Psychological Reports, 1979,45, 867-873. @ Psychological Reports 1979
INFORMATION AND LOCUS OF CONTROL AS FACTORS I N THE OUTCOME OF SURGERY GEORGE A. CLUM, LINDA SCOTT, JUDITH BURNSIDE Virginia Polytechnic Institute and State University Surnmasy.-The present study was aimed at assessing the relationships of locus of control and amount of information patients possess regarding their surgery to several criteria of post-surgical adjustment, utilizing a self-report measure of pain, number of analgesics taken, days in hospital and frequency of complaints. 48 patients about to undergo elective cholecystectomy were evaluated one day prior to surgery and five days subsequent to surgery. The results supported the hypothesis that amount of information was negatively related to outcome especially with respect to pain. There was a correlation of .38 between information and the subjective and behavioral criteria of pain for internal individuals and of .39 between information and the subjective measure of pain found for external individuals. The results were discussed relative to their implications for interventions with surgical patients and the training of health personnel.
The ability to predict response to surgery is important from three vantage points: ( 1 ) Knowing which variables are predictive of response to surgery would help in developing a focus for prevention. For example, if individuals with high pre-surgical anxiety had poorer post-surgical adjustments, intervention strategies could be aimed at reducing the anxiety levels of the patients prior to surgery. ( 2 ) The ability to predict response to surgery would help to identify those patients at risk for surgical complications, increased pain, etc. (3) Individuals who work with surgical patients and in training individuals to work with surgical patients could then devise intervention strategies and training procedures which would help to reduce negative effects of surgery. The relationship of amount of information and type of information a patient possesses or is given prior to scrgery as it relates to outcome of surgery is unclear. For instance, some studies of experimental pain by Staub and Kellett ( 1972) and Johnson ( 1973), and some dealing with surgical pain and recovery, for example, studies by Egbert, Battit, Welch, and Bartlett (1964) and Healey ( 1968), have shown that information is related to the reduction of pain. However, Staub and Kellett provided information about the impending pain stimulus which told subjects exactly what to expect in a way which constituted a clear reassurance that the stimulus would riot be damaging to them. Johnson demonstrated that the specific information about the nature of the sensations to be experienced was an effective means of reducing the stress of the painful stimuli. Subjects who had only general information about the procedure did not attain this reducing effect. In studies of surgery, Egbert, et al. and Healey demonstrated that specific information about the nature of the pain they would experience and means of reducing and adapting to the pain served to reduce dis-
868
G. A . CLUM, ET AL.
comfort and speed recovery. In both of these studies, however, patients were provided with programs to help them deal with the pain and stress of suicide, chus confounding informacion with coping strategies. On the other hand, a recent study by Langer, Janis, and Wolfer (1975) reported thac simple information about the surgery served to magnify pain by causing patiencs to focus on the discomforting aspects of the experience they were abouc to undergo. Only when information was accompanied by providing the patient with a means of coping with the information was an improvement in adjustment afforded. The possible harmful effects of information were also explored by Kanfer and Goldfoot (1966) who reported that specific sensory information reduces pain tolerance possibly by sensitizing subjects to the pain they are abouc to experience. The question arises as to what effect a patient's information regarding his surgical experience has on his post-surgical adjustment. One possibility is chat a person's style of dealing with information will be an imporcant moderator of how such information is utilized. Andrew (1970), for example, reported an interaction berween preparatory information and coping style with information being detrimental to individuals who display denial as their characteristic defense. Similarly, it may be that one's perceived 'locus of control' moderates the information-adjustment to surgery relationship. The 'surgical situation is one in which an internally oriented patient would have few options for exercising control over the environment. When no specific coping skill was caughc, an internally oriented patient might attempt to control the situation by asking for drugs to alleviate the pain and to control what he fears to be complications resulting from the surgery. This would be especially true for those who had a great deal of informacion about surgery since they would have the most knowledge of how to exert control. Externally oriented individuals, on the other hand, would be expected to be uninterested in utilizing informacion and would neither profit by ic nor respond negatively. Accordingly, amount of information would be a negative predictor of response to surgery for internally oriented persons but have no relationship to outcome for externally oriented individuals. This hypothesis was examined in the present study. Specifically, it was hypothesized thac general informacion would be predictive of a negative response to surgery and also that internal individuals would have a more negarive response to surgery as the amount of general information increased. The latter relationship would not obtain for external individuals.
