Surgical Patients Need Us: Psychological Preparation Improves Outcomes by William W. Deardorff, Ph.D., ABPP 6 Credit hours - $149 Last revised: 07/15/2007 Course content © copyright 2007 by William W. Deardorff, Ph.D., ABPP. All rights reserved. ContinuingEdCourses.Net is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. ContinuingEdCourses.Net maintains responsibility for this program and its content. ContinuingEdCourses.Net is approved by the Association of Social Work Boards (ASWB) to offer continuing education for social workers, through the Approved Continuing Education (ACE) program. ContinuingEdCourses.Net maintains responsibility for its courses. ASWB provider #1107. ContinuingEdCourses.Net is approved by the National Board for Certified Counselors (NBCC) as an NBCC-Approved Continuing Education Provider (ACEP) and may offer NBCC-approved clock hours for events that meet NBCC requirements. ContinuingEdCourses.Net solely is responsible for all aspects of the program. NBCC provider #6323. ContinuingEdCourses.Net is approved by the California Board of Behavioral Sciences (CA-BBS) to offer continuing education for MFCCs (MFTs) and LCSWs. CA-BBS provider #3311. ContinuingEdCourses.Net is approved by the Ohio Counselor, Social Worker, & Marriage and Family Therapist Board (OH-CSWMFT) to offer continuing education for counselors, social workers, and MFTs. OH-CSWMFT provider #RST080501 & #RCX010801. Take the Course Take the Test Buy your Certificate

Learning Objectives

This is an intermediate level course. After taking this course, mental health professionals will be able to:

• List four benefits of psychologically preparing patients for surgery
• Discuss two conceptual models that provide the foundation for psychological preparation
• Identify patient coping styles and utilize this in planning interventions
• Design three cognitive behavioral interventions
• List the functions of the immune and neuroendocrine systems
• Build a program of psychological preparation for surgery into your clinical practice

Course Outline

Chapter 1: The psychoneuroimmunology of surgery

Chapter 2: Conceptual models of surgery preparation

Chapter 3: Preparing for surgery: cognitive-behavioral interventions

Chapter 4: Preparing for surgery: psychosocial interventions

Chapter 5: The business of surgery preparation: adding it to your practice

Introduction to the Course

This course will introduce the clinician to the field of psychological preparation for surgery.  This course is an overview and summary of the literature in this area over the past 30 years and including the findings of over 200 studies.  The course will outline a surgery preparation program based upon this empirical research that can be used with patients/clients and is applicable to any type of elective (non-emergency) surgery.  The course will also discuss how surgery preparation can be added to one’s practice.

In chapter one, an overview of the field of psychoneuroimmunology will be presented.  This information provides an understanding as to why preparation for surgery can result in such positive outcomes as improved wound healing, a decreased need for pain medications, less time in the hospital, fewer complications, and a an enhanced surgical outcome overall.

In chapter two, conceptual models of surgery preparation are discussed.  The chapter reviews various interventions including information and education, cognitive-behavioral approaches such as relaxation training and imagery, empowerment and self-efficacy, and the biopsychosocial model.

In chapter three, cognitive-behavioral surgery preparation will be reviewed.  These techniques include cognitive restructuring, relaxation training, and imagery.  The chapter will also review findings in the areas of helping the patient understand and remember medical information, gathering information about the surgery, avoiding medical errors in the hospital, and tailoring the surgery preparation program to the patient’s coping style.

In chapter four, psychosocial interventions for surgery preparation will be outlined.  These include such things as effective doctor-patient communication, assertiveness training, preparing family and friends, spiritual issues, and postoperative pain control.

Chapter five is a brief overview of ideas for integrating surgery preparation into one’s practice.  These “tips” include such topics as targeting specific types of surgery, working with a surgical group practice, and offering the program at a local hospital as well as billing and reimbursement issues.

Much of the material in this course is based upon the book, Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery (Deardorff and Reeves, 1997; New Harbinger Press). The book is designed as a self-guided patient workbook, but might also be used as a clinician guide for surgery preparation.

I am happy to respond to questions or comments about the strategies presented in this course. You may contact me here. You may purchase my book by clicking on Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery.

Chapter 1: The Psychoneuroimmunology of Surgery

Brief Introduction to the Field of Psychoneuroimmunology

From an evolutionary perspective, it was critical for an organism to be able to respond adaptively to environmental threats to increase the chances of survival.  In mammals, these physical responses include changes that increase the delivery of oxygen and glucose to the heart and the large skeletal muscles.  This reaction allows for a “fight or flight” response.  An immune system reaction to a stressful situation is also adaptive since fighting or fleeing in response to a threat carries the risk of injury and subsequent infection.  As such, stress-induced changes in the immune system that facilitate wound repair and help fight off infection would certainly be advantageous (See Segerstrom and Miller, 2004 for a review). 

Modern humans are rarely faced with the kind of threats experienced by our ancestors such as being chased by a large, hungry animal.   Even so, human physiological responses continue to reflect the demands of those early threatening environments (Segerstrom and Miller, 2004).  Psychological threats that do not require a physical response (e.g. fight or flight) such as facing an academic exam, sitting in traffic, getting ready for a major surgery, or going through a divorce, still elicit physical changes (e.g. increased blood pressure, muscle tension) along with an immune system response. If these physical changes continue over the long term, they can have a deleterious effect on one’s health. 

The field of psychoneuroimmunology (PNI) investigates the psychological modulation of immune function. As presented by Kiecolt-Glaser et al. (2002), there are two milestones in the PNI field.  First, Solomon et al. (1964) coined the term “psychoneuroimmunology.”  Second, Ader and Cohen (1975) demonstrated that classical conditioning of immune function was possible.  As discussed by Kiecolt-Glaser, McGuire, Robles, & Glaser (2002), the field of PNI has rapidly expanded over the past three decades and “…psychological modulation of immune function is now a well-established phenomenon…” (Kiecolt-Glaser et al., 2002, p. 15). Psychological stress has been linked with a broad array of adverse health outcomes such as heightened risk for upper respirator infection, accelerated progression of coronary artery disease, exacerbation of autoimmune disorders, and poorer outcome to surgery (See Miller, Cohen, & Ritchey, 2002; Block, Gatchel, Deardorff, & Guyer, 2003 for a review).  

A recent extensive review of the PNI literature along with analysis has provided more support for the stress-immune function link.  In their study, “Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry,” Segerstrom and Miller (2004) completed a meta-analysis of more than 300 studies describing the relationship between psychological stress and immune function.  The analyses supported the conclusion that stressful experiences alter features of the immune system and confer vulnerability to adverse medical outcomes that are either mediated by, or resisted by, the immune system.  For readers interested in further resources in PNI, the following references are suggested: Benjamini, Coico, & Sunshine (2000) and Rabin (1999).

The Psychoneuroimmunology of Surgery

Until recently, researchers faced a “black box” problem when trying to investigate how presurgical variables influenced post-surgical outcomes since the intricate, inner-workings of a surgical patient’s various body systems could not be adequately measured. Thus, most of the research was correlational in nature and the psychophysiological links between pre-surgical variables (and interventions) and postoperative outcomes could only be speculated. With the emergence of the field of psychoneuroimmunology (PNI), investigators are now able to investigate the inner workings of the “black box” and identify how presurgical variables impact the body to affect wound healing and postoperative outcome. The science of PNI basically focuses on the connections between the central nervous system (“mind”) and the immune system (“body”) (Hafen, Karren, Frandsen & Smith, 1996).

Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser (1998) have developed an excellent biobehavioral conceptual model that takes into account the various psychological variables that could influence the immune system, wound healing and, subsequently, short term postoperative recovery. A brief overview of the components of this conceptual model follows:

• The patient’s attitude towards the surgery as well as premorbid personality factors significantly influences the patient’s emotional status during the surgery decision-making process. In turn, emotions have a direct effect on “stress” hormones and these modulate immune function.
• A patient’s psychological status (including both cognitive and emotional factors) influences the type and amount of anesthetic necessary. These medications also have influences on the patient’s immune and endocrine system.
• Health behaviors and health status also have a significant influence over the surgery process, including immune and endocrine function, wound healing, and overall postoperative rehabilitation. As an additional challenge, when patients are under stress, they may be likely to increase negative short-term destructive coping behaviors such as smoking, alcohol, and caloric intake. Of course, increasing these potentially self-destructive behaviors can have a deleterious effect on not only immune and neuroendocrine function, but also postoperative physical recovery.
• In addition to stress, inadequately controlled pain has also been found to have adverse effects on immune and endocrine function (Liebeskind, 1991). This can then impair wound healing and overall recovery from surgery.

Next, the PNI model developed by Kiecolt-Glaser et al. (1998, 2002) is discussed in detail with a review of background research literature in this area. It is important to have an understanding of these bio-behavioral pathways since this model establishes a firm rationale in support of psychological preparation for surgery. Thus, the clinician can be confident that the preparation for surgery procedures are inducing actual physical changes in the patient to enhance surgical outcome. Discussing these issues with the patient presurgically provides an explanatory model that will help increase his motivation and compliance with active participation in a preparation for surgery program. Finally, the PNI area of research relative to wound healing can help convince surgeons that preparation for surgery interventions are indeed valuable from a physical, psychological, and behavioral standpoint.

The Immune and Neuroendocrine Systems

Prior to exploring the details of the bio-behavioral healing model, overviews of the immune and neuroendocrine systems, as well as mechanisms of wound healing, will be reviewed. To appreciate the research findings in the area PNI and surgery, it is important to have some understanding of these important body systems. More detailed information about the immune and neuroendocrine systems can be found elsewhere (Benjamini, Coico, & Sunshine, 2000; Cohen & Herbert, 1996; Kiecolt-Glaser & Glaser, 1995; O’Leary, 1990; Page, 1996; Rabin, 1999; Spence, 1982).

