Psychological intervention based on social cognitive theory: Treating pain, anxiety, and depression in perioperative patients

Abstract

BACKGROUND

Surgery is an effective method for treating certain diseases. Factors such as disease, preoperative fear and tension, surgical stress, postoperative pain, and related complications directly affect the smooth progression and outcome of surgery. Patients may experience a series of psychological and physiological changes during the perioperative period, resulting in anxiety and depression, which may reduce the pain threshold and worsen their prognosis.

AIM

To investigate the effects of a psychological intervention among perioperative patients, based on social cognitive theory (SCT).

METHODS

We enrolled 200 patients who underwent surgical care at The First People’s Hospital of Lin’an District, Hangzhou between January and December 2023. They were categorized into a routine intervention group (n = 103) and a psychological intervention group (n = 97), based on the intervention strategies used. Various assessment tools, including the self-rating anxiety scale (SAS), the self-rating depression scale (SDS), and the Connor–Davidson Resilience scale, were used to measure patients’ negative states and emotions. The pre- and post-intervention scores for these metrics in the two groups were then analyzed.

RESULTS

In the psychological intervention group, the SAS and SDS scores (31.56 ± 5.18 and 31.46 ± 4.57, respectively) were significantly reduced compared to the routine intervention group (P < 0.05). The visual analog scale pain scores at 12 and 24 hours after intervention (6.85 ± 1.21, 4.24 ± 0.72) were notably higher than those in the routine intervention group (P < 0.05). The psychological intervention group also demonstrated superior scores in perseverance (36.08 ± 3.29), self-reliance (22.63 ± 2.91), optimism (11.42 ± 1.98), and resilience (70.13 ± 5.37), compared to the routine intervention group (P < 0.05). Additionally, the psychological intervention group’s confrontation score (23.16 ± 4.29) was higher (P < 0.05). This group also reported lower scores in avoidance (9.28 ± 1.94) and yielding (6.19 ± 1.92) (P < 0.05). Lastly, the Short Form 36 Health Survey scores were significantly higher in the psychological intervention group, indicating a better quality of life (P < 0.05).

CONCLUSION

Psychological intervention measures based on SCT can effectively alleviate pain, anxiety, and depression in perioperative patients.

Key Words: Perioperative period; Social cognitive theory; Psychological intervention; Pain; Anxiety and depression

Core Tip: Patients may experience a series of psychological and physiological changes during the perioperative period, resulting in anxiety and depression, which could reduce pain threshold and worsen their prognosis. Using social cognitive theory, we developed psychological intervention measures to explore their effectiveness in reducing pain, anxiety, and depression in perioperative patients.

INTRODUCTION

Surgery is an effective method for treating certain diseases. However, factors such as preoperative fear and tension, surgical stress, postoperative pain, and related complications directly influence the smooth progression and outcome of surgery. The perioperative period (also known as the entire operative period) covers the preoperative and postoperative phases of medical treatment. At this stage, patients may experience a series of psychological and physiological changes[1,2]. Perioperative nursing is an auxiliary method used before, during, and after treatment. Reasonable psychological intervention could assuage negative emotions in patients, make their pain less intense, and improve their quality of life (QoL), so that they can face treatment with an improved attitude and experience a certain positive effect on their prognosis[3]. Social cognitive theory (SCT) is an essential starting point, while individual behavior, individual cognition, and an individual’s objective environment can also impact human activity; moreover, there are connotations among these factors. Cognitive factors, such as people’s beliefs, motives, memories, and self-reinforcement, guide and dominate behavior; behavioral outcomes are fed back to people who react to this content and structure of their thinking, as well as their own emotions[4]. In recent years, with the promotion and implementation of high-quality nursing in major hospitals, research has come to frequently explore new nursing models to improve patient outcomes and boost nursing quality. Therefore, this study uses SCT to develop psychological intervention measures and to explore their effectiveness in reducing pain, anxiety, and depression in perioperative patients.