METHOD Szbbjects The subjects were 48 male and female patiencs between the ages of 21 and 73 yr. who were abouc to undergo elective cholecystectomy. These patients were chosen from two county hospitals and were eliminated if they had a medical history of organic brain damage, mental retardation, or significant psychological
RESPONSE TO SURGERY
869
disturbances. There were nine males and 39 females with a mean age of 45 yr. The McGill Pain Questio~z?zaire.-The questionnaire is a self-report measure of pain utilizing adjectives which describe the sensory, affective and evaluative components of pain. Two measures of pain were obtained, the pain rating index and the present pain intensity. The pain rating index portion has 20 groups of adjectives divided into three major classes of word descriptors (Melzack, 1975), sensory, affective and evaluative, and a fourth category of miscellaneous descriptors. The 10 groups of adjectives of the sensoFy component describe pain in terms of temporal, spatial, pressure, thermal, dullness, and other sensory properties. The five affective subscales include tension, autonomic arousal, and fear components. The evaluative descriptor is designed to describe over-all intensity of the total pain experience. Finally, a separate measure of present pain intensity is rared on a five-point scale from "mild" to "excruciating," according to the amount of pain that is felt at the time of the testing. Surgery Information Qzcestionnaire.-This questionnaire contains four questions related to the subject's information about complications, post-surgical pain, preparatory procedures, and reasons for needing gall-bladder surgery. This questionnaire was developed specifically for this study to reflect the amount of information each patient had concerning hospital procedures and the nature of the discomfort that he was about to undergo. The four questions were: ( 1) Why is ic necessary for you ro have this surgery?, ( 2 ) What type of pain do you expect to experience after surgery?, ( 3 ) What are some of the procedures necessary to prepare you for surgery?, and ( 4 ) What are some of the complications that sometimes follow surgery? These questions were based on the four main areas of preparatory information rhat was presented to surgical patients by Langer, Janis, and Wolfer ( 1975). Possible answers to each question were listed and one point was scored for each item accurately reported by the patient. Answers rhat reflected accurate knowledge of the preparations, complications, and discomforts were taken from recent nursing journals on the care of surgical patients. Possible scores ranged from 0 to 14. A?zalgesics received.-A tabulation was made from the drug administration record in each patient's file. Pain medications were available upon request during the postoperative period and each administration was recorded by the nurse in the patient's chart. The number of adminisrrations of a pain medication, when based on requests by the patient, can be considered a behavioral index of the magnitude of pain experienced by the patient. Health Locus of ControL Scale.-This scale was developed by Wallston, Wallston, Kaplan, and Maides ( 1976) to assess individuals' perceptions of their control over their personal health. It consisted of 11 true-false questions which yielded scores from 0 to 11; higher scores suggested an external locus of control
870
G. A. U U M , ET AL.
orientation. Wallston and Wallston ( 1978) report alpha reliability of .72 and a number of studies which underscore its ability to predict individuals' willingness to assume responsibility for their health. Procedure Each day on which elective surgeries were scheduled, each of the two hospitals participating in the study were contacted and a list of persons posted for surgery the following day was obtained. Each patient was approached and asked to participate in the study. Seven patients did not participate because they were too ill, were taken out of their room for tests, or were occupied with visitors whom they did not want to leave. Each patient was tested twice, first on the afternoon preceding surgery and then five days after surgery, counting the day after surgery as the first postoperative day. Each patient was tested in his own hospital room, usually while propped up in bed. Two patients took the preoperative measure but not the postoperative measure since they were released a day earlier than the other patients, an administrative procedure limited to those under 25 yr. of age. Three other patients were tested in the preoperative period only because they decided they did not want to continue the study after answering some of the anxiety measures. In the preoperative session, the examiner explained, in general terms, the purpose of the study. Each patient was told that the purpose of the smdy was to gain a better understanding of how patients react to surgical operations so that future programs could be developed to help patients deal with surgical pain more effectively. The final testing took place five days after surgery, after the patients had sufficient time to regain their strength. In this session the McGill Pain Questionnaire was again administered. After the patient had been discharged and their medical records were available, each file was examined and the following data were recorded: ( 1) number of analgesics taken during the post-surgical period, ( 2 ) number of days hospitalized after surgery was completed, with the day of surgery counted as the first day and ( 3) number of times the person had complained of pain, discomfort or the like, as indicated in the nurses' notes.
