LIB iARY Michigan State University OVERDU FINE: 25¢ per day per item .4 [ 3‘}: E mynuguc usmv tummznuus: ' W m in \L 1 1‘4" ',’-” J" m“ book 7J<294 7 remove m from circulatioa records . ‘_-__-- _. A N THE EFFECTS OF PERSONALIZED INFORMATION UPON THE RECOVERY OF SURGICAL PATIENTS By George Patterson Alexander A DISSERTATION Submitted to Michigan State University in partial fulfillment of-the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Counseling and Educational Psychology 1981 a :0: o ABSTRACT THE EFFECTS OF PERSONALIZED INFORMATION UPON THE RECOVERY OF SURGICAL PATIENTS By George Patterson Alexander The purpose of this study was to investigate the effects of personalizing information for surgical patients. More specifically, two elements of the information-giving process were experimentally manipulated in order to examine their differential effects upon patients' recovery. The first variable was an audiotape containing general information about the basic events that occur during hospitali- zation for an operation. A second variable was a questionnaire that was completed by the patient after listening to the audiotape. This questionnaire was designed to provide the patient with the opportunity to ask questions and express concerns during a surgeon's preoperative visit. Subjects in this study consisted of thirty volunteer patients scheduled to undergo orthopedic surgery. Patients were randomly assigned to one of three groups (two treatment and one control). Patients in the first treatment group listened to the information audiotape and Completed the questionnaire. Patients in the second treatment group were exposed only to the audiotape. Control group patients received neither the audiotape nor the questionnaire. Five recovery measures (length of hospitalization, number of oral pain medications administered, number of injected pain medications adminis- tered, the score on an anxiety inventory, and the score on a measure George Patterson Alexander of well-being) were utilized to determine the effects of the treat- ments. The analysis strategy chosen was that of planned comparisons. Two comparisons were conducted, comparing each treatment group against the control group.‘ It was hypothesized that both treatment groups would indicate greater recovery than the control group. Significant differences were discovered for treatment group two, which indicated that listening to the information audiotape alone contributed to a significantly better recovery. No significant differences were discovered for treatment group one, indicating that the addition of the questionnaire did not significantly contribute to recovery. The present investigation has generated a number of recommendations for future researchers in this area of patient care. The first recom- mendation is to replicate the present study with three modifications: l) provide only the questionnaire helping patients ask questions and express concerns to one treatment group, 2) use a larger sample of patients, and 3) provide a method of determining patients' coping style. The second recommendation is to broaden the sample to include patients experiencing various types of operations. The third recom- mendation is to change the content of the information audiotape to include details specific to the operation involved. Finally, it is recommended that the recovery variables be changed to include different types of measures collected at different times. DEDICATION To my parents, George and Dorothy, and to my sister, Ann, from whom I have received love and support that I cannot describe -- it is indeed good to be part of that family; and To my wife, Marcia, who, during all the times of anxiety and frustration, was my "weaver of peace“ and who, when discouragement and disappointment set in, was my "bringer of joy." ii ACKNOWLEDGMENTS It is not possible to reach this point without the help of a number of people. My thanks go to my advisory committee: Bob Win- born, my advisor, patiently and gently, yet firmly, guided me through the intricacies of my doctoral program; Steve Yelon urged me to do things as well as I could and provided me with an example of excel- lence; Martha Karson continually gave me encouragement and positive reinforcement at just the right times; Jim Harkema shared with me his own interests and concerns and showed me an insider's view of the world of surgery. The patients who participated in the study were more helpful to me than I was to them, and their patience and understanding made the entire process of gathering data much easier. The staff in the surgeon's office -- Mary, Dawn, and Kay -- were consistently good natured in the face of some unreasonable re- quests from me, and they assisted me far more than I had any right to expect. Dr. Jack DeBruin not only made his patients available to me but also answered my questions, assisted in the design of certain aspects of the study, ran interference with hospital staff, helped me figure out what was happening when things did not go as I expected, shared with me his interests and experience, and, most important of all, gave freely of his time and effort. iii TABLE OF CONTENTS LIST OF TABLES ........................ LIST OF FIGURES ....................... Chapter I. II. THE PROBLEM, RATIONALE, AND RELATED RESEARCH Rationale ....................... Purpose ........................ Theory and Assumptions ................ Need to Know .................... Anxiety ...................... Beneficial Results of Information ......... Personalized Information .............. Summary ...................... Literature Review ................... The Role of Information .............. The Presence of Anxiety .............. The Interaction Between Information and Anxiety . . The Effects of Defensive Style ........... Summary ...................... EXPERIMENTAL DESIGN AND METHODOLOGY Subjects ....................... Measures ....................... Psychological Measures ............... Physiological Measures ............... Instruments .................... .- . Information Audiotape ............ '. . . Patient Response Form ............... Experimental Manipulation ............... Pilot Study ...................... Hypotheses ...................... Hypothesis One ................... Hypothesis Two ................... Experimental Design .................. Analysis ....................... iv Page vi TABLE OF CONTENTS (Continued) Chapter Page III. ANALYSIS OF RESULTS The Primary Analysis ................. 48 Multivariate Test ................. 50 Univariate F-tests ................. 52 Step Down F-tests ................. 52 Correlation Matrix ................. 55 Observed Cell Means ................ 55 Descriptive Analyses ................. 58 Summary ........................ 66 IV. SUMMARY, DISCUSSION, RECOMMENDATIONS, AND CONCLUSIONS Summary ........................ 69 Discussion ...................... 71 Theory ....................... 73 Sample ........... I ........... 76 Design and Statistics ............... 78 Instruments .................... 79 Outcome Measures .................. 8l Length of Hospitalization ............ 82 Pain Medications ................ 83 STAI ...................... 84 PDQ ....................... 84 Treatments . . . .' ................. 86 Recommendations for Future Research .......... 89 Conclusion . ...................... 9l BIBLIOGRAPHY ......................... 93 APPENDICES .......................... 97 Appendix A: Patient Consent Form ........... 97 Appendix 8: Patient Information Record ........ 99 Appendix C: Transcript of the Information Audiotape . lOO Appendix D: Patient Response Form .......... 102 Appendix E: Self-Evaluation Questionnaire (STAI) . . . l05 Appendix F: Post-Operative Questionnaire ....... 107 Appendix G: Patient Responses on the PRF ....... lll LIST OF TABLES Personal and Demographic Characteristics of Patient Sample .................... Occupations of Patient Sample by Type and Frequency ...................... Previous Operations Experienced by Patient Sample Experimental Design, N = 30 ............. Summary of the Multivariate Analyses of Two Planned Comparisons ................. Univariate F-tests and Step Down F-tests for Compari- son 2: Maximum Treatment Group (Tl) vs. Control Group (T ) ...................... Univariate F-tests and Step Down F-tests for Compari- son 1: Minimum Treatment Group (T2) vs. Control Group (T3) ...................... Correlation Matrix of the Five Dependent (Outcome) Variables ...................... Observed Cell Means by Each Group for the Five Dependent (Outcome) Variables ............ Ranges, Means, and Standard Deviations for Each Dependent (Outcome) Variable Across All Groups . . . . Mean Scores and Standard Deviations by Group for Information-Related Items on the Postoperative Questionnaire .................... vi Page 3T 53 54 LIST OF FIGURES Figure Page 3.l Graphical Presentation of the Means for Each Treatment Group on the Five Dependent (Outcome) Variables ...................... 6T vii Chapter I THE PROBLEM, RATIONALE, AND RELATED RESEARCH RATIONALE Facing an operation is a situation in which most people exper- ience the various unpleasant emotional and cognitive sensations of fear, worry, or uncertainty. It is not an exaggeration to state that this experience is often seen as a crisis by the individual. At the very least, there is the inconvenience of being hospitalized for a period of time and, therefore, removed from one's daily routine. At worst, there is the possibility of disfigurement, disability, or even death. ‘The exact cause of this uneasiness is not clear. It may be some combination of the individual's personality, percep- tion of the situation, and past experiences (Bodley, Jones, & Mather, 1974). Patient education has been used in recent years as a method of alleviating the anxiety that occurs in connection with surgery. During the past ten to twelve years, research has been conducted in which various techniques of educating patients have been investi- gated. A specific aspect of patient education that has received attention is the information-giving process by which patients learn what is going to happen to them before, during, and following an operation. It has generally been accepted that patients benefit from receiving this type of information. It is important that an 1 individual know what is involved, particularly the degree of risk, if he or she is to make an informed decision concerning proposed treatment. As a result of the general acceptance by medical personnel that the patient has a "right/need to know," most patients now receive information about their scheduled operations. There are several issues that surface when the matter of pro- viding patients with information is considered. These can be broadly categorized as issues involving either the form of the information or its content. Various studies have attempted to address these issues. As a result, there eXists a better understanding of some aspects of the information-giving process. This is not to say, how- ever, that a universal or standardized model of the process has been accepted by medical practitioners. It would be more accurate to state that certain major aspects of giving patients information about surgical procedures has been identified. It remains to be determined which elements involved in providing information are the most signi- ficant and how they interact with one another. One of the most important issues in giving information to patients is that of personalizing the information for the individual. While it may be that there are typical elements of information that should be given to all patients (what part of the body is involved or when and how the anesthesia will be administered), it appears that per- sonalizing the information to the specific needs of each patient is important. This has been suggested by several investigators (Miller & Shada, 1978; Schmitt & Nooldridge, l973: Florell, l97l; Auerbach et al., l976; Neiler, 1968). This investigator, however, has been unable to locate any research involving surgical patients where the HE w UH need for personalizing information has been singled out for examina- tion as a separate variable. In this study, the concept of personalized information has a specific definition that contains two elements. First, to personalize information means to present the patient with the basic details relating to the entire operative procedure. Secondly, this concept includes the deliberate attempt by the surgeon to ascertain those aspects of the operative experience about which the patient is concerned and/or wishes more information. It is not uncommon for patients to have unanswered questions (Finesilver, l978) or unexpressed concerns (Bodley, Jones, & Mather, l974). Unless there is a deliberate attempt to identify those questions and concerns, they may not be communicated and may affect the patient's recovery from the operation. If confronted with this issue, most medical personnel would state that they are aware of their patients' need for information that is specific to their situation (Boyarsky, l976; DeLee, l976; Orwoll & Dillon, T974; Reich, l975; Youel, l974). It is unknown how consistently most surgeons actually practice what they claim to do, but it seems reasonable to assume that most surgeons inform their patients about some of the procedures involved. This study was concerned with the importance of determining what additional questions and unspoken concerns patients have. It was assumed that merely telling patients what the operation entails is not enough. In addition, the surgeon needs to know what questions and concerns still exist that might affect the patient's recovery. A related assumption is that receiving personalized information will have a measurable effect upon recovery. PURPOSE The purpose of this investigation was to study the effects of personalizing preoperative information for surgery patients. More specifically, two elements of the information-giving process were experimentally manipulated in order to examine their differential effects on recovery. The first variable was an audiotape containing general information about the basic events that occur during hospi- talization for surgery. A second variable was a questionnaire that the patient completed after listening to the audiotape. This ques- tionnaire was designed to provide the patient with the opportunity to ask questions and express concerns during a surgeon's preoperative visit. A hospitalized patient is exposed to a variety of sources of information. Doctors, nurses, fellow patients, friends, and relatives may provide information. The relevance and accuracy of that infor- mation is variable. The patient can receive, therefore, a mixture of relevant, irrelevant, helpful, and confusing information, depending upon the source. To provide patients in the treatment groups with a common source of information and to decrease the variability of information, an audiotape was utilized in this study. According to the definition of personalized information used in this research, it was necessary to provide basic information about the operative procedures, as well as to attempt to determine if there were questions and concerns that the patients wished to discuss. A questionnaire was provided for patients in one treatment group to assist them to ask questions and express their concerns. This questionnaire, called the Patient Response Form (PRF), requested patients to record items of information they had not received and would like to have. It also asked them to note areas of concern they would like to express. Finesilver (l978) discovered that patients are often reluctant to ask questions they feel the surgeon might consider trivial. Bodley, Jones, and Mather (l974) found that patients often have concerns they will not identify even when they are ques- tioned directly. The PRF was designed so that patients were encouraged to consider both questions and concerns they have before the operation. This investigator was unable to locate any research that speci- fically investigated the effect of personalizing information upon the recovery of surgical patients. Information about the surgical experience is generally accepted to be necessary and valuable. Several investigators have made this point and will be referred to in the literature review section of this study. Beyond the research indi- cating that providing surgical patients with relevant information is beneficial for patients, there haVe been few studies in this area that have provided unequivocal data about the effect of information on recovery. This researcher's purpose was to investigate the effect of personalized information on the recovery of surgical patients, an aspect of patient care that is widely accepted but not well under- stood. THEORY AND ASSUMPTIONS This study was based on four major assumptions, with general theoretical support for two of the assumptions and experimental support for a third. The final assumption is the primary contribution made by the present study to the general area of surgical patient care. The four assumptions are: 1. People need to know what is going to happen to them. 2. A patient experiences anxiety as part of the operative experience. 3. Information about the operation and related procedures is beneficial for both the medical personnel and the patient. 4. Information needs to be personalized to achieve maximum benefit for the patient. Need to Know The need of individuals to be informed about events that involve them has become widely accepted by theorists from various disciplines. Reynolds and Flagg (T977), in describing recent trends in cognitive psychology, stated that theorists in their field typically view man as an "active organism that searches, filters, selectively acts on, reorganizes, and creates information" (p. ll). No matter which parti- cular learning theory one subscribes to, information about one's environment is basic input to the learning process (Hill, l977). Decision-making theorists, while differing on many issues, view infor- mation processing as the basic function of an individual as he or she reaches a decision (Janis & Mann, l977). Kelly's (T955) theory of personality states that man is a psychological being who attempts to know and predict the environment, relying upon the availability of information to make predictions. The concept that an individual has a need to know about events involving him or her has come to be accepted as an implied "right" in many areas of our society. This is particularly true in the medi- cal field. while not a legal document, the American Hospital Asso- ciation's "Patient Bill of Rights" is very clear about the patient's right to information. It states: The patient has the right to obtain from his physician complete and current information concerning his diagnosis, treatment, and prognosis in terms the patient can reasonably be expected to understand (Riemensnider & Richards, T977, p. 03 . Anxiety It is reasonable to assume that most patients facing an operation experience some degree of uneasiness, worry, fear, or tension. These reactions, for the purpose of this study, can be broadly classified as anxiety. One surgeon (Kalouch, T968) relates his own observations of this state among patients: Surgeons, hospitals, surgical diagnosis, and treatment have developed to a high degree of perfection and effectiveness. Average surgical morbidity and mortality rates are reassur- ingly low. They are significantly improving, following complex and extensive surgery. In spite of these realities, surgical patients are generally frightened. The uncertainties attending a surgical procedure still create anxiety (p. 89). The theory concerning the presence of anxiety in surgical patients that is most commonly cited in research dealing with patient care is supplied by Janis (T958). He utilized the emotional drive theory of Miller and Dollard (T94T) in an investigation of a group of surgi- cal patients. The theory suggested that a moderate amount of pre- operative anxiety stimulates a patient's "work of worry," which con- tributes to an adjustment to the threatening stimuli. This adjustment, in turn, contributes to the patient's recovery process. High or low amounts of preoperative anxiety, on the other hand, are likely to adversely affect post-operative recovery. Low amounts of anxiety do not stimulate the work of worrying and high amounts interfere with the adjustment that facilitates recovery. Published research that took the theory of Janis into account has shown mixed results. Auerbach (T973) investigated the relation- ship between