Assignment: Qualitative Research Article Analysis

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ORIGINAL ARTICLE

Patient readmission for orthopaedic surgical site infection: an

hermeneutic phenomenological approach

Lilian Machado Torres, Ruth Natalia Teresa Turrini and Miriam Aparecida Barbosa Merighi

Aim and objective. To explore the individual experience of being readmitted for

surgical site infection resulting from orthopaedic surgery.

Background. Surgical site infection has been a cause of concern worldwide and con-

tributes to the greatest number of hospital readmission occurrences. Health profes-

sionals must understand the meaning of these readmissions for the individual, as an

understanding of these exclusive experiences improves the quality of surgical care.

Design. Qualitative research based on the existential phenomenology of Martin

Heidegger.

Method. Eleven individuals who were readmitted because of surgical site infec-

tion participated in the study. The testimonials were obtained over an 11-month

period in 2014–2015 based on the following leading question: What has it been

like for you to be readmitted because of orthopaedic surgical site infection? The

phenomenological analysis identified the sentiment units of the testimonials and

their interrelation, revealing the meanings.

Results. The revealed contents were fear and insecurity of the unknown, frustra-

tion, and the sense of time passing them by and being unable to live their lives.

The individuals felt neglected, and they experienced their social relationality as

impaired and sometimes approaching a breakdown. The patients connected with

God as an attempt to avoid complications and death.

Conclusion. We urge healthcare professionals to deepen their knowledge of the

dimensions of care by developing competencies that consider the subjectivity of

experiences of the health–disease process. When the only listening that takes place

is qualified listening, the professional’s attitudes compromise his or her ability to

provide true care, which transcends the knowledge of doing and reaches the

knowledge of doing with sensitivity.

Relevance to clinical practice. Nursing care requires an attitude that considers the

patient as more than a carrier of illness and should not be limited to what is

described and prescribed, although the latter cannot be excluded in an organisa-

tional point of view.

What does this paper contribute

to the wider global clinical

community?

• Professionals should develop com- petencies for searching for what is not shown in terms of patients’ experiences with the health–disease process. Such competencies tran- scend ‘knowing how to do’ to achieve ‘knowing how to do with sensitivity’.

• Permanent pedagogic and educa- tion projects should contemplate subjectivity, even in a transversal fashion through other disciplines, and depart from the biomedical model that focuses solely on the disease. Disciplines that include a philosophical component in healthcare training, especially a Heideggerian approach, will help to develop professionals with empathy, that is, those who in addition to looking and hearing will be able to see and listen, allowing patients to be themselves in their singularity and plenitude.

• The need to conduct investigations that highlight the perspectives of the individual is emphasised. Such an approach will contribute to a better understanding of individual needs and consequently improve the quality of care.

Authors: Lilian Machado Torres, PhD, RN, Assistant Professor, Med-

ical Sciences Faculty, School of Nursing, Belo Horizonte, MG; Ruth

Natalia Teresa Turrini, PhD, RN, Associate Professor, Department of

Medical-Surgical Nursing, School of Nursing, University of S~ao

Paulo, S~ao Paulo, SP; Miriam Aparecida Barbosa Merighi, PhD, RN,

Full Professor, Department of Maternal, Children and Psychiatric,

School of Nursing, University of S~ao Paulo, S~ao Paulo, SP, Brazil

Correspondence: Lilian Machado Torres, Assistant Professor, Med-

ical Sciences Faculty, School of Nursing, Al. Ezequiel Dias, 275,

Centro, CEP 30, 130-110 Belo Horizonte, MG, Brazil. Telephone:

+(55)(31)999710806.

E-mail: [email protected]

Key words: infection control, nursing, patients’ experience, phenomenology, sur-

gical nursing

Accepted for publication: 25 December 2016

Introduction

Healthcare-associated infections are considered a public

health problem, and they drive institutions to undertake effec-

tive measures for prevention and control (Giroti & Garan-

hami 2015). One of the locations with the highest incidence of

infections is the surgical site (Despaigne Alba et al. 2013); in

Brazil, the incidence of surgical site infection (SSIs) is 14–16%

according to the National Health Surveillance Agency (2009).