RESULTS The two hospitals were first compared to determine whether there were any difference between them in terms of the criteria. One of the two hospitals had given a somewhat greater number of analgesics while no other differences were found. Patients admitted to the two hospitals were essentially identical on demographic information of age, sex, socioeconomic status, and marital status. Pearson correlations were computed between the level of information as measured by the Surgery Information Questionnaire and each of five criteria of response to surgery including the two subjective measures of pain, number of
87 1
RESPONSE TO SURGERY
analgesics, number of days in hospital, and number of complaints noted in nurses' notes. Significant relationships were found between information and number of analgesics requested ( r = 3 3 , p < .01) and between information and the Present Pain Index ( r = .38, p < .01). The sample was then divided into those scoring high and low on the Health I-E Scale by means of a median split. One-way analyses of variance were then computed to each of the criteria measures. There were no differences between the internal subjects ( M = 1.48) on perceived pain ( F 1 , 4 ( i= 0.00), the painrating index (mean for internal subjects = 14.9; mean for external subjects = 17.7; F1,40 = 0.87, p > .05), number of analgesics (mean for Internal subjects = 16.1; mean for external subjects = 14.9; FIT,(;= 0.22, p > .05), number of days in hospital (mean for internal subjects = .36; mean for excernal subjects = .35 where days are calculated as follows: days 2 8 = 1, days 8 = 0; F1,aF = 0.00), and number of complaints (mean for internal subjects = 2.56; mean for external subjects = 2.87; FIJ4"= .14, p > .05). Level of information was then correlated with each of the outcome measures for both the internal and external groups separately. The results of this analysis are shown in Table 1. As can be seen, for internal subjects amount of information was related to the number of analgesics and the Present Pain Index while information was related only to the Present Pain Index for the external subjects. Internals and externals were compared on the amount of information they possessed. N o differences were found ( F = .99, p > . l o ) . It was possible that the relationship between information and analgesics found for the internal group was attributable to a high relationship between pain and analgesics for this group. Internal subjects, by this reasoning, would be expected to have a higher relationship between pain and analgesics than external subjects. In fact, the reverse was found. For the internal group there was a small correlation between pain and the number of analgesics ( r = .28, p = .09) which disappeared in a partial correlation controlling for the amount of information ( r = .13, p > .lo). In the external group, however, the relationship between pain and analgesics was somewhat higher ( r = TABLE 1 CORRELATIONS BEIWEEN AMOUNT OF INFORMATION AND SURGERY OUTCOMEFOR SUBJECTS INTERNALLY AND EXTERNALLY ORIENTED ON THE HEALTH Locus OF CONTROLSCALE
*p
INFORMATION AND LOCUS OF CONTROL AS FACTORS I N THE OUTCOME OF SURGERY GEORGE A. CLUM, LINDA SCOTT, JUDITH BURNSIDE Virginia Polytechnic Institute and State University Surnmasy.-The present study was aimed at assessing the relationships of locus of control and amount of information patients possess regarding their surgery to several criteria of post-surgical adjustment, utilizing a self-report measure of pain, number of analgesics taken, days in hospital and frequency of complaints. 48 patients about to undergo elective cholecystectomy were evaluated one day prior to surgery and five days subsequent to surgery. The results supported the hypothesis that amount of information was negatively related to outcome especially with respect to pain. There was a correlation of .38 between information and the subjective and behavioral criteria of pain for internal individuals and of .39 between information and the subjective measure of pain found for external individuals. The results were discussed relative to their implications for interventions with surgical patients and the training of health personnel.
The ability to predict response to surgery is important from three vantage points: ( 1 ) Knowing which variables are predictive of response to surgery would help in developing a focus for prevention. For example, if individuals with high pre-surgical anxiety had poorer post-surgical adjustments, intervention strategies could be aimed at reducing the anxiety levels of the patients prior to surgery. ( 2 ) The ability to predict response to surgery would help to identify those patients at risk for surgical complications, increased pain, etc. (3) Individuals who work with surgical patients and in training individuals to work with surgical patients could then devise intervention strategies and training procedures which would help to reduce negative effects of surgery. The relationship of amount of information and type of information a patient possesses or is given prior to scrgery as it relates to outcome of surgery is unclear. For instance, some studies of experimental pain by Staub and Kellett ( 1972) and Johnson ( 1973), and some dealing with surgical pain and recovery, for example, studies by Egbert, Battit, Welch, and Bartlett (1964) and Healey ( 1968), have shown that information is related to the reduction of pain. However, Staub and Kellett provided information about the impending pain stimulus which told subjects exactly what to expect in a way which constituted a clear reassurance that the stimulus would riot be damaging to them. Johnson demonstrated that the specific information about the nature of the sensations to be experienced was an effective means of reducing the stress of the painful stimuli. Subjects who had only general information about the procedure did not attain this reducing effect. In studies of surgery, Egbert, et al. and Healey demonstrated that specific information about the nature of the pain they would experience and means of reducing and adapting to the pain served to reduce dis-
