Psychological predictors of recovery from thoracotomy in patients with lung cancer

PSYCHOLOGICAL PREDICTORS OF RECOVERY FROM THORACOTOM\’ IN PATIENTS WITH LUNG CANCER BY MARK RAYMOND OTIS A DISSERTATION PRESENTED TO THE GRADUATE C...

0 Downloads 1 Views
PSYCHOLOGICAL PREDICTORS OF RECOVERY FROM THORACOTOM\’ IN PATIENTS WITH LUNG CANCER

BY

MARK RAYMOND OTIS

A DISSERTATION PRESENTED TO THE GRADUATE COU^;CIL OF THE UNIVERSITY OF FLORIDA IN P.ARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1979

ACKNOWLEDGEMENTS

support Many people have contributed their time, knowledge, and over the course of this project.

I

would like first to thank C>Tithia

problems Belar and Joel Tobias, who initially introduced me to the their investigated here and enthusiastically supported my efforts with time and interest.

I

would also like to acknowledge the contributions

of Vernon Van De Riet and Franz Epting.

Both men have been important

sources of stimulation and provocation during my training.

The final

stages of this project could not have been completed without the

support and facilities provided by The University of Texas Health

Science Center at San Antonio.

Final completion of the project was

greatly facilitated by the suggestions of Lawrence Schoenfeld.

I

also

extend my appreciation to Jacqueline Goldman, Paul Schauble, and Otto

vonMering for their contributions.

Finally,

I

iriust

extend particular

thanks for the work done by Sally Bower, Michael Webber, and John Robitaille.

11

TABLE OF CONTENTS

ACKNOWLEDGEMENTS

ii

LIST OF TABLES

iv v

ABSTRACT

INTRODUCTION Descriptive Perspectives Etiological Models of Coping and Recovery Vulnerability Model

24

CHAPTER II

METHODS Subjects and Setting Preoperative Measures Postoperative Recovery Measures Procedure

33 33 34 40 45

CHAPTER III

RESULTS Relationship between Patient Demographic Characteristics, Hospital Setting, and the Recovery Course Preoperative Measures Postoperative Variables Relationships between Preoperative Variables and the Recovery Course

47

DISCUSSION

65

CHAPTER

I

CHAPTER IV

1

2

9

48 48 54

58

BIBLIOGRAPHY

75

APPENDIX A

82

APPENDIX

B

83

.-'J'PENDIX C

84

APPENDIX D

85

BIOGR.APHICAL SKETCH

87

LIST OF TABLES

Table

1

Table

2

Sample Characteristics of the Resected and

Results of Discriminant Function utilizing Postoperative Variables as Predictors of Survivors-Nonsurvivors RLC, and

^

Table 3

Mean Scale Scores on the

Table 4

Mean, Standard Deviation, and Range of

Table

5

Correlations among Preoperative Variables

52

Table 6

Mean, Standard Deviation, Range of Postoperative

Table

7

Correlations among Postoperative Variables

57

Table

8

Regression Analyses of Predictor Variables to Clinical Indices and INDEX

60

Table 9

Regression Analyses of Predictor Variables to Self-report Measures

61

Table 10

Regression Analysis of all Predictor Variables to Days-of-hospitalization

63

IV

Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

PSYCHOLOGICAL PREDICTORS OF RECOVERY FROM THORACOTOMY IN PATIENTS WITH LUNG CANCER

By

Mark Raymond Otis

June,

1979

Vernon Van De Riet Chairman: Major Department: Clinical Psycholog)'

Prior research has suggested that patients' capacities to cope

with stress are important determinants of recovery from surgery. A coping-vulnerability model developed by Zubin and Spring would

suggest that a patient's risk for poor recovery is a function of two orthogonal factors:

(1)

vulnerability

,

the patient's inherent

predisposition to a particular failure during recovery, and coping

,

(2)

the patient’s efforts to master a threatening situation.

A patient's coping can be further described by the competencies

available to the patient and the coping effort extended during stress

v

The present study investigated whether personality constructs

generated by this model were potentially predictive of recovery from major

Img

expected that greater coping

It was

surgery.

effort, more effective competencies, and lower vulnerability would

be predictive of better recovery.

Patient vulnerability was measured by an estimate of the

extent of surgical intervention. included:

(1)

Two measures of competency were

information seeking as assessed by physician's

ratings, and (2) patients' beliefs as to whether their actions

determined the course of recovery, as assessed by the Recovery Locus of Control scale (RLC)

,

a measure developed for this study.

measures of coping effort were used:

(1)

Three

hope and (2) positive

affect were assessed with verbal content measures applied to five

minute speech samples, and

(3)

a patient's

willingness to engage in

physical effort was obtained from preoperative pulmonary function studies.

Additionally, a measure of the social support available

to patients was based on a self-report of their contact with sig-

nificant others.

Assessment of immediate postoperative recovery

(one week) was done wdth standard clinical indices, patients'

self-reports, and physicians

'

ratings.

Results showed that recovery criteria were generally independent of one another and that the postoperative period should be

conceptualized as a multidimensional process.

Concurrent validity

and construct validity were established among the competency measures, but the coping effort measures did not intercorrelate

with one another as expected.

As predicted, vulnerability was

independent of coping, and an additional railnerability measure, VI

1

age, was identified.

Stepwise multiple regression analyses showed

an absence of consistent relationships between individual preopera-

tive predictors and postoperative criteria, although significant

predictions were found at the multivariate level.

Psychological

variables predicted most successfully to criterion of longer rather than immediate recovery.

terra,

Positive affect was negatively

correlated with outcome, although the physical effort measure of coping effort functioned as predicted with respect to length of

hospitalization.

Recovery externals, as measured by the RLC,

received less pain medication and tended to have shorter hospital stays.

Greater vulnerability was generally predictive of a more

difficult recovery course. died following surgery,

Although 20 percent of the patients

operative mortality was not related to any

of the demographic, psychological, physiological, or social vari-

ables assessed here.

The results are discussed in terms of the need to differentiate the recovery course into separate components and to frame

prediction hypotheses accordingly.

The source of variation contri-

buting to operative mortality was not identified in this study and deserves furthur investigation.

vulnerability model offers

a

It is concluded that the coping-

productive source of hypotheses, but

that more sophisticated measures of coping effort and competency are needed.

VI

CHAPTER

I

INTRODUCTION

The psychological literature on adult surgery patients suggests that most if not all patients experience an acute period of anxiety and fear, particularly when surgery is accompanied by threats of death, disfigurement, debilitation, or chronic severe illness.

The

need to understand the psychological factors of surgical outcome and to design psychological preparations for the experience is predicated

upon the belief that surgery is a major stressful event placing all

patients at risk for psychological and/or physiological disruption. This has led to considerable interest in identifying pathological mood

states or dysfunctional coping patterns that provoke poor response to

surgical treatment.

In the rush to develop batteries predictive of

surgical failure or to understand more thoroughly failures in coping, it has often been overlooked that the majority of adult surgical

patients have the where-with-all to adapt successfully to the disrupting effects of illness, hospitalization, surgery, and subsequent recovery.

Tlie

aim of this study was to offer a fresh view, proposing

as an alternative to traditional models a concept of adaptation based

on the individual's competencies and effective efforts to master the

emotional and objective aspects of the situation.

Combined with the

knowledge gained from other approaches, this perspective may offer the

opportunity of developing a more rounded understanding of surgery and its effects.

1

.

.

2

Following a literature review of existing work and a proposal to

regard the area from the perspective of an individual's competencies, an investigation will be reported that was an initial effort to test

the utility of this emerging direction.

Previous work has been focused

upon a description of the phenomenological experience of the patient, or engaged in teasing out individual variations in coping that are

related to different outcomes.

It is most

appropriate to begin with

the descriptive approaches, since these provide the data and clinical

basis for more theoretical and experimentally oriented work.

Descriptive Perspectives The first description and interpretation of psychological experience of the surgical patient were provided by Helene Deutsch (1942)

Based on her psychoanalytic therapy with patients who underwent surgery, she placed particular emphasis upon the experience of anxiety and the

meaning of the operation in reality and symbolically. The critical factor in the conquest of operative anxiety was thought to be the amount of preoperative preparation in which the

patient engaged.

From this view, sudden emergency operations were

likely to be followed by traumatic shock reactions, while a more

favorable reaction was likely when the patient had time to assimilate the anxiety signal.

Assimilation was conceived to be the process

whereby the anxiety was perceived and used to initiate preparatory action She further suggested that the object of the fear or anxiety

about the operation is primarily objective (threat of injury, death)

with a significant underlay of symbolic meaning.

Deriving from earlier

3

the fears of castration which have been generalized to the whole body,

particular cathexis attached to the diseased organ will determine the amount and intensity of anxiety mobilized. She was less clear as to exactly what form assimilation takes. She did note that aggressive tendencies were quite common among those

anticipating surgery, and these were interpreted as sNonbolic reactions against punishing parents (replaced by the surgeon)

Typical defense

.

reactions (projection, displacement, passivity) were also noted in the case illustrations.

Although she does not make explicit statements

about preferred means of assimilation, there is the assumption that

over-defensiveness to the anxiety signal will stall initiation of

adaptation and over-sensitivity to the signal will overwhelm the

patient with anxiety.

Thus, the most successful adaptation would

occur when anxiety is sufficiently strong to prompt preparation, but not so overwhelming as to interfere with assimilation.

Subsequent observers (Meyer, 1958; Titchner

§

Levine, 1960)

noted characteristic experiences of the surgical patient and common

defense mechanisms used to handle operative anxiety. ity,

Enforced passiv-

lack of privacy, and the dislocation from normal occupational and

interpersonal patterns were noted as disrupting forces placing additional stress upon the patient.

Realistic anxiety about the operation

could be compounded by feelings of helplessness, guilt over giving up

responsibilities, or vulnerability.

The most commonly noted defense

mechanism to handle these anxieties was denial.

It might be manifested

as outright refutation of objective facts, avoidance of perception (e.g., failing to look at the results of mastectomy) or selective

misperception.

Although Meyer (1958) seemed to feel that denial may

4

serve constructive purposes in certain situations, observers o£ this

period generally labeled it a pathological process leading to delay in seeking treatment, refusals to cooperate with medical advice, and difficult periods of postoperative adjustment.

These early observations and interpretations laid the groundwork Indeed, the formulation of the role of

for much additional research.

anxiety initially proposed by Deutsch has proven to be remarkably resilient and will be seen again and again throughout the literature. The primary limitation to these approaches is their heavy emphasis

upon pathological coping reactions and the lack of description of the process of successful assimilation. Improvements in assessment became possible with the availability of psychometric instruments to validate clinical observations.

These

instruments have demonstrated their value most clearly in the assess-

Confirming the earlier observations, scores on

ment of anxiety.

measures of transitory anxiety [A-State) were consistently high during the preoperative period and declined to normal levels during convalescence.

As expected, scores on a measure of characteristic anxiety

(A-Trait) did not change from pre to post surgery, and changing levels

of A-State were not related to levels in A-Trait (Auerbach, 1973;

Auerbach

§

Edinger, 1977; Johnson, Leventhal,

Urrutia, 1975; Meikle, Brody,

Wadsworth, Dunn,

S

§

S

Dabbs, 1971; Martinez-

Pysh, 1977; Speilberger, Auerbach,

Taulbee, 1973; Wolfer

&

Davis,

1970).

The under-

standing of the patient's experience of anxiety has been refined further by a study which assessed anxiety on each of the first three

postoperative days (Chapman

§

Cox,

1977).

A curv'ilinear response

tendency was found, such that anxiety was relatively low prior to

5

surgery, significantly increased 24 hours after surgery, but decreased

again 48 hours after surgery.

The apparent inconsistency between

these results and those of the former studies probably represents

differences in time of measurement.

The earlier studies generally

obtained measures one week following surgery and thus probably missed the immediate intense changes in transitory anxiety.

Chapman and Cox

across opera(1977) also found that subjective state reactions varied

tive groups.

Kidney donors evidenced markedly less anxiety prior to

surgery than kidney recipients or general surgery patients, but became significantly more anxious than the other patients on the first postoperative day.

General surgery patients did not evidence the rapid

decrease in state anxiety post operatively as noted in the other groups. These results suggest that the subjective meaning and perceptions of the particular operation effect fluctuations in anxiety.

Correlational studies intended to investigate the relationship

between anxiety and recovery provided equivocal results. initially suggested by Deutsch (1942)

,

As

Auerbach (1973) found that

relative elevations in preoperative anxiety, as measured by the State Trait Anxiety Inventory (STAI)

,

had a curvilinear relationship with

postoperative distress, such that patients with relatively high and more low increases of state anxiety over their normal level reported

postoperative distress than those patients with state anxiety. (STAI)

a

moderate increase in

Linear relationships between preoperative state anxiety

and postoperative levels of state pain (Barkdoll,

1975; Martinec-

(Biersner, Urrutia, 1975) and psychotropic drug effects due to anesthesia

Harris,

§

Ryman, 19,77) have also been reported.

On the other hand,

found to obseiv^er and patient rating scales of anxiety have not been

6

be related to postoperative welfare or recovery (Cohen 1975; Wolfer § Davis,

1970'J

and two studies

5

Lazarus,

(Barkdoll, 1975; Bruegel,

between preoperative 1971) reported nonsignificant relationships characteristic anxiety and postoperative pain reports, although a

anxiety third study (Martinez-Urrutia, 1975) suggested that Hi-Trait Lopatients experienced more pain both before and after surgery than

Trait anxiety patients.

The ambiguity surrounding these results may

derive from variation due to alternative criterion measures utilized, different patient populations, and time of assessment.

The importance of time of assessment has been demonstrated in

research investigating short-term and long-term recovery from openheart surgery (Heller, Frank, Kornfeld, Malm

5 Bovvman,

At one

1974).

year follow-up, one-third of the patients reported significant psychological problems which interfered with recovery.

These problems

included anxiety, depression, poor self-esteem, somatic preoccupations, and withdrawal.

These long term adjustment problems were related to

preoperative factors such as poor life adjustment, and

(c)

reluctance to undergo surgery

(a)

and active personality type.

,

(b)

However,

the occurrence of immediate postoperative dysfunction (delirium,

organic brain syndrome) was not related to the preoperative measures, outcome. and immediate outcome was not related to one year psychological and Subsequent studies confirmed the independent nature of immediate

long-term recovery among open-heart patients (Rabiner Rabiner, Wilner

§

Fishman,

1975)

.

&

Wilner, 1976,

Although the incidence of patients

experiencing psychiatric disturbance was found to be similar immediateaf-(;er

surgery and at one year follow-up, the patients with s)Tnptoms

during the immediate post-operative period were no more likely to

.

7

asymptomatic evidence psychiatric s>mptoins at follow-up than patients during hospitalization.

The results suggest that different sets of

disturbance factors play a role in the onset of immediate postoperative and long temi adjustment.

Evidence from another study would suggest

populations. that these findings can also be extended to other surgical The investigators [Kolditz

h

Naughton, 1975) interviewed 200 recovering

of surgery patients and found that they could identify two phases

recovery:

f.l)

full recovery.

sufficient progress to leave the hospital, and

The first phase had three major components:

(2)

resolution

to surgery, of specific operative consequences, resolution of responses

and physician's validation of their readiness to leave.

phase involved:

The second

the ability to resume normal functioning, complete

From these findings

physical recovery, and assurances from physicians. it seems clear that

investigations of the relationship between personal-

and nature ity factors and the recovery course must specify the time

of the recovery process being assessed.

