‘l' ' IIIDI.

 

This is to certify that the

thesis entitled

A COMPARISON OF THREE TYPES OF PRESURGICAL
PSYCHOLOGICAL INTERVENTION WITH MALE
OPEN HEART SURGERY PATIENTS

presented by

Andrea Lynne Van Steenhouse

has been accepted towards fulfillment
of the requirements for

Ph.D. (mggethepartment of Coun-
seling, Personnel
Services and Edu-
cational Psychology

 

 

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Date Decemiaer 12, 1977

0-7639

 

A COMPARISON OF THREE TYPES OF PRESURGICAL
PSYCHOLOGICAL INTERVENTION WITH MALE

OPEN HEART SURGERY PATIENTS

BY

Andrea Lynne Van Steenhouse

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Personnel Services and
Educational Psychology

1978

ABSTRACT

A COMPARISON OF THREE TYPES OF PRESURGICAL
PSYCHOLOGICAL INTERVENTION WITH MALE
OPEN HEART SURGERY PATIENTS

BY

Andrea Lynne Van Steenhouse

The Problem

 

The purpose of this research was to assess the
effects of three types of presurgical psychological inter-
vention on male, open heart surgery patients scheduled for
surgery at the Experimental Research Hospital (ERH) from
November 1976 through November 1977. Prior to surgery all
subjects were tested using psychological measures and
received a 35-45 minute interview of either affective
psychological intervention, cognitive psychological inter-
vention, or control intervention.

This study attempted to examine experimentally
the suggestions of other research that presurgical psycho-
loqical intervention aids the patient in coping with post-
surgical stress, and thus helps to improve convalescence.

A review of the literature covering the psycho-
logical aspects of surgery suggested that some type of

intervention is beneficial to the patient. More

Andrea Lynne Van Steenhouse

specifically, it was implied by the research that several
types of intervention could be appropriate, and that an
evaluation of the effects of different intervention tech-
niques on convalescence is needed. Another aspect of
convalescence reviewed in the literature was the effect
the patient's presurgical attitudes and beliefs might
have on his ability to recover successfully.

Although researchers suggested that presurgical
psychological treatment is effective and that different
treatments could be apprOpriate for certain types of
patients, experimental evidence to support that contention
was not abundant. Much data existed, however, which pro-
vided correlational evidence that personality types or
coping styles were in some way related to convalescence.

This research was designed to correct the limi-
tations inherent in the previous studies discussed in
Chapter I. That is, this study experimentally examined
the effects of certain treatments while controlling for
the several variables identified previously as possibly
responsible for the differences in convalescence rates,
namely, presurgical psychological data, operative data,

and age of the patient.

Design and Methodology

 

The research design was a three-by-two, two-way
design. The effect of treatment was assessed along with

possible effects caused by the person administering the

Andrea Lynne Van Steenhouse

treatment. The independent variables in this study, then,
were the administrator, who was a social worker or a
counselor, and the type of treatment. The three treat-
ments assessed were: (a) affective intervention, (b) cog-
nitive intervention, and (c) control intervention.

There were 12 dependent variables used in this
study to measure various aspects of convalescence. All
were reflective of dependent variables used in previous
research reviewed in Chapter I. They were:

1. Days spent in the hospital from surgery to

discharge

2. Hours spent in the intensive care unit

3. Amount of analgesic medication received

4. Amount of hypnotic medication received

5. Amount of anti-anxiety medication received

6. Amount of anti-psychotic medication received

7. Medical complications while in the intensive

care unit

8. Total medical complications from surgery to

discharge
9. Psychiatric complications while in the inten-
sive care unit

10. Total psychiatric complications from surgery
to discharge

11. Postsurgical depression as measured by the'

Beck Depression Inventory

Andrea Lynne Van Steenhouse

12. Postsurgical depression as measured by the
Zung Self Rating Depression Scale
All data for the dependent variables were taken
from the patient charts, psychiatric assessment forms, or

psychological tests.

Results

The results of the study did not support the
hypothesis that there would be differences between the
three presurgical treatment groups. Supplemental tests
indicated it did not matter on which day of the week the
patient had surgery or whether the patients were highly
internally controlled or highly externally controlled,
as measured on the Rotter IE Scale. There were no dif-
ferences between the treatment groups. A further supple-
mental test showed some relationship between the pre-
surgical psychological tests of anxiety and depression
and the postsurgical psychological convalescence measures
of depression and psychiatric complications while in the

intensive care unit.

DEDICATION

To Pat and Jimmy

There are things which must
cause you to lose your

reason or you have none
to lose.

Lessing

ii

ACKNOWLEDGMENTS

The many months spent in planning, executing and
completing this study brought the formation of several
new relationships and the strengthening of old friend-
ships. I would like to thank those peOple for whose
involvement in this project I am so grateful.

To Dr. Alex J. Cade, my dissertation chairman,
major professor and friend, for his long-time support of
me and his faith in my abilities.

To Dr. Richard G. Johnson, committee member, for
his gentle encouragement and consistent availability
throughout my graduate work.

I am especially indebted to Dr. Sumer Verma, com-
mittee member, who provided the link between the uni-
versity and the hosPital, for his competence as a psy-
chiatrist and teacher, his enthusiasm for research, and
his delightful, Spirited approach to life.

Dr. William H. Schmidt, committee member, and
Dr. Judith Taylor, statistical consultant, were incredibly
helpful in making the world of the statistician meaningful

and relevant; Judith is to be thanked particularly for her

iii

kindness and perseverance, and Bill for his ability to
encourage rigor while not losing sight of the humanness
of research.

I express my gratitude to Evelyn Koenig, my col-
league and friend who shared in the experimental aspects
of the project, for her tenacity, thoroughness and crea-
tivity as a researcher, and even more for her sense of
humor and her willingness to take time to laugh with me.

I would like to thank Addiann Hinds for her care-
ful and discerning editing. Also, thanks to Harold Drane
and the Department of Psychiatry for providing me a com-
fortable home throughout the study.

My family has provided a constant base of support
during my many years of education and their unwavering
encouragement is much appreciated. A special thanks to
my brother, Bob Elliott, and Shiley, Inc. for providing
immediate and precise information and advice.

Finally, to my husband, Patrick Kowaleski, and
son, Jim, who sacrificed so that I might succeed, I am

least able to describe my thanks. They endured so well.

iv

TABLE OF CONTENTS

Page

LIST OF TABLES O O O O O O O O O O O O Vii

LIST or FIGURES. ‘. . . . . . . . . . . ix

Chapter
I. INTRODUCTION AND REVIEW OF THE

LITEMTURE O O C O O O O O O O 1

Introduction. . . . . . . . . . 1

Need. . . . . . . . . . . . 1

Purpose. . . . . . . . . . . 3

Definition of Terms. . . . . . . 3

Generalizability. . . . . . . . 6

Summary. . . . . . . . . . . 7

Review of Related Literature . . . . 7

Surgical Stress . . . . . . . . 7

Measures of Convalescence. . . . . 9
Presurgical Psychological Inter-

vention . . . . . . . . . . 12

Personality Correlates. . . . . . 22

smary O O O O O O O O O O O 2 5

II. DESIGN AND PROCEDURES . . . . . . . 26

Overview . . . . . . . . . . 26

Research Hypothesis . . . . . . . 27

Design over Time . . . . . . . . 27

Experimental Treatments . . . . . 28

Subjects . . . . . . . . . . 30

Setting. . . . . . . . . . . 31

Design over Variables. . . . . . . 34

Variable Matrix . . . . . . . 34

Dependent Variables and Covariates. . 34

Chapter
Procedures . . . . . .
Overview . . . . . .
Intake Procedure . . .
Experimental Procedure .
Postsurgical Procedure .
Instrumentation . . . .

' Measures . . . . . .
Instrument Characteristics

Data Collection . . . .
Data Analysis . . . . .

III. RESULTS. . . . . . . .
Overview. . . . . . .
Covariables . . . .
Hypothesis Testing.

Supplemental Findings. .
Summary . . . . . .

IV. SUMMARY, DISCUSSION AND IMPLICATIONS

Summary . . . . . . .
The Problem . . ' .
Design and Methodology .
Results . . . . . .

Discussion and Implications

Limitations . . . . .
Discussion . . . . .

APPENDICES

APPENDIX

A. INTERVIEWER STATEMENT AND CONSENT FORM

IE. PRESURGICAL TREATMENT CONTENTS AND CHECK-

LISTS O O O O C O C 0

REFERENCES 0 O O O O O O O 0

vi

Page
37
37
38
39
39
40

40
40

47

50
50
52
53
56
65
66
66
66
67
69
69

69
73

82

84
-91

LIST OF TABLES
Table Page
2.1 Demographic Characteristics of Sample . . . 32

2.2 Comparative Figures for ERH and Average of
All Michigan Hospitals Performing Open
Heart Surgery . . . . . . . . . . 33

2.3 Overall Research Design. . . . . . . . 34

3.1 Stepwise Regression F Statistics for Each
Covariate on the Set of 12 Convalescence
Measures . . . . . . . . . . . . 53

3.2 MANOVA Statistics for the Simultaneous Test-
ing of the Treatment, Administrator and
Treatment and Administrator Interaction
on the Convalescence Measures . . . . . 55

3.3 Multivariate, Univariate and Step Down F Sta-
tistics for the Treatment Effect on the Set
of 12 Convalescence Measures . . . . . 55

3.4 MANOVA Statistics for the Simultaneous Test—
ing of Treatment, Day and Treatment by Day
Interaction on the Convalescence Measures . 57

3.5 MANOVA Statistics for the Simultaneous Test-

ing of Treatment, IE and Treatment by IE
Interaction on the Convalescence Measures . 58

3.6 Marginal Means of All Covariables Reported
by Treatment Condition . . . . . . . 59

3.7 Marginal Means of All Dependent Measures
Reported by Treatment Condition . . . . 60

3.8 Cell Means and Standard Deviations of All
Covariables . . . . . . . . . . . 61

vii

Table

3.9

3.10

3.11

4.1

Cell Means and Standard Deviations of All
Dependent Measures . . . . . . .

Stepwise Regression F Statistics for the Three
Psychological Covariates on the Set of 12

Convalescence Measures. . . . . .

Stepwise Regression F Statistics for Three

Psychological Covariates on the Four Psy-

chological Convalescence Measures . .

Comparison of Average Convalescence Data

viii

Page

62

64

65
75

LIST OF FIGURES

Figure Page
2.1 Pretest and posttest design with randomi-

zation . . . . . . . . . . . . 27

2.2 Experimental procedure . . . . . . . 49

ix

CHAPTER I

INTRODUCTION AND REVIEW OF THE LITERATURE

Introduction

 

Interest has intensified recently regarding health
care in the United States (Kimball, 1968; Rabiner, 1975;
Shochet, 1974; Walker, 1973), with emphasis shifting from
strictly physical considerations to psychological influences
(Backus, 1974; Keats, 1956). While the physician's and sur—
geon’s concerns have been directed mainly toward a patient's
physical condition, advances in medical technology and
surgical techniques and the continuing discrepancies in
patient recovery rates have invited investigation of the
psychological influences in health care (Schmitt, 1973;
Shochet, 1974). Medical and surgical advances may, in
fact, have necessitated much investigation of other
influences, since complications continue to affect con-

valescence and mortality in Spite of new techniques.

Need

 

Much has been written about physiological predis-
position to illness and its impact upon recovery. However,

although correlational research exists, with the majority

of those studies attempting to identify psychological
predictors of illness (Andrew, 1970), experimental research
regarding psychological influences on illness and recovery
is scant. More and more specificity is needed to better
identify psychological predisposition to illness and psy-
chological implications for successful recovery (Andrew,
1970; Auerbach, 1973; DeLong, 1970; Hunt, 1975; Kimball,
1968, 1970; Weiss, 1966).

