Methodological challenges inthe study of psychologicalrecovery from modern surgeryMost 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 rapidlyTraditional pre- and post-operative nursing intervention,once commonly taught and practised, must now bere-evaluated as a result of such transformations. However,undertaking research in order to investigate the freshchallenges facing nursing in the modern surgical environ-ment may present many difficulties. Methodologicalissues, such as the application of research approaches,time for adequate data collection, and the utilisation ofpatients as participants undergoing modern surgery willpresent numerous barriers. In this article, Mark Mitchellidentifies and discusses three problematic methodologicalissues 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

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Research and the modern surgical environmentWithin the UK an acute modern surgical environment predominates in theNHS; that is, minimal hospital stay, limited nurse-patient contact, rapid anaes-thesia, minimal access surgery, considerable self-preparation and substantialself-recovery beyond the bounds of the hospital. Approximately 60-65 percent 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 asThe NHS Plan (Department of Health 2000) aims to increase the level of daysurgery activity to 75 per cent of all elective surgery. The average length ofstay for a patient undergoing intermediate day surgery within a dedicated daysurgery facility in Europe is now six hours (Pfisterer etal 2001). Intermediateelective surgery is defined here as planned, uncomplicated surgery under gen-eral anaesthesia which can be undertaken in an operating theatre in less thanone hour. The degree of change in surgical health care cannot therefore beunderestimated. Indeed, Montori (1998) states: 'It is no exaggeration to saythat minimally invasive surgery has opened up a new form of modern sur-gery.' For example, patients undergoing cholecystectomy in the mid 1980sregularly required hospitalisation for up to three weeks, and, consequently, aconsiderable amount of physical nursing intervention. However, such practiceis becoming obsolete as the British Association of Day Surgery has includedcholecystectomy in its list of procedures of which 50 per cent should now bepossible in day surgery facilities (Cahill 1999). Such a transformation in surgi-cal health care will guarantee far-reaching and lasting changes to the way inwhich nurses are educated. For example, the copious physical nursing inter-ventions once required by cholecystectomy patients, hospitalised for manyweeks, such as wound care, pain relief, hygiene and mobility management,are fast disappearing. Only the minority of elective surgical patients willrequire such physical nursing interventions in the future. Robust evidence istherefore required to inform nurse education and practice in this new anddeveloping 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'semotional 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 decadeshave reported a plethora of studies investigating the challenge of improvingpre-operative psychological care (Johnston and Vogele 1993, AAathews andRidgeway 1984, Miller et al 1989, Rothrock 1989, Suls and Wan 1989,Wilson 1981). Much has been recommended over this period, althoughunfortunately 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 whenundergoing surgery is obviously of paramount importance, although giventhat future cholecystectomy patients (for example) will be hospitalised for amere day, psychological considerations may require greater emphasis.Undergoing anaesthesia is a major source of fear, and approximately 7 percent of the population are anaesthetised annually in the UK (Royal Collegeof Surgeons and Royal College of Psychiatrists 1997, Mitchell 2000b).Additionally, studies over four decades concerning pre-operative anxietyhave stated that patients are very anxious about the anaesthesia, pain anddiscomfort, being unconscious and the operation itself, and that this anxietydoes not end as patients are discharged form hospital (Egbert et al 1964,Male 1981, McCleane and Cooper 1990, McGaw and Hanna 1998, Mitchell1997, Ramsay 1972), However, little formal care has been implemented tohelp resolve this challenge (Mitchell 2000a). With the projected increase inday surgery intervention together with the average length of stay in a daysurgery 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, studyingthe most effective nursing interventions relating to psychological recoveryfrom surgery has become a very complex task. Previously, investigating suchrecovery primarily involved researchers visiting the surgical wards to recruitand interview participants. Much time spent by the patient in hospital with-

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Challenge RationaleApplication of The time available on the day of surgery will severely restrict theresearch approach application of the two main approaches, i.e. quantitative and

qualitative. The time restrictions inherent within current and

future day surgery will be the most influential factor.

