Are Counseling Services Necessary for the Surgical Patients and their Family Members during Hospitalization?

Hospitalization is a stressful event that disturbs the physical and psychological well-being of a patient, which can in turn affect physical recovery and medical compliance.[1] Studies reported that lack of preparation for surgery, postoperative symptomology, and negative thoughts and beliefs significantly associated with psychiatric comorbidity.[2] Further, review of literature suggested that health-care professionals, especially surgeons, need to provide information before and after surgery, but doctors are often reluctant and not interested to give required information to patients and their family members related to surgery and to understand their day-to-day concerns.[3] In our previous qualitative study, informational and educational needs are highly ranked among glioblastoma survivors who are ready to undergo surgical interventions during hospitalization. People with lower educational levels and families with low socioeconomic groups are also less informed.[4] Sudden onset of illness, unpreparedness for the hospitalization, fears related to surgery and outcome, surgical cost, and caregiver tasks increase the burden on families. In addition, unpreparedness to hospital stay, hospital rules and regulations, protocols, standing in queues for long hours, hospital shopping, new environment, and language barriers are the few factors that increase stress and anxiety among patients and their caregivers in general.

Counseling is defined as talking-based therapy by a trained therapist. Providing counseling services is extra burden and time-consuming for treating physicians due to increased work load and lack of training in communication. Thus, these counseling services such as presurgical counseling, postsurgical counseling, and predischarge counseling are provided by trained paramedical staff such as medical and psychiatric social workers (MPSWs) in the hospitals.[5] Often, MPSW is the first contact person who provides general information on admission process and resources available in the hospital and renders help in dealing with distress and practical-related issues of ill person and family members.[6] Many budding MPSW professionals including physicians are not aware of what sort of counseling services are needed for newly admitted patients and their caregivers. Therefore, this paper is intended to bring awareness on counseling services and its importance in day-to-day clinical care among the health-care professionals working in the surgical setting, especially during hospitalization.

PREADMISSION COUNSELING

The aim of the preadmission counseling session is to orient the patients and family members about the admission process, importance of planned surgical interventions, hospital protocols or facilities available in the hospital. Detailed information and preadmission counseling facilitates postoperative recovery and pain relief.[7] Preadmission counseling is generally provided at the time/day of admission in the hospital or when admission date is confirmed or tentatively scheduled by the neurosurgeon. Preadmission counseling session covers reasons for admission, importance of surgical interventions, hospital rules, hospital timings (breakfast, lunch, dinner, visiting hours, ward round, number of persons allowed), existing wards (general wards, special wards, its charges), importance of caregiver role during hospitalization, resources available in the hospital (medical shops, leisure and spiritual places, canteens), who is the treating physician or treating team, expected treatment expenditure, and role of each member of multidisciplinary team.

Besides that, it covers disclosing information on utilization of health insurance schemes, availability of health schemes provided by respective State Governments or Central Governments, its eligibility to become a beneficiary of such schemes/programs. In addition, it covers treatment concession available in the hosting hospital for special population such as people or families under below poverty line, senior citizens, and differently abled people. This above information is useful to check the willingness of patients for admission to undergo necessary treatment. It also prepares family members to take up caregiving responsibilities, to arrange required financial resources, and to make alternative arrangements at home. This information is useful to patients and caregivers to become familiar with existing resources in the hospital and hospital protocols. It has been noted that preparatory information services are provided to make aware the length of duration, health-care costs, and number of treatments and complications associated with treatment.[8]

PRESURGICAL COUNSELING

Surgery is frightening event even when surgery is relatively minor. Thus, the aim of the presurgical counseling session is to alleviate surgical fears and psychological preparation for surgical interventions, to impart realistic understanding of the proposed surgery and prognosis, to make them aware of surgical procedure and postsurgical complications, and to orient the patient on operation theater environment.

Most of the time, the patients and family members or caregivers may not be aware of the illness and the surgical procedures. Thus, patients and their caregivers who are waiting for the surgical interventions experience bundle of worries and tensions including distress, anxiety, depression, tendency to have postponing the surgery and uncooperative to surgery. Thus, this session is intended to alleviating the surgical fears, clarify concerns related to surgery, duration of surgery, role of anesthesia, and to prepare the patients to adjust with postsurgical deficits such as body disfigurement, cognitive deficits, postsurgical pain, and disability. This is carefully done in consultation with concern treating neurosurgeon and anesthesiologist. Studies also reported that providing preoperative information has positive effects and reduces postoperative stress, pain, and anxiety in surgical patients.[38910]

