Intensive and Critical Care Nursing (2014) 30, 93—100

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ORIGINAL ARTICLE

From reaching the end of the road to a newlighter life — People’s experiences ofundergoing gastric bypass surgery

Angelica Forsberg ∗, Åsa Engström, Siv Söderberg

Division of Nursing, Department of Health Science, Luleå University of Technology, Luleå, Sweden

Accepted 21 August 2013

KEYWORDSPeople;Obesity;Experiences;PACU;Gastric bypass;Interviews;Qualitative contentanalysis

SummaryObjectives: It is limited research that focuses on people’s experiences from prior to surgeryto the postoperative period after a gastric bypass. The aim of this retrospective study was todescribe people’s experiences of undergoing gastric bypass surgery.Method: A qualitative approach was used. Interviews with ten participants were subjected toqualitative content analysis.Results: The analysis of the interviews resulted in one theme: from reaching the end of theroad to a new lighter life. Prior to surgery participants described a sense of inferiority and thatthey were not able to ‘take any more’. Shortly after surgery participants felt both vulnerableand safe in the unknown environment and expressed needs of orientation and to have thestaff close. Despite information prior to surgery it was difficult to imagine ones’ situation afterhomecoming, thus it was worth it so far.Conclusion: The care given in the acute postoperative phase for people who undergo gastric

bypass surgery, should aim to provide predictability and management based on individual needs.Being treated with respect, receiving closeness, and that the information received prior tosurgery complies with what then happens may facilitate postoperative recovery after a gastricbypass surgery. © 2013 Elsevier Ltd. All rights reserved.

Abbreviations: BMI, body mass index/kg/m2; GBP, gastric bypass; ICU,cf, compare; dnr, diary number.

∗ Corresponding author at: Department of Health Science, Luleå UniveTel.: +46 920 49 38 22; fax: +46 920 49 38 50.

E-mail addresses: angelica.forsberg@ltu.se, angfor@ltu.se (A. Forsbe

0964-3397/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.iccn.2013.08.006

intensive care unit; PACU, post anaesthesia care unit; md, median;

rsity of Technology, SE-971 87 Luleå, Sweden.

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94 A. Forsberg et al.

Implications for Clinical Practice

• Interventions to avoid exposure of one’s body postoperatively could be to plan the placement to avoid passing otherbeds and provide a complete coat prior to mobilisation.

• That the staff postoperatively have access to the information people who undergo a GBP have received prior tosurgery may lead to an understanding of their needs for information and explanation.

• Individual and tangible support and encouragement concerning mobilisation are needed for people after GBP surgery.• That staff are close by and explain and maintain contact with openness which is essential for patients not feel

forgotten in an acute setting.• Another level of care, immediately after GBP surgery, for example a step-down unit may prevent a feeling of being

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besity is an increasing problem for people in the west-rn world. In Sweden about half of the men and about

third of the women are overweight or obese withncreased risk for comorbidities and premature death (Theational Board of Health and Welfare, 2009). Body mass

ndex (BMI = kg/m2) above 25 is defined as overweight andMI above 30 means obesity (Swedish Council on Healthechnology Assessment, 2002). People with obesity whoave lost weight through diets often relapse to their orig-nal weight. The most effective method in a long termerspective to achieve permanent weight loss has beenhown to be surgery (Bult et al., 2008). Gastric Bypass (GBP)urgery in Sweden may be considered for people with aMI above 35 (The National Board of Health and Welfare,009).

In several studies (Hager, 2007; Klingemann et al., 2009;ruseman et al., 2010), people have reported increased sat-

sfaction in daily life after undergoing obesity surgery. Theositive experiences described shortly after obesity surgeryesides weight loss, are improved mobility and strengthBocchieri et al., 2002; Klingemann et al., 2009; Krusemant al., 2010). People often feel more attractive after weightoss (Magdaleno et al., 2011; Wysoker, 2005) and feelingsf increased self-confidence and control have also beenxpressed (Magdaleno et al., 2011; Ogden et al., 2006).egative experiences after obesity surgery in a short termerspective are described as feelings of emptiness, hungerains, and loss of energy, symptoms that influence daily lifeo a great extent (Groven et al., 2010; Lepage, 2010; Ogdent al., 2005).