One area of concern relates to patient responses
to a variety of surgical procedures. Several researchers
have attempted to isolate preoperative personality types
or coping styles and correlate them with postoperative
recovery success. The result has been general agreement
that there are preOperative personality types/coping styles
which correlate with post0perative complications or the
lack thereof; however, these studies have been correla—
tional and very little predictive data exist (Heller,

1974; Kilpatrick et al., 1975; Kimball, 1968).

There seems to be tacit agreement that in most
cases some type of presurgical psychological intervention
would prove useful in diminishing postsurgical difficulties.
Current presurgical treatment programs have developed hap-
hazardly and without controlled evaluation. Researchers
have discussed post0perative measures indicative of good
convalescence and have suggested various types of inter-
vention in an attempt to improve a patient's postoperative

course (Bolton & Bailey, 1956; Brown & Rawlinson, 1975;

Elsberry, 1972; Gilberstadt & Sako, 1967). There appears
to be little standardization of these intervention tech-
niques and even less success in identifying which tech-
niques would be most successful with which patients. A
study of the effectiveness of treatment programs would
serve as a preparatory move to initiate standardized

programs for patients awaiting surgery.

Purpose
It is the purpose of this study to investigate the

effects on male, open heart surgery candidates of three
types of presurgical intervention upon various aspects of
postoperative convalescence. More Specifically this
study will attempt to determine if presurgical psycho-
logical intervention has any effect on the postOperative
course as determined by physioloqical convalescence data
including time in intensive care unit, time in hospital
after surgery, amount and type of medication received,
and type and number of surgical and postsurgical compli-
cations. Psychological convalescence data also will be
gathered by psychiatric assessments of patients and psy-

chological tests of depression.

Definition of Terms

 

Terms used in this study are defined as follows:

Patient--all male open heart surgery patients

at the Experimental Research Hospital (ERH) between the

ages of 18 and 65 who exhibit no gross psychoses or
organic brain syndrome, and who have not previously under-
gone open heart surgery. Females were not included
because there was not a sufficient number within the time

period to warrant their inclusion in the design.

Open heart surgeryr-any valve replacement, coro-

 

nary artery bypass or aneurysmectomy or combination
thereof performed on the heart during which the patient

is on the bypass machine.

Bypass machine--instrument which takes over the

 

process of circulating the patient's blood during surgery

(extra corporeal circulation).

Degree of hypothermia--the degree in centigrade

 

to which the patient's body temperature is reduced

during surgery.

Intra aortic balloon pump (IABP)--the machine

 

used to take over expansion and contraction of a ven-
tricle. Used when patient's heart is not strong enough
to pump on its own; often used to augment heart function

after patient is taken off bypass machine.

Coping style--in this study two coping styles

 

were examined, internal and external. Internals are
persons who believe they are responsible for controlling

their own reinforcers. Externals are persons who believe

that events or reinforcements occur by chance or luck

and are beyond their control.

Surgical complications--the following were con-

 

sidered indices of surgical complications: low cardiac
output, arrest; excessive bleeding; fibrillation (fast
heart); rhythm problems including sinus tachycardia,
atrial flutter and arrhythmias; insertion of pacer; and

difficulty in getting heart to beat.

Postsurgical complications--the following

 

measures were used:

1. Depression--as measured by the Beck Depression
Inventory and the Zung Self Rating Depression
Scale.

2. Amount of medication administered--as measured
by the patient's hospital chart. Included
hypnotics (Sleep), analgesics (pain), anti-
anxiety and anti-psychotics. Dosage was
measured in milligrams per 24-hour periods

through the first five postoperative days.

3. Total length of hospital stay--the number of
days a patient is hospitalized from surgery
to discharge.

4. Length of time in intensive care unit--hours
from surgery to discharge from intensive care

unit.

Postsurgical complications-~the following cate—
gories were divided into two sections--postsurgical com-
plications during time spent in intensive care unit (ICU)
and after ICU care; elevated temperature; low urinary
output; kidney disfunction; cardiac rhythm problems;
cardiac rub; bleeding; incision problems including lung
congestion, atelectasis (collapse of all or part of a
lung) or excessive coughing; small myocardial injury;
return to surgery; hypotension; hypertension; chest pain;
congestive heart failure; blood transfusion; heart mur-
murs; hoarseness due to intubation; muscle spasm; rein-
tubation; depression; disorientation; psychotic organic

brain syndrome; and nonpsychotic organic brain syndrome.

Generalizability

Since the patients involved were treated in a
typical cardiac surgery unit, it can be concluded that
the findings might be true for many male open heart
surgery patients and can be applied to other cardiac
surgery units.

There are no conclusive studies demonstrating
that a person's sex plays a significant role in response
to cardiac surgery; therefore, it might be assumed that
similar findings would be applicable to female open heart
surgery patients as well.

Finally, research indicates there are presurgical

psychological difficulties and postsurgical complications

related to any life-threatening surgery. The results may
benefit all surgical patients and could be used as a
basis in formulating a presurgical training program for

any such surgery.

Summary

The present study focused on one Specific type of
surgery, open heart surgery, and investigated the effects
of certain types of preoperative psychological intervention
on specific psychological and physiological postsurgical

variables.

Review of Related Literature

 

The review of the literature is organized into
four major categories. These are: (a) surgical stress,
(b) convalescence, (c) presurgical psychological inter-
vention, and (d) personality correlates. The literature
will be reviewed as it relates to both general surgery

and open heart surgery.

Surgical Stress

 

General surgery. Janis (1958) was one of the

 

first to examine in detail the experience of surgery and
its psychological components. He found that recovery is
related to the preoperative attitudes of patients. He
strongly suggested studying those preOperative feelings

and carefully considering methods of treatment to alter

the postoperative experience. Shochet (1974) in his model
for a psychiatric liaison service stated that:

AS no illness is limited to its physical mani-
festations, recognition of the psycho-social ele-
ments of illness is imperative. When a patient is
hospitalized, the primary illness is often compounded
by increased anxiety, reactions to separation from
family and familiar surroundings, fear of the unknown
and inability to understand what is happening. Psy-
chosocial factors cansdelay recovery or, in extreme
cases, can destroy the patient's will to survive.

It is essential that these factors be recognized
early in the course of the illness for effective
integration to take place. To accomplish the goal
of early recognition and help, hospital personnel
must be sensitive to the emotional problems that
patients bring with them and to those which develop
in the hospital setting. Care should be provided
in such a way that the patient's anxieties and
emotional concerns are identified and ameliorated
as much as possible. Further, staff objectives and
performances Should reflect awareness of the impact
of staff actions on the patient.

Much research exists which supports Janis' notion
that preoperative attitudes have an effect on the success
of recovery (Kimball, 1968, 1969, 1970, 1973; Bodley et
al., 1974). There is also supportive research to suggest
that presurgical psychological preparation, such as sup—
portive interviews and information, has an impact upon
the postsurgical course (Henrichs, 1969; Hollender, 1974;

Johnson, 1972; Kornfield, 1974; Lasater & Grisanti, 1975).

Open heart surgery. During the past decade the

 

techniques of open heart surgery have become well defined
and much progress has been made in standardizing surgical
procedures (Beagle, 1974). This rapid advancement, plus

the world-wide publicity given it, has helped open heart

surgery emerge as a vehicle to restore physical function-
ing of the heart to many people suffering from congenital
or valvular heart disease (Brambilla, 1973). In fact,
Brown (1975) cites that most patients undergoing such
surgery have been able to return to a lifestyle almost
comparable to that enjoyed by persons not experiencing
heart problems.

Despite this medical sophistication, patients
nonetheless experience physical and psychological diffi-
culties after surgery which seem to be unrelated to their
specific surgical processes. Researchers therefore have
begun directing more and more attention to the psycho-
social elements of general surgery and cardiac surgery
(Kilpatrick, 1975; Heller, 1974; Kimball, 1969). Studies
have investigated patient variables such as time Spent
on the bypass machine and degree of hypothermia, in order
to determine their relevance as factors contributing to

the success of recovery.

Measures of Convalescence

 

Mortality. A fairly consistent but not very

 

sophisticated measure of convalescence is that of mor-
tality. Some of the earlier work by Kimball (1969)
examined death as it related to a patient's preoperative
level of anxiety and depression. In a 1969 study,
Henrichs studied the role of psychological factors in

a patient's acute response to Open heart surgery. He

10

found that a person's age or sex did not relate to opera-
tive mortality, but there was a higher mortality rate for

patients identified as depressed prior to surgery.

Delerium. A common psychological complication of
open heart surgery and a frequent measure of postoperative
recovery is delerium, which is defined by Blachly (1964)
as the presence of symptoms associated with organicity,
such as impaired orientation, memory, intellectual func-
tioning, judgment or lability of affect. Sveinsson (1975)
investigated the incidence or post cardiac delerium and
found a direct relationship with time Spent in the inten-
sive care unit. Despite attempts to correlate the
occurrence of delerium with increased age, with a
patient's sex, time Spent by the patient on the bypass
machine, and other patient variables, delerium remains

very difficult to measure and little conclusive data exist.

Other. More discrete measures of convalescence
subsequently have been developed. In his later work
Kimball (1970) correlated preoperative personality test
scores with such measures as: days spent in the recovery
room, number of hospital postoperative days, major phy-
sical complications, and death.

Kurz (1972) examined the effects of psychosocial
variables on the length of stay in the hospital and found

that sick role expectations and presurgical adjustment

11

were good predictors of both hospital stay and general
postsurgical adjustment. In a study to assess the
reduction of psychological stress in surgical patients,
Langer and Dweck (1975) found that teaching COping
mechanisms to patients could lower the number of patients
requesting sedatives and also lower the amount of pain
medication requested.

In a Similar study using both physiological and
interactional measures, Schmitt (1973) examined the
effect of psychological preparation on general surgical
patients. The physiological measures of convalescence
included blood pressure, pulse, vomiting, and nausea.

She also suggested that
. . . indicators of a smooth postoperative recovery
. . . include the amount and time of the patient's
medication, the number of days medication is
required, how soon the patient resumed oral intake
of food, and length of the hospitalization.

She characterized the above measures as inter-
actional ("soft") in that they are more subject to
patient manipulation than the somatic ("hard") indicators.
They remain, however, less subject to manipulation than a
patient's verbal responses to a questionnaire.

Amount of pain medication requested as an indirect
measure of pain experienced was reviewed by Keats (1956).
He found no relationship between the degree of post-

operative pain experienced and any of the following:

age, sex, type or duration of anesthetic, previous

12

medical history, previous surgical history, previous
hospitalizations, noticeable personality disorders,
obvious personality disorders, obvious personality types,
or presence of preoperative pain.

Regardless of the measure of convalescence used,
most of the research has focused upon correlating pre-
operative patient characteristics with those measures of
convalescence.

Presurgical Psychological
Intervention

 

More recently, it has been suggested that the
predictive postoperative course can be altered and that
time should be Spent investigating methods of preoperative
intervention to promote more effective convalescence
(Hunt, 1974). Intervention is designed to assist the
surgical patient in preparing himself psychologically for
surgery. Two types of presurgical intervention can be
identified: supportive and cognitive. General supportive
psychotherapy, which encourages the patient to discuss
his fears in a reassuring atmosphere, assumes that the
mobilization of fear will lead to the patient's develop-
ing an appropriate response to surgery. On the other
hand, cognitive intervention moves directly to aid the
patient in planning his reSponses to surgery.

Presurgical Treatment I, then, is supportive

psychological intervention designed to stimulate the

13

patient's fear in a conducive atmosphere. Presurgical
Treatment II is cognitive information-giving to assist
the patient in predicting his environment and controlling
his reaction to stress. Both treatments are intended to
minimize postoperative emotional complications and to

facilitate convalescence.

