The implications of integrating positive psychological frameworks into clinical practice in cardiac surgery

Abstract

There is a growing recognition of the significance of the mental and emotional readiness of patients prior to undergoing heart surgery. Self Determination Theory, a part of Positive Psychology delves into the realms of happiness, drive, and satisfaction in life. This theory highlights the importance of autonomy, competence, and relatedness as fundamental basic psychological needs necessary for attaining life satisfaction, motivation, and psychological well-being. To examine these aspects in this study, it is assessed the levels of basic psychological needs, motivation levels, and levels of psychological energy of patients undergoing heart surgery. Basic Psychological Needs Scale, Motivation Scale, and Psychological Energy Scale are used for data collection. Through an analysis involving independent samples t-tests on 55 patients, the research findings revealed these psychological outcomes associated with heart surgery. Following heart surgery, participants showed decreases in their levels of psychological needs satisfaction, motivation, and psychological energy.

Keywords

Cardiac surgery experimental methods cardiopulmonary bypass respiration physiology and management

Introduction

The interplay between psychological states and physical health, particularly in cardiac patients, is a critical area of study within health and clinical psychology. While existing research predominantly highlights the negative psychological impacts of heart surgeries, there is a growing interest in the positive psychological factors that can enhance recovery and health outcomes. Constructs such as motivation, happiness, and social support have been linked to improved health, suggesting that fostering positive psychological states may benefit cardiac patients.¹

Positive psychological variables, including autonomy and life satisfaction, significantly influence motivation and overall well-being. Studies indicate that individuals with higher levels of positive mental health are more likely to recover from affective disorders, emphasizing the importance of psychological well-being in cardiac recovery.² Conversely, anxiety, depression, and stress are prevalent among patients undergoing cardiac procedures, often exacerbating physical symptoms and complicating recovery. For instance, major depression affects approximately 20% of patient’s post-myocardial infarction, and anxiety disorders can significantly impair quality of life and increase mortality risk.^3,4 Moreover, psychosocial factors play a crucial role in cardiovascular disease outcomes, with chronic stress linked to disease onset and progression.⁵ This underscores the necessity for comprehensive psychological assessments and interventions in cardiac care. In summary, while the adverse psychological effects of heart surgeries are well-documented, further exploration of positive psychological constructs is essential for enhancing recovery and overall health in patients facing serious cardiac conditions.⁶

Integrating psychological rehabilitation into cardiac care can significantly optimize recovery outcomes. Research indicates that incorporating psychological interventions within existing cardiac rehabilitation programs can alleviate anxiety and depression, ultimately improving patients’ quality of life.⁷ Such interventions can address the high rates of psychological distress observed post-surgery, emphasizing the need for early detection and management of these conditions. Furthermore, cognitive rehabilitation strategies aimed at enhancing patients’ cognitive resources can facilitate better adaptation to the challenges posed by heart disease and surgery.^8,9 This multifaceted approach not only addresses immediate psychological needs but also promotes long-term recovery and resilience.

Preoperative psychological preparation has also been shown to yield positive outcomes for patients undergoing cardiac procedures. Studies have demonstrated that brief psychological interventions prior to surgery can lead to improved recovery trajectories, including reduced hospital stays and enhanced functional outcomes.^10,11 Such interventions help set realistic expectations, mitigate anxiety, and foster a sense of control among patients, which are crucial for navigating the postoperative period.¹¹ By prioritizing psychological well-being alongside physical health, healthcare providers can significantly enhance the overall recovery experience for cardiac patients, thereby addressing both the psychological and physical dimensions of health.

Method

In this study, descriptive survey method, one of the quantitative research designs, was used to measure the change in basic psychological needs, motivations, and psychological energies of patients undergoing heart surgery before and after surgery.

Sample

The study included 55 patients who underwent open-heart surgery for coronary artery disease, aortic, and/or mitral valve pathology in a single-center cardiovascular surgery clinic in Istanbul, did not develop major complications during the treatment, and were discharged within the normal time. Of the participants, 80% (44) were men and 20% (11) were women. The individuals’ ages, with a mean of 60.05 and a standard deviation of 11.65, varied from 26 to 79. The following was the distribution of marital status: 83.6% (46) were married, 5.5% (3) were divorced, 3.6% (2) were widowed, and 1.8% (1) were single. The participants’ educational backgrounds were as follows: Primary school completion rates were 21.8% (12), secondary school completion rates were 1.8% (1), high school completion rates were 25.5% (14), university completion rates were 41.8% (23), and postgraduate education completion rates were 9.1% (5). Patients in need of immediate attention, those who were illiterate or too old to complete the assessments, and those who had undergone surgery including different techniques such thoracotomy and “beating heart” were excluded from the research.

