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Methodological challenges in the study of psychological recovery from modern surgery

Most cases of elective surgery in the UK are now under- taken in day-case facilities, and the trend is set to increase. Surgical and anaesthetic health care is changing rapidly Traditional pre- and post-operative nursing intervention, once commonly taught and practised, must now be re-evaluated as a result of such transformations. However, undertaking research in order to investigate the fresh challenges facing nursing in the modern surgical environ- ment may present many difficulties. Methodological issues, such as the application of research approaches, time for adequate data collection, and the utilisation of patients as participants undergoing modern surgery will present numerous barriers. In this article, Mark Mitchell identifies and discusses three problematic methodological issues that currently challenge the effective study of psy- chological recovery from modern surgery in the UK

- modern surgery > research approaches > data collection > patients as participants

Research and the modern surgical environment

Within the UK an acute modern surgical environment predominates in the NHS; that is, minimal hospital stay, limited nurse-patient contact, rapid anaes- thesia, minimal access surgery, considerable self-preparation and substantial self-recovery beyond the bounds of the hospital. Approximately 60-65 per cent of all elective surgery is now undertaken in day surgery facilities, and is, therefore, now the norm for the majority of patients undergoing elective sur- gical treatment (Audit Commission 2001). Indeed, this trend is set to grow as The NHS Plan (Department of Health 2000) aims to increase the level of day surgery activity to 75 per cent of all elective surgery. The average length of stay for a patient undergoing intermediate day surgery within a dedicated day surgery facility in Europe is now six hours (Pfisterer etal 2001). Intermediate elective surgery is defined here as planned, uncomplicated surgery under gen- eral anaesthesia which can be undertaken in an operating theatre in less than one hour. The degree of change in surgical health care cannot therefore be underestimated. Indeed, Montori (1998) states: 'It is no exaggeration to say that minimally invasive surgery has opened up a new form of modern sur- gery.' For example, patients undergoing cholecystectomy in the mid 1980s regularly required hospitalisation for up to three weeks, and, consequently, a considerable amount of physical nursing intervention. However, such practice is becoming obsolete as the British Association of Day Surgery has included cholecystectomy in its list of procedures of which 50 per cent should now be possible in day surgery facilities (Cahill 1999). Such a transformation in surgi- cal health care will guarantee far-reaching and lasting changes to the way in which nurses are educated. For example, the copious physical nursing inter- ventions once required by cholecystectomy patients, hospitalised for many weeks, such as wound care, pain relief, hygiene and mobility management, are fast disappearing. Only the minority of elective surgical patients will require such physical nursing interventions in the future. Robust evidence is therefore required to inform nurse education and practice in this new and developing surgical era.

Psychological recovery from surgery is an essential aspect of surgical care (Royal College of Surgeons and Royal College of Psychiatrists 1997). Psychological recovery is defined here as the purposeful attempt to provide

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tangible aspects of nursing intervention aimed at eniiancing an individual's emotional status, together with the planned provision of educational mate- rial. It is therefore more accurate to describe such intervention as 'psycho- educational care' (as do many studies from the US), as information provision, together with emotional aspects of care, conveys a more accurate picture (Mitchell 2000a, 2001). Several reviews of the literature in previous decades have reported a plethora of studies investigating the challenge of improving pre-operative psychological care (Johnston and Vogele 1993, AAathews and Ridgeway 1984, Miller et al 1989, Rothrock 1989, Suls and Wan 1989, Wilson 1981). Much has been recommended over this period, although unfortunately little in the way of real progress has been made, as consider- able emphasis on the physical aspects of care remains (Kleinbeck 2000, Leinonen et al 1996, Leinonen and Leino-Kilpi 1999). Physical safety when undergoing surgery is obviously of paramount importance, although given that future cholecystectomy patients (for example) will be hospitalised for a mere day, psychological considerations may require greater emphasis. Undergoing anaesthesia is a major source of fear, and approximately 7 per cent of the population are anaesthetised annually in the UK (Royal College of Surgeons and Royal College of Psychiatrists 1997, Mitchell 2000b). Additionally, studies over four decades concerning pre-operative anxiety have stated that patients are very anxious about the anaesthesia, pain and discomfort, being unconscious and the operation itself, and that this anxiety does not end as patients are discharged form hospital (Egbert et al 1964, Male 1981, McCleane and Cooper 1990, McGaw and Hanna 1998, Mitchell 1997, Ramsay 1972), However, little formal care has been implemented to help resolve this challenge (Mitchell 2000a). With the projected increase in day surgery intervention together with the average length of stay in a day surgery facility, the problem of anxiety may present a challenge to the nurs- ing profession for many years to come.

