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The immobilization experience : perceptions of young adults with anterior cruciate ligament repair Turner, Liza Jean 1984

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THE IMMOBILIZATION EXPERIENCE: PERCEPTIONS OF YOUNG ADULTS WITH ANTERIOR CRUCIATE LIGAMENT REPAIR By L i z a Jean Turner B.S.N., The U n i v e r s i t y of Saskatchewan, 1979 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES The S c h o o l of N u r s i n g We accept t h i s t h e s i s as conforming to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1984 (c) L i z a Jean T u r n e r , 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements fo r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of N u r s i n g The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6 (3/81) Abstract This study was designed to investigate how young adults with anterior cruciate ligament repair perceive the immobilization experience. The concerns confronting indivi d u a l s following h o s p i t a l i z a t i o n may affe c t their r e h a b i l i t a t i o n and return to musculoskeletal functioning, in which case nurses must understand these concerns in order to provide appropriate care. A q u a l i t a t i v e research approach based on the the o r e t i c a l perspective of phenomenology was used to answer the questions posed in this study. Ten participants were interviewed at home approximately 1, 3 and 4 weeks post-operatively. Indepth unstructured interviews were transcribed and analyzed immediately following each interview. The findings of the study revealed that the participants' immobilization experience occurred in phases which were in t e r r e l a t e d , and evolved around the event of injury. Six phases were i d e n t i f i e d : (a) pre-injury, (b) recognition of injury, (c) contact with the health care system, (d) hospital experience, (e) home experience, and (f) future plans. Additionally, three major themes or concepts emerged—loss, hope, and r e h a b i l i t a t i o n , and together with the phases of the experience, formed the organizational schema for the study. The analytic concepts assisted the researcher in making sense of the experience from the participants' perspective. Loss, hope, and r e h a b i l i t a t i o n appeared with varying intensity in one or more of the phases of the immobilization experience. It i s argued that the i d e n t i f i e d concerns should be incorporated into i n d i v i d u a l i z e d nursing care and r e h a b i l i t a t i o n plans. Implications of the research findings for nursing practice, education, and research are presented. - i i -Table of Contents PAGE Abstract ( i i ) Table of Contents ( i i i ) L i s t of Figures . (v) Acknowledgements ( v i ) CHAPTER ONE: INTRODUCTION Background to the Problem 1 Conceptual Framework 6 Statement of the Problem 9 Purpose 10 Theoretical and Methodological Perspective .. 10 Defi n i t i o n of Terms . 13 Assumptions 14 Limitations 15 Summary 15 CHAPTER TWO: METHODOLOGY Introduction 16 Selection of Participants 16 C r i t e r i a for Selection 17 Selection Procedure 18 Description of Participants 19 Et h i c a l Considerations 21 Data Col l e c t i o n 21 Data Analysis 23 Summary 24 CHAPTER THREE: THE PROCESS OF DATA ANALYSIS Introduction 25 Introduction to the Themes 25 Relationship of the Themes to Kleinman's Conceptual Framework 33 Relationship of the Themes to the Phenomenological Approach 36 Summary 37 CHAPTER FOUR: DIMENSIONS OF THE IMMOBILIZATION EXPERIENCE Introduction 38 - i i i -Phases of the E x p e r i e n c e and R e l a t e d Concepts 40 P r e - I n j u r y 41 R e c o g n i t i o n of I n j u r y 44 Con t a c t With the H e a l t h Care System .... 52 H o s p i t a l i z a t i o n E x p e r i e n c e 60 P r e - o p e r a t i v e concerns 61 P o s t - o p e r a t i v e concerns 62 P h y s i o l o g y , s u r g e r y and the p a r t i c i p a n t s ' e x p e r i e n c e 70 I n t e r a c t i o n w i t h n u r s i n g s t a f f 76 Home E x p e r i e n c e 80 Fu t u r e P l a n s 96 Summary 102 CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING Summary and C o n c l u s i o n s 104 I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e 113 I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n 115 I m p l i c a t i o n s f o r N u r s i n g Research 116 B i b l i o g r a p h y 119 Appendices 124 - i v -L i s t of Figures Page Figure 1. Health care system: Internal structure... 7 Figure 2. Interrelationship between loss and hope ... 31 - v -Acknowledgements I would l i k e to thank f i r s t and foremost Dr. Joan Anderson, chairperson of my committee, for her continual support and c r i t i c a l insight. I would also l i k e to thank Dr. Kathleen Simpson for her o b j e c t i v i t y , encouragement, and expertise as a committee member. I am grateful to the nurses who cooperated with me in id e n t i f y i n g participants for the study, and to the participants who have graciously shared their time and experiences. Without the support of my friends and colleagues this study would not have been possible; to them I am grateful for tolerance and comradeship. F i n a l l y , I wish to thank my grandfather, Harold Guloien, for his undying f a i t h in my endeavours - to him I dedicate this thesis. - . v i -CHAPTER ONE Introduction Background to the Problem Physical movement or a c t i v i t y i s fundamentally important to our existence and i s highly valued by most people (Milazzo & Resh, 1982). In a society where physical a c t i v i t y has come to be valued, immobilization poses multiple problems for individuals with d i f f i c u l t y or i n a b i l i t y to freely and comfortably move from place to place. Physical mobility i s necessary for everyday functioning and i s indispensable to those who participate in regular exercise and sports a c t i v i t i e s . Individuals are taking an active interest in fit n e s s and well-being, and are becoming increasingly involved in sports a c t i v i t i e s (Wassel, 1981). As the amount of leis u r e time in our society increases, the number of i n j u r i e s incurred in sports a c t i v i t i e s also increases. As a result of immobilization following sports i n j u r i e s , healthy young adults are required to make numerous - 1 -changes in their a c t i v i t i e s of daily l i v i n g , work, and recreation. Many individuals p a r t i c i p a t i n g in sports a c t i v i t i e s fear knee i n j u r i e s because these are the most common cause of permanent d i s a b i l i t y in sports. Derscheid and Malone (1980) state that because of i t s exposed position in the limb, great functional demands are placed upon the knee by weight-bearing forces, and the knee i s l i a b l e to suffer injury more frequently than any other j o i n t . Tear of the knee's anterior cruciate ligament i s a frequent source of d i f f i c u l t y , and usually demands surgical repair. Blackburn and Craig (1980) state that repair of the anterior cruciate- ligament following injury i s controversial. The benefits of surgery are not t o t a l l y known, and in some cases the ligament heals without surgical repair. Individuals who do not undergo surgery are required to wear a brace or cast for 8 to 10 weeks for the purpose of resting the affected limb. If surgery i s carried out, a similar period of immobilization i s required to f a c i l i t a t e healing, and r e h a b i l i t a t i o n i s necessary to return to normal functioning. Rehabilitation i s the process of restoring an individual's a b i l i t y to l i v e and work as normally as possible - 2 -after a disabling injury or i l l n e s s . The goal of r e h a b i l i t a t i o n i s to restore the victim's physical and mental functioning as rapidly as possible (Wells, 1982). D e b i l i t a t i o n of the body during, and after, major knee surgery, and the subsequent decrease in physical a c t i v i t y , usually requires r e h a b i l i t a t i o n (Malone, Blackburn, & Wallace, 1980). Nurses caring for persons who have experienced sports i n j u r i e s direct their e f f o r t s toward the restoration or improvement of musculoskeletal body functioning. Roy and Irvin (1983) state that the goal of treatment must be restoration of function to the greatest possible degree in the shortest possible time. This means that r e h a b i l i t a t i o n should begin at the moment of injury. Treatment and r e h a b i l i t a t i o n should blend imperceptibly into one, as acute treatment and early r e h a b i l i t a t i o n can minimize the effects of the injury. Quigley (1981) agrees with early r e h a b i l i t a t i o n and states that the goal of r e h a b i l i t a t i o n i s to provide assistance to individuals for achievement of their goals in the shortest possible time. Therefore, the process of restoration to normal l i f e following i n j u r i e s requires attention to physiological, psychological, and s o c i a l needs. It i s important to study the prototype of young adults with anterior cruciate ligament repair during the period of - 3 -immobilization for a variety of reasons. From the researcher's nursing experience, i t appears that healthy, young adult sports participants are frequently hospitalized for anterior cruciate ligament reconstruction. They usually receive minimal nursing care time. The physical and emotional care extended by nurses to the patient comprise nursing care time. With several patients to care for at one time, nurses tend to spend more time with patients who are older and more physically incapacitated than with young adult sports participants. As a group, sports participants tend to value physical mobility and are susceptible to devastation by i t s absence. Injuries and consequent immobilization affect a l l aspects of l i f e , including goals, occupation, and finances (Barnes, 1977). The researcher was interested in the study of the effects of the immobilization experience for sports participants, and in the factors which influence recovery as there i s no evidence of research, to date, of the concerns confronting individuals during the period of immobilization following anterior cruciate ligament repair. Yet, the concerns confronting individuals following - 4 -h o s p i t a l i z a t i o n may a f f e c t t h e i r r e h a b i l i t a t i o n and r e t u r n to locomotor f u n c t i o n i n g , i n which case, h e a l t h p r o f e s s i o n a l s must understand these concerns i n o r d e r to p r o v i d e a p p r o p r i a t e c a r e . Norman and Snyder (1982) s t a t e t h a t , "Recovery from any i l l n e s s c o n d i t i o n i m p l i e s the need f o r r e h a b i l i t a t i o n , e i t h e r to a former way of l i f e , or to a way of l i f e commensurate w i t h r e s i d u a l a b i l i t i e s " (p. 17). To h e l p i n d i v i d u a l s a s s i m i l a t e h e a l t h care i n f o r m a t i o n , i t i s n e c e s s a r y to study c l i e n t s ' p e r c e p t i o n s of t h e i r e x p e r i e n c e (Norman & Snyder, 1982). The c l i e n t ' s view of h i s or her own r e h a b i l i t a t i o n p r o v i d e s background i n f o r m a t i o n to h e a l t h p r o f e s s i o n a l s f o r the f o r m u l a t i o n of a p e r t i n e n t r e h a b i l i t a t i o n program. The d i s c o v e r y and documentation of the concerns of young a d u l t s at home f o l l o w i n g a n t e r i o r c r u c i a t e l i g a m e n t r e p a i r w i l l c o n t r i b u t e to the development of knowledge about the c l i e n t ' s p e r s p e c t i v e . T h i s knowledge i s b e n e f i c i a l to n urses i n a s s i s t i n g i n d i v i d u a l s to prepare f o r , and cope w i t h , t h e i r p o s t - h o s p i t a l i z a t i o n p e r i o d , and can c o n t r i b u t e to the f o u n d a t i o n upon which to base n u r s i n g p r a c t i c e , and to develop n u r s i n g t h e o r y . As C r a t e (1965) s t a t e s , i t i s not the r o l e of the nurse to attempt to change the b a s i c l i f e p a t t e r n of a p e r s o n , but to s u p p o r t and guide towards a way of l i f e t h a t accommodates - 5 -i l l n e s s . Study of the chosen prototype w i l l provide nurses with information regarding adaptation to the experience of anterior cruciate ligament reconstruction, and can be analyzed within the broader context of immobilization. In this way, study of the particular injury w i l l further our understanding of the experiences of individuals who are immobilized. Conceptual Framework Nurses require an understanding of the experience of their patients. Knowledge and understanding of the concerns of young adults with anterior cruciate ligament repair can ass i s t nurses in planning and implementing nursing care to people with a disturbance in mobility. Kleinman's (1978) conceptualization of the health care system has provided the direction for this study. He describes the health care system as a c u l t u r a l system with symbolic meanings anchored in particular arrangements of s o c i a l i n s t i t u t i o n s and patterns of interpersonal interactions (Kleinman, 1978). He emphasizes the importance of discovering how patients think about health care and i l l n e s s , as well as how they deal with i t . Kleinman conceptualizes the health care system by i d e n t i f y i n g three sectors within which sickness i s experienced and reacted to - 6 -(refer to Figure 1). These are the professional (or the organized healing professions); the folk (which includes sacred and secular folk healers or non-professional healing s p e c i a l i s t s ) ; and the popular (which includes the i n d i v i d u a l , the family, and the s o c i a l network) (Kleinraan, 1978). Professional sector Points of i n t e r a c t i o n , entrance and B e l i e f s Choices and decisions 1 Roles Relationships Interaction settings I n s t i t u t i o n s Folk sector Boundary l i n e s Health care system Points of i n t e r a c t i o n entrance and exit Popular sector: (a) Individual - based (b) Family - based (c) Social nexus - based (d) Community - based Figure 1. Heath care system: Internal structure. (Kleinraan, 1978, p. 86). - 7 -Kleinman (1978) conceptualizes sickness and care as being c u l t u r a l l y patterned. He construes sickness as including disease and i l l n e s s . Kleinman (1978) states: Disease i s the mechanistic, material d e f i n i t i o n of i l l - h e a l t h used primarily by the medical profession and i s the malfunctioning or maladaptation of biologic and psychophysiologic processes in the i n d i v i d u a l ; whereas i l l n e s s represents personal, interpersonal, and c u l t u r a l reactions to disease. Il l n e s s i s shaped by c u l t u r a l factors governing perception, l a b e l l i n g , explanation, and valuation of the discomforting experience. The i l l n e s s experience i s an intimate part of s o c i a l systems of meaning and rules for behavior thus making i t strongly influenced by culture. (p.252) Kleinman goes on to state that: I l l n e s s i s c u l t u r a l l y shaped in the sense that how we perceive, experience, and cope with disease i s based on our explanations of sickness, explanations s p e c i f i c to the s o c i a l positions we occupy and systems of meaning we employ. These have been shown to influence our expectations and perceptions of symptoms, the way we attach particular sickness labels to them, and the valuations and responses that flow from those la b e l s . (p. 252) The concepts of disease and i l l n e s s are explanatory models which comprise the complex, f l u i d , t o t a l phenomenon of sickness. They derive from and help construct c l i n i c a l r e a l i t y . Faced with any episode of i l l - h e a l t h , individuals and their caretakers e l i c i t explanatory models. These are - 8 -notions about an episode of sickness and i t s treatment that are employed by a l l those who are engaged in the c l i n i c a l process. Each individual and each group has one or more explanatory models which help them make sense of any particular episode of i l l - h e a l t h and are designed to answer the question, "Why has i t happened to me?" Explanatory models may be in c o n f l i c t and can affect care. It i s v i t a l l y important for nurses to study and examine the explanatory models of their patients in order to provide e f f e c t i v e care. Kleinman f a c i l i t a t e s this examination by his acknowledgment of the importance of the patient's perception and locating the patient's experience within the broader soci o - c u l t u r a l context. Statement of the Problem This study i s designed to gain an understanding of the worries and questions of young adults experiencing anterior cruciate ligament repair. An understanding of patients' explanatory models w i l l a s s i s t nurses in providing care which exemplifies an appreciation of how individuals perceive their experiences and the ways in which they desire to be helped. This study w i l l therefore address the following questions: 1. What are the concerns of young adults at home during - 9 -the period of immobilization following anterior cruciate ligament repair? 2. What are the patients' perceptions of the impact of these concerns upon the r e h a b i l i t a t i v e process? Purpose The experience of immobilization as perceived by young adults following anterior cruciate ligament repair was explored for the purpose of: 1. Identifying the concerns of young adults during the period of immobilization following anterior cruciate ligament repair at approximately 1 week and 3 to 4 weeks following hospital discharge. 2. Examining patients' perceptions of the impact of these concerns upon the r e h a b i l i t a t i v e process. Theoretical and Methodological Perspective A q u a l i t a t i v e research approach, based on the theoretical perspective of phenomenology, was chosen to answer the questions of this study. Phenomenology i s a philosophy, an approach, and a method (Oiler, 1982). It represents the e f f o r t to describe human experience as i t i s li v e d . This approach was chosen because i t emphasizes the - 10 -understanding of human behaviour from the patient's point of view • The i d e n t i f i c a t i o n of the concerns of young adults, during the period of immobilization following anterior cruciate ligament repair, requires an approach which attempts to understand experiences from the perspective of those being studied. This approach allows the individuals being studied to explicate their world in the manner i n which they view i t ; thus providing the researcher with a deeper and richer understanding than i s usual in the more t r a d i t i o n a l methods of investigation (Rist, 1979). Nursing i s concerned with lived experience and since the aim of the phenomenological approach i s to describe experience as i t i s l i v e d , this research method can e f f e c t i v e l y serve nursing's goal to understand experience (Oiler, 1982). Data c o l l e c t i o n and data analysis vary from the t r a d i t i o n a l research methods. The people who l i v e the experience are the source of data. The researcher i s immersed in the data and as descriptions are compared and contrasted, recurring elements are recorded (Oi l e r , 1982, p. 180). Researchers must reduce their preconceptions to a minimum so that they w i l l be able to receive an object as i t is given to their consciousness (Davis, 1978). - 11 -Kleinman's c o n c e p t u a l framework f i t s w e l l w i t h the phenomenological approach. Each i s concerned w i t h the p a t i e n t ' s p e r c e p t i o n of h i s or her e x p e r i e n c e . Kleinman suggests t h a t the phenomenological approach can be a p p l i e d when comparing how s i c k n e s s i s s o c i a l l y c o n s t r u c t e d i n the every day w o r l d and how i t i s d e f i n e d w i t h i n p r o f e s s i o n a l s e t t i n g s ( K l e i n m a n , 1977). By s t u d y i n g p a t i e n t s ' e x p l a n a t o r y models, the r e s e a r c h e r can examine m u l t i p l e i n t e r r e l a t e d d e t e r m i n a n t s of h e a l t h and s i c k n e s s , e x t e n d i n g w e l l beyond b i o l o g i c a l v a r i a b l e s to v a l u e s , s o c i a l r e l a t i o n s h i p s , s o c i o - p o l i t i c a l s t r u c t u r e s , and economic change ( K l e i n m a n , 1977). The phenomenological approach h e l p s us to understand the i l l n e s s e x p e r i e n c e of i n d i v i d u a l s i n the p o p u l a r s e c t o r ( t h e i n d i v i d u a l , the f a m i l y , and the s o c i a l network) of the h e a l t h care system. The phenomenologist assumes t h a t t h e r e i s something i n the na t u r e of human e x p e r i e n c e , beyond sheer reason or sensory o b s e r v a t i o n , which w i l l produce knowledge ( D a v i s , 1978, p.194). The p r e c e d i n g paragraphs have i n t r o d u c e d the t h e o r e t i c a l and m e t h o d o l o g i c a l p e r s p e c t i v e of the s t u d y . The s p e c i f i c s of the p r o c e s s of the study are d i s c u s s e d i n Chapter Two. - 12 -D e f i n i t i o n of Terms The following terms are defined in order to c l a r i f y their use in this study: 1. Anterior cruciate ligament - the ligaments of the knee extending from the l a t e r a l femoral condyle to the t i b i a l surface in front of the medial t i b i a l tubercle; an extremely strong ligament of the knee, whose main function i s to prevent a forward s h i f t of the knee jo i n t (McCluskey & Blackburn, 1980). 