Presurgical treatment. Janis' (1958) foundation

 

for work with presurgical patients was based upon the
concept of anticipatory fear. It was his contention that
major surgery resembles other types of catastrophies and
disasters in that the patient faces a combination of
three types of danger--"the possibility of suffering
acute pain, of undergoing serious body damage, and of
dying." He further stated that generalizations about
one form of severe physical danger can be applicable to
any other crisis if those same basic threats of pain,
injury, and annihilation exist. It is the patient's
reaction to this impending surgery--fear--that Janis
described as the element suitable for manipulation by
preoperative intervention. It was his hypothesis that

. . . the closer an anticipated threat of body

damage is perceived to be (in Space or time) the

greater will be the individual's motivation to

ward off anticipatory fears by minimizing the

potential danger or by intellectually denying

that he will be seriously affected by it.

Janis believed that without intervention designed to

mobilize fear, the patient's attempt to deny his fear

14

of surgery may fail when the reality of surgery becomes
undeniable, thus resulting in an attack of acute fear.

A supplemental hypothesis stated that

. . . when a person attempts to minimize the danger
after becoming aware of a potential threat, fear
reactions are not extinguished but, rather, are
temporarily held in check only so long as no clear-
cut signs of danger are brought to his focus Of
attention. '

He concluded that an effective mechanism for
treatment of presurgical patients would be that of mobil-
izing a moderate degree of anticipatory fear so that
patients would be less likely to develop emotional dis-
turbances during or after surgery. The arousal of some
amount of fear evoked what he termed a "psychological
inoculation effect," which prepared the patient to meet
the surgery without becoming hostile or resentful. The
process of psychological inoculation included "mentally
rehearsing or fantasying what the danger situation will
be like, vicariously trying out varying reassuring con-
cepts, and then accepting, rejecting, or modifying them
after thinking about their truth value."

Janis concludes that unless a patient experiences
anticipatory fear, he is unlikely to develop his own set
of reality-based reassurances which can be used in the
time of crisis. Further he implies that an individual
with a low expression of anticipatory fear is likely to

rely on grossly overly optimistic expectations and wishful

blanket immunity concepts. These feelings of personal

15

invulnerability disappear when the actual surgery takes
place because the feelings of immunity were based on
denial of fears. Had he addressed his fear, he might
have been able to develop those reassurance mechanisms
in order to respond more realistically to the fears
associated with surgery.

Another study of providing supportive treatments
for open heart surgery patients was done by Burgess (1967).
He selected 36 experimental patients plus two control
groups. The control groups consisted of (a) patients
who were Operated on prior to the experimental group,
and (b) those patients who were operated on after the
experimental group. The treatment for the experimental
group consisted of an hour long, Open—ended informal
supportive visit by a psychiatrist before and after
surgery. The second control group had more long-term
adjustment problems than the experimental groups as
measured by an evaluation of medical records. Burgess
suggests that the low incidence of postoperative adjust-
ment problems in the first control group may be due to
a lack Of sophistication in recording by the physicians
and nurses before the experimental group was studied.
It would appear that his dependent variables were very
subjective and possibly measured more staff attitude

changes than patient adjustment.

16

In a study examining postoperative psychosis,
Layne and Yudofsky (1971) examined subjects undergoing
intercardiac surgery. The experimental cardiac group
received an extensive neurological examination plus a
psychiatric interview including encouragement of the
patient to discuss problems or apprehensions. The control
groups received only neurological examinations. The
major finding was that the preoperative psychiatric
interviews reduced the post cardiac delerium by approxi-
mately 50%. Layne and Yudofsky recommended preoperative
psychological visits on all cardiotomy patients.

Jakubik (1972) examined 60 patients after closed
and Open heart Operations. He found that postOperative
difficulties of depression and delerium were related to
emotional disorders existing prior to the Operation. The
results supported the interaction of psychological and
somatic factors in the develOpment of postoperative
mental disorders. Jakubik further concluded that psy-
chotherapy is very much needed in the presurgical period
as well as postoperatively for neurotic disorders.

The emphasis of most research investigating the
relationship between psychological preparation and the
reduction of postoperative complications has been on
individual preparation. Schmitt (1973), however, investi-
gated the impact of psychological preparation in a group.

The night before surgery, a small group (2-5 patients

l7

and a nurse) met and (a) discussed orientation infor-
mation; (b) requested new knowledge, e.g., how is a
Spinal given; (c) shared feelings of anxiety regarding
surgery; and (d) discussed suggested methods they could
use to facilitate their own recovery. The sessions
lasted approximately 60 minutes. The experimental
patients Showed a reduction in amount of medication
requested and reported a shorter postOperative stay.
Schmitt recommended a wider investigation of differ-
ential preoperative treatments.

In a study of Open heart surgery patients by
Kornfield et al. (1974), a team treatment approach
included a 1 1/2 hour interview with a psychiatrist.
They reported that the patients given the interview had
significantly lower delerium incidence than a comparable
group not seen by the team. They suggested their inter-
views served a therapeutic function by offering the
patients a "reassuring preoperative atmosphere in which
to ventilate their fears. . . ."

Surman et a1. (1974) measured the effects of a
preoperative visit (60-90 minutes) by a psychiatrist on
patients awaiting Open heart surgery. Their result
showed that ". . . as the number of visits mount, [psy-
chiatrist's visit] delerium decreases. This would indi-
cate that psychiatric contact in the preoperative period

can effect a kind Of prOphylaxis against delerium."

18

In 1975, Williams et al. conducted an experiment
on patients about to undergo therapeutic abortions and
measured the effects of two types of preOperative treat-
ments. One treatment was a "cursory" interview, lasting
approximately five minutes, which was intended to be
brief and minimally supportive. The second treatment was
"supportive," lasting approximately 12-15 minutes. Their
study showed that both the cursory and supportive inter-
views significantly reduced the anxiety levels of highly
anxious patients.

These results indicate that patients who have
received various forms of supportive treatment tend to
experience less delerium, less anxiety, request less
medication, Spent less time in the hospital, and gen-
erally convalesce better than those patients not receiv-
ing such treatment.

Although Janis did no experimental investigation,
he suggested it might be appropriate to assist the
patient in formulating reality-oriented assurances. He
stated that

. . . maximally effective preparatory communication
Should have the goal of giving as complete a frame-
work as possible for appraising the potentially
frightening and disturbing perceptions that the
person might actually experience, so as to prevent
the type of surprise and ambiguity that generates

unproductive, energy-consuming reactions of hyper-
vigilance.

19

He states that this material, presented in a non-
threatening manner, can probably influence most patients
to engage in effective mental rehearsal for the impending
surgery.

More recently, Seligman (1975) has postulated
that the inability of a person to be able to predict what
a dangerous event will be like, and his inability to feel
he has some control over that environment, leads to a
feeling of helplessness. He suggests that "stress and
anxiety are considerably greater when events occur unpre-
dictably than when they occur predictably." He further
claims there is a direct relationship between the psycho-
logical state Of helplessness and the risk of death.

He theorized that if a person feels his actions
would have no impact upon the environment, there is no
motivation to attempt to gain control. He states that

. . . the expectation that an outcome is independent
of responding (1) reduces the motivation to control
the outcome; (2) interferes with learning that
responding controls the outcome; and if the outcome
is traumatic, (3) produces fear for as long as the
subject is uncertain Of the uncontrollability of

the outcome, and then produces depression.

His cure for that helplessness, then, is reversing
the expectation that responding will not work. He sug-
gests that: "Being told--particular1y by some 'who should
know'--that a given event is controllable will create an

expectation that the event is controllable; even without

experience of the contingency."

20

Again, it is the expectation of perceived con-
trol, not the actual or experienced control which provides
relief from anxiety--even beyond that of predictability.

Recently several researchers have tested theories
of information-giving. Andrew (1970) investigated the
effects of a stress reduction treatment based upon infor-
mation-giving on two types of patients awaiting hernia
Operations. She found that a brief preparation consisting
of an eight-minute tape could be effective in influencing
recovery from surgery as measured by the amount of medi-
cation requested and the number of days from surgery to
discharge.

Johnson (1972) investigated and found support for
the hypothesis that providing patients with accurate
expectations regarding physical sensations about to be
experienced would reduce stress during confrontation
with a threatening event. She concluded that "information
leading to these accurate expectations has proven more
effective than the usual nursing practice of describing
procedures." She also supported Seligman's contention
regarding predictability and stated that "distress reflects
the degree of incongruity between expected and experienced
sensation."

Support for Seligman's theory also comes from
Langer et a1. (1975) who tested four strategies:

(a) coping device, (b) preparatory information,

21

(c) coping device plus preparatory information, and

(d) control. The coping device patients were taught a
coping device which was essentially reappraisal of the
anxiety-provoking event. They were given information
showing how to distract themselves from an event (surgery),
by redirecting attention to more favorable aspects of
the situation. Patients in the preparatory information
group were given information which contained "accurate
warnings about what to expect, along with pertinent
reassurances." The control group received information
about hospital routine.

The sessions lasted 20 minutes. The researchers
evaluated their strategies by behavioral ratings from
nurses on the floor on such measures as: total number of
pain and sleep medication requested and length of stay
in the hospital. This study sought to compare the
effects of the coping device with mere information
giving without coping strategies.

The results showed that, on nurses' ratings of
patient anxiety and ability to COpe, the coping device
and coping plus information groups did better than the
control group which in turn did better than the infor-
mation only group. On pain medication requested, patients
in all three experimental groups requested less medication

than patients in the control group. There were no

22

differences reported for Sleep medication requested or
on physiological measures such as blood pressure and
pulse rate.

They concluded that cognitive control through
selective inattention is an effective means of reducing
preOperative and postoperative stress. And they found
that teaching the patient to focus on expected suffering
without offering any means of controlling that experience
is a less effective means of dealing with stress.

Generally, research findings suggest that
information-giving, alerting the patient to the exper-
ience of surgery and the postoperative period, tends to
decrease amounts of medication requested and can influence
the number of days the patient Spends in the hospital.

In addition, the combination of giving information plus
helping the patient develop a feeling of control over
his postoperative environment is even more effective in

helping the patient cope with surgical stress.

Personality_Correlates

 

A considerable amount of research has been con-
ducted investigating COping styles and their impact upon
recovery from surgery. Extensive work has been done by
Kimball (1969) who has identified four types of person-
alities based on psychological responses to surgery:

(a) adjusted, (b) symbiotic, (c) anxious, and (d) depres-

sed. His discussions were based upon Open-ended,

23

nondirective psychiatric interviews. His correlations
reported that adjusted patients demonstrated an unremark-
able postoperative course; symbiotic patients experienced
a prolonged period from intensive care unit to discharge;
the anxious patients experienced a greater amount of
cardiac arrhythmias; and depressed patients had the
highest mortality rates. He suggested identifying
patients as poor psychological risks and offering psycho-
therapeutic intervention, paying much attention to dif-
ferent possible modes of intervention.

Henrichs (1969) used the MMPI to identify person-
ality variables which may affect a patient's response to
cardiac surgery. He found that male nonsurvivors
exhibited pronounced preOperative anxiety, while female
nonsurvivors were found to be emotionally overcontrolled.

Kimball (1973), in an update of his previous work,
studied several aspects of the stress of undergoing
cardiac surgery. He attempted to "correlate preoperative
OOping styles with postoperative morbidity and mortality."
Also, one goal was to define characteristics associated
with those preoperative coping styles. Finally, he
wanted to identify the Objective psychological tests
useful in identifying those groups.

Using a battery of tests, he further defined his
four types previously identified as: (a) adjusted,

(b) symbiotic, (c) denying anxiety, and (d) depressed.

24

He claimed that the preoperative identification of his
groups can be of predictive value in terms of post-
operative complications. He stated that patients deny—
ing anxiety or preOperatively depressed patients have
poorer prognoses. He suggested that a psychological
interview is helpful in identifying group characteristics.
The Rotter IE Scale seemed to reflect a correlation Of
low external control for patients in the adjusted group,
suggesting "a greater feeling of control" in the adjusted
group as opposed to a feeling of being a "victim of fate"
in the other three groups.