MATERIALS AND METHODS

Patient characteristics

We analyzed the medical records of 200 individuals who underwent surgical procedures at The First People’s Hospital of Lin’an District, Hangzhou between January and December 2023. We categorized these cases into two groups, based on the intervention techniques used: A routine intervention group (n = 103) and a psychological intervention group (n = 97), as depicted in Figure 1. The inclusion criteria were as follows: (1) Participants must have full medical records available; and (2) they must be aged 18 to 75 years old. The exclusion criteria were as follows: (1) Individuals with a documented psychiatric disorder; (2) patients who had severe perioperative complications and discontinued treatment; (3) patients receiving radiotherapy, chemotherapy, or immunotherapy; (4) patients suffering from critical conditions of blood vessels in the heart and brain, as well as those with advanced liver, kidney, or blood-forming system disorders; and (5) patients with malignant tumors, chronic inflammation, or autoimmune disease.

Figure 1 Technology roadmap. SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; VAS: Visual analog scale.

Intervention methods

Patients in the routine intervention group received standard care, which included individual oral education, daily clinical care, and ward management.

Based on routine intervention, patients in the psychological intervention group received measures based on SCT. These interventions were as follows: (1) During the perioperative period, patients were provided with comprehensive information about the surgery, including the procedures involved, the anticipated outcomes, and potential risks. This approach aimed to foster accurate expectations about the surgery and recovery process among the patients, thereby mitigating feelings of anxiety and fear; (2) Patients were also directed to manage their stress effectively; this included recalling the details of conversations within themselves or outside in their daily work and life, reassessing their roles, embracing their negative thoughts, and seeking appropriate outlets for expression. When self-resolution was not feasible or effective, psychological counseling and emotional support were offered temporarily, to help patients manage their negative emotions. Researchers stressed that the most important thing for patients was to cultivate the ability to resolve their own emotions; (3) Patients’ families and friends were encouraged to offer emotional support and practical assistance during the perioperative period. The presence of loved ones was intended to alleviate anxiety and possible feelings of isolation. Additionally, support networks were established, encompassing family, friends, neighbors, colleagues, and community support groups; and (4) Healthcare professionals provided patients with comprehensive guidance regarding postoperative care, including activity schedules, pain management, and medication administration. Positive reinforcement in the form of praise and encouragement was given when patients adhered to the recommended practices; these actions were intended to bolster their self-confidence in their recovery capabilities and increase their engagement in rehabilitation activities.

Clinical data collection

We searched for patient data in the hospital’s electronic medical records system. We adopted a double-check system with two people and dual-core processors to avoid errors during data extraction: (1) We collected clinical baseline data including sex, age, place of residence, marital status, education level, occupation, medical security form, and family monthly income; (2) We used the self-rating anxiety scale[5] and the self-rating depression scale[6] to evaluate subjective feelings of anxiety and depression. Each scale comprises 20 items that are scored on a scale of 1 to 4 points. We determined the standard score by multiplying the total score for each item by 1.25; (3) We employed the visual analog scale (VAS)[7] to assess and compare the intensity of pain between the two patient groups at 12 and 24 hours after treatment. The scale ranges from 1 to 10, with a higher score indicating more intense pain; (4) We measured the psychological resilience of patients facing challenges using the Connor–Davidson Resilience scale[8] both before and after the intervention. This scale evaluates 25 items across three key dimensions, optimism, self-reliance, and perseverance, with scores ranging from zero to 100. Higher scores imply greater psychological fortitude; (5) We utilized the Medical Coping Modes Questionnaire[9] to assess patients’ approaches to dealing with illness; the questionnaire comprises 20 questions categorized into three coping strategies: confrontation, avoidance, and surrender. The questionnaire yields cumulative scores ranging from 20 to 80; and (6) We used the Short Form 36 Health Survey (SF-36)[10] to score the eight dimensions of quality of life: physical function, physical role, body pain, general health, vitality, social function, emotional role, and mental health. A high score indicates a high QoL.