2. Anterior cruciate ligament repair - surgical repair of the anterior cruciate ligament consisting of rejoining, removing or replacing the torn components of the ligaments. 3. Concerns - the worries and questions of young adults experiencing anterior cruciate ligament repair. 4. Immobilization - the i n a b i l i t y to move freely and comfortably from place to place. 5. Leisure time - free time which one may indulge in rest or recreation (Webster, 1977). 6. Normal locomotor functioning - the a b i l i t y to move freely and comfortably from place to place. - 13 -7. N u r s i n g i n t e r v e n t i o n s - n u r s i n g a c t i o n s which a s s i s t i n a l l e v i a t i n g the concerns of young a d u l t s e x p e r i e n c i n g a n t e r i o r c r u c i a t e l i g a m e n t r e p a i r : p h y s i o l o g i c a l l y , p s y c h o l o g i c a l l y , and s o c i a l l y . 8. R e h a b i l i t a t i o n - the p r o c e s s of r e s t o r i n g i n d i v i d u a l s to t h e i r o p t i m a l s t a t e of f u n c t i o n i n g f o l l o w i n g a n t e r i o r c r u c i a t e l i g a m e n t r e p a i r . 9. S p o r t s a c t i v i t i e s - a v a r i e t y of c o m p e t i t i v e and n o n - c o m p e t i t i v e amateur s p o r t s i n c l u d i n g : b a s e b a l l , b a s k e t b a l l , f o o t b a l l , hockey, r a c q u e t b a l l , rugby, s k i i n g , squash and v o l l e y b a l l . 10. Young a d u l t s - i n d i v i d u a l s from 20 to 45 years of age. Assumptions The r e s e a r c h e r approached t h i s study by p o s t u l a t i n g two fundamental assumptions: (a) t h a t young a d u l t s at home f o l l o w i n g a n t e r i o r c r u c i a t e l i g a m e n t r e p a i r would have concerns r e l a t e d to t h e i r p e r i o d of i m m o b i l i z a t i o n , and would be w i l l i n g t o share t h e i r concerns by o f f e r i n g honest d e s c r i p t i o n s ; and (b) t h a t nurses w i t h knowledge of these concerns can h e l p prepare p a t i e n t s to cope w i t h the problems of i m m o b i l i z a t i o n e x p e r i e n c e d i n the home. - 14 -Limitations The major l i m i t a t i o n of this study i s that the sample was drawn from a single hospital and therefore represents a specialized subgroup of the t o t a l population of young adults with anterior cruciate ligament repair. Summary This chapter has introduced the study and outlined i t s parameters. Information integrated from patients' accounts and presented to appropriate audiences w i l l aid in the education of health service consumers. A study of the concerns confronting young adults at home during the period of immobilization following anterior cruciate ligament repair w i l l contribute to the development of knowledge from the patient's perspective. Nurses with knowledge of these concerns can more e f f e c t i v e l y a s s i s t patients experiencing anterior cruciate ligament repair in preparing for, and coping with, their period of immobilization. The following chapter discusses the methodology of the study. - 15 -CHAPTER TWO Methodology Introduction Phenomenology, a qu a l i t a t i v e research approach, was used to answer the questions posed in this study. This chapter discusses how this approach was used to discover the immobiliziation experience as i t i s li v e d by young adults with anterior cruciate ligament repair. The selection of participants i s discussed within the context of the study's methodology. The c r i t e r i a for participant selection, the selection procedure, a description of the participants, and c r i t i c a l e t h i c a l considerations are described in this chapter. Data c o l l e c t i o n and data analysis are then discussed, and are followed by a summary of the chapter. Selection of Participants A purposive sampling technique was used in this study. The process of purposive sampling involves the drawing of an - 16 -i n i t i a l sample, with the intent of generating data, u n t i l no new information i s forthcoming. Data are collected with the s p e c i f i c purposes of answering the questions, and determining the importance of the emerging concepts (Stern, 1980). As the main concepts or variables become apparent, additional data may be s e l e c t i v e l y collected in order to i d e n t i f y the main categories or variables (Stern, 1980). The researcher proposed that the process of purposive sampling may require fewer than eight, or more than ten individuals, depending upon the saturation of categories which were developed from the data. The process of saturation of categories involves c o l l e c t i o n of data u n t i l the researcher i s s a t i s f i e d that no new information i s being received which further explains that particular concept or category (Stern, 1980). Data c o l l e c t i o n was carried out for 7 weeks during which time the researcher became s a t i s f i e d with the saturation of categories. In t o t a l , ten participants made up the sample. C r i t e r i a for Selection Participants were selected according to the following c r i t e r i a : 1. The participants were male or female, aged 20 to 45 - 17 -years. The researcher was interested in the experiences of young adults of both genders. 2. The participants experienced anterior cruciate ligament repair prior to hospital discharge. The researcher was interested in the concerns of these individuals because of her observation in c l i n i c a l practice of the high incidence of this injury. 3. The participants were able to communicate verbally in English. This was necessary for data c o l l e c t i o n which involved in-depth interviews. 4. The participants were w i l l i n g to share their feelings and concerns. The participants' explications of their experiences were the means to answer the questions of this study. 5. The participants were competent to give informed consent for p a r t i c i p a t i o n in this study. Selection Procedure The sample was drawn from a teaching hospital in a western Canadian c i t y . The researcher gained access to the - i n s t i t u t i o n and chose the subjects who were 3 to 4 days post-surgery, discussed the appropriateness of each subject for inclusion in the study with his or her nurse, and - 18 -/ contacted individuals whom the nurse and the researcher perceived as appropriate for the study. The researcher explained the study to each subject and obtained the written consent of individuals who agreed to participate. At this time, i t was understood that the researcher would contact each participant by telephone 2 or 3 days following hospital discharge to arrange the f i r s t interview. Description of Participants Ten individuals participated in this study. Seven participants were male, and three were female. A l l participants were Caucasian. Their ages ranged from 20 to 38 years, f i v e of whom were 26 to 28 years old. Two were married, fiv e were single and involved in a heterosexual relationship, and three were single without a mate. The two married participants l i v e d in their own homes with a spouse; neither had children. The l i v i n g arrangements of the single participants were as follows: four l i v e d in an apartment with one or more friends, two in an apartment with a mate, one alone in an apartment, and one in a house with his immediate family. Two participants were university students, seven were employed (but on leave of absence from work), and one was unemployed. - 19 -The events leading to h o s p i t a l i z a t i o n varied among participants. For three individuals, injury was immediately followed by surgery, making these events unpredictable or not anticipated. The remaining seven participants incurred i n j u r i e s at least 2 months prior to surgery and were able to make some plans for their period of immobilization. Injury to the anterior cruciate ligament was incurred in a variety of sports: three in soccer, three skiing, two during rugby, one in baseball, and one in v o l l e y b a l l . It i s interesting to note that a l l three female participants were injured during the same sports a c t i v i t y : s k i i n g . Three individuals who were approached were not included in the study. One female moved from the western Canadian ci t y during her f i r s t post-operative week; and two females, one 20 years and the other 21 years of age, refused to part i c i p a t e . Their reasons for refusal included an unwillingness to share some of their time and a strong desire to avoid explication of their experiences. One of the reluctant participants explained, "I don't want to be reminded of i t . I just want to forget everything." - 20 -E t h i c a l Considerations Each participant received from the researcher an explanation about the purpose, nature, and implications of the study. C o n f i d e n t i a l i t y , the right to refuse to answer any questions, and the right to refuse to participate or withdraw from the study, at any time, without prejudice to future treatment were explained and assured. A consent form was given to each participant to sign, and signatures were completed following adequate answers to a l l questions. The form was read to each participant and was signed in the presence of the researcher. The consent form u t i l i z e d by the researcher i s presented in Appendix A. The participants were informed that there would be no f i n a n c i a l renumeration for pa r t i c i p a t i o n in the study. They were also informed that although there were no direct benefits for p a r t i c i p a t i o n , i t would give them an opportunity to describe their experience and might benefit others in the future. A summary of the findings of the study was offered to a l l participants. Data Col l e c t i o n Each participant was interviewed in his or her home - 21 -approximately 1 week and 3 to 4 weeks after being discharged from the hospital. The rationale for this decision was to obtain data during the early phase of the experience of immobilization, and then later in the experience. A l l participants were interviewed twice, and the length of the interview varied from 30 to 120 minutes. The intent of the interview was to c o l l e c t data about the individual's perceptions and thoughts of the experience in question. Individuals undergoing anterior cruciate ligament repair are hospitalized approximately 6 to 7 days and return home with a f u l l length leg cast. This cast i s changed to a f u l l length hinged leg cast three to four weeks post-operatively. The researcher chose to interview participants at approximately 1 week and 3 to 4 weeks following hospital discharge in order to study their experiences at an early and at a later phase of r e h a b i l i t a t i o n following surgery. * Rehabilitation i s a process which begins at the time of injury and i s affected by multiple variables. The researcher's intent was to understand how participants perceive their experience and to examine how their worries and questions affect their r e h a b i l i t a t i v e process. Interviews were tape-recorded and transcribed immediately following each interview. Semi-structured, open-ended questions were u t i l i z e d in an attempt to discover - 22 -i n d i v i d u a l s ' perceptions of their concerns and behaviours used throughout the period of immobilization. Sample questions are l i s t e d in Appendix C. The objectives of the second interview were twofold: f i r s t l y , to c l a r i f y data obtained in the f i r s t interview; and secondly, to c o l l e c t data regarding the experience of immobilization 3 to 4 weeks following anterior cruciate ligament repair. Data Analysis Following each interview, the audiotape was transcribed and examined for similar units of data. These units were organized into categories which appeared similar in substance. Emerging categories were noted and examined in r e l a t i o n to the l i t e r a t u r e . Data clustered in categories formed the conceptual themes. Stern (1980) describes this system of coding as substantive coding, that i s the coding of the substance of data. As data are received, a system of coding i s established according to apparent themes. The data are examined, coded, compared with other data, and assigned to categories according to substance (Stern, 1980). A detailed description of the process of data analysis i s presented in Chapter Three. - 23 -Summary This chapter has described the methodology of this study in three sections. The chapter began with a brief introduction followed by a description of the selection of participants. This section included discussion of the c r i t e r i a for selection, the selection procedure, description of the participants, and e t h i c a l considerations. Secondly, data c o l l e c t i o n was discussed; and f i n a l l y , a discussion of data analysis was presented. Chapter Three describes the process of the analysis of data. - 24 -CHAPTER THREE Process of Data Analysis Introduction The purpose of this chapter i s to explain the process of data analysis. This w i l l be accomplished in three sections: introduction to the themes, relationship of the themes to Kleinman's conceptual framework, and relationship of the themes to the phenomenological approach. It i s the researcher's intent to set forth an explanation of the process of data analysis in order to enhance the reader's understanding of the development of the conceptual themes. Introduction to the Themes The phenomenological approach emphasizes the development of a n a l y t i c a l , conceptual, and categorical components of explanation from the data i t s e l f . Data c o l l e c t i o n and analysis occur concurrently. The researcher develops conceptual categories from the data, and data in each category are similar in substance. As these C - 25 -processes were carried out, the l i t e r a t u r e was s e l e c t i v e l y reviewed according to the substance of the emerging categories. The revelations of data analysis oriented the researcher to view the participants' experience as one which occurs in phases. Phases are experienced in sequence and evolve around the event of injury. As each participant offered his or her s t o r j , i t became evident that the phases of the experience were common phenomena; that each participant experienced each phase; and that each participant had similar phase-related concerns. At this point, the phases of the immobilization experience became the organizational framework for data analysis. The immobilization experience was analyzed in terms of a so c i a l phenomenon which occurs in phases or sequences passing over a period of time (Lofland, 1971). The experience in question was the direct result of an unpredictable event, namely an injury to the knee's anterior cruciate ligament. The participants i d e n t i f i e d concerns which appear to occur in a sequence of phases beginning with the injury and ending with short- and long-term future plans. Participants interpreted their experiences in six phases: (a) pre-injury, (b) recognition of injury, (c) contact with the health care system, (d) hospital experience, - 26 -e) home experience, and (f) future plans. Phases are not independent as each overlaps with adjacent phases and includes a pre- and post-phase period in addition to the major event. For the purpose of data analysis, i t i s not s u f f i c i e n t to organize data merely in sequence. Analytical conceptualization i s the key to a greater understanding of the data and leads to more sound and b e n e f i c i a l findings. Given the notion of phases of the experience the researcher noted that several conceptual categories appeared similar in substance, and hence organized similar categories into three major themes -- the concepts of loss, hope, and r e h a b i l i t a t i o n . These themes emerged during the interviews and when viewed as threads throughout the immobilization experience, make up the participants' explanatory models which help them to make sense of their experience. Throughout the phases, the concepts of loss, hope, and r e h a b i l i t a t i o n occur in varying i n t e n s i t y . These shape the participant's view of his or her experience. The following paragraphs introduce the concepts of loss, hope, and r e h a b i l i t a t i o n . Further explication and integration into the phases of the experience i s presented in Chapter Four. - 27 -Loss i s an i n t e g r a l p a r t of human e x p e r i e n c e and i s pr o b a b l y one of a very few events t h a t i s e x p e r i e n c e d by everyone ( C a r l s o n , 1978). D e s p i t e a m u l t i t u d e of d e f i n i t i o n s of l o s s t h a t e x i s t i n the l i t e r a t u r e , some s i m i l a r c h a r a c t e r i s t i c s can be i d e n t i f i e d . Examples of these c h a r a c t e r i s t i c s are as f o l l o w s : l o s s i s a s t a t e of bei n g d e p r i v e d of or bei n g w i t h o u t something one has had; i t i s p r e d i c t a b l e or u n p r e d i c t a b l e , g r a d u a l or sudden, and n o n - t r a u m a t i c or t r a u m a t i c ( C a r l s o n , 1978; P e r e t z , 1970). In the case at hand, knee i n j u r i e s are u n p r e d i c t a b l e , sudden, and t r a u m a t i c . I n d i v i d u a l s who i n j u r e t h e i r knees d u r i n g s p o r t s a c t i v i t i e s are f a c e d w i t h the r e a l i t y of p o s s i b l y l o s i n g the a b i l i t y to p a r t i c i p a t e i n s p o r t s . E m o t i o n a l responses are h i g h l y charged and accompany the person throughout r e h a b i l i t a t i o n — i n h o s p i t a l and at home. P a r t i c i p a n t s i n t h i s study appeared to have e x p e r i e n c e d r e p e a t e d l o s s e s of v a r y i n g i n t e n s i t y , d u r a t i o n , and impact upon t h e i r l i v e s . I t i s r e a s o n a b l e t o b e l i e v e t h a t i f one i n j u r e s o n e s e l f , immediate l o s s o c c u r s — whether i t be l o s s of m o b i l i t y , independence, or s e l f - e s t e e m . D e f i n i n g a l o s s and u n d e r s t a n d i n g i t s s i g n i f i c a n c e to the i n d i v i d u a l i s a d i f f i c u l t t a s k ( C a r l s o n , 1978). P e r e t z (1970) p u r p o r t s t h a t l o s s i s s i m u l t a n e o u s l y a r e a l event and a p e r c e p t i o n by which the i n d i v i d u a l endows an event w i t h - 28 -personal or symbolic meaning. In other words, a loss i s both objectively (or externally) and subjectively (or i n t e r n a l l y ) interpreted by the ind i v i d u a l experiencing the loss. Carlson (1978) states that a loss i s any change in the individual's situation that reduces the probability of achieving i m p l i c i t or e x p l i c i t goals. She goes on to say that goals exist to s a t i s f y needs, and the severity of the loss i s related to the salience of the goals and the extent of their disruption or extinction. The events surrounding loss take on meaning according to how and how much they affect the individual's actual and potential goal achievement. Physical changes or l i m i t a t i o n s , such as knee injury and the consequent period of immobilization, are disturbing events which threaten the achievement of physiological, psychological, and s o c i a l goals. The meaning of loss i s woven into the person's identity and reaction to loss includes any attempt to repair the disruption (Peretz, 1970). Loss can occur from physiological, psychological, or so c i a l changes. Attempts to cope with loss are characterized by passage through stages of adaptation in which feelings of hope and despair fluctuate with the changes (Lange, 1978). Throughout the data analysis of this study, i t became evident - 29 -that participants were experiencing fluctuating feelings of hope and despair. The concept of hope became v i s i b l e as often, and in as great an intensity, as the concept of loss. For this reason, both loss and hope were included as major a n a l y t i c a l concepts. Loss and hope are complex, in t e r r e l a t e d , universal human experiences (Figure 2). Hope i s a mixture of feelings and