Técnicas de recolección de datos

Coping can be broadly defined as the cognitive and behavioural attempt to master, reduce or tolerate the internal (emotional) or external (environmental) demands associated with a stressful transaction (Folkman 1984, Folkman and Lazarus 1980). However, situations may be perceived differently depending upon aspects of an individual's personality. Therefore, any comprehensive attempt to aid coping prior to day surgery must consider both the psycho- dynamic and transactional perspectives.

Firstly, consideration must be given to the main issues within the psycho- dynamic approach identified in greater detail within the singular approaches to coping with surgery i.e. personality and social cognitions. Such aspects can be broadly considered as being the internal influence. The most pertinent issues within this approach must become the central themes for future psycho- educational management i.e.

HEALTH LOCUS OF - help to establish degree of healthcare control. CONTROL APPRAISAL

SELF-EFFICACY APPRAISAL - help to establish positive viewpoint.

If information provision is limited, as is clearly the case (Chapter 3), many patients will become very anxious e.g. vigilant copers, as the desired additional information may only be gained (if at all) in the few hours prior to surgery. Furthermore, information provision merely on the day of surgery may be too late for many patients. Information provided prior to surgery within the day surgery unit, the individual nurses caring for the patient and the time available for nurse/ patient communication therefore become strong determinants of the quality of information delivered. It cannot be assumed the desired level of information will be automatically provided by formal mechanisms within the day surgery unit or by the nurse in the brief time available. Such a psycho-dynamic consideration i.e. provision of information for individuals with differing coping styles, is frequently overlooked on the day of surgery as a result of numerous vital medical issues. Additionally, by not providing a choice of information, problem focused coping strategies may be weakened i.e. lack of knowledge concerning planned surgery and events on the day of admission. To compensate for this, formal mechanisms for receiving information prior to the day of surgery must be established and the provision of differing levels of information made a necessity, not an option. It must be accepted that patients have differing information requirements and that one level of information provision is no longer appropriate.

Similar problems may ensue for patients who desire the rudiments of control over health issues. The modest time available, heavy medical focus and insufficient information concerning all events may negate all attempts to establish even minimal aspects of healthcare control. The powerful others element may dominate, irrespective of individual wishes and a perceived absence of choice may ensue. Again, if prior knowledge of the situation were to be made available, problem focused coping strategies could be more effectively utilised. For example, day surgery units could run teaching sessions, similar to antenatal classes for expectant mothers. If desired, patients could visit the unit at a pre-arranged time to discuss aspects of their care with staff, view a video- taped presentation, meet with other patients and thereby become more informed of their possible options. This may help to reduce the appraisal of powerful others and encourage the notion of choice, albeit a limited one. Indeed, some day surgery units in the United States of America can be viewed on a webcam, such is the desire for information and to preview the healthcare environment.

Likewise, self-efficacy enhancement may be extremely limited under the pressured circumstances of the operating schedule i.e. not being provided with the desired level of information, written or verbal or positive images of a good recovery. This may prove detrimental to an individual's appraisal of their ability to cope at home prior to surgery and once discharged. The secondary status of such individual wishes can only have an unfavourable effect upon self-efficacy appraisal. During the proposed optional pre-operative visit to the day surgery

unit, outlined above, aspects of social, financial and personal arrangements could be discussed to enable the implementation of additional problem focused coping strategies in order to enhance self-efficacy appraisal.

Secondly, equal consideration must also be given to the main issues within the transactional perspective i.e.

PRIMARY APPRAISAL - visit to day surgery unit to encounter the environment.

SECONDARY APPRAISAL - provision of information, discussion of likely

events on day of surgery, available options, time

to initiate coping strategies.

PROBLEM FOCUSED COPING -ensuring greater social help, arranging extra time off work, pursuit of information.

EMOTIONAL FOCUSED COPING - implicit and explicit messages of safety, skill of staff, well organised day surgery unit.

Enhanced primary and secondary appraisal could commence with the provision of pre-operative visits, meeting the staff prior to the day of surgery, the provision of a structured programme of information and adequate time in which to initiate problem focused/ emotional focused coping strategies. Frequently, the first experience a patient has of the day surgery environment is when they arrive on the morning of surgery. A pre-assessment check commonly occurs a few weeks or months prior to surgery. This mainly concerns checking physical fitness for surgery and frequently does not even occur in the day surgery unit. If prior contact were to be established in the form of a visit, open discussion with staff or virtual tour on a website, patients would gain greater insight into what is expected and hence experience more effective primary and secondary

appraisal. This would give rise to more accurate problem focused coping strategies i.e. ensuring greater social help, arranging extra time off work, negotiating the desired level of information and health control. Enhanced emotional focused coping strategies may arise from the implicit and explicit messages of safety experienced during such an encounter i.e. well organised unit, efficient staff, and the interpersonal skills of the day surgery staff. Put simply, the patient would have greater insight into what was to happen and thereby more time to be more able to undertake (for them) the relevant individual problem focused and emotional focused preparations.