impending surgery and patients' anxiety and found that intermediate amounts of anxiety faciliated postoperative adjustment. Leeb, Bowers, and Lynch (T976) attempted to determine how well patients remembered information that they had received. The authors discovered that patients who admitted to being nervous before the operation remembered the information better than those who viewed themselves as calm. This study provided no means to equate the self-reports of anxiety among patients and it was difficult, therefore, to standard- 'ize the self-ratings they offered. In addition, the assumption that “remembering information is an important variable was not verified. On the other hand, there have been studies reported in the litera- ture that did not support Janis (T958). Cohen and Lazarus (T973) attempted to determine if the method of coping with preoperative fear affected the postoperative recovery of patients. They found that only those patients with self-rated high levels of anxiety scored significantly higher on postoperative measures. Nolfer and Davis (T970) discovered a weak but reliable linear relationship between preoperative fear and recovery measures. Sime's (T976) results indi- cate a similar linear relationship between preoperative fear and postoperative recovery. Vernon and Bigelow's (T974) data failed to support the central premise of the research by Janis (1958) that anticipatory worry is an essential aspect of the patient preparation process that helps reduce the impact of anxiety. The point of each of these studies that did not support the work of Janis (T958) is the suggestion that the relationship between preoperative fear and postoperative recovery may be linear rather than curvilinear. That is, it may be that patients with low levels of preoperative anxiety show better recovery than those with either moderate or high levels. It appears that the investigation by Janis (T958) cannot be consistently replicated. It remains for future studies to verify the findings of Janis (T958) or for a theory incorporating some type of linear relationship between preoperative anxiety and recovery to be developed. The significant point is that most patients facing an operation experience preoperative anxiety. This is the finding of all of the studies mentioned above, both those that supported Janis (T958) and those that did not. Beneficial Results of Information The assumption that both medical personnel and patients benefit if patients have been informed about what is involved in their treat- ment is similar to the previously mentioned assumption that states that people have the right/need to know what is going to happen to them. The assumption that information produces beneficial results is not based on theoretical support, however, but on practical appli- cation. There are three primary reasons why medical personnel believe that giving information is good medical practice. First, most doctors and nurses expect the patient to cooperate in his or her treatment. This expectation is so basic that it is not usually openly acknowledged by the medical personnel. Instructions, directions, and explanations ID are given to patients with the implicit understanding that the patient will'cooperate. This expectation that patients will cooperate is not unrealistic. Despite the occasional, well-publicized mishap involving a surgeon, a Gallup poll taken in T976 reported that physicians in the U.S. are held in high esteem and are, for the most part, trusted (Hardy, T976). In addition, Thrash and Adams (l974) conducted a field study examining the manner in which physicians communicate with their patients and they found that in general patients accept the surgeon's instructions and directions and attempt to comply with them. Secondly, there are sound legal precepts that support the practice of informing patients. Surgeons, in particular, are vulnerable to malpractice suits and one of the most important preventative measures is the informed consent principle. lIt is the responsibility of the surgeon to educate patients so that they can make the decision about the operation in a reasoned manner. Bovarsky (T976) states this imperative: ...the final choice of therapy belongs to the patient, not the doctor. The patient must know everything he wants to know and he must know everything he needs in order to decide for himself whether to have a procedure done (p. 226). This concern is echoed by a number of other surgeons writing in pro- fessional publiCations (cf. Delee, T976; Fisher, T975; Orwoll 8 Dillon, T974; Reich, T975; Youel, T974). Finally, giving information to patients apparently works. There have been several studies that demonstrate that an informed patient tends to experience a better recovery than one who is uninformed. These inves- tigations will be discussed in the literature review section of this study. it 4,, Vii“! 11 Personalized Information This investigator did not find any published research investi- gating the assumption that personalizing information has an effect upon patients' recovery from surgery. On the one hand it has been implied that patients need information for different reasons: 1) so that they can understand and remember what is involved in surgery (Blackwell, T973; Leeb, Bowers, & Lynch, l976; Robinson 8 Merav, l976; Schmitt & Nooldridge, T973); 2) so that they will know the details of their operations (DeLong, T970; Langer, Janis, & Nolfer, T975; Vernon & Bigelow, T974); and 3) so that they will experience the medical staff's concern for them as individuals (Auerbach et al., T976; Bodley, Jones, & Mather, T974: Florell, l97l; Miller & Shada, 1978). Investigation into specific procedures whereby infor- mation is personalized according to the definition mentioned earlier apparently has not yet attracted the interest of researchers. It is this assumption that is the primary focus of the present inves- tigation. Summary Unlike research that is grounded in sound theory, the present study relied on a combination of general theoretical principles and practical applications. The present writer realized that theories in the behavioral sciences tend to be extremely broad and difficult to operationalize (Patterson, T973). Research in patient care, the broad area of which the present study represents only one part, rests on unproven theoretical ground. Therefore, the present study is tot base zips t? oorfilfl E.'.."ul The e:.:ati< of reseg .‘or sun Tree a the eff 3'“?er giv‘ng exam: the lit 1‘9 Dre :‘eet u at k 12 not based on widely accepted and proven theory, but, rather, on assump- tions that appear to be accurate and reasonable. LITERATURE REVIEW There has been considerable research in the broad field of patient education during the past ten or twelve years. The specific area of research involving investigation into methods of preparing patients for surgery, however, has attracted less attention by researchers. There are relatively few published experimental studies in which the effect of information given to patients preoperatively is the primary topic of the research. Because this area of information- giving is not clearly understood and defined, it is necessary to examine certain related aspects of patient preparation. Therefore, the literature in this review will refer to four related areas in the preparation of patients facing an operation: 1) the role of information, 2) the presence of anxiety, 3) the interaction between information and anxiety, and 4) the effects of defensive style. This writer realized that the structure of the literature review forces the research into artificial categories. It is necessary to do so, however, because of the lack of clearly defined categories of investigation in this area. It may be that the variables involved will become clearer as researchers continue to investigate the role played by information in the preparation of surgical patients. All of the studies reviewed are experimental in nature. That is, they meet the minimum requirements of experimental research by including some kind of comparison among groups and statistical analysis of the data (Cox, T958). iersonn operati been or Ir: pm as we: was Tm researc while; 13 The Role of Information The studies in this section are those where the primary concern was to investigate the role information plays in the preparation of surgical patients. While it has been generally accepted by medical personnel that informing patients about the various aspects of the operative experience is a necessary part of patient care, there have been only a few studies attempting to clarify the issues involved. In two studies (Healy, T968; Lindeman & Van Aernam, T971), the research- ers were simply interested in showing that preoperative information was indeed beneficial to patients undergoing elective surgery. Both researchers provided additional information to one group of patients, while a control group received only the information available to all patients. The additional information included greater detail of hospital procedures and more structured explanations of postopera- tive exercises and physical sensations. The outcome measures in Lindeman and Van Aernam's study included physiological variables (length of hospitalization, pain medication, complications). Healy (T968) added a psychological measure. This was a report by the nursing staff of the apparent attitude and cooperation of the patients. Both studies reported that treatment group patients scored higher on the outcome measures. This indicated better recovery for patients receiv- ing the additional information. Investigators who accepted the premise that preoperative infor- mation is beneficial for patients have attempted to manipulate some of the variables involved. Leeb, Bowers, and Lynch (T975) investi- gated the ability of patients to remember the information they had received. They based their study on the assumption that if patients ted to ceerat‘ are if in‘cm' that t! ration scarin: in int. net n in rec iardiz ta kno- 14 are to make a reasoned decision about an operation they need to remember information. The researchers told patients that important information would be given to them and that they would be questioned later about what they had been told. The patients were also instruc- ted to describe the degree of anxiety they experienced before the operation. Within seven days following the operation the patients were interviewed and asked to relate what they remembered of the information given to them before surgery. The results indicated that this group of patients recalled an average of 35% of the infor- mation they received with the self-described "very nervous" patients scoring higher on recall. Two aspects of this study call for caution in interpreting the results. First, it was not completely understood what role recall played in determining the importance of information in recovery from surgery. Secondly, there was the problem of stan- dardizing the self-reports of patient anxiety. This made it difficult to know how to equate various responses. As information-giving became more of a part of patient care, investigators began to experiment with the manner in which the infor- mation was imparted. Working with patients undergoing elective ortho- pedic surgery, Field (l974) combined information with hypnotic sugges- tion to see if hypnosis improved the patients' degree of relaxation. When compared to a control group, the hypnotic group was not signifi- cantly more relaxed. Within the treatment group, however, a signifi- cant correlation was found between depth of relaxation and speed of recovery. The authors suggested that hypnosis may not be appro- priate for everyone and that personality variables not completely understood played an important role in recovery. Egbert et al. (T964), ’55 l1 WET; ”OI b; 15 while not employing hypnosis, had earlier combined muscle relaxation techniques with information. They found that the group receiving the relaxation training used fewer pain medications, had shorter hospitalization periods, and were rated higher on measures of physical and emotional condition. Unfortunately, no control group was used in this study. This makes it difficult to state with certainty that the treatment was responsible for the results. Wilson (T977) compared the recovery of a group of patients that received information about their postoperative physical sensations and the hospital procedures involved to that of a group that received training in muscle relaxation. Mixed results were obtained. Both treatment groups had significantly shorter stays in the hospital. The relaxation group received fewer pain medications and reported less distress over experienced pain. There were apparently no signi- ficant differences between groups on various other recovery measures. Most research in this area has involved personal contact between the individual(s) supplying the information and the patients. Soder- berg (T976), however, investigated the effectiveness of an information pamphlet. She gave one group of patients a pamphlet describing the procedures involved. To another group, she personally gave information about the operative experience. The results indicated that neither the pamphlet nor the personal contact produced significant differences for either treatment group when compared to a control group that received routine preoperative care. There was no indication of any attempt to evaluate the content of the pamphlet and its quality could not be determined from the report of the study. As a result, it was not possible to conclude that printed material is either more made I aria: if ONT in a 1 the pa the r1 ficia group 57One i{AVON (Me 1 16 or less effective than personal contact with patients as a means of providing information. While studies in this area have usually involved individual patients, Schmitt and Wooldridge (T973) conducted a preoperative group discussion, during which patients received information and discussed their experiences while awaiting surgery. The treatment group scored higher on recovery measures than did control group patients. It was not clear, however, whether it was the additional information or the group discussion that produced the differences. The authors made no attempt to unravel this interaction between the treatment variables and it was not determined if the results were the product of one of the variables or of some interaction between them. Another variation of treating the individual patient was reported in a study conducted by Dziurbejko and Larkin (1978). They included the patient's family in the preparation process. The study compared the recovery of those patients with that of patients who received information by themselves. Both treatment groups were also compared to a control group. The patients in both treatment groups showed significantly greater recovery than patients in the control group. However, as with the study by Schmitt and Wooldridge (T973), it was not clear that receiving information with one's family was more bene- ficial than receiving it by oneself. While the patient plus family group scored higher on the outcome measures than did the patient alone group, those differences were not significant and only slightly favored the former group. The implication of those studies that are concerned with the role that information plays in patient preparation is that information 1h re em (if a the case 17 does appear to aid recovery. However, it is not at all clear which of the variables is responsible. It is apparent that there is a need for further research in this area if the effect of information upon recovery is to be understood more completely. The Presence of Anxiety It has been well established experimentally that most patients experience anxiety when facing an operation. For the purpose of this research, the concept of anxiety was broadly defined as an affec- tive and cognitive state involving nervousness, fear, or worry. It appears that this state is common both before and after an operation. The three studies mentioned in this section all verify the presence of anxiety, although each one approaches the matter from different perspectives. Graham and Conley (1971) were interested in deter- mining if they could identify evidence of anxiety at three different times: 1) preoperatively, 2) postoperatively, and 3) at the time of discharge. Patients facing major surgery were compared at those three points in the operative process to determine if, and to what extent, there existed signs and behaviors that pointed to the presence of anxiety. They found such evidence at all three times. Perhaps the most interesting finding was that a self-report measure, in this case an interview between the patient and nurse, appeared to be the most significant indicator of anxiety. However, while the self- report measure yielded the greatest evidence of anxiety, it also provided to be the most difficult measure to quantify. Auerbach (T973) acknowledged that patients experience anxiety as part of the operative experience and attempted to determine more 18 exactly the nature of that condition. He was interested in whether it was a characteristic of an individual's personality (A-Trait anxi- ety) or a situational, transitory reaction to a threatening situation (A-State anxiety). He tested a group of male patients undergoing surgery in a Veteran's Administration hospital and used the State- Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970). The STAI has both trait- and state-anxiety scales and purports to measure each type of anxiety. Auerbach (1973) found that state anxiety reached its highest level about 24 hours before the operation, declined slightly within 24 hours after the operation, and declined even more to its lowest level within 48 hours following the surgery. The trait anxiety scores remained relatively unchanged at all times. Auerbach (1973) concluded that while state anxiety is subject to situational variables, trait anxiety is a stable personality variable that is affected relatively little by the situation. It was also found that patients who experienced anxiety expressed more positive feelings about the entire experience, causing Auerbach to conclude that moder- ate anxiety may be facilitative to the recovery process. This appeared to support the idea of Janis (1958) that moderate levels of anxiety help patients adjust to the threatening situation they face when awaiting surgery. Martinez-Urrutia (1975) conducted an investigation to determine if any relationship existed between anxiety and pain. Specifically, his study concerned the effects of surgery on pain and anxiety. Like Auerbach (1973), Martinez—Urrutia (1975) found that patients experienced high levels of state anxiety preoperatively that declined after the operation. Martinez-Urrutia (1975) concluded that state and trait nxiety ar me same P sMe unlqu easted ar ofthat re There venfiedt nfferent' Tthe aartitula he Inter Thos Hteratur hatinfc that anxi have 613: The stud' interact‘ In a after gu tion and tItatnlen OCCUT‘T‘in SWe d EXErm‘Se particjp 19 anxiety are not necessarily related, even though both exist within the same patient, and that the latter is probably a personality vari- able unique to each individual. He stated that while most people reacted anxiously to an-impending operation, the degree and nature of that reaction varied. There exists an important implication of these studies that verified the presence of anxiety. Because people appear to react differently to the threatening aspects of surgery, the information about the operation may be more effective if it is adapted to the particular needs of the individual patient. The Interaction Between Information and Anxiety Those studies discussed in the two previous sections of the literature review were primarily concerned with supporting the ideas that information is_an important element in patient preparation and that anxiety is experienced by most people facing surgery. Researchers have also been interested in the way information and anxiety interact. . The studies in this section are concerned with investigating this interaction. In an attempt to determine if anxiety experienced before and after surgery could be reduced, Finesilver (1978) combined informa- tion and emotional support in a treatment program. Patients in the treatment group were given basic information concerning the events occurring before and after cardiac catherization. This included simple descriptions of anatomy and physiology, as well as certain exercises and other activities in which they would be expected to participate during the recovery period. Emotional support and 23: if: vi 20 reassurance were offered to foster an atmosphere of concern and respect. The outcome measures were all psychological in nature and included two anxiety measures and a number of instruments measuring the be- havior and attitudes of patients. The results indicated no overall significant differences between the treatment group and a control group. There were, however, significant differences on two of the outcome variables. The treatment group reported lower scores on the scale that measured the amount of distress during the catheri- zation procedure. That group also reported greater satisfaction with the preoperative information. As with any self-report measure, the consistency of the self-disclosure of anxiety was a potential confounding variable. Finesilver (1978) also discovered that patients often had unasked questions concerning their treatment because they were reluctant to bring up issues they felt the surgeon might consider trivial. Florell (1971) was also interested in combining information with emotional support to see if these two variables had a greater effect upon recovery than did emotional support alone. He exposed one treatment group to basic procedural information about the opera- tive experience and to a pastoral counselor on whom they could call for support and reassurance. A second treatment group received only the support component. Both treatment groups had significantly better recovery than the control group. The state anxiety of the treatment groups was higher just before the operation than it was just after. Florell (1971) concluded that this was the result of giving information to patients and that because the information apparently raised the patients' anxiety to a moderate level the position of Janis (T958) ITS SUD;J rattler! 