thoughts which center on the bel i e f that there are solutions to s i g n i f i c a n t human needs and problems (Lange, 1978). Hope is a way of dealing with the uncertainties of the present in anticipation of a more gr a t i f y i n g future, which includes s a t i s f a c t i o n of needs and achievements of goals. The purpose of hope i s to ward off despair. It i s essential to l i f e and growth, and as s i s t s in making l i f e under stress tolerable. During periods of loss, hope enables the ind i v i d u a l to tolerate a d i f f i c u l t s ituation and to maintain motivation. Lange (1978) describes the process of the maintenance of hope as a f f e c t i v e components and cognitive functions which occur in varying patterns as ways of maintaining psychological equilibrium. Affective components are the emotional elements of hope and include: f a i t h , trust, confidence in s e l f and others, and fo r t i t u d e . These components are shown in people's attitudes and behaviour as determination, motivation, i n s p i r a t i o n , and encouragement. - 30 -Figure 2, Interrelationship between loss and hope t Lange (1978) states that r e a l i t y i s perceived and processed through cognitive functions. To sustain hope, an individual must make certain sense out of his or her r e a l i t y . One strategy to uphold hope i s to scan the environment for clues that reassure one's b e l i e f s of hope (Lange, 1978). Hope i s developed from past experience. It i s influenced by x a multitude of factors such as the nature and severity of the loss, the personality of the i n d i v i d u a l , and the interplay between the loss and the personality. Hope i s a motivational force which maintains energy that i s necessary to recover from loss. Hope and loss last for d i f f e r e n t periods of time and w i l l replace each other or exist concurrently at times. Hope maintains and nourishes people - 31 -through d i f f i c u l t t i mes (Lange, 1978). I t has been s t a t e d t h a t the concepts of l o s s and hope were used as a framework f o r i n t e r p r e t a t i o n of the data i n t h i s s t u d y . Another concept which appeared i n each phase i s t h a t of r e h a b i l i t a t i o n . The concept of r e h a b i l i t a t i o n has become i n c r e a s i n g l y p o p u l a r i n the h e a l t h - r e l a t e d l i t e r a t u r e and the word r e h a b i l i t a t i o n has become a word of v i t a l usage. The word r e h a b i l i t a t e d e r i v e s from a L a t i n word meaning " t o r e s t o r e a g a i n " ; t h a t i s , to r e t u r n the i n d i v i d u a l to the s u i t a b l e c o n d i t i o n of a p r i o r time (Webster, 1977). The word connotes v a r i o u s meanings. But, a l l emphasize a r e g a i n i n g of what was l o s t . R e h a b i l i t a t i o n may i n v o l v e the r e t a i n i n g of a v a l u e d a b i l i t y , the c l e a r i n g away of broken or unnecessary components, or the e l i m i n a t i o n of those q u a l i t i e s t h a t d e t r a c t from beauty or f u n c t i o n . The g o a l of r e h a b i l i t a t i o n i s d i r e c t e d toward f u n c t i o n a l a b i l i t y composed of both p h y s i c a l and mental a c t i o n . F u n c t i o n a l a b i l i t y i s b e i n g a b l e to do what you have to do and what you want to do; f o r example, p e r s o n a l t a s k s , a c t i v i t i e s of d a i l y l i v i n g , p l e a s u r e , and work ( W e l l s , 1982). P o w e l l (1968) d e s c r i b e s r e h a b i l i t a t i o n as the p r o c e s s of r e s t o r a t i o n to normal l i f e i n the s h o r t e s t p o s s i b l e time. - 32 -For young adults with anterior cruciate ligament repair, r e h a b i l i t a t i o n means a return to his or her previous l e v e l of musculoskeletal functioning within the shortest possible time. Rehabilitation, loss, and hope are concepts which were present in the phases of the immobilization experience observed in this study. Young adults at home during the immobilization period following anterior cruciate , ligament repair expressed concerns regarding r e h a b i l i t a t i o n . These concerns are discussed in Chapter Four. Relationship of the Themes to Kleinman's  Conceptual Framework Kleinman (1978) describes the health care system as a c u l t u r a l system with symbolic meanings anchored in particular arrangements of s o c i a l i n s t i t u t i o n s and patterns of interpersonal interactions. This system integrates a l l of the health-related components of society, which enables the researcher to assess the experiences of those studied within the broader context of society. Within Kleinman's framework, the patient i s a member of the popular domain of the health care system and has certain b e l i e f s , expectations, and explanatory models. The popular or lay, non-professional domain i s the c u l t u r a l arena in - 33 -I, which i l l n e s s i s f i r s t defined and health care a c t i v i t i e s are i n i t i a t e d . The professional and folk sectors interact with the popular domain and become external factors which affect the health care system. Notions about an episode of sickness and i t s treatment are employed by a l l of those engaged in the c l i n i c a l process the patient, the family, friends, and folk and professional healers. Each group has one or more explanatory models which are used to make sense of a particular episode of i l l health and, added together, these explanatory models form a pluralism of meaning systems, that i s , a variety of interpretations of the experience. In this case, the patients' perceptions, feelings, and attitudes about loss, hope, and r e h a b i l i t a t i o n in r e l a t i o n to the phases of the immobilization experience a s s i s t in forming their explanatory models. The a n a l y t i c a l concepts of loss, hope, and r e h a b i l i t a t i o n are integrated into a sequential phase-like view of the experience and comprise the organizational schema of the study. In a commentary written on Kleinman's "Lessons from a C l i n i c a l Approach to Medical Anthropological Research," Stein (1977) states that Kleinman's major contribution i s his emphasis on process (time). This process may require - 34 -long-term observation rather than the e l i c i t a t i o n of s t a t i c , detached-from-lived-in- r e a l i t y or c l a s s i f i c a t o r y schemes of i l l n e s s . Examples of health-related processes are the i l l n e s s episode, healer-patient transaction, family dynamics, and follow-up care. The researcher in this study was interested in the process of experiencing immobilization following anterior cruciate ligament repair. Kleinman (1978) i s concerned with how people think about i l l n e s s and how they deal with i t . By using Kleinman's framework with the themes of loss, hope, and r e h a b i l i t a t i o n intermeshed into the phases of the experience, the researcher i s able to interpret the physiological, psychological, and socio - c u l t u r a l aspects of this particular vepisode of i l l health. The two dimensions of analysis, sequential and a n a l y t i c a l , complement and enrich one another and provide an opportunity to integrate concepts with phases of the experience. U t i l i z a t i o n of Kleinman's framework promotes analysis of the participant's subjective experiences of loss, hope, and r e h a b i l i t a t i o n within the broad so c i o - c u l t u r a l context. - 35 -Relationship of the Themes to the Phenomenological Approach The phenomenologist studies the phenomena of everyday l i f e in terms of the participant's explanations. To answer the question of how the world i s experienced, an emphasis i s placed on the inner or subjective understandings of behaviours, events, and surroundings (Davis, 1978). The phenomenologist assumes that there i s something in the nature of human experience, beyond sheer reason or sensory observation, which w i l l produce knowledge (Davis, 1978, p. 194). Descriptions are presented in order to c l a r i f y and deepen the understanding of the phenomenon under investigation. The conceptual themes of loss, hope, and r e h a b i l i t a t i o n were developed from the participants' descriptions. As stated e a r l i e r , the participants i d e n t i f i e d concerns which appeared to occur in a sequence of phases beginning with the injury and ending with short- and long-term future plans. The phasic experience as sequence and the themes of loss, hope, and r e h a b i l i t a t i o n as a n a l y t i c a l concepts encompassed the ways in which participants explained their experiences. U t i l i z a t i o n of the phenomenological approach, with the organizational schema of loss, hope, and r e h a b i l i t a t i o n occurring in phases of the experience, promotes understanding - 36 -of the subjective experiences of participants and presents their standpoint. Summary This chapter has presented an explanation of the process of data analysis. The conceptual themes of loss, hope, and \- r e h a b i l i t a t i o n were introduced in r e l a t i o n to the phases of the experience. The notion of an organizational schema i s comprised of the sequential presentation of the data according to phases of the experience and the conceptual analysis of the data with respect to " l o s s , " "hope," and " r e h a b i l i t a t i o n . " Explication of the themes with integration of the l i t e r a t u r e and the participants' accounts i s presented in Chapter Four. - 37 -CHAPTER FOUR Dimensions of the Immobilization Experience Introduction In this chapt er,- the research findings are presented through an integration of the participants' accounts, review of relevant l i t e r a t u r e , and the researcher's analysis. Data are analyzed according to two dimensions: (a) sequence, and (b) concepts. The results of sequential analysis set forth the perceptions and a c t i v i t i e s of participants in sequenced phases. As stated in Chapter Three, the sequence of phases begins with injury and ends with short- and long-term plans. The following six phases are interrelated and overlap with each other; (a) pre-injury, (b) recognition of injury, (c) contact with the health care system, (d) hospital experience, (e) home experience, and (f) future plans. Analytic concepts assisted the researcher to make sense of the meaning of the experience as i t appeared to participants. The concepts or themes of analysis which emerged from this study's data are: loss, hope, and r e h a b i l i t a t i o n . These concepts are universal phenomena and - 38 -appear with varying intensity in one or more of the phases of the experience. The concerns confronting young adults at home during the period of immobilization following anterior cruciate ligament repair are numerous and diverse. These concerns appear to represent, or to be related to, particular losses which occur in the l i v e s of participants. Furthermore, each loss i s interrelated with feelings of hope; that i s , feelings that the loss can be resolved to a certain extent and that the quality of l i f e ' w i l l improve. The patients' perceptions of the impact of these concerns upon the r e h a b i l i t a t i v e process are i l l u s t r a t e d by their perceptions of the impact of loss, and the inter n a l support and motivation for recovery which i s supplied by their hopes. Early r e h a b i l i t a t i o n i s emphasized and encouraged to begin at the moment of injury. Donahoo and Dimon (1977) state that i f one expects normal function to return in an injured area, r e h a b i l i t a t i o n involves guiding i t gently and progressively on i t s return to normality without delaying the healing process. Timing i s of utmost importance since immobilization for too long a period can result in i r r e v e r s i b l e changes in muscle, capsule, and soft tissues about a j o i n t , thereby, permanently l i m i t i n g motion in the future. Conversely, too early a mobilization undertaking can - 39 -result in inadequate healing of the capsule and tissues surrounding a j o i n t . The concept of r e h a b i l i t a t i o n i s applicable to, and addressed i n, most phases of the immobilization experience. An integrative approach i s used to present the findings. Passages from participants' accounts are included to show how these persons viewed their immobilization experience in their own words. Review of the l i t e r a t u r e substantiates the researcher's claims and lays a foundation for understanding the feelings, perceptions, questions, and worries of those under study. In summary, data analyses were carried out via an integrative two-dimensional approach: (a) data were sequentially analyzed according to phases from pre-injury to future plans, and (b) data were conceptually analyzed using the concepts of loss, hope, and r e h a b i l i t a t i o n which assisted the,researcher to make sense of the meaning of the experience as i t i s perceived by participants. Research findings are presented by an integration of participants' accounts, review of relevant l i t e r a t u r e , and the researcher's analysis. Phases of the Experience and Related Concepts Participants explained their experience as a series of acts and a c t i v i t i e s which evolved around the major event of injury to the anterior cruciate ligament in the knee. - 40 -4 The following sections discuss the six phases of the immobilization experience and the related concepts of loss, hope, and r e h a b i l i t a t i o n . Although these concepts appear throughout the phases of the experience, they vary in intensity in each phase. This discussion i s summarized and applied to the various functions of nursing in Chapter Five. Pre-Injury Prior to their i n j u r i e s , participants in this study were active in sports and immensely enjoyed these a c t i v i t i e s in their leisure time. For them, physical a c t i v i t y was highly valued. Evidence to support this claim was found in the transcripts of a few participants (P): P: I've always been very active, I swam a l o t , cycled a l o t . P: I played v o l l e y b a l l the odd time. I'd play fun b a l l , l i k e I said s o f t b a l l , that's about i t . I used to f i s h a l o t . If I ever got the chance. I don't hunt. P: Yeah, you know i t was one thing l i k e when I was in high school and through university I was a very good athlete, I participated a l o t , I played varsity basketball. P: Well I used to run a l o t . I used to do a lot of s t u f f . I can't remember, five miles which i s enough. Plus I'd go swimming twice, three times a week as well, and play squash a couple of times a week. Used to be in great shape. The above data reveal p a r t i c i p a t i o n in a variety of sports: swimming, cycling, v o l l e y b a l l , s o f t b a l l , basketball, - 41 -running and squash. Physical f i t n e s s prior to injury i s important to rehablitation. Garrick (1981) states that the athlete's r e h a b i l i t a t i o n may be expedited by his or her good physical shape at the time of injury, the athlete's zeal for active treatment and by the ready a v a i l a b i l i t y and u t i l i z a t i o n of appropriate medical care. Participants agreed that physical f i t n e s s prior to injury i s b e n e f i c i a l for recovery. P: But heaven help me i f I had been sedentary; I've been physically active for so long. So heaven help me i f I hadn't done that. And I carry things, I'm very strong, I'm f a i r l y strong, because I carry trays and things l i k e that. So, i f I had been in less good physical shape i t would have been even harder to become mobile again. Increasing technology and demands of daily l i f e are causing problems for many individuals in society. Eldridge (1983) states that with the growing numbers of health conscious participants in stress-reducing amateur and recreational a t h l e t i c s , there i s the need for health care professionals to understand the psycho-social dynamics accompanying i n j u r i e s in these sports. Engagement in physical exercise and sports has become a release from stress as evidenced in the following excerpt: P: Something where I could just run and l i k e you see, i f I were frustrated or had a bad day or what have you, basketball was separate. I could go - 42 -out and do r e a l l y r e a l l y well playing basketball. If I had a real s h i t t y day, but that made the difference, i f I did r e a l l y well in basketball, i t made me f e e l good about how the day went. That was important, I needed that. Sport i s a vent for anxiety and f r u s t r a t i o n . It i s also an opportunity to determine one's a b i l i t i e s , enhance sleep, and alternate a c t i v i t i e s . P: Sometimes I'd go running every morning. Sometimes I'd go at 3:00 in the morning or 3:00 at night, just for something to do. Just go far enough to exert yourself, fresh sleep, fresh break. The major lei s u r e a c t i v i t y for participants was sports. Some read for pleasure, but others had no additional outside in t e r e s t s . P: Well, I read a l o t . I'm not r e a l l y that type of person that has a lot of hobbies. If any kind of hobby that I have i s usually getting up and chopping firewood, that's about the only thing that I do, just use the power saw. I just try to keep as active as I can. P:. Well, I don't read' a lot but when I do read, I read a book every two days for a couple of weeks and so on—the same books that I read l a s t time. The major.focus of the pre-injury phase i s the emphasis that participants' put' on sports and their l e v e l of physical f i t n e s s . They made sense of their immobilization by examining this in l i g h t of their pre-injury experiences. Overall, the l i v e s of participants prior to injury were running rather smoothly. However, this smoothness began to roughen with the recognition of injury and i t s anticipated - 43. -consequences. Recognition of Injury This phase centers on the recognition of physiological injury. A c t i v i t i e s leading up to, and immediately following, the injury are included in this phase. For example, given the occurrence and recognition of a skiing injury, the phase included skiing, f a l l i n g , injuring the knee, transport to safety, feelings of loss and hope, and i n i t i a t i o n of r e h a b i l i t a t i o n . Description of the mechanism of injury enhances understanding of the recognition of injury. To begin with, the anterior cruciate ligament i s a central, s t a t i c s t a b i l i z e r of the knee (McCluskey & Blackburn, 1980). Blackburn and Craig (1980) describe the location of the anterior cruciate ligament in the l a t e r a l compartment of the knee and state that, although i t s function i s s t i l l unknown, i t i s apparently an important s t a b i l i z e r of the knee. Acting as a s t a b i l i z e r of the knee j o i n t , the anterior cruciate ligament allows adequate flexion and extension for knee movements. Injury i s frequent because of i t s exposed anatomical position and, due to the potential for permanent d i s a b i l i t y following injury, most sports participants anticipate this injury with great fear. - 44 -Tear of a ligament, commonly known as a sprain, occurs when the ligament i s stressed beyond i t s normal c a p a b i l i t i e s . C o l l e c t i v e l y , sprains are the most common in j u r i e s in sports and occur most frequently in hinged j o i n t s , such as the knee. Wassel (1981) states that, "The extent of damage depends upon the amount and duration of the, force" (p.55). Markham (1983) states that a s t r a i n or sprain of a ligament involves the rupture of a few of i t s f i b r e s , accompanied by hemorrhaging and inflammation. Complete ligamentous tears are associated with p a r t i a l or complete mechanical f a i l u r e of the associated j o i n t . Rupture of the anterior cruciate ligament may be produced by moderate to severe trauma, such as deceleration, while coming to a stop during running, forced rotation, or d i s l o c a t i o n . (Derscheid & Malone, 1980). The i n j u r i e s incurred by participants were the result of p a r t i c i p a t i o n in a variety of sports. Although some s i m i l a r i t i e s existed, the event was perceived somewhat d i f f e r e n t l y by each i n d i v i d u a l . Recognition of the injury occurred through the v i s u a l , auditory, and t a c t i l e senses. The sound of the injury was noted by one of the participants. The knee was injured by a sudden stop and twist which occurred during a f o o t b a l l game, rendering physical mobility impossible. - 45 -P: I injured i t back in August playing f o o t b a l l . It wasn't related to any contact that was made, i t was the simple fact that I hyperextended. I t r i e d to stop quickly and turned around