Other evidence exists which confirms the clinical impression that On self-

surgery is accompanied by a generalized stress response.

than report questionnaires surgical patients reported more stress "loss medical patients on factors of "unfamiliarity of surroundings", Isenberg, of independence", and "threat of severe illness" (Volicer,

Bums, 1977).

The findings appeared to be related to the unfamiliar

and machines and surroundings of surgery, the physical consequences, the knowledge of surgery itself.

Sleep is disturbed in both length

both and quality during the pre and postoperative periods, and may be a

consequence of anxiety, pain, hospital procedure, and

to impaired functioning and slow recovery

S

a

contributor

Dudley, 1976)

§

8

immediately following Depression has also been noted to increase

preoperative levels within two surgery, although it tends to return to or three days postoperatively (Chapman

&

Cox, 1977)

.

In comparison to

for medical treatment, patients presenting at an outpatient department

intractable pain were more cancer patients awaiting surgery to reduce and demonstrated a high fearful, revealed greater physical distress, level of agitation (Hardesty, Burdock, Lenn

§

Trachtman, 1973).

distinguishing characterInterestingly, the authors noted that the m.ost the absence of anger and istic of both groups of medical patients was

by depressed psychiahostility, a pattern very similar to one presented tric patients.

explore the Investigators have also used descriptive designs to will effect a general hypothesis that personality characteristics

patient's recovery and adaptation.

At a general level the hypothesis

linear relationship has been supported by findings of a modest positive (Bultz, 1975; between ego strength and various measures of recovery

Ciller, 1962).

perceive Thus, a patient's general capacities to plan,

to their accurately, and maintain reality contact appear related

course. overall psychological and physiological recovery

More important

subjective percepgeneral factors, however, appear to be the patients'

physiological effects of tions of the operation, and the particular any one surgical procedure.

For example, it was noted previously that

different in postkidney donors and recipients were significantly and donors and operative mood reactions from general surgery patients,

recipients differed markedly from each other (Chapman

S

Cox,

1977).

the voluminous These results are not surprising, as they confirm

literature clinical reports that comprise the remaining descriptive

9

(see Howells,

1976, for a comprehensive collection of such articles).

Drawing upon theory and clinical experience, these observers have the repeatedly confirmed Deutsch's (1942) earliest observation that are meaning and effects of particular operations for the individual the crucial factors determining the adaptive tasks and nature of

recovery course. In summary, descriptive approaches have contributed a basic

understanding of the stressful nature of surgery, documenting characterhospital istic mood reactions and intrusive elements of the illness and experience, and appear particularly suited to describing the unique

procedure. tasks and stressors of a particular illness and operative

Using this as an experiential base, investigators are now turning their attention increasingly to developing over-riding theories or

etiological models that can explain response in a broad range of surgical populations.

Etiological Models of Coping and Recovery

The etiological models can be classified into four types:

(1)

emotion-as-drive models focusing on the arousal of fear and anxiety which lead to constructive preparation or the "work of worrying";

(2)

emotion-as-response models focusing on cognitive threat appraisals and the role of emotional and instrumental coping responses;

(5)

disposi-

tional models focusing on particular propensities of individuals to use one or another coping tj'pes; and,

(4)

situational models ^ocusing

on hospital milieu, sociocultural, or contextual variables.

three models are person centered:

The first

the forces emanating from the

personality determine the style and manner of coping.

The fourth

v/

10

model is primarily "environmental," in that differences between patients are attributed to environmental rather than personality characteristics.

Emotion-as-drive model The first investigator to elaborate Deutsch's (1942) description of anxiety and assimilation was Irving

L.

Janis (1958)

.

In his initial

work, Janis (1958) conducted extensive preoperative and postoperative

interviews with 23 surgical patients and collected additional information from chart notes.

The information derived from these sources was

used to classify the patients into one of three preoperative emotional states: high, moderate, and low fear.

The postoperative interviews

revealed that moderate fear level patients were less likely than resentment, others to display postoperative anger, excessive anxiety,

criticisms of staff, and agitation.

Low and high fear patients

appeared to be unprepared for postoperative stress and were markedly distraught during convalescence.

Subsequently, Janis (1958) collected

retrospective self-reports from 149 students who had undergone surgery. The correlational results supported the original findings.

Addi-

information tionally, these reports indicated that the provision of

prior to surgery affected recovery.

Those patients who were not

informed about the surgery reported feeling:

(1)

little fear prior to

and (2) anger during convalescence,

(3)

resentment towards

surgery,

the staff.

reflective fear To interpret these data he advanced the concept of (Janis,

1958; Janis

8

Leventhal,

1965).

Once fear is stimulated by the

the negperception of threat stimuli, the person attempts to relieve of the threat. ative feelings by remaining vigilant to all features

realistic engaging in the "work of worrying," the individual develops

By

"

11

expectations and plans for action with which to meet and survive the impending danger.

However, high levels of fear may be unproductive

if the person engages in inefficient impulsive behavior or begins to

The strong emotional reactions disrupt vigilance, judgment,

panic.

and increase the probability that extreme forms of avoidance will be

Similarly, low fear level in the face of realistic threat will

used.

not provide sufficient distress to motivate the patient to ''worry.

The person will remain unaware of threat cues due to indifference. Thus, the model predicts that the person experiencing moderate fear

will be the most capable of handling the danger when it finally arises. In sum, Janis proposed the following sequence of events to

explain psychological response to surgery:

(a)

exposure to threaten-

ing stimuli about the impending operation leads to,

fear which motivates,

(c)

(b)

anticipatory

"worry work” strategies, such as seeking

information or reassurance, which lead to

(d)

accurate expectations,

reassurance, and reduced incidence of hostility or distress following surgery.

However, subsequent research has not generally supported the

various components of this model. findings, Leventhal (1963

-

In an effort to replicate Janis'

cited in Johnson et al., 1971) looked at

the relationship between 11 measures of preoperative emotionality and

various indices of postoperative adjustment.

Contrary to the cum'i-

linear model, patients who were lowest in preoperative fear were also lowest in postoperative emotional distress and criticisms of the staff.

In a subsequent study

(Johnson et al., 1971)

levels of pre-

operative fear were assessed on 62 surgical patients with the Mood

Adjective Check List.

The authors reported that the relationship

.

12

between fear and postoperative distress was generally linear.

Patients

low in preoperative fear reported less emotional distress than patients

high in preoperative fear.

These results are compatible with other

studies which also found reliable linear relationships between fear and postoperative distress (Biersner et al 1976; Kolfer

§

.

,

1977; Giller, 1962; Sime,

Davis, 1970).

Tests of the hypothesized sequence between exposure to threat stimuli and final response also present equivocal support.

As predict-

ed, Vernon and Bigelow (1974) found that exposure to a preoperative

condition which increased knowledge about surgery was related to greater preoperative attention to problems, but exposure was unrelated to self-reports of preoperative fear or worry.

Similarly, the extent

of a patient's knowledge about the upcoming procedure has been found to be positively related to active coping efforts of information

seeking, but self reports of fear were independent of coping activity (Sime, 1976).

In contrast, one study demonstrated that patients

provided preoperative information about surgical preparation, pains and discomforts did evidence increased anxiety and fear, although this

did not lead to less postoperative distress during the recovery period (Danger, Janis,

§

Wolfer, 1975).

One possible explanation for these

conflicting findings is that Vernon and Bigelow's failure to provoke fear with their information package was due to relatively less threatening, perhaps more factual information.

This view suggests that threat

stimuli in the form of information may provoke (2)

(1)

fear responses or

problem oriented responses, but that the two seta of responses are

not related to one another and do not necessarily lead to better

recovery

Additionally, the

t)-pe,

quality and extent of information

13

provided may interact with levels of fear or anxiety. investigators [Williams, Jones, Workhoven,

£r

One group of

Williams, 1975) found

that both brief and extensive supportive preoperative interviews

decreased anxiety among high anxiety level patients, but that brief interviews significantly raised anxiety levels among the relatively

nonanxious patients.

Where experimental manipulations intended to increase fear levels through exposure to threatening stimuli have not translated to

changes in the recovery course, interventions intended to distract the

patient from the negative aspects of surgery and to provide instruction in specific coping devices do facilitate the recovery course.

gies

Strate-

with demonstrated effectiveness include instruction in physical

exercises that reduce pain and enhance return of physical mobility (Egbert, Battit, Welch,

§

Bartlett, 1964; Healy, 1968), preoperative

groups that provide support, information and ways the patient can aid in their recovery (Schmitt

S

Woolridge, 1973), and instruction in a

coping device utilizing distraction and cognitive reappraisal through

selective attention (Langer et al

.

,

1975).

In summary, the evidence does not support the two basic assump-

tions of the emotion-as-drive model:

between perception and adaptation, and

between fear and recovery.

(1) (2)

fear as a mediating variable a curvilinear relationship

In attempts to assess more adequately and

to understand these processes several authors have reworked the basic

motivational assumptions of the coping model.

Emot ion-as-response models

More recent conceptualizations of the coping process have taken as their starting points the mediating function of cognitive appraisal

14

Averill, and the place of eraotions-as-responses (Lazarus, 1966; Lazarus, S

In the most general terms,

Opton, 1974; Leventhal, 1970, 1975).

cognitive appraisal is the primary process which distinguishes the

potentially harmful elements of irrelevant.

a

stimulus from the beneficial or

The coping process is not a response primarily designed

response to to reduce the intensity of an unpleasant emotion, but is a courses of a cognitive perception of impending danger and potential action.

Emotions such as fear or anxiety are reactions to the percep-

tion of threat, although they may also serve as stimuli for further Coping responses may be expressed as additional

threat appraisals.

cognitive modes of resolution (benign reappraisal, attentional refocusing, conflict resolving fantasy)

instrumental activity)

or direct action (avoidance, attack,

The particular coping strategy chosen at any

.

of one point in time will be a function of dispositional propensities the individual, the nature of the threat appraisal, and situational

factors (Lazarus et al Leventhal

tion of threat;

.

,

1974).

(1970) posits two independent responses to the percep(1)

emotional reactions and efforts to reduce emotion;

and, (2) awareness of the objective features of the threat and danger

controlling responses to reduce the threat.

He suggests that the two

classes of responses are independent of one another;

they are respon-

sive tc separate elements of the threatening stim.ulus and they do not

cause one another.

When emotional arousal leads to instrumental

action designed to reduce the arousal

,

the process is fear control

.

Actions designed to control fear (avoidance, defenses, reinterpretation) TT.av

have no effect on the actual danger.

Behavior intended lO contiol

the objective features of the threat is termed danger control

.

15

Support for this model was provided by a study with 62 female surgical patients (Jolinson et al

.

,

1971).

Preoperative and post-

operative measures of emotion (moods, pain, anxiety)

w'ere

intercorrelat-

ed and generally showed positive linear relationships with one anotlier

Active danger controlling behaviors (requests for information, daysof-hospitalization) and locus of control beliefs also showed positive

relationships to one another.

But, the measures of emotional and

danger controlling behavior were relatively independent of one another. The implications of this model for medical care are that strategies which enhance the patient's danger controlling coping behavior will improve physical recovery, and techniques designed to facilitate

fear control will improve the patient's emotional adaptation.

In an

initial test of this hypothesis, Johnson and Leventhal (1974) provided two t>pes of preparatory information to patients awaiting an endoscopic a behavioral message,

and (2) sensory-descriptive

examination:

(1)

information.

The behavioral instructions were intended to improve the

patient's danger controlling responses.

The sensory-descriptive

information was intended to reduce idiosyncratic misinterpretations of the experience and reduce emotionality.

As predicted, the sensory-

descriptive information successfully reduced emotionality during the examination.

However, behavioral instruction altered danger control-

ling responses only when combined with the sensory information.

Although situational factors related to the intensely threatening nature of the examination appeared to have caused the interdependency, the results provided additional support for the model.

Similarly,

Sime (1976) found that patients who were experiencing high levels of fear and who were well inform.ed about their illness and treatment

16

received fewer analgesics and sedatives and were hospitalized a shorter However, both

period of time than less well informed counterparts.

less and well informed patients reported high levels of postoperative

negative affect.

Since the administration of analgesics and the

length of hospitalization are both assumed to be somewhat under patient control, it appeared that the patient's coping actions were independent

of their postoperative emotional reactions.

Both Leventhal and Lazarus have developed models with considerable conceptual elegance.

Individual interpretations of threat

stimuli, coping predispositions, intrapsychic and behavioral coping

responses, the role of emotions, and the influence of situational The task for researchers

factors have important places in the models.

now is to identify specific predispositional

,

behavioral response, and

situational factors which account for the variability in outcome.

Dispositional Models Dispositional variables reflect potentialities of the individual They may be organized around coping responses (anxiety, hostility,

approach-avoidance); organized around particular stimuli (attitudes, beliefs, values); or conceptualized from theoretical propositions (field dependence- independence)

Coping disposi-

(Lazarus et al.,1974).

tions are distinguished from the actual coping responses used under

particular circumstances.

Three dimensions of coping dispositions

have been investigated in the surgical literature:

internal -external

locus of control, trait anxiety, and approach-avoidance.

Internal - external control

.

The extent to which patients believe

they can influence their treatment and recovery is reflected in measures of internal -external locus of control

(Rotter,

1966)

.

Internal persons

^

17

believe their actions, skills, and efforts determine their experiences, while external persons believe their experiences are determined by luck, fate, or outside forces.

With respect to health related behavior, internal patients have

been found to seek and obtain more information about disease (Seeman Evans,

1962; Wallston, Maides,

§

§

Wallston, 1976), to be better adjusted

prior to surgery (Kimball, 1972), and to be less anxious preoperatively (Lowery, Jacobsen, § Keane,

1975).

On dimensions of surgical recovery

partly under patient control, internals stayed in the hospital longer and received more doses of postoperative pain medication (Johnson et al.,

1971).

Guttler,

fi

In a study of preparatory communication

Levitt,

1976)

(Auerbach, Kendall,

internals adjusted poorly during dental

surgery when provided with general information; however, they adjusted well when specific information regarding procedures and sensations was

provided.

The opposite relationship was found for externals.

The

authors suggested that specific information enhanced the internal's

propensity to seek and use relevant information. specific information may

For externals, the

have upset their tendency to attribute control

to the environment and jeopardized their adjustment.

Results are limited somewhat by the difficulty in predicting

specific health related behavior from measures of generalized expectancies.

It may be necessary to develop I-E scales more specific to

illness and recovery behavior to predict adequately coping responses (Wallston, Wallston, Kaplan, § Maides, 1976).

Trait anxiety

.

Trait anxiety, a relatively stable individual

disposition to react emotionally to stress, has been related to various aspects of the surgical experience.

As indicated

earlier

,

^

18

high trait anxiety patients have higher state anxiety scores than low trait anxiety patients, both before and after surgery; and both groups

show similar declines in state anxiety scores from pre to post surgery (Auerbach, 1973; Martinez-Urrutia, 1975; Spielberger et al

1973).

,

.

The results suggest that high trait anxiety patients do not perceive

surgery to be more threatening than low trait anxiety patients. However, high trait anxiety was related to increased reports of pain

during both the preoperative and postoperative period (MartinezUrrutia, 1975) (Jolmson et al

greater fear of surgery on the first postoperative day

,

.