The Immune System

The immune system is the body’s primary defense against attackers, both from within the body and from without. According to Kiecolt-Glaser and Glaser (1992), the immune system has two primary functions: to distinguish between “self” and “non-self,” and then to inactivate, destroy, or eliminate foreign substances that are identified as not naturally part of the body (“non-self”).

The immune system contains organs that are found throughout the body. These are generally termed the “lymphoid” organs because they are involved with the development and deployment of lymphocytes (small white blood cells that modulate the immune system response). Lymphoid organs include bone marrow, the thymus, the lymph nodes, the spleen, the tonsils, the appendix, and lymphoid tissue in the small intestine known as Peyer’s patches.

The bone marrow produces cells that will eventually become lymphocytes. There are two major types of lymphocytes, T-lymphocytes and B-lymphocytes. B-lymphocytes (so named because they were first discovered in a chicken gland called the bursa) develop outside the thymus. The B-lymphocytes or B-cells produce circulating antibodies. Antibodies are proteins (belonging to a family of proteins called immunoglobulins) that attack bacteria, viruses, and other foreign invaders (called antigens). Each specific antibody matches a specific invading antigen. The antibodies can inactivate the antigens making them incapable of causing disease. Antibodies “fit” specific antigens commonly described “as a key fits a lock.” Each antibody will attack only a single kind of antigen, and each B-lymphocyte produces only one kind of antibody.

The other major class of lymphocytes is the T-lymphocytes or T-cells. Some of the cells produced in the bone marrow termed “stem” cells migrate to the thymus, an organ that lies high up just beneath the breastbone. These stem cells multiply in the thymus and develop into T-cells (their name is derived from the fact that they develop in the thymus gland). T-cells do not secrete antibodies, but are essential for antibody production.

There are several different groups of T-cells and these have different functions. “Helper” T-cells stimulate B-lymphocytes to produce antibodies as well as “turn on” other T-cells. “Suppressor” T-cells “turn off” the helper T-cells when an adequate amount of antibodies has been produced. Helper and suppressor T-cells communicate with each other by producing chemical messengers such as interferons and interleukins. In a healthy person, the helper/suppressor cell ratio should be in balance. Patients with immunodeficiency diseases have low ratios (too few helper cells relative to suppressor cells) while people with autoimmune diseases have high ratios.

There are other groups of T-cells as well, and these have different functions. Cytotoxic (literally “cell-killing”) T-cells, along with blood cells termed natural killer (NK) cells, patrol the body constantly searching for hazardous abnormal cells. Once these cells are discovered, the cytotoxic T-cells attach themselves and release toxic chemicals to destroy them.  In a process that is similar to antibodies, each cytotoxic T-cell is designed to attack a specific target. Thus, there are cytotoxic T-cells that are specific for cancer cells, for cells that have been infected by viruses, and for transplanted tissue and organs. The activity of cytotoxic T-cells is one reason why immunosuppressant medication must be given as part of organ transplantation procedures. The NK cells are called “natural” because they will go into action without prior stimulation by a specific antigen. Normal cells are generally resistant to NK cell activity; however, tumor cells and cells infected with a virus are susceptible. Therefore, the NK cell is thought to play a critical role in the immune system’s response to cancer. In contrast to cytotoxic T-cells, NK cells attack a broad range of targets including tumor cells and a variety of infectious microbes.

Other important components of the immune system include the macrophages and monocytes, which are cells that act as scavengers (or phagocytes). These cells envelop and destroy microorganisms and other antigenic particles within the body. Monocytes circulate in the blood and macrophages are within the body tissues. Granulocytes are phagocytes that are also capable of destroying invaders. These chemicals contribute to the inflammatory response and are also responsible for allergy symptoms.

The Neuroendocrine System

Surgical stress can affect the neuroendocrine system and, thereby, influence wound healing. The endocrine system is composed of various glands located in different places throughout the body. The major endocrine glands include the pineal, pituitary, thyroid, parathyroids, thymus, adrenals, pancreas, ovaries, and testes. The pituitary gland is considered the “master gland” since its hormones regulate several other endocrine glands and affect a number of body activities. The nervous and endocrine systems are intimately related (hence the term “neuroendocrine”).  

One function of the endocrine system is to secrete hormones when the body is under stress. Hormones can be thought of as “chemical messengers” that influence organs in the body (target organs). Two main hormone groups are utilized by the body to deal with stress and are released in response to it – the catecholamines and the corticosteroids. There are two different types of catecholamines – adrenaline (or epinephrine) and norepinephrine. The catecholamines cause significant physical changes such as rapid heartbeat, constriction of blood vessels, hyperventilation, and blood thickening with more rapid coagulation. This has been termed the “fight or flight response” and, basically, prepares the body for a physically threatening situation. This is an adaptive response when one is being chased by a tiger or running from a fire. Unfortunately, this physical stress reaction is unhealthy when it is in response to a non-physically threatening situation (emotional stress) and/or is sustained over a longer period of time (such as facing surgery or chronic anxiety). When catecholamine levels are too high – such as in chronic stress – the result can be a variety of medical problems such as muscle tremors, diabetes, heart attack, and stroke. In addition, unhealthily elevated catecholamine levels significantly suppress the immune response resulting in an increased susceptibility to infection and delayed wound healing.

Corticosteroids are the other major hormone group that is secreted in response to stress. Corticosteroids include cortisone and cortisol. Similar to the catecholamines, increased levels of corticosteroids are adaptive in response to a physical threat but may be unhealthy under other circumstances. For example (Hafen et al., 1996):

• Cortisone stimulates the kidneys to produce renin, a hormone that increases blood pressure.
• The cells lining blood vessels can be damaged causing the body to respond by secreting more cholesterol in an attempt to repair arterial tears. Subsequently, the accumulation of plaque and cholesterol can lead to atherosclerosis and heart problems.
• Cortisone inhibits Vitamin D activity resulting in a loss of calcium.
• It causes the liver to overproduce glucose, which, over the long term, can increase the risk of diabetes.

The effects of elevated cortisol over a longer term may also create a myriad of physical problems such as (Hafen et al., 1996; McEwen, 1990):

• Progressive nerve loss in certain parts of the brain
• Shrinkage of the spleen and thymus which are essential for the production of white blood cells
• A breakdown of lymphoid tissues in the thymus and lymph nodes which, in turn, reduces the level of T-helper cells and increase the level of T- suppressor cells
• Inhibition of the production of NK cells
• A reduction in interferon, which is important for fighting off viruses

Beyond the acute stress of the surgery process, a surgical patient who has been under chronic stress is likely to be at even greater risk for slower wound healing, postoperative complications, and a longer than normal recovery period.

The Process of Wound Healing

As discussed by Hubner, Brauchle, Smola, Madlener, Fassler, & Werner (1996), wound repair progresses through several stages:

• Inflammation
• Vasoconstriction
• Blood coagulation
• Platelet activation
• Activation of platelet-derived growth factors

Of course, any type of surgery produces a wound and the body will respond by initiating this healing process. The initial stage of wound healing is an inflammatory response. The inflammatory response is important for its contribution to pain, immunity, and the beginning of wound healing. Tissue damage caused by the surgical procedure results in a local release of substances (such as substance P, bradykinin, serotonin, calcitonin, prostaglandins, and histamine, among others) that result in the inflammatory response characterized by vasoconstriction, blood coagulation, increased capillary permeability, and sensitization of peripheral afferent nerve fibers resulting in allodynia and hyperalgesia (Page, 1996; Van De Kerkhof, Van Bergen, Spruijt & Kuiper, 1994; Woolf, 1994). Through a variety of mechanisms (see Kiecolt-Glaser, 1998 for a review), other physical responses also occur including local (Schweizer, Feige, Fontana, Muller, & Dinar, 1988) and systemic hyperalgesia, as well as flu-like symptoms (Watkins, Goehler, Relton, Tartaglia, Silbert, Martin, & Maier, 1994; 1995). The flu-like symptoms, such as fever and malaise, are due to activation of the hepatic vagus or the central nervous system (Page, 1996, Watkins et al, 1994; 1995). The hyperalgesia is due to the sensitization of nociceptive fibers that decrease the threshold necessary to initiate impulse transmission (Woolf, 1994). In other words, the surgical patient is physically more susceptible to painful stimuli (i.e. everything hurts more).  

The wound repair process, as described by Hubner et al. (1996), results in the migration of phagocytes to the damaged site and this begins the process of cell recruitment and replication necessary for tissue regeneration and capillary regrowth. A patient’s immune function plays a critical role early in the wound healing process. Certain cytokines are essential to protect the person from infection and prepare the injured tissue for repair and remodeling (Lowry, 1993). As Hubner et al. (1996) point out, success in the later stages of wound repair is highly dependent on initial events.

Immune and Neuroendocrine Influences on Wound Healing

Stress has been found to impact immune (Glaser & Kiecolt-Glaser, 1994; Herbert & Cohen, 1993; Segerstrom & Miller, 2004) and neuroendocrine function which, in turn, has an impact on wound healing (Kiecolt-Glaser et al., 1998; 2002). As discussed previously, immune function plays a critical role in the early stages of tissue damage repair. In addition to other variables, the tissue-damaging component of surgery has been shown to induce immune and neuroendocrine changes (see Page, 1996 for review). For instance, immune suppression during surgery is evidenced by suppression of natural killer cell activity (NKCA) (Pollock, Lotzova, & Stanford, 1991), lymphocyte proliferation responses, and changes in lymphocyte populations (Tonnessen, Brinklov, Christensen, Olesen, & Madsen, 1987). In general, stress suppresses the immune system’s ability to maintain natural killer cells and lymphocytes. Stress has been shown to increase the number of circulating white blood cells, but decrease the number of circulating B-cells, T-cells, helper T-cells, suppressor T-cells, cytotoxic T-cells, and large granular lymphocytes (Goliszek, 1987; Hafen et al., 1996). All of these factors make a person more susceptible to infection and disease while slowing the wound healing process.