After a GBP, the patient is monitored in a post anaes-hesia care unit (PACU), before being transferred to aard. PACU:s are standard parts of hospital care in mostospitals in the western world. Their main purposes are todentify, prevent and/or immediately treat early compli-ations of anaesthesia or surgery, before developing intoeleterious problems (Vimlati et al., 2009). Obesity and itsomorbidities affect every organ system and the risk forostoperative complications is increased after GBP surgeryResidori et al., 2003). Obese patients are twice more likelyo develop serious respiratory problems during and shortly

fter anaesthetic than non- obese patients (Cook et al.,011). Feared causes of early morbidity and mortalityfter GBP surgery are anastomotic leaks and pulmonarymbolism, which may be difficult to diagnose. Another

Topi

omplication is venous thromboembolism. Concluding, both close monitoring and an early mobilisation are requiredfter GBP surgery (Bult et al., 2008).

A PACU consists of an open environment with manyeverely ill patients being cared for postoperatively simul-aneously in a high-tech environment, and is often a partf the intensive care unit (ICU) (Allen and Badgwell, 1996).rior to surgery patients ranked their most feared postop-rative symptoms as pain followed by vomiting, nausea,nd disorientation (Jenkins et al., 2001). Sedation influ-nces the speed at which a postoperative patient progressedlong a continuum from dependence to independence. Dur-ng this process, the patient is vulnerable and needs supportHumphreys, 2005; Reynolds and Carnwell, 2009). Patientsave reported being cared for in the presence of othereople with mixed levels of satisfaction (Baillie, 2009) andave perceived physical activities in perioperative cares excellent, but desired more information and involve-ent in their care (Leinonen et al., 2001). Postoperative

ecovery is defined as an extended process, where theoal after surgery is to achieve a stable physiology (Allvint al., 2007). There is a lack of understanding of the pro-esses that describe the detailed experiences of surgicalatients in clinical care (Leino-Kilpi and Suhonen, 2006).CUs tend traditionally to be isolated units with some-imes limited contact with other levels of care (Leith,998).

Thus, knowledge about being ill or injured includeshe whole process from the initial stages through to theecovery period at home (Bergbom, 2007). Patients haveeported a great need of information and support beforend after obesity surgery (Grindel and Gatson-Grindel,006).To the best of our knowledge there is a lack ofesearch describing people’s experiences from prior surgeryo the GBP and then through their postoperative period.herefore, the knowledge from this study might improveuch understanding and can be used to design a carerocess that is more in agreement with the patient’seeds.

he aim

he aim of this study was to describe people’s experiences

f undergoing GBP surgery, from the decision-making periodrior to the GBP until two months after the GBP, thus includ-ng the care given at hospital.

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Table 1 Overview of the theme (n = 1) and categories(n = 5) constructed from the analysis of the interviews.

Theme Categories

From reaching theend of the roadto a new lighterlife

Feeling inferior with the body as anobstacle

Waiting for surgeryWaking up and feeling bothvulnerable and safeGetting started and preparing to gohome

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Method

Design

A qualitative approach was used. According to Polit andBeck (2008), qualitative methodology means focusing on thesubjective experience of a certain phenomenon, topic, orproblem.

Settings

The surgery was performed in a hospital in the northern partof Sweden. The PACU consists of an open environment witha number of beds. The participants stayed overnight in thePACU after their GBP and were cared for in a surgical wardboth before and a few days after their stay at the PACU.

Procedure

Thirty patients attending a post-operative surgical clinic onemonth after surgery were requested to participate in thisqualitative research by this nurse-led service. A purposivesample means that people who can answer the aim of thestudy will be selected (Polit and Beck, 2008). The criteria forparticipation were that the participants were over 18, hadundergone GBP-surgery and were willing to talk about it.They received an information letter and a request for partic-ipation. Ten people answered the letter by signing a consentform and were subsequently contacted by telephone.

Participants

A sample of eight women and two men, aged 30—53 years(md = 42 years), participated in the study. All participantsbut one had children, two were single and the rest weremarried or cohabiting. Three participants were on long-term sick leave and the remaining sample were working inprofessions providing care or service. All participants hadmade repeated unsuccessful dieting attempts and struggledwith conditions such as diabetes, sleep apnoea, and/or highblood pressure. The BMI ranges prior to the surgery were35—52 (md = 40). All participants underwent a laparoscopicGBP with general anaesthesia. The reported total weightloss one month after surgery was between 16 and 33 kg(md = 24.8 kg).