1971), and general worrying about hospitalization

,

(Auerbach, 1973)

.

Trait anxiety has not been related to other aspects

of physical recovery or manifest coping behavior. Ap proach-avoidance

.

Approach versus avoidant strategies of

coping with stress have been conceptualized at the cognitive level as

minimization-vigilant focusing (Lipowski, 1970); at the emotional level by avoiding-nonspecific defending (Goldstein, 1959)

and behavior-

;

ally as tackling-capitulating-avoiding Cbipowski, 1970) or vigilant

avoiding (Cohen

§

Lazarus, 1973).

Although sharing similar constructs,

these measures have not demonstrated concurrent validity and may

represent independent dimensions (Lazarus et al

.

,

1974).

Several studies have used the Goldstein sentence completion test (SCT)

as a measure of the patient's disposition to avoid

to remain vigilant

(avoiders) or

(copers) to the emotional aspects of surgery.

Copers were found to take more medication than avoiders, but were not

significantly different on measures of days-in-the-hospital complications, or negative psychological reactions (Cohen 1973).

In another study,

3

,

minor Lazarus,

DeLong (1971) found avoiders typically had

u

.

19

slow complicated recoveries in contrast to copers.

A third study

better recovery found that preparatory information was associated with avoiders or among neutrals, but did not improve the recovery among copers [Andrew, 1970)

.

The results from these three studies are

to experience conflicting; both copers and avoiders have been found

make best use of difficult recoveries, and those who were expected to One problem may be the

preparatory information (copers) did not.

behavior measures of coping disposition do not reflect the actual This possibility is supported by the finding that the

being employed.

and a correlation between a behavioral measure of vigilance-avoidance

dispositional measure was (Cohen §

r_

=

.082,

indicating relative independence

Lazarus, 1973)

lies in Another possible explanation for the conflicting results

the effect of situational variables.

A specific coping behavior may

different be more useful in certain stressful circumstances or at points during long periods of crisis.

For example, behavioral vigilance

immediately following is related to slower, more complicated recoveries surgery (Cohen

S

Lazarus, 1975); however, an active vigilant orienta-

adjustment posttion towards stress was related to better long term surgery (Boyd, Yeager,

8

McMillan, 1973)

.

An active vigilant approach

which may be incompatible with the immediate recovery period,

^.s

long-term marked by incapacitation and pain, while it may enhance activities. recovery marked by growing strength and return to normal

Sit ational model

Situational variables include hospital -treatment characteristics, the nature of surgery, and sociocultural factors.

As in much of

20

American psychology, situational factors contributing to coping have

^

been the object of very little research.

Recovery has not been found to be associated with social class or years of schooling (Cohen (Eisler, Wolfer,

§

§

Lazarus, 1973) or racial group membership

Diers, 1972).

In the only study to focus upon

cultural and social class variables, Tsushima (1968) found patients

with Italian backgrounds showed more overt emotional tension and

hostility than presurgical patients with Irish backgrounds.

Social

class membership was not related to preoperative emotional reactions.

Although social class variables do not appear to be predictive, a more specific set of items

conceding occupational, marital, social,

educational, residential, and family status was predictive of surgical

success among patients with intractable duodenal ulcer (Pascal, Thoroughman, Jarvis, S

Peoples,

5

Jenkins, 1966; Thoroughman, Pascal, Jenkins, Crutcher,

Patients who were relatively environmentally

1964).

deprived and reported poor early relationships with parents showed

poor results at two year follow-up. Marital and family variables appear to be particularly important aspects of treatment and recovery.

The importance of understanding

factor in and support from a family has been implicated as a major

patients favorable recovery and long term well-being among colostomy (Dlin,

Perlman,

5

Ringold,

1969)

and patients with surgically induced

facial disfigurement (West, 1975).

In au observational study, Eisen-

patients drath (1969) noted that mortality am>ong kidney transplant upon appeared to be preceded by a sense of abandonment by a person important whom the patient depended or whose love was a particularly part of their lives.

had a similar loss.

None of the patients who survived the transplant

21

Environmental variables have clearly been related to long-term recovery.

A rich satisfying life context and supportive family are However, environ-

conducive to a return to a fulfilling life style.

mental variables related to immediate surgical recovery have not been

investigated as thoroughly as the ones predictive of long-term success. Ward milieu, patient-staff interaction variables, architectural and

physical design variables, and family variables are potentially important determinants of physician and patient behavior during treatment

and recovery.

Summary The evidence collected in the studies reviewed seems to indicate the following:

(a)

negative mood states such as fear and anxiety are

common among surgery patients, but it is unclear whether they are

related to active coping efforts or recovery;

(b)

the most potent

variable is the operative intervention, since the nature and effects

of

different surgical procedures poses widely varying psychological and

physiological demands;

(c)

the patient's subjective perceptions of the

hospitalisation experience has a major effect on emotional responses and long terra rehabilitation;

(d)

increasing evidence suggests that

emotional responsivity to operative threat is independent of ongoing

danger controlling coping action; and,

(e)

although several important

dimensions of coping have been identified (approach-avoidance, locus of control), relatively few specific dispositional propensities,

behavioral responses, and situational variables that have a place in a comprehensive model have been noted and researched.

From this summary

it seems evident that a perspective is needed which would emphasize

22

identification and assessment of a wider range of attributes of the

patient and environment relevant to the adaptive process.

From the standpoint of methodology, the most difficult problem has been the definition and assessment of postoperative recovery.

Three particular problems stand out.

First, uncontrolled situational

variables may have an unknown effect on criterion recovery measures. For example, Johnson, Johnson, and Dumas (1970)

found that the frequency

of pain medication, length of hospitalization, and occurrence of

infection were related to

t)q)e

of operative procedure, while duration

of anesthesia was associated with capacity to void.

Levels of anxiety

during hospitalization have also been associated with the type of

hospital and cancer diagnosis CLucente 5 Fleck, 1972)

.

These and

other factors, such as institutional policies regarding use of medication and length of hospitalization, customary practices of individual

nurses and physicians, and the availability of specialized services,

may affect criterion measures to the extent that they do not vary as a function of the patients' internal psychological condition or in response to experimental interventions (Wolfer, 1975).

Consequently,

it is probably an error to pull subject populations from a "general

surgery pool," since it is unlikely that they are all exposed to similar conditions and experiences.

It can also be expected that

operative and treatment procedures will interact with different surgery

populations such that criterion measures sensitive to recovery in one group will be confounded in or extraneous to recovery in another group.

Comparison of results between studies utilizing different

patient populations or criterion measures becom.es problematic. potential solution is to choose

a

uniform patient population and

One

recovery tasks carefully select standardized measures tailored to the and demands of that group.

of A second problem is the point in time at which assessment

recovery is made.

It is probably inappropriate to compare patients

assessed assessed during the immediate postoperative period with those

much later during recovery, particularly when they have undergone different surgical procedures.

The former patients are still struggl-

later in ing with the effects of massive physical assault, while

recovery the patients' primary tasks are to reassume the social and The psychological

psychological roles given up during hospitalization.

these and situational factors predictive of successful adaptation to

respective periods may be quite different and it is probabiy wise to regard them as separate areas of inquiry. The final problem that can be noted concerns the multidimensional nature of recovery and the various criterion sources available to

measure progress.

Recovery is composed of several classes of psycho-

logical, physiological, and social criteria.

Investigators have

standard tapped each of these dimensions through patient self-reports,

clinical indices, and physician and observer ratings.

Each of these

sources is subject to biases, such as the situational variables noted above, or a patient's efforts to provide socially desirable responses

rather than "true" self-assessment [Eisler,

V.’olfer,

^

Diers, 19/2).

Additionally, the salient features of recovery for the patient may be extraneous to the physicians' concerns (Kolditz

^

Naughton, 19/5), and

objective clinical indices may provide information about sources of

variation in recovery that are independent of patient or physician assessments.

Therefore, it is probably wise to sample a variety of

recovery criteria from several independent sources.

24

The aim of this investigation was to assess the efficacy of a

vulnerability model in generating new constructs potentially predictive of coping and response to surgery, and to test these constructs on a loniform patient population during a limited period of their recovery.

Vulnerability Model

The model to be considered here is based largely on ones proposed by experimental psychopathologists (Garmezy, 1974; Zubin 1977).

^

Spring,

In common with the approaches taken by previous researchers,

this model makes the basic assumption that each surgical patient is to

some extent vulnerable to physiological and psychological distress

beyond the normal range.

In effect, vulnerability is a measurable

attribute of the individual: during recovery.

a

predisposition to a particular failure

Factors contributing to a surgery patient's vulner-

ability include the extent and nature of disease, physical stamina, and the internal makeup or physiology laid down by genetic influences.

Some acquired factors might include family experiences, ongoing social

involvement, and other life events and roles that enhance or inhibit

development of dysfunction (Zubin

§

Spring, 1977)

.

The highly vulner-

able patient is one for v/hom numerous contingencies of the surgical

experience or minimal levels of stress encountered during hospitalization may provoke episodes of breakdown from a normal recovery pattern. Others may have such a low degree of vulnerability that only the most

catastrophic events will elicit brief periods of disruption.

However,

a patient's vulnerability to any particular breakdown is not the only

contributing factor and being predisposed does not necessarily produce

25

Other factors such as the patient's psychological maturity

dysfunction.

probably contribute to the maintenance of health and equilibrium. A patient's vulnerability is likely to become evident when

internal or external stressors impinge upon the patient.

It is

overly simplistic to think of surgery generally as a "stressful

event."

As Deutsch and the many clinical observers who have followed

her have noted, the patient's evaluation of different events and

experiences during hospitalization and recovery will be a significant

detenninant of what is experienced as stressful.

For one patient the

pain, immobility, and intense medical treatment of the first few

postoperative days may be quite disturbing, while for another the transfer to a regular ward with less mechanical support and more casual medical supervision may lead to a crisis associated with fears

of abandonment and death. The patient will experience an event as stressful when he perceives a discrepancy between the impinging demands and his awareness of

available responses with which to meet the threat [Zubin 1977)

.

&

Spring,

The resulting stress may be thought of as a strain on the

patient's coping abilities. C oping

describes the patient's efforts to master a situation that

may be threatening, challenging, or gratifying (Lazarus et al Murphy, 1974).

.

,

1974;

A principle set of factors which influences the patient'

coping behavior is the competencies which can be brought to bear. the simplest

teirnis,

competence is effectiveness:

In

"it is a person's

feeling that he can have a desired effect" (White, 1975)

.

The follow-

ing are some of the other aspects of coping which must be taken into

account:

(a)

the reflexive actions and instincts adequate to meet

.

26

stressors;

(b)

coping efforts

,

which may be thought of as persistant

trial and error attempts at adaptation; and,

development of mastery

(c)

from successful coping efforts (Murphy, 1974; Zubin

5

Spring, 1977).

An individual's level of competence is developed by consistently

exerting coping efforts to master situations, and consists of the fund of intellectual strategies, social skills, ego defensive maneuvers,

and other acquired capacities that are built up over time.

efforts are distinct from competencies.

Coping

IVhereas the patient's compe-

tencies are capacities, coping efforts are the motivational or attitudinal approach to a particular set of exigencies.

Patients' coping

efforts are often referred to as their "will to live." UTiat is

the relationship between coping, vulnerability, and

recovery breakdown?

Zubin and Spring (1977) suggest that when coping

is disrupted or is inadequate to meet the situation, the length and

severity of an episode of physiological or psychological dysfunction will be determined by the extent of the individual's vulnerability. For the relatively "invulnerable" patient, coping dysfunction may lead to the one "bad night" or the short period of agitation and fear

commonly reported by patients during recovery.

On the other hand,

the

highly vulnerable patient may evidence severe prolonged periods of anxiety, physiological trauma, or perhaps death when coping dysfunction

occurs In trying to predict which patients are likely to experience

coping dysfunctions, one must determine in what component of coping

breakdown is likely to occur.

Will it be the patient’s failure to

perceive potentially threatening events for which preparation is needed?

Is

it the diminution of coping effort,

inadequate competencies.

,

27

or some combination of all three?

Following the lead of Zubin and

Spring (1977) and in conjunction with the prevailing thought within the clinical and observational literature, coping effort appears to be the most likely marker or indicator of the patient's functional level

of coping.

This is because coping effort is a more dynamic aspect of

the patient which is subject to waxing and waning over time and situations, whereas competencies and cognitive abilities are likely to be

more stable attributes.

In effect,

coping efforts are needed to put

the patient's competencies and cognitive appraising into motion.

Therefore, this model suggested that an attempt to identify indicators

or predictors of coping dysfunction must focus upon variables of

coping effort as well as the more well researched competencies. The purpose of the current investigation was to use this perspective to select variables predictive of poor recovery.

Measures judged

to be associated with coping effort, competencies, and vulnerability

were assessed preoperatively and related to various measures of immediate postoperative recovery.

Thus, the effectiveness of each aspect of

the vulnerability model in predicting outcome was assessed.

Preoperative coping effort was assessed with measures of hope , positive affect

and physical effort

,

.

The first two measures were

chosen since they reflected an important aspect of coping effort; that is, the maintenance of positive expectancies and beliefs that a favor-

able outcome will follow action seems to be a necessary precondition to coping activity.

Hope has been noted to be an important aspect of

successful psychotherapy (Frank, 1968; Perley, Kinget, 1971)

8

Placci

and hopelessness has been implicated as a predictor of cervical

cancer (Schmale

8

Iker,

1971), and seriousness of suicidal intent

among depressed patients (Beck, Weissman, Lester, verbal content measure of hope (Gottschalk

S

Traxler, 1974)

St

A

.

Gleser, 1969) has been

significantly associated with the experience of emotional crisis (Gottschalk, 1974), survival time in cancer patients undergoing radia-

tion therapy (Gottschalk, Kunkel

,

Wohl, Saenger,

S

Winget, 1969), and

psychiatric morbidity following six weeks of intensive psychotherapy (Gottschalk, Fox,

§

Bates, 19731.

A more general measure of positive

affect using content analysis of verbal samples has also been developed (Westbrook, 1976)

.

In preliminary analysis this scale has demonstrated

adequate construct validity when applied to speech samples from mothers, reallocated women, students in transition, and psychiatric

patients.

More importantly, levels of positive affect were inde-

pendent of various negative affects, suggesting that people's experience of negative and positive feelings are independent.

Thus, a complete

understanding of patients' efforts to cope with events of surgery must take into account their positive expectancies and feelings.

As a

means of testing this hypothesis, measures of hopelessness (Beck et al

.

,

19741 and fear (Martinez-Urrutia, 1975) were also administered

preoperatively to the patients in the present study.

It was

predicted

that hope and positive affect would be significantly correlated with

one another, but that each would be independent of hopelessness and fear.

The third measure of coping effort, physical effort

,

assessed the

patient's relative physical striving during a medical examination.

It

was thought that this measure would be predictive of the patient's

willingness to engage in various recovery enhancing physical exercises (walking, coughing, arm and leg exercises) despite pain and lack of

29

energy.

Comparable measures had not been previously reported in the

literature.

The social environment in which treatment takes place has also

been implicated as a major factor in the patient's efforts to cope

with physical and emotional stress (Klagsbrun, 1970; Lipowski, 1970; Moos, 1976)

.

These authors emphasize the role professional care-

givers can take in offering support, tailoring treatment to the patient's

physiological needs, and increasing the patient's sense of mastery and fate control.