The stress of surgery also affects the neuroendocrine system. Stress-related changes in the hypothalamic-pituitary-adrenal (HPA) axis can have important consequences for the wound healing process. For instance, elevations in glucocorticoids can temporarily suppress pro-inflammatory cytokines that are essential to the early stages of wound healing by protecting a person from infection and preparing the injured tissue for repair (Kiecolt-Glaser et al., 1998; 2002).

Another neuroendocrine factor in wound healing is the action of growth hormone (GH). Much of a person’s daily GH release has been found to occur during deep sleep (Veldhuis & Iranmanesh, 1996). Although acute stressors have been found to result in temporary increases in GH (Kiecolt-Glaser, Malarkey, Cacioppo, & Glaser, 1994), more chronic stress that disrupts the sleep cycle can lessen GH secretion. This is important since GH has been found to be a factor in enhancing wound healing (Veldhuis & Iranmanesh, 1996). GH is a macrophage activator (Zwilling, 1994) and is important for improved protection from infection after tissue damage.

Stress and Wound Healing: A Review of the Evidence

There have been a great many studies done, both animal and human, that have documented the effects of stress on wound healing, the mechanisms of which have been discussed previously. In a series of nicely designed studies, a group of family members who provided care for a relative with Alzheimer’s disease was studied and compared with a well-matched control group (Kiecolt-Glaser et al., 1994, 1998; 2002; Kiecolt-Glaser, Glaser, Gravenstein, Malarkey, & Sheridan, 1996; Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991). The caregiver group was assumed to be under more chronic stressful conditions. The results demonstrated that the caregivers had poorer immune function. In one of the studies directly related to wound healing, a small standardized wound (removal of a small piece of skin from the inner arm below the elbow) was made. The healing process was carefully monitored for the caregiver and the control groups. Consistent with differences in immune function, it was found that the caregiver group took an average of nine days or longer than controls to heal completely. Photographic data of the wound size demonstrated that the largest differences occurred early in the healing process. Thus, it appears that the early stages of wound repair were most significantly impacted by immune system deficiencies (for a complete discussion of this issue, see Kiecolt-Glaser et. al., 1995; 1998). It should be noted that the caregiver and control groups were matched on all other relevant variables.

In a subsequent study using an animal model, a group of mice was divided into a stress group (placed in restraints) and a non-stressed group. A standardized punch biopsy wound was created and the healing process monitored. It was found that the stressed mice healed an average of 27% more slowly than the control group (Padgett, Marucha, & Sheridan, 1998). Again, it appeared that major differences occurred early in the wound healing process. Based upon assessment of serum corticosterone across the two groups, this may have been the result of a disruption of the neuroendocrine homeostasis that modulates wound healing.

In another study, biopsy scalpel wounds were created in the hard palate of 11 volunteer dental students during their summer vacation and then again during their first major examination (Marucha, Kiecolt-Glaser, & Favagehi, 1998). The investigators were able to establish a rate of healing for each individual by measuring the size of the wound initially and at the point of final healing. This rate of healing was measured at the two time periods: first, during the summer vacation and, subsequently, during the high stress examination period. The healing rate during the high stress period was 10.91 days versus 7.82 days during vacation. Thus, wounds placed three days before a major test healed an average of 40% more slowly than during summer vacation. Beyond looking at group data, the authors note that this slower pattern of healing during stress was uniform across all participants. Certain measures of immune function were also investigated during the course of the study. It was found that there was a 71% decline in certain immune cell indices from the low stress assay period to the high stress assay (see Marucha et al., 1998 for details). This study extended previous research in demonstrating that delays in wound healing can occur in response to acute stressors (the examination) similar to what was found in groups who are chronically distressed (Alzheimer’s caregivers).

As pointed out by Kiecolt-Glaser et al. (1998, p. 1209), the results of these studies have “broad implications for surgical recovery.” The combined results from this series of studies demonstrate that surgical patients who have been under chronic stress are at risk for slower wound healing as well as infection due to immunosuppression; further, the short term stress of going through the surgery process, in and of itself, has the potential to hamper wound healing. These findings have special implications for the chronic back pain patient who chooses to undergo spine surgery. That individual’s immune system is confronted not only with the stress of chronic pain, but also with the situational stress of the surgery. 

The Influence of Pain on Neuroendocrine and Immune Function

Virtually all surgical procedures are associated with mild to severe postoperative pain. An important area of PNI research is whether pain contributes to neuroendocrine and immune function changes. In animal studies, painful stressors that do not cause tissue damage (such as foot shock and tail shock) have been shown to suppress immune function including NK cell activity, lymphocyte proliferation responses, and specific antibody production (Pezzone, Dohanics, & Rabin, 1994; Liebeskind, 1991).  Neuroendocrine changes have also been demonstrated including elevated corticosteriod (Pezzone et al., 1994) and plasma beta-endorphin levels (Sacerdote, Manfredi, Bianchi, & Panerai, 1994).

There are significant neuroendocrine and immune responses to tissue damage (such as surgery), and these have been extensively researched as outlined previously. Beyond the tissue damage, research suggests a connection between the sympathetic nervous system (SNS), the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic-adrenal-medullary axis (SAM), and the immune system (Keicolt-Glaser et al., 1998; Koltun, Bloomer, Tilberg, Seaton, Ilahi, Rung, Gifford, & Kauffman, 1996; Miller et al., 2002) in response to painful stress such as surgery. SNS and HPA axis activation postoperatively is reflected by elevations in plasma levels of epinephrine, cortisol, and beta-endorphin (Salomaki, Leppaluoto, Laitinen, Vuolteenaho, & Nuutinen, 1993). In addition, immunosuppression during surgery is evidenced by a decrease in NK cell activity (Pollock et al., 1991), lymphocyte proliferation, and changes in the lymphocyte population (Tonnessen, et. Al., 1987). 

Although these results cannot firmly verify the role of pain as a factor in neuroendocrine and immune changes in response to surgical stress, there are further findings that support such a conclusion (see Kiecolt-Glaser & Glaser, 1998; Page, 1996 for reviews).  Multiple studies have demonstrated that anesthetic techniques used to block transmission of nociceptive impulses locally (Pasqualucci, Contardo, Da Broi, Colo, Terrosu, Donini, Sorrentino, Pasetto, & Bresadola, 1994), at the spinal cord level (Koltun et al., 1996; Salomaki et al, 1993; Tonnessen & Wahlgreen, 1988), or through systemic anesthetic (Anand, Sippel, Aynsley-Green, 1987; Kehlet, 1984) significantly reduces the neuroendocrine or immune response to surgery. Further, at least two prospective studies have found that epidural anesthesia was associated with a significant reduction in the incidence of postoperative infections, suggesting immune function suppression may have been blocked (Cuschieri, Morran, Howie, & McArdle, 1985; Yeager, Glass, Neff, & Brinck-Johnsen, 1987). This would seem to indicate that adequate pain control via the epidural anesthesia resulted in attenuation of the immunosuppressive effect of surgery. In other research approaches to this issue, successfully controlling postoperative pain with systemic opioids has been associated with a reduction in plasma cortisol levels (Moller, Dinesen, Sondergard, Knigge, & Kehlet, 1988), and pain control with narcotic anesthesia has been shown to suppress the hormonal response to surgery (Lacoumenta, Yeo, Burrin, Bloom, Paterson, & Hall; 1987). Taken together, this line of research does suggest that adequate pain control helps attenuate deleterious neuroendocrine and immunological reactions to surgery. Unfortunately, postoperative pain control is commonly inadequate and a preparation for surgery program can help successfully address this problem.

Health Habits, Health Status and Surgery

As previously reviewed, several variables affecting the neuroendocrine and immune systems have been investigated as they relate to the final common pathway of wound healing and surgical recovery. These include stress (both acute and chronic), the physical trauma of surgery, and resulting tissue damage, as well as pain. In the following section, the mechanisms by which health behaviors and health status influence wound healing will be explored. One important overall finding to keep in mind is that heightened distress, such as facing a surgery, is associated with an increase in risky behavior across all dimensions, such as alcohol and cigarette use (Steptoe, Wardle, Pollard, Canaan, & Davies, 1996). Many patients faced with a stressful situation will utilize more self-destructive coping techniques. These health habits, as well as the surgery process, interact with health status (such as age and physical deconditioning) to impact healing and recovery. 

Alcohol

An impending surgery can be quite stressful for the patient depending on the extent of the operation and the “meaning” the procedure carries with it. For instance, looking forward to a hernia repair is quite different from something like a spinal fusion or coronary artery bypass surgery. Patients who are preparing to undergo a spine operation are often under acute, situational stress associated with the surgery process as well as more chronic stress related to the impact their back pain has had on their lives. As an example, the following scenario is not uncommon in the treatment of spinal disorders.

A patient has a back pain problem that is initially treated conservatively using appropriate interventions (e.g. medications, physical therapy and exercise, epidural blocks). During this time, the patient’s overall level of function may diminish including both work and recreational activities. Once it is determined that the conservative measures will not provide a solution, the surgery option is entertained more seriously. By that time, the patient may be under a variety of psychosocial stressors due to the chronic pain (physical and mental deconditioning as discussed in Gatchel, 1991; 2004).

Patients will occasionally resort to increased alcohol intake as a mechanism for coping with the ongoing stress and/or as a method of self-medicating for pain, sleep, and anxiety. Alcohol has been found to slow wound healing directly due to a slowing of cell migration and deposition of collagen at the wound site (Benveniste & Thut, 1981). There are several other alcohol effects that can influence the body’s ability to heal from a surgery including sleep disruption, increased depression and anxiety, increased smoking behavior due to diminished impulse control, poor nutrition, subclinical cardiac dysfunction, and amplified endocrine changes in response to surgery (Kehlet, 1997; Kiecolt-Glaser et al., 2002; Miller et al., 2002).