Data collection

Personal interviews were used to collect data (cf. Kvaleand Brinkmann, 2009). Participants were asked to tell theirstory about being obese and undergoing a GBP. Clarifyinganswers were asked: such as ‘‘Can you please give me anexample’’. The participants were interviewed between oneand two months after surgery. The interviews took place in

their homes (n = 8) and at their workplaces (n = 2), in accor-dance with their wishes. The interviews lasted between 60and 120 minutes (md = 80 minutes), and were recorded andtranscribed verbatim by the first author.

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Coming home with expectationsabout a changed body

thical approval

pproval for performing the study was given by the Regionalthics Review Board (dnr 1230-10) and the medical headst the hospital. Each participant signed a consent form andonfidentiality was guaranteed. Assurances were given thatarticipation was voluntary and that participants could with-raw at any time.

ata analysis

he interview texts were analysed by the authors using aualitative content analysis approach (cf. Downe-Wambolt,992). Each interview was read through several times inrder to gain a sense of content. The whole text was thenead to identify meaning-units, guided by the aim of thetudy. The meaning units were condensed and sorted intoategories related to their content. A category refers to

descriptive level of content; an expression of the mani-est content of the text. Analysis of what the text is aboutnvolves an interpretation of the underlying message of theext; the latent content (Catanzaro, 1988) and a theme cane seen as an expression of the latent content of the text.he categories related to each other were subsumed into

theme. By moving back and forth between the text andhe output of the content analysis a progressive refining ofata was achieved (cf. Downe-Wambolt, 1992). The analysisesulted in a theme with five categories (Table 1).

esults

he theme and the categories (Table 1) are presented inhe text below and are illustrated with quotations from thenterview text.

rom reaching the end of the road to a newighter life

eeling inferior with the body as an obstacle

articipants described that they desired a healthier life andhat their body had been an obstacle in daily life due to

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heir obesity, with recurring pains, difficulty breathing, andmpaired sleep. Participants expressed difficulties movingnd lack of strength in daily life, which led to trouble tak-ng part in activities. They described feelings of shame andometimes they blamed themselves for having eaten toouch. Participants expressed a fear that people would think

hey were stupid, lazy, and lacking in character relating toheir obesity. Feelings of being less valued and somehowike a second class citizen were described and partici-ants expressed feelings of being stared at because of theireight.

If you’re going on job interviews one feels as a secondarychoice if you don’t get jobs or something that it’s becauseyou’re overweight.

Some participants described that when, before surgery,hey underwent examinations for other conditions, staffad stated that it was impossible to palpate the abdomenecause they were overweight or that the equipment wasoo small. Participants felt ashamed but pretended to beappy and sometimes joked about their obesity — but theylso revealed that they suffered and sometimes cried atight.

aiting for surgery

articipants expressed not being able to handle the obe-ity anymore and that change was needed. Fear of sufferingomorbidities or death related to their obesity was commonnd they thought a lot about advantages and disadvantagesf undergoing surgery. Some participants had noticed thatheir children felt ashamed of them due to their obesity andealised that something radical must be done. Meeting peo-le who had undergone surgery successfully motivated andupported them to make their choice.

And it’s dramatic. . . this needing to have surgery. . . any-way, I saw it as the only thing. . . as a last resort. . . to benormal. . .

Participants were invited to an information meeting athe surgical clinic prior to the decision. Both oral and writ-en information about the surgery were received from theurgeon and participants appreciated this as they found itard to remember the detail. The information was extensivend afterwards perceived as honest and concise.

He went through everything from the risks of surgery tolifestyle changes, thus it wasn’t in anyway beautifying. . .

An oscillation between elation and a will to start theirew life and hesitating prior to the lifestyle changes wereescribed during waiting. Some participants were after-ards satisfied with the long wait because they had more

ime to consider. Participants worried about not beingccepted for the surgery because of weighing too little oroo much and contact with the nurse in the surgical clinicas described as important prior to surgery.