In contrast, there is little mention of how the patient's

family can be utilized to facilitate treatment.

This seems particular-

ly unfortunate since it is this "folk support system" which may be

most likely to reinforce or encourage the patient's efforts to cope effectively.

Therefore, the extent of social contact

betvs'een

the

patient and his family and friends was assessed immediately prior to surgery.

An important aspect of the patient's competencies is a sense of fate control, or belief that one can control events in one's environ-

ment rather than being a passive victim of them (Garmezy, 1974)

.

In a

related sense, the ability to think abstractly, to gather information, and to be able to consider alternative solutions to a problem should

be associated with more effective coping actions.

These aspects of

preoperative competency were assessed on two dimensions: control and information seeking

.

locus of

From the literature review it was

noted that aspects of recovery partly under patient control (medication, length of hospitalization) were related to locus of control orientation. However, it was expected that predicting specific surgery related

behavior from a measure of generalized expectancies such as Rotter's

.

30

I-E Scale (1966) would be difficult, therefore in addition to the

Rotter scale, an experimental scale of locus of control with items specific to recovery behavior was presented to the patients.

A measure

regarding the extent of the patient's information seeking was also added, since previous research had associated information gathering

with both locus of control expectations and recovery behavior.

It was

predicted that both measures would be related to one another and the adequacy of postoperative coping and recovery. Finally, a patient's vulnerability to postoperative distress, is

partially a function of disease factors and the extent and nature of the operative intervention.

Disease which is more widespread or more

debilitating and operative procedures which involve extensive excision leave the patient more vulnerable to excess fatigue, infection, generalized debilitation, or severe trauma.

Patient's vulnerability in this

study was assessed with a measure reflecting the severity of disease and extent of intervention

.

As the model presented suggested that

vulnerability and coping are orthogonal factors predictive of breakdown, it was expected that this measure would be unrelated to preoperative

measures of coping effort and competency. Since several of the preoperative measures used in this study did not have demonstrated relevance to the surgical patient's experience,

several additional face valid items concerning health and well-being

were pressented to the patient.

These were used to establish concurrent

reliability, but they were not used as predictors of recovery. included items concerning:

current estimate of health

,

They

expectancy

for recovery, and anticipated life satisfaction postoperatively

51

Since postoperative recovery is generally regarded as a multidimensional construct, a number of measures were used in the present study to assess the patient's physical and emotional responses during the immediate postoperative period.

The measures were selected to

differentiate between the patients' perceptions of their recovery and standard clinical indices of progress routinely available in medical charts

The indices chosen included patient self-

1973].

reports of their postoperative mood and physical status, the amount of

pain medication utilized, and the length of hospitalization and intensive care.

Although not used as dependent variables in the analysis

of relationships between the recovery course and postoperative variables, physicians' ratings of the patients' progress were also obtained to observe the concurrence between the physicians' perspective and the

other measures of recovery.

Since it is likely that the nature of the

tasks and demands impinging upon a patient change over the entire

period of recovery, postoperative data collection was confined to the immediate postoperative period to add greater precision to prediction.

Statement of h>T>otheses It was predicted that

(a)

measures of vulnerability to poor

recovery would be independent of measures of coping;

(b)

levels of

positive affect and hope would not be related to reported feelings of hopelessness or fear;

(cl a

measure of locus of control orientation

specific to recovery behavior would demonstrate better construct

validity than

a

general dispositional measure of locus of control;

(d)

patients demonstrating greater coping effort, as assessed by a high degree of hope, positive affect, and physical effort, would have more

satisfactory recoveries;

C^)

internals on locus of control and those

who sought more information about their illness and treament would

experience better recoveries due to their greater preparedness;

(f]

patients who received greater social support from significant others would demonstrate more effective coping during the preoperative period and would have relatively good recoveries; and (g) patients with

greater vulnerability, as assessed by extent of operative intervention,

would show poor recoveries.

.

CHAPTER II METHODS

Subjects and Setting

The subjects were 54 patients admitted to the Shands Teaching

Hospital Cn=17) and the Gainesville Veteran's Administration Hospital (n=37j as candidates for major pulmonary resection for lung cancer.

All of the patients were under the care of physicians who were faculty

or residents from the Department of Cardiothoracic Surgery at the

University of Florida, Gainesville, Florida. The final sample, or "resected group," consisted of 35 patients

who actually underwent lung resection.

An "unresected group" consisted

of the remaining 19 patients who, at the time of the operation, were found to be unresectable, had "minithoracotomies," or were found not to have bronchogenic carcinoma.

Final diagnoses in the unresected

group included bronchogenic carcinoma O^tiresectable)

benign tumor, and nontumorous lung abnormality.

,

tuberculosis,

Preoperative data

were collected from the unresected sample, although it was excluded from postoperative data collection.

Data were discarded from two

patients who agreed to participate, but were unable to complete the

paper and pencil protocol The patients in the resected group underwent pneumonectomy Cn=7)

,

double lobectomy (n=l)

resection (n=4)

.

,

single lobectomy (n=25)

,

and wedge

Seven patients in the resected group and one patient

54

Both of the patients

in the unresected group died during recovery.

who could not complete the preoperative protocol had pneumonectomies, and both died during recovery.

Table

1

Sample Characteristics of the Resected and Unresected Groups

Resecte

Variable

Unresected

Age in years Mean SD

57.5 12.2

58.1 10.1

Male Female

15

32

4

3

White Black

16

27

3

8

Sex

Race

SES

Upper middle Middle Lower middle Lower

0

1

4

7

4

15 12

11

Hospital Shands

VA

10

7

9

28

Preoperative Measures

Hope Scale (HS)

.

Gottschalk and Gleser (1969) developed upon content analysis of speecli.

their definition of hope as;

a

Hope scale that is based

Content categories were derived from

"A measure of optimism that a favorable

outcome is likely to occur, not only in one's personal earthly activities but also in cosmic phenomena and even in spiritual or imaginary

35

events" (Gottschalk, 1974).

Five minute speech samples were elicited

from the patients in response to the following standardized instructions:

"I would like you to speak into the microphone of this tape

recorder for five minutes about any interesting or dramatic personal WTiile you are talking

life experiences you have ever had.

I

would

prefer not to answer any questions, so if you have any questions please ask them now."

The instructions were purposely designed by

Gottschalk and Gleser to be ambiguous in order to maximize the projective aspects of the task, and to minimize the effect of the inter-

viewer's behavior. The speech samples were recorded, transcribed, and claused by the investigator.

Two independent raters



both master's level counsel-

ors -- were trained to acceptable levels of interscorer reliability Cr=.87)

and then presented patient transcripts for scoring.

Scores

were summed across categories and to overcome the effect of verbal

fluency a correction factor that is applied to the Gottschalk-Gleser scales was used, such that: HS = Total score X CF

where CF is the correction factor, the number of words in the sample

divided into 100.

The scores were averaged across raters to yield a

final hope score for each patient.

Rater reliability on the summed

scores for the patients' speech samples was r=.96.

Reliabilities on

the seven content categories ranged from r=.65 to r=.91.

The alpha

reliability was ,60 and corrected item to scale correlations ranged from .27 to .48.

Positive Affect (PA)

.

The patients' speech samples were also scored on the Positive

Affect scale (Westbrook, 1976)

,

which was designed to provide a measure

36

of the patient's state experience of positive feelings.

The indepen-

dent raters credited each clause with a score of one for any clause in

which the patient expressed positive feelings.

The scale assumes the

speaker has identified with main characters in recollections or third

person accounts, and the character's positive affects are also scored. The standard Gottschalk-Gleser correction factor was applied to summed

scores and a square root transformation was done to overcome the

positive skew to the distribution.

Scores were averaged across raters

to yield a final Positive Affect score for each patient.

Rater

reliability across the patient population was r=.95. Physical Effort (PEj

Rather than relying upon self-reports or a psychiatric history to

make predictions about the level of physical effort that could be expected from each patient, a behavioral measure^ derived from preoperative pulmonary function tests was used.

The pulmonary function studies

done as a standard part of the preoperative workup of these patients

yield several indices, including measures of forced expiratory volume (FEV)

,

and maximal voluntary ventilation CMV\0

is the volume



The patient's FEV^ q

of gas expired by maximal effort in the first second.

The patient's

is the maximal volume of gas that can be breathed per

minute by voluntary effort.

A patient's M\^ should be sixty times

greater than the FEVj^_q when the patient is working at maximal effort. But the patient's

is probably more responsive to effort, since it

requires some persistence on the patient's part to continue deep

^Suggested by Joe! Tobias, M.D., a cooperating surgeon on the faculty of the University of Florida

57

breathing for the required time (15 seconds)

.

The

FEV^^

q

is less

responsive to this confounding effect since most patients can be expected to put forth their maximum effort for the short interval (1.0 Therefore, the ratio of the patient's predicted MVV

seconds) required. (FEVj^

0

actual

^

MW

would be a relative measure of the

patient's effort, and was used in this study as a measure of "how hard the patient is trying."

This measure seemed particularly relevant to

the present patient population, since deep breathing and coughing are

important postoperative exercises in which the patient must engage to avoid complications (e.g., pneumonia) following surgery.

MW

Each patient's

and FEV^

q

was taken from the standard Pulmonary

Medicine consultation form placed in the medical chart. Recovery Locus of Control (RLC)

.

To explore the efficacy of a locus of control scale more specific to the recovery situation,

15 items written as face valid measures of

locus of control related to surgical recovery were presented to the

patients.

Using a six point Likert type form.at, scored in the external

direction, the items were adapted from the Health Locus of Control scale (Wallston, Wallston, Kaplan, (1966)

I-E scale.

Maides, 1976) and the Rotter

§

An item analysis was run and items were chosen that

showed significant item to scale correlations (r of response choices.

>

.24)

and distribution

From the original pool, eight items were selected .

The resulting RLC scale has a

to 48.

The mean scale score for this

for the final scale (see Appendix A)

potential range from eight

(8)

sample was 26.53, and the standard deviation was 9.05,

The alpha

reliability was .68 and corrected item to scale correlations ranged from .20 to .59.

38

Information Seeking

.

This scale was developed for the purpose of measuring patient

differences in information gathering from physicians.

Two physicians

responsible for preoperative preparation of the patient were asked to rate the extent to which the patient requested clarification or additional information about illness and treatment.

They were requested

to respond by rating the patients on a six point scale ranging from

"no information seeking" to "extremely active information seeking"

(Appendix

B)

.

two ratings were obtained, they were averaged to

UTien

yield one scale score. was assigned that score.

UTien

only one rating was obtained, the patient

Only 25 patients could be used in the analysis

of rater reliability on the scale, since the physicians did not return two independent ratings on 29 patients.

For this selected sample the

interscorer reliability was r=.89, although whether the physicians always responded independently is doubtful since there was little control over their discussion of a patient with one another. Social Contact (SC)

.

Since measures of quality,

t>'pe,

and intensity of support from

family and friends were not available, a measure was developed to assess the extent of contact between a patient and his family and

friends immediately prior to surgery.

The patient was simply asked to

indicate the number of phone calls he had made or received, the number of letters written or received, and the number of visitors received in the hospital, all over the 24 hours preceding assessment.

The frequency

of phone calls, letters, and visitors were summed to yield one score of "frequency of contact."

.

59

Extent of Operative Intervention (EOI) A measure was needed to assess the relative degree of physio-

logical impairment imposed upon the patient by disease and operative factors.

The measure chosen was a thoracic surgeon's estimate of the

average percentage of total lung tissue (of one lung) removed during resection.

Patients were scored on the following basis: pneiimonectomy-

100%, double lobectomy-75%,

single lobectomy-50%, wedge resection-5%

This was intended to reflect the extent of invasion of the cancer, the

severity of the operation, and the relative loss in pulmonary capacity. Validational instruments In addition to the measures already described,

two standardized

instruments and four one item scales designed for the present study were presented to the patients as part of the preoperative protocol.

These measures were intended to provide means of establishing concurrent

validity among the preoperative measures. The Beck Hopelessness Scale (BHS)

(Beck et al

.

,

1974) was developed

to provide a measure of a person's negative expectancies concerning

self and future life and was used in the present study to test the

hypothesis that positive affect and hope were independent of negative mood and expectancies.

The scale has been found to have adequate

internal consistency and showed a high correlation with clinical

ratings of hopelessness (Beck et al

.

,

1974).

It consists of 20 true-

false items drawn from a pool of pessimistic statements by depressed

patients and from a test of attitudes. of 0 or

1

Each response is given

a

score

and the total hopelessness score may range from 0 to 20.

Additionally, the Rotter (1966)

I-E Scale

and scored in the external direction.

was presented to the patients

This scale was entered into the

.

40

protocol to serve as a means of testing the concurrent validity of the RLC

.

The Fear of Surgery Scale (FSS) was adapted from one used by

Martinez -Urrutia (1975) and was worded: "In general, how much fear or concern do you have about this operation?"

Patients were requested to

respond by placing themselves on a six point scale ranging from "no fear" to "extreme fear."

Martinez -Urrutia found that patients reporting

high fear of surgery were more anxious prior to surgery than low fear patients.

Scores on the FSS remained stable from pre- to post-

surgery, despite declines in A-State scores, suggesting that the scale

measures stable or trait dispositions. The Future Satisfaction (FS) scale was intended to measure the extent of the patient's optimism about the quality of life following

surgery and was worded: "How satisfying do you e.xpect your life to be following recovery from surgery?"

Patients responded by rating them-

selves on a six point scale ranging from "very unsatisfying" to "very

satisfying."

The patients were also asked to indicate their Self-

Estimate of Health (SEH) and their Expectations for Recovery (EFR)

.

The SEH was worded: "In general, right now, would you say your health is excellent,

good,

fair, or poor?"

The EFR was similarly worded:

"Do you expect your recovery to be excellent, good, fair, or poor?"

Responses to both items were scored from one (poor) to four (excellent)

Postoperative Recovery Measures Clinical indices In consultation with a thoracic surgeon,

four measures of recovery

which were judged to be good markers of progress were taken from the

.

.

41

days-to-discharge, amount o£ pain medication, time

patients' charts;

in the surgical intensive care unit, and time on ventilator.

Days-to-discharge

(

DAYS) was defined as the number of days

hospitalized in the postoperative period.

The day of discharge was

counted as one day; the day of the operation was not counted. The amount of pain medication

(

ME PS) was determined by first

recording from the chart the frequency, quantities, dosages, and

t>’pes

of analgesics administered to the patient during the first seven postoperative days.

A standard multiplier was applied to the total

quantity of each analgesic to yield its equivalent in milligrams of morphine (Goodman

§

Gilman, 1975) and the resulting morphine equiva-

lents were summed to yield one score such that;

MEDS

=

Morphine +

Tylenol

(1.0)

(#s 1,

2,

3,

4)

Codeine^^ (.083)

+

Percodan (.800)

+

Darvon^^^

(.048)

+

Demerol

+

Tylenol^^ (.540)

(.111)

and Darvocet were recorded from the chart

according to their respective components of Codeine, Tylenol, and Darvon Time in surgical intensive care unit

(

SICU) was defined as the

number of hours the patient remained in the SICU immediately following surgery.

The attending physicians determined when a patient would be

transferred to a regular ward. The time on ventilator was defined as the number of hours during the postoperative period the patient received mechanical breathing

support by means of ventilation.

However, it was found that initiation

and tenriination of ventilation was not reliably reported in the chart

and collection of data on this variable was discontinued during the study

42

Self-report measures

.

