A journey to a new stable state—further development of the postoperative recovery concept from day surgical perspective: a qualitative study

Objective This study aims to further develop the concept analysis by Allvin et al in 2007 and Lundmark et al in 2016 from the perspective of day-surgery patients. Also, to describe how patients experience postoperative recovery in relation to the identified dimensions and subdimensions and to interpret the findings in order to get a deeper understanding of the concept postoperative recovery. Design Descriptive qualitative design with a theoretical thematic analysis. Setting Six day-surgery departments in Sweden. Participants Thirty-eight adult participants who had undergone day surgery in Sweden. Participants were purposively selected. Results Four dimensions—physical, psychological, social and habitual—were confirmed. A total of eight subdimensions were also confirmed, two from Allvin et al’s study and six from Lundmark et al’s study. Recovery included physical symptoms and challenges coping with and regaining control over symptoms and bodily functions. Both positive and negative emotions were present, and strategies on how to handle emotions and achieve well-being were established. Patients became dependent on others. They coped with and adapted to the recovery process and gradually stabilised, reaching a new stable state. Conclusion Postoperative recovery was described as a process with a clear starting point, and as a dynamic and individual process leading to an experience of a new stable state. The recovery process included physical symptoms, emotions and social and habitual consequences that challenges them. To follow-up and measure all four dimensions of postoperative recovery in order to support and understand the process of postoperative recovery is, therefore, recommended.

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Other than as permitted in any relevant BMJ Author's Self Archiving Policies, I confirm this Work has not been accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate material already published. I confirm all authors consent to publication of this Work and authorise the granting of this licence. facilitators for recovery included practical support from next of kin and being well informed and prepared for the recovery process and it´s challenges. It is important for healthcare providers to continue improving preoperative and postoperative information, which must be clear, concise and well timed to support day-surgery patients.

INTRODUCTION
Over time, there has been a transition from inpatient surgery to outpatient surgery -that is, day surgery. Day surgery is defined as surgery in which the surgical patient is admitted and discharged on the same day, or within 24 hours 1 , and accounts for 70%-75% of all surgeries performed 2 . However, the rates of specific types of day surgery, such as carpal tunnel release and cataract extraction, are higher than 90% 3 . Day surgery is preferred by both healthcare providers and patients 1,4,5 . It provides quick and effective care with minimal interruption of patients' daily life, and most patients prefer recovering at home over staying at the hospital 6 .
However, day surgery requires patients to take greater responsibility for their recovery process 7,8 . Although there is no standard definition of postoperative recovery, it is commonly known as "an energy-requiring process of returning to normality and wholeness" 9 . This statement raises several questions: for example, should postoperative recovery be seen as an endpoint or as a process 10 , and what does it mean to be "recovered" 11 ? Postoperative recovery can be described in three phases. Phase I (early phase) starts when the patient leaves the operating room. For medical care, this phase includes close monitoring of vital parameters. Phase II (intermediate phase) begins when the patient is still cared for at the hospital but is not monitored as closely as in Phase I 12 . These two phases focus on goals such as loss of pain, regaining reflexes, and loss of postoperative nausea and vomiting 11 . Patients stay for approximately 1-2 hours at the hospital after day surgery 13,14 . Phase III (late phase) occurs when the patient is discharged from hospital 9,11,12 . Phase III recovery takes time, and has been defined by Alvin et al. 9 as a process of complete return to the usual self or to preoperative health status (or better). It can be a complex and fragile process, with physical, emotional, social and habitual characteristics 9 . For patients to play an active role in their own recovery process, ongoing support from healthcare and next of kin is required after discharge 7,8,15 . Therefore, it is important to understand what the recovery process at home includes and how it can be defined.
Allvin et al. 9 used Walker and Avant's concept analysis approach to define the concept of postoperative recovery, based on four identified dimensions of postoperative recovery: physiological, psychological, social and habitual recovery. In 2016, Lundmark et al. 16 further developed this concept from lung recipients' perspective of their post-transplant recovery process. They found that Allvin's concept analysis was partly applicable to the context of lung transplantation. The main dimensions of the concept analysis were confirmed, although several sub-dimensions were found to be contradictory and were excluded. Six new subdimensions emerged: symptom management, adjusting to physical restraints, achieving an optimum level of psychological wellbeing, emotional transition, social adaption and reconstructing daily occupation 16 16 . Several studies report that day-surgery patients feel lonely and notice a gap between care provided at the hospital and care they receive after discharge 7,8,17,18 . It is therefore imperative to examine that gap and obtain a better understanding of patients' perspective on recovery after day-surgery procedures. Since the number of patients undergoing day surgery is increasing, deeper understanding of the concept of postoperative recovery is necessary in this patient group, in order to better understand the concept of postoperative recovery described by Allvin et al. 9 and re-analysed by Lundmark et al. 16 .
Otherwise, there is a risk that this concept will be used in a population that it is not developed