Analysis strategy

Procedure

The patients received two evaluations, one before and one after cardiac surgery. All patients underwent a median sternotomy procedure while under general anesthesia, and they were all connected to the heart-lung machine. All patients completed questionnaires and measuring devices after being admitted to the hospital, giving their informed consent the day before surgery. While the surveys were being completed, a researcher coded the responses. Each participant took 45 min to complete the surveys. The Ethics Committee of our hospital granted approval for this investigation under the assigned ethics number: 69396709-200.

Scales

Basic Pscychological Needs Scale

The 5-point Likert-type scale was created.¹² BPNS consists of 21 items. Very Accurate and It is an ranging from Not at all true (1). As Need for autonomy, need for competence, and need for relatedness, it has three subscales. The scale’s internal consistency coefficient, which measures its dependability, is 0.87. Created it to gauge the needs that underlie people’s actions and motives. In its modified form, consisting of three subscales, the “competence” subscale, which refers to the person’s belief that he/she is competent and effective in his/her actions; eight items constitute the “relatedness” subscale, which includes establishing close relationships with others and sharing feelings and thoughts with them; and seven items constitute the “autonomy” subscale, which refers to feeling secure in relationships with others and the desire to be independent. “I feel free to decide how to live my life,” “Most of the time, the things I do give me a sense of accomplishment,” and “People in my life care about me” are sample statements for the autonomy, competence, and relatedness subscales, respectively.¹³ The response possibilities on the Likert-type scale, which has five intervals, are 1 = Not at all true and 5 = Very true. The relatedness dimension has a score range of 8–40, the autonomy dimension of 7–35, and the competence dimension of 6–30. Low scores suggest psychological need, whereas high scores show that the person’s demand in the sub-dimension is satisfied. According to modified form reliability analysis, the scale’s Cronbach alpha values were 0.76, the autonomy dimension was 0.73, the competence dimension was 0.61, and the relatedness dimension was 0.73. The relatedness sub-dimension in this study was determined to be 0.82, autonomy to be 0.63, competence to be 0.77, and the internal consistency of the entire scale to be 0.90.

The substantial decreases in autonomy, competence, and relatedness suggest meaningful disruptions in patients’ perceived independence, effectiveness, and social connectivity following cardiac surgery. These decreases may negatively affect rehabilitation adherence, social reintegration, and overall quality of life. Addressing these areas through psychological support interventions is recommended for improved patient outcomes.

Motivation Scale

It is developed by Artiran (unpublished). Internal consistency coefficients indicating the reliability of the scale is 0.67 in this study. The scale consists of the following items: Success is exciting, I don’t get discouraged easily, I don’t give up right away, there is nothing as difficult as setting a goal, I don’t get tired of trying, I have lost my excitement, I continue to resist difficulties, Working is enjoyable, I quickly become complacent and start complaining when faced with difficulties, I cannot accept defeat. The scale’s internal consistency value in this research was determined to be 0.73.

An unpublished scale by Artıran consisting of items assessing motivational persistence and excitement toward goals. Although unpublished, it demonstrated adequate reliability (Cronbach’s α = 0.73). Further psychometric validation is recommended.

Psychological Energy Scale

The psychic energy of people was measured using a scale created by Artıran and Sapancı (unpublished).¹⁴ A set of 150 individuals (M_age = 36.53, SD = 12.55)—72 women and 78 men—were given the 12-item candidate scale as part of the first stage of the scale development process in accordance with the pertinent literature. The scale’s three-factor structure was discovered during the exploratory factor analysis that was done to ascertain the scale’s construct validity. The first component, dubbed Low Energy and including four items overall, had an eigenvalue of 5.13 and explained 42.75% of the variation. The results of the analyses that were done to look at the dependability values of the scale showed that the Cronbach’s Alpha coefficient for the entire scale was 0.85, Low Energy = 0.82, High Energy = 0.85, and Agility = 0.77. These numbers show that the scale has a high level of internal consistency and reliability. The scale’s item-total correlation coefficients varied from 0.43 to 0.65. The correlation coefficients of this data above the conventional threshold of 0.20. These numbers show that the structure of each item is the same. These results from the exploratory factor analysis were retested in a different sample of 167 participants using the confirmatory factor analysis. Examining the model’s fit indices, it was discovered that the model had a good fit based on Xz/SD, RMSEA, S-RMR, NFI, NNFI, GFI, and IFI values were all acceptable, the CFI value was great, and the scale’s construct validity was verified. The Psychological Cognitive, Behavioral Energy Scale, and Beck Depression Inventory showed a large negative correlation (r = 0.66, p = 0.000) in the analyses done to determine the concurrent validity of the scale. The General Attitudes and Beliefs Scale and the Basic Psychological Needs Inventory showed a moderate positive correlation (r = 0.36, p = 0.000) and a moderate negative correlation (r = 0.35, p = 0.000). These results demonstrate the compatibility validity of the Psychological Cognitive, Behavioral Energy Scale.