Smoking

As demonstrated in a myriad of studies (see Porter and Hanley, 2001 for a review), smoking (especially chronic) causes a host of problems related to wound healing and surgery outcome.  Some researchers have speculated that smoking impairs wound healing after surgery primarily due to a decrease in blood flow to the injured tissues (vasoconstriction) and moderate blood levels of carbon monoxide (Leow and Maibach, 1998; Mosely and Finseth, 1977). In other studies, nicotine has been shown to affect a variety of other bodily functions that relate to wound healing such as a decrease in the proliferation of cells within the extracellular matrix and epithelial regeneration (Sherwin and Gastwirth, 1990). In addition, Jorgensen, Kallehave, Christensen, Siana, & Gottrup (1998) have demonstrated that collagen synthesis was hindered in the wounds of smokers relative to a nonsmoking control group. Collagen is the primary determinant of the flexible strength in a wound that is healing. Silverstein (1992) discussed that smoking diminishes proliferation of fibroblasts and macrophages, causes vasoconstriction that reduces blood flow to the injured tissue, and can inhibit enzyme systems for oxidative metabolism and transport. This decreased availability of nutrients important for wound repair, along with the immune system suppression, results in slowed healing time among smokers along with an increased rate of postoperative infections (Silverstein, 1992).

As previously reviewed, smoking can affect the outcome of virtually any type of major surgery. To review in more detail the potential deleterious effects of smoking on surgical outcomes, the area of spine surgery is certainly applicable. Spine surgery is done fairly frequently in the United States and is most often an elective procedure directed at pain relief. Preparation for spine surgery can enhance outcome; smoking cessation may be one goal of the intervention. There are several studies specifically related to smokers and spine surgery. Some investigators believe that in long-term smokers, the intervertebral discs are malnourished due to the vascular and hematologic changes (Ernst, 1993). It is postulated that tissues such as the vertebra and vertebral disc have a limited blood supply anyway and are not able to compensate for the decrease in blood flow that occurs in chronic smokers. Over time, the diminished delivery of oxygen and nutrients to these spine structures leaves them more vulnerable to injury and less able to heal after a surgery.

Hanley and Shapiro (1989) found that there was a negative impact on the postoperative success of lumbar discectomies to treat severe radiculopathies in patients who were very chronic smokers of 15 years or more. It is also believed that smoking may lead to a higher rate of postoperative wound infections (Calderone, Garland, Capen, & Oster, 1996; Capen, Calderone, Green, 1996). Thalgott, Cotler, Sasso, LaRocca, & Gardner (1991) retrospectively reviewed 32 cases of spinal surgery and found that, in the group of patients who sustained an infection after spinal fusion and instrumentation, 90% were cigarette smokers. Of special importance to the field of spine surgery is the effect of smoking on the healing of bone since this specifically relates to a patient’s recovery from a spinal fusion. Brown, Orme and Richardson (1986) reported that the pseudoarthrosis (non-union) rate for spinal fusion patients approached 40%. This compares with a rate of 8% in nonsmokers in the same study. Carpenter, Dietz, Leung, Hanscom, & Wagner (1996) subsequently found that the rate of repeat spine surgery due to a pseudoarthrosis was significantly less for nonsmokers.

There are a variety of explanations for these results. As discussed earlier, one idea is that smoking causes vasoconstriction that diminishes the blood supply to the area of bone growth. Another theory is that smoking impairs osteoblast function, resulting in defective bone healing (de Vernejoul, Bielakoff, & Herve, 1983). Campanile, Hautmann and Lotti (1998) suggest that that there are a variety of negative effects due to smoking that hamper bone growth including the vasoconstrictive and platelet-activating properties of nicotine, the hypoxia-promoting effects of carbon monoxide, and the inhibition of oxidative metabolism at the cellular level by hydrogen cyanide.

If a spinal fusion is being considered in a patient who smokes, there are no clear guidelines about preoperative cessation of cigarette consumption (Porter & Hanley, 2001). Suggestions range from at least 12 hours before surgery to 60 days. The recommendation for at least 60 days is based upon studies showing a nonsmoker can make 1 cm of bone in two months, but that it takes a smoker an average of three months to make the same amount of bone (Whitesides, Hanley, & Fellrath, 1994). Of course, it is also important that the patient remain abstinent from smoking postoperatively while the fusion is healing. This issue would also be part of surgery preparation.

The Physical Deconditioning Syndrome

Physical deconditioning or deactivation syndrome can occur when a patient with a chronic pain problem (e.g. back pain) or physical disability attempts to manage the pain by limiting normal activities, restricting exercise, and/or engaging in extensive bedrest. The deconditioning syndrome can result in a number of unhealthy occurrences affecting virtually every body system including (See Bortz, 1984):

• a decrease in the size, strength and flexibility of muscles and tendons; muscle atrophy at a rate of 1.0 to 1.5% per day of bed rest
• diminished cardiopulmonary capacity (15% in 10 days)
• bone mineral loss, hypercalcemia, hypercalciuria
• immunologic system decrements
• deep venous thrombosis and thromboembolism
• multiple other negative organ system effects

These negative effects have an impact on a person’s ability to heal and recover from a surgery. In addition, healing tissue that is completely immobilized postoperatively tends to become an amorphous, nonfunctional scar with low strength and a vulnerability to re-injury (see Gatchel, 1991; 2004). This is one reason that, in appropriate cases such as orthopedic surgery, surgeons recommend some type of movement on a regular basis beginning very shortly even after a major surgery. Of course, the movement guidelines are designed to facilitate the healing process without putting the surgery results at risk. When done properly, this allows the tissues to heal in a more flexible and strong manner.

Age

As a person gets older, there is an increased risk associated with surgery. As discussed by Segerstrom and Miller (2004), the flexibility of the immune system can be compromised by age and disease. In the area of psychoneuroimmunology, several factors appear to be involved (Kiecolt-Glaser et al., 1998, 2002). First, immune function – in particular, the action of the cellular immune response – diminishes with age (Verhoef, 1990). With this diminished immune response, the older patient is more susceptible to infectious complications. In fact, infection is one of the primary factors for surgical mortality in the elderly (Thomas and Ritchie, 1985).

To further complicate matters, it appears that depression and distress interact more strongly in the elderly person to promote immune system down-regulation. Several studies have demonstrated that older adults show greater immunological impairments in response to stress or depression relative to a younger population (Herbert & Cohen, 1993; Kiecolt-Glaser et. Al., 1996; Segestrom & Miller, 2004). Linn and Jensen (1983) compared older and younger adults on a number of immunological variables prior to elective surgery and postoperatively. It was found that the two groups did not differ immunologically prior to the surgery, but the older group showed more depression of the immune response after surgery relative to the younger group. Of course, older persons are more likely to have other medical problems and these can also influence recovery from a surgery.

Summary and Conclusions

The field of PNI seeks to explain how a variety of factors can have negative effects on wound healing and surgery outcome. PNI research can also help explain how psychological preparation for surgery enhances outcomes. The area of PNI research is likely to continue to provide exciting and useful findings in the area of surgery preparation. Having an understanding of this area provides the clinician with a firm rationale for its use that can be presented to both patients and professionals involved in all areas of surgery.

Chapter 2: Conceptual Models of Surgery Preparation

The clinical research literature has extensively documented that psychological preparation for surgery can significantly enhance outcome. Over the past 30 years, more than 200 research studies with thousands of patients investigating psychological preparation for surgery have found the beneficial effects listed in Table 2-1 (see reviews by Contrada, Leventhal, & Anderson, 1994; Deardorff & Reeves, 1997; Devine, 1992; Johnson & Clare, 1993; Johnston & Vogele, 1993; Johnston & Wallace, 1990; Mumford, Schlesinger & Glass, 1982; Prokop, Bradley, Burish, Anderson and Fox, 1991; Suls & Wan, 1989).

Two excellent reviews of surgery preparation research are the meta-analytic studies of Johnston and Vogele (1993) and Devine (1992). Johnston and Vogele (1993) identified 38 preparation for surgery outcome studies that met specific design criteria including random assignment. Studies were grouped into type of intervention: procedural intervention, sensory intervention, behavioral instruction, cognitive intervention, relaxation, hypnosis, and emotion-focused intervention. Outcomes were assessed across a number of variables. It was found that “significant benefits can be obtained on all of the major outcome variables that have been explored” (p.252). Outcomes were assessed under eight general categories: negative affect, pain, pain medication, length of stay, recovery, physiological indices, satisfaction, and costs. The authors concluded that, “There is now substantial agreement that psychological preparation for surgery is beneficial to patients” (p. 245).

In two sequential investigations, Devine and Cook (1986) and Devine (1992) completed a meta-analysis on 102 and 191 studies, respectively. Inclusion criteria were an experimental design in which a psychological and/or educational intervention for surgery preparation was completed on adult patients who were to be hospitalized for elective surgery. Outcome measures included such items as length of stay, medical complications, respiratory function tests, and resumption of activities. It was found that patients receiving surgery preparation techniques generally did better than controls on all outcome dimensions.

As reviewed previously, PNI research has shown that the physical stress of surgery is considerable and can cause significant body reactions that may impair healing. As discussed by Horne, Vatmanidis, & Careri (1994), “Invasive medical and surgical procedures can be extremely distressing and can adversely affect the patient’s ability to cope, even when the actual procedures are not a real threat in a medical or biological sense” (p. 5). Thus, even if the surgery has a high probability of a positive outcome, there are often negative individual and social effects. Deleterious physical, emotional, and economic consequences of the surgery are experienced not only by the patient, but also by her family, friends, and work associates (Contrada, Leventhal, and Anderson, 1994). Any treatments that can help address the negative effects of the surgical experience are important to pursue.

Psychological Preparation for Surgery: Why Do It?

In the United States, well over 50 million surgeries are performed each year. Of these, approximately 20 percent are in response to an emergency situation and 80 percent are considered “elective.” An elective surgery is one in which the patient and/or surgeon can choose when and where to complete the operation. Elective surgeries can range from being “optional” such as removing a wart, gastric bypass, most spine surgeries, or cosmetic surgery to “necessary” such as tumor removal, coronary artery bypass, hernia repair, hysterectomy, Caesarean, and some spinal surgeries. Table 2-2 illustrates some of the most common elective surgeries.