Factors contributing to the occurrence of SSIs are

grouped into intrinsic or related to individuals, such as

comorbidities, and extrinsic, or modifiable factors, includ-

ing surgical techniques, preparation of the patient’s skin

and surgical time (Harrop et al. 2012).

In orthopaedics, the majority of SSIs are associated with

the use of implants, and some studies have raised the possi-

bility of a progressive increase in the incidence of such

occurrences (Contreras & Sep�ulveda 2014). SSIs are severe

complications with economic, clinical and social impacts

(Campoccia et al. 2013), and its incidence has revealed

rates that have been rapidly increasing annually (Gutowski

et al. 2016). They almost always indicate a failure in the

treatment (Roman�o et al. 2013) that leads to readmission

of the individual with SSI.

A study on a series of 10,158 patients undergoing ortho-

paedic surgery revealed that 2�2% of them returned to the hospital for reasons directly related to the first surgical proce-

dure, and among them, 21�4% for SSIs (Pujol et al. 2015). Considering the data presented for the orthopaedic spe-

cialty, readmissions by SSI were considered a quality mea-

sure in research that analysed individuals with a higher

probability of readmissions after 6414 primary total hip

arthroplasties between 2006–2010 (Saucedo et al. 2014).

However, readmissions for SSI that result in new surgeries

are underestimated, and the majority of cases are pre-

ventable, being a relevant indicator in assessing quality of

care and associated risk management (Pujol et al. 2015).

Background

Despite the limited attention dedicated to hospital readmis-

sions (Kirby et al. 2010), a study on possible associated fac-

tors pointed to infection as the main cause of readmission

after six different procedures. Specifically, in cases of knee

and hip arthroplasty, SSI was the main reason for readmis-

sion (18�8%) (Merkow et al. 2015). In terms of global impacts, SSIs are considered a burden

for healthcare systems because of the associated morbidity,

mortality (Leaper et al. 2013) and its relatively high cost

(Gutowski et al. 2016). Readmissions due to SSIs cost more

than double when compared to readmissions due to other

reasons, such as mechanical failure (Gutowski et al. 2016).

The measures to prevent SSI are well established, and

professionals should know and implement them while pro-

viding health care (Harrop et al. 2012). Specific protocols

for orthopaedic units include actions regarding internal pro-

cedures and strategies for epidemiological surveillance

(R~autia & Nemet 2015).

However, a literature review on the characteristics of

studies that addressed readmissions for SSI after orthopae-

dic surgeries did not find studies that assessed the repercus-

sions for affected individuals (Torres et al. 2015). Pujol

et al. (2015) highlight the importance of investigating revi-

sion surgery and its consequences at the global level.

From the individual’s perspective, being in the hospital

represents a major disruption in their routine (Santos &

Carlo 2013), even with scientific and technological

advances in health recovery (Sanches et al. 2013). In this

context, the associated physical frailty and emotional vul-

nerability are potentialised as a problem that the individual

must experience in the presence of strangers.

For example, few studies have demonstrated experiences

related to being in a hospital due to SSI, regardless of being

the first hospitalisation in people’s lives or subsequent

occurrences. However, admissions or readmissions are

unique experiences that do not repeat in the same manner.

The results of a qualitative study that analysed 14 testimo-

nials from individuals who developed SSI detected signifi-

cant pain, isolation, insecurity and negative economic,

social, physical and emotional impacts, some of which were

long-standing (Andersson et al. 2010). Seventeen patients

who underwent surgery in three hospitals in the United

Kingdom reported experience of despair and a desire to die

when describing how SSI affected their lives and the lives

of their family members (Tanner et al. 2013).

Considering this as a research gap, this study aimed to

explore the experiences of individuals subjected to ortho-

paedic surgical procedures who were readmitted because of

LM Torres et al.

SSI based on the following questions: What is it like to be

readmitted for SSI? How is the readmission for SSI under-

stood from the personal, family and work perspective?

What personal and social effects related to readmission for

SSI does the individual experience?