5130.6, 1 items adjusts. anti-tin and a c in spe experie .‘ne res Jatient 21 was supported. While the information plus support group's rate of recovery was better than that of the treatment group receiving support alone, it was not clear in what manner the two variables interacted to produce the improvement in recovery. Vernon and Bigelow (l974) attempted to determine what specific interaction occurs between information and anxiety to produce an adjustment to threatening stimuli associated with surgery. Patients awaiting elective hernia surgery were divided into a treatment group and a control group. The treatment group heard an audiotape contain- ing specific information about the procedures and events they would experience. The control group was not exposed to the audiotape. The results indicated that the preparatory information did affect patients' attitude and behavior. For example, the treatment group gave evidence of greater confidence in the surgeon, more awareness of potential difficulty, and less postoperative anger. The data indicated no difference between the groups in the amount of anxiety that was present before the operation. Thus, the authors concluded that the position of Janis (T958) about the facilitative nature of the preoperative anxiety was not supported by their data. As a pos- sible explanation, they suggested that hernia surgery may not be sufficiently threatening to raise the patient's anxiety to a level sufficient to produce the adjustment to the threatening aspects of the operation. This raised the interesting question of how severe the surgery must be to arouse anxiety to the point where it contri- butes to that adjustment. Two important implications resulted from the studies described in this section. First, patients may not feel free to ask questions 22 about matters that concern them. Information, therefore, may be incomplete for some patients and a method of identifying those areas of incompleteness would provide a means of optimizing the effect of information. Secondly, the level of severity of the surgery may need to be taken into account. If the operation is not sufficiently anxiety-arousing, there may not be a measurable interaction between anxiety and information. The Effects of Defensive Style Several investigators have become interested in the role played by personality variables within individual patients. One specific example of such a variable is the defensive style employed by patients facing a threatening situation such as an operation. Researchers in the area of patient preparation have looked at two aspects of defensive style: locus of control and method of coping. Those inves- tigations are discussed in this section. While most of the research has investigated coping methods, three studies examining locus of control were located. In an unusual study involving dental surgery patients, Auerbach et al. (1976) hypo- thesized that recovery from surgery for “internals" (individuals perceiving reinforcement as under their personal control) would be aided by receiving specific information. On the other hand, "externals" (those who believe that reinforcement is determined by factors outside their personal control) would recover better if they were exposed to information of a more general nature. Patients were exposed to either a videotape that gave specific information about tooth removal or to one giving general information about the clinic where they 23 were being treated. Each patient was then identified as either an internal or external, based on Rotter's (1966) Internal-External Locus of Control Scale. The results supported the hypothesis. Auer- bach et al. (1976) concluded that individuals supplying information to patients need to take this personality variable into consideration when preparing the information. It appears, however, that identifi- cation of this variable may prove difficult. The use of Rotter's (T966) instrument may not always be possible and further research needs to be conducted to determine an alternative method of classi- fying the locus of control variable. Lowery, Jacobsen, and Keane (1975) arrived at a conclusion similar to that of Auerbach et al. (1976). Their purpose was to determine if locus of control was associated with preoperative anxiety. In an experiment with female patients, the authors found that there were significant differences in self-reported levels of anxiety between internals and externals, with the latter reporting greater stress before the operation. The authors did not include information as a variable in their study. Patients, therefore, received information in the inconsistent manner typical of many surgical experiences. They suggested that the internals actively sought information and were, therefore, less anxious because they were able to impose some sort of order to their experiences. Externals, who did not exercise that type of control over their environment, did not receive the information that would have helped reduce their anxiety. The results of this study were almost identical to those of an earlier investi- gation by Johnson et a1. (l97l), whose work served as an impetus for Lowery, Jacobsen, and Keane (T975). 24 Coping method is an aspect of defensive personality style that has been studied more than locus of control. There have been a number of investigations that attempted to determine what relationship exists between an individual's method of coping and his or her recovery from surgery. Coping has been defined as the characteristic manner in which an individual deals with stress. Generally, in these studies, subjects have been classified as either sensitizers (those who desire and actively seek information), neutrals, or avoiders (those who avoid information). They have been identified, by use of various personality assessments, as typically reacting in one of these three coping styles. The investigation was then conducted with the issues selected by researchers examined. As reasonable as the assumption about the importance of coping style appeared to be, the results of several studies did not support this concept. The hypothesis of research that investigated coping style was that vigilent copers will show greater recovery if they are given specific information. It was assumed, however, that avoiders recovered better if they received little, or no, information. Of the published studies in this area, four indicated that coping style was not significantly related to the type of information received (Andrew, 1970; Sime, T976: DeMonbrun, 1974; Cohen & Lazarus, 1973). The only exception was the work of De Long (1970), who found that vigilent copers recovered better when they received specific infor- mation about the situation they were facing. Avoiders, however, recovered better when exposed to general information. The type of information had little effect upon neutrals who recovered well regard- less of what type of information they received. ”clip! the thrl 0f 1 Cole We: 25 The results of four other investigations indicated that coping style did not interact with information to produce significant differ- ences in recovery. Andrew (1970) found that neutrals showed the greatest recovery. She divided patients into two groups, one which received information and one that did not. Although the results did not indicate any difference due to coping style, the data indi- cated that informed patients had the best recovery rate of all three coping types. Investigations by both Sime (1976) and De Monbrun (1974) produced essentially the same results. Sime (1976) found indications that patients with high levels of preoperative anxiety needed to receive information about what was going to happen. If they did not, they experienced the poorest recovery of the three coping styles. While the other studies mentioned in this section measured the postoperative recovery process of patients, De Monbrun (1974) examined the level of preoperative anxiety. He hypothesized that preoperative informa- tion would affect patients differently. De Monbrun (l974) categorized patients according to their coping method and then measured their preoperative anxiety levels. He found no significant differences among the different groups. When Cohen and Lazarus (1973) compared coping styles, they found that vigilent copers actually showed the poorest recovery among the three groups. Both neutrals and avoiders showed better recovery. In this study, the general assumption about coping style and type of information was not only unsupported, it was directly contradicted. Cohen and Lazarus (T973) expanded the concept of coping style by suggesting that coping involves two things: 1) dispositional coping 26 tendencies (traits of the individual), and 2) active coping processes (specific coping behavior). Even when they considered both aspects (of coping, the authors still found the contradiction mentioned above. They suggested that active coping processes may have had some effect upon recovery but it was not clear how or why that effect occurred. The primary contribution of the work of Cohen and Lazarus (1973) was their concept of the two-fold nature of coping. Additional research, taking this expanded concept into account, may provide greater understanding into the importance of coping style as a variable to consider in patient preparation. One other study relating to defensive style is pertinent to this issue, although it does not fit exactly into the categories of the other studies discussed here. Langer, Janis, and Wolfer (1975) taught patients a specific coping technique and compared the recovery of those patients with that of patients receiving various other treat- ments. They predicted that patients who were taught the coping tech- nique, and used it, would show better recovery than patients who were not exposed to it. Their coping technique consisted of cognitive control through selective attention, calming self-talk, and reappraisal of anxiety-provoking events. They varied the coping technique and information and then compared four groups of patients: 1) a group . that was exposed to the coping technique plus information, 2) a group exposed to the coping technique alone, 3) a group exposed to informa- tion alone, and 4) a control group. The results indicated that the group exposed to the coping technique plus information showed signi- ficantly less anxiety both pre- and postoperatively. It was not clear, however, which aspect(s) of the coping technique was responsible 27 or if it was some combination of all three. Also, it was not deter- mined if information contributed to the results. This study indi- cated that even though the results of investigations involving coping style have been somewhat confusing there is justification for further work with this variable. Summary Research has been conducted in the area of preparing patients for surgery that has involved the role of information, the presence of anxiety, the interaction between information and anxiety, and the effects of defensive style. It appears evident that it is bene- ficial for patients to receive information about the events surrounding their surgery. At this time, however, it is not clear which of several variables involved in information-giving contributes most to patient recovery. Clearly, anxiety is experienced by most patients facing an operation. Because anxiety apparently affects individuals differ- ently, the presentation of information may need to be personalized for each patient. Such personalization may affect the adjustment of patients to anxiety, as well as influence other recovery variables. Some type of interaction occurs between information and anxiety, although that interaction is not well understood by researchers at the present time. One variable that may be important is the level of severity of the operation. If a more severe operation results in greater levels of patient anxiety, the information given for opera- tions 0f greater severity may need to take a different form than that which is given for less severe surgery. While consideration of patients' defensive style has been investigated by researchers, 28 the importance of this personality variable is not clear. So far, the research does not appear to support the assumption that defensive style should be considered. Chapter II EXPERIMENTAL DESIGN AND METHODOLOGY SUBJECTS Thirty volunteer patients were solicited for this investigation during the months of April through July, 1980. Patients were obtained through an agreement reached between the researcher and an orthopedic surgeon engaged in private practice in Lansing, Michigan. Patients of the participating surgeon who were scheduled for elective surgery were asked to participate in the study. There were five selection criteria: 1) the patient would be 18 to 65 years of age, 2) the patient would not have been hospitalized for surgery during the pre- vious 12 months, 3) the present operation would be elective surgery, 4) the present surgery would require hospitalization, and 5) the present surgery would not involve amputation. The hospitalization and operation took place at Ingham Medical Center, located in Lansing, Michigan. The researcher was notified by the surgeon's office staff when a patient who appeared to meet the selection criteria was scheduled to be admitted to the hospital. The researcher contacted each patient by telephone the day before he or she was admitted to inform the patient that a research project was being conducted. The patient was then contacted personally by the researcher after admission to the hospital the next day. At 29 30 that time, the purpose of the study was explained and the patient's consent to participate was secured. Since the subjects for this study were not randomly selected from a defined population, demographic data were collected. These data are included in Tables 2.1, 2.2, and 2.3. Because the data provide a sufficient description of this sample of 30 patients, they support the legitimate generalization to similar samples of patients (Cornfield & Tukey, 1956). Table 2.3, listing the operations experienced by patients parti- cipating in this study, includes the category "Level of Severity Rating". The operations included in this study ranged from moderate to severe. Patients became available for participation as they were scheduled for surgery. Because they were assigned to treatment groups as they became available, it was possible for one or more of the groups to include a disproportionate number of operations of either lesser or greater severity. To determine if this had occurred, a rating of severity for each operation was established and each group was analyzed to determine how the severity of operations had been distributed throughout the groups. The severity rating was determined by the participating surgeon. Following the data-gathering phase of the study, a list of every different operation was made. The surgeon then gave a value, from one to five, for each operation. A rating of one represented less severe operations and five denoted those of greater severity. The patients were not identified with the operations so that the surgeon had no way of knowing who was involved with each operation. The 3T on u z Aem.mvp Rem.mv_ Aam.mv_ Aao.evu Axo.mvm Aum.mmvo_ Axm.mmvo_ Aaopvm m=o_uaaaao m=o_>aca a o m e m N _ o ea amass: . . . m m quu case wwwmww ARM ”Nye Aam mwvm_ Aeo_vm Ann mvp anew“ wmwgawzv up 3 ep ; NP :uop sum pm>m4 Pacowuauzum Aam.mv_ Aum.mwva “Rm.mmvo_ Axm.mmv~ Aao.c_vm ao< oo-_m om-Pe oe-Fm om-F~ o~-o_ Amwmwmm “mmWWWfi asaaam _ap_aaz Ram.mvp Axe.emvam xuapm mate: mama Aem.m¢vm_ Axe.emve_ xam a_asaa ape: Ammmaucwugma new aucmsamsmv czovxamem «caconEoo UPumFgmuumcmgu mpasmm pcmwuaa eo muwumpempuagmsu upsamcmosmo new Fecomcma —.N mpamh 32 Table 2.2 Occupations of Patient Sample by Type and Frequency Occupation Frequency Percentages Automotive Parts Zone Manager 1 3.3% Automotive Production 6 20.0 Court Reporter 1 3.3 Laundry Worker 1 3.3 Legislative Aide l 3.3 Mailroom Supervisor 1 3.3 Maintenance 1 3.3 Mechanic 1 3.3 Minister 1 3.3 Railroad Yard Manager 1 3.3 Realtor l 3.3 Retail Store Clerk 1 3.3 Retail Store Owner 1 3.3 Secretary 1 3.3 Student (College CH‘High School) 5 16.6 Teacher 2 6.6 Tool Shop Foreman l 3.3 Truck Driver 1 3.3 Unemployed 2 6.6 N = 30 33 Anhv m asogw ucwsummshtaxe Awhv N macaw ucmsummehaee aphv p naocw peasaawe~ae .Om mama :o wau 9: E. umnwsummu mp hpwgm>mm ..vo _.w>mp mzu mavCPELmHmU mo U239: 93% o.m N.m F.m F p F LDNMNLONMNNQ’Q'Q'NFNNMVMV aaocm some see mcwuac zuwem>mm cam: Ammcxv zsouomum_cms Pecmump tea acmEmmw_ gopemuca yo e_eamm Aum_v mzmeum ace «papa Pym: eo pm>oEmm Anwgv awecm econ ace muapa F_a: yo Fa>o5mm Ammcxv Avon wmoop mo pm>oemm Aopxcmv xuoa mmoop mo Fa>o2mm Azonpmv coucm» eo mmampmm Auoomv «Puma» capcmpa mo mmmewm Aumpszv Feces» panama we mmampmm cwupsogm coruuzcumcoumm Ame—v a_nwp mo cowumxwe ancmucw vcw :o_po=cmg :mgo Ampxcav mwpmczcuopau ea :o_gmxwm _a>emacp use cowuuauoc cmao Acumepmv xcmpagn mo cowuexww pm>gmu=w new cowuuzvme :mao Aucmgv Fancmoaums mo eowumxpe Fm>gmuew wee copuuaumc emao Ammcxv xsouumum_=mz poo» muamg pamgmuaams eo :owm_uxm Axumnv maqupznvmzo—uac umuamcemg eo cowmpuxm Aumpczv cop—memo mo cowmpuxm Aucazv ea_:uw>e: ~oacmu we cowcaco: Low memocgpcaouamma mo cowummcu Auoomv zsouumeowczm Axuaaxxumcv covmzw —mup>cmo copcmuc< easxm «saw «tp azocw quota azoew mueoegauoo we zuemamweu «mcwuom agpem>om mo Fm>w4 copuaooa apwuom wee copumcmac ea msmz mpqsam Humvee; an umucmvgmnxm meoPHacmao mzop>mea m.