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Psychological preparation for surgery: Patient recall of information
Journal of Psychosomatic Research, Vol. 25, pp. 5142. Prrgamon Pres Ltd. 1981. Printed in Great Britain.
0022.3999/81/010057-06$02.00/O
PSYCHOLOGICAL PREPARATION FOR SURGERY: PATIENT RECALL OF INFORMATION ANTHONY
E. READING*
(Received 29 April 1980; accepted in revisedform
8 September
1980)
Abstract-A study has been undertaken to assess the level of recall of preparatory information supplied by interview in a preoperative setting. A consecutive series of women undergoing minor gynaecological surgery (N = 36) received a preparatory interview on the day prior to surgery, of the form found to improve postoperative patient response. A second interview was conducted after an interval of either 30 min or 3 hr in order to establish the amount of information available for recall. Level of recall compared favourably with those reported in general practice settings, with significantly more information recalled on immediate assessment. A sex difference also emerged, with male interviewers achieving significantly higher levels of patient recall. Patients displayed uniformly positive attitudes towards receiving this kind of interview. The implications of these results are discussed in terms of the explanations put forward to account for the benefits of psychologically preparing patients for surgery.
is accumulating on the benefits of psychologically preparing patients for medical and surgical procedures [l]. In addition to improving psychological adjustment, reports suggest that the benefits of such preparation may extend to reducing medication requirements [2] and length of post-operative hospital stay [3]. The question of principal interest to psychologists is not so much this effect, but rather how this is brought about, assuming that it is psychologically mediated. By understanding the mechanisms and routes of influence it will become possible to specify the optimum preparatory format. A number of explanatory models have been proposed to account for these effects [4]. However, the assumption is tacitly made in the case of informative interviews that the patient is attending to and assimilating the information supplied. Research conducted in other settings suggest that this assumption may be unwarranted, as much of what a General Practitioner tells a patient is forgotten as soon as 5 min after the consultation has ended [5, 6, 71. There is no a priori reason why low recall will not also apply to surgical patients. In fact, evidence suggests this may be more likely, as if patients are anxious as surgical patients are, forgetting will be even more pronounced [8]. The objectives of the current study were two-fold: (a) to establish the degree of recall of preparatory information supplied by interview in a pre-surgical setting. A related question concerned the selectivity of recall, in terms of whether certain aspects of the interview were recalled better than others; (b) to investigate patient attitudes towards receiving information of this kind, as it has been suggested that some patients may display a preference for and respond better to ignorance [9]. in view of these objectives, no attempt was made to study recovery indices. EVIDENCE
SUBJECTS Consecutive admissions to Of the 36 patients seen (mean logical surgery in the form of (TOP) (12) and dilatation and *From the Department SE5 8RX, U.K.
a short-stay gynaecology ward during a 2-week period were interviewed. age = 22.7, S.D. = 8), all were about to undergo elective minor gynaecosterilisation (8), investigation of infertility (1 l), termination of pregnancy curettage (D&C) (4).
of Psychological
Medicine,
57
King’s College
Hospital,
Denmark
Hill, London
58
ANTHONY
E. READING
PROCEDURE Patients were randomly assigned to one of two groups, each receiving two interviews on the day prior to surgery, with a time interval of either 30 min or 3 hr. Four interviewers were used (two males and two females) who worked in same sex pairs. Each interviewer pair worked with patients from both groups,
although
patients
who
were
seen
at
the
first
interview
by
a
female
interviewer
would
also
The first interview consisted of a standard preparatory interview comparable to those given in studies investigating the effects of psychological preparation, varying slightly according to the exact surgical procedure to be performed. The information was categorised in the manner normally reported by studies in this area and presented in the following order: in terms of pre-operative details, brief details of the operation, and post-surgical sensations they could expect to experience. Ten items or bits of information for each operation were supplied. The follow-up interviews were conducted by the other interviewer in each same sex pair. Patients were asked to recall as much as possible from the earlier interview. When it appeared that the patients’ spontaneous recollections were at an end, the interviewer began to probe pre-determined areas. The record of this interview was as complete as possible and made in longhand. Following the completion of the data collection, the recall information was coded according to pre-determined categories and the inter-rater agreement of scoring established. At the first interview, ratings were made as to the level of anticipatory worry and anxiety. In addition, patients were asked to rate how satisfied they felt with staff communication and how well informed they regarded themselves. At the second interview patients were asked to indicate how helpful the information supplied had been and to choose between three response alternatives concerning their preference for being informed in this degree of detail. Finally, at the time of the first interview patients completed a State Trait Anxiety Inventory [IO] and the Mill Hill Vocabulary Scale. receive
their
second
or
follow-up
interview
from
a female.