Heller (1974) attempted to assess (a) the extent
to which psychological factors hinder recovery, (b) the
’nature of the psychological hindrances, and (c) the
existence of preoperative personality correlates and
predictors of recovery. He found that patients with
preoperative manifestations of high anxiety, depression,
emotional lability, and disorganization were less able
to cope with the stress of surgery.

Kilpatrick (1975) tried to use psychological test
data to predict open heart surgery survivors. He did not
replicate Henrich's finding of Significant differences
between survivors and nonsurvivors on the MMPI scales.

He did, however, find that survivors scored higher on the
Cardiac Adjustment Scale, a self-assessment of general

adjustment.

25

AS stated earlier, Jakubic studied patients after
closed and open heart operations and found depression and
delerium not to be correlated with sex, age, marital
status, education, time awaiting surgery or duration of
cardiac disease. He did find, however, that postsurgical
difficulties were related to emotional disorders exist-

ing prior to surgery.

Summary

In reviewing the literature, both physiological
disposition to surgery and the possible impact of person-
ality correlates have been examined. The emphasis has
been on establishing possible predictors correlated with
illness rather than experimentally examining the effects
of patient attitudes on their recovery. Preoperative
psychological preparation has been suggested as a useful
and desirable tool but no evaluation of its effectiveness
with patients has been conducted. Neither has there been
an attempt to identify COping styles with a differential
effective preOperative treatment.

Design and procedures will be discussed in

Chapter II.

CHAPTER II
DESIGN AND PROCEDURES

Overview

The primary purpose of this study was to examine
the effects of preOperative psychological intervention
upon convalescence. The research was conducted with 54
male open heart surgery patients at the Experimental
Research Hospital (ERH). The subjects were assigned
randomly to one of three treatment groups: (a) pre-
surgical treatment I, (b) presurgical treatment II, or

(c) presurgical treatment III.

‘ Before the treatment, all subjeCts were given
tests measuring depression, anxiety, and locus of con-
trol. In addition, they were given two tests measuring
depression after surgery. Pertinent medical and surgical
data also were collected from the patients' charts.

The experimental design and the procedures used
to conduct this study and analyze the results will be

discussed in this chapter.

26

27

Research Hypothesis
The general area of interest about Open heart
surgery patients assessed in this study was: do different
types of preoperative psychological preparation have an
effect upon convalescence. The hypothesis tested, as

stated in its null form, is:

There will be no differences between preoperative
psychological intervention groups on the 12 con-
valescence measures of: hospital days, time in
ICU, medical complications while in ICU, medical
complications during total hospital stay, psychi-
atric complications while in ICU, psychiatric
complications during total hospital stay, Zung
Self Rating Depression Scale scores, pre-Beck
Depression Inventory scores, analgesic medication
received, hypnotic medication received, anti-
psychotic medication received, and anti-anxiety
medication received.

Design over Time

 

This study employed an experimental design using
Single treatment, with posttests given as shown in
Figure 2.1. Subjects were assigned randomly to three
groups. In the figure below, XS represent exposure to
the experimental variables, preoperative psychological
intervention. The numbers 0 represent pretests and 02

1
represent posttests. The R indicates random assignment.

R 01 X1 02
R 01 X2 02
R 01 X3 02

Figure 2.1 Pretest and posttest design with randomization

28

Experimental Treatments
The experimental treatments are:

X1 = presurgical treatment I,
affective intervention

X2 = presurgical treatment II,
cognitive intervention

X3 = presurgical treatment III,
control intervention

A description of the three treatment conditions

follows.

Presurgical Treatment I. Treatment I, reflecting
Janis' contention that giving the patient an opportunity
to discuss and mobilize anticipatory fears leads to better
convalescence, was supportive in nature, with the inter-
viewer attempting to be empathic to the patient's pre-
operative affective state. The primary focus was on
eliciting information about the patient's affect and on
giving him an Opportunity to talk about his fears.
Within that effective focus, the interviewer helped

explore the following areas:

1. The patient's understanding of what he was

told about his disease and surgery;

2. The patient's feelings about his disease and

its limitations;

3. The patient's feelings about and expectation

of his surgery; and

29

4. The patient's fears of surgery, that these
fears are normal and that they have no adverse impact

on the outcome of surgery.

Presurgical Treatment II. Treatment II, reflect-

 

ing Seligman's contention that teaching a patient to
predict and control his environment will reduce surgical
stress, was facilitative, giving the patient the Oppor-
tunity to prepare himself for the postsurgical experience
and helping him establish a method of control over that
experience. The treatment included giving the patient
preparatory information with which he could anticipate
exercising some control over his environment.

The preparatory information included alerting
the patient to psychological possibilities and informing
him that the psychological disturbances experienced post-
surgically are normal and temporary. Such disturbances
include depression, delerium (auditory or visual hallu-
cinations) disorientation (losing track of time, date,
place, etc.), and temporary difficulty with memory. The
activities in the intensive care unit also were discussed,
and the patient was assured that all patients experience
the same monitoring and care. Also, the treatment admin-
istrator discussed small steps of progress, such as
tracheal tube removal, but did not Specify when they

occurred.

30

The control of environment information consisted
of assuring the patient that he could communicate by
Signals when his tracheal tube is in place and that nurses
are there continuously to watch for his signals. The
treatment administrator also discussed the fact that the
patient would experience pain but can ask for pain medi-
cation when needed. The administrator encouraged the
patient to discuss with the staff any perceptual distur-
bances such as hallucinations or disorientation as well
as feelings of depression. Finally, the administrator
assisted the patient in learning to refocus his attention,
e.g., by helping him look at the positive aspects of
surgery to diminish the conscious attention directed

toward pain.

Presurgical Treatment III. Treatment III was
provided to control for the possible effects an inter-
ested interviewer might have on the patient. The intro-
duction was the same as Presurgical Treatments I and II,
but the content consisted of the interviewer asking only

medical history questions. (See Appendix B.)

Subjects

The subjects were selected from the males
scheduled for open heart surgery at the Experimental
Research Hospital from November 1976 through November

1977. A total of 54 subjects were chosen. They ranged

31

in age from 358 months to 779 months, falling into the
18-65 age limitations set by the study. Patients were
assigned randomly to one of the three treatments in order
of the appearance of their names on the surgery schedule.
Any patient exhibiting gross psychosis or organic brain
syndrome during the preoperative psychiatric interview
was not included in the study.

Patient characteristics are summarized in

Table 2.1 for purposes of judging how this group compares

to others (Cornfield & Tukey, 1956).

Setting

There are approximately 540 hospitals in the
United States in which 125,000-137,000 open heart sur-
geries are expected to be performed in 1977 according to
Theta Technology Corporation (1976). The ERH is one of
the 18 such hospitals in Michigan with a total of 4500
projected open heart surgeries during 1977.

The characteristics of the ERH both generally
as a hospital facility and specifically as an open heart
center are presented to facilitate generalization.
Figures presented reflect projected 1976 estimates.
There are an average of 250 open heart surgeries per-
formed per year in the United States and Michigan in
each hospital equipped to perform open heart surgery.

There are an average of 200 open heart surgeries per

32

Table 2.1

Demographic Characteristics of Sample

 

Variables

N

%

 

Age

Mean 641.74 months

Marital Status
Married
Single
Divorced

Type Of Surgery*
Single Coronary Artery Bypass .
Double Coronary Artery Bypass
Triple Coronary Artery Bypass
Quadruple Coronary Artery Bypass
Aortic Valve Replacement
Mitral Valve Replacement
Aneurysmectomy

Education Completed
Grade School
Some High School
"High School Graduate
Some College
College Graduate
Graduate Training

Religion
'Catholic
Protestant
Jewish
Other

Current Employment Status
Currently WOrking
Employed, nor working
Unemployed
Retired

Future Employment Plans
Resume previous employment
New employment necessary
Retirement planned
Permanently disabled

Employment of Spouse
Employed
Not employed
Not applicable

Children Living at Home

UthNI-‘O

children
child

children
children
children
children

Range

358 months-779 m

50
1
3

N
encode-um

NM
wI-‘U'IOUJH

HUIWO‘QN

93
2
5

Mb
QN‘DQWN

 

33

year at the ERH. The figures presented in Table 2.2 are

from the American Hospital Association (1977).

Table 2.2

Comparative Figures for ERH and Average of A11 Michigan
HOSpitals Performing Open Heart Surgery

 

 

. Michigan
Averages ERH
Number of Beds 515 254
Annual Admissions 17,425 9,536
Occupancy Rate 83.8% 81.1%
Number of Personnel 1,856 946

 

The intensive care unit at the ERH is a general
intensive care unit with eight private rooms arranged in
a semi-circle, four of which have outside windows. The
remaining four rooms are used primarily for open heart
surgery patients because they are larger and accommodate
the special equipment. There are three work Shifts, each
with eight full-time registered nurses and one orderly.
There are also two licensed practical nurses, one on the
afternoon shift and one on the midnight shift. Before
being allowed to care for patients monitored by the intra
aortic balloon pump the registered nurses are required to

have extensive didactic and clinical experience.

34

Design over Variables

Variable Matrix

 

The variable matrix was a two factor fully crossed
design. The first factor was the experimental variable
of interest, namely type of treatment, and had three
levels: (a) presurgical treatment I, affective; (b) pre-
surgical treatment II, cognitive; and (c) presurgical
treatment III, control. The second factor was admin-
istrator which was included for control. There were
multiple dependent variables and an equal number of
observations per cell. The overall research design is

diagrammed below in Table 2.3.

Table 2.3

Overall Research Design

 

Treatment I Treatment II Treatment III

 

It
so
a

ll
so

Counselor n = 9 n

n
so
u
so
:3
u
so

Social Worker n n

 

Dependent Variables and
Covariates

 

Two types of data were collected: dependent
variables and covariables. Postsurgical medical compli-
cations, psychiatric complications, recovery time, amount

and type of medication administered, and psychological

35

test data were used as dependent variables. Presurgical

psychological data, age, and Operative measures were used

as covariates.

Dependent variables. The dependent variables

were:

1. Postsurgical hospital measures

a. Time Spent, in hours, in intensive care

unit

b. Total length of hospital stay

c. Amount of medication received divided

into four groups

1.
2.
3.

4.

Analgesics
Hypnotics
Anti-anxiety

Anti—psychotic

2. Postsurgical psychological measures

a. Postsurgical depression measured by the

Beck Depression Inventory

b. Postsurgical depression measured by the

Zung Self Rating Depression Scale

3. Postsurgical medical complications from.

patient charts, divided into two categories:

during ICU and during total length of hospital

stay.

a. Rena1--including low urinary output and

inoperative kidney

f.

36

Cardiovascular--including cardiac rhythm
problems, cardiac rub/friction rub,
infarct, chest pain, congestive heart
failure, hypertension and hypotension.
Lung--including hoarseness due to intu-
bation, reintubation, and respiratory
difficulties, including lung congestion,
atelectasis, and excessive coughing.
Bleeding--including excessive bleeding
and transfusions.

Incision problems--including sternum and
leg problems.

Elevated temperature

4. Postsurgical psychiatric measures--as recorded

by
a.
b.

C.

psychiatrist on patient's chart

Disorientation
Psychotic organic brain syndrome

Nonpsychotic organic brain syndrome

Covariates. The covariates were:

 

l. Presurgical psychological data

a.

Depression, as measured by Beck Depression
Inventory.

Anxiety as measured by State-Trait
Anxiety Inventory, including both state

and trait anxiety.

37

c. Locus of control as measured by Rotter
Internal-External Scale.
2. Operative measures
a. Anoxic arrest time
b. Degree of hypothermia
c. Time on bypass machine
d. Blood loss
e. Surgical complications
1. Low cardiac output requiring the
use of the intra aortic balloon
pump or pacemaker.
2. Excessive bleeding
3. Arrhythmias--including auricular and
ventricular conduction defects, car-
diac arrest, difficulty getting heart
started and sinus tachycardia, atrial
fibrillation and atrial flutter.