As a result of such extensive surgical and anaesthetic advances, studying the most effective nursing interventions relating to psychological recovery from surgery has become a very complex task. Previously, investigating such recovery primarily involved researchers visiting the surgical wards to recruit and interview participants. Much time spent by the patient in hospital with-

Challenge

Rationale

Application of

The time available on the day of surgery will severely restrict the

research approach

application of the two main approaches, i.e. quantitative and

Mode of data collection

qualitative. The time restrictions inherent within current and future day surgery will be the most influential factor. Day surgery practices have rendered some of the more traditional methods of data collection to measure psychological

Day surgery patients as participants

recovery obsolete, for example, amount of analgesia, time taken to mobilise, in-depth interview, etc. The compliant, convalescing, post-operative patient who once provided a very convenient participant no longer exists; i.e. average length of stay is currently six hours in Europe.

in the pre- and post-operative period made possible such methods of data collection. However, this situation has changed with the rise in day surgery, as the majority of patients undergoing intermediate surgery are no longer treated as inpatients. Additionally, hospital stay for surgical inpatients is con- stantly decreasing, never again to return to previous levels; for example, the average length of surgical stay in one study was 2.7 days (Tierney etal 2000). Such alterations in surgical treatment are restricting a number of central aspects within the research process; D the application of quantitative and qualitative research methods D mode of data collection and • modern surgical patients as participants (Table 1). Each aspect will therefore be discussed in greater detail, as they will increas- ingly influence the study of psychological recovery from modern surgery.

Application of research approaches

Application of the fundamental research approaches within the modern sur- gical environment will become increasingly difficult to administer because of the inherent lack of time available. Previously, the principal approaches to research in this field employed quantitative methods (great deal of empirical

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data collected in a very structured manner), with a smaller number employ- ing a qualitative approach (focusing upon in-depth individual interpretation of events) (Johnston and Vogele 1993. Suls and Wan 1989). However, both approaches face future challenges when examining recovery from surgery. For example, the quantitative researcher will increasingly encounter restrict- ed access to patients and their medical records (and hence certain empirical data) as a result of the inherent lack of time on the day of surgery. This will inevitably affect or limit the choice of data collection in order to effectively gauge psychological recovery.

Historically, in order to monitor psychological recovery from surgery, vari- ous physiological, behavioural and emotional measures have been employed (Johnston and Vogele 1993, Mathews and Ridgeway 1984, Miller eta/1989, Rothrock 1989, Suls and Wan 1989, Wilson 1981) (Table 2). However, numerous physiological measures of anxiety such as 24-hour urine collection for cortisol, or blood analysis for adrenaline and nor-adrenaline, may be ren- dered too impractical. Polit et al (2001) divide such physiological measures into in vivo measures (assessment performed directly on the person, such as blood pressure monitoring) and in vitro measures (assessment performed fol- lowing extraction of biological material such as blood). Both measures may be limited in such circumstances, as assessment of the patient's blood pres- sure and pulse rate immediately prior to day surgery has been viewed to be of little value. Almost all patients will experience a rise in blood pressure and pulse rate during the brief window of opportunity available for data collec- tion on the day of surgery (Domar et al 1987, Markland and Hardy 1993, Mealy et al 1996). If a participant's blood pressure and pulse rate is invari- ably raised hours or minutes prior to surgery, it can be safely assumed adren- aline and nor-adrenaline levels may likewise be raised.

Many behavioural measures associated with recovery from surgery will also be very limited, such as the number of painkilling tablets consumed dur- ing the hospital stay, patient activity level, number of complaints made, level of nausea and vomiting, plus numerous other measures of morbidity. Additionally, several emotional measures will likewise be difficult to evalu- ate. For example, many studies have monitored anxiety throughout the whole period of hospitalisation and then employed measures of comparison

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Mode of data collection

Possible outcome measures

Behavioural

Observable aspects of patient behaviour by the medical

and nursing staff, i.e. level of anxiety observed, adjustment to surgery, ease of anaesthesia, number of days in hospital, amount of analgesia consumed, number of days to fully mobilise, number of complications, number of negative statements, and numerous additional observable responses.

