Instructions:  Using the discussion and decisions your group has made during the Module 5 discussion board, write and submit a draft of the following portions of your final paper.  I suggest that you spread out the work among your team members or rotate the responsibility for each week.

A weekly drafts example is attached.  Module 4 DB/Module 5 Draft sample paragraphs are highlighted in yellow; Module 5 DB/Module 6 Draft sample paragraphs are highlighted in green; and Module 6 DB sample paragraphs are highlighted in blue (you will not submit a draft for the Module 6 DB work).  Of course, the synopsis portion will be specific to your article, and the appraisal portion should include application of all concepts relevant to your article.

Synopsis:   Write a study synopsis that includes these main points.

· how the study was conducted

· describe the intervention and procedures for carrying it out

· include measurement instruments and what they measured

· procedures for collecting the data

Appraisal:  Appraise the article in narrative format by answering the following questions.

· Was treatment fidelity accomplished?  Why or why not?

· Were the measurement instruments reliable and valid? Why or why not?

· Were the conclusions of the study supported by the results?  Why or why not?

· Include key statistical results and p-values, if provided, as part of your rationale.



Cardiovascular Critical Care

©2021 American Association of Critical-Care Nurses doi:

Background For women undergoing median sternotomy, especially those with a bra cup size C or larger, breast

support can reduce pain, wound breakdown, and infection.

This study addressed a gap in research, identifying the

best bra after sternotomy in terms of patient satisfaction

and wear compliance.

Objectives To evaluate larger-breasted women’s satisfac- tion and compliance with wearing 3 commercially available

front-closure bras—with a hook-loop closure (the hospital’s

standard of care), a zipper closure, or a hook-eye closure—

after cardiac surgery.

Methods This study used a posttest-only, 3-group ran- domized controlled design. A convenience sample of par-

ticipants were sized and randomly assigned a product that

was placed immediately postoperatively. Participants agreed

to wear the bra at least 20 h/d until the provider cleared them

for less wear. At inpatient day 5 or discharge, and at the

follow-up outpatient visit, subjects completed investigator-

developed surveys. Data were analyzed from 60 participants

by using the 2 test and Kruskal-Wallis analysis of variance;

also, patterns were identified within written comments.

Results Participants were most satisfied with the hook-eye front-closure product before (P = .05) and after (P = .02) discharge.

Participants recommended the hook-eye and zipper prod-

ucts over the hook-loop bra (H = 8.39, P = .02). Wear compli-

ance was strongest in the group wearing the hook-eye bra.

Conclusions The hook-eye closure product had the most satisfaction and greatest wear compliance, and it received

the highest recommendation. A practice change was made

to fit and place the hook-eye bra in the operating room

immediately after surgery. (American Journal of Critical

Care. 2021;30:21-26) AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 21

1.0 HourC E This article has been designated for CE contact hour(s). See more CE information at the end of this article.

BRAS FOR BREAST SUPPORT AFTER STERNOTOMY: PATIENT SATISFACTION AND WEAR COMPLIANCE By Kimberly Bolling, BSN, RN, CCRN, Takako Long, BSN, RN, Cathy D. Jennings, DNP, RN, ACNS-BC, Francis C. Dane, PhD, and Kimberly Ferren Carter, PhD, RN, NEA-BC



22 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

P revious research confirms that women, especially those with larger breasts, can benefit from external breast support after cardiac surgery via median sternotomy.1 Normally, breast tissue without support moves in all directions when a female participates in minimal activity.2 Simple walking and running can displace the breast vertically, mediolaterally, and anteroposteriorly.2,3

A midchest incision in a patient with large breasts further increases the need for a supportive garment to decrease wound tension. Tension at the midline sternotomy incision site has been directly linked to macromastia (defined as breasts large enough to require a bra cup size C or larger),4 which places the patient undergoing cardiac surgery at an increased risk for both sternal wound infection4-7 and postoperative pain, especially during the early recovery period.8,9 Use of a supportive bra may reduce this risk.4-5,9

