The research studies
Our systematic literature review found ten qualitative studies that investigated the experience of total knee replacement surgery. Four of these studies were carried out in the UK, two in the USA, two in Canada, one in New Zealand, and one in Sweden. Four of the studies applied a Grounded Theory approach to analyse the data; four adopted a Content Analysis approach, one applied Interpretative Phenomenology (IP), and one Interpretative Phenomenological Analysis (IPA). All of the studies were published between the years 2000–2005.
Themes and concepts
Seven concepts were identified from the research studies (see table ):
Experience of pain, or different ways of describing pain – featured in seven of the studies.
Perception of the health professionals' role, or the relationship between the patient and the health professional – featured in all ten of the studies.
Expectation of treatment, or the perception of treatment options and outcomes – featured in eight of the studies.
Expectation of condition, or the perceived cause of the condition – featured in four of the studies.
Social context and social support, or the social environment in which people live – featured in six of the studies.
Comparison with others, or the perceived status when compared to others in similar situations – featured in four of the studies.
Coping strategies, or different ways of dealing with knee osteoarthritis, featured in five studies.
Ten second-order interpretations were identified from the research studies (see table ). As the second-order interpretations are the main explanation or theory to emerge from the study, some are direct quotes that were extracted from the findings of the individual papers.
Decision-making regarding TKR surgery
Four third-order interpretations were constructed. When developing third-order interpretations, one has to consider each concept and second-order interpretation in turn. Although the line of argument develops from the second-order to third-order, the third-order interpretations are conceptualised after the formulation of the concepts. The concepts, therefore, shape the conceptual context when developing the third-order interpretations. For example, the literature suggests patients perceive knee osteoarthritis to be associated with normal aging. Patients also have the belief that there are people worse off than themselves and it is they who should have priority for surgery. Taken together with concepts such as, expectation of condition, and comparison with others, our third-order interpretation conceptualise this as 'personal interpretations of social and cultural categories of aging determine judgements about being deserving for surgery'. The line of argument continues with the following second-order interpretations: patients find it difficult to live with the uncertainty caused by the indeterminate waiting time of surgery, while others had negative perceptions of surgery because of the risks they associated with surgery. Taken together with the concept, expectation of treatment, our third-order interpretation conceptualises this as 'expectations of treatments are shaped by the balance between living a life on hold, and the perceived risks associated with surgery'. The line of argument continues with the following second-order interpretations: patients believed they needed to be in constant pain and virtually unable to move before they would seriously consider surgery. For others, the decision to have surgery is influenced by their perception of symptoms, and information sources. Taken together with the concepts, experience of pain, expectation of condition, and the perception of the health professional's role, our third-order interpretation conceptualises this as 'the decision to have TKR is linked to the amount of pain being endured, and the way information about TKR surgery is communicated'. The line of argument continues to include that if patients decide to have TKR surgery, it is determination, life environment, and the role of spouses, which influences expectations and outcomes. Taken together with the concepts, social context and social support, and coping strategies, our third-order interpretation conceptualises this as 'coping strategies and life context can determine short and longer-term outcomes of TKR surgery'.
A further concept that did not feature in the second-order interpretations (i.e. it was not the main conclusion from the authors of the studies), but was evident in all ten of the studies, was the patients' perception of the health professional's role. Patients wanted to be able to trust their health care professional, and would rely on their guidance and support. Many patients perceived their GP or hospital doctor as the 'expert', and wanted their advice when faced with the decision of surgery. While others believed that their GP was the gatekeeper to TKR surgery. However, if patients made the decision to have surgery, they did not want to be critical of the surgery or the surgeon. Therefore, the doctor-patient relationship is an important concept in relation to decision-making regarding TKR surgery, and this has become explicit through the process of conducting this meta-synthesis.