Mode of data Day surgery practices have rendered some of the morecollection traditional methods of data collection to measure psychological

recovery obsolete, for example, amount of analgesia, time takento mobilise, in-depth interview, etc.

Day surgery patients The compliant, convalescing, post-operative patient who onceas participants 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 datacollection. However, this situation has changed with the rise in day surgery,as the majority of patients undergoing intermediate surgery are no longertreated as inpatients. Additionally, hospital stay for surgical inpatients is con-stantly decreasing, never again to return to previous levels; for example, theaverage length of surgical stay in one study was 2.7 days (Tierney etal 2000).Such alterations in surgical treatment are restricting a number of centralaspects within the research process;D the application of quantitative and qualitative research methodsD 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 approachesApplication of the fundamental research approaches within the modern sur-gical environment will become increasingly difficult to administer because ofthe inherent lack of time available. Previously, the principal approaches toresearch 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 interpretationof events) (Johnston and Vogele 1993. Suls and Wan 1989). However, bothapproaches 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 empiricaldata) as a result of the inherent lack of time on the day of surgery. This willinevitably affect or limit the choice of data collection in order to effectivelygauge 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 collectionfor cortisol, or blood analysis for adrenaline and nor-adrenaline, may be ren-dered too impractical. Polit et al (2001) divide such physiological measuresinto in vivo measures (assessment performed directly on the person, such asblood pressure monitoring) and in vitro measures (assessment performed fol-lowing extraction of biological material such as blood). Both measures maybe 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 beof little value. Almost all patients will experience a rise in blood pressure andpulse 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 willalso be very limited, such as the number of painkilling tablets consumed dur-ing the hospital stay, patient activity level, number of complaints made, levelof 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 thewhole period of hospitalisation and then employed measures of comparison

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Ss BeCiiawtecflj!; ["ft^jeftsCogteMj aiMI eoDDsi88csfi]0Mode 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 ofdays in hospital, amount of analgesia consumed,number of days to fully mobilise, number of

complications, number of negative statements, andnumerous additional observable responses.

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

Emotional Self-reported measures of anxiety, self-reported methodsof coping, self-reported amount or degree of pain anddiscomfort, self-reported time to return to 'normal'

between such levels, such as evaluation of anxiety at several stages in thepre-operative phase and again at several stages in the post-operative phase.Clearly, in the modern surgical environment such traditional measures will nolonger be applicable. The manner in which recovery from modern surgery ismeasured in the future by the quantitative researcher will therefore requirevery careful consideration.

Similarly, researchers pursuing a qualitative approach may find gainingaccess to a suitable surgical patient in an unhurried situation (for example,hospitalised for a few days without being acutely ill) in order to conduct anin-depth interview very difficult. Once home, many patients may be tooconcerned with their 'normal' daily lives to continue as participants in aresearch study. For example, in a recent study examining psychologicalrecovery from day surgery, one participant was contacted, as arranged, bytelephone for a brief (10-1 5 minutes) interview 48 hours after intermediategynaecological surgery and general anaesthesia. However, the participantwas not available, as she had travelled to a nearby holiday resort to ride ona large roller-coaster. (Mitchell 2000b). Although only one example, it doesprovide 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 toadequate data collection, is fast disappearing.

Data collectionThe second issue concerns data collection, or more specifically i) similar datacollected within the quantitative and qualitative approaches, and ii) limitedmeasures to gauge 'good and bad' psychological recovery. Firstly, whereasthe fundamental approach to acquiring insight into participants' experiencesmay 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 fromsurgery have been employed more on a practical basis than on the mostvalid: that is, what is considered a valid measure versus what can be reason-ably undertaken. Both research approaches rely on broadly similar methodsof data collection in order to evaluate and comment upon 'good and bad'psychological recovery. The method(s) chosen depend(s) entirely upon theresearcher and the proposed study. Naturally, the data may be interpreted indiffering ways, although, generally, with such a limited choice of indices, thenarrow band of measures utilised may limit all conclusions reached. Suchslender 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 forphysiological data collection, leading to a greater level of emotional data col-lection. Put simply, the choice of 'good and bad' recovery measurements forboth research approaches is becoming very limited. Ultimately, this may pre-vent vital new evidence from being uncovered, as measures of physiologicaland emotional recovery become too limited and impractical.