At the international level, it is relevant for integral care

policies to consider this history dimension in efforts to

improve the quality of care. Such an expansion with a focus

on the provision of care that directs healthcare provision

and education and that considers the need to invest in the

permanent development of nurses in various contexts and

specialties is encouraged.

The study

Aim

To explore the individual experience of being readmitted

for SSI resulting from orthopaedic surgery.

Design

Qualitative research with a phenomenological focus based

on Martin Heidegger’s theoretical framework. This frame-

work has shown to be consistent with and adequate for

nursing research because of its humanistic principles and

study domains, which involve the theory and practice of

care as an attempt to understand how phenomena impact

the health of individuals, their families and the community

(Paula et al. 2012).

A phenomenon, according to Heidegger (2011), must be

understood as something that manifests in itself and that

constitutes one’s way of being; thus, it is understood as an

encounter and not as an outward projection. First, this

understanding is achieved through the factual dimension,

which in our case relates to the testimonials themselves.

Next, it involves hermeneutics, which through interpreting

and seeking meanings reveals the uncovered, which emerges

as a phenomenon (Paula et al. 2012). Heidegger’s

hermeneutics is a method of interpreting reality that leads

to comprehension (Almeida 2014). Using this process,

understanding the human being who experiences a readmis-

sion for SSI after being subjected to an orthopaedic surgical

procedure becomes a practice of care. Because humans are

not detachable from the world (Roehe & Dutra 2014),

experience affects the relationality between this individual

and the surrounding readmission environment. The method-

ology of this study enabled an understanding of the study’s

subject: the readmission for SSI after an orthopaedic surgi-

cal procedure, from a subjective point of view.

Participants

The study included 11 individuals who underwent ortho-

paedic surgery in a Brazilian public hospital and were read-

mitted for SSI during an 11-month period in 2014–2015.

The following inclusion criteria were used: individuals older

than 18 years of age who returned to the hospital with an

indication for readmission because of SSI and who under-

went their first surgical intervention at the same institution.

The starting point for subject selection was the SSI report

from the Hospital Infection Control Committee, which fol-

lows the international criteria of the National Healthcare

Safety Network (NHSN) (2013). In this health institution,

there are no data on readmission for any cause. Data on

the first admission, surgical intervention, SSI and readmis-

sion were verified by the researcher in the hospital informa-

tion system. After the SSI diagnosis and the fulfilment of

the readmission criteria for SSI were confirmed, the individ-

ual was contacted at the admission unit for the necessary

introductions and the first contact related to the study.

Those who agreed to participate received a consent form,

which contained authorisation for audio-recording and

described the study motivation, objectives and procedures.

After the consent document was signed, individual meetings

to record testimonials were scheduled; the meetings took

place at the participant’s bedside. Only the researcher and

the participant were present at the meetings. The study par-

ticipants were identified with the letter ‘P’ followed by a

personal identification number. The number of interviewees

was not established prior to the study, and the collection of

statements was closed when theoretical data saturation

occurred, or when the interaction between participant and

researcher no longer provided elements to sustain or deepen

theorising of the subject (Fontanella et al. 2011). This crite-

rion was evaluated by the researchers as a group.

Data collection

The data were collected through face-to-face nonstructured

interviews conducted by the first author, who is a nurse

with previous experience in surgical centres and with infec-

tion control. A total of 12 interviews were conducted, and

the interviews were not repeated. However, one interview

was discarded because the interviewee withdrew consent

and did not present the reasons why they made this deci-

sion. To reveal the phenomenon of readmission for SSI

from a perspective congruent with the methodological

choice of Existential Phenomenology, the following guiding

question was used: What is it like for you to be readmitted

because of an infection in your surgery site? The question

Original article Patient readmission for surgical site infection

was tested with two individuals to assess its pertinence, and

the testimonials were stored exclusively through recordings.

The question should enable a favourable environment for

intensifying the participant’s verbalisation during the testi-

monial and encouraging the experiential description of the

phenomenon so that meanings are expressed (Paula et al.

2014). The duration of the meetings varied from 30–

45 minutes and respected the participant’s desire for

expression related to the topic. After each testimonial, we

transcribed the interviews without returning to the partici-

pants. We then engaged in repetitive reading of the tran-

scripts to consider the situations that the participant’s

experienced from multiple angles. The interviews were orig-

inally conducted in Portuguese with Brazilian respondents.