Statistical analysis

Statistical analysis was conducted using SPSS version 23.0 (IBM Corp., Armonk, NY, United States). Categorical data were presented as frequencies (n) and percentages (%), and group comparisons were made using the χ² test. Continuous data were reported as the mean ± SD, with group comparisons conducted using the t-test. Statistical significance was set at P < 0.05.

RESULTS

Clinical characteristics

We compared the general data between the routine and psychological intervention groups. There were 77 males (74.76%) and 26 females (25.24%) in the routine intervention group, with ages ranging from 18 years to 66 years. The psychological intervention group included 69 males (71.13%) and 28 females (28.87%), with ages ranging from 19 years to 74 years (P > 0.05) (Table 1).

Table 1 General information about the two groups of patients.

Feature	Routine intervention group, n = 103	Psychological intervention group, n = 97	χ2/t	P value
Sex			0.333	0.564
Male	77 (74.76)	69 (71.13)
Female	26 (25.24)	28 (28.87)
Age in years	40.88 ± 12.46	41.48 ± 11.37	-0.436	0.664
Place of residence			0.559	0.455
City	72 (69.90)	63 (64.95)
Village or town	31 (30.10)	34 (35.05)
Marital status			2.726	0.436
Married	52 (50.49)	42 (43.30)
Single	27 (26.21)	32 (32.99)
Divorced	15 (14.56)	18 (18.56)
Widowed	9 (8.74)	5 (5.15)
Education level			0.864	0.834
Primary and below	17 (16.50)	20(20.62)
Junior high school	29 (28.16)	29 (29.90)
High school or technical secondary school	33 (32.04)	27 (27.83)
Junior college or above	24 (23.30)	21 (21.65)
Occupation			1.606	0.658
On the job	56 (54.37)	46 (47.42)
Take leave or retire	11 (10.68)	10 (10.31)
Individual or farmer	22 (21.36)	28 (28.87)
Unemployed	14 (13.59)	13 (13.40)
Form of medical security			0.589	0.443
Worker with medical insurance	67 (65.05)	58 (59.79)
Medical insurance for residents	36 (34.95)	39 (40.21)
Monthly household income			1.705	0.426
< 5000	60 (58.25)	64 (65.98)
5000-8000	31 (30.10)	26 (26.80)
> 8000	12 (11.65)	7 (7.22)

Data are n (%).

Anxiety, depression, and psychological resilience of patients

Before the intervention, the patients had similar anxiety and depression statuses (P > 0.05). Although both intervention models had some impact on patients, the psychological intervention based on SCT had a more significant inhibitory effect on anxiety and depression (P < 0.05) (Figure 2).

Figure 2 Patients’ anxiety and depression scores. A: Anxiety score; B: Depression score. ^aP < 0.05. SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Before any intervention, the total scores for perseverance, self-reliance, optimism, and resilience showed no significant differences among all patients (P > 0.05). Both intervention models had some impact on the patients; however, the total scores for perseverance, self-reliance, optimism, and resilience were higher in the psychological intervention group, indicating poorer outcomes in the routine intervention group (P < 0.05) (Table 2).

Table 2 Psychological resilience scores in the two groups of patients.

Group	Perseverance	Self-reliance	Optimism	Total
Before the intervention
Routine intervention group	23.95 ± 3.06	10.69 ± 3.19	4.60 ± 1.39	39.24 ± 4.40
Psychological intervention group	23.57 ± 3.18	10.14 ± 3.42	4.53 ± 1.36	38.24 ± 4.97
t value	0.861	1.177	0.360	1.509
P value	0.390	0.241	0.719	0.133
After intervention
Routine intervention group	29.18 ± 4.61	15.86 ± 3.03	8.81 ± 1.85	53.85 ± 5.37
Psychological intervention group	36.08 ± 3.29	22.63 ± 2.91	11.42 ± 1.98	70.13 ± 5.37
t value	12.118	16.098	9.637	21.427
P value	< 0.001	< 0.001	< 0.001	< 0.001

Data are mean ± standard deviation of points, unless otherwise indicated.