In addition to the clinical indices, two self-report measures

were used:

the Welfare Inventory and the Recovery Inventory.

The Welfare Inventory (Wolfer

&

Davis,

is a 20 item self-

1970)

report measure designed to assess the patient's emotional state following surgery.

The patient rates each mood adjective on a six point

scale ranging from "not at all" to "very much."

In

preliminary testing

with the inventory, it was found that thoracotomy patients were unable to make reliable or valid discriminations on the six point scale due

to their general fatigue and inability to attend.

Therefore, the

scale was modified such that patients were asked to indicate whether

they were or were not experiencing each of the 20 moods.

scored in a positive direction (0 or from 0 to 20 (see Appendix C)

.

1)

,

Items were

thus scale scores could range

For the sample in this study, corrected

item to scale correlations ranged from -.04 to .85 and the "Kuder-

Richardson Formula 20” coefficent alpha for dichotomous items was .90. One item was not significantly correlated to the corrected total scale score (Hopeful, r=-,04)

.

on postoperative day three

The inventory was administered to patients (

WI3) and postoperative day seven

(

WI7)

.

Since perfomiance on the inventory was similar for both days of

administration (r=.71), the scores were averaged across days to yield an overall welfare score (WI)

.

In the case of one patient who died on

the sixth day postoperatively and two others who were unable

to.

respond

on the seventh day, scores from the third day were taken as the overall

welfare score. The Recovery Inventory (Wolfer

8

Davis, 1970)

is a 14 item self-

report measure that asks the patients to rate their physical well-

-

45

being on such dimensions as appetite, urination, pain, and ambulation. The patient is asked to respond by rating self on six point scales

defined for each recovery item and to estimate the number of times he As with the Welfare Inventory,

has been out of bed on that day.

preliminary testing with the Recovery Inventory indicated that thoraFor the

cotomy patients could not make reliable discriminations.

present study, the item scales were revised to three point and five point discriminations (Appendix D) a

The Inventory yielded

.

tw'o

measures

recovery score and a self-estimate of the percentage of time spent The recovery score was a summation of 10 items

out of bed that day.

such that the total score could range from 10 to 50.

As with the

original Recovery Inventory, items concerning nursing and medical care and ambulation were not included in the recovery score.

For this

sample, corrected item to scale correlations ranged from .30 to .73 and coefficient alpha was .83.

The last item in the inventory was scored

standard deviation was 9.4. as a separate measure:

The mean scale score was 31.6 and the

percentage of time out of bed.

Three items

(medical care, nursing care, momber of times out of bed) were not

The Recovery Inventory was administered in

included in data analysis.

conjunction with the Welfare Inventory on post-operative day three (RI3)

and seven

(

RI7)

.

Scores were averaged across days to yield an

overall recovery score (RI)

.

The time spent out of bed was scored as

two dependent variables (% OB5 , %OB7)

.

Minimum scores were given on the

seventh day administration to one patient who died on the sixth post-

operative day and to two patients who were comatose and unable to respond

44

Recovery Index

.

This index was devised to provide a composite measure of recovery that could be used as a dependent variable in the analysis of the

relationship between the recovery course and preoperative variables. To develop this index, six postoperative variables

(

ME PS

,

%0B5

,

%0B7

,

WI, RI, SICU) were used as predictors in a discrimnant function analysis

to two apriori groups:

survivors and nonsurvivors.

The resulting

discriminant function score for each patient was their INDEX score, a linear composite of the six postoperative variables. analysis, Wilk's Lambda

=

.4955, which was significant

For the overall (p

<.025).

The standardized coefficents and univariate analyses of variance are

presented in Table

2.

The positive pole of the discriminant function

was associated with longer time in SICU , whereas the negative pole was

associated with more time spent out of bed and relatively more positive The Recovery Inventory and amount of

affect on the Welfare Inventory.

pain medication did not add considerable predictive Table

2

Results of Discriminant Function utilizing Postoperative Variables as Predictors of Survivors -Nonsurvivors

Variable

Standardized weight

%0B3 %0B7 SICU MEDS

-.415

KI RI

-.475

-

F

.262 .486 047 .

.018 a

p.

<

b

p p

-

c

.

05

.01 •

001

45

power, partly because of shared variance with other predictors.

For

membership in Survivor-Nonsurvivor groups, the six measures classified patients with 85

.

7%

efficiency, misclassifying seven patients.

Physicians' postoperative ratings

.

A physician's rating scale was developed to provide an overall measure of recovery that could be used to compare results from the patient's self-reports and clinical indices with the physician's perspective.

It was worded:

"Compared to other patients who have

undergone a similar operative procedure,

I

consider this patient's

overall recovery at this point in time to be:".

The physicians were

asked to respond by rating the patient on a five point scale ranging from "very poor" to "very good."

Procedure Patients were referred by the Department of Cardiothoracic

Surgery at the University of Florida, Gainesville, Florida.

After the

surgeon had informed the patients as to the nature of their illness and the necessity for surgery, the patients were approached individually in their hospital rooms by the investigator or by one of two male

undergraduate psychology students serving as research assistants. After the patients had signed the consent form the examiner went through a standard interview, asking for demographic information and

presenting the social contact, self-estimate of health, and estimate of recovery items.

The patients were then read the standard instruc-

tions for obtaining verbal samples and the patients' speech samples

were recorded on a cassette recorder.

After the patients had provided

the verbal sample, they were given the remaining paper and pencil

instruments (BHS, RLC, I-E scale, F£, FSS j and asked to complete these

46

on their

o\
The examiner returned later to obtain the completed

questionnaires.

In some cases,

the examiner made the assessment that

the patient would be unable to complete the questionnaires, due to

poor eyesight, short attention span, or poor verbal comprehension.

In

these cases, the examiner presented all items orally while the patient

followed along and responded, or remained

assistance when needed.

w'ith the

patient and provided

Two patients did not appear to have the

intellectual capacity to complete the questionnaires and were dropped from the study.

Additionally, forms to assess information gathering

were distributed to two physicians responsible for the patient's

preoperative preparation. Within the first three postoperative days, the patient's chart was inspected to determine whether a thoracotomy or lung resection had

been performed, and whether bronchogenic carcinoma had been found.

If

any of these criteria were not met, the patient was dropped from

further data collection.

Those patients who had undergone lung resec-

tion for cancer were approached by the examiner on the afternoons of the third and seventh postoperative days.

The examiner read all items

from the Welfare and Recovery Inventories and recorded the patients'

responses.

Following the patient's discharge or death, physicians'

and nurses’ notes and medication charts found in the medical charts

were examined to determine the amount of medication, time in SICU, and

number of postoperative days in the hospital

.

Rating forms to assess

overall recovery were distributed on the third and seventh post-

operative days to operative care.

a

physician responsible for the patient's post-

.

CHAPTER III RESULTS

For the analyses of relationships among preoperative variables, the resected and unresected groups were combined.

Potential mean

score differences on the preoperative variables as a function of group t -tests.

membership were evaluated with a set of

There were no signifi-

cant differences except for a marginal indication (t=1.92, p. <.062)

that the resected group reported more operative fear the unresected group

(

FSS X=1 .85)

.

[

FSS X=2.57) than

In the resected group, pulmonary

function tests were not done or not recorded on the chart on nine patients, and these were removed from analyses involving physical effort The resected group (n=55) was analyzed for relationships among

postoperative variables and relationships between the course of recovery and preoperative variables.

Only 30 patients were used in analyses of

the physician's postoperative ratings

were not obtained.

since ratings on five patients

The number of hospital days was not an appropriate

measure for the seven patients who died, therefore only the 28 patients who survived were included in analyses of relationships between days-

to-discharge and preoperative variables.

47

,

48

Relationship between Patient Demographic Characteristics Hospital Setting, and the Recovery Course

,

The relationship between the postoperative recovery variables and the patient's age, race, marital status, socioeconomic status (SES) and admitting hospital was examined in an initial series o£ analyses.

The SES of each patient was determined from an index of social position

based on a weighted (Myers

§

Bean, 1968)

sura

.

occupation and education

of two factors:

Race, marital status, SES and admitting hospital

did not show main effects for any of the post-operative measures, nor

could patients in the two hospitals be differentiated by any demographic variables. p.

Age was positively correlated with time in the SICU (r=.35,

< ,05) and the composite INDEX measure of recovery (r=.53 pi <.05).

Preoperative Measures The relationships between the preoperative variables and the

patient's age, race, marital status, and SES, and the hospital of Age was not significantly correlat-

admission were examined initially.

ed with any of the preoperative measures.

The distribution of SES

membership was collapsed from the standard five positions to three: I.

Middle to upper m.iddle class (n=12)

(n=18)

,

III.

Lower class (n=24)

.

,

II.

Lower middle class

.Analyses of variance indicated main

effects for SES on information seeking (F=8.103, Locus of Control (F=2.729,

p.

<.077).

able by SES level appear in Table

3.

p.

<.001), Recovery

The mean scores for each variIt

may be noted that lower class

patients tended to seek less information from physicians, to adopt

a

more external locus of control, and to have less preoperative contact with family and friends than lower middle to upper class patients.

.

49

Table

5

Mean scale scores on the RLC as a function of SES

,

^

and

RLC

SES I

6.55

24.00

4.75

II

6.88

22.00

3.07

63

30.39

1.44

III

5

.

Patients were also divided into Married (n=31) and Nonmarried Cn=23)

groups.

As might be expected, married patients reported more

social contact (SC X=4.04) than nonmarried patients (SC X=1 .32, t= -2.65, p. <.013).

Interestingly, the Nonmarried group had a higher

mean Hopelessness score (X=5.65] than the Married group (X=2.40, t=3.08,

p.

< .004}.

T-tests to analyze the effects of race indicated that Blacks sought less information (IS X=3.33) than hTiites (IS X=6.00, t=2.54, p •<.014)

and Blacks reported less preoperative social contact

X=1.00) than IVhites (SC X=3.48, t=3.03, p

<.004).

(

SC

The mean score

differences associated with racial group membership is probably an artifact, since all but one of the Black patients fell into the lower class.

Therefore, the results suggest that lower class patients, in

general, sought less information, had less preoperative contact with

friends and family, and tended to attribute control of events to the

environment Potential mean score differences on the preoperative variables as a function of hospital of admission were analyzed with a series of

two-tailed t-tests.

Patients in the Shands Teaching Hospital had

significantly higher I-E scale scores (t=2.9, p

<

.03)

and higher

50

estimates of future satisfaction (t=2.65, p. <.01} than patients in the Veteran's Administration Hospital.

Significant differences were

not found on the remaining preoperative variables.

Intercorrelations among preoperative variables

.

As an initial step in assessing the validity of the preoperative

measures, the intercorrelations among preoperative variables were

calculated using data from both groups. As Table 5 indicates, concurrent validity of the verbal content

measures of hope and positive affect was demonstrated by a .86 correlation

(p.

<.0C1) with one another.

As predicted, neither of these

measures was significantly related to negative mood states of operative fear

( F3S]

or hopelessness

(

BHS )

,

and both hope and positive affect

were positively correlated to the single item measure of future satis-

faction (FS)

.

They were also moderately correlated with RLC , such

that more expressed positive affect was associated with a stronger

external locus of control orientation.

However, the .86 correlation

between hope and positive affect indicates that the scales shared

74"6

common variance and it is therefore doubtful that the Hope scale was

providing a more precise differentiation of a particular mood state than the more generalized m.easure of positive affect. In contrast to the strong positive relationship between these two

verbal content measures of coping effort, hope and positive affect

were negatively correlated at a moderate level with the physical

measure of coping effort.

Additionally, physical effort was positively

related to operative fear, such that greater fear tended to be associated with more physical effort.

Physical effort was not related to

either of the locus of control scales nor to the remaining validational

51

Table 4 Mean, Standard Deviation, and Range of Preoperative Variables

Variable

Mean

SD

Minimum

Maximum

Hope

2.52

3.20

-2.23

13.15

1.34

.61

.34

3.20

.32

.31

0.00

.85

Positive affect Physical effort

^

Recovery I-E

26.53

9.03

8.00

43.00

Information seeking

2.28

1.56

1.00

6.00

Social contact

2.77

3.99

0.00

22.00

Hopelessness

3.81

3.82

0.00

18.00

Fear of surgery

2.28

1.31

i.OO

6.00

Future satisfaction

5.09

1.30

1.00

6.00

Estimate of health

2.93

.95

1.00

4.00

Estimate of recovery

2.00

1.03

1.00

4.00

Rotter I-E

7.98

3.71

0.00

16.00

Note

^

n = 45

52

U

o o

0)

•M

sO

o

UJ

O

XI rO

0%

o

o

I

OS

t-N

o

jz

rt

S

CB


4->

(Q

in

o

O o

«N

CQ

O

o

O

o o

Ui JZ

o 3

o ro

'

rO tN

O o

\0 (N

3 U.

X

««

O

(h

O

U

Od

U O 3

Variables

u.

o o

00

O

in

a

o o

o in in o o 3.

o o

CN

o > c

Preoperative

•H

ft)

>



iH

ft)

w

U

O

K> vO

o o

o

ft)

C

Cm

-H

among

V c o o

V3

ft)

&6 • Correlations

O C

<*4

c

M

'X

r>.

o

o

V'

ft)

S-'

ft)

in

Cu 3. CU

X u ft)

o o

> o ft)

4)

OS

u

w I

(N)

9

C

U 4^ U O

o o

•H

in

X«-t IM ^ Cm

-H

fM K)

ft)

ft)

ft)

ft)

o z zo zo

o o V)

ft-i

O a.

8

i

X u

ft)

>

(S ft)

o

••H in

ft-i

O

w

o.

ej

ft)

in

o

xz

^

3. O

w

OA

> o

C

•-M

ft)

ft)

>-<

in

3

tM

U

U]

ft)

1

OS

WO

*

ft?

ft)

c.

3

C

o JO

AJ ft)

c O o ftO

ft)

> c

•M

ft)

W > u

m M

in

14

ft)

J

4

c

X

o 3

ft)

CO

Vft)

^ c

ft)

in

Cm

in

=O oc

u cO

ft)

ft)

•M

.

m

3 3

-w

ft.

4->

in

u.

in

90

_t)

s

*j

in

ft)

W CO

e recovery

uj x:

.

53

instruments.

In summary, concurrent validity among the three measures

o£ coping effort was only partially established, and there was some

indication that there were two response clusters; one associated with fear-physical effort and another associated with positive affectfuture satisfaction-external recovery locus of control.

Concurrent validity of the RLC was shown by a .32 correlation < .01)_

(p

with the Rotter I-E scale, indicating that the new scale

shared about 10% common variance with the I-E scale.

Moderate con-

struct validity of the RLC was also demonstrated by a significant

negative correlation with information seeking (r=-.41).

However, the

I-E scale was a more adequate predictor of inform.ation seeking, showing a correlation of -.53 with IS

.

To further explore the relationship

between information seeking and locus of control, a median split was used to divide patients into internal and external groups on both the RLC and I-E

.

T-tests using information seeking as the dependent

variable showed that internals as measured by the I-E scale sought significantly more information (IS X=3.18) than externals t=2.02,

p,

(

IS X=2.30,

<.05), while no significant difference was found between

internal and external groups as measured by the RLC

.

Inspection of the intercorrelations among information seeking, hopelessness, I-E scale, and social contact indicated that I-E was

n^atively correlated to information seeking, social contact, and positively correlated to hopelessness.

