PSYCHOLOGICAL PREDICTORS OF RECOVERY FROM THORACOTOM\’ IN PATIENTS WITH LUNG CANCER
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
support Many people have contributed their time, knowledge, and over the course of this project.
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.
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.
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.
extend my appreciation to Jacqueline Goldman, Paul Schauble, and Otto
vonMering for their contributions.
thanks for the work done by Sally Bower, Michael Webber, and John Robitaille.
TABLE OF CONTENTS
LIST OF TABLES
INTRODUCTION Descriptive Perspectives Etiological Models of Coping and Recovery Vulnerability Model
METHODS Subjects and Setting Preoperative Measures Postoperative Recovery Measures Procedure
33 33 34 40 45
RESULTS Relationship between Patient Demographic Characteristics, Hospital Setting, and the Recovery Course Preoperative Measures Postoperative Variables Relationships between Preoperative Variables and the Recovery Course
48 48 54
LIST OF TABLES
Sample Characteristics of the Resected and
Results of Discriminant Function utilizing Postoperative Variables as Predictors of Survivors-Nonsurvivors RLC, and
Mean Scale Scores on the
Mean, Standard Deviation, and Range of
Correlations among Preoperative Variables
Mean, Standard Deviation, Range of Postoperative
Correlations among Postoperative Variables
Regression Analyses of Predictor Variables to Clinical Indices and INDEX
Regression Analyses of Predictor Variables to Self-report Measures
Regression Analysis of all Predictor Variables to Days-of-hospitalization
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
Mark Raymond Otis
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:
the patient's inherent
predisposition to a particular failure during recovery, and coping
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
The present study investigated whether personality constructs
generated by this model were potentially predictive of recovery from major
expected that greater coping
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:
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:
hope and (2) positive
affect were assessed with verbal content measures applied to five
minute speech samples, and
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-
Assessment of immediate postoperative recovery
(one week) was done wdth standard clinical indices, patients'
self-reports, and physicians
Results showed that recovery criteria were generally independent of one another and that the postoperative period should be
conceptualized as a multidimensional process.
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
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.
variables predicted most successfully to criterion of longer rather than immediate recovery.
Positive affect was negatively
correlated with outcome, although the physical effort measure of coping effort functioned as predicted with respect to length of
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
It is concluded that the coping-
productive source of hypotheses, but
that more sophisticated measures of coping effort and competency are needed.
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.
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
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.
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.
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
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
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)
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
noted characteristic experiences of the surgical patient and common
defense mechanisms used to handle operative anxiety. ity,
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
Although Meyer (1958) seemed to feel that denial may
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.
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;
Edinger, 1977; Johnson, Leventhal,
Urrutia, 1975; Meikle, Brody,
Dabbs, 1971; Martinez-
Pysh, 1977; Speilberger, Auerbach,
Taulbee, 1973; Wolfer
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
A curv'ilinear response
tendency was found, such that anxiety was relatively low prior to
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
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)
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)
moderate increase in
Linear relationships between preoperative state anxiety
and postoperative levels of state pain (Barkdoll,
(Biersner, Urrutia, 1975) and psychotropic drug effects due to anesthesia
Ryman, 19,77) have also been reported.
On the other hand,
found to obseiv^er and patient rating scales of anxiety have not been
be related to postoperative welfare or recovery (Cohen 1975; Wolfer § Davis,
and two studies
(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
year follow-up, one-third of the patients reported significant psychological problems which interfered with recovery.
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
reluctance to undergo surgery
and active personality type.
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
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
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
Naughton, 1975) interviewed 200 recovering
of surgery patients and found that they could identify two phases
sufficient progress to leave the hospital, and
The first phase had three major components:
to surgery, of specific operative consequences, resolution of responses
and physician's validation of their readiness to leave.