3. Patient age

Procedures

 

Overview

Subjects included in the study were all male
patients scheduled for Open heart surgery at the ERH
who did not exhibit gross psychosis or organic brain

syndrome.

38

Intake Procedure

 

Pretreatment interview. Upon agreement to

 

schedule cardiac surgery among the surgeons, cardiologist
and patient, the cardiac surgery team, consisting of the
surgeon, nursing staff, a psychiatrist, social worker,
and counselor, was explained to the patient and the

following interviews were scheduled.

l. Surgeon. The surgeon informed the patient
that soon after admission to the hospital a representative
from the cardiac surgery team would visit him to obtain

his consent to participate in this study.

2. Counselor. Two days before surgery the
counselor (doctoral candidate in counseling psychology)
visited the patients. At that time the function of the
cardiac surgery team was described. The consent necessary
was obtained. Copies of the interviewer statement and
consent form are in Appendix A. The counselor explained
the interest of the study, the use of personality inven-
tories, the psychiatric and social work interviews, and
the use of postsurgical medical data. It also was
emphasized that the patient could discontinue partici-
pation at any time; that results were treated in strict
confidence and that final results were available to sub-
jects. The counselor then administered the Beck Depres-
sion Inventory, the Rotter Internal-External Scale, and

the Spielberger State-Trait Anxiety.

39

3. Medical Social Worker. On the same day, two
days before surgery, the medical social worker visited the
patient and elicited relevant social data as is the cur-

rent hospital procedure.

4. Psychiatrist. On the day before surgery, the

psychiatrist assessed the patient's mental status.

Each patient, after having had the preliminary
testing and psychiatric examination, was assigned randomly
to one of the three treatments: Presurgical Treatment I,
Presurgical Treatment II, or Presurgical Treatment III.
Copies of the treatment content and checklists are

presented in Appendix B.

Experimental Procedure

 

Treatment. Subjects received one of three treat-

 

ments. All treatments were presented by either the social
'worker or the counselor. They took approximately 35-45
minutes to administer and were thus comparable in length.
Each subject was treated individually either at his bed-
side in his room with the curtains drawn or in the private
conference room. All treatments were administered on the

day before surgery.

Postsurgical Procedure

 

Psychiatrist. On the second postOperative day

the psychiatrist visited the patient either in the

40

intensive care unit or on the surgery floor and admin-

istered a mental status examination.

Counselor. On the Sixth postsurgical day the

 

counselor visited the patient in his room and administered
the Beck Depression Inventory and the Zung Self Rating

.

Depression Scale.

Instrumentation

 

Measures of presurgical depression, anxiety, and
locus of control were assessed by the Beck Depression
Inventory, the Spielberger State-Trait Anxiety Scale and
the Rotter Internal-External Scale respectively. Two
instruments were used to assess the postoperative measure
of depression--the Zung Self Rating Depression Scale
(SDS) and the Beck Depression Inventory (BDI). Those
measures and the instruments used to assess them are

discussed below.

Measures

The pretest measures of the patient's depression,
anxiety and locus of control were used as covariates.
The post-treatment measure of the patient's depression

was used as a dependent variable in this study.

Instrument Characteristics
Rotter Internal-External Scale. The Rotter

Internal-External Scale (IE) is an instrument which

41

measures the degree to which an individual accepts per-
sonal responsibility for what happens to him (Rotter,
1962, 1975). It is a 29-item, forced choice test with
six filler items. The subject is asked to respond as he
believes the nature of the world to be. Persons who
score high on the IE are described as regarding fate or
chance as causes for consequences, and are thus more
externally controlled; persons who score low are identi-
fied as those who view consequences as occurring because
of their own actions and are thus more internally con-
trolled.

Reliability measures for internal consistency are
reported as .49 - .83 for test-retest, and .65 - .79 for
Spearman Brown split-half reliability (Joe, 1971).
Rotter (1966) suggests that because of the additive
nature of the score in addition to having items which
are not comparable, "split-half or matched-half relia-
bility may underestimate internal consistency."

Seeman and Evans (1962) examined the validity of
the IE Scale with a study of hOSpital patients and the
attempts Of those patients to control their environment
in the hospital setting. They measured the number of
questions patients asked the medical staff, how much they
were aware of their condition, and their satisfaction
with feedback from physicians and nurses. They found

that those scoring low on the IE Scale (internals) were

42

more aware of their condition, questioned staff more
and were less satisfied with the amount of feedback
they were getting.

Burnes et a1. (1971) found the IE score correlat-
ing with high ego strength (K values) and low pathology
(F scores) on the MMPI. They concluded that such cor-
relations suggest a "sense of control over external events
is related to self control and competency in handling
events." Johnson et a1. (1970) examined surgical patients'
attempts to control their environment in a hospital set-
ting. Using dosages of analgesics received they found
that patients who scored higher on the IE Scale (mean of
9.0 on a Short form of the IE Scale) received more anal—
gesics while there was no difference between the medium
and low IE group.

Several researchers have contradicted Rotter's
1966 claim that the IE Scale is free from the social
desirability set (Gold, 1968; Berzins et al., 1970).
Rotter (1972), however, concludes that studies lend

. . . strong and relatively consistent support to
the hypothesis that generalized expectancy--that
one can affect the environment through one's own
behavior--is present in at least two different
cultures, can be reliably measured, and is pre-
dictive of logical behavioral construct referents.

The Rotter IE Scale was used in this study to

assess the degree of self-perceived control over life

events.

43

Spielberger State-Trait Anxiety Inventory (STAI).
The STAI was developed in 1964 to provide a self-report
index of two types of anxiety: state--at the moment, and
trait--genera1 anxiety over time.

It is a two-part questionnaire with 20 questions
per part and with a possible score range of 20—80 per
side. The 20 statements for state anxiety ask the indi-
vidual to describe his feelings at the preSent moment.
The 20 statements for trait anxiety ask the individual to
describehis feelings generally. The response categories
for state anxiety are (a) not at all, (b) somewhat,

(c) moderately so, and (d) very much so. The response
categories for trait anxiety are (a) almost never,
(b) sometimes, (c) often, and (d) almost always.

Spielberger (1970) reports high test-retest
reliability for trait anxiety, .73 - .86, and low test-
retest reliability for state anxiety is expected because
of factors unique to the time of testing. Internal con-
sistency reliability coefficients of .83 - .92 are
reported for both state and trait scores.

He reports correlations of .75 - .77 with the
IPAT Anxiety Scale and .79 - .83 with the Taylor Manifest
Anxiety Scale. He also cites construct validity of the
STAI as state anxiety as a "transitory emotional state"
and trait anxiety as a "relatively stable personality

trait." In an investigation of patients' reactions to

44

surgery, Spielberger (1973) found that the difference
between presurgery and postsurgery scores on state
anxiety were highly significant; conversely, the pre-
surgical and postsurgical trait differences were not
statistically significant. Spielberger's conclusions
were supported in a 1975 study by Auerbach who studied
STAI state and trait scores both pre- and postsurgically.
He found pre- and postsurgery differences in state anxiety
to be significant whereas pre- and postsurgery differences
in trait means were not Significant. He also suggested
that his findings supported Janis' finding that inter-
mediate levels of preoperative anxiety (34-41 state
score) were facilitative of postoperative adjustment.

Martines-Urrutia (1975) investigated the effect
of surgery on anxiety and pain. He found that state
scores as measured by the STAI were considerably higher
before surgery on those patients who also had high scores
on a Fear of Surgery Scale. He also reported high pre-
operative trait anxiety scores correlated with greater
postoperative experience of pain as measured by the
Melzack-Torgerson Pain Questionnaire.

In this study the STAI was used to measure

patient's preoperative anxiety and general anxiety.

Beck Depression Inventory (BDI). The Beck

 

Depression Inventory was used in this study to examine

the level of depression a patient was experiencing. The

45

inventory is a 21 question test with four or five responses
per category. The 21 questions assess intensity of mood,
pessimism, sense of failure, dissatisfaction, guilt,
expectation of punishment, self-dislike, self-accusations,
suicidal ideas, crying, irritability, social withdrawal,
indecisiveness, body image changes, work retardation,
insomnia, fatigability, anorexia, weight loss, somatic
preoccupation, and loss of libido. Beck (1967) suggests
that the total score reflects a combination of patient
symptoms and the severity of each symptom.

In this study the format of the BDI was revised
by omitting categorical labels above each set of items.

In addition, each set of responses to a question was
lettered rather than Shown with numerical score values.
Also, the BDI was filled out by the patient rather than
read to him as in the standard instructions. Schmickley
(1974) reports having used the BDI in this self-report
manner with satisfactory results, and asserts the validity
of that procedure.

A Split-half reliability test for internal con-
sistency resulted in a score of .86 (Pearson r) between
odd and even questions; the corrected Spearman-Brown
brought the reliability score up to .93 (Beck, 1967). A
test of concurrent validity demonstrated that the BDI
corresponded to another measure of depression, the

patient's clinical state as diagnosed by psychiatric

46

interview. Beck reports correlations of .62 - .73
between BDI scores and psychiatrists' clinical interviews.

Beck reports evidence of construct validity with
the BDI and correlations with scores on hostility inward
scores, and decrease in depression index scores following
administration of antidepressant drugs. Beck also sug-
gests that the BDI differentiates depression from anxiety,
giving an r of .59 (Pearson r) with clinical ratings of
depression and .14 with clinical ratings of anxiety.

Beck cites a Significant negative correlation
between the BDI and educational level as measured by
number of grades completed in school. That is, "patients
with lower educational attainment tended to have higher
BDI scores than those with higher educations." This
indicates that perhaps more highly educated people are

less likely to report their depression.

Zung Self Rating Depression Scale (SDS). Another

 

measure employed in this study to measure depression was
the Zung Self Rating Depression Scale. The SDS measures
depression using what Zung (1974) refers to as the common
clinical characteristics of depression including: "per-
vasive affective disturbances, physiological disturbances,
psychomotor disturbances and psychological disturbances."
The scale has 20 items and the subject is asked
to reSpond to each item as it relates to him at the time

of testing. There are four possible responses: (a) none

47

or a little of the time, (b) some of the time, (c) good
part of the time, and (d) most or all of the time.

Zung (1967) reports that the SDS is able to dif-
ferentiate patients who are depressed from patients with
other diagnoses with a correlation of .43 to .65. He
also cites Significant correlation with the Beck Depression
Inventory, .72 - .76 (Zung, 1969), and the D scale of the
MMPI, .59 - .75 (Zung, 1967). He cites no correlation
between the SDS scores and age, annual income, intelli-
gence levels, marital status, or sex.

The measure of reliability, dependability of the
instrument each time it is used, was examined by inter-
correlation of items. He cites a .73 split-half relia-
bility coefficient (Zung, 1972).

Buros Mental Measurements Yearbook (1972)
reported that there is a negative correlation (r = -.28)
between SDS scores and years of education, suggesting,
again, that more highly educated peOple are less likely
to admit being depressed.

The SDS was used in this study to assess post-

surgical depression.

Data Collection

 

All medical and surgical data were obtained from
the patient charts. Psychiatric data were obtained from
the psychiatric mental status examination form and psy-

chological data were Obtained from the posttest scores.

48

All data were collected through the date of discharge

for patients admitted between November 1976 and November
1977, except for medication information which was collected
through the fifth postsurgical day. The experimental pro-

cedures are displayed graphically in Figure 2.2.

Data Analysis

 

There was a preliminary analysis to explore the
relationship between the set of covariates and the depen-
dent measures. A two-way analysis was used to test the
data even though there was only one factor of interest in
order to control for the administrator as a factor. A
two-way multivariate analysis of variance on the set of
12 dependent variables was performed.

There were also four supplemental analyses:

1. Groups having surgery on different days of the

week were compared.