The remaining correlations

were consistent; social contact and information seeking were negatively

correlated to hopelessness

.

One possible explanation for these results

is that internals actively sought

information from physicians and

solicited support from friends and family, and consequently felt less

hopeless

54

As predicted, the vulnerability measure of operative intervention

was independent of the measures of coping effort and competency.

However, a -.55 (p

<.001) correlation between operative intervention

and fear of surgery was an unexpected finding indicating that greater

expressed fear was associated with less excision in the subsequent operation.

Among the validational instruments, concurrent validity of the Hopelessness scale was demonstrated by consistently negative correlations with social contact, information seeking, future satisfaction,

estimate of health, and expectations for recovery.

The one item

scales of expectations of outcome, future satisfaction, and estimate

of health showed consistent positive correlations with one another.

Po stoperative Variables

Descriptive data on the postoperative variables are presented in Table 6.

The most important information was the absence of a signifi-

cant mean change in the patients' subjective report of welfare and

recovery from postoperative days three to seven.

It is possible that

patients did not experience significant changes in their physical or emotional status during this early period of recovery.

On the other

hand, the positive skew and relatively narrow range of the score

distribution on the Welfare Inventory may indicate that it was insensitive to changes in emotional welfare.

In contrast, the percentage of

time spent out of bed clearly reflected changes in status from day

three (%0B5 X=.24) to day seven

(

%0B7 X=.41) and may have been a more

sensitive measure of progress during this immediate recovery period.

55

Table 6 Mean, Standard Deviation, Range of

Postoperative Variables

Minimum

Maximum

SICU

79.26

163.93

12.00

990.00

Hospital^ days

11.68

5.54

5.00

32.00

Pain medication

93.41

62.45

15.20

302.10

15.34

4.63

5.00

20.00

15.77

4.69

4.00

20.00

30.06

8.49

12.00

45.00

33.87

10.65

10.00

53.00

.24

.21

0.00

1.00

.41

.31

0.00

1.00

3.57

1.07

1.00

5.00

3.34

1.34

1.00

5.00

Mean

Variable

SD

Welfare Inv.

#3

Welfare Inv.

#7

Recovery Inv.

#3

Recovery Inv.

#7

%Tirae out

of bed #3

%Time out of bed #7 Phy Rating #3

^

.

Phy. Rating #7

^

Note^ Note

n = 28 n = 30

56

The general question concerning the postoperative variables is the extent to which they were intercorrelated or the degree to which

particular measures contributed independent information.

A related

question is the nature of the interrelationships that existed among the three criterion sources;

physicians, patients, clinical indices.

As an initial step, the postoperative variables correlation matrix was

calculated and appears in Table

7.

The first three measures are

clinical indices, the next eight are derived from patient selfreports, and the last two are physician ratings. .As

can be seen, the patients' self-ratings were generally inter-

correlated from low to high levels with one another, while the clinical indices were relatively independent of each other and the ratings. The physician's ratings were also relatively independent from the

other criterion sources.

The one striking exception was the number of

days spent in the hospital by survivors, which was negatively correlated with the recovery score, the percentage of time out of bed on the

seventh day, and physician's ratings.

The relationship between days-

in-the- hospital and physician's ratings is not surprising since the

discharge date was determined by the physician, and was consequently another measure of the physician's evaluation of the patient's progress. Since physician's ratings were also positively correlated to of bed and the patient's seventh day recovery score,

tim.e

out

it is possible

that the physicians were using the patient's return of physical mobility

and self-report of subjective physical state as markers of readiness

for discharge.

Among the self-report measures, the time out of bed on the third

postoperative

da)'

was not related to any of the other measures and

57



rt

o

oe

*

X

fO

CM

c

JZ

••H

C.

W

C5

K>

02 4t

X

\0

o o

o

c

CL

3

O

•o &>

E

Xi

^

O

4->

KJ

H

<4m

K5

3 » O *3 C C E ^

O

o w O 0) y > V c

> c Variables

U

O >

nC K)

o

NO

>o

r-

o o

t--

MC

o>

%

X) in

K) ro

o • u > OS

4)

o o

CM

O

c-

O o

lO

Postoperative

X

> o • o > 4)

C

a:

h~i

4) among

^

<0

(m 4>

4)

00

O c 4) > Z

4^

o o

r*-

Correlations

o o

n <4^



^ > 2 MC 4>

4)

m

fx

«:

LO

C Oo V 'sy c.

O o

C9

•3

o c E O NO

O

CL tr.

C

O o

tr.

>s et

3: *3

>s

•3 4->

=1 L3

ir

V5

=

CL

c

X

X re

*3

C E O C 4-> re re o C)

c

X-

44 —

a. >H

4)

4>

a

rs.

U

re

4

C

HI

4.

.

c>

c

44

>

X

X-

XX

c c re

re .

>

4>

2

tx

c

>

c o >

.

4)

C

%

> c u > o c



C£ X-

4>

^

> C O 4) O > y ac

c XX

4.)

KJ

3 O

«e

*3

c o £ Xi i-

4-1

3 C *3 o y E J3

Ra-

4-(

o

#3

ting Phy.

aa

58

appears to be an independent aspect of recovery.

By the seventh day,

this variable was moderately to strongly related with measures from

each of the three criterion sources.

As expected, the Welfare Inventory

and Recovery Inventory were positively correlated. with one another.

Relationships between Preoperative Variables and the Recovery Course The primary objective of this analysis was to test the main h)p)otheses that greater coping effort, more effective competencies,

more social support, and lower vulnerability would be predictive of

better recovery.

The preoperative variables were entered into a

stepwise linear regression analysis designed to assess the independent

contribution of each variable to a criterion of one of the postoperative In the first stage, a set of five preoperative variables

measures.

were entered as predictors in stepwise fashion until no additional variable' from the set

w'as

capable of producing a change in R- greater

than .01 or where the overall F ratio of goodness of fit became non-

significant

(p >

.05).

The five variable set consisted of positive

affect, social contact, information seeking, recovery locus of control, and extent of operative intervention.

The high correlation of Hope

and Positive Affect would introduce problems associated with multi-

colinearity if both were entered as predictors, thus the more general

measure of positive affect was retained and the measure of hope was deleted.

The measure of physical effort was analysed independently,

since entering it into the equation would reduce the overall sample size to n=26.

Six such regressions were performed, one each for:

amount of

pain medication, number of days hospitalized, average welfare score,

average recovery score, percentage time out of bed on the third day, and percentage time out of bed on the seventh day.

59

Since age was significantly correlated with time in SICU and the INDEX measure of recovery, regressions onto these criteria were done in two steps.

In the first step,

the age variable was entered into

the equation in order to statistically equate patients and provide a

relatively unbiased test of the hypotheses.

During the second step,

the five preoperative variables were allowed to enter in stepwise

fashion.

Two such analyses were performed, one each for time

in SICU

and the INDEX score. In the second stage,

an additional stepwise regression was

performed, at this point allowing the measure of physical effort to

enter in stepwise fashion, where it had been

in the previous

shovv-n

independent analysis to be significantly correlated with the dependent variable.

From inspection of Tables

8

and

9,

in which the results of the

tests of the main hypotheses are given, the absence of a strong or

consistent relationship between individual preoperative predictors and any of the postoperative criteria is immediately evident.

As Table

8

indicates, the only two predictors which contributed independently to

criteria were Positive Affect to days-of-hospitalization and Recovery Locus of Control to amount of pain medication.

At the overall level,

various combinations of preoperative variables predicted at significant levels to dependent criteria of time in SICU, days-of-hospitalization,

pain medication,

INDEX of recovery, and the Recovery Inventory, although

inspection of the coefficients of determination, R

2 ,

indicates that

only 22 to 30 percent of the variance in the recovery criteria was

accounted for.

The regression analyses for the four patient self-

report measures (Table

9)

showed that only the subjective report of

physical status was significantly related to the predictors.

60

LO

4->

X u X C Z HH

o > o o o

(N

P

oc -H

O



rsi rsj

12

2.94 •

"h

O n

o

CN

.

S

c:

o3 +->

o

O

•H

cc

o c

o

1-H

•H in

Variables

to

(NJ

• 1

O

CC





00

to

to to





Csj

«

« 1

1

cti

^oc

rsj

-H

00 to

(N







o

1

cn CN

INDEX

o u ^

o

•H

o E

and

B H



cr:

'=d•

t3

X to

c o

to

m

Predictor

3.76^



X

t-H r'

f-H

o







\

!

Indices

4-)

of

5 •H <+J

c3

+J

4->

O

g3

CD

o

^cc

g3

r^ 1^

to

.H

0 S

• I

•H Analyses

rvj

U) Clinical

X

rt

rt

•H

r\

X

f—

Cu

o

CN

LO

CN





•r4

w

o





(/)

o

to

3.93



0

t

1

Regression

P

c3 4->

0 CQ

•H

o

^DO

to

.H

0 3

o

O'* t—

LO (N





to •

O

1

to

:d

u )— :/)

.27



0

o

(N

Cl.

B

O to

o o

LO CN

to

f-H



n

C3

LO to





1

CO ',

w

t/5

CJ

0

M

o P ^

o

O

o >

X)

•rr

•r-i

rt

-0 -H

0 ^ 03 Cl. > J-i

P

•r-:

iA

O Cl-

p

0

Po 01

Xc ^ c X Pu C.

0 c

> o O X 0 0 p X o

p o3

CnC

= c 0 T-i XO X0 0 c:



^ P 0 c C- 0 > 0 O P G

c p

5

•—

in

^ •H

i->

0

P

0 G o o CO 0

0 *H

1

S-i

0 0

p —> X

X

-L->

LTi

r-.

V

V

o o

4J *H

o cc

<

vl



61

lO

o

o S

•H -M

+j

r^

X c

-^3

rt

M

+->

O

•»“»

CO

1

O *13 OC O n ^ 4-> C 4o c u 4 4-* o r C«

O

O E

fO

o 3


lO CN

in

o

CL

B

CO

•H CO

Variables

•H

+J

X

C 1

w ^c

4->

a 4-»
CO

o

^OC «H

O 3

ns

Measures

r3

4L

Predictor

C O O a 'h 4-> o :3 0- c 4-1.

of

0 LO rH

rH

CL

B

^

o


CO

•H CO

I

I

Self-report

Analyses

rt 4->

>s

to

Regression

G)

£0

^ O > o a o

o c o > c

a: I—

LO CM

s: (N

DjO

-H

0 5

CN

00

00 CN

r-i-H

(NJ

3.11

r-' CNJ

B 1

CO

rt 4->

O U ^ o rt 4-> 4- C 1— O o

>

O

CO

^

OC *H

ns

o 5

O

O

Ch

e

• 1

mO

4 O o 0 H rt •H O 4 4 >

4-J

0 H O V) 44 P 4-



ct,



• 1

^

o 4 4 -P O 3 > O O CJ o O 4 oc c

X

O

> 4-)

CTl*

CN

CNJ •



in

3 O o

4->

o

t-H

(NI

cc

•H CO

-^



c o H



O P O > •r* o 4 o 4 O p O P P3 >< O

'P

p rt

s JO 4 H O u. O cn O •



3 O 4

CO

P

— 0 3 •H P 0 o O 0 1

C’*

CO

(regression)

P P > .4

P

62

In an independent analysis,

the measure of physical effort was

shown to be significantly correlated with the postoperative criterion

days-in-the-hospital (r=-.48,

p.

The results of the stepwise

<.01).

linear regression analysis in which physical effort was allowed to

enter to days-in-the-hospital are summarized in Table 10.

The results

were consistent with earlier regressions, in that no one variable

contributed independently to length of hospitalization, although the overall test was significant and 52% of the variation in the criterion

could be accounted for by the predictors. Inspection of the signs and values of the beta weights indicates that higher expressed positive affect was generally associated with

poorer recovery on all criteria except time in SICU. to what had been predicted.

In contrast,

This is opposite

the measure of physical

effort functioned as predicted, although on only one recovery criterion. Low scores on the RLC, which suggest an internal locus of control,

were associated with increased use of pain medication and longer

postoperative hospitalization.

The remaining beta signs show a

consistent trend whereby a more internal locus of control was associated

with more adequate recovery.

Post hoc analysis showed that the Rotter

I-E scale did not significantly predict use of medication, nor was it

related to any of the other recovery criteria, confirming the assumption that a specific measure of locus of control would be more powerful

than a general dispositional measure.

Social contact was significantly

correlated to use of pain medication and self-estimates of recovery, although it did not make an independent contribution at the multivariate level.

Greater extent of operative intervention was similarly

related to more time in SICU, and lower self-estimates of recovery and

63

Table 10 Regression Analysis of all Predictor Variables to Days-o£-hospitalization^

R

Positive affect

.56

.46, D

Recovery Locus of Control Informat ion seeking Social contact Extent of operative intervention

-.24

-.35

.04

-.17

-.05

-.20

.02

Physical effort

-.42

-.48, b

.52

R^ F (regression)

Note^ n = 21

Beta weight

Simple

Predictor variable

3.30^ a p < 05 b p. < .01 .

.

64

welfare.

Age, which can also be considered an inherent measure of

vulnerability, was positively correlated to time in SICU. Several post hoc analyses were also done to further inspect the

relationship between preoperative variables and the recovery course.

Comparison of survivors and nonsurvivors on the preoperative variables yielded no significant differences.

This held true across all psycho-

logical, physiological, demographic, hospital setting and operative

intervention variables.

Clearly, there was a major source of variation

in outcome that was uncontrolled in this study, particularly for the

nonsurvivor subset.

.Mthough fear of surgery has been extensively

studied in previous investigations, here it was only found to be

related to amount of pain medication (r=.36,

p.

< .05)

.

However, it

was not significantly correlated to the responses concerning intensity and amount of pain on the Recovery Inventory.

The Beck Hopelessness

Scale was negatively correlated to the average welfare score (r=-.36, p.

<.017), but was otherwise unrelated to the recovery course.

The

three one-item scales assessing future satisfaction, expectancy for recovery, and quality of life were not related to postoperative

outcome

CHAPTER TV

DISCUSSION

In the present study, age was the only demographic variable which

predicted significantly to recovery.

Since increasing age in this

generally older sample was probably indicative of increased susceptibility to disease and physical stress, it can be considered an additional measure of vulnerability that had been originally unspecified.

Factors related to hospital of admission, SES level, marital status, and race did not directly relate to recovery and consequently were not

sources of confounding. As predicted, the verbal content measures of hope and positive

affect were independent of negative affects and did not vary as a

function of patient's background.

These results were consistent with

previous findings that trace measures of positive and negative affects are independent of each other (Westbrook, 1976).

Thus, there is

increasing evidence that to fully understand a person's experience of events, assessment of positive as well as negative feelings is needed.

However, the high correlation between the specific measure of hope and

the general measure of positive affect used here would indicate that

considerable work is still needed to differentiate the set of positive feelings into more discrete dimensions or categories.

As seen in the

present study, the respective intercorrelations between these two verbal content measures and the remaining preoperative measures and

65

.

66

the postoperative measures were nearly identical, and indicated that the two scales were not differentially discriminating the patient's

experience or variation in recovery.

Since there is little basis for

referring to hope and positive affect as separate experiential phenomena,

positive affect will be used in the rest of the discussion as

a

general term implying the full range of positive feelings. UTio

was experiencing relatively greater positive affect in the

face of life threatening illness and major surgery?