Psychological preparation for surgery might be appropriate for any elective procedure in which there is time to plan ahead for the intervention. Surgery preparation meets a number of important needs. First, the physical and emotional stress of surgery can negatively impact the outcome; there are a number of psychological interventions that have been shown to alleviate these effects. Second, the health care system is changing in a way that will make the surgery preparation interventions even more important. There is a significant trend towards outpatient surgery, placing much more responsibility on patients and their families to complete pre- and postoperative activities that would have previously been done by the hospital staff. This trend is occurring for all types of surgery, many of which would never have been done on an outpatient basis just a few years ago.

The Trend Towards Outpatient Surgery

Both the United States and Great Britain (see Contrada et al., 1994; Mitchell, 1997), have seen an increase in the number of outpatient surgeries. For instance, well over half of all surgical procedures in the United States are now performed on an outpatient basis, and this number is rising (for current statistics see Ambulatory Surgery in U.S. Hospitals, 2003).  This trend is driven by several factors. In the United States, one of the primary factors has been to reduce skyrocketing healthcare costs. By moving away from the traditional fee-for-service delivery of healthcare, the managed care systems can control inpatient admissions and shift as many procedures as possible to same-day surgery programs. Since approximately three-quarters of all Americans with health insurance are enrolled in some type of health maintenance organization (HMO), this is a formidable group.  Beyond reducing costs, other factors fueled this movement towards outpatient surgery. These include technology development, improvements in pain medication and anesthesia, and patient-related factors.

High technology and surgery

In the past 25 years, multitudes of surgeries have become easier and safer to perform due to technology advances in surgical procedures that result in much less invasiveness. Imaging techniques, such as magnetic resonance imaging (MRI) and computerized tomography (CT) scans, allow a much greater ability to identify problem areas preoperatively, making the surgery process much more efficient. Microscopic techniques have greatly decreased the invasiveness and level of tissue damage during the operation. Other advances that have also decreased the level of invasiveness and/or made the surgery more accurate include the use of lasers, fluoroscopy, and arthroscopic techniques.

Improved Pain Medication and Anesthesia

In the earlier days of surgery, the use of general anesthesia required that a patient had to stay in the hospital to be carefully monitored for post-anesthesia nausea and vomiting. Advances in general anesthesia over the past several years have decreased risk overall and diminished these types of side effects. Newer, faster-acting agents do not cause vomiting and these current drugs have a much shorter recovery time. In addition, longer acting local anesthetics can be directly injected into the incision sites resulting in improved acute postoperative pain control. Once the patient is discharged from the outpatient surgery center, improvements in pain medications (both oral and other methods of delivery such as the transdermal patch) have made them more effective, safer, and easily monitored on an outpatient basis.

Improved Patient Self-control and Satisfaction

All other things being equal, most patients would choose to undergo an outpatient surgery rather than an inpatient operation since hospital stays can be disruptive in so many ways (being away from family, missing more time at school or work, etc.). When an individual undergoes an outpatient surgery (versus an inpatient admission), there are often several benefits, including a shorter waiting time in terms of getting the surgery scheduled (which means less preoperative anxiety), the ability to recuperate postoperatively at home (which is preferred by most patients), and outpatient surgeries consistently report fewer postoperative infections than inpatient surgeries, likely due to the fact that patients are not exposed to bacteria normally present in the hospital (Benson, 1996; Cohen, 1995).

The Challenges of Outpatient Surgery

Even with all the positive aspects of outpatient surgery, there are many potentially negative factors that particularly relate to the issue of preparation for surgery. When undergoing an outpatient surgery, the individual patient and her family must assume a significant portion of the pre-surgical preparation and post-surgical care (Eddy & Coslow, 1991). Information about postoperative activities must be not only understood by the patient, but also fulfilled properly. In the past, much of this was the responsibility of healthcare providers within the hospital setting. This might include such things as medication regimen, physical activity requirements, and restrictions. Two types of surgery that are being done more and more on an outpatient basis are spinal procedures including fusions (single level) and bariatric procedures. Examples of postoperative instructions for these operations can be seen in Tables 2-3 and 2-4. In Table 2-3 postoperative instructions are presented for a spinal fusion (adapted from guidelines available through The North American Spine Society).

In Table 2-4, postoperative instructions are presented for after a bariatric surgery (adapted from guidelines available through The American Society for Bariatric Surgery).

Clearly, some of the postoperative instructions might be difficult for the patient to understand fully, and adequate compliance is often an issue. As will be reviewed, psychological preparation for surgery specifically targets helping patients to understand and follow through on postoperative instructions.

Preparation For Surgery: Conceptual Models

A preparation for surgery program will often involve multiple components such as a variety of cognitive behavioral techniques (e.g., information gathering, cognitive restructuring, various types of relaxation training). In the early research, many studies attempted to parcel out the active components of a surgery preparation program by comparing one technique against another, or a combination of techniques compared with a single approach (Deardorff, 2000; Horne et al, 1994; Prokop et al, 1991). Generally, it has been found that a combination of approaches is more effective when compared to a unilateral intervention. Having some understanding of psychological preparation for surgery conceptual models is important since these guidelines will determine the approaches to individual patient assessment and treatment.

Psychological preparation for surgery programs have been based upon a variety of different “models” including:

• informative preparations
• pre-operative education
• cognitive behavioral approaches
• empowerment and self-efficacy
• individual and social self regulation
• biopsychosocial

As shall be seen, there is a great deal of overlap amongst these models. The list presented here progresses from the least to the most comprehensive interventions. Therefore, the approaches presented at the beginning of the list are generally contained within those near the bottom.

Informative Preparations

The idea that providing patients with realistic information about their surgery (compared to those less informed) will improve outcome can be traced to Janis (1958; 1971). Subsequent studies have generally demonstrated a positive correlation between preoperative surgical knowledge and postoperative outcome (see Prokop et al, 1991; Shuldham, 1999 for reviews). Studies have identified two different types of information that might be provided – procedural and sensory. Procedural information consists of basic information about the surgery experience including preoperative activities, events that would occur during the hospital stay, and postoperative recommendations. Sensory information has often been added to the procedural information in an attempt to enhance the outcome. Sensory information describes what sensations the patient can expect throughout the surgery experience, including what he will feel, hear, taste and see.

Individualized information

Although the provision of procedural and/or sensory information has usually been found to enhance surgical outcome, this is not a consistent finding. Researchers have speculated that the reason for these inconsistencies may to due to the patients’ individual coping styles in response to a stressor such as impending surgery. Studies have focused on a coping dimension of information-seekers (also called sensitizers, copers, or monitors) versus information-avoiders (also called repressors, avoiders, or blunters). Information-seekers typically respond to a stressful situation by gathering detailed information about it, while information-avoiders will do just the opposite (see Miller, 1987; 1992; Miro & Raich, 1999; Prokop et al, 1991, for reviews).

A number of studies have investigated how a patient’s coping style (information-seeking vs. information-avoiding) affects preparation for surgery (see Miro & Raich, 1999 for a review). It has generally been found that patients do best when the amount and detail of pre-surgical information provided matches their individual coping styles. There is some indication that providing information in a manner that is inconsistent with the patient’s coping style (e.g. providing detailed information to an information-avoider) can actually have deleterious effects (see Prokop et al. 1991 for a review).

Preoperative Education

Preoperative education is an expansion of the simple information provision approach to surgery preparation. Preoperative education or teaching is defined by Devine and Cook (1986) as providing the patient with health related information, psychosocial support, and the opportunity to learn specific skills in preparation for surgery. Preoperative education programs might include a number of components: provision of information, interactive education done either individually or in groups, inclusion of family members, and teaching of specific skills helpful for recovery. Several meta-analytic reviews have demonstrated the beneficial effects of preoperative education on surgery outcome (Hathaway, 1986; Devine & Cook, 1986; Devine, 1992; Shuldham, 1999).

Cognitive-Behavioral Approaches

Depending on the definition used, preoperative education approaches may or may not include cognitive-behavioral (CB) techniques. For the purposes of this discussion, CB approaches will be treated separately and formulated as an expansion of the preoperative education techniques. CB preparation for surgery programs are primarily designed to teach patients self-control strategies that will decrease the stress, anxiety, and pain associated with the surgery experience (see Contrada et al., 1994; Prokop et al., 1991 for a review). CB approaches use a variety of techniques such as cognitive restructuring and deep relaxation training. The cognitive interventions are based upon the premise that a patient’s thoughts about the surgery will determine the amount of emotional and physical stress experienced. Thus, changing a patient’s maladaptive thoughts is one means of reducing stress. Cognitive restructuring is a way of helping patients to identify “unhealthy” or “irrational” thoughts, and combating or substituting these with “coping” or “healthy” thoughts. It is based upon the early work of Ellis (1975), Beck (1979) and Meichenbaum (1977). Cognitive restructuring is also referred to as changing an individual’s “self-talk.” Turk (2002) has summarized the five assumptions that characterize the cognitive behavioral treatment approach:

1. People are active processors of information rather than passive reactors to environmental contingencies.

2. A person’s thoughts can influence affective and physiological arousal, both of which may serve as impetus for behavior. In addition, affect, physiological arousal and behavior can influence one’s thoughts. 

3. Behavior is reciprocally determined by both the environment and the individual.

4. If an individual has learned maladaptive cognitive, affective, and behavioral patterns, then treatment should be focused on changing these patterns with intervention across all dimensions (cognitive, affective, physiological, and behavioral).

5. Just as a person in instrumental in developing and maintaining maladaptive patterns, the individual must take an active role in changing these responses.