Data collection
The 18 participants in sample I underwent surgery between December 2015 and July 2016, and were recruited from four different day-surgery departments 8 . The remaining 20 participants (sample II) underwent surgery from June to September 2017 and came from two different day-surgery departments 18 (Table 1). Interviews were performed by two of the authors (KD for sample I and KH for sample II). Interview locations were chosen by the participants ( Table 1). All interviews were audio-recorded and transcribed verbatim.

Interview guide
The interview guides used for both sample I and II consisted of questions that mainly focused on the participants' experiences of postoperative recovery after discharge. Thus, patients were asked about their experience of the first day after surgery (samples I and II) and their recovery until the interview date (first 14 days for sample II and first 22-57 days for sample I). To cover patients' experiences of recovery after day surgery, patients were asked to reflect on having the surgery as a day surgery, and to compare their experience with any previous experiences of undergoing surgery.

Ethical considerations
The study follows the Declaration of Helsinki 20 . Samples I 8 and II 18 were approved by the regional ethical review board in Uppsala, Sweden (reference number: 2015/262). Participants received both written and verbal information about the study and gave their written consent. A deductive thematic data analysis 19 was performed, with a focus on the dimensions and subdimensions of postoperative recovery according to the concept analyses by Allvin et al. 9 and Lundmark et al. 16 .

Data analysis
The analysis process was as follows: 1. Transcribed interviews from each sample (I and II) were read separately several times by two of the authors (EA and UN) independently. The other authors (KD, MJ and KH) were familiar with the data, since they had been involved in the original data collections and had read the data several times.
2. Two of the authors (EA and UN) conducted a deductive analysis of the key components of postoperative recovery based on the work of Allvin et al. 9 and Lundmark et al. 16 Thereafter, all five authors processed the analysis. 3. The authors jointly finalised the results by finding descriptions and citations from the interviews that captured the content of each sub-dimension. The authors then reflected on the findings and discussed different ways of interpreting the results in relation to the sub-dimensions.

Rigour
Credibility was guaranteed by having two authors (EA and UN) conduct the analysis separately and then discuss it with the remaining authors (KD, KH, and MJ), all of whom were familiar with the data corpus, until consensus. To enhance transferability, the data analysis was clearly described in order to allow readers to form their own judgement, as far as possible. Credibility and confirmability also come from all of the authors (EA, UN, KD, KH and MJ) having a theoretical and practical knowledge of the postoperative context, which improved their understanding 21

FINDINGS
Participants' experiences of the postoperative recovery process after day surgery were confirmed to fall within the four main dimensions described by Allvin et al. 9 and Lundmark et al. 16 . In total, nine sub-dimensions were found; of these, eight sub-dimensions aligned with those identified by Allvin et al. 9 (n=2) and Lundmark et al. 16 (n=6). One sub-dimension was changed to the opposite meaning: from "Becoming independent" to "Becoming dependent".
There was also a linguistic change of the name of one of the sub-dimensions that originated from Allvin et al. 9 . Table 2 presents the sub-dimensions identified by Allvin et al. 9 , Lundmark et al. 16 and the present study.