Many female patients undergoing cardiac sur- gery are reluctant to discuss their breast support and breast pain issues with their care providers.10 In one study, most women were surprised by and unprepared for the breast pain they experienced after sternotomy and did not know how to manage breast symptoms.10

Further, care providers may not acknowledge or address breast issues when teaching women how to care for themselves after discharge from the hospital after car- diac surgery.10 Early during the postoperative period, the healing midchest inci- sion site and drainage tubes

can also impact use of a bra. Care providers may not advise these patients to wear a bra immediately postoperatively because regular bras interfere with nursing care11; however, King et al,2 in the Women’s Recovery from Sternotomy-Extension (WREST-E) study, suggested the importance of consistent education about and reinforcement of the need for a comfortable

and supportive bra after surgery. Brocki et al12 sug- gested actually placing the bra on the patient at the end of the surgery, which ensures breast support soon after closure of the skin incision.

The optimal bra for wear after sternotomy closes in the front, because moving both arms around the back simultaneously can cause incisional (and ster- nal) tension.12 Second, and perhaps most important, the optimal bra is both comfortable and supportive. If a woman is dissatisfied with the bra, she may con- sciously decide not to wear the garment regardless of its importance or necessity.

Although researchers have explored the effect of a supportive bra on pain reduction, functional status, infection at the surgical site, and sternal wound heal- ing in this population,7,9,11 we found only 1 study that elicited feedback from both patients and nurses regard- ing a particular postoperative bra—in this case, one that aimed to help prevent pressure ulcers.13 In a best- evidence review of 6 randomized controlled trials of postoperative external support devices,14 only 1 study specifically evaluated the effectiveness of a postoper- ative bra in reducing pain and promoting sternal heal- ing in female patients.11 We found no recent research that focused on a patient’s satisfaction with a commer- cially available bra and compliance with the provid- er’s instructions for wear after sternotomy.

Consequently, we designed this study to answer the question, Which of 3 commercially available breast support products—standard-of-care hook- loop bra (similar to Velcro brand ), zipper bra, or hook-eye bra (Figure 1)—results in the greatest user satisfaction and wear compliance? This study contrib- utes to the limited knowledge base regarding the type of product that will both satisfy larger-breasted women after sternotomy and yield optimal wear compliance among patients after sternotomy.

Methods Design, Setting, and Participants

This study was approved by the institutional review board at Carilion Clinic and was conducted in accordance with that board’s standards and the ethi- cal standards set forth in the Declaration of Helsinki. The study used a 3-group, posttest-only randomized, controlled, longitudinal design. It was conducted

About the Authors Kimberly Bolling is a registered nurse in the cardiac sur- gery intensive care unit and Takako Long is a registered nurse in the cardiovascular progressive care unit, Carilion Roanoke Memorial Hospital, Roanoke, Virginia. Cathy D. Jennings is a clinical nurse specialist, Carilion Roanoke Memorial Hospital. Francis C. Dane is a professor of psychol- ogy, Radford University, Radford, Virginia, and a professor of interprofessionalism, Virginia Tech Carilion School of Medicine, Roanoke, Virginia. Kimberly Ferren Carter is senior director, nursing research, Carilion Clinic, Roanoke, Virginia.

Corresponding author: Kimberly Bolling, BSN, RN, CCRN, Carilion Roanoke Memorial Hospital, 1906 Belleview Ave, Roanoke, VA 24014 (email:

Many women undergo- ing cardiac surgery are

reluctant to discuss their breast issues with

their providers. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 23

from June 1, 2016, through June 8, 2017. The study took place at a 703-bed academic medical center in the southeastern United States; the center’s cardio- vascular institute has been providing cardiac surgical services since 1982 and performed more than 500 cardiac surgical procedures in 2017. During the study period, the institute featured 4 cardiac surgery oper- ating rooms, an 11-bed cardiac surgery intensive care unit, and a 25-bed progressive care unit.