~ apes» 34 time lag between the last operation performed for this study and the establishment of the severity ratings was about four weeks. During that month or so, the surgeon performed several more operations, making it unlikely that he was able to connect a patient to his or her opera- tion. This "blind rating" was employed to guard against the possi- bility of the surgeon's recollection of specific patients. It was felt that if the surgeon was reminded of specific patients, parti- cularly those who had experienced greater difficulty with an operation than was normal, the operation might be rated as more severe because of that patient's problems. The surgeon reported that he did not remember which patients had which operations. The criteria used to construct the severity rating included the following elements: 1) expected degree and intensity of pain, 2) threat to patients' ambulation, 3) convalescence and rehabilita- tion time, and 4) potential for serious complications (e.g., infec- tion, pneumonia, phlebitis, pulmonary thrombosis or embolus). As noted in Table 2.3, the means of the severity ratings for each group are almost identical, indicating that none of the groups was dispro- portionately populated by patients who had experienced previous opera- tions of greater or lesser severity. MEASURES This study involved five recovery measures (dependent variables). The concept of patients' recovery from surgery employed in this study included the elements of both “recovery" and "welfare,“ as described by Wolfer (1973). He conceived of patients' welfare as the "complex, multidimensional, and changing affective and cognitive state of an 35 individual as he undergoes hospitalization" (Wolfer, 1973, p. 396). Recovery, on the other hand, "can be viewed as the process of restora- tion and/or attainment of normal physiological and anatomical func- tioning" (Wolfer, 1973, p. 396). Each of the dependent variables in this study was designed to measure either welfare (psychological outcome) or recovery (physiological outcome). For the sake of con- sistency, all dependent variables were referred to as measures of recovery, for that is the term most often used in published research in this area. There were two psychological recovery measures utilized in this study: 1) the State-Trait Anxiety Inventory (STAI) and 2) the Post- Operative Questionnaire (POQ). Three physiological recovery measures were included: 1) length of hospitalization, 2) injected pain medi- cations, and 3) oral pain medications. Psychological Measures The State-Trait Anxiety Inventory was developed by Spielberger, Gorsuch, and Lushene (1970) to measure both trait and state anxiety, with a subscale for each. The trait anxiety subscale measures rela- tively stable individual differences between persons in their ten- dency to respond to stress in a particular manner. The state anxiety subscale (Appendix E) identifies the transient emotional condition experienced by an individual that is characterized by tension, appre- hension, and heightened autonomic nervous system activity. Having an operation is often represented as a type of crisis experience that produces situational, or transitory, anxiety (Auerbach & Killman, 1977). Therefore, to measure the degree to which the patient 36 experienced situational anxiety during the postoperative period, the state anxiety subscale of the STAI was used in this study. .The test-retest reliability of the state anxiety subscale was reported as ranging from .16 to .27 for females and from .25 to .54 for males (Spielberger, Gorsuch, & Lushene, 1970). These low ranges of reliability were not unexpected, the authors explain, as state anxiety is by nature sensitive to situational variabilities existing at the time of testing. Internal consistency was determined to be a more meaningful index of reliability for this subscale. Cronbach's (T951) alpha computation produced reliability coefficients ranging from .83 to .92. Since the present study used the state anxiety subscale as a recovery outcome measure, this range was determined to be acceptable. . Spielberger, Gorsuch, and Lushene (1970) reported that the state anxiety subscale of the STAI was validated by creating both normal and stressful situations and then having subjects experience each situation. Subsequent changes were measured, resulting in coefficients ranging over the various conditions from .83 to .93 for females and from .89 to .94 for males. The state anxiety subscale includes items measuring various levels of intensity so that the instrument is useful over a wide range of situations evoking state anxiety. The state anxiety subscale was normed on various populations, including college students, high school students, psychiatric patients, and prisoners. The most significant normative data for this study were those for medical and surgical patients. The subscale provided an appropriate measure of the situational anxiety experienced by the sample of surgical patients participating in the present study. 37 In addition, it provided a means of comparing that sample with the larger population of surgical patients from which the sample was drawn. The second psychological outcome measure was the Post-Operative Questionnaire (Appendix F), which was developed by the researcher for this study. The purpose of the Post-Operative Questionnaire was to measure patients' sense of well-being as they prepared to leave the hospital. It was designed to indicate how the patients felt in relation to three aspects of his or her experience: T) their general attitude and mood during hospitalization, 2) how they felt phsyically during this time, and 3) an overall perception of the treatment received from the individuals caring for them. I It appears that a patient's mood varies during the period of hospitalization. It is usually assumed that patients are anxious to go home and that their sense of well-being is greatest at the time of discharge. That assumption may not be accurate and it would . be informative to have some indication of how the patient feels at that time (Wolfer & Davis, 1970). The POQ was developed to measure the patients' sense of well-being at the time of discharge. It also attempted to indicate which elements of the surgical experience affected that sense of well-being. Since the POQ had been developed for this study, there were no existing validity data available. During the pilot study of this investigation, patients were asked if there were items on the POQ that should be deleted, added, or changed. Minor revisions in the wording of two of the items were the only changes recommended and incorporated. Because there were no reliability data available, an 38 internal consistency estimate was obtained that yielded a Cronbach alpha reliability coefficient of .85 (Cronbach, 1951). Physiological Measures In addition to the two psychological outcome measures mentioned above, three physiological variables were used in this study. The first was the length of time each patient spent in the hospital. In each case, the patient was admitted to the hospital during the afternoon preceding the day of the operation. The day of admission was not counted but the day-of discharge was. Therefore, the length of hospitalization began with the day of the operation and included each day through the day the patient left the hospital. The length of hospitalization was included as an outcome measure because it is the mostdirect indication of the recovery process. Patients were not discharged from the hospital until they met certain criteria established by the surgeon (e.g., able to be up on one's feet for extended periods of time, able to care for one's bodily needs, able to manage pain with oral medications). The length of hospitalization varied with the type of operation and each patient was individually judged able to leave based on the recovery criteria. The number of pain medications taken by injection was the second physiological measure. Pain is an almost universal experience for patients recovering from an operation and the measures taken to relieve pain are among the most important aspects of postoperative care. The patient's recovery process is significantly affected by the degree to which pain is present. The more severe pain experienced by patients in this study was controlled by intramuscular injections. Therefore, 39 this variable was determined to be an important measure of the degree of recovery. The type of medication, the dosage, and the frequency of adminis- tration were established by the surgeon as part of the "orders" for each patient. The pain medications were not administered automati- cally but had to be requested by the patient at the established inter- vals. Those administered by injection included a morphine compound and/or Demerol, a synthetic narcotic. The number of injections was determined by referring to the patient's chart. The final physiological outcome measure was the number of pain medications administered orally. This variable was included because one criterion for discharge from the hospital was the ability of the patient to control pain with oral medications.) The transition from injections to medications taken orally was a significant measure of the degree to which the patient had progressed in the recovery process. The type of medication, along with the dosage and frequency of administration, were established by the surgeon. The oral pain medications were administered only at the request of the patient. The type of medications taken orally included Tylenol #3, Empirin #3, Talwin, and Percodan. The number of medications was determined by counting how many were recorded on the patients' charts. INSTRUMENTS The purpose of this study was to investigate the effect(s) of personalized information on the recovery of surgical patients. The 40 two instruments used to give information to patients are described below. Each of them was developed by the researcher for this study. Information Audiotape An audiotape (Appendix C) of approximately five minutes in length was prepared by the researcher and the participating surgeon. It was then recorded by the surgeon. The purpose of this audiotape was to provide the patients with highlights of what they would exper- ience during their time in the hospital. It included a brief descrip- tion of the procedures, events, and physical sensations that would occur. It did not include any details about the specific operation each patient faced. That information had been provided by the surgeon during an office visit when the diagnosis of the patient's condition had been made and the operation recommended. Audiotapes had been used by a number of researchers to give information to patients facing surgery (cf. Vernon & Bigelow, 1974; Andrew, 1970; De Long, 1970; Field, 1974). It appeared that this technique provided an inexpensive and efficient method of reviewing the highlights of the experience the patients were going to face during their hospitalization. It was decided that the voice on the tape should be that of the surgeon to lend authority and credibility to the information given. Patients in treatment groups 1 and 2 were exposed to this audiotape. Patient Response Form The Patient Response Form (Appendix D) was a questionnaire de- signed to assist patients in asking questions and expressing concerns. patiei of in: T) enc 2) unc tion, 4) ade respcn tainty fore, surges expose. TnCTUdT 41 Even though they had received information about the operation pre- viously, it is not uncommon for patients to forget or become confused about what they had been told (Leeb, Bowers, & Lynch, l976; Schmitt 8 Wooldridge, 1973). As a result, patients may have questions they would like to ask or fears and uncertainties they would like to express (Finesilver, 1978; Bodley, Jones, & Mather, 1974). The PRF was developed to provide a structure that would encourage patients to review what they knew about their operations. The areas of interest and concern that were addressed by the PRF include: 1) emotional and cognitive reactions to the proposed operation, 2) understanding of the purpose and procedures involved in the opera- tion, 3) upsetting life situations that might affect recovery, and 4) adequacy of the content of information provided. The patients' responses on the PRF directed the surgeon to those areas of uncer- tainty and concern confronting the patient. The questionnaire, there- fore, provided the basis for the preoperative discussion between surgeon and patient. Only patients in treatment group 1 (T1) were exposed to the PRF. The responses by the ten patients in T1 are included in Appendix G. EXPERIMENTAL MANIPULATION Each prospective patient was identified by the participating surgeon's office staff. The day before the patient was scheduled to be admitted to the hospital, the researcher contacted the patient by telephone. A brief explanation was given to the patient stating that the surgeon and the researcher were cooperating in a research 42 study and that the researcher would contact the patient the next day following admission to the hospital. The patients were told that at that time a more detailed explanation of the study would be given. Before the initial meeting with each patient, the researcher had systematically performed a random assignment of the patient to one of the three experimental groups. The researcher had taken 30 slips of paper and written group 1, group 2, or group 3, followed by a number from one to ten, on each piece of paper. One slip was drawn for each prospective patient and assignment was made to one of the three treatment groups. This resulted in ten patients being assigned to each group. Although each patient was given an oppor- tunity to decline to participate in the study, none did. Therefore, each patient who was approached was assigned to the group that had been previously determined for that patient. I The researcher met the patient in his or her hospital room with- in an hour or two following admission. The study was described as an attempt to determine some of the aspects of the surgical experience that affected patients' recovery. The patient was asked if he or she was willing to participate and if so, a consent form (Appendix A) was signed. The demographic information was then recorded on the Patient Information Record (Appendix B). The outcome measures, which were identical for all patients, were described and the method by which they would be collected was explained. Two treatment groups and one no treatment (control) group were utilized in this study. Patients in treatment group 1 (T1) were given the audiotape containing the information about the events involved 43 in the surgical experience. They were instructed in the use of the recorder/playback machine and shown how to use the earplug if they wished privacy when listening to the tape. They were instructed to listen to the tape as often as they wished so long as they heard it at least once before the surgeon's preoperative visit the next day. They were also given a copy of the PRF and instructed to com- plete it after listening to the information tape. They were told that when the surgeon visited them prior to the operation he would read the PRF and use their responses as the basis for his discussion with them. In addition, they were given the STAI and POQ and instructed when and how to complete them. The STAI was to be completed within the first 48 postoperative hours and the P00 on the morning of the day they were discharged from the hospital. After telling the patients he would visit them again before they went home, the researcher an- swered any questions patients had about the study and then left. Those patients assigned to treatment group 2 (T2) were given . only the information tape. Their instructions were identical to those given to patients in T], except they were not given the PRF and no mention of it was made. They were merely told that the surgeon would visit them before the operation the next day. The researcher gave instruction on how to complete the STAI and P00 and, after asking if there were any questions, told the patients he would visit them again. Those patients assigned to the no treatment (control) group were instructed concerning the STAI and POQ. No mention of either the audiotape or the PRF was made. They were then told that the researcher would visit them again before they wre discharged. Before 44 leaving, the researcher answered any questions they had. The control group experienced all things in common with the treatment groups - except the information tape and the PRF. Therefore, the assumption was made that there were no differences between the control group and the treatment groups except the treatment (Isaac & Michael, 1971). Following the operation, the researcher visited each patient to remind him or her about the STAI and POQ and to answer questions about either form. The questionnaires were kept by the patients until they were discharged, after which they were returned to the researcher by the nursing staff. The nursing staff was told that a research study was being con- ducted but received no details about the nature of the study. The cooperation of the head nurse on the orthopedic ward was secured and it was requested that no information about the study be given to any of the nurses. It appeared, from reports by the patients, that the nursing personnel were generally oblivious to the study. It was assumed that they had no measurable effect upon the study. PILOT STUDY A pilot study was conducted before the study itself began. Six patients, two assigned to each group, were contacted. The purposes of the pilot investigation was to test both the instruments and the overall procedure. No substantive changes in the instruments resulted from the pilot study, though two procedural changes were incorporated into the official study. It was decided to contact prospective patients by telephone before admission to the hospital. This contact would 45 acquaint them with the researcher and the fact that the study was being conducted. Also, it was decided to collect the physiological data from the patients' charts after the data-gathering phase for all patients had been completed. It was determined that it would be easier to locate the patients' charts once they had been sent to the central medical records department. HYPOTHESES This study was concerned with the overall question of whether ,or not information about the operative experience contributed to the recovery of surgical patients. Two elements of the information- giving process were examined to determine if either contributed to recovery. Those two elements were the information audiotape and the Patient Response Form described above. Hypothesis One The first hypothesis addresses the issue of whether or not there is any difference between T3, the no treatment (control) group, and T2, the group receiving the least treatment. The first hypothesis, therefore, deals with the question, "Does treatment make a difference?" Ho: There is no difference on the outcome measures between the means of the group receiving no treatment (control) and the means of the group receiving the least treatment. H]: There is a difference on the outcome measures between the means of the no treatment (control) group and the means of the group receiving the least treatment. 46 Hypothesis TWo . The second hypothesis addresses the issue of whether or not there is a difference between T3, the no treatment (control) group, and T], the group receiving the most treatment. The second hypothesis, therefore, deals with the question, "Does adding treatment make a difference?" Ho: There is no difference on the outcome measures between the means of the group receiving no treatment (control) and the means of the group receiving the most treatment. H1: There is a difference on the outcome measures between the means of the group receiving no treatment (control) and the means of the group receiving the most treatment. EXPERIMENTAL DESIGN Consistent with the hypotheses given above, an experimental design was employed for this study. The l x 3 factorial design with multiple dependent variables is shown in Table 2.4. ANALYSIS The data were analyzed by performing a multivariate analysis of variance to test for differences among the three treatment groups. Planned comparisons were made, utilizing the Finn Multivariate Analysis of Variance’(Finn, 1977). Simple comparisons were established to test for differences between each treatment group and the no treatment (control) group. Since the degrees of freedom for the mean squares between were two, two comparisons were employed that corresponded to the two hypotheses stated above. One degree of freedom was used for each comparison.v 47 Table 2.4 Experimental Design, N = 30 Information Tape and PRF . Information Tape Control (Treatment Group 1) (Treatment Group 2) (Treatment Group 3) N = 10 N = 10 N = 10 STAI 5T1 .. ~ .. POQ x2 n u Length of X .. " Hospitalization 3 Injected Pain X ,, " Medications 4 Oral Pain X ,, " Medications 5 In addition to having been analyzed as part of the multivariate analysis, the patients' responses on the STAI and the POQ were reported in a descriptive fashion. The data for the other three dependent variables (injected pain medications, oral pain medications, and length of hospitalization) were also reported in a descriptive manner. Chapter III ANALYSIS OF RESULTS The Control Data Corporation Cyber 7500 computer system in the Computer Center at Michigan State University was used in calculating the statistical analysis for this study. The level of significance for all tests was .05. Chapter III includes the reporting of the statistical analysis of the results of this study. The primary analysis of the tests of the hypotheses is reported first. Descriptive analyses of the various aspects of the data are also reported. THE PRIMARY ANALYSIS There were two planned comparisons established to analyze the data. The first comparison was between T2, the group receiving mini- mum treatment, and T3, the control group. The purpose of this com- parison was to determine if the information audiotape alone made any difference in the recovery of surgical patients. The second comparison was between T], the group receiving maximum treatment, and the control group. The purpose of this comparison was to determine if, and to what degree, the addition of the Patient Response Form (PRF) to the information auditape produced any differ- ence in patient recovery. 