Physical dimension
The physical dimension describes physical symptoms and signs related to the surgery and postoperative recovery process, along with the challenges of coping and regaining control over bodily functions and the physical problems that were experienced.

Regaining control over bodily functions
Regaining control over reflexes occurs during hospital recovery; therefore, this formulation was deleted from the original sub-dimension. The participants described regaining control over bodily functions directly after surgery; as Informant 6 (sample I) described: "I've got to build up (my muscle strength) from scratch, as I've lost my muscle strength". In order to regain control and cope with the physical consequences of the surgery, the participants described learning new ways of using their body and aids/tools such as crutches. Despite Moving was quite wobbly, it takes a while before you learn how to walk with crutches…The brain has to learn to find a new balance point…. it takes a while… (Informant 4, sample I) Physiotherapists were important facilitators in the patients' work to regain control over their bodily functions. Physiotherapists' support was needed for patients to challenge themselves to improve their physical functions with exercise, without jeopardising their recovery. Some participants were surprised when they realised that recovering and regaining control over bodily functions took longer than expected. Some commented that they were counting the days until they would feel recovered and achieve a new, stable physical state.

Conserving energy
Because they felt exhausted, the postoperative patients felt that they had to conserve energy. "Being exhausted" was described as extreme tiredness, having difficulty concentrating and being very emotional. In order to cope with daily life, patients needed to conserve their energy, which limited their ability to participate in daily activities. Their body restricted their activities, and they needed to balance activities with rest to conserve energy.
… to listen to your body ... you need to rest, but still be able to walk … to go to the store, take the car and go shop … and then rest. I felt it... to put up my leg and rest ... I was operated on a Tuesday, I went to work on Monday ... and worked just over half the day, then I just collapsed… (Informant 17, sample I) The participants described the importance of giving themselves time to rest and move slowly forward, step by step. Being on sick-leave due to the surgery and subsequent recovery process was a new experience for some. However, many participants also described their adaption and

Symptom management
The recovery process involved the management of physical symptoms. In general, such postoperative symptoms bothered the participants and caused worries and questions. The participants described symptoms of pain and swelling in the surgical wound or pain in other body parts. Other symptoms were signs of infection, fever, dizziness, bleeding from the wound, difficulty concentrating, numbness in parts of the body, gastroenterological problems and symptoms related to the plaster.
In order to manage their symptoms, participants contacted their healthcare services for advice or information, or used different self-management strategies. Described self-management strategies included positioning the surgical area high up to avoid swelling and pain, eating food with a laxative effect and being observant for signs of wound infection. Participants managed their pain by using different pain-management strategies such as avoiding activities or movements causing pain, or using pain medications. When the prescribed pain medication was insufficient, participants tried to solve the problem themselves by asking family members or friends if they had other pain medication. Others chose to avoid taking pain medication because they found that it affected them negatively. The psychological dimension describes positive and negative emotions, strategies to handle emotions and achieve wellbeing, and reflections on the information provided and the recovery process.

Emotional transition
A range of positive feelings were expressed, such as happiness and gratitude. Some participants described an emotional transition from being very energised and positive immediately after the surgery, to experiencing a setback after this positive period, and described it as being "wound-up ... then, some days later, you lose your breath" (Informant 6, sample II). Worries were commonly expressed about the consequences of the surgery, and how these would influence patients' recovery and their ability to return to work. In addition to not receiving information from the surgeon who performed the surgery, patients described receiving information "too soon" postoperatively, while they were still affected by the anaesthesia. When patients were discharged from the recovery unit before they felt fit to go home, they were left with unanswered questions that caused trouble and worries when they arrived at home.

Achieving an optimum level of psychological wellbeing
The participants focused on minor progression in their recovery, and mentioned that their recovery was satisfactory and went better than expected. They felt that they reached an acceptable level of wellbeing, despite setbacks and problems such as pain and tiredness. Some participants described how recovering at home and having support from their families and friends were the main factors in achieving an optimum level of psychological wellbeing during recovery. One strategy to handle psychological wellbeing was to divide the recovery period into shorter time periods and plan activities that distracted the participants from their frustration over their symptoms and the time it took before they felt recovered or reached their "new stable state".
We are going away this weekend and that will be nice, you  The social dimension comprises participants' reflections on becoming dependent, on limitations due to their surgery and on how they had coped with and adapted to the recovery process and their new stable state.