Physiological

Blood pressure, pulse, respirations, cortisol excretion in urine, palmar sweat, blood analysis for cortisol, adrenaline and nor-adrenaline.

Emotional

Self-reported measures of anxiety, self-reported methods of coping, self-reported amount or degree of pain and discomfort, self-reported time to return to 'normal'

between such levels, such as evaluation of anxiety at several stages in the pre-operative phase and again at several stages in the post-operative phase. Clearly, in the modern surgical environment such traditional measures will no longer be applicable. The manner in which recovery from modern surgery is measured in the future by the quantitative researcher will therefore require very careful consideration.

Similarly, researchers pursuing a qualitative approach may find gaining access to a suitable surgical patient in an unhurried situation (for example, hospitalised for a few days without being acutely ill) in order to conduct an in-depth interview very difficult. Once home, many patients may be too concerned with their 'normal' daily lives to continue as participants in a research study. For example, in a recent study examining psychological recovery from day surgery, one participant was contacted, as arranged, by telephone for a brief (10-1 5 minutes) interview 48 hours after intermediate gynaecological surgery and general anaesthesia. However, the participant was not available, as she had travelled to a nearby holiday resort to ride on a large roller-coaster. (Mitchell 2000b). Although only one example, it does provide some indication as to the future trend in rapid recovery from such

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surgery. Put simply, the traditional 'researcher friendly' post-operative peri- od of inpatient recovery and convalescence, once extremely conducive to adequate data collection, is fast disappearing.

Data collection

The second issue concerns data collection, or more specifically i) similar data collected within the quantitative and qualitative approaches, and ii) limited measures to gauge 'good and bad' psychological recovery. Firstly, whereas the fundamental approach to acquiring insight into participants' experiences may differ between the quantitative and qualitative approaches, the meth- ods of collecting data are often, for convenience and accessibility purposes, very similar, that is, behavioural (eg, time spent in hospital), physiological (eg, blood pressure) and emotional (eg, self-rated questionnaire) data col- lection (Fitzpatrick and Dawson 1997) (Table 2).

Indeed, Salmon (1992) states the indices utilised to measure recovery from surgery have been employed more on a practical basis than on the most valid: that is, what is considered a valid measure versus what can be reason- ably undertaken. Both research approaches rely on broadly similar methods of data collection in order to evaluate and comment upon 'good and bad' psychological recovery. The method(s) chosen depend(s) entirely upon the researcher and the proposed study. Naturally, the data may be interpreted in differing ways, although, generally, with such a limited choice of indices, the narrow band of measures utilised may limit all conclusions reached. Such slender differences between the two approaches may therefore render con- clusions as less distinguishable, as researchers are forced to pursue a con- stantly narrowing band of indices in modern surgery, such as limited time for physiological data collection, leading to a greater level of emotional data col- lection. Put simply, the choice of 'good and bad' recovery measurements for both research approaches is becoming very limited. Ultimately, this may pre- vent vital new evidence from being uncovered, as measures of physiological and emotional recovery become too limited and impractical.

Secondly, this may not always necessarily be detrimental to the study of psychological recovery, at least from the viewpoint of finally producing a pre- operative anxiety management nursing care plan. Employing differing meth-

ods of data collection has led in the past to many opposing conclusions, which may have delayed the development of effective programmes of pre- operative psychological intervention (Manyande et al 1992). Moreover, Bond and Thomas (1992) suggest that other problems of measurement also impede data collection, such as operational definitions, diversity of patient perceptions (quality of staff or environment or both), and influences upon patient satisfaction (measures dependent upon patient expectations). Research into psychological recovery from surgery has been burdened in the past by esoteric debates concerning the most effect measure of anxiety: that is, is anxiety more effectively measured via physiological methods (largely objective data) or by emotional and behavioural methods (largely subjective data). The debate may become less intrusive, as the brief window of oppor- tunity now available for data collection may render numerous physiological and behavioural measures too impractical or simply invalid (Table 2).

