El Barrio y la Delimitación de Zona de Monumentos

hospital preparation for in ITU on their return who are recovering nursing staff. Issues surgery. Nurse and from surgery, attention from surgery and include:- Indices of Physio introduction for paid to interaction returned to the general recovery important to

patients. ITU video between nurse and ward. nurses; postoperative

presentation sleeping patient, patient pain, especially

responses to recognition of pain

mechanically aided behaviours in semi­

respiration and the conscious patients and

patients first awakening the ITU environment.

after anaesthesia. limitations and possible

improvements.

Results

The pilot investigations were unsuitable for formal analysis. However, the notes taken during the pre-operative preparations, the nursing discussions and the transcriptions o f the post-operative interviews (Appendix 4) were reviewed by two clinical psychologists and then discussed with the investigator. The principal findings are outlined below:

Preoperative preparation: The patients are interviewed separately by the junior medical staff and routine notes taken. There is an opportunity for the patients to ask questions. Any questions asked tend to be medical, or reassurance is sought regarding the post­ operative pain control. The patients as a group, with close relatives in attendance, are then addressed by the nurses and physiotherapists. The preparation is comprehensive, all aspects o f the procedures are explained, occasionally repeated. Besides procedural

information some effort is made to describe sensation, e.g. the pre-medication will make you feel drowsy, relaxed and sleepy, if you try and move suddenly, sit up, you might feel a bit dizzy. Patients' questions here seem to relate to visiting arrangements, particularly to the ITU and pre-operatively on the day o f operation. Visitors are acceptable to the

nursing staff on both occasions, although patients seem to want to deter their relatives from visiting. Discussion occurred between the patients and their relatives. The patients were concerned that their relatives would be too upset seeing them immediately prior to the operation or ventilated post-operatively. The patients questioned the nurses about their appearance in ITU but less to reassure themselves than to discourage the relatives from visiting. Following these discussions the patients and relatives watched the ITU video presentation, with a physiotherapist present. They were encouraged to ask questions after the video. The majority o f questions related to post-operative pain. The next most important issue seemed to be artificial ventilation, the patients not liking the notion o f being out of control. This notion o f loss o f control was then generalised to the pre-medication, being anaesthetised and the early post-operative period.

ITU: On return from the operating theatre the patients are settled on the ventilator and assorted monitors. The nurse always speaks to the patient before any procedure which the patient may feel. The patients wake approximately 2 to 4 hrs after arrival in ITU,

although some spontaneous movement occurs before this. On waking the patients tend to 'fight ' the ventilator and are generally agitated. All patient movement is responded to by the nurses who speak to the patient by name and reassure them. 'Let the machine breath for you, don't worry, everything is fine' are the most common phrases. The patients were sedated to reduce the ventilator distress. Although in two cases relatives waited outside the ITU for news, they did not wish to see the patient at this time.

Post-operative Interviews: Both patients said they found all the pre-operative preparation interesting and helpful. Both also described their anxiety and isolation on the day of operation prior to surgery and both were glad when the process began with transportation

to theatre. Their other major concern was post-operative ventilation. They both described the feelings related to assisted respiration as frightening, no control over breathing, swallowing and unable to speak. They praised the ITU staff for their reassurance and support. Both patients recalled some pain, but thought it was well controlled initially. The pain was apparently worse when they returned to the cardiac ward but they felt more able to cope with it. The older patient described persistent fatigue post-operatively and felt he could not recall all the information he had been given pre-operatively.

Nurse Discussion: The nurses suggested they would make an assessment o f the patient’s recovery at about 5 hours post-operatively. Besides completing a pain assessment they would also comment on the physical, neurological and psychological state o f the patient. They explained that on some occasions they felt the patient was not recovering well but could not specify a reason, the term 'can't quite put my finger on if was suggested.

Discussion

The purpose of this investigation was to examine the current preparation for major surgery from the patients perception. To identify focal events or times when the patients would be receptive to additional psychological intervention and what form of

intervention would be beneficial.