RESULTS Of the 36 patients in the sample the majority had previous experience of hospitalisation, with 20 patients having had earlier operations although none had had gynaecological operations and a further 6 having given birth in hospital. None had previously undergone their current operation procedure. Response to questions on attitudes towards the operation are shown in Table 1, with 47% rating themselves as at best poorly informed and only 8% considering themselves to be very well informed. TABLE
l.-DISTRIBUTION TOWARDS
Attitude ~.
statement
OF
PSYCHOLOGICAL
PATIENT
RATINGS
PREPARATION
ON
ATTITUDES
AND SURGERY
Attitude ratings on 4.point scale: % patients scoring at each point -_____ 2
3
HIGH 4
25% 5% 27% 36%
22% 19% 13% 30%
44% 50% 35% 11%
8% 25% 25% 22%
2%
0%
29%
69%
LOW 1 Informed about procedure Satisfaction with communication Worry regarding surgery Fear of surgery Helpfulness of preparation (assessed at follow-up interview)
p-
Only 38% of the sample said they were able to ask questions when seen by the admitting doctor in Out-Patients. In spite of this, 75% of the sample rated themselves as either satisfied (50%) or very satisfied (25%) with staff communication. In terms of statements on worry and fear relating to the operation, 60% described themselves as either very worried or as having some worry with 27% being not at all worried and 33% declaring themselves to be very frightened or frightened, with 36% denying fear altogether. Recall scores are presented in Tables 2 and 3. For scoring purposes it was decided to adopt the following criteria. For each of the ten bits of information a score of two was assigned if recall was complete. Any part recall of each bit of information attracted a score of one. Accordingly the maximum score possible became twenty. Agreement over coding of information recalled was in all cases in excess of 95%, as all verbatim reports were scored by two independent judges. Table 2 shows mean recall scores according to interviewer and delay interval. A distinction is drawn between items volunteered
Psychological TABLE
preparation
Z.-RECALL
OF
for surgery:
PREPARATORY
patient
INTERVIEW
59
recall of information
ACCORDING
TO
DELAY
INTERVAL
ANDSEXOFINTERVIEWER
Mean number Immediate
Sex of interviewer
(within 30 min) Including items prompted
Items volunteered
N
of items elicited at follow-up out of a total of 20
interview
Delayed (3 hr later)
N
Including items prompted
Items volunteered
Female Female
3 2
10.6 12.0
10.6 13.0
3 7
7.1 9.1
8.3 10.0
Male Male
I 8
14.8 15.0
18.0 17.2
I 5
13.0 10.4
17.5 12.8
Comparison Comparison P < 0.05).