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,
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
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
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
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
perceive Thus, a patient's general capacities to plan,
to their accurately, and maintain reality contact appear related
course. overall psychological and physiological recovery
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
the voluminous These results are not surprising, as they confirm
literature clinical reports that comprise the remaining descriptive
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:
emotion-as-drive models focusing on the arousal of fear and anxiety which lead to constructive preparation or the "work of worrying";
emotion-as-response models focusing on cognitive threat appraisals and the role of emotional and instrumental coping responses;
tional models focusing on particular propensities of individuals to use one or another coping tj'pes; and,
situational models ^ocusing
on hospital milieu, sociocultural, or contextual variables.
three models are person centered:
the forces emanating from the
personality determine the style and manner of coping.
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
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.
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:
little fear prior to
and (2) anger during convalescence,
reflective fear To interpret these data he advanced the concept of (Janis,
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
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,
and increase the probability that extreme forms of avoidance will be
Similarly, low fear level in the face of realistic threat will
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:
exposure to threaten-
ing stimuli about the impending operation leads to,
fear which motivates,
"worry work” strategies, such as seeking
information or reassurance, which lead to
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
between fear and postoperative distress was generally linear.
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,
Tests of the hypothesized sequence between exposure to threat stimuli and final response also present equivocal support.
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,
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)
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
quality and extent of information
provided may interact with levels of fear or anxiety. investigators [Williams, Jones, Workhoven,
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
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.
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
Woolridge, 1973), and instruction in a
coping device utilizing distraction and cognitive reappraisal through
selective attention (Langer et al
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.
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
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.
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
cognitive modes of resolution (benign reappraisal, attentional refocusing, conflict resolving fantasy)
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;
(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
Support for this model was provided by a study with 62 female surgical patients (Jolinson et al
Preoperative and post-
operative measures of emotion (moods, pain, anxiety)
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.
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
The behavioral instructions were intended to improve the
patient's danger controlling responses.
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.
Sime (1976) found that patients who were experiencing high levels of fear and who were well inform.ed about their illness and treatment
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
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)
(Lazarus et al.,1974).
tions are distinguished from the actual coping responses used under
Three dimensions of coping dispositions
have been investigated in the surgical literature:
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
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,
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.,
In a study of preparatory communication
internals adjusted poorly during dental
surgery when provided with general information; however, they adjusted well when specific information regarding procedures and sensations was
The opposite relationship was found for externals.
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, a relatively stable individual
disposition to react emotionally to stress, has been related to various aspects of the surgical experience.
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
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
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)
ally as tackling-capitulating-avoiding Cbipowski, 1970) or vigilant
Although sharing similar constructs,
these measures have not demonstrated concurrent validity and may
represent independent dimensions (Lazarus et al
Several studies have used the Goldstein sentence completion test (SCT)
as a measure of the patient's disposition to avoid
to remain vigilant
(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,
DeLong (1971) found avoiders typically had
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
and a correlation between a behavioral measure of vigilance-avoidance
dispositional measure was (Cohen §
indicating relative independence
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
Lazarus, 1975); however, an active vigilant orienta-
adjustment posttion towards stress was related to better long term surgery (Boyd, Yeager,
An active vigilant approach
which may be incompatible with the immediate recovery period,
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
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
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.
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
Jenkins, 1966; Thoroughman, Pascal, Jenkins, Crutcher,
Patients who were relatively environmentally
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,
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
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
Summary The evidence collected in the studies reviewed seems to indicate the following:
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;
the most potent
variable is the operative intervention, since the nature and effects
different surgical procedures poses widely varying psychological and
the patient's subjective perceptions of the
hospitalisation experience has a major effect on emotional responses and long terra rehabilitation;
increasing evidence suggests that
emotional responsivity to operative threat is independent of ongoing
danger controlling coping action; and,
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
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
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)
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).
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
uniform patient population and
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
Recovery is composed of several classes of psycho-
logical, physiological, and social criteria.
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,
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.
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.
The model to be considered here is based largely on ones proposed by experimental psychopathologists (Garmezy, 1974; Zubin 1977).
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.
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
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.
a patient's vulnerability to any particular breakdown is not the only
contributing factor and being predisposed does not necessarily produce
Other factors such as the patient's psychological maturity
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.
overly simplistic to think of surgery generally as a "stressful
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)
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).