49 The analysis strategy using planned comparisons was chosen for two reasons. First, planned comparisons provided a means of testing specific hypotheses. For this study, it was hypothesized that there were differences between each of the two treatment groups and the control group. Two comparisons were established to determine if any differences actually existed. Secondly, planned comparisons provided the most powerful test of the hypotheses. This was particularly important for this study where a relatively small sample size was employed. The greater power of planned comparisons was more likely, than other tests that might have been used, to indicate if significant differences existed in the relevant population. The procedure used to describe the results of the analysis of the data was as follows. First, the results of the multivariate test of each hypothesis were examined to determine if significant differences existed. Second, if significant differences were dis- covered on the multivariate tests, the univariate F-tests of the dependent variables were examined to help determine which variables contributed to the results. Third, if the univariate F-tests did not indicate which variables were responsible for the significant results of the multivariate test, the step down F-tests were examined. The step down F-tests indicated which of the variables, when adjusted for the other variables, contributed to the significant results of the multivariate tests. The adjustment of variables by the step down F-tests was a procedure by which each dependent variable was considered as independent of the other variables. This independent consideration determined whether or not any of the variables contributed 50 to the significance indicated by the multivariate tests. Fourth, a correlation matrix was examined to help determine any causal rela— tionships among the variables that accounted for significant differ- ences indicated by the step down F-tests and the multivariate tests. Fifth, the observed cell means were examined to help determine the size and direction of differences among the treatment groups. Multivariate Test A multivariate test was conducted for each of the two hypotheses. The first hypothesis stated that there was a difference on the outcome measures between the means of the group receiving minimum treatment (T2) and the means of the control group (T3). The second hypothesis stated that there was a difference on the outcome measures between the means of the group receiving maximum treatment (T1) and the means of the control group. _ An examination of the multivariate test (Table 3.1) for hypothesis one, which is referred to in the table as "Comparison 1," revealed that there was a significant difference when the minimum treatment group (T2) was compared to the control group (T3): F = 3.1257 with 5.23 degrees of freedom and p < .0269. Thus, the null hypothesis that there were no differences between T2 and T3 was rejected. There was no significant difference for comparison 2: F = 2.2637 with 5.23 degrees of freedom and p < .0821. Therefore, the null hypothesis stating that there were no differences between the maximum treatment group (T1) and the control group (T3) was not rejected. 51 me. ea eeaewee=e_me m» geese peeueeu .m> F» ezeco “casueech A v Fume. ume~.~ m~.m weesueec» saewxez ”N eem_eeeseu m . N . . . A by eeecu Feceeeu m> A by eeeco aceEHeech «memo “mug m mm m pewsaeec» answer: up :em_ceeEeu :egu mmep e e .u.e eeeeem eeevee>pu~=z mpewce>_upez meem_eeeeeo emceepe exp we memapee< eue_ce>_upez we» we xgeesem F.m epeeh 52 Univariate F-tests Since no significant difference for comparison 2 was discovered, no further consideration of this comparison was reported. However, the results of the univariate and step down F-tests for comparison 2 are included in Table 3.2. To determine which variable(s) contributed to the significant difference for comparison 1, the F-tests for each variable were examined (Table 3.3). It was discovered that none of the univariate tests produced significant results. Therefore, to account for the significance found by the multivariate test for comparison one, the step down F-tests were examined. Step Down F-tests . The step down F-test indicates whether or not a particular variable has contributed to significant results on the multivariate test after its mean has been adjusted to account for the linear relationship between that variable and the other variables. The step down F- test section of Table 3.3 is arranged to indicate if a variable has contributed to significant findings when it has been adjusted for each variable located above it on the table. An examination of the step down F-tests for comparison 1 indicated that when oral pain medications was adjusted for length of hospitalization, a significant difference occurred (p < .0014). It appears, therefore, that the significant results of the multivariate test are not attributable to a single variable in isolation but rather to oral pain medications when adjusted for its relationship with length of hospitalization. Oral pain medications, when adjusted for length of hospitalization, was significantly different between T2 and T3. Conversely, length 53 upmo. wepm.¢ «sup. comm.p smoo.~__ ace mmmm. omem._ omen. ummm. Nepo.~e ~ umeuie exec euem “we“-m eue_ee>ee= Ampv eeeso pegeeeo .m> APFV eeecw acesueec» Eesvxez "m :emwceeseo gem mumeeue exec eeum eee mummu-u eue_ee>we: ~.m e—eeh 54 me. ea eeaeee_=eemt mumm. comm. “mam. opus. oooo.me com mmoe. «emu. emmu. mmP—. come.m H umeuim czeo eeum umeuie eaewee>Pea Amhv eeeew peeeeeu .m> ANHV eeegw peeEuemc» sneeze: up eem_geeseu so» mummpue ezeo emem eee mumeuue euevce>we= m.m m—ee» 55 of hospitalization, when adjusted for the number of oral pain medi- cations, was significantly different between the groups. The impli- cation is that if groups experienced the same length of hospitalization the oral pain medications administered to each group would be signi- ficantly different. On the other hand, if groups were administered the same number of oral pain medications their length of hospitali- zation would be significantly different. Correlation Matrix An examination of the correlation matrix (Table 3.4) indicated whether any contribution was made by relationships among the dependent variables to the significant results of the step down F-tests for comparison 1. The correlation between oral pain medications and length of hsopitalization was .861, the highest correlation among any of the variables. The next highest correlation was between the P00 and the STAI (.688). Only one other correlation exceeded .50, injected pain medications and the POQ at .544. Most of the correla- tions were in the .20 to .40 range. Observed Cell Means An examination of the observed cell means (Table 3.5) indicated the size and direction of the differences between T2 and T3 for the various dependent variables. Of particular interest were the differ- ences for length of hospitalization and number of pain medications. The step down F-test for comparison 1 indicated that the significant differences between T2 and T3 were attributable to these two variables when each was adjusted for the other. When length of hospitalization was adjusted so that both groups showed the same number of days in 56 eeeeee. eeemee. Nemeem. ..meee. mpeemm. eea eeeeme. eeeeee._ mummmm. eeeemw. Nemee_. e AeEeeueov acmeemeeo e>ww we» we xweuez eewuepeeceo ¢.m mpeew 57 _.NN m.ee F.e m.e P.N Apocecoee me ..em ~.em P.e e.a ¢.m Aecaeemacw asseeeze Ne a.e~ e.em e.m e.m _.m Aeeaseaaaw saswxmzv .w eea H peeeeeeeo me_eewce> Aeseeazov peeeemeeo e>wm we» cow eeeew seem he meme: ~peu ee>emmeo m.m epeew 58 the hospital, the difference between the number of oral pain medi- cations for the two groups was even greater than reported in Table 3.4 (9.4 for T2 and 6.5 for T3). Apparently it was this difference that accounted for the significant results on the multivariate test. DESCRIPTIVE ANALYSES In addition to the formal description of the analysis of the results in the preceding section, certain other aspects of the data are important. In this section, those additional aspects are des- cribed. The relationships among the means for each group are discussed for each outcome measure. THe correlations of each outcome measure with all the others are presented. Finally, the information-related items on the POQ are discussed. An examination of the observed cell means (Table 3.5) resulted in the emergence of a confused picture of the data. As stated in the hypotheses, it was expected that the two treatment groups, T1 and T2, would produce results on the outcome measures that indicated that patients in those two groups experienced better recovery than did patients in the control group, T3. That trend would be noted by lower values for groups 1 and 2 on the outcome measures. The means for the five measures suggested that this was not always the case. For length of hospitalization, the trend was exactly as expected. Patients in T1 were hospitaTized for the fewest number of days (5.1), patients in T2 slightly longer (5.4), and patients in T3 the longest (7.1). A similar trend occurred with the STAI scores. The STAI 59 measured the state anxiety that patients experienced during the first 48 hours after surgery. Lower scores are associated with less reported anxiety. T] had the lowest score (36.8), T2 the next lowest (39.2), and T3 the highest (40.5). Even though these results occurred in the expected direction, neither produced significant differences on the multivariate test. For the other three variables, the results did not follow the expected trend. That is, on none of the remaining three outcome measures were the means for both T1 and T2 lower than those for T3. The implication is that patients in T1 and T2 did not show consistently greater recovery as measured by these three outcome variables. The means for oral pain medications showed that T1 used the fewest number (5.4), as expected. However, T3 used fewer (6.5) than did T2 (9.4). This indicated that while T1 used slightly fewer oral medications than T3, T2 used significantly more (45%) than T3 and 74% more than T]. Injected pain medications also indicated a trend other than that which was expected. T], which was expected to use fewer injec- tions than T3, actually used more than either of the other two groups. The means for T.I (9.4) show a usage rate more than twice that of T2 (4.1) and 55% more than T3 (6.1). The only expected trend for this variable was the usage for T2, which was 33% less than that of T3. The trend for the POQ scores was similar to that which occurred for injected pain medications. The POQ measured the patients' sense of well-being at the time of discharge from the hospital, and the lower the score the greater that feeling. T1 had the highest score 60 (29.7), with T3 the next highest (27.1), and T2 the lowest (24.1). Instead of reporting a greater sense of well-being than T3, as was expected, patients in T1 apparently had the least sense of well- being of the three groups. The means of the three groups for each outcome measure are graphi- cally presented in Figure 3.1. The magnitude of similarities and differences among the means is indicated by these graphs. The expected trend was for both T1 and T2 to indicate greater recovery than T3 by reporting lower scores on each variable. If this trend had occurred, the line on each graph would move generally upward from left to right. As indicated in the discussion above, that result occurred on only two of the outcome measures, length of hospitalization and scores on the STAI. The remaining three measures produced mixed results. For injected pain medications and the P00, T2 had better results than T3, with T1 experiencing the worst outcome for all three groups. For oral pain medications, T1 showed better recovery than T3, but T2 reported the poorest recovery of the three groups. It is important to note, however, that when consideration is restricted to comparisons between T2 and T3, which represent the comparison that produced signi- ficant results, T2 showed better outcome than T3 on all variables except oral pain medications. Table 3.6 presents the ranges, means, and standard deviations for each of the five outcome measures. This data is not broken down by group but is computed across the three groups. It is possible, therefore, to determine how a particular group's performance fits into the overall performance of all the groups by consulting Table 3.6. 10 8 4n >5 0‘6 ‘3 6 q. 0 t 4 .0 '5: z 2 10 m 8 IS 8 f6 .2 'c 6 Q) 2 ‘8 4 S. Q) 13 2 3 Z 40 35 d) 5.. ‘§ 30 25 20 Figure 3.1 61 ,I' Length of Hospitalization d 1 1 Treatment Group >/\/ Oral Pain Medications 4/ \ ’ Kr“ Injected Pain Medications \\ .0’ T1 T2 T3 Treatment Group Graphical Presentation of the Means for Each Treatment Group on the Five Dependent (Outcome) Variables 62 Table 3.6 Ranges, Means, and Standard Deviations for Each Dependent (Outcome) Variable Across All Groups Variable Range Mean 3.0. Length of Hospitalization 3-17 days 5.86 3.45 Oral Pain Medications 0-27 7.10 6.80 Injected Pain Medications 0-40 6.53 7.24 STAI 24-61 38.83 8.61 POQ 17-46 28.96 7.63 There were ten correlations among the outcome variables in this study (Table 3.4). The correlation between length of hospitalization and oral pain medications (.861) was discussed earlier. It appeared that it was this relatively high degree of relationship between these two variables that accounted for the significant results found for comparison 1. One other correlation fell within the high range. That was the correlation between the two self-report outcome measures, the STAI and the POQ (.688). Of the remaining eight correlations, six were considered to be moderate and two fell into the low range. The six moderate corre- lations were: 1) length of hospitalization and injected pain medi- cations (.389), 2) length of hospitalization and the POQ (.330), 3) oral pain medications and injected pain medications (.310), 4) oral pain medications and the POQ (.404), 5) injected pain medications and the POQ (.544), and 6) injected pain medications and the STAI (.329). The two correlations that were considered to be low were 63 those between the STAI and length of hospitalization (.140) and between the STAI and oral pain medications (.236). The two self-report questionnaires, the STAI and the POQ, measured certain psychological aspects involved in being hospitalized for surgery. The purpose of each item on the STAI was to contribute to an overall indication of the degree to which patients experienced temporary anxiety during the first 48 hours following an operation. Each of the STAI items was examined to determine if any clarified or amplified the process by which giving information to patients affects their recovery from surgery. None of the items appeared to be more indicative of this process than the others. Therefore, it was determined that there was no reason to discuss any of the individual items or responses. Examining specific items and respdnses on the POQ, however, appeared to provide additional insight into patient recovery. The POQ, which measures the patient's sense of well-being just before leaving the hospital, is composed of items relating to various issues involved in the surgical experience. Because this study was designed to investigate the effects of information upon patient recovery, it was determined that an examination of those POQ items concerned with the information-giving process would provide additional under- standing of that process. There were four items that involved infor- mation. Those items were numbers two, three, four, and ten. Table 3.7 displays those items and the means and standard deviations for each group's responses. The scoring of the POQ was designed so that the lower the score the greater the reported sense of well-being by the patient. The 64 .eeeepee cmuuee e mueemeeeeg eceem LezeF <«e .coe an» :e mseew we» Ppe we umwp epepesee e meweueee w xweeeee<« a. e. _._ m.P m._ m.~ coweeeeoe Paewmsee we e=_e=aemcee== .e_ n. m. F.F m.p m.w m._ mmeemece Age>eueg we eewmmecesH .e m. m. m. m.— n.— m.P mmeeeeeeemee we eewuemecee .m m._ o.P o.— m.~ e.p N.P ee>weeec eewpeEeewew new: eeweuewmwuem .N mp Ne _w m» Nw _w wsaee meeegw meeeeu . .o.m stmcmmz ecweceewumeeo e>wueeeeepmee mew ee mseum eeuepem1eewee5eeweH Lew eeeeo ze meewuew>ee eeeeeeum eee meeeem :eez w.m opeew 65 clearest indication of the differences among the three groups on these four items is found by noting the mean score for each group. Item number two is the item most directly related to how well informed the patients felt. The mean scores indicate that T2 felt best in- formed (1.4), closely followed by T1 (1.7) and T3 (1.9). While the differences for this item were very small, these results followed the expected trend. Patients in the two treatment groups perceived themselves better informed than did those in the control group. Items three, four, and ten are less obviously related to the information-giving process. These items measured certain elements of the role information played in preparing the patients for their experience. Item number three measured the patients' perception of preparedness. The mean scores indicated that T3 reported the highest perceived level of preparedness (1.5), followed by T2 (1.7), and T1 (1.8). Again, the differences were small and these results do not follow the expected trend. The patients' general impression of how their recovery was pro- gressing was measured by item number four. For this item, the results did not follow the expected trend. T3 reported the most optimistic outlook (1.3), with T2 (1.5) and T1 (1.9) apparently less optimistic. This item indicated that both treatment groups reported greater con- cern about the outcome of their operations than did the control group. Once again, the differences among the groups were small. Finally, item number ten measured how well patients understood their physical condition at the time of discharge from the hospital. As with items three and four, the trend was not as expected. The control group (T3) reported better understanding of their physical 66 condition (1.5) than did either of the treatment groups (1.9 for T2 and 2.3 for T1). These four information-related items on the P00 indicate that the control group reported better outcome on three of the items. Only on item number two, which directly measured the patients' satis- faction with the information they received, did the two treatment groups report better results than the control group. The differences on all of the items were small but the trend was clearly indicated. The treatment groups were more satisfied with the information they received. The control group, however, felt better prepared in general, believed their recovery was progressing more satisfactorily, and understood their physical condition better. SUMMARY The primary analysis of the data revealed that there was evi- dently a significant difference between the minimum treatment group (T2) and the control group (T3). This finding supported hypothesis one. There was no support for hypothesis two, which stated that a difference existed between the maximum treatment group (T1) and the control group. It appeared that the significant difference between T2 and T3 was not accounted for by a single dependent variable. Rather, it was the relationship between two of the variables, length of hospi- talization and oral pain medications, that contributed to the signi- ficant results for comparison one. This relationship was indicated on the step down F-test for comparison one and supported by the high 67 degree of correlation (.861) between these two variables. The size and direction of the differences between T2 and T3 were shown by an examination of the observed cell means. That examination indicated that when oral pain medications was adjusted for length of hospitali- zation the difference between the two groups was even greater than that which was indicated. Descriptive analyses were reported that indicated the differences among the groups on each