The overlap between these two approaches is where the psycho-educational support, required by day surgery patients, might therefore be found. It is the balance between what the individual desires in order to cope with the adverse situation and what is actuallyprovided that becomes the decisive factor i.e.

- desired level of information required versus actual provision.

- desired level of health control versus the influence of powerful others. - desired level of self-efficacy enhancement versus actual level provided.

- desired level of primary and secondary appraisal versus permissible opportunities.

However, it may be matching of coping style with the correct level of information that is the most important element as this has the potential to impact greatly upon appraisals of both health control and self-efficacy. For example, if a patient experiences raised anxiety in association with day surgery as a result of insufficient information i.e. vigilant coper (psycho-dynamic approach), and

primary and secondary appraisal of the experience cannot fully take place until the morning of surgery (transactional approach), anxiety may remain increased, or become even greater. This may occur as the desired level of information has not been automatically provided and the related problem focused coping strategies (active pursuit of information) and emotional focused coping strategies (awareness of staff being helpful in providing information once admitted) cannot be effectively mobilised. Some secondary appraisal can obviously occur i.e. reliance upon previous healthcare experience, although for the majority of patients, prior contact with the day surgery unit is zero. The lack of desired information could have a 'domino effect' upon the perceived level of health control i.e. lack of insight may lead to ignorance of available options and increased perception of powerful others. Reduced information provision may likewise have a negative effect upon appraisal of self-efficacy i.e. lack of help and advice on how to cope at home in the hours following surgery (Diagram 5 p.57a).

The major overlapping aspects between the two psychological approaches to coping therefore provide the key areas for the future psycho-educational management of patients prior to day surgery. Acceptance of differing coping styles, desired elements of health control, required self-efficacy enhancement, permissible primary and secondary appraisal versus the extent to which the day surgery environment is perceived to meet such individual requirements is of paramount importance.

In summary, coping ability has been identified utilising three differing approaches. The psycho-dynamic approach considers unconscious cognitions driven by past experiences, consistent over time and exerting a strong influence over an individual’s ability to cope. The transactional approach considers the interaction between the person and their environment and emphasises cognitive appraisal (primary and secondary) and the resultant coping strategies (problem solving and emotional solving approaches) arising from the individual encounter. The third approach combines these broad internal and external influences and is therefore referred to as the convergent or combined approach. This approach may be more applicable in future, modern surgical healthcare situations, as little time is available in which to identify individual requirements or for adequate individual appraisal of the situation to take place.

Singular aspects concerning recovery have been investigated in great depth in a quest to uncover the most effective preparatory methods. Personality variables such as Type A behaviour have been examined in relation to pre- operative stress although little conclusive evidence has been established. Contemporary research, however, has gained greater success with vigilant and avoidant personality traits. Such studies have indicated patient preparation for a stressful medical event should always involve matching the amount of information provided with the patients’ preferred coping style i.e. providing more information for vigilant copers and less for avoidant copers.

Four further aspects considered to greatly influence recovery from surgery are health locus of control, self-efficacy, social support and optimism. Achieving

some health control when required has been linked with more favourable outcomes and a reduction in anxiety. More positive views of coping has also assisted as patients frequently have little knowledge of what is to happen to them and consequently little time in which to consider how they might cope. Social support can also have a positive effect upon the post-operative recovery rate and an optimistic view of events is of clear benefit.

Greater flexibility within surgical healthcare delivery is required and may arise out of necessity as the modern surgical environment moves inexorably towards greater minimal access surgery and reduced hospital stay. If evidence can be uncovered to support the need for such elements of psycho-educational management within modern elective surgery a formal plan of psycho- educational intervention could be established i.e. acceptance of and provision for individuals with differing coping styles, consideration of health control and assistance in achieving positive self-efficacy appraisals.

However, one final challenging aspect remains - information provision. Information provision is central to coping in the modern surgical arena and implicit in the psychological approaches and singular aspects of coping outlined above. Information provision has been identified as a major national and international challenge to day surgery (Chapter 4). A vast number of studies have examined information provision because of its central role in surgical recovery. Therefore, because of its complexity, specific role in coping with surgery and future role in modern day surgery, information provision will be discussed separately and in greater detail in the following chapter.

CHAPTER 3