A principle set of factors which influences the patient'
coping behavior is the competencies which can be brought to bear. the simplest
competence is effectiveness:
"it is a person's
feeling that he can have a desired effect" (White, 1975)
ing are some of the other aspects of coping which must be taken into
the reflexive actions and instincts adequate to meet
which may be thought of as persistant
trial and error attempts at adaptation; and,
development of mastery
from successful coping efforts (Murphy, 1974; Zubin
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.
IVhereas the patient's compe-
tencies are capacities, coping efforts are the motivational or attitudinal approach to a particular set of exigencies.
efforts are often referred to as their "will to live." UTiat is
the relationship between coping, vulnerability, and
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,
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?
it the diminution of coping effort,
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
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.
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.
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)
and hopelessness has been implicated as a predictor of cervical
1971), and seriousness of suicidal intent
among depressed patients (Beck, Weissman, Lester, verbal content measure of hope (Gottschalk
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
Winget, 1969), and
psychiatric morbidity following six weeks of intensive psychotherapy (Gottschalk, Fox,
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
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.
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.
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
patient's relative physical striving during a medical examination.
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
Comparable measures had not been previously reported in the
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
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)
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
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
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.
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.
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
for recovery, and anticipated life satisfaction postoperatively
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-
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
measures of vulnerability to poor
recovery would be independent of measures of coping;
positive affect and hope would not be related to reported feelings of hopelessness or fear;
measure of locus of control orientation
specific to recovery behavior would demonstrate better construct
general dispositional measure of locus of control;
patients demonstrating greater coping effort, as assessed by a high degree of hope, positive affect, and physical effort, would have more
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;
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.
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)
single lobectomy (n=25)
Seven patients in the resected group and one patient
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.
Sample Characteristics of the Resected and Unresected Groups
Age in years Mean SD
Upper middle Middle Lower middle Lower
Hope Scale (HS)
Gottschalk and Gleser (1969) developed upon content analysis of speecli.
their definition of hope as;
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
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.
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.
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.
the seven content categories ranged from r=.65 to r=.91.
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
of the patient's state experience of positive feelings.
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.
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.
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
breathing for the required time (15 seconds)
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^
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.
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
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)
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.
From the original pool, eight items were selected .
The resulting RLC scale has a
The mean scale score for this
for the final scale (see Appendix A)
potential range from eight
sample was 26.53, and the standard deviation was 9.05,
reliability was .68 and corrected item to scale correlations ranged from .20 to .59.
This scale was developed for the purpose of measuring patient
differences in information gathering from 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"
two ratings were obtained, they were averaged to
yield one scale score. was assigned that score.
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,
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.
of phone calls, letters, and visitors were summed to yield one score of "frequency of contact."
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,
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
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
Each response is given
and the total hopelessness score may range from 0 to 20.
Additionally, the Rotter (1966)
and scored in the external direction.
was presented to the patients
This scale was entered into the
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
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,
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
days-to-discharge, amount o£ pain medication, time
in the surgical intensive care unit, and time on ventilator.
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
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;
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
In addition to the clinical indices, two self-report measures
the Welfare Inventory and the Recovery Inventory.
The Welfare Inventory (Wolfer
is a 20 item self-
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."
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.
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)
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
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
on the seventh day, scores from the third day were taken as the overall
welfare score. The Recovery Inventory (Wolfer
is a 14 item self-
report measure that asks the patients to rate their physical well-
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
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.
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.
(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)
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
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
WI, RI, SICU) were used as predictors in a discrimnant function analysis
to two apriori groups:
survivors and nonsurvivors.
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
The standardized coefficents and univariate analyses of variance are
presented in Table
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
Results of Discriminant Function utilizing Postoperative Variables as Predictors of Survivors -Nonsurvivors
%0B3 %0B7 SICU MEDS
.262 .486 047 .
power, partly because of shared variance with other predictors.
membership in Survivor-Nonsurvivor groups, the six measures classified patients with 85
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,
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.
