to them following
discharge: ‘I had to pretend a little bit at home, in front
of my little girl, that I was feeling alright …you know, you
have to’ (38 years, Australia-born, multiple procedures).
The experiences of women in Australia undergoing
reproductive health day surgery resemble those of
women internationally: day surgery is not pain-free
and there is scope for improving discharge assessment
and pain management. The majority (69.5%) reported
pain following discharge from day surgery and more
than a half were still in pain 48 hours after surgery. The
experience of postoperative pain varies greatly however
and it may be difficult to predict pain-related experiences
of patients (see also Barthelsson et al 2003; Burumdayal
and MacGowan-Palmer 2002). Factors that may be
relevant include age, previous day surgery experience
and information provision prior to surgery.
Our research corroborates other accounts of an
inverse relationship between reports of postoperative
pain and age (Callesan et al 1998; Yellen and Davis
2001), raising questions about changes in reporting
patterns. Burumdayal and colleagues (2002) argued,
‘some patients may believe that pain builds character and
feel ashamed to admit pain unless questioned in depth
or indirectly.’ Our findings demonstrate that the pain
experience may be worse for women with more than one
experience of day surgery than those without, suggesting
that patients’ previous experience with pain may cloud
their postoperative pain perception’ (Magnani et al 1989)
and ‘might well alter their pain threshold’ (Burumdayal
et al 2002), suggesting the value of demographic and
medical data for pain assessment.
Our data also indicate the positive role of information
provision on patients’ experience of pain (Kratz 1993;
Linden and Engberg 1996): women who felt that the
information provided was easy to understand were
less likely to report having pain following discharge or
within 48 hours of discharge from hospital. As reported,
private patients were more likely to report that day
surgery information was inadequate. It is therefore
necessary to improve information provision, particularly
given the ‘push’ of the current Australian government
Australian Journal of Advanced Nursing 2007 Volume 24 Number 4 Download full-text
for people to access private health insurance and seek
health care as private rather than public patients (Moorin
and Holman 2006).
Given the diversity of patients’ experiences,
individual assessment of each patient is necessary.
Information provision needs to be improved for all
people undergoing day surgery, particularly private
patients. Roberts and colleagues (1995), based on the
Australian study on patients’ pain-related difficulties
almost 10 years ago, recommended that in the
immediate postoperative period health professionals
or social workers provide routine home visits: this
has not eventuated. Our finding that women reported
difficulties managing at home, reinforce the continued
need for day surgery patients to access services that
provide domiciliary and community-based care.
Agboola, O., Davies, J. and Davies C. 1998-9. Laparoscopic sterilisation:
the immediate and long term post operative side effects using bupivacane
infiltration and didofenac. Journal of One Day Surgery, 8(3):7-9.
Australian Government Department of Health and Aged Care. 1999. Study to
identify and promote day surgery expansion opportunities in Australia. Final
report. Canberra: Australian Government Department of Health and Aged Care.
Barthelsson, C., Lutzen, K., Anderberg, B. and Nordstrom, G. 2003. Patients'
experiences of laparoscopic cholecystectomy in day surgery. Journal of Clinical
Bates, M.S. 1996. Biocultural dimensions of chronic pain: implications for
treatment of multi-ethnic populations. Albany: State University of New York Press.
Burumdayal, A. and MacGowan-Palmer, J.H. 2002. A survey of pain
at discharge and anaesethetists’ prescribing practice following daycase
laparoscopic sterilisation. The Journal of One Day Surgery, 12(1):11-13.
Callesan, T., Bech, K., Nielsen, J., Andersen, P., Hesselfeldt, P., Roikjaer, O.
and Kehletl, H. 1998. Pain after groin hernia repair. British Journal of Surgery,
Carr, C.J. and Thomas, V.J. 1997. Anticipating and experiencing post-operative
pain: the patients' perspective. Journal of Clinical Nursing, 6(3):191-201.