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

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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 alsoimpede data collection, such as operational definitions, diversity of patientperceptions (quality of staff or environment or both), and influences uponpatient satisfaction (measures dependent upon patient expectations).Research into psychological recovery from surgery has been burdened in thepast by esoteric debates concerning the most effect measure of anxiety: thatis, is anxiety more effectively measured via physiological methods (largelyobjective data) or by emotional and behavioural methods (largely subjectivedata). The debate may become less intrusive, as the brief window of oppor-tunity now available for data collection may render numerous physiologicaland behavioural measures too impractical or simply invalid (Table 2).

Day surgery patients as participantsThe third and final challenge for data collection within this area of researchconcerns participants who, while consenting to a research study, are alwaysdischarged from hospital the same day, and can therefore no longer bemonitored as closely as they once were. For example, once a prospectiveparticipant 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 theinformation or instructions imparted to them within the bounds of thestudy. 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 considerablenumber of studies employing modern surgical patients randomise patientsinto groups in this way, either in the pre-operative or post-operative period(Mitchell 1999a, 1999b). Ensuring and monitoring such group allocationwas arguably far easier when patients were hospitalised. Such groups arefrequently provided with information to read or instructions to follow aspart 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 andRidgeway 1984, Rothrock 1989, Wilson 1981). For example, in studies byCaberson (1995) and Markland and Hardy (1993) concerning relaxationprior to day surgery, an element of patient choice was given. Patients couldchoose which research group to be allocated to; that is, experimental groupor routine care group. This is frequently undertaken, as previous studieshave demonstrated that patients do not conform to the planned researchschedule if it is not deemed to be of personal value or indeed impedes theirrapid recovery (such as a day out to ride the roller-coaster). It is thereforeextremely difficult for the researcher in this field to ensure participantsremain randomised with limited controls, when recovery almost entirelyoccurs at home.

The captive, malleable, surgical inpatient frequently employed as aresearch participant and upon whom hypotheses could at one time be rea-sonably tested, is rapidly disappearing. Contact is considerably less becauseinpatient elective surgery is considerably less. The opportunity for researchermanipulation is reduced as a result of the time restrictions inherent with daysurgery. Also, when a study involves experimental groups randomised intodiffering forms of recovery (typically differing levels/types of informationprovision) the ability to truly obtain an unbiased sample is very difficult.Additionally, the notion of a control group receiving routine nursing care israpidly becoming an outdated research tool. Civing the label of 'routine care'to the hasty, medically dominated intervention provided during an averagesix 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 bevery limited. Indeed, as stated, supplementary intervention provided to anexperimental group frequently involves differing levels/types of informationprovided 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 aplethora of internet sites are now easily accessible. In other words, the self-reliant patient preparing for or recovering from surgery at home can nowgain information from a huge variety of sources and can thereby easily cir-cumvent 'controls' the researcher may have planned.

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Future measurement of psychological recoveryEvaluating psychological recovery from modern surgery is becoming a verychallenging task. When examining patients' experiences of day surgery, thetime needed for data collection, measuring 'good and bad' recovery andparticipant behaviour present numerous challenges. Psycho-educationalaspects of care will be of vital importance in the future as minimal hospitalstay and reduced contact with hospital personnel affects an ever-increasinggroup of patients (Mitchell 2003). Indeed, in a recent Audit CommissionReport (2001) ten indicators of good practice were employed to measure theeffectiveness of day surgery facilities. Eight of these measures related to theprovision of adequate information: i.e. psycho-educational aspects of care.The Audit Commission viewed these measures as central to the deliveryeffective day surgery. Below are some recommendations pertaining to eachof the previous three sections that may not only benefit the patient but alsohelp in the gaining of valuable information to increase nursing knowledge.