The behavioral component of CB approaches primarily focuses on teaching patients self-regulating techniques that induce a state of deep relaxation (also termed the “relaxation response”). The specifics of these methods will be reviewed later. Briefly, they include such things as breathing exercises, hypnosis, progressive muscle relaxation, or other techniques to induce a physiological state of deep relaxation. The relaxation response is associated with positive physiological results that can enhance wound healing and surgical outcome. A variety of studies have found CB surgery preparation program can provide numerous positive outcomes, many of which have been discussed previously (See Devine, 1992, Horne, Vatmanidis & Careri, 1994; Johnston & Vogele, 1993, Prokop et al., 1991 for reviews). The details of a cognitive restructuring approach relative to surgery patients will be discussed in the next chapter.

Self-efficacy and Empowerment

Although extensive research has demonstrated the benefits of preoperative education and CB programs, the psychological mechanisms by which these effects occur are not exactly clear (Pellino, Tluczek, Collins, Trimborn, Norwick, Kies & Broad, 1998; Oetker-Black & Taunton, 1994). The theoretical concept of self-efficacy (and the related idea of empowerment) has been applied to the area of surgical preparation in an effort to explain positive outcomes. These concepts have also guided the expansion of the preoperative education and CB approaches.

Self-efficacy

Self-efficacy has been researched in the psychological literature for quite some time since originally formulated by Bandura (1977). According to this theory, “expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences” (Bandura, 1977, p. 191). Self-efficacy is a belief that one can effectively perform a given behavior and that the behavior will result in desired outcomes. Importantly, motivation and perseverance in performing specific behaviors is dependent on the individual’s evaluation her self-efficacy. If the individual does not believe that the behavior can be performed, motivation and perseverance decrease. Thus, self-efficacy mediates the relationship between knowledge and action. In the simplest terms, there are three basic tenants of self-efficacy theory: 1) self-efficacy is situation specific; 2) self-efficacy can be altered through various means such as education, practice, and role modeling; and 3) increased self-efficacy can improve outcomes relative to specific behaviors.

Bandura (1977) postulates that an individual’s self-efficacy for a situation comes from four sources of information. Performance accomplishments are behaviors that the individual has actually performed or practiced. This source of information is the most influential for self-efficacy since it is based on personal mastery experiences. Verbal persuasion occurs when an individual is guided by suggestion into believing that he can perform the activity. Verbal persuasion is usually provided by someone who is perceived as an authority or expert in the area. Vicarious experience, or modeling, is obtained by seeing others similar to oneself perform the activity. Physiological states are information the individual receives from his level of arousal in response to the specific situation. For instance, if you experience a high level of physical arousal (e.g. anxiety) when thinking about a stressful situation you are facing (e.g. the surgery process), then you may be more likely to conclude that your ability to cope with it is low (diminished self-efficacy).     

There is a substantial body of research demonstrating that enhancing self-efficacy (e.g. through educational programs) is related to improved health outcomes (See Bandura, 1991; Oetker-Black & Taunton, 1994; Pellino et al., 1998 for reviews). Perceived self-efficacy has specifically been found to improve coping with pain (Pellino & Ward, 1998) and compliance with recommendations after surgery (Bastone & Kerns, 1995; Mahler & Kulik, 1998). It has been hypothesized that many of the benefits of psychological preparation for surgery programs are actually due to the enhanced self-efficacy (Mahler & Kulik, 1998; Oetker-Black & Taunton, 1994; Pellino et al., 1998).

Empowerment

Although patient education programs for surgery have been investigated and implemented for many years, there has been a recent shift from the traditional medical model of patient education to more of an “empowerment” model (Pellino et al., 1998). Early preparation for surgery programs were based upon a traditional medical model, or “disease-based model” in which the healthcare provider is the expert who decides the content, amount and detail of the information that is provided to the patient relative to her surgery. In this model, the provider is the primary decision-maker and problem solver (see Pellino et. Al., 1998 for a review).

The empowerment model of patient education is based on the idea that health educators can assist patients in gaining knowledge, developing skills, and identifying resources relative to the surgery experience.  Empowerment has been described as a process of enabling others to take control of their own lives (Pellino et al., 1998). In this process, patients are also taught to actively reassess various issues in an ongoing manner and modify their coping strategy accordingly. Thus, the patient will be taught to take appropriate charge of her own care on a daily basis (Anderson, 1995).  In the empowerment approach, the teaching is interactive and the patient helps to determine the content of the surgery preparation program.

The concept of empowerment is closely related to the construct of self-efficacy; the differences are subtle. Self-efficacy is a belief that one can effectively perform a behavior and the behavior will result in the designated outcome. However, someone other than the patient might determine the “designated outcome” or goal. In contrast, empowerment encourages the patient to become an active participant in identifying and choosing healthcare related goals. Once these goals are established, the probability that they will be achieved is increased through enhancing self-efficacy. As portrayed by Pellino et al (1998), empowerment directly influences self-efficacy, which in turn, affects outcome. 

The concepts of self-efficacy and empowerment are especially important given the increase in outpatient surgery that makes patients much more responsible for implementing their own preoperative and postoperative care.

Individual and Social Self-regulation

As discussed by Contrada et al. (1994), two interrelated sets of theoretical principles derived from research in the areas of psychological stress (Lazarus, 1966; Lazarus & Folkman, 1984), illness cognition (Leventhal & Johnson, 1983) and social support (Cohen, 1988) can provide a conceptual framework for understanding how psychological interventions enhance surgical outcome. These are the principles of individual self-regulation and social self-regulation.

Individual Self-regulation

The principle of individual self-regulation involves “cognitive and behavioral activity whereby the patient influences the course of surgical recovery” (Contrada et al, 1994, p. 221). Individual self-regulation is an intra-personal process including cognitive (e.g., appraisal and coping) and emotional (e.g., level of arousal) components. As will be discussed in greater detail later, this coping process occurs in response to many different stressors that occur throughout different phases of the surgery experience and postoperative recovery.

For most patients, surgery is a significant stressor or threat since it is perceived as having the potential for severely negative consequences (Contrada et al., 1994; Lazarus & Folkman, 1984). This is reflected in the content and extent of patients’ worries about the surgery process (see Table 2-5 for a list of common fears; Deardorff & Reeves, 1997; Johnston, 1988). When first informed of the need for an operation, a patient will develop an internal “problem representation” of the surgical stressor. This problem representation defines the dimensions, features, and implications of the threat (or perceived danger) of the impending surgery. A patient’s problem representation has objective and subjective elements. The objective problem representation includes the patient’s perception of the “facts” about the surgery experience such as the mechanics of the operation itself, its effects on physical functioning, the projected recovery time, and behaviors that will be required for postoperative rehabilitation. The subjective problem representation is the patient’s emotional response to his objective problem representation.    Subjective problem representation might include worry about being able to cope with the surgery, anxiety over the loss of function, and depression in response to perceived long-term deficits postoperatively

The amount of threat experienced by a patient is related not only to his or her appraisal of the danger implications of the surgery, but also how much the threat is buffered “by the perceived availability of personal and social resources to mitigate these dangers” (Contrada et al., 1994, p. 229). When the appraisal of the danger or threat is greater than the buffering resources, the result is a stress response. The self-regulation model has two important postulates related to surgery preparation interventions. First, it is the patient’s formulation of the surgical threat, and not that of the health care professional, that needs to be understood and modified. Second, if the patient can be provided with an accurate mental representation of the surgery experience, then she will have a reality-based framework to guide self-regulation (Contrada et al., 1994; Leventhal, Diefenbach & Leventhal, 1992).

Contrada et al (1994) also reviewed the area of patient coping activities. Coping activities by the patient will be determined by her problem representation of the threat of surgery. Coping involves two different types of individual self-regulation that correspond to the objective and subjective components of the problem representations (how the patient perceives the stress related to the surgery experience). Problem focused coping consists of efforts designed to deal with objective elements of the problem. Relative to surgery, problem-focused coping might include patient behaviors that enhance physical recovery and decrease the probability of complications such as engaging in range of motion exercises, practicing breathing procedures and, ultimately, returning to usual activities of daily living. Later on in the surgery recovery process, problem-focused coping may include resuming social, family, and occupational roles. Emotion focused coping refers to decreasing distress and other subjective responses. Pre-operatively, this might include controlling anticipatory anxiety and distress. Immediately following surgery, this might encompass such things as cognitive behavioral methods to diminish suffering and encourage emotional acceptance of temporary physical and social limitations. A preparation for surgery program should include components that teach patients both problem and emotion focused coping skills.

As the patient proceeds through the surgery experience, the problem representation and coping activity will be modified based upon ongoing appraisal. Appraisal is the process of modifying and updating the problem representation based upon new information from external sources, perceived changes in physical and psychological wellbeing, and evaluation of the effectiveness of coping procedures (Contrada et al., 1994). There are two types of ongoing appraisal – adaptive and outcome. In adaptive appraisal, after the various coping behaviors are completed, the patient assesses their effectiveness and outcome as compared to her own goals. Outcome appraisal is the patient’s evaluation of her progress (usually most salient postoperatively) as influenced by social comparison processes. It is important to note that social psychology research suggests patients will generally compare themselves to other patients who are recovering at a faster rate (termed, “upward comparison”; Contrada et al., 1994; Festinger, 1954).

Although it is possible that this upward comparison could result in the patient emulating successful coping strategies, it seems that negative consequences are more likely. Family members and patients may tend to select unrealistically successful models for social comparison purposes such as those who are younger, have had a less serious surgery, or have a less significant medical history (Taylor 1983). This type of upward comparison has the potential for the patient and family members to set unrealistic criteria for evaluating coping efforts and overall progress. Clinically, this is certainly seen in the area of postoperative spine rehabilitation. It is not uncommon for patients to begin making comparisons once they are released to begin postoperative physical therapy. In the spine rehabilitation setting, there are ample opportunities for this type of upward comparison and the negative effects are not infrequent.