The correlations

were moderate, but there was some indication that those patients tending towards an external recovery locus of control ("recovery externals") and who expressed greater expectations of future satisfac-

tion experienced more positive affect preoperatively.

However, positive

affect did not vary directly with physical effort as predicted, but in fact showed a negative correlation.

On the basis of these findings,

concurrent validity among the three hv'pothesized measures of coping effort was not established.

Subsequent analysis of the relationship

between coping effort and the recovery course demonstrated that the association between positive affect and recovery was consistently in the poor direction, while more physical effort during a preoperative

examination was predictive of less time in the hospital.

These

latter results can be interpreted as indicating that patients

w'ho

were

disposed to try harder when confronted with physical tasks of treatment were able to regain minimal levels of mobility and functioning more

quickly and leave the hospital earlier.

Clearly, more evidence was

obtained demonstrating that physical effort is a valid measure within the general domain of coping effort than was obtained for positive

affect

67

The indirect relationship between positive affect and recovery is puzzling.

It is possible that a mediating cognitive variable,

such as

selective inattention, cognitive misperception, or denial led patients at risk to be somewhat naive and to experience unrealistic feelings of

optimism.

Perhaps, as Janis fl958) posits, the optimistic patients

were not experiencing sufficient fear or anxiety to motivate "worry This possible explanation is indirect-

work" or effective coping action.

ly supported by the finding that greater physical effort was associated

with greater expressed fear of surgery.

Although fear itself was not

strongly related to the recovery course, perhaps it has its effect by

motivating responses such as physical effort. The possibility that patients expressing high positive affect did not take an active problem solving approach to their illness and

recovery is further suggested by the moderate positive correlation between positive affect and the RLC

.

It was noted by the investigator

that "recovery externals" would typically make many positive statements

regarding their trust in physicians' and God's capacities to care for them, and it is possible they were unaware of the effort or tasks

expected of them during recovery. The RLC demonstrated adequate internal consistency, although the alpha reliability can be expected to drop somewhat on subsequent samples.

Concurrent validity for the RLC was shown by a moderate

correlation with the established Rotter I-E scale.

The shared variance

between the measures was sufficiently low to enhance discriminant validity.

The new scale successfully predicted extent of information

seeking prior to surgery, although the I-E scale was a better predictor

during the preoperative period.

The more accurate test of the utility

^

68

of the new scale showed that behavior during the recovery period was consistent with locus of control h>^)otheses, when internal-external

expectations were assessed with the RLC

The more general I-E scale

.

was not predictive to the recovery period.

Thus, the findings provide

preliminary evidence of the construct validity of the RLC and demonstrate the utility of a more specific recovery related measure. The relationship of locus of control orientation to recovery is

probably limited to those aspects of the treatment setting somewhat under patient control.

The results from this investigation were

consistent with earlier findings that internals seek more health

related information (Seeman 1976; Wallston, Wallston,

§

Evans,

Kaplan,

§

1962; Wallston, Maides

S

Kallston,

Maides, 1976), have longer post-

operative hospital stays and receive more pain medication following surgery [Johnson et al., 1971).

Tnese findings can be interpreted as

suggesting that internals make more effort

than externals to self-

manage their pain, anxieties, and disability through requests and

communications to the staff, and consequently receive more medication and lengthier treatment.

Although the original item pool for the RLC consisted about evenly of internally and externally worded items, seven of the eight items in the final scale were externally worded.

The internally

worded items did not correlate with the final scale, nor were they

internally consistent with one another.

These findings are consistent

with other evidence that locus of control may consist of at least two

orthogonal dimensions (Levenson, 1973; Wallston, Wallston, 1978).

8

DeVellis,

Specifically, these researchers are suggesting that internal

beliefs may be orthogonal to external beliefs, and that external fate

69

and chance beliefs should be considered separately from external control by powerful others.

From the perspective of this model, the

RLC is primarily a measure of external expectations regarding fate and

chance in the recovery environment.

Development of additional scales

to assess dimensions of external expectations from physicians and

staff and to tap internal beliefs would potentially enhance prediction to the recovery period.

Additionally, generalizing item content to

the broader context of hospitalization might improve the new scale's

prediction to behavior during the preoperative period.

In this

study, the generalized Rotter I-E scale was a better measure of preojjerative locus of control beliefs. In addition to seeking more preoperative information,

internals,

as measured by the Rotter I-E scale, received more preoperative

social contact, reported higher expectations of future satisfaction

and recovery outcome, made a higher self-estimate of their current

health, and endorse fewer statements of hopelessness and despair.

As

already suggested, these results could be interpreted as meaning that internals felt less hopeless and had higher expectaxions for the future as a consequence of their efforts to control the environment by

seeking support and soliciting information.

However, analysis of the

demographic variables indicated that lower class patients received less social contact, sought less information, and adopted a more

external locus of control.

Consequently, the difference between

internal and external patients may be partially a function of SES factors.

For example, most of the lower class patients in both hospi-

tals had been referred from rural clinics or out of state physicians,

while many of the middle class patients, particularly in the Shands,

70

were local residents.

Thus, the lower social contact among lower

class patients may have been a function of the inability of their

relatives to travel to visit, rather than a reflection of their external locus of control orientation.

Although information seeking varied as expected with locus of control, it was not an independently significant predictor of recovery. This finding is consistent with Sime (1975)

,

who found no relationship

between a patient's self-report of preoperative information seeking and standard clinical indices.

However, Sime (1976) did find that

information seeking was positively correlated to amount of information obtained, and that amount of information interacted with levels of fear.

Increased information benefited most those who reported high

preoperative fear, as measured by their use of analgesics, sedatives, and days-of-hospitalization

Other research has shown that information

.

is most helpful when it provides instruction in specific recovery

enhancing activities or strategies aiding cognitive appraisal and ego-

defensiveness (Egbert et al 1974; Langer et al

.

,

1975).

.

,

1964; Healy,

1968; Johnson

§

Leventhal

Since the amount and type of information

obtained is at least partially a function of the e.xtent and effectiveness of the patient’s information gathering strategies, future research could improve upon the understanding of this aspect of competence by

assessing qualitative dimensions.

For example, collecting information

about the extent and nature of illness may not be as effective in

preparing for surgery as inquiring about the effects of surgery, the nature of the recovery room, and the behavior expected of the patient during treatment.

.

71

It was seen that increased social contact was related to greater

use of pain medication and more positive self-reports of physical status during the postoperative period.

Given the descriptive-

correlational design of this study, it is not knora whether social support was an etiological factor to these recovery criteria, or

whether it was simply covarying with other factors, such as locus of control or SES.

It is significant, however, that a

measure as simple

as the one used here showed any relationship at all to the preoperative

and postoperative experience.

This preliminary evidence could be

improved with more thorough assessments of the hospital milieu, family-

patient characteristics, and the patients' roles in social and vocation al networks

The study did not directly test the hypothesized inter-

relationships between vulnerability, coping effort, and competency, although as predicted, the vulnerability measure used here was independent of the coping measures.

The vulnerability measure also consistent

ly predicted to outcome; extent of operative intervention was signifi-

cantly related to three of the recovery criteria and evidenced marginally significant relationships to two others.

It was shown that an

additional measure of vulnerability, age, was significantly related to time in SICU.

These findings suggest that increasing attention must

be given to identifying additional sources of vulnerability, such as

length and severity of illness, physical stamina, and operative factors This seem.s true for both theoretical and practical reasons:

twenty

percent of the resected group died, and there were no variables discriminating survivors from nonsurvivors.

72

A basic assumption of

the vulnerability model is that if patients

are equally "at risk," with respect to inherent vulnerability to

postoperative complications (distress, death, slow recovery), coping factors should predict to variability in outcome.

To test this assump-

tion, one might define a group of Hi Vulnerability patients

with

measures of inherent risk and use recovery criteria to divide them into groups of Hi Vulnerability-Poor Recovery and Hi VulnerabilityIf the assumption holds, measures of coping effort

Good Recovery.

and competency should discriminate between patients in the two groups. However, finding valid measures of recovery outcome will continue It was found that during the first

to be a problem in such analyses.

week of recovery, different criterion sources of information (patients,

physicians, clinical indices) did not generally overlap.

Undoubtedly,

some measures will be found to lack construct validity as accurate

measures of the recovery period.

nondemanding emotional

A particular need exists for

self-report measures to assess the patient's immediate

responsivity and physical progress.

But the accumulating

evidence would suggest that recovery proceeds along a number of parallel, but independent, courses.

Rather than making a general prediction

to recovery from specific preoperative variables, increased emphasis

should be placed on stating precise comes.

relationships to particular out-

The parallel response model (Leventhal, 1975) is one means of

generating such statements. An additional problem concerns the definition of "good" and

"poor" recovery.

For example, longer hospitalization and increased

use of pain medication have t>q)ically been indicators of

recovery course.

a

poor

However, one might also wonder whether external

locus of control patients, who receive less medication and tend to be

discharged earlier, were adequately treated.

Similarly, ambulation

can be expected to increase as strength and energy returns and pain

subsides, but excessive ambulation during the immediate period may be

detrimental to the patient and possibly a marker of agitation rather than improved functioning.

Development of adequate criteria is also

hampered by the lack of base rate data for different operative procedures

.

The changing nature and tasks of recovery over time is another

related issue.

It is strongly suspected that the weak relationship

found in this study between preoperative measures and recovery outcome was at least partially a function of the recovery period under study.

The findings here were consistent with other investigations showing that immediate outcome does not tend to be strongly

logical factors

(Heller et al., 1974; IVolfer

§

related to psycho-

Davis,

The

1970).

additional finding that the best prediction could be made to the one longer term criteria (days-in-the-hospital) in the study also supports this explanation.

The overall findings suggest that

coping factors

identified thus far will be most predictive of response during the later stages of recovery as the patients become less dependent upon

hospital staff and must rely

upon their own resources and competencies.

It was the investigator’s impression that any potential differences in

inmiediate recovery due to an individual patient’s strengths or weak-

nesses were overcome by the massive medical care provided.

In effect,

hospital staff assume major coping functions for the patient. The question remains, however, as to vshat factors contribute to

variability during the immediate period.

This is

a

particularly

74

relevant concern to high risk procedures, such as the one investigated Operative mortality was not related to the psychological,

here.

physiological, setting, or operative variables assessed in the study. If the assumption is correct that psychological factors do not play a

major role in immediate outcome, increased attention to operative technique and vulnerability variables may improve prediction of catastrophic

outcome.

An additional explanation for the weak association found between

preoperative and postoperative criteria concerns methodological issues. Although the vulnerability model suggested that coping effort variables would be potentially the most sensitive to outcome, hope and positive affect did not demonstrate concurrent or construct validity, and the

third measure, physical effort, was only related to one measure of recovery.

As already discussed, more precise measures of competency

and social factors are also needed.

Finally, if coping factors do

play only a small role during immediate outcome, larger sample sizes and replication will be needed to observe small but reliable relationships.

With the relatively small sample used here, the amount of

variation in outcome that could be accounted for was not large, and further decreases would be expected if the multiple regression equations

were cross validated.

BIBLIOGRAPHY

Andrew, J.M. Recovery from surgery, with and without preparatory' instruction for three coping styles. Journal of Personality and Social Psychology , 1970, 223-226.

Auerbach, S.M. Trait-state anxiety and adjustment to surgery. Journal of Consulting and Clinical Psychology, 1975, 40, 264-

^

271'.

Auerbach, S.M. § Edinger, J.D. The effects of surgery-induced stress on anxiety as measured by the Holtzman Inkblot Technique. Journal of Personality Assessme nt, 1977, 41, 19-24.

Auerbach, S.M., Kendall, P.C., Cuttler, H.E., & Levitt, N.R. /Anxiety, focus of control, ty'pe of preparatory information, and adjustment to dental surgery. Journal of Consulting and Clinical Psychology 1976, 44, 809-818 ,

Barkdoll, D.L. Relationship of patients' and spouses' preoperative anxiety and patients' postoperative pain. (Doctoral dissertation, Catholic University of America, 1975) Dissertation Abstracts International 1975, 1143B-1144B. XUniversity Microfilms No. 75-19). ^ .

,

Beck, A.T., Weissman, A., Lester, D., 8 Traxler, L. The measurement of pessimism; The hopelessness scale. Journal of Cons ulting and Clinical Psychology 1974, 861-865. ,

Biersner, R.J., Harris, J.A. 8 Ryman, D.H. Emotional predispositions to psychotropic drug effects. Journal of Consulting and Clinical Psychology 1977, 945-945. ,

Boyd,

I., Yeager, M.

McMillan, M. Personality styles in the postoperative course. Psychosomatic Medicine, 1973, 35 23,

8



4C.

Bruegel, M.A. Relationship of preoperative anxiety to perception of postoperative pain. Nursing Research 1971, 20, 26-51. ,

Bultz, B.D, The use of psychometrics in predicting surgical recovery. (Doctoral dissertation, 'United States International University, 1974). Dissertation Abstracts Internat ional, 1975, 3571B. (University Microfilms No. 74-24 )*(

A

76

Chapman, C.R. § Cox, G.R. Anxiety, pain, and depression surrounding elective surgery: A multivariate comparison of abdominal surgery patients with kidney donors and recipients. Journal of Psychosomatic Research 1977, 7-15. ,

Cohen, F. § Lazarus, R.S. Active coping processes, coping dispositions and recovery from surgery. Psychosomatic Medicine, 375-389. 1973,

DeLong, R.D. Individual differences in patterns of anxiety, arousal, stress-relevant information and recovery from surger>". (Doctoral dissertation. University of California, Los .Angeles, Dissertation Abstracts International 1971, £2, 554A1971) 555A. (University Microfilms No. 71-16, 307). .

,

Deutsch, H.

Some psychoanalytic observations in surgery. Psychosomatic Medicine , 1942, 4, 105-115.

Dlin, B., Perlman, A. § Ringold, E. Psychosexual responses to ileostomy and colostomy. American Journal of Psychiatry, 1969, 26, 374-381.

Egbert, L.D., Battit, G.E., Welch, C.E. 8 Bartlett, M.K. Reduction of postoperative pain by encouragement and instruction of patients. New England Journal of Medicine, 1964, 270, 825-827.

Eisendrath, R. The role of grief and fear in the death of kidney transplant patients. American Journal of Psychiatry, ^ ^ 581-387. 1969,

m,

Eisler, J., Wolfer, J.A. 8 Diers, D. Relationship between need for social approval and postoperative recover)- and welfare. Nursing Research 1972, 21, 520-525. ,

Ellis, B.W. 8 Dudley, H..A. Some aspects of sleep research in surgical stress. Journal of Psychosomatic Research, 1976, 2^, 303-308. Frank, J. The role of hope in pyschotherapy Journal of Psychiatry , 1968, 383-595.

.

International

Garmezy, N. The study of competence in children at risk for severe psychopathology. In E. .Anthony 8 C. koupernick (Eds.), The Child in his family: Children at psychiatric risk (Vol New York: Wiley Sons, 1974. 5), 8 Giller, D.W. Some psychological correlates of recovery from surgery. Texas Reports on Biology and Medicine 1962, 20, 366-376. ,

77

Goldstein, M.J. The relationship between coping and avoiding behavior and response to fear arousing propopanda. Journal of 247-252. Abnormal and Social Psychology 1959, ,

Goodman, L.S. ^ Gilman, A. [Eds 1 The pharmacological basis of therapeutics (5th Edition). New York: McMillan Publishing .