Eligible study participants were women (≥18 years old) who were not pregnant and were undergoing nonemergent cardiac surgery via median sternotomy. They had no history of chest radiation, breast reduc- tion, mastectomy, or median sternotomy; wore a min- imum of a C-cup bra size; spoke English; and were able to verbalize their understanding of the study. The prod- uct to which a participant was randomized had to be available in her measured bra size (hook-loop bra [Surgical Bra, DeRoyal Industries]: 36.0-55.0 in; zip- per bra [Genie Zip bra; TriStar Products]: 39.0-52.5 in; hook-eye bra [Carefi x Mary bra; Tytex]: 32.0-54.0 in). The participants were asked to wear their bra for a minimum of 20 h/d, removing it only to bathe or to launder it.

Instruments Outcome measures included satisfaction before

and after discharge and wear compliance after dis- charge. The literature we reviewed included no mea- sures for these outcomes; therefore, we developed measures for use. Satisfaction with the bra before discharge was measured on postoperative day 4 or 5 by using a question about satisfaction (self-report); results ranged from 1 to 10 (1 = completely dissatis- fi ed, 10 = completely satisfi ed). The survey after dis- charge included the same satisfaction item, a question about whether the participant would recommend the bra to other women undergoing sternotomy (rating scale, 1 = defi nitely would not recommend to 5 = defi nitely would recommend), a question about the amount of time the bra was worn after discharge (compliance), and an opportunity to provide any comments about the product. The postdischarge survey was administered at the follow-up offi ce visit, which generally occurred between 20 and 40 days after surgery.

Protocol We reviewed the daily surgery schedule to identify

potential study participants. We screened inpatients who were currently hospitalized and outpatients who were visiting the center’s presurgical testing clinic. Then, study team members requested assistance from each patient’s nurse to determine whether the patient

would be interested in receiving information about the study. If the patient was interested, a study team member met with her and provided both informa- tion about informed consent and a written study information sheet.

After confi rming that all of the patients’ questions had been addressed and obtaining their verbal consent to participate (the institutional review board had granted a waiver of signed consent), a member of the research team measured the participant’s chest/ band and cup sizes. Participants were randomized to 1 of the 3 product groups (hook-loop bra [the hos- pital’s standard of care], zipper bra, or hook-eye bra) through the use of a random numbers table. If a par- ticipant was randomized to wear a bra that was not available in her size, she was excluded from the study and was given the standard of care (the hook-loop bra). If the selected product was available in the par- ticipant’s size (on the basis of the manufacturer’s sizing recommendations), the appropriately sized product was delivered to the cardiac surgery operat- ing room on the day of the procedure. The staff in the operating room applied the bra to the patient at the end of surgery, before she was transferred to the car- diac surgery intensive care unit.

Sample Size We calculated effect size using the estimation

approach described by O’Brien and Muller15 for analysis of variance studies. On the basis of esti- mates of between-means variance (1/33) and within-group SD (1.49), and using a rating of satisfaction between 1 and 10 for 2-way analysis of variance, we estimated an effect size of 0.6. Using this estimated effect size, a power of 0.80,

Figure 1 Sample bra products (left to right): DeRoyal Industries Surgical Bra (hook-loop closure; similar to Velcro brand), TriStar Products Genie Zip (zipper closure), Tytex Carefi x Mary (hook- eye closure).



24 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

and an of .05, we deemed a sample size of 20 participants per group to be sufficient.

Statistical Analysis We used SPSS version 25 for statistical analysis.

Because none of the measures were normally dis- tributed, we use the Kruskal-Wallis analysis of vari- ance, and we report median values and interquartile ranges for continuous variables. We used the 2 test for categorical variables.