Participants remembered a strange feeling the day of

urgery, related to feeling relatively healthy and yet becom-ng hospitalised. They wanted the surgery done as soon asossible and where the surgery was delayed or cancelled,hey felt disappointment.

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It’s like. . . oh no. . . for you’re prepared and everything. . .

that you’ll do the surgery. . . yes, I had wanted to do it atonce but had to wait for three weeks.

Participants described that they felt worry about notaking up or not recovering after surgery. Prior to surgery

hey were informed about the risks, for instance potentialeakage from the gastric surgery site after surgery. Some par-icipants felt hesitant and wondered if they ever would seeheir children again. When the anaesthetist explained theonitoring during and after surgery and the nursing staff

t the ward described what they did, and gave approxi-ate times for what would happen; a sense of security was

xpressed. Some participants experienced a lack of informa-ion and expressed dismay when finding, for example, thatheir legs would be bandaged for blood-flow issues or thathey had not been aware of the surgery being performedalf standing, which concerned them.

aking up and feeling both vulnerable and safe

eelings of being vulnerable and completely dependent ontaff were remembered by participants in connection withaking up in the PACU setting. Participants compared wakingp after surgery to being in a haze and feelings of confu-ion were described. They wanted to sleep but were worriednd some participants stated that they experienced worryn case a leakage may have occurred. Directly upon awak-ning patients received an orientation about where theyere, what time it was and the outcome of the surgery. Thispproach and visit by the surgeon and to impart detailednformation about the surgery was described as relaxing andarticipants appreciated that the information was repeated.

Yes I was most happy that I survived the risk of leakagebecause it was this we all were talking about and wereafraid of.

The high technological environment at the PACU wasescribed as unknown and strange. Participants were wellnformed prior to surgery about the risks of complica-ions and nobody wanted to be without monitoring. Theyescribed both a sense of safety and worry related to this.articipants who had previous employment in the hospitaletting found their work had helped them recognise whatifferent equipment was there for. Some participants didot understand the function of the equipment. When theyoved in the bed alarms sounded and they wondered if

omething was wrong, which made them avoid moving torevent triggering the alarm.

It’s like you were in a movie that was really weird thusI didn’t understand why it sounded all times. . . yes and Ihad something on my finger.

The dynamic environment with many other patients andometimes a high level of noise was described as affectingarticipants’ recovery after surgery, and some stated theyould have preferred a single room. Despite this they wereot often seriously disturbed because they were aware of

he complications that may occur and why the monitoringas necessary. To constantly see staff and know that staff

aw and heard them was expressed as providing a sense ofecurity. Participants were informed in advance that their

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time of constant monitoring was limited and described asense of confidence because of the expectation that theirlives would be better after surgery. They heard that otherpatients at the PACU appeared sicker than them and seemedmore unwell. Some participants said that they felt that thesepatients’ needs were of higher priority and therefore theysometimes refrained from asking help for themselves.

And it was thus acute. . . those who really needed helpand then I felt I didn’t need help and they’ll come whenthey come. . . I felt. . . so then I just waited for my turn.

Participants described that they felt exposed when theywent from their bed to the bathroom at the PACU. Theshirt was open in the back and often too small. Showingtheir backside and passing in translucent clothes in front ofothers felt embarrassing but another perspective was thusdescribed. To see others, sometimes with the same bodysize felt liberating and participants felt they were not alone.That the staff behaved naturally and seemed familiar withthe situation was described as contributing to a permissiveatmosphere and it felt normal to appear with fewer clothes.This was compared to being at the bathhouse.

It’s like it’s okay then. . . that all are in the same situationas you’re in. . . maybe in various ways but. . .

At the PACU, a sense of invisibility and feeling like a num-ber was described by participants when things were donearound them and staff rushed past. Feelings of being seenand not being one in the crowd were expressed when staffintroduced themselves with names and smiles on first con-tact. Eye contact, openness, and smiles when staff rushedpast on their way to other severely ill patients was describedas essential in feeling not forgotten.

That they’ve made eye contact with me. . . just such athing makes a big difference that when I lie awake andthey pass my bed and they really look at me. . . and thatthey see that I see them. . . that they see me. . .

