The influence of psychological factors on recovery from hysterectomy

Introduction

Hysterectomy is one of the most common gynaecological procedures performed in the non-pregnant woman.¹ It can be performed through an incision in the abdomen, vagina or by a laparoscopic-assisted method. A Cochrane review of approaches to hysterectomy found a shorter hospital stay in women who have had a vaginal rather than a laparoscopic-assisted or abdominal hysterectomy,² and the National Institute for Health and Clinical Excellence (NICE) has recommended a vaginal approach as first line.³ Regardless of this, in the real-life pragmatic situation, hospital statistics report that women who have undergone a vaginal hysterectomy, with no abdominal incisions, have an average postoperative stay of 3.2 days in England,⁴ which is longer than the laparoscopic approach and not much different to the stay after the abdominal route (Figure 1). This may indicate that in strictly controlled experimental designs clinicians are potentially achieving optimum care efficiency through their beliefs about therapy and through the inadvertent psychological preparation of all patients. This could be in the form of stringent consent procedures with increased access to support mechanisms and follow-up. It may be that patients' and healthcare professionals' beliefs and expectations of recovery play a more significant part in what actually occurs outside clinical trial settings. Aspects of this could be amenable to psychological intervention to improve recovery outcomes.

Figure 1.

Incisions for hysterectomy and their associated recovery outcomes in clinical trials

Psychological preparation

Psychological preparation incorporates a range of strategies designed to influence how a person feels, thinks or acts (emotions, cognitions or behaviours). The benefits of psychological preparation for surgery have been evaluated in a meta-analysis.⁵ It identified many different types of psychological preparation, including procedural information, sensation information, behavioural instruction, hypnotic and relaxation training, psychotherapeutic interventions and cognitive behavioural approaches. They were found to be beneficial for a range of outcome variables such as negative affect, pain and pain medication, length of hospital stay, behavioural recovery, clinical recovery, physiological indices and satisfaction.

Information-giving

Patients give high importance to the information given to them by healthcare professionals over other sources. It influences behaviours such as when to return to normal activity and the degree of analgesia use.⁶ However, there is much variance in the beliefs and practices of healthcare professionals in the advice they give to patients.⁷ Information- giving to patients preoperatively can be categorized into sensory, procedural and behavioural. Sensory information describes the experience, for example what it will feel like and any other relevant sensations (e.g. taste, smell, sight). Behavioural instruction consists of telling patients what they should do to facilitate either the procedure or their recovery from the procedure, for example instructions about postoperative breathing exercises to help prevent respiratory infections. Procedural information describes the process that the patient will undergo, i.e. what will happen, when it will happen and how it will happen. As a result patients should be more aware of what to expect which will result in reduced anxiety with reduced pain sensations – this could, for example, be in the form of a DVD.⁸

Women undergoing elective gynaecology laparoscopy who were given procedural information about the surgery had significantly less analgesic requirements and reported a more rapid return to full health.^9,10 In addition, stress has been linked to the slower healing of wounds through psychoneuroimmunological mechanisms¹¹ and reducing anxiety has been defined as one of the principles of conducting a pre-anaesthetic consultation.¹² Although preoperative information is available, consideration should be given to including those categories of information which improve recovery.

Relaxation

Relaxation techniques can be used before surgery to reduce tension and anxiety. These include progressive muscle relaxation (where each muscle group is tensed and then relaxed), simple relaxation (each muscle group is relaxed in turn), breathing techniques (e.g. practice of diaphragmatic breathing) and guided imagery (e.g. imagining a pleasant, relaxing environment). A mixture of relaxation training and sensory and procedural information-giving was used as preoperative preparation for patients undergoing a cholecystectomy. The group who received this preparation reported less pain and higher levels of activity.¹⁰

Cognitive therapy

Cognitive interventions aim to change how an individual thinks, especially about negative aspects of the procedure. The patient's coping tendency has also been studied in relation to the information patients need. People can cope with situations through mainly problem-focused strategies or emotional-focused strategies. Those who use problem-focused strategies make plans to improve the situation and feel better when these are followed through. Emotional-focused individuals tend to alter their own cognitive interpretation of the situation rather than change it, for example ‘looking at the bright side’.¹¹ A randomized trial of procedural information, cognitive coping techniques and general ward information given to patients who had a hysterectomy showed that cognitive coping had the most effect on recovery.¹²