Developed by Artıran and Sapancı, this unpublished scale has been validated through exploratory and confirmatory factor analyses, demonstrating robust psychometric properties (Cronbach’s α = 0.85).

Analysis

The study comprised 55 patients who underwent open heart surgery at the Single Center Cardiovascular Surgery Clinic in Istanbul for coronary artery disease, aortic, and/or mitral valve pathology. All patients were released on schedule and without experiencing any significant issues during their care. There were two sets of measurements—preoperative and postoperative. Excluded from the study were individuals who required emergency care, were illiterate, or were unable to complete the exams because of factors including advanced age or surgical methods such as thoracotomy or beating hearts. Under general anesthesia, all patients in both groups underwent a median sternotomy technique and were attached to a heart-lung machine. A staff member categorized the respondents’ responses while they were answering the questionnaires. Each participant took 45 min to finish the questions.

Skewness and kurtosis values were analyzed in order to choose the best statistical techniques for the participant data, and it was found that the pertinent values fell within the range of the normal distribution. The basic psychological needs, motivation, and psychological energy of the individuals were compared before and after the surgery using a paired samples t-test. The analysis was done with the SPSS 27 software.

Results

In this study, pretest and post-test data for five different measures (Psychological Energy, Motivation, Competence, Relatedness, and Autonomy) were compared. Paired Samples t-Test results show that there are significant differences for all measures (p = 0.000). As shown in Table 1, results indicates that there was a statistically significant change between pre-test and post-test in each measure. Intensive care hospital stays: average 1.3 days, average hospitalization period 5.3 days.

Table 1.

Paired samples t-test results comparing psychological outcomes pre- and post-cardiac surgery (N = 55).

Variables	Pre-test	Post-test	t	df	p	Hedges’ g	Effect size
Variables	Mean (SD)	Mean (SD)	t	df	p	Hedges’ g	Effect size
Energy	365.27 (683.09)	286.00 (579.46)	6.39	54	0.000	0.86	Large
Motivation	392.72 (488.55)	313.63 (479.33)	9.53	54	0.000	1.28	Large
Competence	214.00 (310.67)	169.63 (279.52)	7.56	54	0.000	1.01	Large
Relatedness	318.18 (407.38)	224.72 (486.80)	9.42	54	0.000	1.26	Large
Autonomy	260.18 (335.81)	212.72 (325.15)	7.17	54	0.000	0.96	Large

As seen in Table 1, significant decreases with large effect sizes were observed in psychological energy, motivation, competence, relatedness, and autonomy after cardiac surgery, highlighting the importance of psychological support interventions.

Psychological energy

Hedges’ g = 0.86 levels are significantly lower, t(54) = 6.394, p = 0.000, since the pre-test mean (M = 365.273) on the energy measure was significantly higher than the post-test means (M = 286.000). The variation in the measures is matched by a significant effect size.

Motivation

The pre-test mean (M = 392,727) in the motivation measure was greater than the post-test means (M = 313,636). Hedges’ g = 1.28, t(54) = 9.537, p = .000, are significantly greater. This suggests that individuals’ motivation levels have significantly decreased. The size of each large effect measure is reflected in the difference between them.

Competence

The pre-test mean (M = 214,000) in the competence measure was greater than the post-test means (M = 169,636). Hedges’ g = 1.01, t(54) = 7.565, p = 0.000, significantly higher. The levels have significantly dropped. There is a significant impact from the variations in the measurements.

Relatedness

The pre-test mean (M = 318,182) in the relatedness measure was greater than the post-test means (M = 224,727). Much greater, Hedges’ g = 1.26, t(54) = 9.424, p = 0.000. Levels have dramatically dropped. A large effect size is corresponding to the difference between the measures.

Autonomy

Hedges’ g = 0.96 indicates a substantial decline in the autonomy measure, with the pre-test mean (M = 260.182) being significantly greater than the post-test mean (M = 212.727), t(54) = 7.172, p < 0.001. A big effect size is correlated with the measurement difference.