Analysis of Written Comments We also analyzed participants’ comments about

the bra they received. Three independent coders (K.B., K.F.C., C.D.J.) categorized the qualitative data, and discrepancies were resolved through discussion among all coders until consensus was reached.

Results Participants

Of the 97 patients assessed for eligibility for inclusion in this study, 28 did not meet the inclu- sion criteria; 69 patients consented to participate and were randomized (Figure 2). The zipper product did not come in a large enough size for 3 patients, who were removed from the study and given the standard-of-care product. Six of the randomized participants (1 in the hook-loop group, 2 in the zip- per group, and 3 in the hook-eye group) were lost to follow-up (they were intubated or sedated, which

affected their ability to communicate, or they died). We included 60 participants in the final analysis; 20 participants were randomized to each group. The study ran 53 weeks, ending when the 60th partici- pant had been enrolled and had completed the post- discharge survey. No harm or unintended effects occurred in any group. The 3 groups were demo- graphically similar (Table 1).

Satisfaction With Bra On postoperative day 5 or the day of discharge

(whichever occurred first), we found significant dif- ferences in patients’ satisfaction with the various products (H = 5.88, P = .05). Participants were less satisfied with the hook-loop bra (satisfaction score 8.5 out of 10.0) than with the zipper bra (10.0) and the hook-eye bra (9.5). This pattern of satisfaction continued after discharge (H = 7.7, P = .02): partici- pants were significantly less satisfied with the hook- loop bra (7.0) than with the hook-eye bra (8.0); satisfaction with the zipper bra (7.5) fell between the other 2 (Figure 3). Participants recommended the standard-of-care product (hook-loop bra; rec- ommendation score 4.0 out of 5.0) significantly less (H = 8.39, P = .02) than they did both the zipper (5.0) and the hook-eye (5.0) products. The recom- mendation rating varied most for the hook-loop bra (interquartile range 4.0); for the other products, the recommendation rating varied little (interquartile range for both 1.0, P = .009).

Figure 2 CONSORT flow diagram for study enrollment.





Excluded (n = 28)

• Did not meet criteria (n = 28)

Patients assessed for eligibility (n = 97)

Randomized (n = 69)

Allocated to zipper front closure (n = 25)

• Received allocated intervention (n = 22)

• Did not receive allocated intervention

(bra not large enough; n = 3)

• Allocated to hook-eye front closure (n = 23)

• Received allocated intervention (n = 23)

• Did not receive allocated intervention

(n = 0)

Allocated to hook-loop front closure (site

standard; n = 21)

• Received allocated intervention (n = 21)

• Did not receive allocated intervention

(n = 0)

• Lost to follow-up (intubated/sedated;

n = 1)

• Discontinued intervention (n = 0)

• Lost to follow-up (intubated/ sedated;

mortality (n = 3)

• Discontinued intervention (n = 0)

• Lost to follow-up (intubated/sedated (n = 2)

• Discontinued intervention (n = 0)

• Analyzed (n = 20)

• Excluded from analysis (n = 0)

• Analyzed (n = 20)

• Excluded from analysis (n = 0)

• Analyzed (n = 20)

• Excluded from analysis (n = 0) AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 25

Wear Compliance We assessed participants’ compliance with wear-

ing the bra during the postoperative period using postdischarge reports of wear 7 days per week and at least 20 hours per day. We found no significant difference in wear compliance between the products ( 2

2 = 2.5, P = .29). The percentage of patients wear-

ing the assigned bra as instructed, however, did vary among the products (Table 2). The participants who reported wearing the hook-eye product 7 days per week also reported wearing it 24 hours per day. Four participants—3 assigned the hook-loop bra and 1 assigned the zipper bra—did not wear the assigned bra at all after discharge.

Qualitative Feedback Respondents provided comments related to their

perceptions of the bra; the support it provided; mal- functions; and any rubbing, cutting, irritation, or com- fort issues. The comments were consistent with the results of the statistical analysis, indicating discom- fort and rubbing with the hook-loop product and malfunctions with the zipper product. Participants also noted some rubbing with the hook-eye product.