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
The examiner returned later to obtain the completed
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.
these cases, the examiner presented all items orally while the patient
followed along and responded, or remained
assistance when needed.
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.
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'
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.
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.
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.
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
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)
Lower class (n=24)
Lower middle class
.Analyses of variance indicated main
effects for SES on information seeking (F=8.103, Locus of Control (F=2.729,
able by SES level appear in Table
The mean scores for each variIt
may be noted that lower class
patients tended to seek less information from physicians, to adopt
more external locus of control, and to have less preoperative contact with family and friends than lower middle to upper class patients.
Mean scale scores on the RLC as a function of SES
Patients were also divided into Married (n=31) and Nonmarried Cn=23)
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,
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
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
Patients in the Shands Teaching Hospital had
significantly higher I-E scale scores (t=2.9, p
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
<.0C1) with one another.
As predicted, neither of these
measures was significantly related to negative mood states of operative fear
and both hope and positive affect
were positively correlated to the single item measure of future satis-
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
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
Table 4 Mean, Standard Deviation, and Range of Preoperative Variables
Positive affect Physical effort
Fear of surgery
Estimate of health
Estimate of recovery
n = 45
U O 3
o in in o o 3.
o > c
V c o o
&6 • Correlations
Cu 3. CU
X u ft)
> o ft)
U 4^ U O
X«-t IM ^ Cm
o z zo zo
o o V)
c O o ftO
W > u
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)_
with the Rotter I-E scale, indicating that the new scale
shared about 10% common variance with the I-E scale.
struct validity of the RLC was also demonstrated by a significant
negative correlation with information seeking (r=-.41).
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,
<.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
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.
Table 6 Mean, Standard Deviation, Range of
of bed #3
%Time out of bed #7 Phy Rating #3
Phy. Rating #7
n = 28 n = 30
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.
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
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,
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
Among the self-report measures, the time out of bed on the third
was not related to any of the other measures and
3 » O *3 C C E ^
o w O 0) y > V c
> c Variables
o • u > OS
> o • o > 4)
O c 4) > Z
^ > 2 MC 4>
C Oo V 'sy c.
o c E O NO
C E O C 4-> re re o C)
c c re
c o >
> c u > o c
> C O 4) O > y ac
c o £ Xi i-
3 C *3 o y E J3
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
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
were entered as predictors in stepwise fashion until no additional variable' from the set
capable of producing a change in R- greater
than .01 or where the overall F ratio of goodness of fit became non-
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:
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.
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
Two such analyses were performed, one each for time
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
independent analysis to be significantly correlated with the dependent variable.
From inspection of Tables
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.
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,
INDEX of recovery, and the Recovery Inventory, although
inspection of the coefficients of determination, R
only 22 to 30 percent of the variance in the recovery criteria was
The regression analyses for the four patient self-
report measures (Table
showed that only the subjective report of
physical status was significantly related to the predictors.
X u X C Z HH
o > o o o
o u ^
5 •H <+J
u )— :/)
o P ^
0 ^ 03 Cl. > J-i
Xc ^ c X Pu C.
> o O X 0 0 p X o
= c 0 T-i XO X0 0 c:
^ P 0 c C- 0 > 0 O P G
0 G o o CO 0
p —> X
O *13 OC O n ^ 4-> C 4o c u 4 4-* o r C«
C O O a 'h 4-> o :3 0- c 4-1.
0 LO rH
^ O > o a o
o c o > c
O U ^ o rt 4-> 4- C 1— O o
4 O o 0 H rt •H O 4 4 >
0 H O V) 44 P 4-
o 4 4 -P O 3 > O O CJ o O 4 oc c
3 O o
c o H
O P O > •r* o 4 o 4 O p O P P3 >< O
s JO 4 H O u. O cn O •
3 O 4
— 0 3 •H P 0 o O 0 1
P P > .4
In an independent analysis,
the measure of physical effort was
shown to be significantly correlated with the postoperative criterion
The results of the stepwise
linear regression analysis in which physical effort was allowed to
enter to days-in-the-hospital are summarized in Table 10.