to catch a b a l l that was behind me and I hy perextended i t and I twisted i t on the j o i n t . And that i s how I tore i t . P: I heard a rip and then a crunch. Everyone thought I was faking i t because they wanted a new down, because we were going for a touchdown. They thought, oh yeah, get up, get up, come on, we'll-give you another down! Well, I didn't get up. One participant, who was injured while skiing alone heard a loud cracking sound emanate from the knee. This was followed by a burning sensation. To this person, these symptoms indicated an injury, and the ind i v i d u a l immediately * began the process of r e h a b i l i t a t i o n by slowly and car e f u l l y making her way to safety and help. Researcher(R): T e l l me about how you injured your knee? P: Mine was a sports injury. It was a ski injury. Actually i t i s a f a i r l y common ski injury. I had caught my heel, as the heel was stationary and I had a forward twisting f a l l , I f e l l to the l e f t , so that's why I hurt i t , my l e f t knee. The respondant went on to say: P: Yeah, i t was a forward twisting on a stationary heel. So I heard i t as opposed to feeling i t . There was no large swelling and di s f i g u r a t i o n and I didn't lose a lot of movement, but okay, at the time i t hurt. It made a loud cracking sound. Almost to my mind i t echoed over the h i l l s . It was r e a l l y loud and I could f e e l a sl i g h t burning sensation in the knee and I knew I had done something nasty. I ended up skiing down because I was alone at the time and there wasn't anybody out with me. So I did end up very - 46 -c a r e f u l l y skiing down, very slowly, and very c a r e f u l l y down to the chalet and then I think I rode the chair or the gondola, no, i t was the gondola down to the base. So i t was during an a t h l e t i c event that i t happened. Immediate i n i t i a t i o n of r e h a b i l i t a t i o n in the above example exemplifies concern with the consequences of injury. Derscheid (1981) states that r e h a b i l i t a t i o n i s begun as soon as possible as i t can make the difference between being able or not being able to return to sports. Generally, sports i n j u r i e s . may be caused by physical contact between participants, are frequently related to training regimens, and may be iatrogenic (Markham, 1983). One participant who had recently returned to vigorous physical a c t i v i t y injured his knee while playing soccer. He was not certain of the extent of the injury or of i t s implications, and following loss of mobility, made the decision to seek professional assistance. P: It a l l started about three weeks ago I guess. I was just out kicking a b a l l around in a fun soccer game and one l i t t l e turn I guess, and that was i t . Hurt my knee r e a l l y bad. I never hurt myself before so I had no idea what was wrong. I thought I had broken my leg or something l i k e that. I got up after a while, and got to the sid e l i n e s , and then after about ten minutes on the sid e l i n e s , i t just didn't bother me at a l l anymore. I thought I must have just twisted i t and away I went. I went back and played for another half hour. That night I couldn't walk. The next morning I was straight into the hospital and they X-rayed i t , and couldn't find anything wrong and I went to my doctor, and he said to rest i t . I rested i t and then I went back out. - 47 -According to Ekstrand and G i l l q u i s t (1983), this i s a t y p i c a l case. Soccer i s the most popular sport in the world with more than 22 m i l l i o n players: with increased p a r t i c i p a t i o n , the number of i n j u r i e s and interest in these i n j u r i e s has increased. The recognition of injury varies with the sport, as does the immediate treatment of injury. Sports injury i s the result of a cumulation of variables — experience, s k i l l , s t y l e , personality t r a i t s , playing surface, equipment, warm-up and cool-down exercises, muscle strength, and physical and mental states (Ekstrand and G i l l q u i s t , 1983). Fast starts and stops are the cause of most i n j u r i e s to the anterior cruciate ligament. A basketball injury was the cause of one participant's problems, a baseball injury for another, and a rugby injury for a t h i r d . P: The i n i t i a l injury was playing basketball. I was probably pushing off, l i k e I was running as I pushed off with this foot. Just as I caught the b a l l , this foot was pushing off and i t just went....I can remember just a snap, a searing pain in the back of my head, and I just f e l l down and banged my knee and from there they just whistled me on to a truck and took me to emergency. P: My injury was a two-part thing. The f i r s t part I did l a s t year when I was cross — country skiing, and then the rest of i t sort of came about this summer during a baseball game. I was just playing a fun game and went around one of the bases. That's when i t happened. I didn't f a l l down or anything, but when I went around, I f e l t something in my knee go, and then after that i t swelled, and I couldn't walk for about a week. The s i l l y thing about i t was I also had a tournament - 48 -the next week. P: It was just a rugby accident that happened quite early on in the game. I think what happened was, that I was going to tackle someone, and I was just taken. Certain feelings surrounded the event and were experienced by most participants. Feelings of pain, shock, uncertainty, and depression are evident in the following passages: P: I was just in a state of shock, I couldn't fe e l anything. P: I was pretty sure I needed surgery. P: It i s just that I'm not much of a hospital person. I don't imagine anybody i s , and to have to go three or four days was j u s t . . . . P: Yeah, a great big shock. More of a shock in a way too, because I pretty well knew the seriousness of the injury. I knew that i t had, to be pretty serious because I injured c a r t i l a g e in my other knee, so I knew what had happened and I knew that i t meant a h e l l of a long recovery time. It is just a pretty depressing sort of situation you have to face. Participants experienced feelings of loss when they recognized injury. With these feelings were feelings of hope _ that the situation was not devastating and that l i f e would improve. P: I didn'.t know what to do...got up and played again. Thought i t was just a sprain and would be okay. Hope i s real and refers to becoming involved in a process. Hope exists where temptation to despair also exists - 49 -and offers the chance to review good p o s s i b i l i t i e s as well as bad (Werner-Beland, 1980). Marcel (1962) indicates two elements in the concept of hope: wish and b e l i e f . If the wish does not coincide with the b e l i e f , the patient may not comply with the given advice. Premature reentry into sports may occur and end with another injury. The patient must be w i l l i n g and able to change b e l i e f s , and evidence must be given to unlock self-destructive b e l i e f s . The following examples i l l u s t r a t e the strength of b e l i e f s and f u l f i l l m e n t of wishes: P: I played in the baseball tournament anyways. I got, l i k e I couldn't walk. It got to the point, I didn't know what i t was, so I just kept trying to walk anyways and then by Friday, Saturday i t was okay and Sunday i t was okay too. Then I went and saw a doctor after that. P: Well maybe this i s n ' t completely as bad as, maybe i t i s not a r e a l l y bad whatever i t was. P: I've had two arthroscopic operations done on the knee. I went through a whole summer with physiotherapy just putting the leg back into shape... because I did want to get back and play basketball. I figured that i t was a l l looked after, there was nothing else to worry about. I bought a ...brace. I would tape i t up...so that I could hardly move my knee. I knew that I had support and away I'd go and play. But every now and then i t would wrench...so I think over the time I worked that other c a r t i l a g e . . . free, and just as I was in September playing f o o t b a l l . . . . Some participants hoped for new technological advance. For others, their only hope was a good knee. P: I just read in the paper where they... developed a new machine that apparently - 50 -greatly reduces the comeback time from knee i n j u r i e s . P: I am just worried about having a good knee. An example follows which points out loss, hope and r e h a b i l i t a t i o n . The participant i s describing a previous injury which resulted in minimal loss of f l e x i b i l i t y following intensive r e h a b i l i t a t i o n . The participant goes on to say how he hoped at the time of his current injury that similar r e h a b i l i t a t i o n would solve the problem. P: Medial ligament. I had i t before. In that time I did experience swelling and r e a l l y a large loss of movement, and I couldn't flex very well and I saw a physio-therapist who did massage therapy on i t and that seemed to help and I sort of regained most of the strength. It wasn't too bad. This was, afterwards i t was painful, but I didn't have a lot of swelling. It was painful through the joi n t and I lost a l i t t l e f l e x i b i l i t y . Participants told varying stories of the events which occurred following injury. From their accounts, the next phase appeared to include the events leading to hos p i t a l i z a t i o n and was categorized as the participants' contact with the health care system. One participant perceived his injury as "just a sprain" and contacted a physician with his own notion of treatment. P: Well, l i k e I say, I thought i t was just a sprain, so I went to a doctor. After I got down here and talked with him about i t , I wanted him just to look at i t and t e l l me what I should do; how I should rebuild i t . And he kind of — he came back and told me that I needed an operation. - 51 -Contact with the health care system requires decision-making regarding who, where, and when to implement action. The following section w i l l discuss these decision-making processes with respect to the participants' immobilization experience. Contact With the Health Care System This phase i s comprised of the participants' decision to seek health care following injury, contact with the health care system, and decision to follow the advice and treatment suggested by health care professionals. The decision to seek health care following injury depended upon pain, i n a b i l i t y to mobilize, i n a b i l i t y to participate in sports a c t i v i t i e s , current l i f e s i t u a t i o n , persuasion from friends and family, and fear of reinjury. P: Hurt my knee r e a l l y bad...after about ten minutes on the sidelines i t just didn't bother me at a l l anymore...I went back and played. That night I couldn't walk. The next morning I was straight to the hospital. P: They just whistled me on to a truck and took me to emergency. P: Well unfortunately I was in the middle of moving and having quite a b i t to do. I had just accepted my new job here in the c i t y and so I was in the middle of moving. So that's why I didn't seek medical help right away because I was s t i l l mobile and because i t wasn't outrageously bad. Loss of mobility i s the key factor in determining whether or not to seek health care. If mobility i s present, - 52 -action i s less l i k e l y . Prior to contact with the health care system, one participant reviewed l i t e r a t u r e about his problem and two others attempted to relieve the problem with a brace. Knowledge and alternative treatment are methods of lessening loss of mobility and increasing independence. P: I even read up on some books. I got hold of a doctor friend and had one of his books on how to diagnose. Almost a self-diagnosis on my knee. I learnt- a l l about i t myself. P: That was the hardest thing to accept and I think that's why I kept pushing myself with the braces, with the tape, saying that i t w i l l go away...And i t never r e a l l y did go away. P: Brace was a bit awkward and I saw other people on the f i e l d with them on and I talked to them and they said they were great and they wouldn't go on the f i e l d without i t . I was very determined to keep mine in the right position. One participant perceived the situation as "different than others" because immediate health care was not sought. P: Like I think i t i s a l i t t l e d i f f e r e n t in my case than in some others because i t wasn't l i k e I had the surgery as soon as i t happened. Because that would be d i f f e r e n t , you're not r e a l l y thinking about i t , something breaks, you f i x i t . It i s not l i k e , i t might not break and then trying to decide whether you can get by with just wrapping i t up. This person l i v e d with the problem for several months before deciding to undergo surgery. Loss of mobility constantly nagged the person and losses began to increase in number such as loss of a b i l i t y to play tennis and squash. In - 53 -a discussion of the o r e t i c a l concepts of grieving, Werner-Beland (1980) assumes that any i l l n e s s produces some degree of personal disequilibrium, and response takes on greater significance with those who l i v e with i l l n e s s continually; loss of one's own functioning i s always present. Loss of mobility i s a constant reminder of the tenuousness of perfect health. In this case, constant external and internal recognition of a problem prompted seeking health care. .When asked who they contacted following injury, participants answered one of three resources: general practitioner, emergency room physician, or a friend working as a secretary i n an acute care ho s p i t a l . P: I saw my family doctor and she sent me to this other doctor, a s p e c i a l i s t . P: As soon as I moved down here I saw a doctor and he recommended me to an orthopedic surgeon. P: A friend took me to emergency. The preceding data displays the next step in the process of usage of the health care system. Individuals with sports i n j u r i e s usually enter the system via their general practitioner and he or she in turn refers the victim to an orthopedic s p e c i a l i s t . For those who enter by way of an emergency department, orthopedic s p e c i a l i s t s are usually summoned by the emergency room physician. - 54 -For one participant, the q u a l i f i c a t i o n s and specialty of the admitting physician were a mystery. P: While I was there, I was seen by the admitting doctor, I suppose, and then after that the orthopedic, I guess intern came around and I made a request for Dr. . So he happened l u c k i l y to be in the hospital on that day. You know, not on c a l l , but just walking through. So they got him over, and he said he would do i t the following Monday. So that's what I did. It i s important to note that lay persons attach meaning to the competence of health care professionals. The previous and following passages make this clear. P: Yeah, so when we f i r s t arrived, my friend was checking to see who the orthopedic surgeon was on c a l l , because she wanted to double check who was around at the time. So that's what we did. I n i t i a l l y , then, we were sort of asking what the story was. Taking down the i n i t i a l d e t a i l s of the accident and s i t t i n g in the waiting room then coming back a l i t t l e l a t e r to get some more d e t a i l s . Three participants v i s i t e d more than one general practitioner or one surgeon prior to a correct diagnosis. One individual was diagnosed as having a sprain and underwent withdrawl of f l u i d from the knee and cast application three consecutive times before a f i n a l diagnosis. As this person explained: P: I was admitted to emergency. They did a test, they diagnosed me as a possible sprain, so i they put on a soft cast and sent me home. It got very painful that night, so I had to go back and see a doctor. He drained i t and diagnosed i t as a sprain. So he threw a cast on i t . . . t h a t night i t f i l l e d up with f l u i d again. Two days later I went - 55 -back and he did the same thing. He drained i t and s t i l l thought i t was a sprain -- put a cast on i t again. Another participant was instructed to return home and rest the knee. P: He said to rest i t so I went and I rested i t . One participant v i s i t e d a s p e c i a l i s t who was unable to perform the necessary surgery. P: I saw a s p e c i a l i s t and he couldn't do the operation, he just thought i t was a c a r t i l a g e . This patient i n s i s t e d on a r e f e r r a l to another s p e c i a l i s t who consented to perform the surgery as a "favour" (as perceived by the patient) to the general p r a c t i t i o n e r . P: Yeah I saw my family doctor, she had sent me to this other doctor, but he was a jerk. I just didn't f e e l confident enough so she set me up an appointment with him, I missed my appointment and i t was going to be another three or four weeks before I could see him. And I said, well forget i t , I can't wait that long. So she made another appointment and I saw this other s p e c i a l i s t and that's when he informed me i t was cartilage but that he didn't do that type of operation. And she talked to Dr. and he did i t more or less as a special favour to her because otherwise I wouldn't have been able to see him u n t i l sometime in February and by then i t would have been way too long. Trust and confidence are factors which influence the participants' decision regarding a competent surgeon. Time i s a factor which patients are forced to deal with and which raises questions regarding preventive r e h a b i l i t a t i o n . The - 56 -next passages i l l u s t r a t e varying length of time from injury to contact. P: The fellow in emergency was moving me a l l around, twisting i t . It was probably about two or three weeks after the injury I was able to come down and have the cartilage removed. P: Two months before I got to go to the c l i n i c . So in the interim i t ended up doing more damage, because I played a l l the time. P: I think I was in emergency about six days > straight before they f i n a l l y put me in hospital for two days. They put a cast on i t for two weeks, took i t off, figured i t was s t i l l a sprain, and started me on therapy to try to rebuild i t . And that's when I came out here and got i t checked. They diagnosed i t as a torn ligament. On the other hand, someone assessed in the emergency room received immediate attention, yet was not certain from whom this attention emanated. P: I didn't r e a l l y have to wait very long. R: Who asked you questions? P: Well, I suppose she's a nurse. The g i r l that was operating the computer, the f i l i n g . . . . D e f i n i t e l y a nurse. She said we would get the doctor to see me as soon as possible. It f e l t a l i t t l e b i t weak during that time. I didn't f e e l that bad u n t i l I got in there and then I wanted a glass of water... star ted to have a l i t t l e bit of pain. But that passed.... I was feeling a b i t weak, they decided to get a wheelchair. It appears that i n i t i a l contact with the health care system can be a confusing experience for young adults with anterior cruciate ligament repair. Loss and hope are of paramount significance in this phase. Loss of control leads - 57 -to feelings of powerlessness which, as defined by Johnson (1967), i s a perceived lack of personal, or int e r n a l control of certain events or in certain situations. Seeman (1959) defined powerlessness as the expectency or the probability held by the individual that his own behaviour cannot determine the outcomes or reinforcements he seeks. Contact with the health care system reinforces this b e l i e f ; i t i s either perplexing or not s a t i s f a c t o r y . An example from one participant's account substantiates this claim: P: I just didn't f e e l confident enough so she set me up an appointment..., i t was going to be another three or four weeks before I could see him. And I said, well forget i t , I can't wait that long . . . . Knowledge i s viewed as a means of increasing control over the s i t u a t i o n . Johnson (1967) speaks of powerlessness as perceived external control of events in the learning variable, expectancy. Operating as such, powerlessness influences learning either in the sense of acquisition of knowledge or of developing e f f e c t i v e , goal-directed behaviour. P: Knowing what goes on with your knee, or why i t did what i t did, should be important, because i t could be used as preventative means i f anything else happens. Factors which influenced the decision to seek health care and undergo surgery related to pain, immobility, and the proposed outcome of surgery. The following accounts were - 