THE EFFECTS OF ROCKING CHAIR MOTION ON POSTOPERATIVE ILEUS DURATION, SUBJECTIVE PAIN, PAIN MEDICATION USE AND TIME TO DISCHARGE FOLLOWING ABDOMINAL SURGERY by Robert Lee Massey, BSN, MS, RN CNAA - BC Dissertation Presented to the Faculty of the Graduate School of The University of Texas Medical Branch in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas Medical Branch June, 2007 Copyright by Robert Lee Massey 2007 The Dissertation Committee for Robert Lee Massey Certifies that this is the approved version of the following dissertation: THE EFFECTS OF ROCKING CHAIR MOTION ON POSTOPERATIVE ILEUS DURATION, SUBJECTIVE PAIN, PAIN MEDICATION USE AND TIME TO DISCHARGE FOLLOWING ABDOMINAL SURGERY Committee: Judith C. Drew, PhD, RN, Supervisor Michael Warren, MD Alice T. Hill, PhD, RN Terry Throckmorton, PhD, RN Sheryl Bishop, PhD Kathy Lucke, PhD, RN __________________ Dean, Graduate School Dedication I wish to dedicate this project to all the patients I have cared for during the past twenty- six years, my wife Mona, my mother-in-law Jeannine Molles, daughter Sarah and son Brett. I also wish to dedicate this to my late mother who always encouraged me to continue to grow and learn both as a person and scholar. Acknowledgements This dissertation embodies remarkable sacrifice and endurance, not only by me, but also my family, friends, colleagues and teachers. Words of appreciation cannot express my gratitude to all those who encouraged, supported and guided my venture towards academic and scientific self actualization. I wish to thank: Dr. Judith C. Drew, my supervising professor, who taught me how to appreciate knowledge the qualitative paradigm can offer when seeking knowledge as a quantitative scientist. She also has a firm grasp of the quantitative world as she demonstrated while guiding me through this dissertation. I personally enjoyed and continue to be amazed how she thinks and phrases ideas and concepts into the written word in such a beautiful and scholarly manner. Her guidance and encouragement kept my feet firmly grounded and my vision focused. Dr. Alice Hill, director of a wonderful doctoral program that provides each student an opportunity to challenge themselves academically, intellectually and as budding scientists all the while encouraging and allowing myself and my peers to explore our own areas of interest. I am particularly appreciative of her always having time to sit down and listen to my ideas despite her numerous obligations. Dr. Terry Throckmorton, a person who I have gained tremendous respect for. Terry has guided me through a rigorous institutional review process and also provided outstanding mentorship. She was and still is there when I need someone to discuss not only this dissertation but other ideas I had and continue to generate in order to make research a routine part of nursing clinical practice. I am truly honored to be associated with her. Dr. Sheryl Bishop, for her wonderful knowledge of statistics along with her use of humor allowed me to learn and grow as a student. I truly appreciate her ability to guide me through the analytical phases of the project. She has a unique ability to allow the student to develop a database, analyze and report the data on their own and then offer critical yet positive constructive feedback in a manner that allows one to learn and understand the rationale involved in the complex world of statistics. Dr. Michael Warren, whose support and encouragement for this project and during my tenure as a leader of a urology unit at UTMB is truly appreciated. He supported me and the unit nurses to seek new knowledge and implement new ideas for clinical practice and research without hesitation. His participation as a member of this dissertation committee is very much appreciated. v Dr. Kathy Lucke, who graciously accepted being a member on my committee and the scholarly advice and counsel she provided. I truly appreciate her addition to my committee after the loss of a previous member. Dr. Pamela Watson, dean of the School of Nursing for her leadership and dedication to the growth of aspiring nurse scientists. vi THE EFFECTS OF ROCKING CHAIR MOTION ON POSTOPERATIVE ILEUS DURATION, SUBJECTIVE PAIN, PAIN MEDICATION USE AND TIME TO DISCHARGE FOLLOWING ABDOMINAL SURGERY Publication No._____________ Robert Lee Massey, PhD The University of Texas Medical Branch, 2007 Supervisor: Judith C. Drew Rocking motion may be useful in resolving postoperative ileus (POI) in cancer patients who have undergone abdominal surgery. Operations of the abdomen result in gastrointestinal dysmotility, to some extent, in all patients because abdominal surgical procedures to remove abdominal tumors require large abdominal incisions, extensive dissection, and manipulation of the bowel that initiates a surgical induced stress response commonly known as, postoperative ileus. In this study, the effects of a rocking chair motion as a moderator of the surgical stress response and mediator of the gas and distention effects of POI in abdominal surgery cancer patients compared to standard care was examined. Two groups of postoperative abdominal surgery cancer patients were randomly assigned to the rocking or non-rocking groups. The outcome variables assessed were duration of time to first flatus, subjective pain, total pain medication received and time to discharge. The hypotheses tested were there were no differences in duration of time to first flatus indicating resolution of POI, subjective pain, total pain medication received and time to discharge from the hospital. The rocking group had a reduction in time to first flatus and no differences in subjective reports of pain, total pain medication received and time to discharge from the hospital. Results indicated the rocking chair motion is effective in postoperative abdominal surgery cancer patients reducing the duration of postoperative ileus. vii Table of Contents List of Tables ......................................................................................................... xi CHAPTER 1: INTRODUCTION............................................................................1 1.1 The Problem..............................................................................................1 1.2 The Overall Aim .......................................................................................5 1.3 Hypotheses and Specific Aims .................................................................5 1.4 The Target Population...............................................................................7 1.5 Etiology and Clinical Significance of POI................................................8 1.6 Assessment and Dynamics of POI............................................................8 1.7 Pathophysiology of POI, Sources of Complications and Risks................9 1.8 Rocking as Intervention: Theory and Research......................................11 1.9 Summary.................................................................................................13 CHAPTER II: LITERATURE REVIEW / THEORETICAL FRAMEWORK....14 2.1 Definitions and Descriptions of POI.......................................................14 2.2 Causes, Risks, and Costs of POI.............................................................15 2.3 History of POI, Standards of Care, and Treatment Effects.....................17 2.4 Assessing and Evaluating POI................................................................22 2.5 Theoretical Framework for the Study.....................................................28 2.6 Fit of Benson’s Theoretical Framework and Study Aims ......................30 2.7 Summary.................................................................................................37 CHAPTER III: METHODOLOGY .......................................................................39 3.1 Overall Aim and Research Design..........................................................39 3.2 Hypotheses and Specific Aims ...............................................................42 3.3 Variables and Operational Definitions....................................................43 3.4 Instruments and Measures.......................................................................47 3.5 Setting, Target Population, and Subject Recruitment.............................65 3.6 Protection of Human Subjects and Informed Consent............................67 3.7 Subject Inclusion and Exclusion Criteria................................................68 viii 3.8 Determination of Sample Size and Over-Sampling................................70 3.9 Randomized Group Assignments ...........................................................71 3.10 Pre-Study Staff Education and Training...............................................72 3.11 Protocol Instructions for the Rocking Chair Group (Arm 1)................74 3.12 Protocol Instructions for the Standard of Care Group (Arm 2) ............75 3.13 Data Collection Procedures...................................................................77 3.14 Data Analysis Procedures .....................................................................79 3.15 Threats to Validity and Sources of Error ..............................................80 CHAPTER IV: RESULTS.....................................................................................90 4.1 Purpose and Hypotheses Tested..............................................................90 4.2 General Results .......................................................................................92