The responses were then translated into English by a pro-

fessional translation service.

Ethical considerations

The study complied with the ethical principles of human

subject research and was approved by the Research Ethics

Committee of the School of Nursing of the University of

S~ao Paulo, Brazil, and the coparticipating institution (Dr.

Luisane Maria Falci Vieira – Protocol number 527.293).

Among the fundamental ethical aspects, we emphasise that

there was nondiscrimination in the selection of the partici-

pants, who were not exposed to risks other than discomfort

arising from verbalising their experiences, impressions and

desires, and that the privacy and confidentiality of the testi-

monials were ensured. The interviewed individuals did not

show or express such discomfort.

Data analysis

For the organisation and analysis of the meanings contained

in the testimonials, we sought to identify the units of meaning

that were most significant to the participants and aim of the

study. This methodology, recommended by a Brazilian

researcher who supports a rigorous delimitation of the study

theme, facilitates a deep analysis of the meaning of expres-

sions (Josgrilberg 2000). Units of meaning are expressions or

phrases that contain a meaning related to the experiences

specific to individuals who are readmitted because of SSI. The

careful reading of each interview enabled the extraction of

units of meaning that were grouped with the units of meaning

from other testimonials. Thematic categories were derived

from the interrelation of the units, linking the meanings that

the individuals revealed. A phenomenological analysis based

on Martin Heidegger’s framework revealed what was latent

or concealed in the experiences.

Rigour

The methodological rigour included the systematic collec-

tion of data from the institutional reports and systems; the

respect for the participants’ privacy during the interviews,

which were conducted exclusively by one of the researchers;

the verbatim transcriptions of the testimonials; the identifi-

cation of the units of meaning; and the categorisation of

the discovered meanings. In qualitative research, it is neces-

sary to pay attention to the delimitation of the study object,

research issues, strategies and attitudes during data collec-

tion and to the choices made during data organisation,

analysis and propositions. Empathy, understood as the abil-

ity to feel what it would be like to be in another person’s

situation and circumstance, is also essential for creating an

environment favourable to intensifying the experiential

description of the study object and encouraging the expres-

sion of meanings (Paula et al. 2014).

Results

The 11 participants included six men and five women with an

average age of 54 years. Five were retired, two were unem-

ployed, and four were formally employed. Eight were mar-

ried, two were single, and one was a widow. During the

reading of all of the testimonials, the units of meaning were

highlighted and grouped according to the following thematic

categories, which revealed the readmission phenomenon

essence: Experiencing insecurity and fear, experiencing frustra-

tion, perceiving that time is passing you by, impaired social

relationships, experienced neglect and attachment to God.

Experiencing insecurity and fear

Insecurity is embodied in statements about not knowing

what could happen:

I went back to the emergency room and the doctor said: “Oh!

Things got complicated.” A whole world goes through your mind.

The doctor said that the infection is subsiding, but it is hard to

believe. You do not see it. It gives you a certain fear about what

might happen. (P8)

I was afraid of everything but mostly of losing my leg. . .. I do not

want to talk anymore. I am sorry, but it bothers me a lot because I

am still afraid. (P6)

Not knowing about the future is reflected as uncertainty

about what could still happen:

What can still happen to me? I do not know. It seems that it’s get-

ting better, but I am even afraid to look and see if it really is. (P9)

LM Torres et al.

It is like reexperiencing something that I did not know about the

first time. It is a feeling of not knowing what to do. I’m apprehen-

sive. . . let’s see what will happen. (P4)

The absence of experts or medical specialties in all care

settings when health care is needed causes insecurity:

I had to come to a larger center. I am afraid of going my town,

getting there and not finding resources. Will the doctors be able to

get rid of this infection that is stuck in my bone? (P1)

Frustrations arise in relation to the (im)possibilities that

the participants envision and are associated with the way

they perceive the care provided.