Discussion This study aimed to identify the best bra for

patients after sternotomy in terms of satisfaction and wear compliance. The participants in this study were least satisfied with the hook-loop front-closure bra, the standard of care at the study site. They were most sat- isfied with the hook-eye closure bra and recommended that bra and the zipper bra over the hook-loop bra. The zipper product did not come in sizes for women with very large breasts, and the zipper frequently malfunctioned. With regard to wear compliance, none of the participants wearing the hook-eye bra reported not wearing the bra at all. Overall, wear compliance was strongest in the group wearing the hook-eye bra. On the basis of these findings, we have determined that the hook-eye closure product yielded the most satisfaction (it was given the highest recommendation) and greatest wear compliance in this study.

The strengths of this study include the experi- mental design and the sample size, which is large enough to provide sufficient statistical power. The study contributes to the limited knowledge related to bra selection to promote satisfaction and wear com- pliance. The limitations of the study include the lack of availability of zipper products for women with very large breasts (we had to exclude from the study such women who had been randomized to the zipper prod- uct). The study was not powered to detect differences in compliance. The findings supported a change in

practice: the hook-eye bra is now the product used as the standard of care for this patient population at the study site. In addition, the bra is placed imme- diately after surgery while the patient is still in the operating room (a practice recommended by Rochon et al7), rather than later, after they have been moved to the intensive care unit, which was the standard pro- cedure at our site before the study.

This randomized trial is generalizable to samples like the one used in this study. We did not include in this study women with breasts smaller than a bra cup size C; therefore, more work is needed in order


Table 1 Demographic variables by group

Chest size, mean

(SD), in

Cup size, %





Body mass index,a

mean (SD)

PREVENA Incision


System, % yes





39.9 (4.0)





28.6 (8.5)






39.0 (7.0)





30.2 (9.0)


39.4 (6.0)





28.1 (8.6)


PHook-eye H or ( 2)Hook-loop Zipper

a Calculated as weight in kilograms divided by height in meters squared.

Value in group

Figure 3 Satisfaction with bra before and after discharge.

S a ti

sf a ct

io n

w it

h b













Hook-loop Hook-eyeZipper

Before discharge After discharge

Variable Patients wearing product, %

Table 2 Wear compliance as a function of product

7 d/wk

24 h/d

(among those

wearing 7 d/wk)











PHook-eye 2Hook-loop Zipper



26 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

to understand the best bra for women with smaller breasts after sternotomy. Given that we used only 1 brand for each closure type, future investigations should examine brand variability with regard to fit and comfort. This study focused only on women, but obese men with macromastia may require breast support; this topic also warrants further study. Study of new products would be beneficial as they emerge on the market. Finally, more study is needed in order to evaluate the approach of combining both a bra and an external chest support device.

Conclusion This study contributes to the currently limited

literature related to patients’ bra preference after sternotomy. By promoting use of the bra that engen- ders the most satisfaction and wear compliance, nurses can facilitate the availability and postsurgical appli- cation of the appropriate bra, thereby lessening a patient’s risk for adverse effects—including infection, healing issues, and pain—that are known to occur when bras are not worn after sternotomy. Replica- tion studies are warranted in different populations.

ACKNOWLEDGMENTS This work was performed at the Cardiovascular Institute of Carilion Roanoke Memorial Hospital. The study was completed as a Carilion Nursing Research Fellowship. The authors gratefully acknowledge the contributions of Debra Pullen, BSN, RN, Sandy Wilson, RN, Sara Gill, BSN, RN, Maria Cristofis, and Laura Kate Jennings, BA, all from Carilion Clinic, Roanoke, Virginia.