58 -given: P: It was r e a l l y p a i n f u l . I missed a l o t of work because I couldn't walk for days at a time, and i t would be so easy to hurt i t again, a l l you had to do was to turn the wrong way. P: Well i f i t was going to prevent the knee from slipping out a l l the time, then I wanted i t done. Because I would be walking and everytime I'd take a step with this leg, there was that b i t of uncertainty. I realized i t was time to get i t done. Once you make up your mind to get i t done i t ' s not so bad. I wanted to get back and play basketball. P: I can t e l l the difference between a strong knee and weak knee and I just didn't want to continue on..... He...said I had an 80% chance of complete success which...is f a i r l y high. I think I can work on i t . I am f a i r l y active. I could commit myself to physio.... I think I can get i t back within a f a i r l y good range of motion. But his diagnosis was good and I appreciated him giving me the option of surgery. Participants, in deciding to undergo surgery, possessed hope. Hope i s central to important needs and r e f l e c t s wishes that might come true — wishes for return to previous musculoskeletal functioning. Hope includes confidence, f a i t h , i n s p i r a t i o n , and determination (Lange, 1978). Participants had a goal, determination, a certain amount of confidence, and interest and involvement in physical health. P: That was my primary concern of having the operation. Not the fact that I'm going to be out of sports and I can't play as hard as I used to...you look to the future, I don't want to have to put up with a swollen joint and a painful j o i n t although there's probably a l o t in medicine today that can a l l e v i a t e that. P: I've psyched myself up for i t . I've just - 59 -become decisive about i t . There's nothing I can do about i t . This i s the only way i t i s going to be healed, so I have to accept that and continue on the best way that I can. P: I want to get out and do things. And that's just because my l i f e s t y l e i s usually l i k e that. P: I don't foresee too much trouble getting back to the same l e v e l of mobility. Doctor said I had an 80% chance, which I think i s high. And with a decent amount of work, I think I can get back to the same amount of mobility. P: I want i t to be healed just as soon as i t can be. I don't want anything to go wrong. With hope for improved musculoskeletal functioning, participants underwent anterior cruciate ligament repair. Their experiences during h o s p i t a l i z a t i o n were varied and informative. Hospitalization Experience The hospital experience phase begins with hospital admission and ends with discharge home. Events and meanings of prior and subsequent phases af f e c t , and are affected by, the hospital experience: phases intermesh and are inter r e l a t e d with each other. In no other phase i s the nurse's direct impact upon patients as s i g n i f i c a n t as i t i s during the hospital experience. Participants verbalized a sense of powerlessness and loss of control while simultaneously addressing their short- and long-term plans. Nurses influence these feelings by verbal and non-verbal - 60 -communication with patients; generally they were viewed as a source of power and control. The i d e n t i f i e d concerns, which relate to the hospital experience, are divided into four subsections: (a) Pre-operative concerns, (b) Post-operative concerns, and (c) Physiology, surgery and the participants' experience, and (d) Interaction with nursing s t a f f . Pre-operative concerns Admission to hospital created feelings of fear, anxiety, and powerlessness. One participant experienced a three-hour wait before contact with a nurse, and used this time to worry and ponder the si t u a t i o n . P: The waiting doesn't do a l o t for you. It says admitting time from 12:30 to 2:00 so I figure I am going to go in at five minutes to 2:00 because I got a whole day to lay around...in at 12:30 and I wasn't admitted u n t i l 3:30 by a nurse. P: ...minute you're stuck there a l l you can do is just wonder what's going to happen to you. Szasz (1961) states that people do not do well in situations lacking in norms. People need familiar human objects, norms, and rules. Without familiar norms, rules, and object relationships, anxiety increases and t y p i c a l responses are apt to follow. The hospital experience involves removal of familiar human and inanimate objects; patients are unfamiliar with hospital norms; and anxiety may develop. Others were concerned about the success of surgery, - 61 -v a l i d i t y of others' claims, intensity of pain, perceived lack of pre-diagnostic surgery, extent of injury, and actual surgical intervention. They explained as follows: P: I went in hearing a l o t of diff e r e n t things from other people. Not knowing what kind of pain was the biggest thing. I didn't know what the intensity would be. I can handle pain, just so long as I know how much i t i s going to be. P: Well he never did an arthroscopy on my knee. And that i s the only way you can r e a l l y t e l l what i s wrong with i t . I kept t e l l i n g him, i t can't be serious. So when I went under the knife I wasn't sure what was wrong with i t . I was hoping that maybe i t was just a cartilage that had folded over. So when I woke up, I s t i l l wasn't sure what was wrong u n t i l he came in and told me. Once surgery i s carried out concerns are focused on immediate worries such as physical pain and a l l e v i a t i o n of this pain. The following section describes the participants' post-operative concerns. Post-operative concerns Length of hospital stay for young adults with anterior' cruciate ligament repair varied from four to eight days. The post-operative concerns confronting those studied were numerous and affected physiological, psychological, and so c i a l aspects of the participants. Pain was of paramount concern to a l l participants. Immediate post-operative pain was described as: P: I remember myself trying to get off the table, i t was so pai n f u l . - 62 -P: There was a l o t of pain. P: I didn't know what I expected. The f i r s t time I experienced pain was when they woke me up in the recovery room. Complaints of severe muscle contractions or spasms in the knee were reported by a l l participants and appeared to occur prior to relaxation. This was experienced as pain. -P: They hurt. Spasms I mean, they don't t i c k l e . P: It i s hard to explain what i t feels l i k e . It's l i k e an e l e c t r i c a l shock that starts down at the bottom of your thigh and i t just shoots i t s way up to the knee and then when i t hit s the knee everything tightens up. I find that i t only happens when you're r e a l l y relaxed. Reassurance from nurses a l l e v i a t e d fear of damage resulting from muscle spasms. P: She reassured me of the fact that i t was just a muscle spasm.... She said that was very common in an operation l i k e t h i s . So I f e l t better after that. She reassured me more than having the doctor come 'round and say that. P: I thought I damaged i t . . . . She came in and reassured me that i t was a very common thing to have muscle spasms and I didn't do any damage. Twedt [1975] states that a l l orthopedic patients have two problems in common: [1] pain, and [2] fear of pain. The muscles of the knee and the join t i t s e l f are supplied by the femoral nerve on the front of the thigh which supplies the - 63 -quadriceps, and the s c i a t i c nerve with i t s main divisions on the posterior surface which supplies the hamstrings and the gastrocnemius. Manipulation of these nerves and their associations causes extreme pain [Donahoo & Dimon, 1977] and together with post-operative swelling i s responsible for the intense pain f e l t by participants. Intramuscular injections of meperidine hydrochloride were given the f i r s t 1 to 3 post-operative days, followed by oral acetaminophen with codeine phosphate. Participants reported varying degrees of effectiveness of these analgesics. P: The demerol i s f a n t a s t i c . It helped the pain. P: I needed more demerol. It wasn't strong enough. P: I liked the tylenol with codeine. It was good. It kept me ahead of the pain. One participant abhorred injections and consented only after deciding the amount of pain from treatment would be less than the pain from surgery. P: When I was on demerol, I got uncomfortable and had to admit to myself that I had to c a l l a nurse. Those needles are h o r r i b l e . I s t i l l have the - 64 ,-bruises on my hip but one pain outweighs the other and discomfort in your leg outweighs the needle at the time. Analgesics are fast acting; however, they are eff e c t i v e for only a short period of time. Complications can arise from analgesic i n j e c t i o n , such as disorientation and loss of memory. P: The problem with the drugs i s you lose a l l respect of r e a l i t y or time.... There are a couple of days that are just complete washouts, just can't remember them. P: The demerol would l a s t for an hour and I could only have i t every three hours. This same individual rationalized his behaviour by comparing present pain to past experience. P: I've played sports a l l my l i f e and I've been in a l o t of pain. I've strained ligaments before. It wasn't this bad. Anesthetic into the femoral nerve blocked post-operative pain and enabled the following patient to s i t up in bed and talk with v i s i t o r s two hours following surgery. P: When I went into the operation, they put the tourniquet on my leg and applied the block. I guess femoral block i s what they c a l l i t . And when I came out, I was in recovery and there was a throb; that's a l l i t was. I did not hurt a b i t . And I had v i s i t o r s within two - 65 -hours after the operation. So i t didn't bother me. I could s i t up in bed and I could talk. Drugs used in nerve blocks produce i n s e n s i t i v i t y to pain without loss of consciousness. Falconer et al [1978] state that "Nerve block anesthesia i s secured by placing the drug around the main nerve supplying the area of operation. This w i l l block the conduction of the impulses to the brain and i s sometimes called "conduction anesthesia'" [p. 204]. Removal of the davol drain was reported as producing excruciating pain. Preparation for removal involves administration of analgesic and verbal reassurance by the nurse. Three participants explained: P: I think probably the most painful part was when they pulled the drains. I think that was the most painful part of the whole thing. P: Oh that's a whole unique pain in i t s e l f . And they warn you. You can't do anything, you can't psyche yourself up for i t . The nurse gives you a _shot of demerol and then comes back half, an hour l a t e r . Okay, we're going to take your drain out. Then she whips i t out. P: You r e a l l y can't prepare yourself for i t . It's out in a second, but you f e e l i t coming a l l the way out. I didn't look. A l l I did was close my eyes • and I had a feeling she wrapped i t around her hand and just yanked i t straight out. - 66 -Participants offered limited knowledge of the purpose and position of the davol drain; in fact, one participant was surprised by the presence of a drain. P: They never t e l l you they are going to stic k a drain in your knee. You find out after they've put i t in and they are t e l l i n g you they are going to take i t out. P: It was underneath the cast. It comes out your knee and straight down the inside of the cast. P: I'm thinking that maybe i t ' s just s i t t i n g on the skin by the i n c i s i o n . A l l I know i s here i s this bottle beside me getting f i l l e d up with blood. I don't know where i t ' s going. I'm not looking.... And maybe there's some complications or something, but I don't r e a l l y want to know about i t . I don't know, i t could be stuck in the middle of my back for a l l I know. P: The drain was put in through the bottom of the cast, and came up through here, and two i n c i s i o n s , and they had a l i t t l e drainage cannister down here. Extreme pain diminished to general discomfort after the f i r s t 2 or 3 post-operative days. P: And then after that [removal of drain on second post-operative day] i t was just sort of a d u l l , nagging pain. P: It's okay the f i r s t couple of days because you're so drugged you don't notice i t . But then...off the drugs i t ' s almost . impossible to get i t in a comfortable position. - 6 7 -Nurses play a s i g n i f i c a n t role in the prevention and r e l i e f of pain. Careful assessment i s the basis for judging degree of anxiety and suffering, and the nurse i s available to implement any comfort measure that w i l l a l l e v i a t e the pain. Evaluation of intervention i s ongoing; analgesics may be i n e f f e c t i v e or too strong for a particular patient [Twedt, 1975]. As Twedt [1975] states: Orthopedic patients usually have an increased anxiety l e v e l due to the threat of the orthopedic disorder, the presence of pain, and the anticipation of pain of yet unknown in t e n s i t y . The tension resulting from fear often increases the degree of pain. The nurse should l e t the patient know immediately by her manner and her assurances that her care w i l l be gentle and that she w i l l not allow him to suffer unnecessarily. And i f the patient can be warned beforehand that some treatments are accompanied by unavoidable pain, such as in the fracture reduction, h e ' l l probably be less apprehensive. Pain involves the whole person, and pain that continues for some time reduces the capacity of the person to tolerate more. Prompt administrations of analgesic drugs give the patient a secure feeling that his pain can be controlled. Distractions that take the patient's mind off his pain offer periods of welcome r e l i e f . Such diversions as music, reading, or crafts can sometimes provide comfortable interludes, but the orthopedic patient must be protected from overstimulation (p. 40) Lack of knowledge regarding surgical intervention and related anatomy and physiology was - 68 -a concern for a l l participants. P: A l l I know i s , that ba s i c a l l y i t was a bone graft. So they took a ligament from a knee cap and bits of bone. I assumed that they d r i l l e d holes in the shin bones and...took those bone tips and put them in those holes, hoping that the bones would graft holding that ligament in place. Because that's where my i n c i s i o n s l i e . P: They t e l l you, supposedly, what happens. You r e a l l y don't have a clue as to what your knee looks l i k e . I think i t would be much better i f you knew that. P: Well, I don't know where he got that tendon from, I mean some people say i t comes out of the hamstring.... P: When you get into the hospital and someone says to you, do you have any questions to ask? You have nothing in your head at that time. U n t i l they walk away. P: I would have like d to have seen a model of a knee.... I s t i l l don't know exactly what he did.... I think he pulled out a tendon somewhere and tied i t i n . The above accounts exposed varying perceptions of the surgical procedure. Tendon replacement, ligament replacement, and bone graft are three explanations of the technique used in anterior cruciate ligament repair, l i t e r a t u r e , regarding physiology, and surgical one's understanding A succinct review of the pertinent anatomy, intervention, w i l l enhance of the participants' - 69 -physiological experience. Physiology, Surgery and the Participants' Experiences The anterior cruciate ligament i s a strong ligament which serves to hold the femur in correct r e l a t i o n to the plateau of the t i b i a (Donahoo & Dimon, 1977). Tears of this ligament result from: (a) hyperextension, (b) hyperextension and int e r n a l rotation of the leg with external rotation of the body, (c) external rotation valgus cutting action, (d) deceleration, (e) a force which drives the t i b i a in an anterior direction when the knee i s flexed at a 90 degree angle, and (f) conjunction with medial or l a t e r a l c o l l a t e r a l leg i n j u r i e s (Roy & I r v i n , 1983). If the ligament i s torn in i t s midportion, the success rate following surgery i s very low. If a piece of bone i s avulsed with the ligament (which rarely occurs) and can be replaced, the chances of f u l l recovery are much increased (Roy & I r v i n , 1983)., Dersheid and Malone (1980) state that surgical repair of mild or moderate tears i s arguable. Treatment may include early motion with s p l i n t i n g when not exercising to immobilization of up to six weeks (Derscheid & Malone, 1980). Wassel states that, "Physicians who choose a closed treatment immobilize the knee in i t s anatomical and functional position u n t i l scarring begins and f a c i l i t a t e motion as scarring continues" (Wassel, 1981, p. 55). The - 70 -benefits of surgery are not t o t a l l y known, and in some cases the ligament heals without surgical intervention. Hughston states that, "Reconstruction surgery in acute cases appears to be too much unnecessary surgery" (Hughston, 1980, p. 1612). His results indicate a f a i l u r e rate in acute medial ligament repair of 5%, and in acute posterior cruciate ligament repair of 2%. New and experimental procedures aimed at finding satisfactory treatment and r e h a b i l i t a t i o n for acute anterior cruciate tears are ongoing (Roy & Ir v i n , 1983). A combination of i n t r a - and extra-a r t i c u l a r procedure, transfer of a portion of the pat e l l a r , semitendinous, or g r a c i l i s tendon through the knee; or use of a r t i f i c i a l ligaments are alternative treatments for repair (Roy & I r v i n , 1983). Hughston states that, "Use of a r t i f i c i a l ligaments i s s t i l l in the experimental stage" (Hughston, 1980, p. 1612). To date, an a r t i f i c i a l ligament suitable for use in reconstructive anterior cruciate ligament surgery in the human knee has not been developed. It i s evident from the l i t e r a t u r e that participants were experiencing major surgery which remains controversial. Success rate varies — participants should be well informed prior to consent. Hospitalization during surgical repair posed many - 71 -problems for participants. Sleep, n u t r i t i o n , elimination, and hygiene patterns were disrupted resulting in f r u s t r a t i o n and feelings of powerlessness. Dizziness was another concern concern to one ind i v i d u a l as evidenced by the following statement: • P: I had two sleeping p i l l s and two p a i n k i l l e r s . I couldn't go to sleep i f my l i f e depended on i t . A display of concerns follows: t P: It was just the l i t t l e tiny aggravating things, l i k e my arms going to sleep when I wanted to go to sleep myself. The la s t night I didn't get any sleep, because a l l I was thinking about was getting out and going home. P: Just the real simple things...I'm not a person who sleeps on my back, so a l l of a sudden I am on my back. My elbows, hands would go numb.... P: I didn't eat in 3 days. That's a long time, and considering they pumped so much f l u i d in me, and you r e a l l y can't get r i d of i t , because you don't f e e l comfortable going in the ur i n a l s . P: If I f e l t a l i t t l e cleaner I would have f e l t better. P: I would have liked to have washed my head a couple of times while I was there. P: I didn't l i k e to c a l l the nurse, but how am I supposed to bathe on my own. P^When I stood up to walk around on crutches my head would have a l o t of motion, disorientation, I was dizzy. Much of the success of orthopedic surgery depends on the i d e n t i f i e d by the participants. Sleep was of paramount - 72 -knowledge and s k i l l of the nurses who"provide post-operative care (Twedt, 1975). The concerns i d e n t i f i e d above focus upon satisying basic human needs, such as, sleep, hunger, and elimination. Sleep was disrupted by discomfort and change of regular sleeping position. Loss of appetite, d i f f i c u l t y voiding, and lack of personal hygiene were i d e n t i f i e d concerns. Several participants did not wash their hair during h o s p i t a l i z a t i o n . Patients were hesitant to ask nurses for help with personal hygiene, yet valued the benefits of cleanliness. Sa t i s f a c t i o n of hunger and sleep, and attention to hygiene were concerns which existed throughout the hospital experience. Post-operatively, another major concern was immobilization due to casting of the affected limb. Complications result from immobility and although increasing a c t i v i t y appears to be the easiest solution, i t i s not always possible in the immediate post-operative period. Complications a r i s i n g from prolonged