of the dependent variables. These differ- ences did not always follow the expected trends, as stated by the hypotheses. Both treatment groups reported better outcome than the control group on two of the recovery measures. For the other three measures, the control group reported better recovery than at least one of the treatment groups. However, when the comparison was re- stricted to the minimum treatment group (T2) versus the control group, T2 reported greater recovery on four of the five variables. This finding was important because it was the comparison between these two groups that produced indication of significant differences on the multivariate test. Correlations among the variables were presented. As suggested by the step down F-test for comparison 1, the correlation between length of hospitalization and oral pain medications was high. It was determined that the relationship between these two variables contributed to the significant results on the multivariate test for comparison 1. Of the remaining nine correlations, one was considered relatively high, six were moderate, and two were in the low range. Finally, the information-related items on the P00 were examined. One item measured the satisfaction of the patients with the information 68 they received before their operations. The two treatment groups reported greater satisfaction than did the control group. On the other items, however, the control group consistently reported greater recovery than did the two treatment groups. Chapter IV SUMMARY, DISCUSSION, RECOMMENDATIONS,_AND CONCLUSIONS SUMMARY The purpose of this study was to investigate the effects of personalized information upon the recovery of surgical patients. TWo elements of the information-giving process were experimentally manipulated to examine their effects on recovery. One element was an audiotape containing information about the basic events that occur during hospitalization for surgery. The second elmeent was a question- naire that patients completed after listening to the audiotape. This questionnaire, the Patient Response Form (PRF), provided patients the opportunity to ask questions and express concerns during the surgeon's preoperative visit. The concept of personalized information for patients was defined as the activity of providing both basic information about the operative experience and the opportunity to ask questions and express concerns that might arise before the operation. It was expected that patients assigned to the two treatment groups would experience greater recovery, as indicated by specific measures of the recovery process, then patients assigned to the control group. Thirty patients facing elective orthopedic surgery were randomly assigned to one of three groups (two treatment groups and one control 69 70 group). One treatment group listened to an information audiotape and also completed the PRF (the maximum treatment group). The second treatment group listened to the audiotape but did not complete the PRF (the minimum treatment group). The control group was exposed to neither the audiotape nor the PRF. Recovery from surgery was determined by five outcome measures that were identical for all patients. The statistical analysis of the data employed two planned com- parisons established a priori. The first comparison contrasted the minimum treatment group (T2) with the control group (T3). The second comparison contrasted the maximum treatment group (T1) with the control group (T3). Significant differences were discovered for the first comparison. No significant results were discovered for the second comparison. Hence, support was found for the hypothesis stating that differences existed between the treatment group exposed to the information audiotape alone and the control group. Trends were found in the data that further supported the signifi- cant results for comparison 1. The most revealing was the discovery that on four of the five outcome measures the observed cell means for the treatment group T2 indicated greater recovery than the means for the control group. While no statistical support was discovered for comparison 2, there existed the indication that the treatment group T1 showed greater recovery than the control group on three of the five measures. These trends suggest that both treatment groups recovered at a greater rate than the control groups. 71 DISCUSSION The minimum treatment group (T2) recovered at a significantly greater rate from orthopedic surgery than did the control group (T3). These results indicate that a minimum amount of information (audio- tape alone) is more beneficial to patients than what was considered to be a greater treatment (audiotape plus the Patient Response Form). These results indicate that the use of an external source of information, such as an audiotape, provides a flexible means by which information can be presented to patients before their operations. The information audiotape provides a medium of communication that allows the patient an opportunity to refresh his or her memory about what is going to happen. It provides the patient with some degree of control over, and responsibility for, securing that information. Under the discussion of the sample utilized in this study, reported later in this chapter, it will be noted that all of the patients involved in this investigation were exposed to a thorough information- giving process in the hospital. The results, which indicated that patients who listened to an audiotape experienced greater recovery than control group patients, may be even more revealing in light of this situation. The control group patients received this infor- mation from the nursing staff, yet the treatment group patients still showed greater recovery. It may be that in a situation where such information is not provided, the use of an audiotape providing infor- mation would produce even greater differences. This study has indicated that use of an audiotape offers a pro- mising medium for transmitting information to surgical patients. 72 Possible changes in both the content and the process involved in the use of audiotapes are offered in the discussion of the instruments used in this study. The trends noted in the data, which were discussed more fully in the previous chapter, provide important information that serves as a background to the present discussion section. Table 3.5 shows the differences among the three experimental groups across the five outcome measures. Figure 3.1 presents the same data in graphical form. The results indicated that T1 patients showed better recovery than the control group (T3) on three of the five measures. T2 patients showed better recovery than the control group on four of the five recovery measures. Therefore, patients in both treatment groups indicated better recovery than did patients in the control group for the majority of the outcome measures. In an effort to explain this study's data as completely as possible, the author discussed the results of this study with three physicians and the head nurse on the orthopedic ward where the patients were hospitalized. In addition to the participating orthopedic surgeon, one general surgeon and one emergency room physician were consulted. The results of the study were described, along with the treatment strategy, and the physicians were asked their opinions concerning the issues involved. The aggregate number of years of medical practice represented by this group amounted to 44 years. Many of the sugges- tions made by these physicians were incorporated into this discussion section. It is the purpose of this section to focus attention on possible explanations of the results of the study. To accomplish this purpose, 73 the discussion material has been divided into five topics: 1) theory, 2) sample, 3) design and statistics, 4) instruments, and 5) outcome measures. Theory A possible cause of the outcome of this study might be a mis- understanding of what was purported to be theoretical support for the need that surgical patients have to receive personalized infor- mation. The concept of personalized information involved giving the patient both the basic details of the operation and hospitaliza- tion, as well as the opportunity to ask questions and express concerns. As mentioned earlier, it was expected that the addition of the Patient Response Form to the information audiotape (T1) would produce a signi- ficantly greater indication of recovery. The lack of statistical support for this expectation may have resulted from faulty theoretical formulation. It is possible that information does not need to be personalized for each patient. The results of this study indicate that providing only basic information may be of significant benefit to the recovery process. Patients assigned to the treatment group exposed only to the information audiotape (T2) indicated significantly greater recovery than the control group patients.‘ This finding supported that aspect of the theory stating that information is important to surgical patients. Several of the previous studies investigating the role of information, in which information was reported to have been instrumental in posi- tively affecting recovery, apparently did not attempt to personalize “the information given (cf. Lindemann & Van Aernam, l97l; Dziurbejko & 74 Larkin, 1978; De Long, 1970; Wilson, 1977; Florell, l97l; Langer, Janis, & Wolfer, 1975). However, in none of those studies was per- sonalized information an experimental variable, so it cannot be con- cluded, based on the results of those studies, that personalized information is not important. An explanation offering more promise is that the coping style of patients should be considered, which was not investigated in the present study. While the results of those studies that examined coping style are mixed, it may be that this variable is very important. Coping style refers to the manner in which patients typically deal with frightening situations. Three styles have been identified: 1) those patients who attempt to deal with frightening situations by seeking out and using information have been designated "sensitizers," 2) those who neither seek out nor avoid information have been desig- nated "neutrals," 3) those patients who actively avoid information and will not attend to it when it has been provided have been desig- nated "avoiders." Coping style appears to affect patient recovery from surgery, although the nature of that effect is not yet understood. Andrew (1970) found that when patients were informed, neutrals showed the greatest recovery, followed by sensitizers and avoiders. Cohen & Lazarus (1973) discovered that avoiders and neutrals both indicated better recovery than sensitizers. De Long (1970) determined that sensitizers recovered better if they received specific information and avoiders recovered better if they received general information. Sime (1976) did not find coping style to be significantly related to recovery, but she did discover that patients with a high degree 75 of fear benefited most from preoperative information. Her results, while not significant, included trends that indicated that coping style does play some role in patient recovery. Another variable that is similar to coping style, and which may contribute to the interaction between information and patient recovery, is locus of control. This concept is based on Rotter's (1966) work that attempted to describe the degree to which an individual attributed reinforcement to his or her own behavior. Two researchers have investigated the role played by locus of control in the recovery of surgical patients. Patients were identified as either "externals“ (those who believed reinforcement results from something outside their control) or as "internals" (those who believed reinforcement is contingent upon their behavior). Lowery, Jacobson, and Keane (1975) did not experimentally manipulate locus of control and infor- mation, but they discovered that externals exhibited significantly greater preoperative anxiety than did internals. The emphasis of their study was that patients vary in the way in which they perceive the impending operation. Auerbach et al. (1976) discovered that internals indicated greater adjustment to the surgical experience when they were given information specific to the operation, while externals adjusted better when given information of a more general nature. The importance of these studies for the present discussion is the suggestion that patients have different methods of approaching an operation. Taking those differences into consideration may be important when the content and style of delivery of information is _being planned. The present study, by presenting the information 76 in the same manner to all patients and ignoring coping style, may have overlooked a crucial aspect of the relationship between infor- mation and recovery. Each of those studies that investigated coping style concluded that information needs to be tailored to the individual patient. It would appear, then, that the present study's concept of personalized information is not entirely accurate. This concept may have greater impact if it is expanded to include the need for determining patients' coping style. That determination would allow the preparation of the information to take into account how each patient perceives the information. As a result, information could be presented in one way for those patients who seek out and use infor- mation and in another way for thoSe patients who do not want infor- mation as detailed or complete. Sample The sample for the present study was small (N = 30), for both convenience and economy reasons. Isaac and Michael (1971) state that a small sample, from 10 to 30 subjects is "large enough to test the null hypothesis, yet small enough to overlook weak treatment effects" (p. 69). This is particularly true for exploratory research, of which the present study is an example. It is possible that orthopedic surgery patients are not as likely to view their operations with as much concern as patients undergoing other types of operations. Orthopedic surgery is usually not life- threatening in nature and, therefore, may not arouse the patients' anxiety to the same degree as other types of surgery. Basic bodily functions, such as eating, breathing, and elimination, are usually 77 not greatly affected by orthopedic surgery. While orthopedic surgery may be as serious as other types, patients may not perceive it as such and may not feel as anxious. A number of patients in the present study conlnented that they were not as worried about ‘the present opera- tion as they had been about others they had experienced. This conclusion concerning the perceived seriousness of orthopedic surgery was reached by other researchers investigating information and patient recovery (cf. Graham & Conley, 1971; Cohen & Lazarus, 1973; Vernon & Bigelow, 1974). This conclusion is supported by the fact that the patients' mean anxiety score on the STAI for the present study was 38.8, which was lower than the normative score of 42.6 for surgical patients reported by Spielberger, Gorsuch, and Lushene (1970). The patients in this study were well-informed by the hospital staff. The head nurse on the orthopedic ward where the patients were hospitalized reported that the nursing staff routinely conducts a thorough information-giving procedure with each new patient. This includes both individual instruction by one of the nurses, as well as group discussion with all of the patients scheduled for surgery the following day. The topics covered by this procedure include orientation to general hospital procedures, discussion of surgery- related items (wound drainage, care of the incision, pain, medication), and postoperative exercises and activities. When appropriate, new patients are visited by other patients who have already undergone a similar operation and are able to share their experiences. The results of the present study may have been affected by the characteristics of the sample that have been mentioned. The sample 78 size, the relative lack of perceived seriousness of their operations by the patients, and the thorough information received from the nursing staff, all may have influenced the results in ways that were not measured. Design and Statistics The findings that there were no significant differences for comparison 2 may have been the product of an imprecise analysis of the data resulting from a poorly planned design. If this were the case with the present study, differences between these two groups may have been obscured by unexplained error in the data. There were no obvious errors employed in the design used in this study. No important variables were knowingly disregarded. The degree of seriousness of the operations, which was determined to be the most important single variable, was carefully controlled. There were no demonstrated demographic variations among the groups. While patients were not randomly selected, because of the necessity of utilizing patients as they became available over a period of time, they were randomly assigned to the treatment groups. This provided the basis for the assumption that there were no important differences among the groups. The most powerful analysis strategy available for a small sample size, that of planned comparisons, was utilized for this study. This analysis strategy tested the hypotheses as precisely as intended. This strategy identified the apparent cause of the significant differ- ences for comparison 1 as the relationship between the length of hospitalization and the number of oral pain medications administered. 