Participants wanted detailed questions about their con-dition answered and when they did not get their needstaken care of immediately because of the priority of otherpatients, participants desired an explanation why. Staff firsttold about what would happen, then asking when partici-pants wanted it to happen was described as creating a senseof safety. If the staff did not explain anything, for example,when they examined participants’ surgical wound, partici-pants wondered if something was wrong.

Getting started and preparing to go home

Participants expressed that they were well informed, forexample about the importance of early mobilisation aftersurgery to prevent complications. When the informationprovided prior to surgery did not correspond, e.g. earlymobilisation to prevent thrombosis, participants describedfeeling worried and wondered why the disparity.

Fear that the wound on the stomach would dehisce

when participants sat up or coughed was described andthey needed support from staff to do these actions effec-tively. Holding a pillow against the wound and adequate painmanagement prior to mobilisation seemed to help. Some

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articipants appreciated that staff said that they seemed toave strength in spite of being obese. Drinking enough liquidas important and participants knew that they had to ingest

certain amount with a teaspoon before discharge. This ledome participants to experience some degree of stress andhey needed support to confirm how much they had drunk.

Relief that surgery was over and expectations to startheir new life were told both in connection with care at theACU and within arrival to the ward. Participants appreci-ted the silence in the two- or three-bed rooms at the ward.etting rid of catheters, wearing own clothes and being able

o move freely were described as contributing to feelingealthier. They were grateful to have been monitored andelt confidence that they now managed themselves.

Now it’s my new life that begins and now. . . yes. . . now Iwant to get started. . . drinking. . . get started and now Iwant to come home.

Some participants regretted closeness to the staff at theACU and felt alone in their room at the ward. To share

room with others who had the same operation felt goodecause sharing their experiences sometimes helped themeceive an understanding of what they had been through.

oming home with expectations about a changedody

articipants expressed both fear and expectation afteromecoming, wondering how to manage the new situation.espite information prior to surgery they said it was diffi-ult to imagine how it would be. To feel hunger and noteing able to eat like before was described as frustrating.

Others no longer felt hunger, but the food took moreonsideration than before because of increased demandsor planning to ingest sufficient food. Participants expressedhat they were in an on-going process to learn which foodhey could tolerate.

Then it’s a little difficult to imagine when people tellabout how it will be. . . in reality now I realize I’ll neverbe able to drink like I did.

Several participants had problems with dumping syn-rome, something that they experienced as a severeroblem. The fear of dumping was described as similar ton antabuse effect and helped them to retrain from eatingoo much or wrong foods. Participants described a new sensef control because they knew that their changed anatomyimited their previous overeating.

[dumping] You feel damn bad. . . it’s difficult to pinpointwhat is happening but I felt that I was cold-sweating andhad heart palpitations and I never want to perceive thatagain.

A sense of being lightweight was expressed by partic-pants. Their ability to move already had increased andhey described that the vicious circle was broken; now theyould go for walks, which led to further weight decrease.

articipants expressed expectations with enthusiasm; run-ing, skiing, and doing other things like sit in a regular chairith armrests now felt possible. Difficulties to understand

he body’s appearance was described. Participants still felt

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hysically large even if they could see the change in theirror and felt clothes becoming too big.

It feels. . . so as I’m still big-sized or by any means I thenthink. . . I might move a little bit too much. . . sometimesmore than I need.

A few participants reported that their body felt weakfter surgery and they could not perform physical activitys well as before. These participants also worried that theeight loss was too progressive and concern about not beingble to influence it were expressed. Participants felt theyad sufficient support from the surgical clinic after surgerynd were informed that the weight tends to stabilise within

year after surgery.Participants described positive attention by people in

he environment, often about their appearance and it feltood. Some participants felt thus dismayed and examinedld photos to see if it really was that bad. When some par-icipants revealed their GDP surgery, comments were madebout being cheaters compared to people who had struggledo lose weight in the normal way. Some participants agreednd felt ashamed, but others stated that choosing surgeryo lose weight is not a shortcut.

I feel like a cheater who has cheated by losing weight andnot struggled and suffered. . . but I have in my way. . .

All participants stated that the difference in daily lifeas enormous. Participants related to their situation before

urgery and despite their lifestyle changes with someiscomfort that surgery brought, that it was worth it, soar. They described a completely different motivation inaily life.