of immediate and delayed significant (F = 6.39, df = 1, P < 0.01). of male interviewers and female significant (F = 5.64, df = 1,
TABLE
3.-RECALL
OF PREPARATORY
INTERVIEW
BROKEN
DOWN
BY
CONTENT
OFINFORMATION
Mean
Sex of interviewer
Female Female Male Male Total
number
of items recorded at follow-up according to content
interview
Details relating to the operation
Information on postoperative sensation
2.75 (45%) 3.60 (60%)
2.8 (46%) 2.6 (43%)
3.5 (47%) 3.9 (48%)
8 13
5.50 (91%) 5.00 (75%)
5.0 (83%) 4.1 (68%)
6.4 (80%) 5.5 (68%)
36
Out of a total of6
Out of a total of6
Out of a total of8
N
Pre-operative details
6 9
and total items recorded which include both those elicited and those prompted. It can be seen that the male interviewers achieved consistently higher recall scores for both prompted and elicited material. Similarly, consistently more material was elicited from follow-up interviews conducted immediately as compared with those carried out after a delay of 3 hr. An analysis of variance compared separately the total recall scores and each of the categories for the two delay intervals and the sex of the interviewer. Recall was found to be significantly higher for short delay intervals and for when the interviews were carried out by males. There was no significant interaction between conditions. In Table 3 mean and percentage recall according to interviewer in terms of content of the material recalled is shown. Information recalled is broken down into recall of pre-operative details, details of the operative procedure and details referring to the post-operative recovery period in terms of the nature of the wound, post-operative sensations, and availability of pain killers. Although percentage recall tended to be higher for information presented first (pre-operative details), irrespective of who supplied the information and conducted the follow-up interview, there was no support for any part of the preparatory interview being significantly better recalled. Finally, patients were asked to give their attitude towards receiving information of this kind, and to rate how helpful they considered it to be. As shown in Table 1, 98% of patients found it to be of some or great help, with all but one patient confirming that they preferred to be told about such things than left in ignorance. Pearson product moment correlations were computed between STAI scores and recall measures with none reaching significant levels. No association was found between prior experience of hospitalisation and level of recall. Similarly, there was little variation in intelligence between groups and this was not correlated with recall.
60
ANTHONY E. READING DISCUSSION
In conducting evaluations of the effects of psychological preparation the degree of recall of information supplied needs to be established rather than assumed. Research has shown that a substantial proportion of information offered to patients in a clinical interview is not assimilated. There is reason to believe that such forgetting may be even more pronounced in the presurgical context owing to the inhibitory effects of anxiety on learning [ll], and the fact that high proportions of surgical patients experience moderate to high levels of pre-operative anxiety [ 121. Whether or not information provided in a preparatory interview is available for recall has implications for the way in which the benefits of psychological preparation are explained. If the exact content or details are regarded as important then it follows that these should be assimilated by the patient and available for recall. Alternatively, if preparation is beneficial through mechanisms akin to abreaction, in terms of the emotional significance surrounding receiving a supportive interview from an interested staff member, then the quality of the interaction rather than the degree of information would be critical. A number of explanations for the effects of preparation have been proposed. Ja,nis [12] suggested that preparation might work by ensuring an optimum amount of anxiety for adjustment. Alternatively, the parallel response model [13] and the coping model [14] both state that the specific information imparted is responsible for the benefits through either the inoculatory effects of information [15], or by indicating opportunities and means of coping which can be utilised and so facilitate the recovery course [ 141. The question as to the level of recall of information was addressed in the present study. The results show that under favourable conditions a substantial proportion of the information supplied is available for recall, with approximately three-quarters of material supplied by male interviewers elicited at follow-up. The total recall scores compare favourably with those reported elsewhere on immediate testing [5, 61 where about half the material was forgotten. The recall scores obtained for some sections of the information, which are higher than those commonly reported, may be the result of categorising the information present, as this has been found to facilitate remembering [ 181 and is standard practice in the provision of psychological preparation. It is not entirely clear why female interviewers in this study achieved consistently lower recall scores. It is possible that greater attention was paid to the male interviewers by the patients owing to their closer association with the predominantly male surgical staff. An important feature of communication effectiveness has been found to be higher recall of information given by a high-status figure [17]. In the present study patients were unselected and so had a variable level of past experience of hospital procedures, although prior experience of hospitalisation was not found to be related to level of recall. Inevitably patients will differ in terms of prior knowledge, as the preparatory interview will not constitute the only source of information. Preparation is an integral part of pre-operative procedure. It is necessary to distinguish psychological preparation from preparation of other kinds, as well as from general ward conversation between patients and staff. The primary purpose of psychological preparation is to improve the patient’s psychological adjustment. It is understood to refer to an interview held by a staff member with the sole purpose of providing specified information and for reassurance about the forthcoming surgery.