Co.

,

1975.

Gottschalk, L.A. A hope scale applicable to verbal samples. Archives of General Psychiatry , 1974, 779-785.

Gottschalk, L.A., Fox, R. 8 Bates, D.E. A study of prediction and outcome in a mental health crisis clinic. American Journal of Psychiatry, 1973, 130, 1107-1111. Gottschalk, L.A. ^ Gleser, G.C. The measurement of psych ological states through the content analysis of verbal be havior Berkeley: University of California Press, 1969. .

Gottschalk, L.A. Kunkel R., Wohl T.H., Saenger, E.L. 8 Winget C.N. Total and half body irradiation. .Archives of General Psychiatry 1969, 574-580. ,

,

,

,

Burdock, E.I., Lenn, E..A. § Trachtman, B.A. Profiles of psychological distress in physical illness. Proceedings of the 81st .Annual Convention of the Am erican Psychological Association 1975, 569-370.

.Hardesty, A.S.,

,

Healy, K.M.

Does preoperative instruction make a difference? American Journal of Nursing 1968, 1, 62-67. ,

Heller, S.S., Frank, K.A., Kornfeld, D.S., Malm, .J.R. § Bowman, F.O. Psychological outcome following open-heart surgery. Archives of Internal Medicine 1974, 134, 908-914. ,

Howells, J.G. (Ed.). aspects of surgery

Modem perspectives New York:

.

Janis, I.L. Psychological Stress. Sons, 1958.

in the psychiatric 1976. ,

Brunner -Mazel New York:

John Vviley

8

Janis, I.L. § Leventhal H. Psychological aspects of physical illness and hospital care. In B. Kolman (Ed.), Handbook of Clinical Psychology New York: McGraw Hill, 1965. ,

.

Johnson, B.A., Johnson, J.E. S Dumas, R.G. Research in nursing practice: The problem of uncontrolled situational variables. Nursing Research, 1970, 19, 537-342.

78

Johnson, J.E. 8 Leventhal, H. Effects of accurate expectations and behavioral instructions on reactions during a noxious Journal of Personality and Social medical examination. 710-718. Psychology 1974, ,

Contribution of Johnson, J.E., Leventhal, H. 8 Dabbs, J.M. emotional and instrumental response processes in adaptation Journal of Personality and Socia l Psychology to surgery. 1971, 2^, 55-64. .

The experience of open-heart surgery. Kimball, C.P. 57-65. of General Psychiatry , 1972, Cancer, emotions, and nurses. Klagsbrun, S.C. of Psychiatry, 1970, 126 1257-1244.

Archives

.American Journal

,

Patients’ definition of recovery Kolditz, D. 8 Naughton, R.A. (Doctoral dissertation, Columbia from an acute illness. Dissertation Abstracts International University, 1975) (University Microfilms No. 75-15, 760). 1975, 56, 161B-162B. .

,

Reduction of psychoDanger, E.J., Janis, I.L. 8 Wolfer, J..A. Journal of Experimental logical stress in surgical patients. 155-165. Social Psychology 1975, ,

Psychological stress and the coping process Lazarus, R.S McGraw Hill, 1966. York:

New

.

The psychology of Lazarus, R.S., .Averill, J.R. 8 Opton, E.M. In G.V. Coelho, coping: Issues of research and assessment. D.A. Hamburg, 8 J.E. .Adams (Eds.), Coping and adaptation New York: Basic Books, 1974. .

Levenson, H. patients. 1975,

4_l,

Multidimensional locus of control in psychiatric Journal of Consulting and Clinical Psychology, ^ 597-404.

Findings and theory in the study of fear communiLeventhal, H. cation. In L. Berkowitz (Ed.), Advances in experimental 5 New York: social psychology Vol Academic Press, 1970. .

The consequences of depersonalization during Leventhal, H. illness and treatment - .An information processing model. In New J. Howard, 8 A. Strauss C^ds.), Humanizing health care York: John Wiley 8 Sons, Inc., 1975. .

Physical illness, the individual and the coping Liposwski, Z.J. process. Psychiatry in Medicine , 1970, ]^, 91-102.

Relationship of locus of Lowery, B., Jacobsen, B. 8 Keane, A. Psychological Reports, ‘control to preoperative anxiety. 1975, 57, 1115-1121.

79

A study of hospitalization anxiety in Lucente, R.E. § Fleck, S. Psychosomatic Medicine 408 medical and surgical patients. 304-312. 1972, ,

Anxiety and pain in surgical patients. .Martinez-Urrutia, A. Journal of Consulting and Clinical P.sychology 1975, 43, 347442. ,

An investigation into the Meikle, S., Brody, H. 8 Pysh, F. psychological effects of hysterectomy. Journal of Nervous and Mental Disease, 1977, 164 36-41. ,

Some psychiatric aspects of surgical practice. Psychosom atic Medicine 1958, 20 203-214.

Meyer, B.C.

,

,

Moos, R.H. A social ecological perspective on medical disorders. In E. Wittkower 8 H. Warnes (Eds.}, The psycho New York: Harper somatic app roach to medical practice Row, 1976. .

8

Coping, vulnerability, resilience in childhood. Murphy, L.B. In G.V. Coelho, D.A. Hamburg 8 J.E. .Adams (Eds.}, Coping and New York: Basic Books, 1974. adaptatio n .

A decade later: A follow-up of social Myers, J.K. 8 Bean, L.L. New York: John Wiley and Sons, 1968. class and mental illness. Pascal, G.R., Thoi'oughman J.C., Jarvis, J.R. 8 Jenkins, W.O. Early history variables in predicting surgical success for Psychosomatic Medicine intractable duodenal ulcer patients. 1966, 2^, 207-215. ,

,

Hope and discomfort as Perley, J., Winget, C.N. 8 Placci, C. Comprehensive factors influencing treatment continuance. Psychiatry, 1971, 12 557-565. ,

Psychopathology observed on Rabiner, C.J. 8 Willner, A.E. follow-up after coronary bypass surgery. Journal of Nervous and Mental Disease, 1976, 165 295-501. ,

Psychiatric complicaRabiner, C.J., Willner, A.E. 8 Fishman, J. Journal of Nervous tions following coronary b>^ass surgery. and Mental Disease 1975, 160 342-548. ,

,

Generalized expectancies for inteiTial versus Rotter, J.B. Psychological Monographs external control of reinforcement. 1966, (1, Whole No. 609).

,

^

Schmale, .A.H. 8 Iker, H. Hopelessness as a predictor of cervical Social Science and Medicine, 1971, 5, 95-100. cancer.

,

80

Psychological preparation of Schmitt, F.E. 8 Wooldridge, P.J. lOS-116. Nursing Research 1975, surgical patients. ,

Seeman, M. setting.

S

Alienation and learning in a hospital Evans, J.W. 772-782. American Sociological Revie w, 1962,

Relationship of preoperative fear, type of copings Sime, A.M. and information received about surgery to recovery from Journal of Personality and Social Psychology 1976, surgery. 40 53-38. ,

,

Spielberger, C.D., Auerbach, S.M., Wadsworth, A.P., Dunn, T.M. Emotional reactions to surgery. Journal of Taulbee, E.S. 55-38. Consulting and Clinical Psychology 1973,

S

Tlioroughman J.C., Pascal, G.R., Jenkins, W.O., Crutcher, J.C. Psychological factors predictive of surgical Peoples, L.C. Psychosomatic success in patients with duodenal ulcer. Medicine, 1964, 26, 618-624.

8

,

,

Surgery as a human experience Titchner, J.L. 8 Levine, M. New York: Oxford University Press, 1960.

.

Responses of Irish and Italian patients of two Tsushima, W’.T. Journal of Personal social classes under preoperative stress. 43-48. ity and Social Psychology 1968, ,

Effect of information about a Bigelow, D.A. potentially stressful situation on responses to stress impact. 50journal of Personality and Social Psychology , 1974,

Vernon, D.T.

8

59.

Volicer, B.J., Isenberg, M.A. 8 Burns, M.W. Medical -surgical differences in hospital stress factors. Journal of Human Stress 1977, 3, 3-15. ,

Kaplan, G.D. 8 Maides, S.A. Wallston, B.S., Kallston, K.A. Development and validation of the health locus of control Journal of Consulting and Clinical Psychology (HCL) scale. 1976, 44, 580-585. ,

,

Maides, S. 8 Wallston, B.S. Health related Wallston, K.A. information seeking as a function of health related locus of Journal of Research in Personality control and health value. 215-222. 1976,

Development of Wallston, K.A., Wallston, B.S. 8 DeVellis, R. the multidimensional health locus of control (MHLC) scales. Manuscript submitted for publication, 1978.

,

81

Adaptation to surgically induced facial disfigureWest, D.W. ment among cancer patients. (poctoral dissertation, State University of New York at Buffalo, 1973]. Dissertation (University Abstracts International 1973-74, 34, 4442A. Microfilms No. 73-29, 151). ,

Westbrook, M.T. Positive affect; A method of content analysis Journal of Consulting and Clinical for verbal samples. Psychology , 1976, 44 715-719. ,

The concept of healthy personality: What do we really mean? Counseling Psychologist 1975, £, 3-12.

White, R.W.

,

Williams, J.G.L., Jones, J.R., Workhoven, M.N. 8 Williams, B. The psychological control of preoperative anxiety. Psycho physiology , 1975, 12 , 50-54. Wolfer, J.A. Definition and assessment of surgical patients' welfare and recovery. Nursing Research 1975, 22, 394-401. ,

Wolfer, J.A. 8 Davis, C. Assessment of surgical patients preoperative emotional condition and postoperative welfare. Nursing Research , 1970, 1_9, 402-414.

Vulnerability - a new view of scicophrenia. 8 Spring, B. Journal of Abnormal Psychology, 1977, 86, 105-126.

Zubin, J.

APPENDIX A

Recovery Locus of Control Scale Items Corrected item to scale correlations

Item

1.

A good fast recovery from surgery is largely a matter of good fortune,

.50

2.

No matter what I do, if I am going to have a slow difficult recovery, I will have a

.20

slow difficult recovery. 3.

So many complications can happen to you during recovery from surgery that you never know how or when one might occur

.32

4.

People who have an uneventful, quick recovery are just plain lucky.

.46

5.

Without the right breaks, recovery from surgery will be slow and difficult.

.59

6.

Trusting to fate will not be as effective as taking definite courses of action during recovery.

.21

7

So many unexpected things could happen during my recovery period that there is really no point in my learning everything I can about what I should do, now.

.

8.

This place is run by a few doctors, and there is nothing the patients can do to change things. Note:

.

52

.38

The scale is scored in the external direction, with each item scored from 1 (strongly disagree] to 6 (strongly agree! for the seven external items and reverse scored for the one internal item.

82

appendix b

PHYSICIAN’S AND NURSE’S PREOPERATIVE RATING FORM

PATIENT’S NAME

RATER'S POSITION:

SURGEON (or Surgical Residents)

[please circle)

NURSE

ANESTHESIOLOGIST

Instructions

Please rate this patient with respect to how active he/ she is in seeking information about his/her illness and treatment Does this patient initiate from you. discussions about his treatment or does he passively accept what you say without further inquiry? Does the patient ask you to clarify or further explain points of information or does he accept what he is told without asking for further elaboration or clarification? PLE.\SE CIRCLE THE NUMBER ON THE SCALE

BELOW that best indicates how actively this patient has sought information from you.

4

1

5

6

EXTREIELY ACTIVE INFORMATION SEEKING

NO INFORMATION SEEKING

S3

APPENDIX C Welfare Inventory Scale Items Corrected item to scale correlations

Item

Comfortable Pleased Worried Uncertain Relieved Weary Depressed Satisfied Tense Annoyed Confident Relaxed Frustrated Uneasy Hopeful Frightened Content Miserable Peaceful Encouraged Note:

.51 .40 .54 .52 .50 .50

55 .59 .64 .64 51 .60 77 .68 -.04 55 .60 .46 .85 .49 .

.

.

.

The patient is asked to indicate whet he is or is not experiencing each feeling. The scale is scored in the positive direction with each item scored 0 Cno) or 1 (Ves] for the positive affects and reverse scored for the negative affects.

84

.

,

.

APPENDIX D Recovery Inventory Scale Items

Instructions:

The purpose o£ this form is to get your evaluation You may feel good of your condition right now. about some aspects of your condition and very poor important for us to It is about other aspects. know this, so please try to be as frank as possible. .No one but the project interviewer will see your answers

Make your ratings simply by indicating whether you feel good, fair, or poor with relation to each of Please make your judgements the following areas. in comparison to how you usually feel at home.

1. 9

Corrected item to scale correlation

Scale

Item

Appetite

Poor

Fair

Good

.44

Poor

Fair

Good

.61

5

Stomach condition (i.e., upset, nausePoor ated, vomiting)

Fair

Good

.

4.

Bowel condition (i.e. gas pain)

Poor

Fair

Good

.40

5.

.Ability to urinate

Poor

Fair

Good

.30

6

.

Ability to do things Poor for yourself

Fair

Good

.66

7

.

Ability to move around

Poor

Fair

Good

.75

8

.

Interest in what is going on around you

Poor

Fair

Good

.46

%

Strength

^

energy

85

57

.

86

9.

Corrected item to scale correlation

Scale

Item

Your nursing care

Poor

Fair

Good

_

Good



10.

Your medical care

11.

How much pain have you had today?

None Very little Some Much Very much

How intense has the pain been today?

Very mild Mild Moderate Int ense Very intense

12.

Poor

Fair

13.

How many times have you been out of bed today'

14.

About what percent of the time have you been out of bed today? Note:

.51

.52

The recovery score is a summation of items 1 thru 8 plus items 11 and 12. The remaining items are treated as separate indices. Items 1 thru 10 are scored 1 (poor), 3 (fair), or 5 (good). Items 11 and 12 are scored in a positive direction from 5 (none or very mild) to 1 (very much or very intense)

BIOGRAPHICAL SKETCH Mark Raymond Otis was

bom

on February 28, 1950, in Queens,

New York, and spent the better part of his childhood and adolescence in Valley Forge,

Pennsylvania.

He graduated from Conestoga Senior

High School in Paoli, Pennsylvania, in J-one of 1968.

He attended

Union College in Schenectady, New York, for the next five years, graduating with a Bachelor of Science in Psychology in June, 1973.

Following his undergraduate education, he began graduate

work in

Psychology at the University of Florida, where he completed a

Master of Science degree in Psychology in 1975 and continued to work toward the Doctor of Philosophy.

He completed a Residency in

Clinical Psychology at the University of Texas Health Science

Center at San .Antonio in August, 1978, and remained there to do Second Year Residency while completing the dissertation.

Upon

completion of the Doctor of Philosophy he will begin work as a Clinical Psychologist.

87

a

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Associate Professor of Clinical Psychology

1 certify that 1 have read this study and tliat in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

1 certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

•fjacqueline Goldman

Professor of Clinical Psychology

I certify that I have read this study and tliat in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Paul Schauble

Professor of Psychology

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

Clinical Psychology

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

This dissertation was submitted to the Graduate Faculty of the Department of Psychology in the College of Liberal Arts and Sciences and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the Degree of Doctor of Philosophy.

June, 1979

Dean, Graduate School

1979
Surgery, Adjustment (Psychology)
English