The pre-operative preparation of the patients was comprehensive, the staff were understanding and encouraged questions. However, the patients seem slightly over burdened with information and slightly in awe of the whole procedure. This was

consistent with the notion o f major surgery being perceived, quite understandably, as an event of such magnitude to constitute a threat. Apart from pain and the ventilation

procedure patients questions were limited at this time. Although they seemed reluctant to allow their relatives to visit them in ITU and some patients discouraged visiting

The patients interviews demonstrated that they recalled some o f the preparation post- operatively. They also referred to a period of isolation prior to the operation on the day of surgery. They felt that the staff were allowing them to rest quietly when they were not engaged in any preparation e.g. bathing and changing into a hospital gown. Since the majority o f patients had no visitors at this time they were acutely aware of the isolation and seemed to miss the social support.

In ITU the principal problem was a tendency to fight the ventilator, biting the tube and general agitation. These behaviours suggest that despite inordinate difficulties and gross physical frailty the patients were trying to restore some measure of personal control and has echoes o f reported behaviours in response to trauma (Taylor and Anmar,1996) This Ventilator' distress was recounted by the patients interviewed post-operatively as well as being observed by the investigator. Within four hours of the operation the patients did respond to their names and questions about pain. Taken together the self reported distress and the observed patient nurse interaction suggested that patients would be receptive to any psychological intervention at this very early post-operative stage.

The patients clearly felt most out of control during assisted ventilation in the initial post­ operative period but were receptive enough utilise relaxation as a coping response. The chosen focal event for perception of control was therefore assisted ventilation.

To exclude the effects of social support from the treatment effects o f perception o f control it was necessary to include a control group o f subjects who received the same amount o f attention as the treatment group. During early recovery in ITU patients were isolated from their normal social network although the nursing staff did supply some support and assistance. There was a second time o f social isolation for the patients, often self imposed, on the day of operation prior to the surgery. These two occasions would form the focus for social support.

Enhanced perception of control would be achieved by relaxation training, a reliable coping skill. The relaxation would be targeted to the muscle groups related to breathing and accompanied by counselling which emphasised the patients role in 'breathing with the ventilator'. Thus the relaxation could form a specific behavioural set relating to a focussed event and reflect 'self efficacy' rather than a more nebulous 'locus o f control'. Although the relaxation of the respiratory muscles during ventilation might make the subjects feel more comfortable there would be no effect on assisted respiration. The relaxation would be taught by the investigator pre-operatively on the day prior to surgery and rehearsed again on the day o f surgery. Audio-taped instructions would be left with the pre-operative patient for practice. Taped instructions would be played to the patients in ITU as they woke from the anaesthetic.

Social support subjects would be seen at the same schedule, but their instructions would be to leave everything to the highly experienced staff. They too would have taped instructions which would reflect the need to rely on the staff to 'do everything for them'.

The nurses were willing to provide an objective recovery and pain measure. A 'nurse recovery' questionnaire was devised. (Appendix 5)

Conclusion

During the investigation into the preparation o f patients for major surgery it was very clear that the patient disliked the loss o f control and suffered a sense o f social isolation. Curiously the isolation was sometimes self imposed usually at times when the patient felt most vulnerable and out o f control. The patients clearly gained some social support from the staff and other patients but it was not clear that either the patient or the staff were aware o f this interaction. The patients also clearly struggled to regain control at the first opportunity.

This investigation demonstrated a relationship between social support and control over events. The patients divorcing themselves from their social network at the point they felt most out o f control. These were the focal points to introduce the psychological

intervention which would enhance subjective perception o f control. It was also

important to establish how much of the observed effect o f the treatment was due to the enhanced social support.

This investigation informed the choice of intervention thought to be most beneficial to the major surgery patient. While it would have been ideal to teach the ‘relaxation’ to the perception of control group prior to admission for surgery the admitting procedure at the time o f the study made this impossible. However since the ‘social support’ schedule was fitted to the times that patients felt most isolated, immediately pre-operatively and in ITU, the other groups preparations mirrored this schedule. The following chapter examines the efficacy o f perception o f control as a preparation for major surgery.

PERCEPTION OF CONTROL AS PREPARATION FOR MAJOR SURGERY: THE