Psychological
preparation
for surgery:
patient
recall of information
61
There has been a comparative neglect of the patient’s attitude towards information supplied in the course of preparatory counselling. Reading et al. [2] found a uniformly positive response to receiving preparatory information amongst a group of gynaecological surgery patients. Similarly, Vernon and Bigelow [ 181 found greater confidence expressed in nurses amongst prepared patients as well as less postoperative anger. In the present study, the results of the follow-up questions are unequivocal, with patients indicating a strong preference for being told. This was not affected by how adequate they felt the previous communication to be, or whether they felt they had the opportunity to ask questions. It would be interesting to compare ratings of helpfulness with recovery indices in order to assess the degree of concordance between self-report of helpfulness and measures of functional outcome, as there are indications that information may have the result, for some patients as least, of becoming tuned into the pain and discomfort [14]. Cohen and Lazarus [9] suggested that patients displaying a vigilant coping style may experience more complications in the post-operative course, owing to the fact that this approach may be inappropriate in the context of post-operative incapacitation and dependence. Greater attention to the patient response as a function of attitudes and personality coping style may improve the information yield. In conclusion, the implications of this study are two-fold. Firstly, while recall of information is variable, affected by interviewing style, the results indicate the content can be assimilated, which is a pre-requisite to explanations suggesting that the exact content influences postoperative response. Secondly, the study confirms the variable levels of patient satisfaction described elsewhere [8], with patients displaying a strong preference for receiving preparatory counselling. REFERENCES 1. LEY P. Psychological studies of doctor-patient communication. In Contributions to Medical Psychology (Edited by RA~HMAN S.), Vol. I. Pergamon Press, Oxford (1977). preparation for minor 2. READING A. E., ROUND L., BOOTH N. and NEWTON .I. R. Psychological gynaecological surgery. Unpublished. pain 3. EGBER~ L. D., BA~TIT E. W., WELCH C. E. and BARTLETT M. K. Reduction of post-operative by encouragement and instructions of patients. N. Engl. J. Med. 270,825 (1964). preparation for surgery. Sot. Sci. Med. 4. READING A. E. The short term effects of psychological 13A, 641 (1979). 5. BRADSHAW P. W., LEY K., KINCEY .I. A. and BRADSHAW J. Recall of medical advice. Comprehensibility and specificity. Br. J. Sot. C/in. Psychol. 14, 55 (1975). study of 6. JOYCE C. R. B., CAPLE E., MASON M., REYNOLDS E. and MATTHEWS J. A. Quantitative doctor-patient communication. Q. J. Med. 38, 183 (1969). with 7. LEY P., BRADSHAW P. W., KINCEY .I. A. and A~HER~ON S. T. Increasing patient’s satisfaction communication. Br. J. Sot. Clin. Psychol. 15,403 (1976). x. LFY P. and SPELMANM. S. Communicating with /he Patient. Staple Press, London (1967). and recovery from surgery. Psychosom. 9. COHEN F. and LAZURUS R. S. Active coping dispositions Med. 35,375 (1973). 10. SPIELBERGER C. D., GORSUKH R. L. and LUSHENE R. E. State Trait Anxiety Inventory Manual. Consulting Psychologist Press, Palo Alto (1970). 11. SPIELBERGERC. D. Anxiety and Behaviour. Academic Press, New York (1966). 12. JANIS I. L. Psychological Stress. John Wiley, New York (1958). of emotional and instrumental 13. JOHNSON J. E., LEVENTHAL H. and DABBS J. M. Jr. Contribution response processes in adaption to surgery. J. Pers. Sot. Psychol. 20,55 (1971). stress in surgical patients. 14. LANCER E. J., JANIS I. L. and WOLFER J. A. Reduction of psychological J. 0~. Sot. Psycho/. 11, 155 (1975). on the sensory and distress components of pain. 15. JOHNSON J. E. The effects of accurate expectations J. Pers. Sot. Psychol. 27,261 (1973).
62
ANTHONY E. READING
16. LEY P., BRADSHAW P. W., EAVES D. and WALKER C. M. A of information presented by doctors. Psychol. Med. 3,217 (1973). 17. HOLLAND C. I. and WEISS W. The influence of source credibility on communication effectiveness. Publ. Opin. Q. 15,635 (1952). 18. VERNON D. T. A. and BIGELOW D. A. Effect of information about a potentially stressful situtation on response to stress impact. J. Pen. Sot. Psychol. 29,50 (1974).