Firstly, as the time required for data collection on the day of surgery is verylimited, the pre-assessment clinic may provide an ideal opportunity for datacollection. A pre-assessment visit is a pre-arranged hospital visit before theday 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 thatdata collected at this period could limit any results. For example, patient anx-iety may demonstrate little increase six to eight weeks prior to surgery whensuch pre-assessment frequently takes place. Nevertheless, some day surgeryunits have other times when patients visit to experience the environmentprior to the day of surgery. This may also become an ideal opportunity fordata collection. Contact in the outpatient department when day surgeryreferral is initiated could additionally be employed or contact via telephoneduring the pre-operative phase.

Secondly, measuring 'good and bad' recovery from surgery may remaindemanding because of the narrowing band of reliable and practical indicesavailable. Additionally, patient expectations may vary considerably. Patientexpectations have been frequently highlighted as problematic, as they can bothhelp or hinder recovery dependent upon whether expectations have matched

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actual experience (Ruuth-Setala et al 2000). For example, many patientsbelieve 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 48hours (Donoghue et al 1995, Mitchell 2003), With the inherent time con-straints on the day of surgery, other reliable measures beyond the bounds ofthe hospital and outpatient department may be required. Other such forms ofdata 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/interviewsconcerning recovery from specific surgical procedures, general practitioner per-spectives, questionnaires/intervievi/s to gauge how unexpected problems werehandled and questionnaires/interviews undertaken by the community nursingteam. Much information is gathered prior to day surgery during the pre-assess-ment check although currently few, if any, post-assessment interviews takeplace to evaluate the care and treatment received. Much valuable informationcould be routinely gained if such dialogue were to be established. Valuableinformation could be obtained during post-assessment interviews as part of anoutpatient appointment, telephone interview, or district nurse visit, andbecome a potent tool for both clinician and researcher

Finally, day surgery patients utilised as participants in studies concernedwith recovery from surgery present many challenges, A by-product ofincreased self-care is the heightened sense of patient independence from theconfines of the hospital setting. Indeed, in a study of day surgery patients byBostrom et al (1994) the first two weeks following discharge were seen as themost important time as patients were frequently striving to regain greaterhealthcare autonomy. Day surgery is therefore heavily reliant upon a consid-erable amount of self-care and care provided by relatives (Hazelgrove andRobins 2000, Singleton et al 1996, Thatcher 1996, Willis et al 1997), Indeed,the care once provided by nurses for patients recovering from surgery is nowinevitably undertaken by relatives. In a recent study by Hirst (2002) it wasrevealed 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 today surgery. However, as the level of day surgery activity increases, so toomust the percentage of relatives involved in caring for a patient who has

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undergone modern elective surgery. Although the degree of care requiredfollowing 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 24hours following surgery (Royal College of Surgeons of England 1992).

ConclusionThe 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 suchmodern surgery is therefore a very important issue for the nursing profession.Little is known about the most effective nursing Interventions relating to suchmodern, rapid surgical treatment and recovery. The gaining of participantsand the collection of data was arguably less challenging when elective surgi-cal patients remained in hospital for a number of days and weeks during thepre- and post-operative period. However, this situation no longer prevailsand will never return. Within the changing surgical healthcare arena manyaspects of research methodology will become increasingly difficult to admin-ister. The application of the fundamental research approaches will be limitedconsiderably by the lack of time on the day of surgery. This will largely havea negative influence upon many aspects of data collection. Clarity and actionare 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 daysurgery 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 indiffering ways dependent upon the researcher's perspective and ultimatelyon the patient's individual evaluations. However, the number of intrusivedata collection episodes within the convalescing period beyond the confinesof the hospital will always be limited in the future as patient recovery is sorapid. Therefore, the indices employed must be scrutinised closely prior tocommencement of any study and good rationale provided. Finally, partici-pants are more independent and self-caring within this new era of surgicalintervention. 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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