Pain and QoL of the patients

We recorded the patients’ VAS scores 12 and 24 hours after the intervention. Compared to the routine intervention group, the VAS scores of patients who received the psychological intervention based on SCT were significantly lower (P < 0.05) (Figure 3).

Figure 3 Visual analog scale score. ^aP < 0.05. VAS: Visual analog scale.

Before any intervention, the SF-36 scale scores did not show significant disparity (P > 0.05). The results indicated that perioperative patients who received psychological intervention based on SCT had higher SF-36 scores, suggesting a better QoL for this group (P < 0.05) (Figure 4).

Figure 4 The Short Form 36 Health Survey scores of the two groups. A: Denotes physical function; B: Physical role; C: Refers to body pain; D: Indicates general health; E: Vitality; F: Social function; G: Emotional role; H: Mental health. ^aP < 0.05. PF: Physical function; PR: Physical role; BP: Body pain; GH: General health; VT: Vitality; SF: Social function; ER: Emotional role; MH: Mental health.

Coping style of the patients

Without any intervention, the scores for confrontation, avoidance, and yielding among all patients demonstrated no significant differences (P > 0.05). After the psychological intervention, the confrontation score increased, while the avoidance and yielding scores decreased (P < 0.05). However, there was no significant change in the routine intervention group (P < 0.05) (Figure 5).

Figure 5 Coping styles between the two groups. A and D: Portray the confrontation dimension; B and E: Depict the avoidance dimension; C and F: Indicate yielding.

DISCUSSION

Surgery is an effective means of treating disease; however, it is also a stressor. Patients experience disease-related stress after illness. During the perioperative period, patients are prone to fear, anxiety, depression, and other emotions due to factors such as the environment, disease, surgery, and prognosis, which increase their pain sensitivity and are not conducive to the implementation of surgery and postoperative rehabilitation[11]. The traditional nursing model is disease-centered, and nursing measures do not involve initiatives, which makes it difficult to alleviate the negative emotional environment that patients encounter before surgery and to facilitate rapid recovery afterward. In recent years, with the implementation and development of high-quality nursing in China, research hotspots include exploring new nursing models and improving the quality of nursing. SCT is a learning theory proposed by Albert Bandura, a well-known American psychologist[12]. This concept posits that learning occurs by observing others’ actions, outcomes, and environmental influences, which shape one’s behavior, beliefs, and attitudes. This theory highlights the dynamic interplay between an individual’s actions, personal characteristics, and environmental elements. The current study employs various questionnaires to assess patients undergoing treatment across multiple dimensions, including psychological state, pain perception, and coping mechanisms. The goal was to gain a holistic understanding of how psychological interventions informed by SCT can effectively alleviate the pain, anxiety, and depression experienced by patients during the perioperative period.

Mental interventions can reduce anxiety and depression in perioperative patients and improve their psychological resilience

This study indicates that after the psychological intervention based on SCT, perioperative patients who had experienced anxiety and depression showed increased perseverance, self-reliance, optimism, and psychological resilience. This implies that the psychological intervention model has significant value in improving the psychological state and resilience of perioperative patients. Due to a shortage of relevant surgical knowledge, patients often have serious concerns about the surgical method, safety, and postoperative rehabilitation effect. These concerns can aggravate depression, anxiety, and other adverse psychological conditions, resulting in reduced immune function and poor treatment compliance, which is not conducive to postoperative rehabilitation[13-15]. Psychological support based on SCT focuses on eliminating patients’ negative psychological emotions such as tension and fear. Through education that promotes knowledge regarding health, benign communication, limb relaxation, music, and other methods, patients’ poor cognition can be corrected, and their negative psychology and emotions can be alleviated, enabling them to better cooperate with the treatment process and facilitate postoperative rehabilitation.