Yet, another important intervention required in this session is assessing and understanding the psychosocial needs and issues of both patients and their caregivers. This can be done with the help of bio-psycho-social-spiritual model. This assessment may cover situational changes, i.e., perceptions, family, decision-making, and spiritual beliefs; psychological issues, i.e., stress, anxiety, distress, fear of prognosis, fear of pain, and fear of death; concerns related to body image, expectations, postsurgical pain, possible deficits, past experiences, knowledge deficits, and willingness to know about the information. Based on the psychosocial need assessment, the appropriate and tailor-made psychosocial interventions can be planned in the following sessions. In this session, obtaining consent for surgical interventions may be considered formally. Risk can be difficult concept to communicate with a patient and their family members. Thus, the health-care professionals must be careful in providing information.[3]

POSTOPERATIVE COUNSELING

Postoperative period usually begins immediately after surgery and continuous until patient is discharged from the hospital. The aim of the postoperative counseling session is to address the postoperative fears and emotional issues and to provide supportive care for patients and caregivers.

In this session, if the patient is conscious after surgical interventions and ready to hear the bad news and family gives permission to reveal the bad news and interact with the patient, a brief session on breaking the bad news and education about illness can be initiated. The other day-to-day concerns such as suture removal, wound cleaning, body image, pain education and management, drug compliance, postoperative cognitive deficits, upper and lower limb weakness (if present), and explaining the possible recovery would be of great benefit for patients. The brief education about illness and providing required information helps the patient to adjust with postoperative conditions. This can be done by MPSW with close consultation with treating neurosurgeon on every day basis.

With respect to caregivers, the caregivers needs to be educated in detail about illness causes, prognosis, surgical side effects and reasons, caregiver responsibilities and roles during hospitalization can be carried out. The other psychosocial interventions such as enhancing social support, strengthening existing coping abilities, and improving self-efficacy, measures in reducing distress, stress, and anxiety management, and providing supportive work with caregivers along with patients can be carried out. In this context, MPSW job is to coordinate to address the day-to-day concerns of caregivers and patients and keep informing them for further treatment plan by discussing with treatment team. The studies also reported that patients and family members who are satisfied with preoperative preparation for surgical interventions are significantly associated with postoperative psychological adjustment. Patients and their carers who are dissatisfied with preparation are more likely to develop psychiatric comorbidity.[2] Therefore, postoperative counseling is essential.

PREDISCHARGE COUNSELING AND FOLLOW-UP

The aim of the predischarge counseling session is to prepare the patient and family to get discharge from the hospital and to ensure adhering to treatment regimen such as radiation therapy, chemotherapy or physiotherapy, and psychosocial care and retaining them to continuity of care. However, preparing the patients to get discharged from the hospital is an ongoing process that begins during the preoperative period. The patient is prepared for possible recovery, events, deficits unfold and gradually assuming self-care during postoperative period. In this stage explaining about wound care and dressing, bathing, side effects of drugs, medication timings, how to take them, activities allowed and not allowed, dietary modifications and restrictions are important. The special attention has to be given to strengthening the coping abilities and create the realistic hope on recovery in patients and care givers.

Further, guidance to access health insurance, helping in accessing welfare benefits if eligible, clarifying individual questions and concerns, and follow-up care can be added. Another important dimension is educating and preparing caregivers to continue the caregiver duties at home, and emergency management plan needs to be explained. Sometime, patients’ do get discharge from the hospital with many unaddressed psychosocial needs. MPSW should take the responsibility to make appropriate referrals are done with the help of treating team. Fixed appoints and contact numbers of MPSW can be given to patients and caregivers to address ongoing psychosocial concerns and continuing the therapeutic relationship for further sessions and ensure follow-up care. This retains the hope and trust on treating team among patients and family members. The studies reported that the discharge counseling services have positive effect on self-care and alleviating the problems that they encounter.[11]

In a concluding note, providing preparatory and adequate information on preoperatively, postoperatively, and predischarge has many positive effects on patient's physical recovery, coping, attitude, reduction in anxiety and mood disturbances and allowing the patient and caregivers to prepare for the future.[12] MPSWs play a significant role by providing informational, educational and by addressing psychosocial issues of patients and their family members. They ensure retaining patients for follow-up and adhering them to treatment regimen in various phases of illness. MPSWs also give remainders periodically to caregivers and patients to address the day-to-day concerns related to illness and treatment. Further, MPSWs enquire about patient current status and update the same for the treating team. Hence, every newly admitted patients for surgical interventions and their caregivers can be referred to MPSWs prior to the admission and during hospitalization for necessary counseling services and address the psychosocial needs effectively. Figure 1 depicts the counseling services that are necessary for the surgical patients and their family members during hospitalization.

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Figure 1

Counseling services for surgical patients and their caregivers during hospitalization

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