79 Planned comparisons are, however, a conservative analysis. There is a greater likelihood of Type II error, of failing to reject the null hypothesis when it is false and thus failing to detect differ- ences between groups that do exist (Leary & Altmaier, T980). Instruments The two instruments used in this study were the information audiotape and the Patient Response Form (PRF). The audiotape was designed to provide information about the basic details of the opera- tive experience. It was prepared by the researcher and the partici- pating surgeon and recorded by the surgeon. The attempt was made to provide a compromise between specific and general information to neutralize the effects of various coping styles. However, it is possible that this compromise was ill-advised, since it appears that coping style is an important variable that ought to be considered when investigating information and recovery from surgery. Audiotapes providing information have been utilized in a number of similar studies (Andrew, 1970; De Long, 1970; Field, 1974; Vernon & Bigelow, 1974). The effectiveness of information received via an audiotape, as contrasted with information received by some other medium, has not been reported in any of the literature surveyed for this study. In each investigation where audiotapes were used, including the present study, the contrast has been between the content of the information given, not between various media of transmission. The results of this study support the assumption that use of an audiotape is a valid means of providing information. It is important to note that the 80 significant differences for the treatment group exposed to the audio- tape alone resulted in spite of the information received from the nursing staff. It may be that the differences would have been even greater if patients had not been exposed to that extra information. The lack of significant results for the treatment group exposed to the audiotape plus the PRF suggests that the PRF may have had some negative effect that was not measured. The PRF was designed to provide patients with an external device that would assist them in considering the information they had received so that they might ask questions and express concerns. An attempt was made to include areas of information that would prompt questions and concerns. As indicated by the patient responses on the PRF (Appendix G, questions 14 and 15), there did not appear to be substantial areas of information that the patients did not receive. It is difficult to determine, based on such a small number of patients completing the PRF (N = 10), the degree to which this instrument prompted questions and concerns. The participating surgeon reported that patients expressed appreciation for the PRF and it was his opinion that those patients exposed to the PRF asked more specific questions than did the other patients in the study. The extra information that the control group patients received may have decreased the effectiveness of the information audiotape for the treatment groups. The PRF apparently accounted for some effect on T1 patients that was not measured. It may have been that those patients received too much information and did not know how to cope with it. Or, it may have been that the PRF aroused anxiety that was not dissipated. Apart from these two possible sources of 81 variance that were not controlled for, there do not appear to be other aspects of the two instruments that introduced error variance into the data that obscured significant differences among the groups. Outcome Measures There were five outcome measures used in this study: T) the length of hospitalization, 2) the number of oral pain medications administered, 3) the number of injected pain medications administered, 4) the State Anxiety subscale of the State-Trait Anxiety Inventory, and 5) the Post-Operative Questionnaire. Researchers investigating the effects of information upon recovery of surgical patients have used several different outcome variables, usually combining those that are pSychological in nature with those that are physiological. Examples of psychological measures have included personality tests, anxiety inventories, interviews between medical personnel and patients, evaluations of patients' moods and behaviors, and questionnaires designed to measure patients' reactions to their experiences. Physio- logical measures have included blood pressure, number of pain medi- cations administered, temperature, wound healing progress, length of hospitalization, number of sedatives administered, pulse, and ease of elimination. There does not appear to be any single outcome measure, or any combination of several measures, that imparts greater accuracy to the determination of patient recovery. Wolfer's (T973) recommendation that outcome measures include some combination of both psychological and physiological measures has apparently been incorporated by most researchers in this area. Several investigators have suggested that 82 physiological variables produce more valid data when they are reported for as long a period as possible. Recording physiological data over the entire postoperative period, even continuing after the patient has left the hospital, provides data that are more informative than those recorded over only a few days. It has also been suggested that the psychological variables include data gathered at several different times during the postoperative period. The emotional state of the patient changes during this time and gathering psychological data at only a single time may not reflect these changes. Length of hospitalization. This is a common recovery measures for investigations in this field. While there were no significant differences for this variable glppg, there were trends discovered that indicated that some differences existed among the groups. As reported in Table 3.5, T1 patients were hospitalized two fewer days than were the control patients. The participating surgeon stated that the average cost per-day of hospitalization amounts to around $200, which means that T1 patients spent an average of $400 less than did the control patients. When that figure is multiplied by the number of days of hospitalization for all surgical patients in the U.S. each year, there is the indication that a considerable amount of money might be saved by information-giving procedures. An additional way to determine if length of hospitalization accurately reflected true differences among the groups would have been to establish a typical length of hospitalization for each operation before it occurred and then compare the actual time with the projected time. That would have yielded supplementary data that addressed the 83 issue as to whether or not the treatments affected this recovery measure . Pain medications. There may be good reason to question the validity of this outcome measure, even though it has been commonly used by other investigators. Individuals vary in their ability to withstand pain and since there was no attempt to measure that vari- ability, those differences may have introduced error variance into the data. Another source of possible confounded data was the differ- ence in style of delivery among the nurses. Some nurses, holding the medication tray in plain view, approached the patient with a statement such as, "It's time for your shot now." Other nurses would merely mention that the time for medication had come if the patient wanted it. Others would leave it up to the patient to request the medication with little or no prompting. It is reasonable to aSsume that patients who would take the medication when it was offered in plain view might not take it if the burden of requesting it fell to them. It is possible that some patients took medications primarily because they felt that it was the proper behavior to show that they wanted to cooperate with the medical personnel. The separation of the injected pain medications from those admin- istered orally may have introduced some confusion into the data gener- ated for this variable. The switch from injections to oral adminis- trations is a subjective determination by the surgeon in response to the report of discomfort by the patient. The variation among patients in their ability to handle pain might have caused some patients to remain on injections longer than they actually needed to, while 84 other patients switched to oral medications sooner than they should have. Considering the relatively short average length of hospitali- zation for all patients, one day longer, or even part of one day, during which injections were taken would have had considerable effect on this recovery measure. Since the possible number of pain medica- tions is determined by the length of hospitalization, taking a greater number of injections would have resulted in fewer oral medications and vice versa. .SIAI. The anxiety inventory was administered during the first 48 postoperative hours. The importance of anxiety as a recovery measure might have been strengthened by administering the STAI preopera- tively as well as postoperatively. If the STAI had been administered before the treatment, or in the case of control group patients, at the time the researcher discussed the study with the patient, and then again during the early postoperative period, the data might have indicated more clearly the effect of information upon the patient's experience of anxiety. A difference between the two scores would have been a more significant indicator of that effect. .399. The POQ was designed by the researcher to attempt to measure the patients' sense of well-being at the time of discharge from the hospital. As indicated by Table 3.5, T1 patients reported the least sense of well-being of all the patients. The overall trend was sup- ported by the scores on those specific items relating to the information (Table 3.7). This finding was directly contrary to the expectations of this study. 85 One possible explanation relates to the time of administration of the POQ. As mentioned earlier, it was given to patients just prior to their leaving the hospital, which means that T1 and T2 patients completed the POQ on the fourth or fifth day of hospitalization follow- ing the operation, while T3 patients completed it on the sixth or seventh day. It is generally true that the longer the time since the operation, the better patients feel. Therefore, Tl patients were reporting their sense of well-being at a point in their recovery when they may not have felt as good physically. The validity of this explanation is weakened, however, by the fact that T2 patients who completed the POQ at approximately the same time as T1 patients, reported a greater sense of well-being than both TI and T3 patients. It may be that administration of the POQ at approximately the same time in the recovery process, regardless of the length of hospitali- zation, would produce a better indicator of the patient's sense of well-being. Another possible explanation for the finding that T1 patients apparently experienced a lesser sense of well-being is that they may have been sensitized to a negative "mind set" by their experience with the PRF. Only T1 patients completed the PRF, the purpose of which was to encourage them to think about and verbalize possible negative thoughts and feelings. Indeed, they were ordered to report questions and concerns they had. In addition, they were reinforced by the surgeon for expressing their negative thoughts and feelings. It is possible that this negative mind set was carried over to the POQ so that T1 patients were more willing to report negative aspects of their experiences than were T2 and T3 patients. 86 As reported in Chapter II, the reliability coefficient for the POQ was reasonably high at .85. This indicates that the POQ performs relatively well in measuring the patients' sense of well-being. Since most patients are anxious to leave the hospital, resulting in a certain buoyancy that may or may not endure, it might have been more meaningful to administer the POQ at some point after the patient had returned home. Perhaps a report of one's sense of well-being two weeks after leaving the hospital would have provided a more stable measure of this variable. Preoperative medications occasionally cause temporary postoperative amnesia so that some of the patients may not have remem- bered how they actually felt before and shortly following the operation. Reflection and recollection at a later date would allow recall of those feeling that have been sharpened over time. Such feelings nay provide the basis for more accurate reflection of a patient's sense of well-being. Treatments When treatments are poorly developed or carelessly administered, unexplained variation may be introduced into the data. When this occurs, significant differences are more difficult to identify. While the treatments in the present study were neither poorly developed nor carelessly administered, there are limitations to the treatment that may have contributed to the results. The first and most obvious limitation was the sample size. Practical concerns limited the amount of time allowed for the treatment phase of this study, thereby limiting the number of subjects. As it was, treating 30 patients consumed four months. Because treatment groups of ten 87 patients each barely meetings the required minimum number of subjects, increasing the group size to 15 patients each would possibly have increased the likelihood of finding significant differences. A related limitation was the utilization of one surgeon, operating in one surgical specialty, located in one hospital. While this arrange- ment allowed greater control over the treatment variables, it also increased the impact of any confounding variables that might have been present. For example, it is possible that the surgeon uninten- tionally treated patients differently. While he did not know before the preoperative visit which patients were in which group, he was easily able to identify them at the time of the visit. He may have been more personable, or taken more time, or appeared more concerned with some of the patients than with others. With more than one surgeon involved, the impact of that type of behavior would be lessened. Treating patients undergoing only orthopedic surgery is another possible limitation of this study. The nature of orthopedic surgery, which is usually not life-threatening, has already been mentioned. What is not known is the effect this treatment would have on patients facing surgery that they perceived to be more serious. Orthopedic patients are often not physically hindered in their recovery to the same degree as are patients recovering from other types of surgery. A third possible limitation involved the use of only one hospital. This is particularly pertinent in this investigation because of the information-giving program practiced in this hospital. In addition, these patients were confined to only one floor of the hospital, thus limiting their exposure to a small number of medical personnel. Varia- tion in behavior by only a few of the medical personnel might have 88 confounded the results and it is not known if this limited exposure affected the treatment and thereby contributed in an unknown manner to the results. These limitations bear upon the treatment program because of the possible effects of confounding variables mentioned above, as well as because of the limited generalizability of results. In addi- tion to these limitations, there are three other aspects of the treat- ment that may have accounted for the results of this study. First, there was no way to determine preoperatively whether or not the patients understood what they had been told. As indicated by patient responses on the PRF (Appendix G, questions 14 and 15), patients did not appear to indicate that there were areas of information they had not received. However, there was no way to determine the degree to which the infor- mation they had been given was understood. Their responses to question 7 (Appendix G) indicates that they apparently felt they had received enough information. The items of additional information listed in response to question 8 suggests, however, that their understanding was not complete. Closely related is the question of whether sufficient time to assimilate the information was provided. It is possible that the patients did not have enough time to think about the information they had received. Also, the information they were given by the nursing staff came so soon after they listened to the audiotape that they might have been simply overloaded with details. As a result, they may have been more confused than enlightened, especially if the information was contradictory, and their responses on the PRF may have reflected that confusion. It might be an improvement to 89 give the information audiotape to patients before they enter the hospital so that they can take it home with them to use at their convenience. This would allow more time to process and assimilate the information. Finally, it may improve the treatment if the outcome measures were expanded to include additional variables and if they were col- lected over a longer period of time. In addition to those data col- lected during the postoperative period while the patient is still hospitalized, it may be more meaningful to measure the patients' recovery over the first several days at home. If the variables were expanded, they could include such things as: l) the length of time the patient was confined to bed, 2) how long pain medications were taken, 3) how soon the patient returned to work or other normal acti- vities, 4) how soon sexual activity was resumed, and 5) how soon the patient was able to leave home and/or drive. RECOMMENDATIONS FOR FUTURE RESEARCH As a result of the present study's findings, certain recommen- dations can be made for future investigations into the effects of information-giving on the recovery of surgical patients. These recom- mendations are based on the two assumptions that 1) information plays an important role in patients' recovery from surgery and 2) a complete model for the presentation of information does not yet exist. The recommendations for future research fall into two stages. First, the present study could be replicated with three modifications: 1) expose one treatment group to the PRF alone, 2) use a larger sample 90 size, and 3) make provision for determining patients' coping styles. It would be beneficial in testing the various components of the design to maintain a tighter control over extraneous variables that result from using patients undergoing one type of operation, performed by one surgeon, in one hospital. The effectiveness of the PRF could be indicated by its use alone. A larger sample would decrease the sampling error and provide the basis for greater assurance in generali- zing the results to other similar patients. The increased sample size would also make possible the use of a less conservative statistical analysis of the data. Determining the patients' coping styles would provide for what appears to be a crucial element in designing appro- priate information-giving procedures. The second stage, which would build upon the improvements incor- porated into the research mentioned above, might involve research which included: 1) broadening the sample, 2) changing the content of the information audiotape, and 3) revising the recovery measures. Broadening the sample would involve utilizing patients undergoing various types of operations, under the care of different doctors, in different hospitals. It would be particularly important to deter- mine how information-giving strategy affects different types of patients. The generalizability of significant results would be expanded as the type of patients exposed to this treatment is broadened. The content of the information audiotape could be modified to provide specific deatils about the operation the patient is facing. Instead of the tape with general information, the conference between the surgeon and the patient during which the operation is prescribed could be recorded. The patient would then take that tape home to r89) to t Jper This that used the be a pita in t poin othe Pres; over Datie 91 replay at his or her leisure, which could provide repeated exposure to the surgeon's explanation, to his or her own questions about the operation, and to the surgeon's responses and further explanation. This tape would provide information about what is going to happen that would be far more specific than the general information tape used in the present study. In addition, by taking the tape home the patient would have more time to assimilate the information provided. Finally, the outcome variables could be revised. The STAI could be administered both preoperatively, following admission to the hos- pital, and postoperatively during the first 48 hours. Any difference in the scores might indicate the effect of the treatment to that point. It would be interesting to use physiological outcome measures other than those used in this study (e.g., pulse, temperature, blood pressure). Those recovery measures that are used could be collected over a longer period of time, extending for several days after the patient has left the hospital and returned home. CONCLUSION Four conclusions resulted from the present investigation: 1) Surgical patients who were exposed to an information audiotape experienced a significantly better recovery than control patients. 2) The difference in recovery was attributed to the relationship between two of the recovery variables, length of hospitalization and the number of oral pain medications administered. and n The e givi vhil cons for I‘lnl und Cdr 92 3) These results further strength the findings of other researchers and suggest that information audiotapes provide an effective means of providing information to surgical patients. 4) Surgical patients who completed the Patient Response Form, in addition to listening to the information audio- tape, did not recover at a significantly greater rate than control patients. The primary question that remains centers around why a maximum and more personalized treatment did not produce significant results. 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Counseling adult patients: Assessment of two tech- niques for reduction of presurgical anxiety. Dissertation Abstracts International, 1976,.31, 5534A. Spielberger, C. 0., Gorsuch, R., 8 Lushene, R. The state-trait anxiety interview. Palo Alto: CounsultingPsychologists.Press, 1970. Thrash, A., 8 Adams, Y. The rhetoric of physicians: A field study of communication with colleagues and patients. Unpublished disser- tation, Louisiana State University, 1974. Vernon, D. T. A., 8 Bigelow, D. A. Effects of information about a poten- tially stressful situation on responses to stress impact. Journal of Personality and Social Psychology, 1974,.29, 50-59. Weiler, M. C. Postoperative patients evaluate preoperative instruction. American Journal of Nursing, 1968, p8, 1465-1467. Wilson, J. F. Determinants of recovery from surgery: Preoperative instruction, relaxation training and defensive structure. Disser- tation Abstracts International, l977,‘§§, 1476-14778. Wolfer, J. A. Definition and assessment of surgical patients' welfare and recovery: Selected review of the literature. Nursing Research, 1973,.22, 294-401. Wolfer, J. A., 8 Davis, C. 0. Assessment of surgery patients' post- operative emotional condition and postoperative welfare. Nursing Research, 1970.