The surgical experience can be divided into different phases, each of which has its own unique challenges and coping issues that will influence individual self-regulation. According to Contrada et al. (1994), the four general phases of the surgery experience include (I) the decision to have the surgery; (II) the preoperative testing, admission to the hospital and surgery; (III) the acute recovery either in the hospital or immediately postoperative at home; and (IV) the longer term postoperative rehabilitation issues. Across these four phases, there are four major issues related to adaptation to the surgical experience (Contrada et. Al., 1994, p.230):

1. The immediate physical danger represented by the surgery itself that includes such things as the threat of general anesthesia, the incision, resection, reconstruction, catheterization, and immediate postoperative complications.
2. The aftereffects of undergoing these procedures, including such things as pain, discomfort, disorientation, fatigue, and a reduced capacity for physical activity and ambulation. These are essentially the subjective and functional effects of the surgery itself on the patient. These threats begin just after surgery (the middle of phase II) and decrease through phases III and IV.
3. The patient’s potential inability to enact valued social roles including such things as engaging in family, occupational, and leisure activities. The threat to social roles begins in phase III and increases through phase IV.
4. The long-term management of a possibly chronic medical condition. Long-term management issues might include such things as the need to diet, exercise, take medications, and undergo follow-up visits. This threat occurs in phase IV.

These issues will vary in “relative salience” through the surgery experience. The physical danger and subjective/functional effects dominate during the period immediately surrounding the surgery while social role issues and long-term management issues become increasingly salient after the acute phase of postoperative recovery and over the long term. Each of these issues, within each of these phases, can be addressed as part of a psychological preparation for surgery program.       

Social self-regulation

The interpersonal aspect of self-regulation (“social self-regulation”) comes from the premise that the social context in which the individual functions significantly determines the impact of a life stressor. As discussed by Contrada et al. (1994), social self-regulation involves exchanges between the patient and members of his social network (family, friends, and coworkers).  Individual self-regulation is intrapersonal while social self-regulation is interpersonal.

Although a patient’s social network may consist of several levels, the primary support person (spouse, significant other, close family member) is often considered the most important and is investigated frequently in the clinical research. However, these principles might also apply to the larger social network, especially when the patient does not have a support person in the home to help with surgical recovery. Social self-regulation has two main components. Task-focused social self-regulation involves the surgical episodes as a stressor and describes interaction between the patient and caregiver that evolve around the task of understanding and coping with the surgery. Role-focused social self-regulation describes the social roles enacted by the patient and significant other(s).

Similar to the patient, the significant other will also have a set of adaptive goals and these will be interrelated, but different, from those of the patient. Even though both patient and partner will share the goal of optimizing the patient’s recovery from surgery, the task focus will differ for each individual due to their own specific mental representations of the problem. In addition, the partner does not have access to the patient’s internal experience related to the surgery process (e.g. level of pain and discomfort, thoughts about the surgery, worries, etc.). The partner, however, is in a unique position to either enhance or diminish the patient’s overall coping ability. A partner who has an accurate view of the surgery experience will likely help the patient develop a similar representation that will, in turn, aid the patient’s overall coping and achievement of adaptive goals. However, a partner who has inaccurate and unrealistic beliefs will increase the chances that the patient will also adopt a maladaptive view. Examples might include looking towards a surgery as a “cure” when it is not, the belief that the surgery will forever limit certain activities, and discrepancies in beliefs about the postoperative pain experience (as discussed by Contrada et al. (1994).

“In effect, the partner is a mirror in which the patient may see an image that exaggerates, minimizes, or more or less accurately reflects his or her medical status and emotional state. If these reflections bias the patient’s self-appraisal in either direction, before surgery, or at any stage of recovery, there is a risk of negative consequences including over/under-utilization of pain medication, too slow/rapid resumption of daily activities, and non-optimal timing in returning to work.” (p. 240).

An ongoing difference in views may be an obstacle to developing a cooperative approach for coping and can produce interpersonal conflict in other areas of the relationship. In addition, the partner’s evaluation of the patient’s coping efforts can either enhance or impede this ongoing process.

A patient’s partner can provide assistance in a variety of ways including tangible assistance, emotional support, and informational support (See Contrada et al., 1994, for a review). Tangible assistance includes direct efforts to assist the patient such as helping with health behaviors, activities of daily living, and/or work-related endeavors. Emotional support includes any efforts directed at reducing the patient’s worries and elevating his spirits. Informational support is the provision of suggestions that will help the patient cope more effectively with recovery tasks (e.g. pain management, doing prescribed exercises, resuming social roles and function). The manner in which the partner provides these different types of support will either enhance or inhibit recovery. The degree of discrepancy between the patient’s and partner’s mental representations of the problem will determine whether the support provided is appropriate or not. An example might be when the patient is seeking informational support about how to manage an acute pain flare-up and the partner provides emotional support instead. This could actually cause the patient’s situation to worsen by making the lack of ability to control the pain even more salient. The surgery episode has the potential to significantly impact the patient’s and partner’s social roles.

In summary, the surgical patient is often faced with the threat of significant disruption in a number of valued role areas: work function and career, as a parent and spouse, community involvement, recreational activities, gender-identity, and no long being a “well person.” The loss of role function may lead to depression and lowered self-esteem in the patient as well as placing additional strain on the social support systems that are already trying to cope with the surgery process itself. Further, in response to taking care of the surgical patient and responsibilities that he cannot perform, the partner may also experience role-loss such as occupational position, being a parent and/or spouse, community pursuits, and recreational activities. Partners who experience role loss over the long term can also develop their own low self-esteem, anger, depression, and resentment towards the patient for “causing the loss” (Contrada et al., 1994).  For a complete and detailed discussion of psychosocial role adjustment see Cohen (1988), Contrada et al. (1994), Coyne and Delong (1986) and Perlin, Mullan, Semple & Skaff (1990).

During the surgical recovery process, the partner is likely to relinquish or modify various normal responsibilities and assume the caregiver role. For a variety of reasons (See Contrada et al., 1994; Coyne & DeLongis, 1986), the caregiver may become under- or over-involved in the patient’s recovery, either of which can have negative consequences. Caregiver under-involvement is due to the partner adopting a set of “goals” that are less than what is appropriate and required. This will prevent the partner from facilitating the patient’s recovery, requiring the patient to draw more on the support of others or on individual efforts. Caregiver over-involvement also results from the partner having a set of inappropriate goals based upon his own mental representation of the problem. Caregiver over-involvement can impede the patient’s recovery in many ways. It can lead to negative behaviors such as being overly aggressive in encouraging the patient’s recovery, slowing the patient’s resumption of activity by continuing to complete these responsibilities, and reinforcing the “sick role” by inappropriate nurturing.  Further, a well-intended but overzealous caregiver can be perceived as intrusive, controlling, and critical which may strain the patient-partner relationship (Contrada et al., 1994). In some cases, a negative cycle situation may develop in which the partner/caregiver alternates between under-involvement and over-involvement depending upon interactions with patient behavior.

Consistency between the patient’s and partner’s mental representations of the surgical problem and efforts towards concordant adaptive goals is a critical element in recovery. Social self-regulation expands the concepts of surgery preparation beyond the individual to include the patient’s family, friend, coworkers, healthcare professional, and others, as appropriate. The model also underscores the importance of considering a patient’s social relationships as a target of intervention for surgery preparation.

The Biopsychosocial Model of Surgery Preparation

As with many medical treatment programs, there has been a move from the strictly medical model to a biopsychosocial model over the past several years. A biopsychosocial model takes into account not only the physical aspects of the medical problem and surgery, but also the patient’s individual psychological make-up, coping resources, and social issues.

Any physical problem and treatment (such as surgery) can be conceptualized from a biopsychosocial perspective (Engel, 1977). Biopsychosocial concepts related to pain began with the formulation that the pain experience is impacted by higher order processes in the brain (Chapman, Nakamura & Flores, 1999; Melzack and Casey, 1968; Melzack and Wall, 1965; 1982; Sternbach, 1966). This conceptual model requires an investigation and understanding of the biological, psychological, and family-social factors influences related to the problem. The biopsychosocial approach can be thought of using an “open-systems” model of relationships that contains multiple feedback loops. (See Figure 2-1)

For example, interactions can occur in an almost endless number of ways among the following influences on surgical outcome:

• the patient’s health status, health habits, medical condition, and type of surgery
• the patient’s psychological status and coping resources
• the healthcare professionals involved in the patient’s treatment and all of the other subsystems,
• family members’ behavior towards the patient and amongst themselves in response to the surgery,
• the patient and family’s interaction with extra-familial systems such as relatives, friends, and coworkers

The open system model describes how changes in any of the subsystems (e.g. the relationship between the patient and partner) may reverberate within all systems (e.g. the patient’s own health status, the emotional status and behavior of family members, etc.).

Figure 2-1. The biopsychosocial conceptual model of the surgery experience. Adapted from Chapman et al. (1999, p. 43).

A biopsychosocial model of surgery preparation dictates that all aspects of the surgery and recovery experience are appropriate targets for intervention. The open mode of systems and subsystems also shows that any subsystem has the potential to exert a negative influence on the entire surgical recovery if appropriate intervention is not provided. For example, a surgery patient may successfully complete and utilize a surgery preparation program that focuses on cognitive-behavioral techniques (an intra-personal treatment focus) only to be faced with recovering in a family systems environment that is non-supportive, dysfunctional, and unhealthy. If the surgery preparation program does not assess the family environment and intervene as appropriate, the CB techniques will likely be doomed to fail (as would any other program that “missed” an important source of intervention and preparation).

Summary and Conclusions

Psychological preparation for surgery models have been developed using a variety of surgical experiences. As such, they can easily be adjusted to take into account the different coping and recovery challenges (cognitive, emotional, and physical), as well as the individual and family issues, presented in the case of any particular surgery. It is important for the clinician to be aware of the various surgery preparation models to successful designed treatment intervention for specific cases. In the next two chapters, a variety of surgery preparation components will be reviewed. These techniques, most often combined into a surgery preparation treatment package, are based upon the surgery preparation conceptual models discussed in this chapter.