Social adaption
The participants felt that it was important to continue with their social life and normal activities, both for themselves and for their families. Social adaption could be facilitated by using digital follow-up support or planning, and by receiving help from family and friends to engage in activities, even when the participant had restrictions. Participants also experienced limitations in social activities such as attending activities or visiting friends. Fear of participating in activities or events where there was a risk that people would bump into them was an obstacle to regaining full social function.

Becoming dependent
In contrast to the sub-dimension "Being independent" by Allvin et al. 9 , the participants in the present study described how they became dependent on support from family, friends and healthcare services during their recovery process. For example, when being discharged from the hospital, they needed help with transportation home from their family. They also needed a family member to be vigilant and supportive, and to stay overnight for the first few postoperative days. Being dependent was experienced as "being paralysed" and, although it was not always desirable, the participants asked for help from family, friends or neighbours in activities that they had managed themselves before surgery. Feeling insecure if they were sent home too early, not feeling ready to be discharged or other worries made the patients dependent on professional care from the healthcare system. Such needs were expressed by asking for follow-up and support from healthcare after discharge, in order to manage expected and unexpected issues during their recovery period.

Habitual dimension
The habitual dimension describes how the participants recovered to their new stable state, as they gradually stabilised their daily activities, their desire to return to work and their worries about working.

Reconstructing daily occupation
Participants gradually stabilised daily activities that they had managed to do independently before surgery, such as getting dressed, taking a shower, handling toilet habits and other everyday activities such as taking long walks. Success in common everyday activities such as cooking by themselves was expressed as "an art". Personal characteristics such as endurance positively contributed to the reconstruction; as one of the participants commented, you have to be "somewhat stubborn" (Informant 8, sample I). There were also activities that the participants could not manage yet but yearned to do.  The participants described a will and desire to recover and return to work and ordinary life.
Some held to the desire to do activities that had not been possible before the surgery, which were now possible again thanks to the surgery. It was sometimes difficult for patients to accept restrictions and being absent from the work due to a "small" bodily dysfunction or postoperative health consequences. Therefore, it was very important for them to be able to return to ordinary habitual activities such as driving or biking, since these activities indicated that recovery was in process.
I really look forward to just having to start driving a car again and start riding a bike…. (Informant 16, sample I) For some participants, a substitute was not an option; therefore, they declined sick-leave and stretched their limits to return to work. At the same time, some participants worried that they would be unable to work independently and would be dependent on colleagues, due to immobility or not having regained enough function or strength after the surgery.