0022.3999/81/010057-06$02.00/O
PSYCHOLOGICAL PREPARATION FOR SURGERY: PATIENT RECALL OF INFORMATION ANTHONY
E. READING*
(Received 29 April 1980; accepted in revisedform
8 September
1980)
Abstract-A study has been undertaken to assess the level of recall of preparatory information supplied by interview in a preoperative setting. A consecutive series of women undergoing minor gynaecological surgery (N = 36) received a preparatory interview on the day prior to surgery, of the form found to improve postoperative patient response. A second interview was conducted after an interval of either 30 min or 3 hr in order to establish the amount of information available for recall. Level of recall compared favourably with those reported in general practice settings, with significantly more information recalled on immediate assessment. A sex difference also emerged, with male interviewers achieving significantly higher levels of patient recall. Patients displayed uniformly positive attitudes towards receiving this kind of interview. The implications of these results are discussed in terms of the explanations put forward to account for the benefits of psychologically preparing patients for surgery.
is accumulating on the benefits of psychologically preparing patients for medical and surgical procedures [l]. In addition to improving psychological adjustment, reports suggest that the benefits of such preparation may extend to reducing medication requirements [2] and length of post-operative hospital stay [3]. The question of principal interest to psychologists is not so much this effect, but rather how this is brought about, assuming that it is psychologically mediated. By understanding the mechanisms and routes of influence it will become possible to specify the optimum preparatory format. A number of explanatory models have been proposed to account for these effects [4]. However, the assumption is tacitly made in the case of informative interviews that the patient is attending to and assimilating the information supplied. Research conducted in other settings suggest that this assumption may be unwarranted, as much of what a General Practitioner tells a patient is forgotten as soon as 5 min after the consultation has ended [5, 6, 71. There is no a priori reason why low recall will not also apply to surgical patients. In fact, evidence suggests this may be more likely, as if patients are anxious as surgical patients are, forgetting will be even more pronounced [8]. The objectives of the current study were two-fold: (a) to establish the degree of recall of preparatory information supplied by interview in a pre-surgical setting. A related question concerned the selectivity of recall, in terms of whether certain aspects of the interview were recalled better than others; (b) to investigate patient attitudes towards receiving information of this kind, as it has been suggested that some patients may display a preference for and respond better to ignorance [9]. in view of these objectives, no attempt was made to study recovery indices. EVIDENCE
SUBJECTS Consecutive admissions to Of the 36 patients seen (mean logical surgery in the form of (TOP) (12) and dilatation and *From the Department SE5 8RX, U.K.
a short-stay gynaecology ward during a 2-week period were interviewed. age = 22.7, S.D. = 8), all were about to undergo elective minor gynaecosterilisation (8), investigation of infertility (1 l), termination of pregnancy curettage (D&C) (4).
of Psychological
Medicine,
57
King’s College
Hospital,
Denmark
Hill, London
58
ANTHONY
E. READING
PROCEDURE Patients were randomly assigned to one of two groups, each receiving two interviews on the day prior to surgery, with a time interval of either 30 min or 3 hr. Four interviewers were used (two males and two females) who worked in same sex pairs. Each interviewer pair worked with patients from both groups,
although
patients
who
were
seen
at
the
first
interview
by
a
female
interviewer
would
also
The first interview consisted of a standard preparatory interview comparable to those given in studies investigating the effects of psychological preparation, varying slightly according to the exact surgical procedure to be performed. The information was categorised in the manner normally reported by studies in this area and presented in the following order: in terms of pre-operative details, brief details of the operation, and post-surgical sensations they could expect to experience. Ten items or bits of information for each operation were supplied. The follow-up interviews were conducted by the other interviewer in each same sex pair. Patients were asked to recall as much as possible from the earlier interview. When it appeared that the patients’ spontaneous recollections were at an end, the interviewer began to probe pre-determined areas. The record of this interview was as complete as possible and made in longhand. Following the completion of the data collection, the recall information was coded according to pre-determined categories and the inter-rater agreement of scoring established. At the first interview, ratings were made as to the level of anticipatory worry and anxiety. In addition, patients were asked to rate how satisfied they felt with staff communication and how well informed they regarded themselves. At the second interview patients were asked to indicate how helpful the information supplied had been and to choose between three response alternatives concerning their preference for being informed in this degree of detail. Finally, at the time of the first interview patients completed a State Trait Anxiety Inventory [IO] and the Mill Hill Vocabulary Scale. receive
their
second
or
follow-up
interview
from
a female.