Day surgery patients as participants

The third and final challenge for data collection within this area of research concerns participants who, while consenting to a research study, are always discharged from hospital the same day, and can therefore no longer be monitored as closely as they once were. For example, once a prospective participant has had a research study outlined to them, their decision to con- sent or otherwise may arise in part from their desire to truly receive the information or instructions imparted to them within the bounds of the study. For example, random allocation to a certain group within a quasi- experimental research study (control or experimental group), or to contin- ue as directed once discharged from the hospital setting. A considerable number of studies employing modern surgical patients randomise patients into groups in this way, either in the pre-operative or post-operative period (Mitchell 1999a, 1999b). Ensuring and monitoring such group allocation was arguably far easier when patients were hospitalised. Such groups are frequently provided with information to read or instructions to follow as part of the study. This can be problematic, as many studies examining psy- chological recovery frequently employ differing amounts or types of infor- mation for comparison. For example. Croup 1 - relaxation information;

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Croup 2 - hospital leaflet only (Johnston and Vogele 1993, AAathews and Ridgeway 1984, Rothrock 1989, Wilson 1981). For example, in studies by Caberson (1995) and Markland and Hardy (1993) concerning relaxation prior to day surgery, an element of patient choice was given. Patients could choose which research group to be allocated to; that is, experimental group or routine care group. This is frequently undertaken, as previous studies have demonstrated that patients do not conform to the planned research schedule if it is not deemed to be of personal value or indeed impedes their rapid recovery (such as a day out to ride the roller-coaster). It is therefore extremely difficult for the researcher in this field to ensure participants remain randomised with limited controls, when recovery almost entirely occurs at home.

The captive, malleable, surgical inpatient frequently employed as a research participant and upon whom hypotheses could at one time be rea- sonably tested, is rapidly disappearing. Contact is considerably less because inpatient elective surgery is considerably less. The opportunity for researcher manipulation is reduced as a result of the time restrictions inherent with day surgery. Also, when a study involves experimental groups randomised into differing forms of recovery (typically differing levels/types of information provision) the ability to truly obtain an unbiased sample is very difficult. Additionally, the notion of a control group receiving routine nursing care is rapidly becoming an outdated research tool. Civing the label of 'routine care' to the hasty, medically dominated intervention provided during an average six hour stay in a day surgery unit may be a poor comparison, as any sup- plementary care on the day of surgery (for the experimental group) will be very limited. Indeed, as stated, supplementary intervention provided to an experimental group frequently involves differing levels/types of information provided in the days and weeks prior to or following surgery. For the deter- mined participant who does not receive the desired additional informa- tion/instructions within the bounds of a study, the media, NHS Direct, and a plethora of internet sites are now easily accessible. In other words, the self- reliant patient preparing for or recovering from surgery at home can now gain information from a huge variety of sources and can thereby easily cir- cumvent 'controls' the researcher may have planned.

Future measurement of psychological recovery

Evaluating psychological recovery from modern surgery is becoming a very challenging task. When examining patients' experiences of day surgery, the time needed for data collection, measuring 'good and bad' recovery and participant behaviour present numerous challenges. Psycho-educational aspects of care will be of vital importance in the future as minimal hospital stay and reduced contact with hospital personnel affects an ever-increasing group of patients (Mitchell 2003). Indeed, in a recent Audit Commission Report (2001) ten indicators of good practice were employed to measure the effectiveness of day surgery facilities. Eight of these measures related to the provision of adequate information: i.e. psycho-educational aspects of care. The Audit Commission viewed these measures as central to the delivery effective day surgery. Below are some recommendations pertaining to each of the previous three sections that may not only benefit the patient but also help in the gaining of valuable information to increase nursing knowledge.

Firstly, as the time required for data collection on the day of surgery is very limited, the pre-assessment clinic may provide an ideal opportunity for data collection. A pre-assessment visit is a pre-arranged hospital visit before the day of surgery to check fitness for surgery, and is highly recommended (Department of Health 2002). This window of opportunity for data collec- tion is currently not widely utilised. However, it must be understood that data collected at this period could limit any results. For example, patient anx- iety may demonstrate little increase six to eight weeks prior to surgery when such pre-assessment frequently takes place. Nevertheless, some day surgery units have other times when patients visit to experience the environment prior to the day of surgery. This may also become an ideal opportunity for data collection. Contact in the outpatient department when day surgery referral is initiated could additionally be employed or contact via telephone during the pre-operative phase.