-lg, 402-414. Youel, M. A. Beyond diagnosis and treatment. The Journal of Bone and Joint Surgery, 1974, pp, 200-204. APPENDICES APPENDIX A PATIENT CONSENT FORM rese pose 1111‘: of fid 111's obt res ide SO mi fl an 0f APPENDIX A PATIENT CONSENT FORM I, , have had the purpose of this research project explained to me. I understand that the general pur- pose of this study is to improve procedures by which patients receive information about their operation. I understand that the personal information collected during the course of this study is essential to the research. This information is con- fidential and will not be released to anyone without my written per- mission. I give George P. Alexander, the researcher, permission to obtain any necessary information from my medical records. In any research report prepared.subsequent to this project, I will not be identified by name, and any identifying information will be changed so as to protect my identity. I understand that I can stop my partici- pation in this project at any time. This consent agreement will ter- minate September 1, 1980, but confidentiality will be extended inde- finitely. I understand that my participation in this study does not guarantee any beneficial results to me. I understand that, at my request, I can receive additional explanation of the study after my participation is completed. 97 98 I certify that I have read this document, or had it read to me, prior to signing it. Signed Date 0 APPENDIX B PATIENT INFORMATION RECORD APPENDIX B PATIENT INFORMATION RECORD Name Birthdate Code Nos____ Address Phone No. (Street) (city) (zip) Occupation Race Sex Marital Status Family Structure Educational Level Major Type of Operation Previous Operations (type, date, recovery) *‘k‘k'k‘k'k'k***************************************************************** Sedatives (date, type, no. administered) Total Days Mean Pain Medications (date, type, no. administered) Total__Days_____Mean STAI ‘ POQ: l 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 Mean_______. 99 APPENDIX c . TRANSCRIPT OF THE INFORMATION AUDIOTAPE APPENDIX C TRANSCRIPT OF THE INFORMATION AUDIOTAPE This tape is designed to acquaint you with the events surrounding the surgery that has been scheduled for you. Prior to your admission to the hospital, during the office consultation, you will have been acquainted with some of these events and with the details of your proposed surgery. Upon arriving at the hospital, you will go through registration where certain forms will be filled out. You will be sent to the laboratory for certain blood tests and, upon occasion, you will have a chest x-ray taken. After you have arrived on the ward where your room will be, the nursing staff will explain certain preoperative procedures and will acquaint you with those events that precede your being taken to the operating room. Late in the afternoon on the day prior to your operation, or early that evening, you will be visited by the anesthesiologist. He will discuss with you the types of anesthesia that are available and, to some extent, you will have some choice in the matter. He will also discuss the preoperative medication you will take. On the day of the operation, about one hour before, you will receive the preoperative medicine. This will make you a little groggy. You will then be taken down to the operating room suite and your family will be able to accompany you to the oper- ating room door. They will then go to the waiting room and you will be taken into the operating room suite. You will lie on your cart awaiting the time when you will be taken into the operating room. There may be a slight delay at this time while the room is being pre- pared. When it is ready, you will be taken inside, the anesthetic will be administered, and the operation will be performed. You will not be aware of the time you are in the operating room, and it will seem that shortly after you were taken into the room you will wake up in the recovery room. As with most surgery, there will be some postoperative pain. Adequate pain medication will be administered to you periodically, at your request, to help control this pain. All pain cannot be completely controlled, for that would involve adminis- _tering another anesthetic. During the postoperative period, you will be involved in physical therapy, depending upon the type of operation you had. This may involve training for crutch walking, how to wear a sling, hand exercises, or whatever is specific for your type of surgery. A question often asked concerns the time you will spend in the hospital. This will vary, of course, but generally speaking a person will be discharged from the hospital when he or she is what we call "independent." This means that you will be able to get up and around and take care of your essential needs. Also, that you 100 lOl require only oral pain medication. At the time of your discharge, you will be given instructions concerning your activity and how soon you should return to my office for a visit. You will also be given a prescription for pain medication to take at home. This essentially covers the main events occurring during your stay in the hospital. During the morning of the day of your operation, I will visit you and we will discuss in detail your particular operation and attempt to answer your questions. Following this tape, please fill out the Patient Response Form so that we may discuss your responses together when I visit you before your operation. (Note: this sentence was included only on the tape heard by patients in treatment group 1.) APPENDIX D PATIENT RESPONSE FORM APPENDIX D PATIENT RESPONSE FORM Patient Code No. Date Directions: After you have listened to the tape that gives information about your operation, please fill out this form. It is very common for people to feel nervous when they are about to have an operation. This form is designed to help you think about the information you received and about questions you may want to ask your doctor. Your doctor is expecting you to fill out this form so that the two of you can discuss your operation when he/she visits you later. Answer each question as completely as you can according to how you feel ppy, You may listen to the tape more than once if you desire. For those ques- tions calling for a yes or no answer, please circle your response. 1. When you think about your operation, what feelings and thoughts do you have? 2. When a person is going to have an operation, there are usually some things he or she worries about. What are the things that worry you? 3. Is there something that someone could do to help you with those problems (question #2), and if so what would that be? yes no 4. What do you dislike most about being in the hospital now? 5. Do you understand the reason for your operation? yes no 6. Do you understand exactly what your operation will do? yes no 102 7. 10. ll. 12. 13. 103 Below is a list of some of the things that are involved in your operation. Do you understand as much as you would like to about each one? . 7a. How you will be prepared (physical preparation)? yes no 76. The anesthesia?_ yes no 7c. The operating room? yes no 7d. The recovery room? yes no 7e. Physical sensations (such as pain or discomfort) that you may have after your operation? yes no 7f. Any complications that may occur? yes no If you don't understand what is involved in your operation (ques- tions 7a - 7f above), what additional information would you like to have? Have you had any difficulties at home or at work recently that might increase your concern about your operation? yes no Are you worried about the attitude of your family (or other impor- tant people in your life) toward your operation, and if so, what are you worried about? yes no Are you confident that things will go smoothly at home while you are in the hospital, and if not, what are your concerns? yes no Have you noticed any change in your mood (the way you feel about things) since you were told that you needed an operation, and if so, what change has occurred? yes no What operations have you had in the past, and what were your experiences with them? Were they good or bad experiences? T4. 15. l6. 17. 104 Was there any information about your operation that you felt was not important or that you would rather not have been told, and if so, what was it? yes no Was there any information about your operation that you did not receive that you would like to have, and if so, what would that be? yes no When people are facing an operation, it is not unusual for them to be frightened. On the scale below, please circle the number that matches how frightened you feel. 0 l 2 3 4 5 6 7 8 9 not frightened frightened a great at all deal How many times did you listen to the information tape? APPENDIX E SELF-EVALUATION QUESTIONNAIRE STAI APPENDIX E SELF-EVALUATION QUESTIONNAIRE STAI d H CH d ..l o o o o o o o o o o o o o o Developed by C. D. Spielberger, R. L. Gorsuch, and R. Lushene STAI FORM X-l Patient Code No. Date Directions: A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appro- 8 o prite number to the right of the statement to _. >, ” indicate how you feel right now, that is, at this 7;, ,_. '3', '5 moment. There are no right or wrong answers. ,_. 2 t; a Do not spend too much time on any one statement "1 g $ >, but give the answer that seems to describe your *5 o E if, present feelings best. 2 "' > feel calm ................................... l 2 3 4 feel secure ................................. l 2 3 4 am tense .................................... l 2 3 4 am regretful ................................ l 2 3 4 feel at ease ................................ l 2 3 4 feel upset .................................. l ' 2 3 4 am presently worring over possible misfortunes l 2 3 4 feel rested ................................. l 2 3 4 feel anxious ................................ l 2 3 4 feel comfortable ............................ l 2 3 4 feel self-confident ......................... l 2 3 4 feel nervous ................................ l 2 3 4 am jittery .................................. l 2 3 4 feel "high strung" .......................... l 2 3 4 am relaxed .................................. l 2 3 4 —-l U" 0 HHHHHHHHHHHHHHH 105 16. 17. l8. 19. 20. 106 I am content ................................... I am worried ................................... I feel over-excited and "rattled" .............. I feel joyful .................................. I feel pleasant ................................ NNNNN wwwww b-b-fi-h-h APPENDIX F POST-OPERATIVE QUESTIONNAIRE APPENDIX F POST-OPERATIVE QUESTIONNAIRE Patient Code No. Date Directions: After a person has had an operation and nears the time to be discharged from the hospital, he or she will have thoughts and feelings about the experience. The purpose of this form is to give you the opportunity to record some of your reactions to your experience. Please answer each question as you feel ri ht ppg, Questions with stars (*) have room for comments, in addit on to your answer. If you would like to comment about other questions, please feel free to do so on the last page. Put a check ( ) or (X) on the line next to your answer. Please read each answer carefully. * 1. Think back to the evening before your operation, after the doctor visited you. Were you afraid or worried at that time? I felt not at all afraid or worried I felt a little afriad or worried I felt fairly afraid or worried I felt very afraid or worried I felt extremely afraid or worried What were you afraid or worried about? 2. Think back to the evening before your operation, after the doctor visited you. Did you feel that you had received enough infor- mation about your operation? received all of the information I wanted. received most of the information I wanted. received some of the information I wanted. received a little of the information I wanted. did not receive any of the information I wanted. HHHI—OH 107 108 Think back to the evening before your operation, after the doctor visited you. Did you feel that you were prepared for the operation? 1 felt completely prepared 1 felt mostly prepared 1 felt somewhat prepared 1 felt mostly unprepared l felt extremely unprepared During the first couple of days after your operation was over, were you afraid or worried about the outcome of your operation? 1 felt not at all afraid or worried l felt a little afraid or worried l felt fairly afraid or worried l felt very afraid or worried 1 felt extremely afraid or worried What were you afraid or worried about? Think back over the days since your operation. Have you felt physically about the way you expected to feel? I have felt much better than I expected to feel I have felt somewhat better than I expected to feel I have felt about the way I expected to feel I have felt worse than I expected to feel I have felt much worse than I expected to feel Think back over the days since your operation. Did you have any difficulty sleeping at night? I did not have any trouble sleeping I have very little trouble sleeping I had some trouble sleeping I had trouble sleeping most of the time I had trouble sleeping every night Think back over the days since your operation. How would you evaluate the amount of pain you experienced? I had practically no pain I had very little pain I had some pain I had quite a bit of pain I had an extreme amount of pain TO. 11. 12. 109 Think back over the entire time you have been in the hospital, from before the operation until now. How do you feel about the way you have been treated by the medical personnel (nurses, doctors, etc.)? I was given the best possible treatment I was treated well I was treated all right I was treated worse than I should have been I was treated much worse than I should have been lllll Think back over the days since your operation. How has your mood (the way you feel about things) been during this time? My mnod has been very good all of the time (happy, cheerful, etc. My mood has been good most of the time My mood has varied--sometimes good, sometimes bad My mood has been bad most of the time My mood has been very bad all of the time (unhappy, depressed, etc.) Do you feel that you understand your physical condition at the present time? I understand my condition as well as I would like to I understand quite a bit about my condition I understand a little about my condition I understand very little about my condition I don't understand my condition at all If the doctor discharges you in the next day or two, do you feel that you are ready to go home? I am sure that I am ready to go home I am pretty sure that I am ready to go home I am probably ready to go home I am not sure that I am ready to go home I am not ready to go home As you think about the future, how do you feel about the outcome of your operation? I am completely confident about the outcome I am mostly confident about the outcome I am fairly confident about the outcome I am not confident about the outcome I am not at all confident about the outcome 13. 14. * 15. 110 Do you feel that your operation will improve the quality of your life (make you happier, or let you do things you couldn't do before)? I am sure that my operation will improve my life I think that my operation will improve my life I am not sure if my operation will improve my life I do not think my operation will improve my life I am sure that my operation will not improve my life Do you feel that you will be able to do the normal physical activities as quickly as most other people who have had your operation? I am sure that I will be active as quickly as other people I think that I will be active as quickly as other people I don't know if I will be active as quickly as other people I don't think I will be active as quickly as other people I am15ure that I will not be active as quickly as other peop e If you knew another person who was facing an operation like yours, would you recommend that he or she be treated like you were? I would recommend treatment exactly like mine I would recommend treatment mostly like mine I would recommend treatment somewhat like mine I would recommend treatment different than mine I would recommend treatment much different than mine In what ways would you recommend different treatment? APPENDIX G PATIENT RESPONSES ON THE PRF Question APPENDIX G PATIENT RESPONSES ON THE PRF 1. When you think about your operation, what feelings and thoughts do you have? 2. When some length of operation depressed thoughts worry that something could go wrong never walk again death what everything is all about success of operation how soon I can go home delay on the day of the operation ability to be active in sports after operation a person is going to have an operation, there are usually things he or she worries about. What are the things that worry you? basically, is everything going to be okay what I'm going to feel like afterward 3. Is there something that someone could do to help you with those problems (question #2), and if so, what would that be? yes - 2 no- 4. What 8 talk with my minister be with my family . explain and give some idea of how long everything will take do you dislike most about being in the hospital now? the atmosphere, with people accepting their sickness or illness things out of my control not having a private room not being with my daughter just being in the hospital 111 10. 112 (continued) waiting until so late in the day to have my operation the waiting Do you understand the reason for your operation? yes - 10 no - 0 Do you understand exactly what your operation will do? yes - 7 no - 3 Below is a list of some of the things that are involved in your operation. Do you understand as much as you would like to about each one? 7a. How you will be prepared (physical preparation)? yes - 6 no - 4 7b. The anesthesia? yes - 8 no - 2 7c. The operating room? yes - 8 no - 2 7d. The recovery room? yes - 8 no - 2 7e. Physical sensations (such as pain or discomfort) that you may have after your operation? yes - 8 no - 2 7f. Any complications that may occur? yes - 5 no - 5 If you do not understand what is involved in your operation (questions 7a - 7f above), what additional information would you like to have? what it is all about how long the operation will last if my whole leg will be shaved how they get the bone chips out from between two other bones if the cold weather will affect my knee Have you had any difficulties at home or at work recently that might increase your concern about your operation? yes - O n - 10 Are you worried about the attitude of your family (or other important people in your life) toward your operation, and if so, what are you worried about? yes - 1 no - 9 my mother is not going to come like she did before 113 11. Are you confident that things will go smoothly at home while you are in the hospital, and if no, what are your concerns? yes - 9 no - l everything 12. Have you noticed any change in your mood (the way you feel about things) since you were told that you needed an operation, and if so, what change has occurred? yes - 5 no - 5 worry being tied down for a period of time 13. What operations have you had in the past, and what were your experiences with them? Were they good or bad experiences? ear; bad experience with no improvement in my hearing knee; pain and discomfort was worse than I expected varicose veins; results not too good and disappointed with hospital care, especially doctor's lack of concern tonsils; nothing bad I can remember ureter repair; some bad experiences with complications and more surgery knee; good experience but doctor said nothing to me about improvement--he would come in and not say anything to me except tell me to raise my knee to the level of his hand and when I couldn't he would leave again and not say a thing to me 14. Was there any information about your operation that you felt was not important or that you would rather not have been told, and if so, what was it? yes - 1 no - 9 just how long the pain and recuperation would take 15. Was there any information about your operation that you did not receive that you would like to have, and if so, what would that be? yes - 3 no - 8 explain what is going to take place exactly what they are going to do when I'm under how long pain will last 16. When people are facing an operation, it is not unusual for them to be frightened. On the scale below, please circle the number that matches how frightened you feel. 0 1 2 3 4 5 6 7 8 9 not frightened frightened a at all great deal 11 111 l l 1 ll 114 17. How many times did you listen to the information tape? (Note: this quention was given only to those patients in treatment group 1. one time - 4 two times - 5 three times - l