RESULTS Of the 36 patients in the sample the majority had previous experience of hospitalisation, with 20 patients having had earlier operations although none had had gynaecological operations and a further 6 having given birth in hospital. None had previously undergone their current operation procedure. Response to questions on attitudes towards the operation are shown in Table 1, with 47% rating themselves as at best poorly informed and only 8% considering themselves to be very well informed. TABLE
l.-DISTRIBUTION TOWARDS
Attitude ~.
statement
OF
PSYCHOLOGICAL
PATIENT
RATINGS
PREPARATION
ON
ATTITUDES
AND SURGERY
Attitude ratings on 4.point scale: % patients scoring at each point -_____ 2
3
HIGH 4
25% 5% 27% 36%
22% 19% 13% 30%
44% 50% 35% 11%
8% 25% 25% 22%
2%
0%
29%
69%
LOW 1 Informed about procedure Satisfaction with communication Worry regarding surgery Fear of surgery Helpfulness of preparation (assessed at follow-up interview)
p-
Only 38% of the sample said they were able to ask questions when seen by the admitting doctor in Out-Patients. In spite of this, 75% of the sample rated themselves as either satisfied (50%) or very satisfied (25%) with staff communication. In terms of statements on worry and fear relating to the operation, 60% described themselves as either very worried or as having some worry with 27% being not at all worried and 33% declaring themselves to be very frightened or frightened, with 36% denying fear altogether. Recall scores are presented in Tables 2 and 3. For scoring purposes it was decided to adopt the following criteria. For each of the ten bits of information a score of two was assigned if recall was complete. Any part recall of each bit of information attracted a score of one. Accordingly the maximum score possible became twenty. Agreement over coding of information recalled was in all cases in excess of 95%, as all verbatim reports were scored by two independent judges. Table 2 shows mean recall scores according to interviewer and delay interval. A distinction is drawn between items volunteered
Psychological TABLE
preparation
Z.-RECALL
OF
for surgery:
PREPARATORY
patient
INTERVIEW
59
recall of information
ACCORDING
TO
DELAY
INTERVAL
ANDSEXOFINTERVIEWER
Mean number Immediate
Sex of interviewer
(within 30 min) Including items prompted
Items volunteered
N
of items elicited at follow-up out of a total of 20
interview
Delayed (3 hr later)
N
Including items prompted
Items volunteered
Female Female
3 2
10.6 12.0
10.6 13.0
3 7
7.1 9.1
8.3 10.0
Male Male
I 8
14.8 15.0
18.0 17.2
I 5
13.0 10.4
17.5 12.8
Comparison Comparison P < 0.05).