Secondly, measuring 'good and bad' recovery from surgery may remain demanding because of the narrowing band of reliable and practical indices available. Additionally, patient expectations may vary considerably. Patient expectations have been frequently highlighted as problematic, as they can both help or hinder recovery dependent upon whether expectations have matched

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actual experience (Ruuth-Setala et al 2000). For example, many patients believe that day surgery equates to minor surgery and are frequently unpre- pared for the level of pain, discomfort, and incapacity during the first 24 to 48 hours (Donoghue et al 1995, Mitchell 2003), With the inherent time con- straints on the day of surgery, other reliable measures beyond the bounds of the hospital and outpatient department may be required. Other such forms of data collection may include short and long term post-discharge evaluation, postal questionnaires, internet questionnaires, telephone interviews, question- naires/interviews to gain the carer's perspectives, questionnaires/interviews concerning recovery from specific surgical procedures, general practitioner per- spectives, questionnaires/intervievi/s to gauge how unexpected problems were handled and questionnaires/interviews undertaken by the community nursing team. Much information is gathered prior to day surgery during the pre-assess- ment check although currently few, if any, post-assessment interviews take place to evaluate the care and treatment received. Much valuable information could be routinely gained if such dialogue were to be established. Valuable information could be obtained during post-assessment interviews as part of an outpatient appointment, telephone interview, or district nurse visit, and become a potent tool for both clinician and researcher

Finally, day surgery patients utilised as participants in studies concerned with recovery from surgery present many challenges, A by-product of increased self-care is the heightened sense of patient independence from the confines of the hospital setting. Indeed, in a study of day surgery patients by Bostrom et al (1994) the first two weeks following discharge were seen as the most important time as patients were frequently striving to regain greater healthcare autonomy. Day surgery is therefore heavily reliant upon a consid- erable amount of self-care and care provided by relatives (Hazelgrove and Robins 2000, Singleton et al 1996, Thatcher 1996, Willis et al 1997), Indeed, the care once provided by nurses for patients recovering from surgery is now inevitably undertaken by relatives. In a recent study by Hirst (2002) it was revealed that 50 per cent of all British adults would provide care for a rela- tive at some stage throughout their lives, although this was not specific to day surgery. However, as the level of day surgery activity increases, so too must the percentage of relatives involved in caring for a patient who has

undergone modern elective surgery. Although the degree of care required following such surgery can sometimes be minimal, the criteria for all day sur- gery clearly states that patients must be cared for by an adult in the first 24 hours following surgery (Royal College of Surgeons of England 1992).

Conclusion

The NHS Plan (Department of Health 2000) aims to increase the level of sur- gery undertaken in day surgery facilities to 75 per cent of all elective surgi- cal procedures. The study of how patients recover psychologically from such modern surgery is therefore a very important issue for the nursing profession. Little is known about the most effective nursing Interventions relating to such modern, rapid surgical treatment and recovery. The gaining of participants and the collection of data was arguably less challenging when elective surgi- cal patients remained in hospital for a number of days and weeks during the pre- and post-operative period. However, this situation no longer prevails and will never return. Within the changing surgical healthcare arena many aspects of research methodology will become increasingly difficult to admin- ister. The application of the fundamental research approaches will be limited considerably by the lack of time on the day of surgery. This will largely have a negative influence upon many aspects of data collection. Clarity and action are required immediately as we are currently in the midst of this surgical rev- olution. Additionally, the valid measurement of 'good and bad' recovery ver- sus what can reasonably and ethically be undertaken may be growing as day surgery expands and diversifies.

No one measure is ever likely to give finite answers to the process of psy- chological recovery from surgery, as recuperation may always be gauged in differing ways dependent upon the researcher's perspective and ultimately on the patient's individual evaluations. However, the number of intrusive data collection episodes within the convalescing period beyond the confines of the hospital will always be limited in the future as patient recovery is so rapid. Therefore, the indices employed must be scrutinised closely prior to commencement of any study and good rationale provided. Finally, partici- pants are more independent and self-caring within this new era of surgical intervention. Post-assessment clinic interviews and enrolling the help of com-

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munity staff may be the only way to proceed for researchers striving to estab- lish firm evidence for surgical nursing intervention, fit for the 21st century, which promotes effective psychological recovery from surgery.

Dr Mark Mitchell BA, MSc, RGN, NDN Cert, RCNT, RNT, Senior Lecturer, University of Salford, School of Nursing, Eccles, Manchester, UK.

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