confinement to bed may include: pneumonia, pulmonary emboli, thrombophlebitis, muscular atrophy, weakness, and decubitus ulcers (Hogberg, 1975). Hogberg (1975) goes on to say that the nurse should maintain the patient's rest while introducing nursing measures to counteract i t s undesirable e f f e c t s . Encouragement of deep breathing and coughing exercises, - 73 -frequent position change, and bed exercises p a r t i c u l a r l y for the lower limbs are nursing interventions which prevent undesirable complications (Hogberg, 1975). Tears of the anterior cruciate ligament are immobilized for up to 6 weeks, despite surgical intervention (Malone, Blackburn, & Wallace, 1980). If closed treatment i s implemented, the limb i s immobilized in a s p l i n t and exercises are limited. In the case of open treatment or surgical repair, a f u l l length leg cast, that i s from toes to upper thigh, i s worn. The extent of immobilization i s greater than that which accompanies most other i n j u r i e s , and positions the individual with unique d i f f i c u l t i e s , such as l i v i n g with the weight of a f u l l length leg cast. Some surgeons apply a hinge cast approximately 10 days following surgery, which allows protected and increased range of motion (Malone, Blackburn, & Wallace 1980). Immobilization poses multiple problems for individuals in s p l i n t s or casts (Milazzo & Resh, 1982). The majority of concerns i d e n t i f i e d in the l i t e r a t u r e relate to the complications of immobility. Davies and Stone (1971) i d e n t i f i e d the following concerns: sluggish peripheral c i r c u l a t i o n , decreased muscle tone, urinary retention, decubitus ulcers, constipation, forced dependency, depression and s o c i a l i s o l a t i o n . In a study in 1982, Milazzo and Resh - 74 -found the complications of immobility as: pneumonia, venous thrombosis, pulmonary emboli, decubitus ulcers, depression, and h o s t i l i t y . Casts present numerous concerns for nurses. Brown (1975) c l e a r l y describes two primary concerns as follows: F i r s t , in the process of drying to a hard cast, the plaster generates enough heat to burn the surface of the encased tissue i f the cotton has been stretched too thin or i f natural evaporation of the moisture i s slowed down or impeded. Secondly, the soft cast i s subject to d i s t o r t i o n , denting, and aligment damage for up to forty-eight hours after application. (p. 39) Prevention of skin i r r i t a t i o n or burning i s accomplished by: (a) positioning the cast in an elevated pose on soft pillows allowing natural evaporation on a l l sides; (b) freeing the cast from any covers; (c) handling gently; and (d) observing for intense continuous pain, odor, drainage, and excessive heat. Assessment of c i r c u l a t i o n , warmth, sensation, movement, and pain to the extremity i s one of utmost importance (Brown, 1975, p. 40). Care of the cast should be explained to patients who wear these immobilizing agents. Brown (1975) summarizes cast care in the following excerpt: Do not: place foreign objects under cast; physically abuse; get d i r t y ; get wet; p u l l out padding; scratch; or walk on new cast. Do: attend to broken cast immediately; ensure soft cast i s repaired; bring crutches and shorts for cast changes; seek medical care i f observe changes in - 75 -c i r c u l a t i o n , warmth, sensation or limb; thoroughly clean and gently following cast removal. (p. 41) movement of the handle the limb Cast care i s extremely valuable for recovery. Some examples of the perceptions of participants with respect to cast care include: P: I re a l i z e that a scratch can get infected and be horrible underneath the cast. I think i t i s just logic to me not to get i t wet, because I know what i t ' s made out of. P: The thing about bathing I picked up from one of the nurses in the hos p i t a l . . . put a board across the tub...And don't stick anything down i t , don't scratch i t . Cast care i s taught, in part, by nurses. The way in which teaching and other aspects of nursing care are carried out i s given meaning by patients. The following subsection discusses the participants' interaction with nursing s t a f f . Interaction with nursing s t a f f Presentation of the discussion of participants' perceptions of nursing begins with perception of the knowledge nurses have about patient care. Data revealed the following statements: P: I don't know i f they were as informed as you'd l i k e them to be. P: One nurse came in and she was asking me some questions and asked i f I had any questions. She couldn't even answer my f i r s t question, so I just thought what's the point? R: What information did you want? - 76 -\ P: Basi c a l l y , what was the procedure and how long i t took to recuperate and why. Because I r e a l l y wanted to get back on my feet as soon as possible. P: They were f a i r l y knowledgeable about the kind of operation I had, and they could answer any question that I had. If not, they gave that question to the doctor or resident. P: When they came in...to make sure your c i r c u l a t i o n in your toes i s okay, one in particular would double check on that, every time she came i n . So they were r e a l l y good. P: I could ring the buzzer i f I f e l t uncomfortable about something, and they would be there, not snarky, or why did you ring the buzzer? P: When you wake up in the middle of the night, l a s t thing you want to do i s phone the nurse to come in just to r o l l up your bed so that you can try and go to the washroom. R: So you f e l t hesitant about c a l l i n g the nurse? P: The only time I would c a l l her i s i f I was r e a l l y in pain. One participant expressed great concern regarding the decreased amount of nursing care given following the immediate post-operative period. The researcher does not imply a value judgment at this point,' but i s simply presenting data. The participant stated: P: I found the nursing care okay to a p o i n t , . . u n t i l ...the l a s t couple of days. Then I don't know. They seemed to have gotten this idea in their head that you're a l o t better now ...But now you can't do anything. Your leg doesn't bother you that much, but once you get off those drugs, you can't get comfortable....I think they lose their patience...I think they need to be there more at the end than at the beginning because... suddenly - 77 -you can't do any thing.... There i s no way you can psychologically prepare yourself for i t u n t i l i t i s there. Comparison of di f f e r e n t nurses' a b i l i t i e s was carried out by patients. P: You become f a i r l y aware of who's good at i t and who i s n ' t (giving i n j e c t i o n s ) . P: A new nurse would come on and she'd want to put them some other way (pillows). One participant f e l t that the nurse was "boss." P: Oh yeah, she's the boss. I just go along with whatever she says. Generally, nursing care was perceived as s a t i s f a c t o r y . When asked a perception of nursing care, one participant stated: P: You couldn't ask them to be more e f f i c i e n t with the number of people that they had to work with....They were excellent. Friendliness, attention to d e t a i l , encouragement, and a smile are perceived c h a r a c t e r i s t i c s of quality care. P: Nurses come around to see you and talk to you.... Tremendous care. P: Some of them stood out a l i t t l e more than others because one would ask you a p a r t i c u l a r question. P: They pushed sometimes which i s good. P: They made a big difference. They were always there with a smile.... Patients expected discharge teaching from nurses. Two - 78 -participants were surprised at the lack of such teaching. Its relevance became more important in the following phase of the home experience as this i s where knowledge acquired in hospital was applied to daily l i f e s ituations. P: I got home and I realized that nobody had told me what to expect at a l l about anything...I wish they had. P: On the day I was discharged... i t seemed the nurses were asking me when I was going to be discharged. Clearly, discharge teaching was a need for these participants. Fear of the unknown i s a frightening experience and can be a l l e v i a t e d by the provision of information. Discharge teaching can also include determination of goals. One participant spent her time in hospital thinking about the future; this i s a time when nurses can as s i s t a patient in setting r e a l i s t i c goals. P: I spent most of my time either day dreaming or just thinking about what I was going to do when I got out. Participants perceived their experience with nursing as satisfactory with some areas requiring improvement. They perceived their experience with medicine in a similar way. One difference was that participants viewed nursing as more v i s i b l y present than medicine. P: The doctors always seem to be in such a rush...and you never r e a l l y want to bother them. P: The nurse i s the nurse and the doctor i s - 79 -the doctor. If you're going to ask a question you might as well ask the doctor. They don't seem to have time too often, though. P: The only time I saw my doctor was just before the operation. Participants attached meaning to their perceptions of the functions and r e s p o n s i b i l i t i e s of nursing s t a f f . They perceived nurses as twenty-four hour care givers who were in control of their experience. Generally, most participants were s a t i s f i e d with the nursing care that they received. The nursing care of young adults experiencing anterior cruciate ligament repair focuses on the improvement of the patient's a b i l i t y to function independently and reach the previous l e v e l of musculoskeletal functioning. The concerns i d e n t i f i e d during the hospital experience centered around the surgery. In the following phase, the home experience, concerns were focussed on l i v i n g with the consequence of surgery such as decreased independence, f r u s t r a t i o n , and generally coping with daily l i v i n g . Home experience Impending hospital discharge mobilizes fear, anxiety, and joy. Even though this i s the event for which participants have been waiting, i t i s a frightening experience which raises feelings of doubt about self-care and r e h a b i l i t a t i o n . - 80 -The lack of patient preparation regarding adequate discharge knowledge i s of great concern to the researcher and w i l l be discussed later in this section. Participants expressed concern regarding knowledge of the wound, cast, and a b i l i t y to carry out a c t i v i t i e s of daily l i v i n g . Participants expressed feelings of loss regarding the security of h o s p i t a l i z a t i o n . A sense of powerlessness appeared to overcome a few participants in hospital and served as a negative force in the recovery period. One participant f e l t overwhelmingly helpless. Another participant f e l t sad and liv e d through a "Why me?" period. He stated: P: I talked to the guy upstairs and said, "Did I deserve t h i s , what did I do? I want to get out of t h i s . " Self-blame i s evident in the next passage: P: I was actually a bit angry at myself for having gone and have this happen. It's a bit of anger at yourself... for playing a sport in which that could happen. Playing a sport at that time and I didn't r e a l l y f e e l I was in shape enough to play . Depression was rampant but one participant was able to see an end to the experience of immobilization. P: I get a l i t t l e down. I know i t ' s coming off, and i f worse comes to worse, i t w i l l be l i k e i t was before. I ' l l s t i l l be able to walk and w i l l have a high degree of mobility. You just got to prevent yourself from...getting ... depressed because i t i s going to come of f . I know that. - 81 -Surprise and dependence are the key concepts in the nex,t passages. Participants were concerned with unexpected happenings, a longer than anticipated recovery period, loss of independence and loneliness. P: There are things coming up which are unexpected. P: I went into shock because he i s t e l l i n g me three months. Three months i s nothing. Now I find out i t i s going to take at least 8 months. It's hard to take. P: After being so independent for a while, and just being around here for a while, i t i s hard to grown accustom to i t . P: It i s hard to have somebody wait on you. P: Those s t a i r s I'm only going to see when I go down and get this cast off. So I am here for at least another two weeks before I get out that door. R: How do you f e e l about that? P: I guess i t r e a l l y depends upon the type of person you are. In the l a t t e r passage, the individual f e l t t o t a l l y i s o l a t e d . By the second ,interview, the in d i v i d u a l had returned to work and could manage with l i f e ' s a c t i v i t i e s "not too bad" . P: Not too bad. Most things I can get along with. But I can't cook, so I more or less have to rely on delivery foods, fast foods, or some of my friends. Responses to immobilization varied. Feelings of boredom, loneliness, and f r u s t r a t i o n were a few of the - 82 -feelings expressed. One participant expressed the wish to change the environment: P: It would have been nice to get away from these surroundings because i t i s kind of d u l l . Two participants complained of boredom and restlessness: P: I'm a l i t t l e r e s t l e s s . Sometimes get up in the middle of the night. P: I get r e s t l e s s , I r e a l l y get bored and cranky when I get r e s t l e s s . I get t i r e d of reading a l l the time. Hope appeared to accompany acceptance of loss of mobility and their present s i t u a t i o n . P: It's funny you know, because I've had a l o t of di f f e r e n t thoughts about things now that I've got a l l this time... things are progressing f a i r l y well I think. P: I guess the injury thing was whether i t would work...it i s putting a l o t out, not just physically, but I haven't been working... now i t looks l i k e i t s almost ready to go. In a l l i t s forms, loss i s simultaneously a real state and a perception by which the in d i v i d u a l endows the event with personal or symbolic meaning. Each loss carries a threat of subsequent or future loss and must be appropriately given significance and recognition. In 1979, Lambert and Lambert defined loss as a condition whereby an in d i v i d u a l experiences deprivation of, or complete lack of, something that was previously present. In keeping with Peretz (1970), loss i s fundamental human experience that spans the entire l i f e continuum. It i s ever present, ever occurring, and responsible for invoking happiness and unhappiness. The manner in which each individual views loss depends on past experiences with loss, the value placed upon the lost object, and the c u l t u r a l , psychosocial, economic, and family supports available for dealing with the loss. Each individual creates his or her own means of coping with loss. The fashion in which loss i s viewed affects the individual's a b i l i t y to cope with i t s presence and i t s recurrence. In this case, the loss i s deprivation of mobility. Participants place high value on physical f i t n e s s ; mobility i s necessary for f i t n e s s , and when l o s t , forces the individual to mobilize alternative ways of coping. Coping with loss at home requires adjustment for sa t i s f a c t i o n of physical, emotional, and s o c i a l needs. For example, one participant rearranged the kitchen and l i v i n g room to f a c i l i t a t e easier a c c e s s i b i l i t y and manoeuverability. Loss of part of one's physio-psychosocial well-being, in this instance mobility, affects three aspects of the whole person: state of physiological function, ideas and feelings about the s e l f , and s o c i a l roles (Lambert and Lambert, 1979). - 84 -Alteration in any one of these aspects affects the others, as the three are i n t r i c a t e l y intermeshed to form the whole. Participants described the d i f f i c u l t i e s of walking, carrying out a c t i v i t i e s of daily l i v i n g , and t r a v e l l i n g — a l l physical and s o c i a l requirements of l i f e . P: I want to walk, I want to get out, I want to get moving. P: I'm good for about half an hour and then I've got to s i t down. P: I can make a cup of tea and then, what am I going to do with i t ? I can't carry anything. P: You're used to depending on crutches. You leave them anywhere, and suddenly you turn around and go somewhere... i t i s a trek across the floor just to find the crutches. P: I want to see them (family). I was going to book i t before I had surgery but I didn't know how I'd f e e l . Physical a c t i v i t y , p a r t i c u l a r l y the a b i l i t y to walk was not only u t i l i z e d for leisure a c t i v i t i e s , i t was necessary for obtaining finances and maintaining economic security. Walking was an important component of the se l f for those engaged in so c i e t a l productivity. P: I walk a l o t at work. My job requires a lot of walking and you have to be f a i r l y agile P: When I t e l l people, they think I s i t on the other end and I just s i t for eight hours. But I don't s i t down at a l l . I run machines and send out reports. P: A lot of walking. Just constantly on my - 85 -f eet. Loss of a b i l i t y to work concerned participants as documented below. P: I think the biggest thing when i t comes to this kind of operation, especially i f you're working, i s the time that's involved in recuperation and I think the type of work that I do. I'm always in the f i e l d and i t ' s not d i f f i c u l t . V i s u a l i z i n g the affected limb was of concern for one participant as documented below. P: I probably w i l l not want to look at i t , I'm thinking about the cast c h a n g e s h o u l d I look at i t . I probably w i l l have to have a look. But I know i t i s going to look nasty. Attitude was deemed v i t a l l y important for recovery and for warding off depression as described in the following excerpts: P: It sort of boi l s down to your attitude, i f you're sort of happy and involved... feeling fine, you f e e l busy and then you don't dwell on i t , i t w i l l heal just as well too. P: The f i r s t day I got back here I was r e a l l y depressed because suddenly these four walls around you and you r e a l i z e that you're going to be here for quite some time. And the amount of s t a i r s I got to go up and down...there i s no way I'm going to do that for a while. The preceding content has addressed psychological concerns. Physiological concerns and reaction to the same are the focus of the following subject matter. Physiological - 86 -concerns at home were similar to concerns in hosp i t a l . Pain, sleep, n u t r i t i o n , and hygiene were the four major concerns i d e n t i f i e d by participants. Pain was moderate to severe at the time of the researcher's f i r s t interview and with one exception, diminished by the second interview. Pain, sleep, n u t r i t i o n , and hygiene appeared to be in t e r r e l a t e d . For example, appetite was poor and sleep was minimal in the presence of pain. Hygiene increased comfort and hence, improved appetite and sleep. An array of accounts substantiate this claim. P: I am due for another shower. After, I f e e l r e a l l y clean, r e a l l y good. I think cleanliness i s the biggest thing with this cast on. -R: How's your appetite been? P: It's been off, I eat maybe once a day. But I normally wouldn't do i t the same. P: Sometimes I wonder i f my appetite i s s t i l l a l i t t l e low, I s t i l l can't eat very much. I think i t i s a l l psychological. Get ti r e d of eating, you have to prepare i t . P: It gets to be aching at night, but I don't l i k e those pain p i l l s , they give me very strange dreams. P: The f i r s t couple of nights home here, i t was bothering me. Just uncomfortable. It would wake me up but i t wasn't intense...it was aggravating. P: I was dozing off last night and I had a twitch in my leg. P: The only thing that s t i l l r e a l l y bothers me is that I just can't get comfortable. I can't get to sleep because my leg i s bugging me. - 87 -P: I think I had muscle spasm for the f i r s t three nights. P: The problem right now i s , I'm not getting enough exercise, and I am not getting enough sleep. f P: I s t i l l have pain. It i s s t i l l tough to sleep at night. I have actually had to take some sleeping p i l l s . Marked improvement was perceived by the fourth post-operative week and was communicated to the researcher during the second interview. Pain at the operative s i t e and pain due to muscle spasms had lessened. Appetite had improved and sleep came easier. P: I've been sleeping pretty good