DISCUSSION
This study found that the main dimensions and some of the sub-dimensions described by Allvin et al. 9 and Lundmark et al. 16 were applicable to recovery after day surgery. However, recovery after day surgery makes the patient dependent on their surroundings; therefore, one sub-dimension was linguistically changed. It should be noted that in the present redevelopment of the concept of postoperative recovery, we focused on late postoperative recovery. All interviews in this study were performed between postoperative day 14 and day  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 18 57, and focused on recovery after discharge. Allvin et al.'s 9 concept analysis included both early and late postoperative recovery. This difference may explain why the sub-dimension "Regaining control over bodily functions" in the current study did not include "control over reflexes", since recovery of protective reflexes and motor activity mainly occurs in the first phase of the recovery process. Another sub-dimension that differed from the original description by Lundmark et al. 16 was "Achieving optimal psychological wellbeing" 16 . From a day-surgery perspective, this sub-dimension was described as maintaining a positive attitude, focusing on positive aspects and achievements, and the importance of support from the next of kin. Although the original sub-dimension also described maintaining a positive attitude, the meaning was that patients were grateful for the opportunity for a new chance in life 16 .
Another difference was the importance of getting enough information to raise reasonable expectations and support from next of kin and healthcare services. Both Allvin et al. 9 and Lundmark et al. 16 briefly mentioned the need for social support after surgery; however, information about what to expect after surgery was not mentioned at all, and the focus was on the positive effect of social support. These aspects may have been emphasised in the present study due to a mismatch between expectations and reality for patients undergoing day surgery. Previous studies have shown that day-surgery patients expect their recovery to be fast and smooth, and to have a minimal impact on their everyday life 6 ; similarly, the participants in this study expressed surprise that their recovery was more demanding and took longer than expected. Several other studies also reported an experienced lack of information and support after day surgery 7,8,17 . Therefore, this can be considered as an important issue that is still not properly addressed in day-surgical care.
The concept developed by Allvin 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   19 entirely based on interviews with patients 16 . The main dimensions and several of the subdimensions described by Lundmark et al. 16 were confirmed in the present study, despite differences in the type of surgery and timing of interviews (which were 12 months postoperative in Lundmark et al. 16 . Thus, postoperative recovery after minor and major surgery has similarities, and it is reasonable to discuss whether the postoperative recovery process is generic. Two crucial central questions for describing postoperative recovery as a concept are: should postoperative recovery be seen an endpoint or as a process 10 , and what does it actually mean to be recovered 11 ? Berg et al. 7 described postoperative recovery as "Rollback to ordinary life", while Barthelsson et al. 22 described it as "Returning to activities of daily life". In the present study, we suggest describing the postoperative recovery as a process, starting from a "Presurgery state" and ending with a "New stable state" (Figure 1). Our findings emphasise that postoperative recovery is an individual process and a transformative journey, including how the physical, psychological, social and habitual dimensions affect each other in a continual and dynamic process that leads to a new stable state. This new stable state is not necessarily a state that is the same as that before surgery, or a return to pre-surgical functions. In many cases, the surgery itself was done to improve mobility and to reduce or remove dysfunctions.
For example, some participants described how they were now able to do activities that were impossible before the surgery. For these participants, the new stable state was experienced as being more functional than the preoperative state. In other cases, such as when patients could not return to work, the new stable state involved adjusting to a state with a permanent decrease in or loss of preoperative functions. This way of describing the postoperative period as a process has similarities with McMullen et al.'s 23 study, in which postoperative recovery among patients who had surgery for bladder cancer was described as a transformative process  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   20 that started with preoperative decision-making and ended with mastery of self-care and reintegration into the activities of daily life. In the present study, it became obvious that the participants were not fully recovered at the time of the interviews -that is, they had not reached a new stable state. Defining the end of the recovery process and determining when the new stable state is established may also depend on the surgery and its consequences for the patient. Patients suffering from a severe disease or injury, as in Lundmark et al.'s 16 study, did not want to return to their preoperative state, which had included suffering and issues related to decreased lung function in that case. In another study, patients undergoing major leg amputation due to an arterial disease stated that they experienced recovery after approximately 6 months upon regaining their functional independence. Functional independence varied, but was often related to the preoperative level of function 24 . These different perspectives on how to determine when the postoperative process is actually over require further study. For day-surgery patients, follow-up on their recovery after 6-12 months is suggested, along with a focus on their experience of what made them feel recovered. The concept of a new stable state also needs to be further explored and confirmed by other studies.

Limitations
This study is a secondary deductive analysis of interviews that were used in two previous studies. Neither of those sets of interviews were conducted with a focus on the dimensions described in previous concept analyses. This can be seen as both a strength and a limitation, and the chance that interviews focusing on postoperative recovery as a concept may have had a different content cannot be excluded. However, this may also be a strength, as the interviews were not influenced by descriptions of postoperative recovery, unlike those by Allvin et al. 9 or Lundmark et al. 16 Furthermore, the interviews were conducted 14-57 days after the surgery. Therefore, it is possible that there is more information about the recovery process after day surgery that has not been found in this present study.