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.
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
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
Table 10 Regression Analysis of all Predictor Variables to Days-o£-hospitalization^
Recovery Locus of Control Informat ion seeking Social contact Extent of operative intervention
R^ F (regression)
Note^ n = 21
3.30^ a p < 05 b p. < .01 .
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
Clearly, there was a major source of variation
in outcome that was uncontrolled in this study, particularly for the
.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,
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.
three one-item scales assessing future satisfaction, expectancy for recovery, and quality of life were not related to postoperative
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
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
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?
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.
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.
latter results can be interpreted as indicating that patients
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
The indirect relationship between positive affect and recovery is puzzling.
It is possible that a mediating cognitive variable,
selective inattention, cognitive misperception, or denial led patients at risk to be somewhat naive and to experience unrealistic feelings of
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
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,
1962; Wallston, Maides
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.
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).
Specifically, these researchers are suggesting that internal
beliefs may be orthogonal to external beliefs, and that external fate
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.
study, the generalized Rotter I-E scale was a better measure of preojjerative locus of control beliefs. In addition to seeking more preoperative information,
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.
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,
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
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.
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:
percent of the resected group died, and there were no variables discriminating survivors from nonsurvivors.
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
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
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.
some measures will be found to lack construct validity as accurate
measures of the recovery period.
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
For example, longer hospitalization and increased
use of pain medication have t>q)ically been indicators of
However, one might also wonder whether external
locus of control patients, who receive less medication and tend to be
discharged earlier, were adequately treated.
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
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
(Heller et al., 1974; IVolfer
related to psycho-
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
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.
hospital staff assume major coping functions for the patient. The question remains, however, as to vshat factors contribute to
variability during the immediate period.
relevant concern to high risk procedures, such as the one investigated Operative mortality was not related to the psychological,
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
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.
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-
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. ,
I., Yeager, M.
McMillan, M. Personality styles in the postoperative course. Psychosomatic Medicine, 1973, 35 23,
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 )*(
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). .
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,
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.
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. ,
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 .
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.
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:
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.
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.
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:
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,
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.
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.
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. .
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.
Psychological preparation of Schmitt, F.E. 8 Wooldridge, P.J. lOS-116. Nursing Research 1975, surgical patients. ,
Seeman, M. setting.
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,
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.
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,
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.
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.
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.
Recovery Locus of Control Scale Items Corrected item to scale correlations
A good fast recovery from surgery is largely a matter of good fortune,
No matter what I do, if I am going to have a slow difficult recovery, I will have a
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
People who have an uneventful, quick recovery are just plain lucky.
Without the right breaks, recovery from surgery will be slow and difficult.
Trusting to fate will not be as effective as taking definite courses of action during recovery.
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.
This place is run by a few doctors, and there is nothing the patients can do to change things. Note:
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.
PHYSICIAN’S AND NURSE’S PREOPERATIVE RATING FORM
SURGEON (or Surgical Residents)
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.
EXTREIELY ACTIVE INFORMATION SEEKING
NO INFORMATION SEEKING
APPENDIX C Welfare Inventory Scale Items Corrected item to scale correlations
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.
APPENDIX D Recovery Inventory Scale Items
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.
Corrected item to scale correlation
Stomach condition (i.e., upset, nausePoor ated, vomiting)
Bowel condition (i.e. gas pain)
.Ability to urinate
Ability to do things Poor for yourself
Ability to move around
Interest in what is going on around you
Corrected item to scale correlation
Your nursing care
Your medical care
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
How many times have you been out of bed today'
About what percent of the time have you been out of bed today? Note:
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
on February 28, 1950, in Queens,
New York, and spent the better part of his childhood and adolescence in Valley Forge,
He graduated from Conestoga Senior
High School in Paoli, Pennsylvania, in J-one of 1968.
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
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.
completion of the Doctor of Philosophy he will begin work as a Clinical Psychologist.
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.
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.
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.
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.
Dean, Graduate School