Coll, A.M., Ameen, J.R.M. and Moseley, L. 2004. Reported pain after day
surgery: a critical literature review. Journal of Advanced Nursing, 46(1):53-65.
de Beer, D. and Ravalia, A. 2001. Post-operative pain and nausea following day
case gynaecological laparoscopy. Journal of One-Day Surgery, 11(3):52-53.
Donoghue, J., Pelletier, D., Duffield, C. and Gomez-Fort, R. 1995. Laparoscopic
day surgery: the process of recovery for women. Ambulatory Surgery, 3(4):171-177.
Fraser, R.A., Hotz, S.B., Hurtig, J.B., Hodges, S.N. and Moher, D. 1989.
The prevalence and impact of pain after day-care tubal ligation surgery.
Gagliese, L., Jackson, M., Ritvo, P., Wowk, A. and Katz, J. 2000. Age is not an
impediment to effective use of patient-controlled analgesia by surgical patients.
Hein, A., Norlandera, C., Bloma, L. and Jakobsson, J. 2001. Is pain prophylaxis
in minor gynaecological surgery of clinical value? A double-blind placebo
controlled study of paracetamol 1g versus Lornoxicam 8 mg given orally.
International Journal of Ambulatory Surgery, 9(2):91-94.
Jakobsen, D.H., Torben, C., Schouenborg, L., Nielsen, D. and Kehlet, H. 2003.
Convalescence after laparoscopic sterilization. Journal of Ambulatory Surgery,
Kratz, A. 1993. Preoperative education: preparing patients for a positive
experience. Journal of Post Anaesthesia Nursing, 8(4):270-275.
Linden, I. and Engberg, I.B. 1996. Patients' opinions of information given and
post-operative problems experienced in conjunction with ambulatory surgery.
Ambulatory Surgery, 4(2):85-91.
Lipton, J.A. and Marbach, J.J. 1984. Ethnicity and the pain experience. Social
Science and Medicine, 19(12):1279-1298.
Magnani, B., Johnson, L.R. and Ferrante, F.M. 1989. Modifiers of patient
controlled analgesia efficacy II: chronic pain. Pain, 39(1):23-29.
Millar, J.M. 1997. US ambulatory surgery projections are inappropriate.
Ambulatory Surgery, 5(3):121-124.
Mitchell, M. 2000. Anxiety management: a distinct nursing role in day surgery.
Ambulatory Surgery, 8(3):119-127.
Mitchell, M. 2003. Impact of discharge from day surgery on patients and carers.
British Journal of Nursing, 12(7):402-408.
Moorin, R.E. and Holman, C.D. 2006. Does federal health care policy influence
switching between the public and private sectors in individuals? Health Policy,
Roberts, B.L., Peterson, G.M., Friesen, W.T. and Beckett, W.G. 1995. An
investigation of pain experience and management following gynaecological
day surgery: differences between open and closed surgery. Journal of Pain and
Symptom Management, 10(5):370-377.
Ryan, G.W. and Bernard, R. 2003. Techniques to identify themes. Field
Scientific Software Development. 1991-2004. ATLAS*ti. www.atlasti.com.
Stockdale, A. and Bellman, M. 1998. An audit of post-operative pain and nausea
in day case surgery. European Journal of Anaesthesiology, 15(3):271-274.
Strauss, A. and Corbin, J. 1990. Basics of qualitative research: grounded theory
procedures and techniques. Newbury Park: Sage Publications.
Taenzer, A.H., Clark, C. and Curry, C.S. 2000. Gender affects report of pain
and function after arthroscopic anterior cruciate ligament reconstruction.
Tham, C. and Koh, K.F. 2002. Unanticipated admission after day surgery.
Singapore Medical Journal, 43(10):522-526.
Watt-Watson, J., Stevens, B. and Garfinkel, P. 2001. Relationship between
nurses' pain knowledge and pain management outcomes for their postoperative
cardiac patients. Journal of Advanced Nursing, 36(4):535-545.
Yellen, E. and Davis, G. 2001. Patient satisfaction in ambulatory surgery. AORN