CONCLUSION
This study largely confirmed the concept of postoperative recovery as described by others, and further developed it in a day-surgery context. Postoperative recovery was described as a process with a clear starting point, followed by a dynamic and individual process leading to an experience of a new stable state. The recovery process included physical symptoms, emotions and social and habitual consequences that challenges them. The patients used several strategies to cope with these challenges, and adapt to the recovery process, and gradually stabilized in order to achieve a new stable state. Important facilitators for recovery included practical support from next of kin and being well informed and prepared for the recovery process and it´s challenges. Therefore, it is important for healthcare providers to continue to improve preoperative and postoperative information, which must be clear, concise and well timed in order to be supportive for day-surgery patients.

Disclaimer
The funders have neither been involved in any part of the study, nor in writing the manuscript or the decision to submit the manuscript for publication.

Competing interests
None declared.

A data sharing statement
No additional data are available.     known as "an energy-requiring process of returning to normality and wholeness" 9 . This 77 statement raises several questions: for example, should postoperative recovery be seen as an 78 endpoint or as a process 10 , and what does it mean to be "recovered" 11 ? occurs when the patient is discharged from hospital 9, 11, 12 . Phase III recovery takes time, and 87 has been defined by Alvin et al. 9 as a process of complete return to the usual self or to 88 preoperative health status (or better). It can be a complex and fragile process, with physical, 89 emotional, social and habitual characteristics 9 . For patients to play an active role in their own 90 recovery process, ongoing support from healthcare and next of kin is required after discharge 7, Allvin et al. 9 used Walker and Avant's concept analysis approach to define the concept of 114 and re-analysed by Lundmark et al. 16 . Otherwise, there is a risk that this concept will be used 115 in a population that it is not developed for -in this case, day-surgery patients. This study focuses on the late postoperative recovery process, which occurs after discharge, when the 117 patient is left alone without monitoring by healthcare. The sample consists of 38 participants in total (sample I, n=18 and sample II n=20), who 138 underwent a day-surgical procedure. Inclusion criteria in both samples were: undergoing day 139 surgery, being >17 years of age, being able to understand written and spoken Swedish.   (Table 1). Interviews were performed by two of the 158 authors (KD for sample I and KH for sample II). Interview locations were chosen by the 159 participants ( Table 2). All interviews were audio-recorded and transcribed verbatim. The study follows the Declaration of Helsinki 21 . Samples I 8 and II 18 were approved by the The analysis process was as follows:   Lundmark et al. 16 Thereafter, all five authors processed the analysis. al. 9 and Lundmark et al. 16 . Participants' experiences of the postoperative recovery process after day surgery were 231 confirmed to fall within the four main dimensions described by Allvin et al. 9 and Lundmark et 232 al. 16 . In total, nine sub-dimensions were found; of these, eight sub-dimensions aligned with those identified by Allvin et al. 9 (n=2) and Lundmark et al. 16 (n=6). One sub-dimension was 234 changed to the opposite meaning: from "Becoming independent" to "Becoming dependent". 235 There was also a linguistic change of the name of one of the sub-dimensions that originated 236 from Allvin et al. 9 . Table 2 presents the sub-dimensions identified by Allvin et al. 9 , Lundmark 237 et al. 16 and the present study.  The participants described the importance of giving themselves time to rest and move slowly    In addition to not receiving information from the surgeon who performed the surgery, patients 329 described receiving information "too soon" postoperatively, while they were still affected by 330 the anaesthesia. When patients were discharged from the recovery unit before they felt fit to 331 go home, they were left with unanswered questions that caused trouble and worries when they 332 arrived at home. The participants focused on minor progression in their recovery, and mentioned that their 339 recovery was satisfactory and went better than expected. They felt that they reached an 340 acceptable level of wellbeing, despite setbacks and problems such as pain and tiredness. Some  The participants described a will and desire to recover and return to work and ordinary life.