868
G. A . CLUM, ET AL.
comfort and speed recovery. In both of these studies, however, patients were provided with programs to help them deal with the pain and stress of suicide, chus confounding informacion with coping strategies. On the other hand, a recent study by Langer, Janis, and Wolfer (1975) reported thac simple information about the surgery served to magnify pain by causing patiencs to focus on the discomforting aspects of the experience they were abouc to undergo. Only when information was accompanied by providing the patient with a means of coping with the information was an improvement in adjustment afforded. The possible harmful effects of information were also explored by Kanfer and Goldfoot (1966) who reported that specific sensory information reduces pain tolerance possibly by sensitizing subjects to the pain they are abouc to experience. The question arises as to what effect a patient's information regarding his surgical experience has on his post-surgical adjustment. One possibility is chat a person's style of dealing with information will be an imporcant moderator of how such information is utilized. Andrew (1970), for example, reported an interaction berween preparatory information and coping style with information being detrimental to individuals who display denial as their characteristic defense. Similarly, it may be that one's perceived 'locus of control' moderates the information-adjustment to surgery relationship. The 'surgical situation is one in which an internally oriented patient would have few options for exercising control over the environment. When no specific coping skill was caughc, an internally oriented patient might attempt to control the situation by asking for drugs to alleviate the pain and to control what he fears to be complications resulting from the surgery. This would be especially true for those who had a great deal of informacion about surgery since they would have the most knowledge of how to exert control. Externally oriented individuals, on the other hand, would be expected to be uninterested in utilizing informacion and would neither profit by ic nor respond negatively. Accordingly, amount of information would be a negative predictor of response to surgery for internally oriented persons but have no relationship to outcome for externally oriented individuals. This hypothesis was examined in the present study. Specifically, it was hypothesized thac general informacion would be predictive of a negative response to surgery and also that internal individuals would have a more negarive response to surgery as the amount of general information increased. The latter relationship would not obtain for external individuals.
METHOD Szbbjects The subjects were 48 male and female patiencs between the ages of 21 and 73 yr. who were abouc to undergo elective cholecystectomy. These patients were chosen from two county hospitals and were eliminated if they had a medical history of organic brain damage, mental retardation, or significant psychological
RESPONSE TO SURGERY
869
disturbances. There were nine males and 39 females with a mean age of 45 yr. The McGill Pain Questio~z?zaire.-The questionnaire is a self-report measure of pain utilizing adjectives which describe the sensory, affective and evaluative components of pain. Two measures of pain were obtained, the pain rating index and the present pain intensity. The pain rating index portion has 20 groups of adjectives divided into three major classes of word descriptors (Melzack, 1975), sensory, affective and evaluative, and a fourth category of miscellaneous descriptors. The 10 groups of adjectives of the sensoFy component describe pain in terms of temporal, spatial, pressure, thermal, dullness, and other sensory properties. The five affective subscales include tension, autonomic arousal, and fear components. The evaluative descriptor is designed to describe over-all intensity of the total pain experience. Finally, a separate measure of present pain intensity is rared on a five-point scale from "mild" to "excruciating," according to the amount of pain that is felt at the time of the testing. Surgery Information Qzcestionnaire.-This questionnaire contains four questions related to the subject's information about complications, post-surgical pain, preparatory procedures, and reasons for needing gall-bladder surgery. This questionnaire was developed specifically for this study to reflect the amount of information each patient had concerning hospital procedures and the nature of the discomfort that he was about to undergo. The four questions were: ( 1) Why is ic necessary for you ro have this surgery?, ( 2 ) What type of pain do you expect to experience after surgery?, ( 3 ) What are some of the procedures necessary to prepare you for surgery?, and ( 4 ) What are some of the complications that sometimes follow surgery? These questions were based on the four main areas of preparatory information rhat was presented to surgical patients by Langer, Janis, and Wolfer ( 1975). Possible answers to each question were listed and one point was scored for each item accurately reported by the patient. Answers rhat reflected accurate knowledge of the preparations, complications, and discomforts were taken from recent nursing journals on the care of surgical patients. Possible scores ranged from 0 to 14. A?zalgesics received.-A tabulation was made from the drug administration record in each patient's file. Pain medications were available upon request during the postoperative period and each administration was recorded by the nurse in the patient's chart. The number of adminisrrations of a pain medication, when based on requests by the patient, can be considered a behavioral index of the magnitude of pain experienced by the patient. Health Locus of ControL Scale.-This scale was developed by Wallston, Wallston, Kaplan, and Maides ( 1976) to assess individuals' perceptions of their control over their personal health. It consisted of 11 true-false questions which yielded scores from 0 to 11; higher scores suggested an external locus of control