It’s just amazing. . . I’m very happy that I got thisopportunity. . . my whole life is new.

iscussion

his study shows that participants before surgery felt infe-iority and shame related to their obesity. The describednferiority is in line with Brown et al. (2006) and Puhl et al.2008) who state that living with obesity may be a stigma.onrad (1987) describes the term stigma, which means that

person sees himself or herself as inferior and not as a wholeerson. This can lead to lower self-confidence and gives thepportunity for people in the environment to discriminatend discredit the person. The results show that participantselt ashamed when health care staff commented on theirbesity and when they received comments from other peo-le that they were cheaters compared to people strugglingo lose weight in a normal way. Lepage (2010) describeshat people who had undergone obesity surgery felt ashamedhen they were obese and finally felt guilt and like a fakehen they decided to have surgery. When the staff told them

hat it is not wrong to be medically treated for a mortalisease, they felt relieved.

Postoperatively at the PACU participants experienced aeeling of being both vulnerable and safe. Showing their

ody and passing in translucent clothes in front of otherselt embarrassing. According to Widäng et al. (2008), thentention in caring should be to treat every patient indi-idually and gain an understanding of one’s conceptions of

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ntegrity. The result shows that seeing others in a similarituation and that the staff seemed familiar to the situationontributed to a sense of a permissive atmosphere. Widängt al. (2008) found that when the physical environment isn obstacle to provide caring in a discrete way, the patientsay require mentally shifting their boundaries of integrity

o find a way of managing the situation. According to Nådennd Saeteren (2006), patients who were treated for cancern spite of their new and strange environment maintainedheir dignity because they were treated with respect byhe staff. Being confirmed as a person and not treated asn object gave patients a feeling of affiliation. This can beinked to Edvardsson et al. (2005) who theorise that ‘‘sensingn atmosphere of ease’’ means experiences of being able toocate oneself in familiar and safe surroundings.

Participants in this study described a sense of safetyelated to their closeness to the staff at the PACU.agerström and Bergbom (2006) have studied care givenhen undergoing general elective surgical procedures. The

elationship between the nurse and patient was described asssential and it was also essential not to be left alone. Thistudy shows that when other severely ill patients requiredriority, participants avoided asking for help; they put them-elves in a second place. This is in line with Engström andindberg (2012), who have investigated mothers’ experi-nces of a stay in an ICU after a complicated childbirth.others stated that they were probably less ill than thether patients and thus they felt less important. Allen andadgwell (1996) have described the environment at theACU, with many severely ill patients being cared for simul-aneously as unique in the modern hospital, but a necessity.his place demands that staff must prioritise to satisfy acuteeeds immediately. According to Edvardsson et al. (2005),t is understandable that patients in a rapid intensive careulture may not feel treated or seen in the same way as innother context, for example a hospice. Häggström et al.2012) found that nurses in the ICU settings felt they wereorced to balance between patient needs and caregivers’esources and consequently the care could be compromised.his result shows that when nurses at the PACU explain whyaiting is necessary and maintained contact with openness,articipants felt seen and not forgotten. Edvardsson et al.2005) noted that when staff were personal, sharing jokesnd sorrow with the patients, that this facilitated the feelingf engagement and gave a sense of security.

Participants prior to the GBP surgery were well informedbout medical risks and changing lifestyles; despite this par-icipants felt anxiety on the day of surgery. Pritchard (2009)hows that feelings of anxiety prior to surgery may dependn fear of the unknown and the experience of loss of con-rol. Participants in this study missed information abouthat would happen with their body during and after surgery.ntonovsky (1987) states that if the unknown is explained

n a satisfactory way it strengthens one’s sense of compre-ensibility and makes things manageable; in the context ofhis study, means a need of tangible information. Spalding,003 found that video information relieved patients’ anxi-ty prior to surgery. In the film sequence, visual events were

hown and detailed information was given about the specificurgery. Patients reported that previously received informa-ion became clearer and they knew what to expect. Thisan be linked to participants in this study who related their

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previous experiences and the information prior to surgeryto their postoperative experience. They expressed content-ment when expected things happened and when they didnot, participants were worried and wondered why. Kvalvaag-Gronnestad and Blystad (2004) note that over-informationabout issues that do not come true have led to increased anx-iety for patients’ who have undergone surgery. When staffprovide realistic and adequate information, the patients’experience a sense that staff possesses knowledge and skillswhich contribute to provide a sense of ‘‘being in safehands’’.