SEE ALSO For more about care after sternotomy, visit the Critical Care Nurse website,, and read the article by Liu et al, “Topical Lidocaine Patch for Postthoracotomy and Poststernotomy Pain in Cardiothoracic Intensive Care Unit Adult Patients” (October 2019).

REFERENCES 1. El-Ansary D, Adams R, Toms L, Elkins M. Sternal instability fol-

lowing coronary artery bypass grafting. Physiother Theory Pract. 2000;16:27-33.

2. King KM, Parry M, Southern D, Faris P, Tsuyuki RT. Women’s Recovery from Sternotomy-Extension (WREST-E) study: examining long-term pain and discomfort following sternot- omy and their predictors. Heart. 2008;94(4):493-497.

3. Scurr J, White J, Hedger W. Breast displacement in three dimensions during the walking and running gait cycle. J Appl Biomech. 2009;25(4):322-329.

4. Copeland M, Senkowski C, Ergin MA, Lansman S. Macromas- tia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Card Surg. 1992; 7(3):275-278.

5. Copeland M, Senkowski C, Ulcickas M, Mendelson M, Griepp RB. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg. 1994;129(7):757-759.

6. Van Leersum NJ, Van Leersum RL, Verwey HF, Klautz RJM. Pain symptoms accompanying chronic poststernotomy pain: a pilot study. Pain Med. 2010;11(11):1628-1634.

7. Rochon M, Gibb D, Castells AMS, et al. Quality improvement: chest support to aid recovery following medial sternotomy in female cardiac patients. Wounds UK. 2017;13(2):50-57.

8. Hawthorne MH. Women recovering from coronary artery bypass surgery. Sch Inq Nurs Pract. 1993;7(4):223-244.

9. King KM, Tsuyuki R, Faris P, Currie G, Maitland A, Collins-Nakai RL. A randomized controlled trial of women’s early use of a novel undergarment following sternotomy: the Women’s Recovery from Sternotomy Trial (WREST). Am Heart J. 2006;152(6):1187-1193.

10. Moore SM. A comparison of women’s and men’s symptoms during home recovery after coronary artery bypass surgery. Heart Lung. 1995;24(6):495-501.

11. Naismith C, Street, A. Introducing Cardibra: a randomised pilot study of a purpose designed support bra for women hav- ing cardiac surgery. Eur J Cardiovasc Nurs. 2005;4(3): 220-226.

12. Brocki BC, Thorup CB, Andreason JJ. Precautions related to midline sternotomy in cardiac surgery: a review of mechanical stress factors leading to sternal complications. Eur J Cardio- vasc Nurs. 2010;9(2):77-84.

13. Cooper DN, Jones SL, Currie LA. Against all odds: preventing pressure ulcers in high-risk cardiac surgery patients. Crit Care Nurse. 2015;35(5):76-82.

14. Tsang W, Modi A, Ahmed I, Ohri SK. Do external support devices reduce sternal wound complications after cardiac surgery? Interact Cardiovasc Thorac Surg. 2016;23(6):957-961.

15. O’Brien R, Muller K. Unified power analysis for t-tests through mul- tivariate hypotheses. In: Edwards L, ed. Applied Analysis of Variance in Behavioral Science. Marcel Dekker; 1993:297-344.

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1.0 Hour Category BC E Notice to CE enrollees:

This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives:

1. Identify why bra selection and wear compliance is important for women after sternotomy. 2. Discuss strengths and limitations for various closure types of bras used for women after sternotomy. 3. Describe the type of bra closure that resulted in greatest user satisfaction and wear compliance for women

after sternotomy.

To complete the evaluation for CE contact hour(s) for this article #A21302, visit and click the “CE Articles” button. No CE evaluation fee for AACN members. This expires on January 1, 2023.

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development by the American Nurses Credentialing Center’s Commission on Accreditation, ANCC Provider Number

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tered Nursing (CA BRN), CA Provider Number CEP1036, for 1.0 contact hour.



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