Hospital stays and Medical Procedures


Overview
The Hospital as a Distinct Culture
           A hospital patientís loss of control
           How patients cope with the hospital culture
           The role of Nurses in hospital culture
            Patient-centred care: an ideal in the hospital

The Psychological Impact of medical Procedures
           The psychology of mammography
           The psychology of magnetic resonance imaging

Day Surgery

In the Hospital
            The emergency department
            Recovering from survey
            The Intensive-Care Unit
            Discharge
            Palliative Care

Alternative Settings for Healthcare and their Cultures
            Worldview and healthcare
            Causes, treatments & prevention
            Religion and spirituality
            Survey of alternate worldviews and settings
 


The Hospital as a Distinct Culture

The language, rituals and expected outcomes for spending time in the hospital are very different from most other everyday settings.

 Average length of hospital stay in Canada 1999-2000 was 7.1 days. Most stays are brief as outpatient-having a some largely non-invasive procedure done and returning home or as a day patient -having a more involved and somewhat invasive procedure, but not staying overnight. Often will need help getting home that evening.

Emergency patients - may be in the hospital for only a short period of time, or they may be embarking on a much longer stay. Generally, today, there are long waits at emergency and people may be repeatedly bumped for more pressing cases.

Pre-booked procedure patients, on waiting list, may also get bumped for one reason or another. Poole et al report that 237 Canadians died waiting for transplants in 2002.

Hospitalization leads to a loss of control due to the long waits, strange language, forced procedures, demands for information or body access. Spencer et al (1995) report a spinal chord patient found adjusting to the hospital as difficult as adjusting to his new disability.

<Figure 5-1> indicates a survey of "powerful other" control beliefs, indicating an increase during the hospital stay while  internal and external locus of control beliefs did not change (Halfens, 1995) .

Polimenni & Moore (2002) report that perceived powerlessness lead to lesser satisfaction with the hospital stay.

            A hospital patientís loss of control
Hospitals represent total institutions (Goffman, 1961) where they take control over nearly everything that the patient does, including having social exchange, eat, sleep, be manipulated, etc.

Patients differ in their response to hospital culture, where there may be
 "activists" who want to take control  or "delegators" who wish to be controlled (Kelner, 1995).

Interaction with hospital staff may also affect the patients level and sense of control when labeled as a "problem patient" and given less control or respect. 

This stance of the patient may simply be a form of reactance, where they are responding to loss of control with some anger and resistance.  The staff may also undergo counter reactance.

Taylor (1979) suggests that patients who are accustom to being in control, having higher levels of education and generally younger are more likely to develop reactance.

Learned helplessness may also be an outcome of hospitalization, where the patient relinquishes all control and takes on a passive attitude.

This is more likely to occur under disempowering care, where over assistance (e.g., in feeding) takes away control. In contrast, empowering care is more likely to have positive results in terms of lower stress response.

Informational control is also likely to occur, where some will be in greater desire for information, (e.g.,  and  other looking for less information (e.g., blunters).

Miller & Mangan (1983) examined these style in  a 2 x 2 study with high and low information conditions. They found that those in opposing conditions (e.g., high info blunters) showed more stress (measured by heart rate).

Poole et al indicate this refutes the "uniformity myth" that all patients are alike a require lots of information.

They also suggest that relaxation training is beneficial to all patients prior to hospitalization.

Patient choice can be helpful such as "walk or ride?" to operating theatre. Most are happy with their choice.

Depersonalization occurs when the loss of identity is happening due to loss of clothes, control, sleep, privacy, name (e.g., becoming "a gallbladder" or what ever).

This may be especially powerful under conditions of isolation or extreme (technological) control (e.g., Intensive Care Unit).


            How patients cope with the hospital culture

Active or passive modes emerge having to accept the "powerful other" or fall into reactance and possible abuse.

Building solidarity among patients is a more positive methods of coping with hospital culture.  This enables the sharing of experiences, learning from others a little further along; may be group cohesion or pairing up.

Family members or friends may assist in coping through social support regarding communication, consultation and treatment recovery.


         The role of Nurses in hospital culture

A central part of healthcare in a hospital (along with orderlies, technologists & physicians), often seen as "patient advocates."  Generally have greatest amount of contact with patients.

Behaviour is shaped by rituals of the profession, including therapeutic and occupational forms.

Therapeutic rituals involve the specific patient-nurse interactions such as taking vital signs, bathing patients and administering medication. These are directed at providing therapy or remediation.