Chapter 3: Preparing for Surgery: Cognitive-Behavioral Interventions

The first part of a preparation for surgery intervention should include assessment of the patient. Having an understanding of common patient fears and worries (as presented in Table 2-5 in the previous chapter) can help guide the patient assessment (Johnson, 1988; Trousdale, McGrory, Berry, Becker & Harmsen, 1999).   In addition, it is important to obtain an initial evaluation of the patient’s understanding of the surgery and related issues. This initial assessment can be completed by obtaining answers to the areas listed in Table 3-1 (Block, 1996; Deardorff and Reeves, 1997; Horne, et. Al., 1994).

These are very general categories of patient assessment. The preparation for surgery intervention actually represents a process of ongoing assessment and adjustment of intervention strategies, as dictated by the biopsychosocial model. Other important areas of assessment will be discussed under the various treatment components.

Individualized versus “Prepackaged” Programs

Just as there are many conceptual models of psychological preparation for surgery interventions, there are also a variety of methods for developing these types of programs. Differences occur across programs both in the structure (e.g., individualized, group, or a combination thereof) and in content or specific components (e.g., cognitive behavioral, relaxation training, music therapy). Surgery preparation programs that are individualized involve the patient working with a healthcare professional one-on-one (e.g., psychologist, social worker, nurse, health educator). In this approach, the preparation program is completely individualized and can be constantly modified and customized based upon patient issues that are presented. Although this can be a very effective approach, it is often not feasible due to cost, time constraints, and staff resources. Therefore, most surgery preparation programs offer a blend of individualized and group treatment with pre-formatted structured components. No research studies could be located that have investigated whether one approach works better than another does (e.g. individual vs. group).  

Common psychological preparation for surgery program components that fall under the general category of cognitive-behavioral interventions will be reviewed. These might also be termed “individual self-regulation” approaches as discussed in the previous chapter. These are techniques that are implemented by the individual and directly target internal processes such as thoughts, emotions, and physiological status. The following chapter will review psychosocial interventions or those that might be term “social self-regulation.”

Components of Surgery Preparation

Gathering Information

One of the core components of any psychological preparation for surgery program is helping patients gather relevant information about the surgery process. The information gathering is impacted by several factors including the coping style of the patient, the patient’s ability to understand and remember important medical information, and the doctor-patient relationship.

Coping Style of the Patient

Information-seekers versus information-avoiders

The provision of information regarding surgery details has generally been found to enhance surgical outcome but this result is impacted by the patient’s coping style. As reviewed in the previous chapter, some patients are information-seekers while others are information-avoiders. For information-seekers, the general rule is “the more information the better.” Alternatively, information-avoiders do much better with only general information about the surgery experience and may even do worse if too much detail is provided. A very simple set of questions to assess a patient’s coping style relative to information gathering can be found in Table 3-2. In addition, actual measures that assess an individual’s information-seeking style have been developed (Miller, 1987). Prior to providing medical information, the patient’s coping style should be assessed in some manner.

Early research in surgery preparation demonstrated that patients who possessed accurate information about their surgery did better overall. Realistic information allowed patients to develop accurate expectations and coping strategies.

Later research showed that the provision of information was best tempered by the coping style of the patient. Patients who tend to agree with the above statements are “information-seekers” and do better with more specific and detailed information. Those who disagree with the above statements do better with very general information. The patient’s coping style relative to information gathering should be assessed in the early stages of surgery preparation and the intervention designed accordingly.

External locus of control and self-efficacy

In a recent study, the effects of patients’ external health locus of control (EHLC) and self-efficacy (SE) on surgery preparation for surgery outcomes were studied in a group of patients facing coronary artery bypass graft surgery (CABG) (Shelley & Pakenham, 2007). As discussed by Shelley and Pakenham (2007), and reviewed in this course, two general strategies have been used to improve surgical outcomes – information instruction and cognitive coping. The authors were interested in how a patient’s coping style might affect the successfulness of surgery preparation. EHLC refers to “the belief that outcomes in ambiguous health-related situations, such as CABG, are the result of powerful others, including doctors, other care providers, family and friends” (Shelley & Pakenham, p. 184). EHLC has been found to be a predictor of outcomes to CABG; lower levels of EHLC were associated with improved health outcomes. SE refers to the patient’s confidence in her ability to behave in ways that will lead to desired outcomes. Studies have related SE to improved patient participation in health care. Given these findings, Shelly and Pakenham (2007) hypothesized that patients who were “matched” on SE and EHLC (high on both, or low on both) would show improved outcomes in response to a surgery preparation program.  Conversely, the researchers hypothesized the “unmatched” patients (one high and the other low) would be better off with standard care (no surgery preparation). The results are complicated but generally supported the hypothesis.

This study, and others to be reviewed later, underscores the importance of matching the surgery preparation program to the coping style of the patient. If a patient is an information-avoider with high EHLC (believes outcome is in the hands of the doctors) and low SE (low confidence that his own behavior can impact the treatment outcome), doing an intensive preparation for surgery program with a high level of education has a great likelihood of actually making the patient more distressed about the surgery.  

Understanding and Remembering Medical Information

Research has consistently demonstrated that surgical patients are dissatisfied with the amount of preoperative information that they receive (see Deardorff & Reeves, 1997; Pizzi, Goldfarb, & Nash, 2001; Webber, 1990 for reviews). In addition, even if information is provided, several problems have been found including the “readability” of the written information, patients’ level of understanding, and their recall for medical information.

Although the situation has improved somewhat since the Webber (1990) review, surgical consent forms often contain highly detailed information written at a level that is far beyond that which most patients can understand (Pizzi et al., 2001). Generally, it has been found that surgical informed consent documents are written at the level of a scientific journal or specialized academic magazine. Clearly, this is beyond the readability capacity of most laypersons facing a surgery. As concluded by Webber (1990), “in summary, written materials are desired and appreciated by patients; however, more attention needs to be given to producing them at a reading level appropriate to their intended audience” (page 1095). Possibly due to their frustration in attempts to understand the information, it has been found that about 40% or less of patients actually read surgical informed consent forms carefully (Deardorff & Reeves, 1997).

As an example of the “readability” problems, Christopher, Foti, Roy-Bujnowski & Appelbaum (2007) completed a review of 154 clinical mental health research studies that utilized informed consent forms. All forms were assessed using several standard “readability” formulas.  The overall mean readability scores for the informed consent forms ranged from grades 12 to 14.5. In addition, the higher the risk of the study, the higher the mean readability score of the forms.

A review of medical informed consent studies reached similar conclusions (Pizzi et al., 2001). The results of the National Assessment of Adult Literacy survey in 2003 (http://nces.ed.gov/NAAL) are now being analyzed and published. Part of the 2003 survey included a measure of health literacy defined as, “the ability to use literacy skills to read and understand written health-related information encountered in everyday life.” Although it is beyond the scope of this discussion to define the complex classification system used in the survey, 75 million Americans are estimated to possess Basic and Below Basic health literacy skills with 114 million at the Intermediate level and only 12 million at the Proficient level. It is very unlikely that Americans with Basic or Below Basic health literacy (and probably the vast majority in the Intermediate group) would be able to read and comprehend most informed consent forms since they are written at a 12 to 15 years of education readability level (See Pizzi et al., 2001 for a review).  Research findings in this area present serious problems for the practitioner in obtaining informed consent. Given these findings, one critical aspect of surgery preparation is to help the patient understand the operation and facilitate the informed consent process.

In addition to the readability of patient education materials, research has indicated that patients generally remember very little of the information presented to them regarding their surgery and this is true whether the information is provided in written or verbal form (see Deardorff, 1986; Ferguson, 1993; Shuldman, 1999; Webber, 1990 for reviews). This memory problem may be due to the nature of the information being presented, the fact that surgery patients are quite distracted due to the entire surgical experience process, or some other issues. Thus, although highly understandable and appropriate information may be provided to surgery patients, they may not recall this information. 

It is not surprising that patients are often dissatisfied with the doctor-patient relationship and are reluctant to request information from surgeons, family doctors, or other healthcare professionals involved in the pre-surgical process. As part of a surgery preparation program, it is important to teach patients how to ask questions and where to go for answers. In the following chapter, simple assertiveness training techniques are reviewed; these will often be used in psychological preparation for surgery interventions. In addition, patients can be informed that they can get information from many sources, not just the doctor’s office (although that is the best place to start). Other sources might include the hospital, the library, governmental agencies such as the National Institute of Health (NIH), and the Internet.

In order to help surgery patients with the information gathering process, a variety of questions have been established as part of a more self-guided preparation for surgery program (See Table 3-3, adapted from Deardorff and Reeves, 1997).  Patients can be taught to get these questions answered preoperatively as necessary for their particular surgery and from the appropriate information source (which may not always be the doctor’s office).

Informed consent

Inadequate informed consent has been the basis for successful lawsuits in surgery. Patients have made the case that if they had adequate informed consent, they would have not undergone the elective surgery or would have chosen some other treatment option (See Benton, 2001; Benzel and Benton, 2001). These cases were made even though the usual consent forms had been signed by the patients.  As concluded by Benzel and Benton (2001, p. 33), “One of the main problems with the consent process is that it is just that – a process. Usually, it does not take place only during the final counseling of the patient regarding risks, benefits and alternative of an operation.  To one degree or another, it takes place during each physician-patient encounter that precedes an operation.” Making sure a patient acquires accurate and understandable medical information is important to all areas of surgery practice and is part of the surgery preparation process. 

Information Gathering and The Internet

With the explosion of the use of the Internet and medically-related websites, it is important to address this issue specifically with patients. The Internet can be a powerful tool in terms of medical information gathering related to any surgery. However, a strong caveat is in order relative to this information resource. There is a great deal of misinformation being promulgated through this media. In encouraging patients to gather information about their surgery, there need to be warnings abo