Resilience is an individual’s ability to adapt and successfully cope with adversity[16,17]. Perioperative patients generally experience great psychological pressure; they often have negative emotions such as pessimism and disappointment, resulting in decreased psychological resilience. Psychological intervention measures based on SCT can guide patients to correctly perceive common adverse reactions or complications that may occur during the perioperative period through professional medical knowledge, case study explanations, and other methods. SCT can also encourage patients to recover their health in addition to helping them maintain good physical cognition and preserve their mental health, thus greatly improving their psychological resilience as well as mitigating their anxiety and depression.

Mental intervention can reduce patients’ pain and boost QoL

After the psychological intervention, perioperative patients experienced a significant reduction in pain and notable improvements in each dimension of the SF-36, suggesting that this intervention mode is effective and feasible for reducing patients’ pain and improving their QoL. Perioperative pain is a complex physiological and psychological reaction caused by noxious stimulation of the body. This can lead to poor immune function in patients, reduce the effectiveness of follow-up treatment effect, and prolong hospitalization through the interactions of the psychological-neuro-immune system. Thus, it is necessary to implement appropriate interventions.

Pain can arise due to a primary disease, punctures during surgery, inflammatory reactions to catheter-related operations, and other factors; it can induce delirium, agitation, convulsions, and other symptoms and is not conducive to patients’ recovery and prognosis[18]. Drawing from the framework of SCT, healthcare providers can equip patients with insights into the nature of their pain, available treatments, and self-care techniques. This education aims to enhance patients’ understanding of their condition and thereby alleviate their apprehension and doubts. Recognizing that emotional well-being can influence pain perception, psychological support can assist patients in more effectively regulating their emotions, which can subsequently have a positive impact on their experience of pain. Furthermore, such interventions may reduce the incidence of typical postoperative complications and potentially shorten hospital stays. Mental health is closely correlated with QoL. By encouraging family members to communicate with patients, their sense of support increases, and their strong sense of dependence is adapted. Through psychological counseling, a patient’s negative mood can be alleviated, and their self-concept and role adaptation can be enhanced. This effectively reduces the inherent stimulation source and improves QoL. Hence, it is necessary to strengthen psychological interventions during the perioperative period[19,20].

Mental interventions can change patients’ coping style

Patients requiring surgery are usually psychologically fragile, and surgical treatment adversely affects both the mind and body. Patients are prone to somatic symptoms and negative emotions. Without timely intervention, they are likely to develop more serious anxiety disorders and depression, which can affect postoperative recovery. Patients with severe depression may have suicidal thoughts that threaten their lives[21-23]. We found that after the psychological intervention, perioperative patients’ confrontation scores increased while their avoidance and yielding scores decreased. This implies that the psychological intervention based on SCT positively influenced their psychological coping styles. Using SCT, medical personnel can guide patients to acquire accurate knowledge of their health, maintain a positive attitude, and deepen their belief in disease treatment and family support so that they can take positive steps according to the established rehabilitation plan, achieve their expected goals, and improve their prognosis[24]. The psychological intervention helps patients avoid yielding and avoidance behaviors, improves their subjective initiative, and maximizes their ability to participate in rehabilitation, effectively promoting limb rehabilitation. Psychological coping styles are closely associated with mental health; positive coping styles can reduce anxiety and depression and promote mental well-being.

CONCLUSION

In summary, psychological intervention measures based on SCT have a clear concept, strong logic, and compact and reasonable processes. When combined with actual nursing work, they form a systematic and independent process and framework that helps alleviate patients’ anxiety and depression and reduces pain. Our results confirm that psychological intervention measures based on SCT can help to control the various sources of stress impacting patients during the perioperative period through nursing measures, thereby improving psychological resilience and QoL, alleviating anxiety and depression, and reducing patients’ pain.

However, our study faced several constraints. It was a single-center retrospective study with a sample from only one hospital, leading to limitations in the selection of cases. In future studies, we will include multiple institutions in our research and select sufficiently large samples to provide a more reliable basis for psychological intervention based on SCT.