2. Patients were divided into high external and
high internal scores and their convalescence data were

examined.

3. Cell means were computed for examining and

describing patterns of interest.

4. Data on the relationship between the covari-

ates and dependent variables were explored.

All supplemental data were analyzed to provide

descriptive evaluation of the data.

49

 

Patient scheduled
for surgery

 

 

 

 

Admission
Nursing Information
Medical Testing

 

 

 

 

 

Consent form

Counselor
Gives tests

 

 

 

Social WOrker
Collects social data

 

 

 

 

 

Psychiatrist
Regular patient visit

(Treatment I) Treatment LII [Egeatment IIIT

lSurgery I

 

 

 

 

 

 

 

 

 

 

 

 

Collection of Data

 

 

 

Operative Measures
Hospital chart - surgical data
type of surgery, time on bypass
machine, anoxic arrest, degree
of hypothermia, blood loss
Hospital chart - surgical complications
IABP, excessive bleeding, rhythm
problems

 

 

 

 

 

PostOperative Measures
Hospital chart - medication requested,
time in ICU, total hospital stay,
psychological problems
Psychological information - Beck
Depression Inventory, Zung Self
Rating Depression Scale

 

 

 

Figure 2.2 Experimental procedure

CHAPTER III
RESULTS

Overview

Hypothesis test results are presented in this.

chapter.

The results of this experiment were based on

measures of convalescence for each of the 54 male patients

who underwent open heart surgery. The data collected on

those measures of convalescence were:

1.

2.

ll.

12.

Number of hospital days

Time spent in ICU

Total number of medical complications

Number of medical complications while in ICU
Total psychiatric complications

Psychiatric complications while in ICU

Zung Self Rating Depression Scale score
Post-surgery Beck Depression Inventory score
Analgesic medication received

Hypnotic medication received

Anti-psychotic medication received

Anti-anxiety medication received

A preliminary analysis was performed using a

multivariate analysis of covariance (MANCOVA). The

50

51

multivariate test for relationship between the covariables
and the dependent variables was not significant, permitting
the discarding of the covariables in the analysis. A two-
way multivariate analysis of variance (MANOVA) was used
for the analysis since there were two factors of interest,
one being the administrator and the other being the treat-
ment. The administrator factor was included simply to
control for possible differences between the two admin-
istrators; because there was no particular interest in
that factor, no test was done. The primary factor of
interest was treatment which involved three leVels.

These were: (a) presurgical treatment I, affective;

(b) presurgical treatment II, cognitive; and (c) pre-
surgical treatment III, control.

This hypothesis test was done with an alpha level
of .05.

Supplemental data were gathered and analyzed to
provide for descriptive evaluation of the data, although
formal hypotheses were not stated. The supplemental
comparisons explored were divided into four segments.
First, groups having surgery in the beginning of the
week, that is on Monday or Tuesday, were compared with
‘patients having surgery later in the week, Wednesday,
Thursday, and Friday. Second, patients were divided
into high internals (score of 4 or less on the Rotter IE)

and high externals (score of 10 or more) and their

52

convalescence data were examined. Third, the cell means
of the treatments groups were computed to facilitate
understanding of the treatment. Fourth, supplemental
data on the relationship between covariates and dependent

variables were examined.

Covariables ‘

 

An overall multivariate test of the relationship
between the nine covariates of (a) IE score, (b) age,
(c) state anxiety, (d) trait anxiety, (e) pre-Beck score,
(f) bypass time, (9) anoxic arrest, (h) blood loss and
(i) degree of hypothermia and the set of 12 dependent
variables indicated no relationship (F = 1.17, p .165).
They were, therefore, rejected as a set of covariables.
The relationship for each separate covariate is shown in
Table 3.1.

I The overall multivariate test indicated that
there was no significant association between the set of
covariables and the set of dependent variables. Also,
examination of the stepdown F-tests for each of the
covariables suggested there was no candidate for a
covariate and thus shows no support for the appropriate-
ness Of using an analysis of covariance. Therefore, the
multivariate analysis to test the research hypothesis was

done without any covariates.

53

Table 3.1

Stepwise Regression F Statistics for Each Covariate
on the Set of 12 Convalescence Measures

 

 

 

Multivariate F test F = 1.17 p < .165

Covariate F df p <
IE .95 12,36 .506
Age '1.34 12,35 .237
State Anxiety 1.67 12,34 .118
Trait Anxiety 1.42 12,33 .205
Pre-Beck 1.51 12,32 .171
Bypass Time 1.11 12,31 .382
Anoxic Arrest .38 12,30 .959
Blood Loss 1.55 12,29 .163
Hypothermia 1.03 12,28 .443

 

Hypothesis Testing

 

The hypothesis was directed at exploring group
differences between types of presurgical psychological
treatments. A two-way multivariate analysis of variance
was used to test this hypothesis. The probability of a
Type I error for testing the treatment effect was set at
.05. There was insufficient evidence to suggest that one
treatment would be superior to another thus the hypothesis

is nondirectional. Stated again,

H There will be treatment group differences on the
set of 12 convalescence measures of hospital
days, time in ICU, total medical complications,
medical complications while in ICU, total psy-
chiatric complications, psychiatric compli-

cations while in ICU, Zung Self Rating

1:

54

Depression Scale score, pre-Beck Depression
Inventory score, analgesic medication received,
hypnotic medication received, anti-anxiety
medication received, and anti-psychotic medi-
cation received.

There will be no treatment group differences

on the set of 12 convalescence measures.
A two-way design was used to control for the pos-
sibility of an administrator effect. An inspection of
the MANOVA analysis as Shown in Table 3.2 revealed no
significant differences for treatment, administrator nor
the interaction of treatment and administrator.

The F statistics for the treatment factor (F =
.65, p < .880), for the administrator factor (F = 1.35,
p < .232) and for the interaction of treatment and admin-
istrator (F = 1.07, p < .391) were not significant at the
.05 level. Although there was a lack of significance
shown by the multivariate test, in the absence of admin-
istrator effect or interaction, a table of univariate and
stepdown F statistics will be preSented in Table 3.3 to
aid in understanding the treatments.
Upon further examination it can be seen from

Table 3.3 that even considered separately none of the
dependent variables was Significant. In summary, the
hypothesis that predicted there would be differences

between the groups was not supported.

55

Table 3.2

MANOVA Statistics for the Simultaneous Testing of the
Treatment, Administrator and Treatment and Admin-
istrator Interaction on the
Convalescence Measures

 

Multivariate

 

 

Sources F df p <
Treatment :65 24,74 .880
Administrator 1.35 12,37 .232
Interaction 1.07 24,74 .391

Table 3.3

Multivariate, Univariate and Step-Down F Statistics for
the Treatment Effect on the Set of 12
Convalescence Measures

 

 

 

Multivariate F = .6519 df = 24,74 p < .8802
Variable Univariate F p.< Step Down p <
Hosp Days .13 .875 .13 .875
ICU Time .94 .398 1.00 .377
Total Comp .68 .511 .33 .720
ICU Comp 2.25 .117 l 1.43 .251
Tot Psy 1.93 .156 1.86 .167
ICU Psy 1.48 .238 .44 .648
Zung ' 1.75 .184 .99 .379
Post Beck 1.22 .305 .13 .880
Analgesics 1.33 .275 .21 .814
Hypnotics .60 .553 .32 .727
Anti Psychotics 1.00 .376 .96 .393
Anti Anxiety .55 .583, .58 .563

 

56

Supplemental Findings

 

The supplemental findings reported in this section
include: (a) multivariate analysis of variance to test
the effects of day of surgery on the dependent measures;
(b) multivariate analysis of variance to test for the
effects of high internal and high external scores on the
dependent measures; (c) presentation of cell means for
treatment effect on covariates and dependent measures;
and (d) description of the relationship between covariates
and dependent variables.

As none of these analyses was conducted to test
formal hypotheses, the results are reported for descrip-
tive information only.

The first supplemental investigation was that Of
effects of the day of surgery on convalescence.r A two-
way multivariate analysis of variance was used to test
this relationship with a .05 significance level. The
MANOVA analysis, Table 3.4, revealed no Significant dif-
ferences for treatment, day, nor treatment by day inter-
action.

The F statistics for the treatment factor
(F = .65, p < .882), for the day factor (F = 1.13,

p < .371), and for the interaction of treatment and day

(F = .76, p < .766) were not significant.

57

Table 3.4

MANOVA Statistics for the Simultaneous Testing of Treat-
ment, Day and Treatment by Day Interaction on the
Convalescence Measures

 

Multivariate

 

Sources F df p <
Treatment .65 24,72 .988
Day 1.13 12,3 .371
Interaction .76 24,72 .766

 

Another area of interest was the possibility of
high internal (score of 4 or less) or high external
(score of 10 or more) on the IE Scale on the set of
dependent measures. A two-way multivariate analysis was
used to test this relationship with a .05 Significance
level. The MANOVA results are presented in Table 3.5.

The F statistics for the treatment factor (F =
1.04, p < .478), for the IE factor (F = .73, p < .699),
and for the interaction of treatment and IE (F = .64,

p < .842) were not significant at the .05 level. This
indicated there was no difference between the convales-
cence rates of high externals and high internals.

Another source of information regarding the
results of hypothesis tests is that of cell mean compari-
sons. The cell means for presurgical treatments I, II

and III on all covariates are presented in Table 3.6.

58

Table 3.5

MANOVA Statistics for the Simultaneous Testing of Treat-
ment, IE and Treatment by IE Interaction on the
Convalescence Measures

 

 

Source Multivgriate df p <
Treatment 1.04 24,16 .478
IE .73 12,8 ‘.699
Interaction .64 24,16 .842

 

From the table (3.6) one can note that there are
small differences between the groups on the covariates.
A least squares analysis of the effects and their cor-
responding standard errors support the fact that these
differences are due to chance. These results support
the efficacy of randomization in this sample.

AS stated earlier, there were no significant
differences between treatments on any dependent measure
of convalescence. For further discussion, however,
marginal means for presurgical treatments across all 12
dependent variables are presented in Table 3.7. In
addition, cell means and standard deviations on all
covariates are presented in Table 3.8 and cell means
and standard deviations on all dependent variables are
presented in Table 3.9.

In the absence of significant differences, let
us pursue some patterns of interest. On eight measures,

or three-fourths of all dependent variables, treatment III

59

 

 

 

 

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63

had more successful convalescence experiences. They spent
10.3 days in the hospital while treatment I spent 11.1

and treatment II spent 11.6. They Spent 9.39 hours less
in ICU than treatment I and 17.61 less hours in ICU than
treatment II. Treatment III also had fewer medical com-
plications while in ICU (.89) and fewer total complications
(1.6) than treatment I (1.2 and 1.9 respectively) or
treatment II (1.1 and 2.2 respectively). In addition,
they had no reports of psychiatric complications in ICU
nor any during the total hOSpital stay. On the other
hand, treatment I reported .39 psychiatric complications
while in ICU and 1.1 during the total hospital stay, and
treatment II reported .17 while in ICU and .72 totally.

Their scores on both the BDI (6.81) and Zung SDS
(32.9) were lower than treatment I (9.1 and 37.1 respec-
tively) or treatment II (6.6 and 33.3 respectively). The
only measure on which treatment III did not do better
than either treatment I or treatment II was on hypnotic
medication requested. They received almost twice as much
hypnotic medication (20.0) as treatment I (11.7) and
treatment II (10.8).

These patterns indicate the control group to be
doing better with convalescence as measured by these
eight measures.

The final supplemental analysis was a regression

analysis performed on the set of 12 dependent variables

64

using the three presurgical measures of state anxiety,
trait anxiety and pre-Beck Depression Inventory scores

as independent variables. The test for association
between dependent variables and independent variables
showed a significant relationship, F = 1.516, p < .055.
The variable yielding the greatest contribution was

state anxiety, F = 1.88, p < .071. A stepwise regression

is presented in Table 3.10.