408
Some held to the desire to do activities that had not been possible before the surgery, which 409 were now possible again thanks to the surgery. It was sometimes difficult for patients to 410 accept restrictions and being absent from the work due to a "small" bodily dysfunction or 411 postoperative health consequences. Therefore, it was very important for them to be able to For some participants, a substitute was not an option; therefore, they declined sick-leave and 417 stretched their limits to return to work. At the same time, some participants worried that they 418 would be unable to work independently and would be dependent on colleagues, due to 419 immobility or not having regained enough function or strength after the surgery.

421
The process of postoperative recovery 422 The findings emphasize postoperative recovery as a process, starting from a "Pre-surgery 423 state" and ending with a "New stable state" (Figure 1 This study found that the main dimensions and some of the sub-dimensions described by 439 Allvin et al. 9 and Lundmark et al. 16 were applicable to recovery after day surgery. However, 440 recovery after day surgery makes the patient dependent on their surroundings; therefore, one  in this study expressed surprise that their recovery was more demanding and took longer than 463 expected. Several other studies also reported an experienced lack of information and support 464 after day surgery 7,8,17 . Therefore, this can be considered as an important issue that is still not 465 properly addressed in day-surgical care.  In another study, patients undergoing major leg amputation due to an arterial disease stated In present study the patients used several strategies to cope with symptoms and discomfort in 504 the recovery process, to gradually stabilized in order to achieve a new stable state. Important  This study is a secondary theoretical thematic analysis of interviews that were used in two 515 previous studies. Neither of those sets of interviews were conducted with a focus on the 516 dimensions described in previous concept analyses. This can be seen as both a strength and a 517 limitation, and the chance that interviews focusing on postoperative recovery as a concept 518 may have had a different content cannot be excluded. However, this may also be a strength, as 519 the interviews were not influenced by descriptions of postoperative recovery, unlike those by 520 Allvin et al. 9 or Lundmark et al. 16 It cannot be excluded that additional information would had 521 been sought if further interviews were conducted. However, 38 participants are a rather large 522 sample in qualitative studies, and consistent information emerged from the two samples.

523
Furthermore, the interviews were conducted 14-57 days after the surgery. Therefore, it is 524 possible that there is more information about the recovery process after day surgery that has 525 not been found in this present study. It can also be questioned if theoretical thematic analysis 526 is the most suitable method for analysing our data. As our purpose was to re-analyse the 527 concept of postoperative recovery and thereby code the data to suite this specific research 528 question, i.e. a theoretical interest. Theoretical thematic analysis was therefore considered to 529 be the most appropriate method.  several strategies to cope with these challenges, and adapt to the recovery process, and 538 gradually stabilized in order to achieve a new stable state.

reasons and interests in the research topic
The interviewers were specialized nurses with professional experience from postoperative care but had not personal or professional connection or relation to the informants. Their professional experience increased their possibility to deeper the interviews.

407
Some held to the desire to do activities that had not been possible before the surgery, which 408 were now possible again thanks to the surgery. It was sometimes difficult for patients to 409 accept restrictions and being absent from the work due to a "small" bodily dysfunction or 410 postoperative health consequences. Therefore, it was very important for them to be able to For some participants, a substitute was not an option; therefore, they declined sick-leave and 416 stretched their limits to return to work. At the same time, some participants worried that they 417 would be unable to work independently and would be dependent on colleagues, due to 418 immobility or not having regained enough function or strength after the surgery.

420
The process of postoperative recovery 421 The findings emphasize postoperative recovery as a process, starting from a "Pre-surgery 422 state" and ending with a "New stable state" (Figure 1 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  This study found that the main dimensions and some of the sub-dimensions described by 438 Allvin et al. 9 and Lundmark et al. 16 were applicable to recovery after day surgery. However, 439 recovery after day surgery makes the patient dependent on their surroundings; therefore, one description by Lundmark et al. 16 was "Achieving optimal psychological wellbeing" 16 . From a 449 day-surgery perspective, this sub-dimension was described as maintaining a positive attitude, 450 focusing on positive aspects and achievements, and the importance of support from the next 451 of kin. Although the original sub-dimension also described maintaining a positive attitude, the 452 meaning was that patients were grateful for the opportunity for a new chance in life 16 .