Experiencing frustration

Experiencing the readmission process for SSI results in frus-

tration, grief and fatigue, and the participants associate it

with suffering:

I have never imagined having to go back: doctor, hospital, we want

distance from everything that can mean pain. One imagines that

the hospital means pain, death, and suffering. (P9)

I was feeling fatigued when it started all over again: being admitted

again, suffering again, always hoping to get better. (P3)

Frustration appears in response to SSI and readmission

and to the time spent on something unexpected:

The word that sums up what we are feeling after 10 months in the

hospital is frustration with always being hospitalized. This going to

and coming from hospitals. . . the frustration continues. Perhaps

because of the delay in getting here, the lack of concrete answers,

and what is more frustrating is that those who live in the country

are at the mercy of anything; in my case, “anything” did not solve

the problem. (P1)

Time appears in different ways in the reports. Although

it is always verbalised in chronological order (days, weeks,

months), it is associated with its individual and familiar

meaning.

Perceiving that time is passing one by

The temporal or chronologic dimension has various

angles among the interviewees, but it is always associated

with what is lost in life, with what is not being carried

out:

Only at the end, the doctor said that it would be about six weeks.

Oh! Six weeks is not six days. I’ve been here for three months, and

nobody tells me how much longer I will stay. (P9)

The professionals collect material for tests. They have already dis-

continued the antibiotic for 10 days. And I am still here for two

months. . . Do you know what this is? (P3)

The information about days and weeks does not have the

same connotation for the affected individuals that it has for

health professionals:

The doctor says it is simple, just a little infection, a few more days

and it will be resolved. But when you are admitted for this reason

and time passes by. . . (P11)

I don’t know what to say because it was a month that disap-

peared from my mind. I don’t know what to say about this time

period, and I am here with no perspective of when I will leave.

(P1)

Some of the interviewees live far away from the admit-

ting institution, which evokes experiences such as missing

family members and home and a preoccupation with their

routine activities.

Impaired social relationships

In the reports, it was clear that the hospital is not like

home for the participants. They have wistful memories of

the people, spaces and situations of their daily lives and

expressed as experiencing isolation:

This is not our home. I keep remembering my city, family,

friends. . . I miss the folks a lot. (P2)

You would like to be in your own home, with your family. This is

not my home. I would like to be lying down on my bed, receiving

visitors with my mom’s coffee, which is really good, strong, and

sweet. You know that family never leaves my mind? (P10)

There is a certain discomfort among interviewees when

they perceive that they are a burden to their family mem-

bers and are altering family dynamics:

Our absence is a sacrifice for our children. Being here complicates

things for everyone. (P7)

Now, being here again. . .I wonder about the house, the people,

how they organize things, food, clothes. You cannot focus on here

or there. (P8)

Affective life is also impaired, and the participants ver-

balised the fear of disruptions in their relationships with

their spouse and children:

I worry whether I will be able to ride a bicycle again. My girlfriend

comes here now because I am hospitalized. We are not seeing each

other much. (P10)

Original article Patient readmission for surgical site infection

The questions I ask are not the same ones my son asks me. The

same way I wanted to have him around, he also wanted me over

there. There is no way you can stop thinking about the children,

about the family. . . (P1)

Social issues and work activities also stood out in the

interviewee statements:

I hope to get out of this situation because I think I am still young,

I love life, I really want to enjoy life, I love to dance, walk,

travel. . . (cried). (P4)

Because I am a school teacher, I had many activities, and today

there are seven families being fed because seven people substituted

for me. That is good, because I must be very good at what I do.

(P1)

There were also obvious issues related to experiences

about the care (or lack of care) they received.

Experienced neglect

Experiences of the quality of care and the divergent

responses of professionals or institutions to the individual

or his/her family caused great disappointment and are

defined by a large gap between the care and what is actu-

ally experienced:

The doctor discharged me twice with generalized infection. . . it

was the worst part of the treatment. This coming and going was

because of a medical error and left me extremely disappointed. My

foot became crooked, the implant was removed, and the doctor

discharged me with septicemia. (P1)

I was operated on again after three days in the emergency room.