now, i t doesn't bother me now. P: I'm better. I'm s t i l l t i r e d because I can't get that f u l l sleep, you're always waking up. P: My appetite has picked up since I l e f t the hospital. As previously stated, one participant continued to experience moderate to severe pain, four weeks post-operatively. This individual had the cast removed four weeks e a r l i e r than others and did not wear a hinge cast. P: ...a l o t of pain. I f e l t I might have torn something on the side. It i s always there when I am sleeping. It's f a i r l y sore now, there's s t i l l a spot that I can't f e e l , which i s numb. I am waiting for i t to come back... . Return to pre-injury l e v e l of musculoskeletal a c t i v i t y i s the goal of r e h a b i l i t a t i o n . At the f i r s t interview, - 88 -a c t i v i t y was minimal -- short distance walks had been undertaken; by the second interview, a c t i v i t y had increased and some participants were walking one to two miles. It i s worth remembering an account presented e a r l i e r that displayed s o c i a l i s o l a t i o n . For this person, a major obstacle of physical a c t i v i t y was three f l i g h t s of s t a i r s . As w i l l be noted l a t e r , s t a i r s were a common fear. Physical a c t i v i t y comprised of walking, stretching, and strengthening exercises for the entire body; housework; outings; and, regular physiotherapy. Participants explained their p a r t i c i p a t i o n in physical a c t i v i t y in the following manner: P: I've walked home, i t takes me a while. It took me forty minutes the f i r s t time, and about t h i r t y minutes the second time. P: You know when you go out, you carry things on your back. I've been out a l i t t l e b i t , up to the bank. P: I've been doing stretching and back exercises. Exercises with the rest of my body about half an hour every day. P: It i s kind of a drag in the rain, getting around. I found out with slippery t i l e f l o o r s . P: I vacuumed the rug, cleaned the rug yesterday, cleaned the stove...I'm actually starting back to o f f i c e work. P: I can get up. Like i f I'm s i t t i n g here, this i s where I l i v e now, in the l i v i n g room. Emphasis of short-terra exercise i s on strengthening, - 89 -stretching, and improving f l e x i b i l i t y of the entire body, as well as the affected limb. Roy and Irvin (1983) state that the athlete who has had reconstructive knee ligament surgery may take three to six months to complete the r e h a b i l i t a t i o n program. These authors outline a program for knee r e h a b i l i t a t i o n after injury of surgery which emphasizes strengthening, stretching, and improving f l e x i b i l i t y of the unaffected side while improving cardiovascular endurance and strength of the affect limb. During the home experience, participants focused their exercise on these areas, that i s , on the affected limb and the cardiovascular system. Some examples of exercises encouraged during the cast immobilization period are: 1. Hamstring sets are performed by pushing the foot backward against resistance and maintaining isometric contraction for five seconds. This i s repeated 25 times every hour during the waking day. 2. Straight leg raises are performed by lying on one side and ra i s i n g one leg three l e v e l s , then lowering i t ; 3. Cardiovascular endurance i s improved by rapid crutch ambulation and using a bicycle tergometer with the unaffected leg only. Weightbearing i s discouraged to allow time for proper healing. - 90 -Participants explained their program as follows: P: I've just been doing straight leg exercises around the house. I started a program for a l l ' my body. I just hope that w i l l help. P: Walking, stepping on i t , but no weight at a l l . . . . P: B a s i c a l l y , the warmup i s just walking...I try to do a few stretches inside the thing. P: I'm just going to keep flexing the knee...I w i l l probably use hamstring tighteners. Rehabilitation requires knowledge of how to restore function and when to encourage this restoration. It also involves helping the patient to adjust to permanent " lim i t a t i o n s and a s s i s t i n g him or her in obtaining appropriate devices to f a c i l i t a t e function. Ideally, the patient, nurse, physician, and family work together so that the desired a c t i v i t y i s c l a r i f i e d and can be performed (DonahOo & Dimon, 1977). A c t i v i t y was limited due to fear of f a l l i n g . Participants were greatly concerned with damaging the knee and undergoing additional treatment. Caution was a common behavior as evidenced in the following passage: P: If exercise hurt, I wouldn't do i t . Maybe I should stay off i t a bit more. P: You know I'm careful never to do anything that might hurt me. P: I am r e a l l y trying to be careful about not in j u r i n g i t again. I want everything to be r e a l l y - 91 -perfect. P: Stairs have been quite upsetting to me. I've been r e a l l y nervous about going over forward on the s t a i r s going down. P: I came down real hard on the s t a i r s and I was a l i t t l e worried i f that would do any damage. P: Going down s t a i r s i s a l o t more frightening than going up. Family and friends helped the patient at home by giving support and a s s i s t i n g with routine tasks such as cleaning and meal preparation. The patient's family and friends play a s i g n i f i c a n t role during the time of i l l n e s s , and their reactions contribute to the patient's response to i l l n e s s (Kubler-Ross, 1969). Participants expressed grateful appreciation to friends and family for support during the immobilization experience. P: It's important to have someone care for you. P: I couldn't imagine t h i s , I couldn't imagine getting around; even just getting around the house without somebody here to take care of me. I get a lo t of support from my friends. P: It i s helpful i f people keep contacting you. I've had a f a i r amount of phone c a l l s from people. P: . . . i f your family could v i s i t you while you recuperate, that would be hel p f u l . P: It i s r e a l l y nice to have support from someone else you know, say a loved one, or someone close to you.... Change of environment was valued by participants. - 92 -c S o c i a l i z i n g was a need that was s a t i s f i e d by walks, outings with friends and family, and t r a v e l . P: I take my dog for a walk. P: Sometimes I go out just walking around here, go up to the store and come back, so I figure probably a couple of miles. P: I had a couple of friends stop in here on Saturday...I wanted to go to a pub. So we piled into my truck and I gave the keys to my friend and away we went. P: My friend coaches l i t t l e kids soccer. I'm going to watch that. P: My family i s coming down and we're going out. P: I plan to go t r a v e l l i n g for a week. Mode of transportation was d i f f i c u l t to begin with but > i t improved as time passed. At the second interview, participants shared experiences of using the buses, a t a x i , and a personal truck. P: Not being able to drive i s a real bummer. P: I'm not interested in riding the buses just yet. So I can take a taxi when I r e a l l y have to go somewhere. P: I can take the bus now. P: So I hopped in my truck and drove to the store. Rehabilitation, as stated e a r l i e r , involves physiological, psychological, and s o c i a l processes. The surgery i t s e l f posed many problems for participants at home, - 93 -such as pain, discomfort, and fatigue. These problems were d i r e c t l y related to the cast which was changed two and four weeks post-operatively. Cast changes provided an opportunity to view the unknown, that i s , the affected limb with i t s mysterious scars. Reactions to this event varied: surprise, s a t i s f a c t i o n , or disgust. P: It was a surprise looking at my leg with a couple of holes in i t . P: I figured a small i n c i s i o n on each side and when I saw i t , i t was incredi b l e . About 6 inches long on each side. I didn't expect that. P: Oh, i t didn't bother me, i t surprised me, because i t wasn't there when I went i n . They are nice scars. They are well done. P: The scar looked t e r r i b l e . . . I thought i t was a mess...I never had a leg that looked so bad. Participants' perceptions of their condition, cast use, and discomforts varied depending upon the i n d i v i d u a l . Common concerns were: itchiness and shrinking of the leg, heaviness of the cast, and discomfort from the cast belt. P: The cast i s getting itchy. My leg i s getting itchy. When i t does that, I just try and ignore i t . P: It's a heavy cast. P: It's the belt across my back, digs into your back a b i t . Knowledge of cast changes varied from detailed to none - 94 -at a l l . Participants explained: P: Yeah, there w i l l be a cast going on with a hole in the knee and braces so that I can bend my knee a b i t . P: I ' l l have the hinge cast put on. I don't know what that constitutes. P: I get i t changed Monday. They are going to give me a hinge cast I think, something that i s going to enable me to do straight leg exercises. P: I'm going in on Monday to the emergency to have this changed. I don't know who's going to change i t . In the beginning paragraphs of this section the researcher expressed concern regarding the lack of patient preparation for discharge home. Participants expressed many concerns, p a r t i c u l a r l y about the wound i t s e l f , cast care, re-organization of the home, bathing, reasons to contact the health care system, and r e h a b i l i t a t i o n . Participants explained their needs in the following manner: P: Every time' I got up i t r e a l l y hurt. I guess the blood running into the knee. I didn't know what I was to expect because nobody told me anything. A couple of times i t happened... maybe I should go back to the hospital and t e l l them i t hurts. P: ...and the teaching, maybe improving ' cast care and re-organization of your home. P: Suddenly, my apartment wasn't as convenient as i t should be. Suddenly, I've got to move my bed out here in the l i v i n g room. Now, i f I had known a l l about this a l o t before hand, I could have - 95 -spent a couple of days doing i t before I l e f t . P: And the bathing.... P: I didn't know what non-weightbearing meant. Vertical? Horizontal? P: I didn't know what exercises to do or what would happen. It i s evident that discharge teaching was necessary for these patients. Werner-Beland (1980) states that nurses teach patients what we think they need to know in order to sustain or regain health. It i s time for nurses to teach patients what they want to know in addition to what nurses f e e l they need to know. Following six to eight weeks in a cast, participants were eager to shed their plaster and implement plans for the immediate and long-term future. A thoughtful summation of the immobilization experience follows: P: It's been quite an adventure. Future Plans This phase emerged with two components which differed according to time: short-term plans and long-term plans. As participants increased and improved physical mobility, thoughts and ideas concerning the future were brought to mind. The researcher obtained data regarding short- and long-term plans during both interviews. - 96 -Participants' concerns centered around the notion of return to previous musculoskeletal functioning. With this recovery, they believed that other aspects of their l i v e s would return to "normal", such as work and recreation. Short-term plans primarily consisted of physiological r e h a b i l i t a t i o n which i s accomplished by improving general health and pa r t i c i p a t i n g in an exercise program with a physiotherapist and independently at home. During the f i r s t interview, 1 week following surgery, participants focused on concerns of daily l i v i n g and physical functioning. By the second interview, participants expressed concern with s o c i a l plans in addition to physiological needs. For those who were on leave from work, or who were intending to return to work or school, the concept of r e h a b i l i t a t i o n was perceived as quick, intensive work. The fastest possible r e h a b i l i t a t i o n was a common goal. For one participant, this was conceived of as a two month period. P: I'm not sure when I ' l l be physically able to start work again. I'd l i k e to start in two months. Others were uncertain of the future but made plans in antic i p a t i o n for recovery. P: I am always trying to think ahead, planning ahead, just exactly what I can do...my main worry right now i s just finding a job. P: So when I came here what I wanted to do was - 97 -work and perhaps go back to school in a year round position. Plans to return to work were ever present as participants intended to be economically independent, despite uncertain physical l i m i t a t i o n s resulting from the immobilization experience. P: He said after f i v e months the leg should be in good shape i f I am true to form in my physiotherapy. So I ' l l gear myself for fi v e months. But I w i l l be looking for work as soon as I can walk on i t . P: I think the way things are going I could start in the new year. It would be a l i t t l e over' three months. I am anxious to do that. Return to school was a viable alternative for those who were unable to return to work and appeared to be a coping behavior which helped participants deal with i n a b i l i t y to work. Five participants explained: P: Yes, a whole bunch of changes, taking an extra year. If I can't work, I might as well just go to school. P: I might even go to summer school. Pick up the courses I missed and spend the summer down here. Take some courses and relax. Two participants shared their concerns about a dubious future: P: I'm r e a l l y up in the a i r . I've been actually f a i r l y transient for the la s t couple of months. P: I'm r e a l l y not sure just what's going to happen. I ' l l find out when this comes o f f . I know - 98 -this i s going to be r e a l l y s t i f f , because when they took the f i r s t cast off I couldn't bend i t . Progress was measured by physical mobility which allowed the a b i l i t y to carry out a c t i v i t i e s of daily l i v i n g and offered hope for future p a r t i c i p a t i o n in sports a c t i v i t i e s . P: I'm getting a lot more mobile. I've been too busy trying to do things to worry about a l o t of s t u f f . P: I'm on weights now. I am already on weights which i s surprising. They are starting to stretch, today they've started to stretch i t , I mean r e a l l y stretch i t l i k e get i t bent, push i t out, not so much out but bending i t past 90 i s what they're after. It was pretty painful but that's what's got to be done. Return to a t h l e t i c a c t i v i t i e s , work, , and a familiar environment were i d e n t i f i e d as the most important components of long-term plans. Two participants stated this c l e a r l y : P: Well, the doctor...the people at the rehab said that i t takes about three years to f u l l y recover.... Ligaments deteriorate so i t takes a long time to build up...I was hoping that I could be running by January. That's what I figured I'd be doing.... Which i s no way. So I just want to get on a bike again, as soon as I can...I'm an avid golfer and I love to golf in tournaments.... That may be shelved for the summer too. So there goes my summer, you know the thing that I r e a l l y do look forward to i f nothing else i s that. I l i k e to golf a l l year 'round. P: I want to get back in my place so I can get started on a few things and get back to work. I'm just anxious to get going, but re a l i z e that I have to take i t very slowly. Others explained their plans for sports a c t i v i t i e s as - 99 -follows: P: I plan on joining some kind of exercise club where they have weight machines. P: As long as I can start jogging again, that's great. I'm sure i t w i l l build up real fast in this case. P: Physio, non-impact sports, cycling and hamstring strengtheners.... Eriksson( 1982) states that i t takes a long time for an injured sports participant who has been operated upon to return to sports again. Muscle functioning and muscle i t s e l f may d r a s t i c a l l y change and require extensive r e h a b i l i t a t i o n prior to p a r t i c i p a t i o n in sports. Eriksson (1982) believes that the f i n a l goal of orthopedic treatment should be return to work and return to sports a c t i v i t i e s . Participants expressed feelings of anxiety and sadness related to i n a b i l i t y to return to sports. P: Oh, because of a l l t h i s , I'm t i r e d now you know. P: That r e a l l y bothers me not playing f o o t b a l l . P: I'm going crazy just s i t t i n g around. P: Well, as far as basketball goes, I r e a l l y don't know i f I should give up on i t e n t i r e l y . I ( find i t very hard to do that. It has been a major part of my l i f e ever since I was about 15. That's a l l I have ever r e a l l y done. It was an escape, I 'used to go for two hours or three hours and not think about a thing...just run...used to be exhausted, and f e e l good about i t . Now a l l of a sudden that seems to be taken away from me. - 100 -Young adults with anterior cruciate ligament repair expressed feelings of loss. Immobilization caused feelings of dependency and loss of power and control. A t h l e t i c and occupational goals were thwarted. Rather than being the centre of a c t i v i t y , the individual f e l t pushed to the periphery — becoming an outsider dependent on the ministration of others. As Delaney-Naumoff (1980) points out, to deprive a person of work i s to remove one of the most important controls in his or her l i f e . This applies to sports a c t i v i t i e s as well as work. Despite the prevalence of loss in their l i v e s , participants retained hope which was exemplified by travel plans and hope for future improvement. There was a feeling that a l l this must have some meaning, and i t would pay off eventually i f endured for a l i t t l e while longer. Participants spoke of t r a v e l , s o c i a l i z i n g and hope: P: My s i s t e r l i v e s in so I could go stay with her for a week and then I have a friend that's going to be there and I can come back with her. P: I'm planning a t r i p to after my next cast change, just for a l i t t l e holiday, to get away. I'm changing my environment. P: I ' l l be changing my environment for a while. I am looking forward to t r a v e l l i n g . P: I have a good s o c i a l l i f e . I know a l o t of people, I have a lot of good friends...I went to a show. P: I have a feeling that I w i l l probably give - 101 -myself a year and do some firm physiotherapy for a year. P: I sort of foresee in the next two weeks the inflammation going, I hope. I'm looking forward to having a boney knee. I'm f a i r l y pleased. I f e e l good about my knee. So now, I f e e l good about i t , which i s a good attitude. I f e e l okay about i t . And I r e a l l y can't think of anything that i f I were to do i t d i f f e r e n t l y . Although the future was as unpredictable as the past, the process of r e h a b i l i t a t i o n continued. Generally, participants did not regret undergoing surgery. They hoped for strength and the a b i l i t y to be physically active in the future. Throughout the phases, physical fitness was a salient concern. In the phase of future plans, this concern was of utmost importance as i t was perceived as a prerequisite return to p a r t i c i p a t i o n in preferred sports. Summary This chapter has presented the research findings as an integration of the participants' accounts, reviewed l i t e r a t u r e , and the researcher's analysis. Data were analyzed along two dimensions: (a) sequence, and (b) concepts. Sequential analysis described the perceptions and concerns of young adults with anterior cruciate ligament repair according to phases of the immobilization experience. Conceptual analysis provided the researcher with a means to - 102' -make sense of the immobilization experience as i t i s l i v e d and interpreted by participants of the study. The concepts of loss, hope, and r e h a b i l i t a t i o n emerged from the data and together with phases of the experience formed the iorganizational schema of the presentation of findings. Chapter Five presents a summary and the conclusions of the study, as well as implications for nursing. - 103 -CHAPTER FIVE Summary, Conclusions, and Implications for Nursing Summary and Conclusions This study was designed to gain an understanding of the concerns of young adults during the period of immobilization following anterior cruciate ligament repair, and of the factors which affect their recovery. The concerns