A certain degree of intimacy is present, but the style and degree will vary.

Empathy and authority are also required and are supported by the uniform, their knowledge and familiarity and use of communicative language. 

Language is two dimensional, more familiar when speaking with patients and more formal with other hospital staff. Shifting between mode may be needed.

Nurses  are thus expected to carryout both technical and socio-emotional care when dealing with patients and the challenges of having to carryout such a broad and often challenging occupation may lead to burnout.

Their occupational rituals pertain to the interactions that are scripted by  the interactions among nurses and between them and other hospital staff. Specific hierarchies are part of the hospital culture and will shape the interactions among all of its members.

  Patient-centred care: an ideal in the hospital

By focusing on the needs and comfort of the patient hospitals can increase patient satisfaction and facilitate healing. As such there is a  re-organisation of the hospital setting, including furniture, art, music, as well as the provider-patient interaction.


The Psychological Impact of medical Procedures
           The psychology of mammography
There are costs and gains for this and any other procedure.

The costs are sometimes painful as in the case of more invasive procedures, or they may be psychological in terms of a false positive reading (estimated 1-14%).

Distress and increased stress response may occur for some period of time, and may damage the confidence of the woman to carryout self-examinations (Absetz, et al, 2003).

Benign breast biopsy may result from the false positive, where there is likely to great short-term stress response (Andrykowski, et al., 2002). 60 to 90 % of biopsys are benign.

The benefits come in psychological comfort and early diagnosis for correct negative and positive results.  Further, in spite of the distress from a false positive, the ongoing behaviour of seeking mammography is encouraged by a previous false result.


           The psychology of magnetic resonance imaging

MRI is also moderately invasive, but more so on a psychological than physical manner. It requires laying still inside the magnetic chamber or bore. movement causes "ghost" readings and may destroy the scan, requiring another session. Breathing heavily may cause  such poor readings and one is likely to be Velcro secured.  MRIBasics  GEhealthcare

The machine is very loud (bang, bang, bang, bang,...) and each series of images may take four minutes, up to 90 minutes in one long session. Also no metal, including slivers or artificial heart parts.

Claustrophobia is a significant possibility and those with a predisposition towards it may have  difficulty. Others may develop it as a result of their MRI experience and it may take some time for that to wane.

For those who may be more seriously affected by such an event, sedation through intravenous or oral administration may be required. (70% of people fare well, 20% find it difficult and 5 % cannot complete it.

Relaxation, hypnosis, distraction and other anxiety reducing methods may also be used or trained with in preparation for the MRI session.

 

Day Surgery (or daycare surgery) may be carried out in a clinic or hospital setting.
Key elements to a successful day surgery involve: 1) adequate preparation, 2) timely discharge, 3) adequate home support (While & Wilcox, 1994).


In the Hospital

In 1997 & 1998  10,200 days spent in the hospital by 100,000 Canadians.


The emergency department - where it all begins for many people, usually in distress and / or disorientation. Busy place that can be impersonal and frustrating.

Triage - involves early sorting and classifying of patients and their urgency for treatment.  Admission staff need to have good communication and empathic skills.

Roughly 30% of emergency patients are discharged that day (15% of those arrived via ambulance).

Bettering the emergency experience can involve clear communication and a continuity of care, where the  same provider treats a patient through his or her stay.

            Recovering from surgery - may be short or rather lengthy. 

Psychoeducational care will help insofar as it can help to alleviate concerns over incapacitation, bodily sensations or pain, and uncertainty. 

Information on self care as well as procedures and expected recovery is provided.
 

        Pain management following surgery - may involve patient-controlled analgesia (PCA). This may help to reduce the overall amount of pain medication taken and may involve alock-out interval to avoid over medication. Studies suggest effective and works best with training.

            The Intensive-Care Unit (ICU) - Involves the most technological aspects of patient care, often total control by machine and providers. Patients are generally depersonalised and may take some time to recover.

Poole et al. report a three stage process of recovery from ICU care:
1) incommunication stage where the patient is unconscious or barely conscious and usually have few or no memories.
2) readaptation stage is when the patient is aware of his or her situation and struggle for recovery, recognising one's dependence on machines.
3) reflexion stage is where the patient makes an attempt to understand and move beyond the trauma or disease as well as the ICU experience.

Some patient reports involve a sense of trust and comfort in the machines as well as the staff although their recall of the technology may be vague (Russell, 1999).