My surgery was because of a bad job by a doctor who should not

be a doctor, should choose another profession. (P6)

The participants also evaluate the healthcare system in

relation to the quality of the service provided. There is a

general belief that one cannot expect much from the public

service, reinforcing the experience of disappointment and

neglect:

How many hospitals will I need to go to for an answer? All they

have done is push me from one place to another. Rarely in the

public health care network can you find a good infectious disease

specialist, and when you do, they are scarce and expensive. (P1)

Complaints surface that the professionals do not

acknowledge the patients’ symptoms:

I become outraged. I went to the doctor who operated on me

and he said, “It is a problem with the muscles”. A kind of tor-

ture. I went back several times, would get an x-ray, a test, and

would tell myself, “there is something wrong”. . . and now, I am

like this. (P4)

It creates the feeling that everything went wrong when the doctor

examines you and says “It is simple, just a small infection; a few

more days and everything will be resolved”. (P11)

The distrust regarding the care being provided leads indi-

viduals to question the treatment or instructions – even as

they related to taking antibiotics, for example:

A “drain” was going to be placed, but it took too long, and I

asked, “Aren’t you putting in the drain?” I waited so it wouldn’t

become too swollen. The doctor said, “We won’t put it in.” I

waited, disoriented. And confusion grows in your mind. (P3)

I was counting the 14 days of antibiotics, but the doctor said,

“You don’t need to count; we are counting.” But I counted any-

way. (P5)

Finally, the religiosity demonstrated in the next category

expresses the participants’ faith in a superior being that sees

everything and decides.

Attachment to God

Faith in God is related to healing and the possibility of

going home. It includes the consideration that everything

happens according to divine will, including the SSI:

Deep inside, I wait for God. He knows what He does; what is sup-

posed to be will be. God will be around. (P11)

Everybody says it will improve, and we are waiting because this is

what everybody wants. To leave cured. In fact, I wanted this since

the first time. . .. I believe in God, and He wanted me to come

back. (P9)

There is hope that God will lead the treatment and labo-

ratory tests, will intervene in the results and will enlighten

professionals so that drugs will work to cure the SSI that

caused the readmission and prevent the patient from leav-

ing:

With faith in God, it won’t be long before I leave. I ask God for

the strength to get treatment and get out of this situation. I came

with the certainty that under God, I would be cured. (P2)

There are still two weeks to finish the antibiotics. I do not know if

I will be able to go then, but God willing, everything will be all

right. (P7)

I hope from the bottom of my soul that I will get out of here

cured! God is good! I very much hope and pray to God to

enlighten the doctors, get my treatment right. I want to leave! (P8)

LM Torres et al.

Some doubts and issues are dissipated because of faith

and hope in a God who has the power to define, decide,

resolve and ultimately to cure:

Oh my God, how is it going to be? I thought I was going to die,

but I thought, “God is the only one who can decide,” and I was

thinking of God, waiting for God. I have faith! (P3)

Actually, I do not know if I am going for surgery again. The doctor

told me that he would check if the medication is working. I have

faith that I will be healed. (P5)

Finally, readmission for SSI is associated with the possi-

bility of death. Although there is a divine plan, the partici-

pants have hope and faith that they will survive:

There was a man in the other room who died of infection. I think

it is not my case, but God is with me, and it will not happen. (P8)

Everything will be all right. Hope and faith in God are what make

us endure the wait. Even death comes only when God wishes,

right? (P5)

These ontological unifications revealed the sense behind

their readmission for SSI, according to the patient perspec-

tive.

Discussion

SSI concretises the readmission that again brings the indi-

vidual in contact with health professionals in the hospital

environment. These individuals feel fear and insecurity

because they have already faced a similar situation.

The testimonials point to fear in the sense of the possibil-

ity of being in danger of death, sequelae, or reduced mobil-

ity or independence. Studies on direct and indirect impacts

of SSI in orthopaedic surgery, or only related to recovery

have shown that individuals anticipate a threat to their

ability to participate in routine activities or the need to

adapt after orthopaedic surgeries (Rodrigues et al. 2012,

Nagai et al. 2014). Fear implies perceiving what will or

may happen through concrete means (Heidegger 2011).