Table 3.10

Stepwise Regression F Statistics for the Three Psy-
chological Covariates on the Set of 12
Convalescence Measures

 

StepWIse df

 

Covariates F p <
State Anxiety 1.88 12,36 .071
Trait Anxiety 1.21 12,35 .317
PIG-BECK 1057 12,34 .148

 

A regression analysis was also performed using
the scores of the post-Beck, Zung SDS, and psychiatric
complications in ICU as dependent variables and the three
presurgical measures of state anxiety, trait anxiety and
pre-Beck scores as independent variables. The F statis-
tics for association between dependent and independent
variables was Significant, F = 3.039, p < .001. A step-

wise regression to analyze the contribution of each

65

correlate indicated a Significant contribution from the
variable state anxiety, F = 5.52: P < .001m That step-

wise regression is presented in Table 3.11.

Table 3.11

Stepwise Regression F Statistics for Three Psychological
Covariates on the Four Psychological
Convalescence Measures

 

 

Covariates F df p <
State Anxiety 5.52 4,44 .001
Trait Anxiety 1.60 4,43 .193
Pre-Beck 2.38 4,42 .067

 

It can be seen from Table 3.11 that whatever
association there is stems primarily from the pretest

of state anxiety.

Summary

The primary research question, that of treatment
effect, yielded nonsignificant results on a MANOVA.
Therefore, the research hypothesis that there would be
differences between treatment groups was not supported.

Supplemental tests indicated these findings
remained the same when a two-way MANOVA was computed for
the effects of day of surgery, and when compared for high
internal and high external scores. A final supplemental
test indicated a relationship between the state anxiety
scores and the postsurgical psychological convalescence

measures .

CHAPTER IV

SUMMARY, DISCUSSION AND IMPLICATIONS

Summary
The Problem

The purpose of this research was to assess the
effects of three types of presurgical psychological inter-
vention on male, open heart surgery patients scheduled for
surgery at the Experimental Research Hospital (ERH) from
November 1976 through November 1977. Prior to surgery all
subjects were tested using psychological measures and
received a 35-45 minute interview of either affective
psychological intervention, cognitive psychological inter-
vention, or control intervention.

This study attempted to examine experimentally
the suggestions of other research that presurgical psycho-
logical intervention aids the patient in coping with post-
surgical stress, and thus helps to improve convalescence.

A review of the literature covering the psycho-
logical aspects Of surgery suggested that some type of
intervention is beneficial to the patient. More specifi-

cally, it was implied by the research that several types

66

67

of intervention could be appropriate, and that an evalu-
ation of the effects of different intervention techniques
on convalescence is needed. Another aspect of convales—
cence reviewed in the literature was the effect the
patient's presurgical attitudes and beliefs might have

on his ability to recover successfully.

Although researchers suggested that presurgical
psychological treatment is effective and that different
treatments could be apprOpriate for certain types of
patients, experimental evidence to support that contention
was not abundant. Much data existed, however, which pro-
vided correlational evidence that personality types or
coping styles were in some way related to convalescence.

This research was designed to correct the limi-
tations inherent in the previous studies discussed in
Chapter I. That is, this study experimentally examined
the effects of certain treatments while Controlling for
the several variables identified previously as possibly
responsible for the differences in convalescence rates,
namely, presurgical psychological data, Operative data,

and age of the patient.

Design and Methodology

 

The research design was a three-by-two, two-way
design. The effect of treatment was assessed along with
possible effects caused by the person administering the

treatment. The independent variables in this study, then,

68

were the administrator, who was a social worker or a
counselor, and the type of treatment. The three treat-
ments assessed were: (a) affective intervention, (b) cog-
nitive intervention, and (c) control intervention.

There were 12 dependent variables used in this
study to measure various aspects of convalescence. All
were reflective of dependent variables used in previous

research reviewed in Chapter I. They were:

1. Days Spent in the hospital from surgery to

discharge
2. Hours Spent in the intensive care unit
3. Amount of analgesic medication received
4. Amount of hypnotic medication received
5. Amount of anti-anxiety medication received
6. Amount of anti-psychotic medication received

7. Medical complications while in the intensive

care unit

8. Total medical complications from surgery to

discharge

9. Psychiatric complications while in the inten-

sive care unit

10. Total psychiatric complications from surgery

to discharge

69

ll. Postsurgical depression as measured by the

Beck Depression Inventory

12. Postsurgical depression as measured by the

Zung Self Rating Depression Scale

All data for the dependent variables were taken
from the patient charts, psychiatric assessment forms, or

psychological tests.

Results

The results of the study did not support the
hypothesis that there would be differences between the
three presurgical treatment groups. Supplemental tests
indicated it did not matter on which day of the week the
patient had surgery or whether the patients were highly
internally controlled or highly externally controlled,
as measured on the Rotter IE Scale. There were no dif-
ferences between the treatment groups. A further supple-
mental test showed some relationship between the pre-
surgical psychological tests of anxiety and depression
and the postsurgical psychological convalescence measures
Of depression and psychiatric complications while in the

intensive care unit.

Discussion and Implications

 

Limitations

 

The limitations of this study provide a framework

within which to interpret the results, and before discussing

70

the implications of the findings, several caveats should
be explored. The effects of the experimental procedures
as well as some unavoidable consequences of clinical
research must be addressed.

The lack of validity data for the dependent
variables in this study introduced a threat to internal
validity. Recovery from Surgery is a complex process
which is not easily quantified, although measures such
as the amount Of time Spent by the patient in the inten-
sive care unit have been considered as indicators of
recovery. Despite their intuitive appeal, however, the
factors used in this study have not been validated as
measures of convalescence.

Further threats to the internal validity of this
study were the instruments used to measure presurgical
depression, anxiety and locus of control. Although all
were reported to have adequate validity and reliability,
they remain self-report instruments subject to deliberate
falsification and distortion. It is difficult to be sure
that patients were able to record their true feelings,
particularly when denial of feelings has been found to
be a major defense system a patient uses when faced with
a life-threatening situation.

A threat to external validity was the nonrandom
selection of patients. It was not feasible to randomly

select patients from the various Michigan hospitals which

71

perform open heart surgery because of time, distance, and
individual hospital policy limitations. Therefore, the
findings cannot be generalized beyond this sample. How-
ever, the Cornfield-Tukey (1956) bridge argument allows
us to infer that these findings might hold true for
similar populations.

A concern relating to both the internal and
external validity of the study was the pretesting of
patients. The decision to pretest patients on measures
of anxiety, depression and locus of control may have
resulted in alerting the patients to the researcher's
interest areas. Because the pretesting experience was
the patients' first encounter with the experimental
sequence, it is impossible to measure if and/or when that
exposure might have affected their responses. Not only
could the exposure have affected the impact of the psy-
chiatric interview or the presurgical treatment, it is
even more likely it may have affected the dependent
variable of postsurgical depression. These posSible
reactive effects of pretesting could have controlled by
including a no treatment control group which received no
pretest; however, that would have required 18 additional
subjects, inclusion of which were not within the SOOpe
of this study because of time limitations.

An even more serious limitation was the possi-

bility of reactive effects of the experimental procedures.

72

The patients' awareness that they were participating in a
study may have been responsible in part for their manner
of convalescence. This consideration presented an
intriguing problem. Since it was physically impossible
to provide unobtrusive treatment, and it was ethically
and legally impossible to provide treatment without a
consent form, the patients were fully aware they were
being studied and were told that the psychological aspects
of surgery were of interest to the investigators. Unfor-
tunately the impact of their knowing they were involved
in a study as well as the focus of the study is unknown.
Such an unknown lessens our ability to claim the effects
of treatment would be the same for a group of subjects in
a nonexperimental setting.

Another possible source of invalidity was that of
the subjects' contemporary history. All patients were
located on the same floor of the hospital both before and
after surgery except for the few days each Spent in the
intensive care unit. There was no way to measure nor
control for the impact the patients and their families
might have had on each other. Further consideration of
these'limitations will be presented in the discussion of
the results.

In summary, the validity and reliability of the
dependent measures and the presurgical psychological tests

were possible threats to the internal validity of this

73

study. These extraneous variables may themselves have
produced effects which make the conclusions drawn less
certain. Threats of both internal and external validity,
which make generalization more difficult, included
reactive effects of pretesting, reactive effects of the
experimental procedure, contemporary history of the sub-

o

jects and lack of random selection.

Discussion

 

Despite the claims of previous research that
certain types of presurgical psychological intervention
would be advantageous to the patient, there were no
differences between the results of three presurgical
treatments in this study. There are a variety of possible
conclusions, the obvious being the acceptance of findings
that the treatments used in this study had no impact. The
treatments may not have been long enough. The presurgical
time frame, however, did not permit a longer treatment.
The patients usually were admitted no more than two and
one-half days before surgery; as an example, a patient
would ordinarily be admitted late Saturday afternoon for
surgery early Tuesday morning. It would have been
preferable to have had a longer relationship with each
patient, and perhaps to have investigated the effects of
family interaction on the patient's recovery.

Another possible conclusion is that the lack of

differences between the treatments may have been related

74

to the sensitivity of the dependent variables to the
treatment. As stated, all of the 12 dependent measures
had been used in previous research to assess patient
convalescence, however, their validity has not been
assessed. It may be there are more appropriate measures
of convalescence.

In addition to alternative measures of convales-
cence, it is also possible that more differences in
recovery rates would be reflected in long-range data;
long-range measures might also be helpful in describing
more fully the total scope of convalescence. Most depen-
dent variables in this study were collected through the
fifth postsurgical day or for Six days. It would be
interesting to find out which persons went back to work
as planned, how the patients evaluated the quality of
their lives, which patients were readmitted for further
medical problems, and what were the long-range mortality
rates.

To aid in further interpreting the results, the
actual findings Should be considered. Statistics for
amount of time spent in intensive care, total length of
hospital stay from surgery to discharge and typical
dosages of medication were not readily available from
previous research. The averages of all three treatments

were presented in Chapter III, and in Table 4.1 treatment

75

groups with the worst convalescence rates on four depen-

dent variables are compared with McGoon's averages

reported in 1969.

Table 4.1

Comparison of Average Convalescence Data

 

 

Dependent Measure McGoon ERH
Average number of days _
from surgery to discharge 10 21 days 11.61 (T 1)
Anti anxiety medication 2-8 mg/day 5-2 (T I)
(Valium) mg/day
Time Spent in ICU Less than 4 1/4 (T II)

. 5 days days

Analgesic medication 3-12 mg/daY 20 (T II)
(Morphine) mg/day

 

It can be seen that

even the patients in Treatment

I who had an average length of stay in the hOSpital after

surgery of 11.61 days were within the average of 10-21

days cited by McGoon.

The Treatment I anti-anxiety medi-

cation average Of 5.2 mg/day was also within the 2-8 mg/day

average cited.

Treatment II subjects stayed an average

Of 4 1/4 days, below the 5-day average maximum time spent

in ICU.

The only measure on which the patients in this

study exceeded McGoon's suggested average was analgesic

(pain) medication received, at 20 mg/day in Treatment II

versus McGoon's average of 3-12 mg/day.

Although this

figure is somewhat imprecise due to equating all analgesics

76

administered, including Darvon, Tylenol and Emperim II,
with morphine, the results may be attributable to the
patients having been told by the administrator that they
had much control over the amount and intensity of the

pain they experienced, and their having been directly
instructed by the administrator to ask for pain medication
when they needed it.

Postsurgical measures of depression indicate that
even the groups scoring highest on both the Beck Depression
Inventory and the Zung Self Rating Depression Scale had
relatively low scores of depression. Treatment I had the
highest average BDI score, 9.06. A score of 18.7 was
reported to indicate mild depression. Similarly, Treat-
ment I had the highest average score on the SDS, 37.11.
Zung reported average scores of below 40 are indicative
of no psychopathology or evidence of depression. It
appears, therefore, on the basis of these tests that
even the groups which score highest on the depression
indices were not depressed after surgery.