Participants in this study stated that the differencein daily life after surgery and weight loss was enor-mous. Despite extensive information being provided priorto surgery it was difficult to imagine ones’ situation afterhomecoming. Ogden et al. (2006) found that people expe-rienced shock and insecurity about their decision shortlyafter the obesity-surgery. Despite the extensive informa-tion, they felt unprepared for the seriousness and describednegative experiences like hunger as almost unbearable.This study shows that participants related to their situa-tion before surgery and despite the life-changing experienceit was worth it and that they felt a completely differentmotivation in daily life, so far. According to Antonovsky(1987), the sense of meaningfulness is a motivational com-ponent and determines whether a situation is appraised aschallenging, and if it is worth making commitments andinvestments. Participants in this study expressed their GBPas a way to realise their hope and longing for a new health-ier life. Groven et al. (2010) have interviewed women afterobesity-surgery and the dramatic weight loss during the ini-tial month was described as positively life transforming.The women used afterwards the metaphors ‘‘honeymoon’’to describe their experiences of overall increased well-being. Benzein and Saveman (1998) have described hope as ahuman phenomenon without sharp boundaries, interwovenwith expectation and desire. The concept of hope can beunderstood as a dynamic future faith, which can make lifemore bearable. A person needs motivation to believe thatlife is worth living now and in the future (Kylme, 2005).

Study limitations

This study has limitations. At the return-visit after surgery 30people were contacted and interested in participating, butonly ten people finally participated, which can be seen asa weakness. Therefore, the characteristics and experiencesof those people who chose to not participate would be beeninteresting to determine. Of the participants eight out often were women in middle-age with a BMI over 35 beforesurgery. This is consistent with the typical GBP populationin Sweden (The National Board of Health and Welfare, 2012),as GBP surgery is more common among women (75%) and themost common ages at the time of surgery are between 35and 50 years. A BMI over 35 is generally a criterion for havingthe surgery. Participants’ narratives were rich and the num-ber of interviews required is the number needed to answer

the aim. The purpose with research in the qualitative con-text is to gain an understanding of the individual experienceof a topic (cf. Holloway and Wheeler, 2010). That the inter-views were performed only after surgery may be a weakness

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hen participants were in a changing situation which mayave affected their view of the time before surgery. It hadeen possible to interview participants twice, even beforeurgery, but people who are waiting for elective surgery areften in a vulnerable situation (cf. Kvalvaag-Gronnestad andlystad, 2004). According to Morse (2002), an experience in

ts entirety often can be reconstructed when a person hasecovered and gained perspective of the event.

onclusion

articipants described prior to surgery a sense of inferiorityelated to their obesity and after surgery they felt both vul-erable and safe in the unknown environment at the PACU.o avoid exposure of one’s body postoperatively, it is ofmportance to plan the placement in the open setting at

PACU, to avoid passing other beds and provide a completeoat prior to mobilisation.

This study indicates, without generalising, the impor-ance to further strengthen the newfound motivation to

healthier life for people who undergo a GBP. The careiven in the acute postoperative phase should aim to provideredictability and management based on individual needs.eing treated with respect and that staff are close by,xplaining and maintaining contact with openness, is essen-ial to avoid feelings of being unseen and forgotten in thecute setting. Individual and tangible support and encour-gement concerning mobilisation and liquid intake seemsmportant. Likewise that the information received prior tourgery complies with what then happens postoperatively.mportantly, that PACU staff have access to the informationeople undergoing a GBP receive prior to surgery may con-ribute to a better understanding of their needs. Anotherevel of care, immediately after GBP surgery, for example,ny type of step-down unit may maintain a safe care butrevent a feeling of being less ill than other patients’ andherefore under- prioritised.

uthor contributions

tudy design: AF, ÅE, SS; data collection: AF; data analysis:F, ÅE, SS; drafting the manuscript: AF, ÅE, SS. ÅE and SSupervised the study.

unding

his research was funded by Department of Health Science,uleå University of Technology, Sweden.

onflict of interests

he authors declare there is no conflict of interest.

cknowledgements

hanks to those who participated in this study and sharedheir experiences. Thanks also to the nurse at the surgicallinic who recruited participants.

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