of immediate and delayed significant (F = 6.39, df = 1, P < 0.01). of male interviewers and female significant (F = 5.64, df = 1,
TABLE
3.-RECALL
OF PREPARATORY
INTERVIEW
BROKEN
DOWN
BY
CONTENT
OFINFORMATION
Mean
Sex of interviewer
Female Female Male Male Total
number
of items recorded at follow-up according to content
interview
Details relating to the operation
Information on postoperative sensation
2.75 (45%) 3.60 (60%)
2.8 (46%) 2.6 (43%)
3.5 (47%) 3.9 (48%)
8 13
5.50 (91%) 5.00 (75%)
5.0 (83%) 4.1 (68%)
6.4 (80%) 5.5 (68%)
36
Out of a total of6
Out of a total of6
Out of a total of8
N
Pre-operative details
6 9
and total items recorded which include both those elicited and those prompted. It can be seen that the male interviewers achieved consistently higher recall scores for both prompted and elicited material. Similarly, consistently more material was elicited from follow-up interviews conducted immediately as compared with those carried out after a delay of 3 hr. An analysis of variance compared separately the total recall scores and each of the categories for the two delay intervals and the sex of the interviewer. Recall was found to be significantly higher for short delay intervals and for when the interviews were carried out by males. There was no significant interaction between conditions. In Table 3 mean and percentage recall according to interviewer in terms of content of the material recalled is shown. Information recalled is broken down into recall of pre-operative details, details of the operative procedure and details referring to the post-operative recovery period in terms of the nature of the wound, post-operative sensations, and availability of pain killers. Although percentage recall tended to be higher for information presented first (pre-operative details), irrespective of who supplied the information and conducted the follow-up interview, there was no support for any part of the preparatory interview being significantly better recalled. Finally, patients were asked to give their attitude towards receiving information of this kind, and to rate how helpful they considered it to be. As shown in Table 1, 98% of patients found it to be of some or great help, with all but one patient confirming that they preferred to be told about such things than left in ignorance. Pearson product moment correlations were computed between STAI scores and recall measures with none reaching significant levels. No association was found between prior experience of hospitalisation and level of recall. Similarly, there was little variation in intelligence between groups and this was not correlated with recall.
60
ANTHONY E. READING DISCUSSION
In conducting evaluations of the effects of psychological preparation the degree of recall of information supplied needs to be established rather than assumed. Research has shown that a substantial proportion of information offered to patients in a clinical interview is not assimilated. There is reason to believe that such forgetting may be even more pronounced in the presurgical context owing to the inhibitory effects of anxiety on learning [ll], and the fact that high proportions of surgical patients experience moderate to high levels of pre-operative anxiety [ 121. Whether or not information provided in a preparatory interview is available for recall has implications for the way in which the benefits of psychological preparation are explained. If the exact content or details are regarded as important then it follows that these should be assimilated by the patient and available for recall. Alternatively, if preparation is beneficial through mechanisms akin to abreaction, in terms of the emotional significance surrounding receiving a supportive interview from an interested staff member, then the quality of the interaction rather than the degree of information would be critical. A number of explanations for the effects of preparation have been proposed. Ja,nis [12] suggested that preparation might work by ensuring an optimum amount of anxiety for adjustment. Alternatively, the parallel response model [13] and the coping model [14] both state that the specific information imparted is responsible for the benefits through either the inoculatory effects of information [15], or by indicating opportunities and means of coping which can be utilised and so facilitate the recovery course [ 141. The question as to the level of recall of information was addressed in the present study. The results show that under favourable conditions a substantial proportion of the information supplied is available for recall, with approximately three-quarters of material supplied by male interviewers elicited at follow-up. The total recall scores compare favourably with those reported elsewhere on immediate testing [5, 61 where about half the material was forgotten. The recall scores obtained for some sections of the information, which are higher than those commonly reported, may be the result of categorising the information present, as this has been found to facilitate remembering [ 181 and is standard practice in the provision of psychological preparation. It is not entirely clear why female interviewers in this study achieved consistently lower recall scores. It is possible that greater attention was paid to the male interviewers by the patients owing to their closer association with the predominantly male surgical staff. An important feature of communication effectiveness has been found to be higher recall of information given by a high-status figure [17]. In the present study patients were unselected and so had a variable level of past experience of hospital procedures, although prior experience of hospitalisation was not found to be related to level of recall. Inevitably patients will differ in terms of prior knowledge, as the preparatory interview will not constitute the only source of information. Preparation is an integral part of pre-operative procedure. It is necessary to distinguish psychological preparation from preparation of other kinds, as well as from general ward conversation between patients and staff. The primary purpose of psychological preparation is to improve the patient’s psychological adjustment. It is understood to refer to an interview held by a staff member with the sole purpose of providing specified information and for reassurance about the forthcoming surgery.