Hypnosis

This is an artificially altered state of consciousness characterized by heightened suggestibility and receptivity for direction to modify behaviour, attitude, anxiety, pain management and stress-related illness. Hypnosis may be seen to act either as a cognitive or a relaxation intervention. There is now evidence from a meta-analytical review that hypnosis positively affects immune function and may work through psychoneuroimmunological mechanisms.⁹

Emotion-focused intervention

Information-seeking is more common in people who have an internal locus of control. The locus of control is a psychological term referring to the extent to which individuals believe they control events that affect them. People can have a perceived internal or external locus of control. People with an external locus of control will believe strongly in other people, fate and in their destiny, whereas someone with a strong internal locus of control will believe that they have the ability to influence their own future. Those with an internal locus of control benefit from knowing more information and are able to reduce their anxiety levels about forthcoming surgery, whereas the same information may increase the anxiety levels of someone with an external locus of control as they may rather not know the details.¹³ Emotion-focused intervention aims to reduce the negative emotions that are predictive of negative postsurgical outcome.

Using psychological interventions to improve the quality of postoperative recovery

Although psychological interventions have been shown to improve outcomes, it would be important to establish which interventions improve which outcome.

There is much heterogeneity among studies in their definition of a favourable recovery outcome, and what a favourable outcome might be to clinicians and patients. Recovery has many components including measurable clinical aspects such as vital observations, normalizing of test parameters, the use of analgesia, return of physiological function such as passing urine or opening their bowels, number of days as an inpatient and mobility. Clinical interventions need to be evaluated for quality as well as efficacy.¹⁴ From the perspective of the patient, a favourable outcome may be more related to important aspects of their lives such as being able to sleep normally, looking after their families, socializing, feeling emotionally back to normal or being able to go back to work. In the past, patient education followed the traditional disease-based model, where the provider was the expert who decided what information and how much of it the patient should receive. The provider becomes the primary decision-maker and problem-solver. Outcomes of this model are the patient's compliance with the provider's suggestion. In an empowerment model, health providers assist patients in gaining knowledge, developing skills and identifying resources. Empowerment enables patients to take control of their own lives. This model recognizes the psychosocial as well as the physical aspects of health and disease. Empowerment and self-efficacy are closely related constructs. Psychological interventions which increase empowerment and self-efficacy could be a cost-effective way of improving those aspects of recovery which the patients value as well as traditional clinical measures. More research is needed into which psychological interventions improve which recovery outcomes. Through qualitative in-depth analysis of patient's views and experiences, we can establish which recovery outcomes are valued by them and then test which psychological interventions lead to their improvement.

Impact of research on health outcomes

There is already evidence that a formal enhanced recovery programme for surgery improves recovery and reduces hospital stay,¹⁵ and the ESTReP (Enhanced Surgical Treatment and Recovery Programme) has transformed the way in which colorectal surgery is delivered in the UK.¹⁶ Their programme combines known clinical predictors of recovery (such as early feeding after surgery, not using nasogastric tubes or surgical drains) with positive psychological factors such as patient education and health promotion. The ESTReP programme has lead to a reduction in the average hospital stay from 9–10 days per patient to 6 days. The authors of the study conclude that this has helped to generate extra bed space to treat more patients, and under the payment by results scheme, has generated more income for their trusts as well as helped meet 18-week targets.¹⁶ They have shown that the programme is cost-efficient based on the daily cost on a general or surgical ward of £400, and have gaining support from the Department of Health. Similar programmes for gynaecology should be developed and tested objectively for effectiveness.

Conclusion

Psychological preparation has been shown to be an important factor in the patient's surgical experience. These can be affected by the beliefs of healthcare providers in the way they counsel their patients. With an increasing drive towards a shorter length of stay in all specialties, efficient patient preparation is an important area. In the example of the route taken for hysterectomy, operative incision itself does not seem to account for the differences in recovery and the discrepancy between the everyday clinical situation and that of clinical trials. Psychological variables in the patient which are influenced by the beliefs and practices of healthcare professionals could account for these differences. The rigorous consent procedures in clinical trials and the participant support facilities through access to healthcare professionals and researchers as well as activities such as newsletters will have psychological consequences on the patients involved, regardless of which treatment arm they are in. This could account for the better outcomes seen in trials. Recovery outcomes could be improved in real-life situations through the use of psychological interventions aimed at recovery outcomes which are valued by patients in particular, the use of well-designed information-giving, cognitive therapy and emotion-focused therapy to match those seen in clinical trials.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor MS

Contributorship Both authors contributed equally