Health professionals identify fear but do not sufficiently

value it. In the absence of such reflection, the fear reflects

the conception of the one who cares rather than one who is

cared for. Consequently, the patient does not have the

opportunity to talk about what he/she feels and to have the

professional listen what is said, understand its meaning and

translate it back, and an opportunity is lost for care provi-

ders to amplify their ability to understand the experience of

readmission due to SSI.

Those issues add to patients’ frustration with healthcare

professionals and their competence and with the perceived

poor quality of healthcare institutions. A Romanian study

that assessed patient satisfaction on SSI associated with

health care in an orthopaedic unit found that care providers

should be concerned with providing clear and objective

information because it directly influences patients’ percep-

tions regarding the health professionals and the healthcare

institution (R~autia & Nemet 2015). An understanding of

the course of the disease and of the received care minimises

patient frustration about what happened during the read-

mission. Heidegger (2011) shows that in the absence of a

service with desired quality, there is a gap, and what is

pending in the healthcare provision is not available.

Readmission status removes the opportunity for individu-

als to follow and participate in their own care. Heidegger

(2011) shows that there is the desire for something that is

already understood, a role in determining the way individu-

als would like to be cared for. Frustration arises from a

possibility-of-being, which readmission patients perceive as

different from what they actually experience.

The illness experience is unique and individual. Such an

understanding constitutes a conceptual richness that needs

to be internalised by nurses (Queiroz 2015) so that they

can better attend to care demands.

The true sense of care presupposes a communication pro-

cess that enables the individual to participate in the interlocu-

tion in a context that follows them and that is not complete

without them. Welcoming, care and attention are competen-

cies that need to be developed and, from the patient’s perspec-

tive, are based on an intersubjective relationship that respects

and considers the individual, sharing decisions and listening to

reports that demand to be listened to. According to Heidegger

(2011), what comprises an individual’s being only makes

sense when, within the self, the individual becomes under-

standable from the perspective of being.

One of the issues that justify the improvement of care is

the prolonged time of orthopaedic treatments, which

imposes a financial burden on the individual and on health-

care institutions (Rodrigues et al. 2012, Kapadia et al.

2014). American and European studies reported that SSIs

in general require readmissions, long recoveries, the

increased use of antimicrobials and increased lengths of

stay (Harrop et al. 2012, Zimmerli & Moser 2012, Nacke

et al. 2013). However, this chronological time has different

meanings for the professionals and the readmitted individu-

als. The former quantify time without considering its mean-

ing for those who are no longer able to live how and where

they used to.

The participants perceive time passing them by and

removing from them the possibility of being. They describe

and identify spaces in their homes, scents and the activities

Original article Patient readmission for surgical site infection

of family members; to those who listen and look for what

is hidden, such comments point to an ‘existence that disap-

pears’ because they are readmitted. These memories and

references comfort those who need to feel that they belong

and are sheltered; they become a form of living ‘what can-

not be lived’ during readmission and are relevant to an

understanding of the experience of individuals who remain

in hospitals for months.

Given the threat of disruption, patients need to have their

absence recognised because their readmission leaves an

unoccupied space. In Heidegger (2011), to occupy a place

is being in this place, and the desire to be close to others

may be understood as being where humans are never only

in themselves, but relating with others and with things.

Surgical procedures must be followed, but a gesture or a

look beyond what can be seen and the sharing of care

allows the individual to realise that their care provider can

give meaning to what they cannot verbalise. Allowing

patients to participate requires nurses to judicially evaluate

the risks and benefits of each situation (Tobiano et al.

2015).

When readmitted patients perceive that they are not wel-

come to participate in the construction of an intersubjectiv-

ity that respects and considers their suffering (2015,

Queiroz 2015), they experience neglect from the healthcare

institutions, which minimise their history and complaints

and demand additional time for treatment, which means

less time for the patient to live his or her life. The construc-

tion of a dialogue in a relationship requires listening

because it allows speaking.

Patients know how they feel and how they are treated,

regardless of their technical ability to evaluate the health-

care service (R~autia & Nemet 2015). Health care, specifi-

cally of physicians and nurses, shows paths that allow

patients facing readmission the necessary autonomy for

self-care. Heidegger (2011) defines authentic care as care

that establishes a bond between the one who provides care

and the one who is cared for. Configuration of the care

provided is based on reliability and in the expectation of

the responses required from the understanding of those

involved (Graham et al. 2015).