Psychological
preparation
for surgery:
patient
recall of information
61
There has been a comparative neglect of the patient’s attitude towards information supplied in the course of preparatory counselling. Reading et al. [2] found a uniformly positive response to receiving preparatory information amongst a group of gynaecological surgery patients. Similarly, Vernon and Bigelow [ 181 found greater confidence expressed in nurses amongst prepared patients as well as less postoperative anger. In the present study, the results of the follow-up questions are unequivocal, with patients indicating a strong preference for being told. This was not affected by how adequate they felt the previous communication to be, or whether they felt they had the opportunity to ask questions. It would be interesting to compare ratings of helpfulness with recovery indices in order to assess the degree of concordance between self-report of helpfulness and measures of functional outcome, as there are indications that information may have the result, for some patients as least, of becoming tuned into the pain and discomfort [14]. Cohen and Lazarus [9] suggested that patients displaying a vigilant coping style may experience more complications in the post-operative course, owing to the fact that this approach may be inappropriate in the context of post-operative incapacitation and dependence. Greater attention to the patient response as a function of attitudes and personality coping style may improve the information yield. In conclusion, the implications of this study are two-fold. Firstly, while recall of information is variable, affected by interviewing style, the results indicate the content can be assimilated, which is a pre-requisite to explanations suggesting that the exact content influences postoperative response. Secondly, the study confirms the variable levels of patient satisfaction described elsewhere [8], with patients displaying a strong preference for receiving preparatory counselling. REFERENCES 1. LEY P. Psychological studies of doctor-patient communication. In Contributions to Medical Psychology (Edited by RA~HMAN S.), Vol. I. Pergamon Press, Oxford (1977). preparation for minor 2. READING A. E., ROUND L., BOOTH N. and NEWTON .I. R. Psychological gynaecological surgery. Unpublished. pain 3. EGBER~ L. D., BA~TIT E. W., WELCH C. E. and BARTLETT M. K. Reduction of post-operative by encouragement and instructions of patients. N. Engl. J. Med. 270,825 (1964). preparation for surgery. Sot. Sci. Med. 4. READING A. E. The short term effects of psychological 13A, 641 (1979). 5. BRADSHAW P. W., LEY K., KINCEY .I. A. and BRADSHAW J. Recall of medical advice. Comprehensibility and specificity. Br. J. Sot. C/in. Psychol. 14, 55 (1975). study of 6. JOYCE C. R. B., CAPLE E., MASON M., REYNOLDS E. and MATTHEWS J. A. Quantitative doctor-patient communication. Q. J. Med. 38, 183 (1969). with 7. LEY P., BRADSHAW P. W., KINCEY .I. A. and A~HER~ON S. T. Increasing patient’s satisfaction communication. Br. J. Sot. Clin. Psychol. 15,403 (1976). x. LFY P. and SPELMANM. S. Communicating with /he Patient. Staple Press, London (1967). and recovery from surgery. Psychosom. 9. COHEN F. and LAZURUS R. S. Active coping dispositions Med. 35,375 (1973). 10. SPIELBERGER C. D., GORSUKH R. L. and LUSHENE R. E. State Trait Anxiety Inventory Manual. Consulting Psychologist Press, Palo Alto (1970). 11. SPIELBERGERC. D. Anxiety and Behaviour. Academic Press, New York (1966). 12. JANIS I. L. Psychological Stress. John Wiley, New York (1958). of emotional and instrumental 13. JOHNSON J. E., LEVENTHAL H. and DABBS J. M. Jr. Contribution response processes in adaption to surgery. J. Pers. Sot. Psychol. 20,55 (1971). stress in surgical patients. 14. LANCER E. J., JANIS I. L. and WOLFER J. A. Reduction of psychological J. 0~. Sot. Psycho/. 11, 155 (1975). on the sensory and distress components of pain. 15. JOHNSON J. E. The effects of accurate expectations J. Pers. Sot. Psychol. 27,261 (1973).
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16. LEY P., BRADSHAW P. W., EAVES D. and WALKER C. M. A of information presented by doctors. Psychol. Med. 3,217 (1973). 17. HOLLAND C. I. and WEISS W. The influence of source credibility on communication effectiveness. Publ. Opin. Q. 15,635 (1952). 18. VERNON D. T. A. and BIGELOW D. A. Effect of information about a potentially stressful situtation on response to stress impact. J. Pen. Sot. Psychol. 29,50 (1974).