870
G. A. U U M , ET AL.
orientation. Wallston and Wallston ( 1978) report alpha reliability of .72 and a number of studies which underscore its ability to predict individuals' willingness to assume responsibility for their health. Procedure Each day on which elective surgeries were scheduled, each of the two hospitals participating in the study were contacted and a list of persons posted for surgery the following day was obtained. Each patient was approached and asked to participate in the study. Seven patients did not participate because they were too ill, were taken out of their room for tests, or were occupied with visitors whom they did not want to leave. Each patient was tested twice, first on the afternoon preceding surgery and then five days after surgery, counting the day after surgery as the first postoperative day. Each patient was tested in his own hospital room, usually while propped up in bed. Two patients took the preoperative measure but not the postoperative measure since they were released a day earlier than the other patients, an administrative procedure limited to those under 25 yr. of age. Three other patients were tested in the preoperative period only because they decided they did not want to continue the study after answering some of the anxiety measures. In the preoperative session, the examiner explained, in general terms, the purpose of the study. Each patient was told that the purpose of the smdy was to gain a better understanding of how patients react to surgical operations so that future programs could be developed to help patients deal with surgical pain more effectively. The final testing took place five days after surgery, after the patients had sufficient time to regain their strength. In this session the McGill Pain Questionnaire was again administered. After the patient had been discharged and their medical records were available, each file was examined and the following data were recorded: ( 1) number of analgesics taken during the post-surgical period, ( 2 ) number of days hospitalized after surgery was completed, with the day of surgery counted as the first day and ( 3) number of times the person had complained of pain, discomfort or the like, as indicated in the nurses' notes.
RESULTS The two hospitals were first compared to determine whether there were any difference between them in terms of the criteria. One of the two hospitals had given a somewhat greater number of analgesics while no other differences were found. Patients admitted to the two hospitals were essentially identical on demographic information of age, sex, socioeconomic status, and marital status. Pearson correlations were computed between the level of information as measured by the Surgery Information Questionnaire and each of five criteria of response to surgery including the two subjective measures of pain, number of
87 1
RESPONSE TO SURGERY
analgesics, number of days in hospital, and number of complaints noted in nurses' notes. Significant relationships were found between information and number of analgesics requested ( r = 3 3 , p < .01) and between information and the Present Pain Index ( r = .38, p < .01). The sample was then divided into those scoring high and low on the Health I-E Scale by means of a median split. One-way analyses of variance were then computed to each of the criteria measures. There were no differences between the internal subjects ( M = 1.48) on perceived pain ( F 1 , 4 ( i= 0.00), the painrating index (mean for internal subjects = 14.9; mean for external subjects = 17.7; F1,40 = 0.87, p > .05), number of analgesics (mean for Internal subjects = 16.1; mean for external subjects = 14.9; FIT,(;= 0.22, p > .05), number of days in hospital (mean for internal subjects = .36; mean for excernal subjects = .35 where days are calculated as follows: days 2 8 = 1, days 8 = 0; F1,aF = 0.00), and number of complaints (mean for internal subjects = 2.56; mean for external subjects = 2.87; FIJ4"= .14, p > .05). Level of information was then correlated with each of the outcome measures for both the internal and external groups separately. The results of this analysis are shown in Table 1. As can be seen, for internal subjects amount of information was related to the number of analgesics and the Present Pain Index while information was related only to the Present Pain Index for the external subjects. Internals and externals were compared on the amount of information they possessed. N o differences were found ( F = .99, p > . l o ) . It was possible that the relationship between information and analgesics found for the internal group was attributable to a high relationship between pain and analgesics for this group. Internal subjects, by this reasoning, would be expected to have a higher relationship between pain and analgesics than external subjects. In fact, the reverse was found. For the internal group there was a small correlation between pain and the number of analgesics ( r = .28, p = .09) which disappeared in a partial correlation controlling for the amount of information ( r = .13, p > .lo). In the external group, however, the relationship between pain and analgesics was somewhat higher ( r = TABLE 1 CORRELATIONS BEIWEEN AMOUNT OF INFORMATION AND SURGERY OUTCOMEFOR SUBJECTS INTERNALLY AND EXTERNALLY ORIENTED ON THE HEALTH Locus OF CONTROLSCALE
*p
