Modelo SERVQUAL

A major focus of this research was to examine the relationship of fighting spirit, optimism and positive mood to the indices of recovery. In the present study, preoperative

142 Discussion Chapter 2

wellbeing and fatigue were the best predictors of recovery. Fighting spirit predicted patients’ positive mood, and better function in hospital. It is at this time that patients particularly need a determined fighting spirit as they must be very involved in their recovery and motivate themselves to perform exercises and practice walking in order to successfully mobilize. This is not an easy task as they are still experiencing pain, and need to be ‘fighters’ to keep going. By follow-up, fighting spirit still predicted positive mood, but now bodily, rather than functional recovery. Fighting spirit is a promising concept for use in future studies of recovery following surgery. However, a simpler measure needs to be developed which is more relevant to surgical patients. The MAC has a number of questions which, whilst relevant to patients with a life-threatening illness such as cancer, appear unduly pessimistic and irrelevant to patients undergoing surgery. Study 3 will explore the possibility of developing such a measure.

Patients in this study had a comparatively low fighting spirit (27 of 63 patients scored 47 or less on fighting spirit) when contrasted to the norms for a group of 400 mixed- cancer patients reported in the MAC manual (Watson, Greer and Bliss, 1989) (Table 2.38). There are no norms for non-patient groups, or patients anticipating surgery with which to compare this study population. Fighting spirit may be aroused by a life- threatening disease, in a way that it is not by the anticipation of surgery. An indication that fighting spirit may have been at a low level comes from looking at the cut-off scores for psychotherapy for cancer patients. Patients who scored a combination of 12+ on helplessness, and 47 or less on fighting spirit, were invited to take part in therapy to improve their fighting spirit and alleviate their helplessness in a study by Moorey and Greer (1989). Levels of Helplessness and Fatalism are higher than the normative means in the current study, with 38 of 63 scoring 12 or above on helplessness. Watson, Greer and Bliss (1989) report a significant trend of increasing fatalism with age, although not

143 Discussion Chapter 2

helplessness, and this may account for the high levels of fatalism. Perhaps surgical patients feel at their most helpless just prior to surgery, when they must put control of their life in the surgeons hands (Eisendrath, 1987). Helplessness in the current study seemed to be part of an overall distress dimension, which included less positive psychological state, together with somatic components, such as greater fatigue and poorer health. Surgical patients who feel they are not in control often suffer from anxiety, depression and anger (Eisendrath, 1987; Morris and Roy le, 1988).

Table 2.38

Study Means, Standard Deviations and Normative Means for Fighting Spirit, Helplessness and Fatalism, as Measure by the MAC

Measures Arthroplasty Study N = 63

Normative Sample N = 400

Scores used to determine psychological morbidity Fighting Spirit Helpless Fatalism Mean SD 49.06 4.98 11.55 2.33 20.42 2.59 Mean SD 51.7 6.1 8.6 2.5 17.7 3.7 Mean 47 or less 12 + Not specified

If fighting spirit could be enhanced, it would be interesting to see if this further improves recovery, and Study 4 endeavours to do this with a social support intervention.

Optimism as measured by the LOT was disappointing as a predictor of recovery. Apart from one association at follow-up with less physical difficulty, it was not associated with any aspect of recovery, including wellbeing. Optimism has been found in previous research to be predictive of surgical outcome (Chamberlain, Petrie, Azariah, 1992; Scheier, Mathews, Owens, Magovem, Lefebvre, Abbot and Carver, 1989), although these studies used different measures of recovery.

144 Discussion Chapter 2

Patients’ levels of dispositional optimism were somewhat lower than the levels reported in the normative samples, seen in Table 2.39, of 357 undergraduate men and 267 undergraduate women (Scheier and Carver, 1985), 405 Dutch subjects (166 students and 239 adults) (Mook, Kleijn and Henk, 1992), and an elderly adults sample of 22 males and 66 females (Guamera and Williams, 1987). This may relate to age, or social circumstances, or cultural factors. The arthroplasty study by Chamberlain, Petrie and Azariah (1992) which used the LOT, failed to report the means in their paper, so no comparison could be made. It may be that the group of patients in the current study were neither particularly optimistic or pessimistic.

Table 2.39

Study Means Standard Deviations and Normative Means for Optimism as Measure by the LOT

Subjects Arthroplasty Study Mean Age Normative Sample Yoimger Group Mean Age: Normative Sample Dutch) Normative Sample Elderly Group Mean Age: 84

Mean SD Mean SD Mean SD Mean SD

Combined Sample 19.62 2.96 NS* 24.9 3.9 20.74 4.68 Males 19.76 3.26 21.03 4.56 NS NS Females 19.53 2.79 21.41 5.22 NS NS Students - NS 24.1 3.7 NS Adults 19.62 2.96 NS 25.4 3.9 NS *NS = Not specified

The LOT has been the subject of much debate in the literature. Some doubts have been cast on whether the scale is unidimensional, or forms two distinct dimensions (Marshall, Wortman, Kusulas, Hervig and Vickers, 1992; Schwarzer, 1994). Lai (1994) has reported that the predictive power of the LOT is conferred by the positive half of the test rather the negative, which implies that the positive subscale may more validly measure what the complete scale was designed to assess, namely optimism. The negative subscale showed no significant correlation with physical symptom levels in Lai’s (1994) study of 200

145 Discussion Chapter 2

undergraduates, whereas the positive subscale did. Support for this view comes from Mook, Kleijn and van der Ploeg (1992) who report higher mean scores for the negatively worded items. These authors conclude that the negative items of the LOT do not so much measure optimism, but the dimension of (reversed) negative affectivity, that is, the absence of pessimism. The current study found optimism correlated with a less negative rather than a more positive mood, which supports this conclusion.

Schwarzer (1992) also draws attention to the fact that there is no clear distinction between situations, actions and capabilities in the scale, which means subjects must create their own scenario when responding. Zullow (1991) warns that individuals with an optimistic explanatory style who dwell on negative events and explain them frequently may score as pessimistic on the LOT, and individuals with a pessimistic explanatory style who do not ponder on negative events may score favourably on the LOT. However, the LOT has been successfully used in other health and surgical outcome studies, and it is not clear why it failed to predict outcome in the current study. Study 3 will explore the possibility of creating a different measure of optimism.