Communication is really important especially around the patients as they may be somewhat cognizant of what is being said around them even if they are in a comma or under a general anesthetic.

Important to keep up the personal treatment though, especially from family.

Communication is also important surrounding "end-of-life" issues and arrangements that need to be made with family.

Expertise models suggest that the provider is expert, while negotiated models suggest that practitioners, patients and family each have a voice. 

 Discharge - planning for discharge is important and there may be discrepancies between providers and patients expectations. 

Dependency and stress on family may be central along with medication administration, and rehabilitation activities and appointments.
 

Age may be important here where Canadians under 65 years of age have an average of 7.7 days per stay while those over 65 have an average of 35.3 days. 

Confidence and mobility can play a role here in the patient's ability to be safely discharged, yet social support and economics may also play roles.

Palliative Care - occurs when an illness has been progressive-worsening in spite of treatment.

This continues on toward advanced illness or to the point of imminent death. 

Palliative care involves maintaining the best possible quality of life and minimizing suffering through the control of symptoms, family support, and enhanced meaning.

Pain management is often central to palliative care along with spiritual guidance or logo-therapy. 

Euthanasia may occur, raising ethical and moral issues surrounding rights to die and assisted suicide.  Living wills may involve the encouragement of a physician to issue a do not resuscitate order should the patients breathing or heart fail.

A mixed management model of care is present here when preparing the patient for dying while also providing life-sustaining treatment.

See also Chronic Illnesses and Dying


Alternative settings for health care

Aside from the mainstream medical model of treatment in hospital, there exist other distinct sub-cultures of health that each have their own location,  language, rituals, and worldview.

   Cultural diversity in the treatment of illness

        Biomedical treatments - antibiotics and other drugs, chemotherapy, surgery, radiation, immunizations....

        Personalistic treatments - inducements to have spirits leave the body, 
            such as cupping (heated glass over body) Shaman may call forth the spirits through ritual. 

        Naturalistic treatments - diet, herbs, astrology or feng shui may be used to find 
            most auspicious time and place for health. Largely by bringing harmony back to the mind and body. 

        Santeria - the santero is called when someone is sick to consult an Orisha (diety).  
        This is found in Cuba where they may also use teas, potions, salves and poultices with medicinal herbs, as well as other ritual ceremonies. Drawn from Congo and Christianity.  

    Cultural diversity in the prevention of illness   In a multicultural society there may be numerous approaches to preventing illness such as traditional western medicine, meditation, herbal treatments, naturopathy, acupuncture, prayer, not cut hair, not tell people that one is pregnant, special diet, .... 

Traditional ceremonies may be used such as Baci by Asians, sweet grass or sweat lodges by Natives.

 Religion, spirituality and health care

Religious commitment and a sense of spirituality can benefit one's physical health.  
Religious beliefs may have an impact on one's acceptance or seeking of medical treatment,   i.e., Sabbath, blood transfusions,  as well as the type of treatment: healing circles and sand painting ceremonies, drumming festivals.  See Santeria, (and below).



Survey of Healthcare Approaches

In thinking of other cultural settings for healthcare, each with it's own 'culture.' In Canada there are multiple systems of healthcare, one can survey a number of those traditions that are a currently found here.

Ayurvedic Medicine takes place in everyday settlings or in specialised locations.  The principle techniques are describred here AC-UK.
  
 Naturopathy - Very similar to traditional western medicine, generally setting is a little less formal than mainstream medicine, but makes us of natural treatments for disease and illness.  See naturopathyonline  naturalhealers   CCNM for some information on specific techniques.
 

Homeopathy - Again similar in place and style to mainstream medicine, but also resting on a worldview that is largely rejected in traditional western medicine. 

Europe and the Americas have a historical tradition of herbalists and witches who have
explored the healing powers of plants and minerals, potions and powders.

 Native American traditions - Tend to be closer to the place of living. Elders advise on herbal and ritualistic  treatments for health problems. The use of ....



    Health Care in
Cuba - is a blend of modern and cultural forms. Mainstream Cuban healthcare is central to the Cuban Identity. It also involves  Santeria and other African and indigenous remedies as well as Chinese Medicine.

Santeria - takes place in the home and in public and private spaces.  The eye and tongue are everywhere and the seeds (beads) and statues with keys and feathers and  photographs. See -Santeria,links and sites


Mayan Medicine