Confronted with these experiences, the readmitted indi-

vidual connects to religion and spirituality in the light of

the inevitable: the SSI that led to the readmission. Reflec-

tion on the relationship between humanity and God has

various aspects: proximity, following and divine blessing,

including salvation of the soul in the case that death, which

is always present, prevails.

To identify the role of spirituality in the context of an ill-

ness with some risk of death, Yong et al. (2015) analysed

their results according to the phenomenological view; they

verified that spiritual beliefs gave seriously ill individuals a

greater sense of purpose, which helped them make neces-

sary adjustments. Despite this, there is a need for studies

that clarify its influence in health and its mechanisms of

action (Reinert & Koenig 2013).

The testimonials contributed to an understanding that

the work of professionals, especially nurses, should not be

limited to what is described and recommended. It is impor-

tant for nurses in infection prevention control too. The

experiences of readmitted individuals included the most

intimate and subjective aspects of their current way of

being: the desire to have their feelings recognised, to have

time to live during readmission, to feel like they are wel-

come, to be working towards autonomy and to be able to

organise their relationships with themselves, with others,

and with their spirituality.

Limitations

The study was conducted at a single healthcare institution

with a sample of subjects that was relatively small,

although adequate for qualitative research. Therefore, the

generalisability of the results is constrained, although con-

sistent with previous literature. Considering the search by

understanding such experience, there is no intent to univer-

sally generalise the study conclusions or to close the investi-

gation. Given the lack of publications on this theme, other

studies that cover different aspects of readmission for SSI,

both for individuals at risk of this event and for those who

provide care, will enhance the results of the present study

by continuing in the same direction, that is, promoting true

care that liberates the individual (receiving care).

As a global contribution, it should be emphasised that

international protocols for SSI may and should consider the

experiences of the individual exposed to the unexpected

event. Epidemiologic data could consider not only measures

related to health and disease but also the more subjective

aspects of health problems.

Conclusion

Research conducted in the light of the existential frame-

work of Martin Heidegger allowed us to understand the

experience of individuals subjected to orthopaedic surgical

procedures and readmitted for SSI. This experience is

unique and personal, and it requires a sensitive view of

needs that are not obvious. The work of nurses requires an

attitude that considers the individual as more than a bearer

of illness. Quality listening allows the speaker to say more

LM Torres et al.

than what is spoken. Viewing all these dimensions demands

a professional with reflective training based on the experi-

ence of the other to potentialise true care, which is a libera-

tor in an existential dimension.

Given that protocols and guidelines on the prevention

and control of SSI are available, it is up to health profes-

sionals to develop competencies that include openness, lis-

tening and comprehension of experiences beyond the

health–disease process to provide better care for those who

are readmitted for SSI and to promote care that transcends

‘knowing how to do’ and achieves ‘knowing how to do

with sensitivity’.

Relevance to clinical practice

Nursing care requires an attitude that considers the patient as

more than an object or a carrier of illness and should not be

limited to what is described and prescribed, although the lat-

ter cannot be excluded in an organisational point of view.

Quality listening leads health professionals to reflect on car-

ing for someone who, after being readmitted, shares the most

intimate and subjective experiences that comprise the self.

Widening the horizon beyond the quantitative aspects of

SSI improves the quality of care and contributes to greater

attention to prevention and control. Disciplines that include

a philosophical component in healthcare training, especially

a Heideggerian approach, will help to develop professionals

with empathy, that is, those who in addition to looking

and hearing will be able to see and listen, allowing patients

to be themselves in their singularity and plenitude.

Funding

This research received no specific financial support from

any funding agency in the public, commercial or not-for-

profit sectors.

Contributions

All authors have agreed on the final version and met at

least one of the following criteria: substantial contributions

to conception and design, acquisition of data or analysis

and interpretation of data, and drafting the article or criti-

cally revising it for important intellectual content.

Conflict of interest

No conflict of interest has been declared by the authors.

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