confronting these individuals may affect their r e h a b i l i t a t i o n and return to musculoskeletal functioning, in which case nurses must understand these concerns in order to provide appropriate care. There i s no evidence of research done to iden t i f y and understand the concerns facing individuals during the period of immobilization following anterior cruciate ligament repair. A q u a l i t a t i v e research approach, based on the theoretical perspective of phenomenology, was used to answer the questions of this study. The phenomenological approach focuses on the meaning given to experience by the people who - 104 -l i v e i t ; i t was chosen because i t emphasizes the understanding of human behavior from the patient's perspective. The discovery and documentation of the concerns of young adults with anterior cruciate ligament repair, during the immobilization period, w i l l contribute to the development of knowledge about the patient's perspective, which in turn, a s s i s t s nurses in planning and implementing nursing care. Kleinman's (1978) conceptualization of the health care system provided the framework for this study. Kleinman emphasizes the importance of discovering how patients think about health care and i l l n e s s , as well as how they deal with i t . He focuses on the perceptions of individuals and the forces which influence those perceptions. This framework complemented the researcher's interest in studying the perceptions of immobilized participants and the factors which affected their recovery. An understanding of patients' explanatory models w i l l a s s i s t nurses in providing care which exemplifies an appreciation of how individuals perceive their experience and in what ways they desire to be helped. The phenomenological approach and Kleinman's conceptual framework f a c i l i t a t e d f u l f i l l m e n t of the purpose of the study. The experience of immobilization as perceived by participants was explored for the purpose of: (a) i d e n t i f y i n g - 105 -the concerns of young adults during the period of immobilization following anterior cruciate ligament repair at approximately 1 week and 3 to 4 weeks following hospital discharge, and (b) examining the patient's perceptions of the impact of these concerns upon the r e h a b i l i t a t i v e process. Ten individuals participated in this study. Each participant was interviewed twice in his or her home, approximately 1 week and 3 to 4 weeks following hospital discharge. Unstructured interviews were used to c o l l e c t data. During each interview, the participant constructed an account of his or her experience. Participants explained how they interpreted their experience, and how they made sense of events and surroundings. They i d e n t i f i e d worries and questions about the injury, hospital and home experience, and the future. The findings of the study showed that the participants' immobilization experience occurred in phases which were int e r r e l a t e d , and evolved around the event of injury. Six phases were developed: (a) pre-injury, (b) recognition of injury, (c) contact with the health care system, (d) hospital experience, (e) home experience, and (f) future plans. Three major themes or concepts emerged — loss, hope, and r e h a b i l i t a t i o n ; in addition to the phases of the - 106 -experience, these formed the organizational schema for the study. The analytic concepts of loss, hope, and r e h a b i l i t a t i o n assisted the researcher in making sense of the experience as i t was perceived by the participants under study. These concepts are universal phenomena and appear with varying intensity in one or more of the phases of the immobilization experience. The research findings were presented by an integration of the participants' accounts, relevant l i t e r a t u r e , and the researcher's analysis. The concerns confronting young adults during the period of immobilization, following anterior cruciate ligament repair, were numerous and diverse. These concerns appeared to represent or to be related to losses which occurred in the l i v e s of the participants. Furthermore, each loss was interrelated with feelings of hope that the loss could be somewhat resolved and that the quality of l i f e would improve. The concept of r e h a b i l i t a t i o n was addressed throughout the immobilization experience. Rehabilitation began at the moment of injury. Its goal was to provide assistance to individuals for achievement of restoration to a previous l e v e l of musculoskeletal functioning in the shortest possible time period (Quigley, 1981). The process of restoration to normal l i f e following i n j u r i e s required attention to - 107 -physiological, psychological, and s o c i a l needs. Prior to injury, participants were active in a variety of sports and placed high value on physical f i t n e s s . They agreed that physical f i t n e s s , prior to injury, was b e n e f i c i a l for recovery. Injuries incurred by participants were the result of p a r t i c i p a t i o n in a variety of sports. Although some s i m i l a r i t i e s existed, the event of injury was perceived somewhat d i f f e r e n t l y . Recognition of injury varied with the sport and immediate treatment varied with the intensity of injury. Injury resulted in loss of mobility which was the major loss of the immobilization experience. Loss of mobility influenced the whole individual and gave r i s e to additional losses. Certain feelings surrounded the event of injury and were experienced by most participants: pain, loss of mobility, hope for technological advance, and uncertainty about the future were the major concerns expressed by the participants. The decision to seek health care following injury depended upon pain, i n a b i l i t y to mobilize, i n a b i l i t y to participate in sports a c t i v i t i e s , current l i f e s i t u a t i o n , persuasion from friends and family, and reinjury. - 108 -Loss of mobility was the key factor in determining whether or not to seek health care. If mobility was possible, action was less l i k e l y . The two major entry points into the health care system were the general practitioner and the emergency room physician. For most participants, contact with the health care system was a confusing experience. Once contact was made, decisions were required for consent to surgery. Factors which influenced the decision to undergo surgery were: pain, immobility, and the proposed prognosis. Hope for successful surgery was expressed by a l l participants. Involvement in decision-making was important to participants; this increased a sense of control which decreased feelings of powerlessness. Another means to gaining control was gathering information relevant to the condition — knowledge was viewed as a means of control. In no other phase was the nurse's direct impact upon patients as s i g n i f i c a n t as i t was during the hospital experience. Nurses were viewed as a source of power and control. The length of hospital stay ranged from 4 to 8 days during which time the following concerns were of major importance: pain at the operative s i t e , fear of pain, muscle spasm, presence of davol drain, Insomnia, loss of appetite, hygiene, elimination, cast care, and immobility. - 109 -Participants' perceptions of nurses and nursing care focused on possession of knowledge, a b i l i t y to provide care, and amount of s a t i s f a c t i o n with care, power, control, and attitude. Participants expressed concern regarding abrupt t r a n s i t i o n of the amount of nursing care time during recovery. They explained that nurses were not as v i s i b l e 3 to 4 days post-operatively, and expressed concern that despite progress they required nursing care. The major difference between nursing and medicine was perceived as the amount of time spent with patients. Nurses were perceived as providers of care twenty-four hours daily, whereas physicians were viewed as v i s i t o r s to the patients. Impending hospital discharge mobilized feelings of fear, anxiety, and joy. Participants explained their return home as loss of the security of the hospital. They were immersed in an environment which demanded a certain degree of independence for comfort and survival and questioned the se l f by thinking "Why me?" Feelings of loss of independence, loneliness, boredom, and restlessness were paramount concerns during the home experience. Participants complained about lack of discharge teaching, and s p e c i f i c a l l y outlined the following factors to consider prior to hospital discharge: explanation of (a) surgical procedure, (b) cast care, (c) management of - 110 -a c t i v i t i e s of daily l i v i n g , (d) reasons to contact the health care system, and (e) r e h a b i l i t a t i o n . As physical mobility increased, future plans were made regarding exercise, work, and recreation. The phase of future plans emerged with two components which di f f e r e d according to time: (a) short-term and (b) long-term. Concerns centered around return to previous l e v e l of musculoskeletal functioning. With this recovery, participants believed other aspects of their l i v e s would return to normal, such as work and recreation. Short-term plans focused on physical r e h a b i l i t a t i o n which was perceived as being accomplished by improving general health, and by par t i c i p a t i n g in an exercise program with a physiotherapist and at home. Long-term plans focused on return to a t h l e t i c a c t i v i t i e s , work, and a familiar environment. Despite the prevalence of loss in their l i v e s , participants retained hope for recovery as exemplified in I t r a v e l plans and hope for future musculoskeletal improvement. Generally, participants did not regret undergoing surgery. They offered advice for others which emphasized maintenance and improvement of physical and mental health, immediate attention to the problem, and planning prior to - I l l -h o s p i t a l i z a t i o n . The fastest possible return to previous musculoskeletal functioning was the goal of r e h a b i l i t a t i o n . A number of conclusions can be drawn from the findings of t h i s study. The f i r s t i s that young adults with anterior cruciate ligament repair e l i c i t explanatory models which help them to make sense of their immobilization experience. The meaning attached to this experience gives direction for behaviour throughout the six phases of the experience. Therefore, i t i s v i t a l l y important for nurses to understand the patient's perspective and to incorporate this understanding into the planning of nursing care. The second conclusion i s that young adults with anterior cruciate ligament repair have some common concerns which should be considered during the planning and implementation of nursing care. When given the opportunity, patients are able to a r t i c u l a t e what i s important to them about their experience — physiological, . psychological and s o c i a l responses; worries and questions; and their impact upon the r e h a b i l i t a t i v e process. Nurses should anticipate these concerns and address them in the time of pre-operative, post-operative, and discharge teaching. Patients need information; they fear the unknown and prefer to be prepared for upcoming events. - 112 -Another major conclusion of this study i s that for young adults with anterior cruciate ligament repair, every loss i s accompanied by some hope. Loss of mobility i s the major loss for participants and affects the physiological, psychological, and s o c i a l aspects of l i f e . Loss of mobility gives r i s e to other losses, such as loss of comfort and sleep, loss of independence and control, loss of self-esteem, and loss of a b i l i t y to work and participate in sports. Loss of mobility i s the focus of concern during the period of immobilization. F i n a l l y , the researcher concludes that each patient should receive i n d i v i d u a l i z e d nursing care and an individualized r e h a b i l i t a t i o n program with emphasis on physical fitness and preferred sports. The goal of r e h a b i l i t a t i o n i s to return to previous l e v e l of musculoskeletal functioning in the shortest possible period of time. , Implications for Nursing Practice The findings of this study can give direction for nursing practice and can r e i t e r a t e the need for nurses to l i s t e n to patients and to teach them content and s k i l l s that they want to learn. Nurses need to l i s t e n to the concerns of patients from - 113 -their perspective. Nursing i s a s o c i a l process in which nurses are continually interacting with patients in ways that are imperfectly measurable or predictable (Passos, 1973). Patients are individuals and need v to have their concerns listened to and acted upon. Nurses' perceptions may vary from those of patients . Therefore, nurses must share their perceptions with patients, while at the same time, offer support and reassurance. Patients can be perceived as passing through a series of phases in the immobilization experience. Attention to i d e n t i f i e d concerns in the three l a t t e r phases w i l l enhance the quality of patient care. As the condition of patients improves in hospital, they should not be ignored. 'Nurses must understand that hospital patients often f e e l powerless and helpless. Therefore, patients need to be reminded that they are s i g n i f i c a n t and deserving of nursing care throughout the h o s p i t a l i z a t i o n period. F i n a l l y , patients need discharge teaching. They are f e a r f u l , anxious, and unprepared. Discharge teaching must involve physiological, psychological, and s o c i a l components. Content could include: methods for pain r e l i e f ; assessment of c i r c u l a t i o n , sensation, warmth, and movement of the affected - 114 -extremity; cast care; a c t i v i t i e s of daily l i v i n g , including hygiene, n u t r i t i o n , sleep and elimination; physical a c t i v i t y ; and, reasons to contact a physician or an emergency department. Patients should also be informed of their course of r e h a b i l i t a t i o n and prognosis or be given directions for attainment of this information. Rehabilitation should begin at the moment of injury and should be ind i v i d u a l i z e d to meet personal needs and preferences.-Implications for Nursing Education Nursing students need to be introduced to the idea of the importance of the patient's perspective early in their education. They need to be aware that the nurse's perspective may differj from the patient's perspective and that both should be mutually discussed. Nursing students must be knowledgeable regarding the notion that patients attach meaning to events, behaviours, and surroundings, including nursing care. Loss, hope, and r e h a b i l i t a t i o n are universal concepts which should be included in nursing c u r r i c u l a and i d e n t i f i e d in phases of the immobilization experience. Nursing students should be knowledgeable of the theories of loss and the complimentary concept of hope, and the process of r e h a b i l i t a t i o n . Also, a thorough knowledge of nursing' care - 115 -for individuals with orthopedic conditions i s necessary for the general p r a c t i t i o n e r . Nursing students need knowledge of and practice with communication s k i l l s such as interviewing, developing a trusting relationship, l i s t e n i n g , r e f l e c t i n g , and empathizing. Furthermore, students need an increased awareness awareness of the importance of: patient involvement in planning care and making decisions, encouragement, positive reinforcement, developmental concerns, discharge teaching, and an individualized r e h a b i l i t a t i o n plan to suit the patient's needs and l i f e s t y l e . Nursing students must be professional and appreciate the value of high quality patient care. Implications for Nursing Research The quality of the data could have been improved by conducting interviews with a larger number of patients who had experienced anterior cruciate ligament repair. Nonetheless, the data generated for this study possesses a certain depth and richness. Additional data may have substantiated the researcher's claims and added to the researcher's findings. In retrospect, the findings may have been enriched by interviewing participants four or fiv e days post-operatively in hospital in order to discover fresh and - 116 -current perceptions of the hospital experience, and expectations of the home experience. A study of nurses' perceptions of the immobilization experience of patients i s another p o s s i b i l i t y , as well as a study focused on isolated variables such as the influence of family and friends on the immobilization experience. Several research questions arise as a direct result of this study. These questions would benefit from future investigation; in summary, these questions are: (a) How does a discharge teaching program benefit young adults with disturbance in mobility? (b) What are the concerns of the patient's family and how do these influence the patient's r e h a b i l i t a t i v e period? (c) What are the concerns of adolescents with anterior cruciate ligament repair? (d) What are the concerns of professional athletes with anterior cruciate ligament repair, and how do these d i f f e r from the concerns of amateur athletes? (e) How do nurses perceive the patient's hospital experience? and (f) What are nurses' attitudes towards young healthy adults hospitalized with sports i n j u r i e s ? The participants' perceptions of disturbance in mobility suggest concern for the i d e n t i f i c a t i o n of losses and hopes throughout the immobilization experience, and well-planned - 117 -i n d i v i d u a l i z e d r e h a b i l i t a t i o n programs. It has been the researcher's intent to discover and document the concerns of young adults during the immobilization experience following anterior cruciate ligament repair. The findings contribute to the development of knowledge about the patient's perspective. 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Grief responses to  long-term i l l n e s s & d i s a b i l i t y . Reston, V i r g i n i a : Reston. Yaffe, M. (1983, March). Sports i n j u r i e s : Psychological aspects. B r i t i s h Journal of Hospital Medicine,29(3), 224-232. - 123 -Appendices - 124 -their experiences, and how they desire to be helped, in order to improve the quality of patient care. A l l information received w i l l be c o n f i d e n t i a l . This consent form w i l l be placed on your f i l e and your name w i l l not be included in my notes. YOUR REFUSAL TO PARTICIPATE IN THIS STUDY WILL IN NO WAY PREJUDICE YOUR FUTURE TREATMENT. IF YOU DECIDE TO PARTICIPATE IN THIS STUDY AND THEN CHANGE YOUR MIND, YOU MAY WITHDRAW WITHOUT PREJUDICE TO YOUR FUTURE TREATMENT. YOU ALSO HAVE THE RIGHT TO REFUSE TO ANSWER ANY QUESTIONS. If you have any questions concerning this study, please f e e l free to ask at any time. I have included my name and telephone numbers. I understand the nature of this study and give my consent to p a r t i c i p a t e . Participant's signature Researcher's signature Dated at , this ,day of ,1983. - 126 -Appendix B Physician Consent Form I, the undersigned, give permission to Liza Turner RN BSN (MSN student) to contact patients whom are admitted under my services for anterior cruciate ligament reconstruction. I also grant approval to Liza Turner to interview these patients in their homes at approximately 1 week and 3 to 4 weeks post-operatively. I understand the interviews w i l l be transcribed, and the data w i l l be analyzed and written in the form of a Master's thesis. Physician's signature Researcher's signature Dated at , this day of , 1983. - 127 -Appendix C Sample Questions 1. T e l l me about how you injured your knee. 2. How did you f e e l about requiring surgery to repair your torn ligament? 3. How did you react when you were admitted to hospital? 4. What worried you about returning home with a f u l l length leg cast? 5. Are you having any pain in your knee and leg? 6. How has this injury r e s t r i c t e d your mobility? 7. What concerns you about being immobilized? 8. What changes have you made in your a c t i v i t i e s of your daily l i v i n g ? 9. What are your concerns about your hospital stay? 10. How do you get the information you need? 11. What information do you need? 12. How involved would you l i k e to be in what i s happening to you? 13. How do you f e e l about having your cast removed? 14. What types of a c t i v i t i e s do you expect to participate - 128 -15. When do you expect to be able to participate i n these a c t i v i t i e s ? - 129 -

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