These findings are clearly in conflict with the
majority of the literature reviewed in Chapter I in which
it was suggested that patients were likely to experience
depression postsurgically.

In Chapter III it was shown that the Treatment III
group did better on 8 of the 12 postsurgical measures.

Although that difference was not significant, the

77

possibility exists that those scores might reflect the
lack of interference with the patient's denial. In both
Treatment I and Treatment II the patient's impending
surgery was overtly discussed. In Treatment III that
discussion was not facilitated by the interviewer and
may have allowed the patient to use denial, which can be
an effective COping device.

Let us further examine the environment in which
the patients were treated. As stated, hospital policy
did not allow the patients to be treated without full
knowledge of participation. More important was the
unfeasibility of controlling the interest of the staff.
It was necessary that the surgeons be supportive of the
project before its inception since their permission was
necessary. The surgeons, therefore, were alerted to the
intent of the study. It is difficult to believe they
were not affected by the proposed interest of the
researchers; it is also possible their knowledge could
have affected the way they treated their patients.

The natural curiosity of the nursing staff was
also impossible to avoid. The patients, often delighted
to be'so well informed and attended to by the researchers,
often Shared the details of the experimental experience
with the nurses. Informal conversations between the
nurses and researchers indicated that the patients, in

addition to relating the focus of the presurgical tests

78

to the nurses, reported they were both "fascinated“ by
the psychiatrist's interview and "intrigued" by the pre-
surgical treatment offered by the counselor or social
worker. In this very direct manner the nurses also
became alerted to the focus of the study.

The entire staff appeared to become attuned to
the psychological implications for the patients, and were
eager to be a part of the impact. Although that sort of
participation could have been an ultimate gOal of any
team approach, it made it impossible to ferret out those
elements of presurgical attention which might be respon-
sible for helping the patient cope with the stress of
surgery.

On the other hand, it is possible that no single
treatment or service can itself make a difference in a
patient's response to surgery. It may be that just having
had someone pay special attention to their need could
have been reSponsible for the patients' Similar con-
valescence rates. The lack of differences between groups,
overall low incidences of medical and psychiatric compli-
cations combined with the normal amounts of medication
received could be a result of an effective package or
atmosphere which developed over the course of the study--
that of caring closely for the patient in a way which

enhances his responses to surgery.

79

In addition to the surgeons' and nurses' involve-
ment, the small size of the hospital facilitated patient
interaction and involvement in the study. The floor on
which the patients Spent the majority of their time had
17 rooms, 20 beds, and one lounge where patients admitted
for open heart surgery inevitably met with each other. AS
the study progressed the patients who were admitted on
Monday for surgery on Thursday met the patients who had
been admitted Saturday for surgery on Tuesday. Those
patients in the hospital since Saturday usually informed
newcomers about the extensive care to be received, the
attention being offered, and frequently filled in the
new patient on what to expect. Presurgical patients also
met postsurgical patients who offered an entirely dif-
ferent perspective. It is interesting to note that in
the supplemental analysis conducted to see if there were
differences between those admitted early or late in the
week, there were no differences. A probable explanation
is that once the surgery schedule became regular, there
were virtually always pre- and postsurgical patients on
the floor regardless of the day of the week.

More interference arose on the day before surgery
when each patient and his wife were given a tour of the
intensive care unit. More often than not at least one
of the patients in ICU was an open heart surgery patient

whom the touring patient had met previously on the floor.

80

A tradition spontaneously evolved in which the ICU patient
gave the touring patient the "high sign" to indicate that
all was well. During post-testing the counselor fre-
quently was told that the "high Sign" was a very impactful
incident in the presurgical period. Another important
experience for a presurgical patient was watching the
postsurgical patient taking his daily exercise walk
around the floor while giving encouragement to the patients
awaiting surgery. These examples are indicative of the
type of patient interaction for which it was impossible to
control.

Therefore, implications for future researchers
are many. Generally, the role of the psychological pre-
operative attitudes or coping styles, operative measures,
and age of the patient need to be explored further. If
they are in fact responsible for any differences in the
convalescence of patients, the variables used in this
study were not adequate to detect those differences.
Moreover, the treatments themselves need to be evaluated
more comprehensively. Perhaps a comparison of longer
treatments versus Shorter treatments or even treatments
including families would provide more conclusive evidence
of their effectiveness. Long-term convalescence data
also need to be examined.

Finally, to avoid diluting the results of a study,

conducting research Simultaneously in several hospitals or

81

in a large hospital with as little staff involvement in
the study as possible is essential. Only then can we
begin to differentiate between that which sounds intui-
tively appealing to the researchers and that which
actually proves to be useful or beneficial to the

patient.

APPENDICES

APPENDIX A

INTERVIEWER STATEMENT AND CONSENT FORM

APPENDIX A

INTERVIEWER STATEMENT

I am Andrea Van Steenhouse, part of the Cardiac
Surgery Team which includes the surgeons, nursing staff, a
social worker and a psychiatrist. Perhaps your doctor has
mentioned to you that we are looking at how patients respond
to Open Heart Surgery. we are interested in finding ways to
better prepare patients for surgery and to help make that
experience as comfortable as possible.

This will involve talking with a social worker and
psychiatrist, as all open heart surgery patients do. The
additional involvement is your filling out these three psy-
chological inventories now and two others postoperatively.
These are to give us an idea of how you feel approaching
surgery. Later today the social worker or I will stop in
briefly and ask you a few questions. The day prior to sur-
gery the psychiatrist will come in on his regular visit with
patients. That same day, either the social worker or I will
come back and you will have an Opportunity to discuss your
surgery and any concerns you might have.

'Of course all information resulting from our con-
tacts is confidential. If at any time you change your mind
about participating, please let us know.

This is the consent form. It describes what will
be taking place and that you will have access to the study

results once we are finished. Do you have any questions?

How do you feel about participating?
82

83

CONSENT FORM

I have been informed that Dr. Sumer Verma is
conducting a study on the psychological aspects of open
heart surgery. I freely consent to take part in this study.
The study has been explained to me; I understand the
explanation that has been given. I understand that my
participation will involve completing three psychological
inventories prior to surgery and two after surgery; two
interviews with a psychiatrist, one before and one after
surgery; and two interviews with a social worker prior to
surgery. I further understand that:

1. I am free to discontinue my participation
in the study at any time without penalty.

2. the results of the study will be treated
in strict confidence and that I will
remain anonymous (within these restrictions
results of the study will be made
available to me at my request).

3. my participation in the study does not
and cannot guarantee any beneficial.
results to me.

4. at my request, I can receive additional
explanation of the study after my
participation is completed.

 

Signature

 

Date

APPENDIX B

PRESURGICAL TREATMENT CONTENTS AND CHECKLISTS

1.

2.

APPENDIX B

PRESURGICAL TREATMENT I

Outline Checklist
l 2 3 4 5

Introduce self

 

Ask patient how decision for
surgery evolved

 

Discussed initial feelings
regarding surgery

 

Discussed current feelings
regarding surgery:

a. issue of death

 

b. issue of pain

 

c. other (list)

 

 

Ask patient his expectations
from surgery

 

Gave patient opportunity to
ask questions

 

Closing - thanked patient

 

84

85

TREATMENT I

Hello, I am Andrea Van Steenhouse/Evelyn Koenig with the
Cardiac Surgery Team. As I/Andrea explained, one of us
would stop by to talk with you about your surgery.

1.

Can you tell me how you happened to come in for surgery:
what kind of problem have you been having (get
patient to lead up to surgery decision).

Response: empathic to above facts

How did you feel when they told you you had to have
surgery?

How do you feel about that now?

Heart surgery is a major kind of surgery and most
patients feel pretty frightened--have you experienced
that? (Reassure patient that it is a normal feelng

and nothing for them to be ashamed or embarrassed about)

What do you expect from surgery/what do you hope for?
How did you handle that, feel about that--when
patient responds to how it came about.

Are there any special feelings or concerns that you
have that we haven't discussed?

I appreciate your talking with me. Thank you.

86

PRESURGICAL TREATMENT II

Outline Checklist
1 2’3 4 5

Alerted patient to psycho-
logical possibilities

depression

 

delerium (auditory or
visual hallucinations)

 

disorientation-~time,
place, erson

 

temporary difficulty With
memory

 

activity

patient equipment monitored

 

large numbers of people
on rounds

 

Steps of progress

a.

b.

trach tube out

 

chest tubes out

 

arterial line out

 

levine tube out

 

foley pulled out

 

Asking questions is good

 

Patient can communicate by signals

 

Patient will have pain and
discomfort but can ask for pain

medication (don't wait too long)

 

Patient can discuss perceptual
disturbandes, confusion or
depression with nurses

 

87
Teach patient to refocus attention

a. assisted patient in thinking of
positive aspects of surgery

 

b. using analogies, helped
patient learn to concen-
trate on other than
physican condition

 

88

TREATMENT II

Hello, I am Andrea Van Steenhouse/Evelyn Koenig with
the Cardiac Surgery Team. As I/Andrea explained, one of us
would stop by to talk with you about your surgery.

When you have surgery you go directly to surgery
which is on the second floor. From surgery you are taken to
the Intensive Care Unit rather than the recovery room like
most surgical patients. Once you get to the ICU, you
will find that you will be attached to a-lot of equipment
(if specific types come up refer to nurse). They will come
out a step at a time as your condition warrants. All
patients are attached to the same equipment. There will be
a lot of treatments going on continually and you will be
awakened frequently for those treatments. You will also
notice that there will be a large number of people coming
in--doctors, nurses, respiratory people, lab and tray, etc.,
and that too is done for all patients.

Given the fact that you have been through major sur-
gery you have had a lot of medication and you are in an
environment where you cannot tell the time of day, etc., and
you are awakened frequently. Some patients tend to become
a little confused--they won't know exactly where they are or
what things have happened recently. This happens because of
all of the environmental things, it usually passes quickly,
and is nothing to be concerned about. Sometimes a few days
after surgery you may begin to feel quite depressed. This
again is temporary and nothing to be concerned about.

There are some things that you can do to help make
yourself more comfortable. First you can ask questions any
time about anything that is happening. PeOple are sometimes
reluctant to ask questions because the doctors seem too busy
or they are afraid it will sound Silly or they are afriad
that the doctor might become angry with them. The doctors
and nurses here encourage you to ask questions whenever
you have them.

Since you will have some pain and discomfort, let the
nurses know when this occurs. Pain medication will be
ordered for you and you can ask the nurses for it when you
need it. It is better to ask before the pain becomes too
severe. If you should experience any confusion, let the
nurses know and they will assist you with that.

Should you need to communicate these things while the
tube is still in your mouth, you can communicate with the

89

nurse by signals with your hand. The nurse is always in the
room and is used to anticipating patients' needs and will
respond to any attempt to communicate.

In addition to the above, it sometimes helps if you
have pain or discomfort to refocus your attention on posi-
tive things. For example, if you are really interested in
doing something and sustain a minor cut you usually don't
notice it until after you are finished. In a Similar way,
you c ould be less uncomfortable if you concentrate on
things besides your feelings of pain. Can you think of
things-~either positive aspects of surgery or things
norma-ly p1easant--for you to think about which you could
sort of plan ahead to use?

DO you have any questions?

4.
5.

10.
11.

90

PRESURGICAL TREATMENT III
Outline Checklisp
l 2 3 4 5

Can you tell me how you came
to be here for surgery?

 

Have you ever been in‘the
hospital before?

 

What kinds of illnesses did
you have?

 

When did you go back to work?

 

What kinds of activities have
you been able to do?

 

What kind of activities have
you been able to continue?

 

When was the decision to have
surgery made?

 

How did you decide to have
surgery?

 

What has the physician told
you about your surgery?

 

What have the nurses told you?

 

Do you have any questions?

 

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