A 21-item Likert-type scale assessing autonomy, competence, and relatedness. The scale showed strong reliability in this study (Cronbach’s alpha = 0.90 overall; autonomy = 0.63, competence = 0.77, and relatedness = 0.82).

Conclusion

The purpose of scientific research is to obtain information that will help people. In this research, the aim was to examine the effects of heart and cardiovascular illnesses on psychological factors. In this study, it was tested how the concepts of basic psychological needs, motivation, and psychological energy, which are the subject of this research, are affected by heart surgery.

Based on the findings, it can be concluded that individuals who undergo heart surgery experience a decrease in positive values. Findings suggest that heart surgery may have a detrimental impact. It can be argued that significant alterations in physical well-being and medical procedures not only influence negative psychological factors like anxiety, depression, and fear, but also impact the positive aspects being considered.

There is a considerable body of research that has established a strong connection between depression and anxiety and negative health outcomes in individuals with cardiac conditions. Known organic risk factors for heart diseases include advanced age, gender, smoking, hypertension, abnormal lipid levels, diabetes, and previous infections. Psychosocial risk factors include low socioeconomic status, lack of social support and social isolation, stressful work and family life, depression, anxiety, hostility and anger, and type D personality.¹⁵ However, overlooking psychosocial risk factors may have negative effects on the disease prevention and treatment process.

Conversely, there is a paucity of literature that has examined the impact of positive psychological factors, such as optimism, on the health outcomes of cardiac patients.¹⁶ The positive perspective that has been effective in psychology in the last 20 years has enabled us to learn various new psychological variables. Among these, examining the concepts of life satisfaction, positive emotions, motivation, and psychological energy has both contributed to psychotherapy treatment processes and provides valuable information for physical health

The mental health of patients of heart surgery is still not the main focus and it seems that preparing patients mentally before surgery can lead to better outcomes after surgery. However, more research is needed to find out how to help individuals and to understand why some methods work better than others. The implementation of a Positive Psychology (PP) proved to be viable, well-received, and correlated with enhancements in the mental health of patients of heart surgery is still not the main focus and it seems that preparing patients mentally before surgery can lead to better outcomes after surgery.¹⁷ However, more research is needed to find out how to help individuals and to understand why some methods work better than others. The implementation of a Positive Psychology (PP) proved to be viable, well-received, and correlated with enhancements in a majority of psychological assessments within the population of cardiac patients.¹⁸ The implementation of positive psychology intervention was found to be viable and well-received among a group of individuals experiencing acute cardiac illness.^19
–21 Researchers have developed a different classification system to assess and increase personal motivational behaviors.²² We consider by supporting similar evaluations of patient psychology and motivation in such case studies, this classification will enable practitioners utilize these techniques to improve patient outcomes and support doctors discover more effective strategies for increasing patient motivation. Suggestions for future research, the integration of clinical practices for patients undergoing cardiac surgery may beneficial to center on promoting positive values for individuals undergoing heart surgery and providing valuable insights for healthcare professionals, practitioners, and caregivers interested in exploring the positive impacts of psychology in this setting majority of psychological assessments within the population of cardiac patients.²³ The implementation of positive psychology intervention was found to be viable and well-received among a group of individuals experiencing acute cardiac illness.²⁴ The psychotherapy approaches and practices that form the basis of resilience interventions include cognitive-behavioral therapy, acceptance and commitment therapy, mindfulness-based therapy, attention and interpretation therapy, problem-solving therapy, and stress inoculation. Furthermore, a number of training courses place an emphasis on cultivating one or more aspects of psychological durability.²⁵ Suggestions for future research, the integration of clinical practices for patients undergoing cardiac surgery may beneficial to center on promoting positive values for individuals undergoing heart surgery and providing valuable insights for healthcare professionals, practitioners, and caregivers interested in exploring the positive impacts of psychology in this setting.

A brief preoperative physical education program and a few weeks postoperative physical education course have both been found to have positive impacts on the neurophysiological condition of individuals who have had heart surgery. After heart surgery, patients’ cognitive performance may be enhanced by including physical education in their rehabilitative regimen.²⁶

Cardiac surgery significantly impacts patients’ psychological needs, motivation, and energy. Integration of validated positive psychology frameworks within clinical cardiac care could provide holistic support, promoting better mental health and recovery outcomes. Future research should further investigate these interventions and their mechanisms of effectiveness.

Limitations

The primary limitation of this study is its small sample size, limiting the generalizability of findings. Future research should replicate findings in larger and more diverse populations to validate results.

Additionally, the Motivation Scale used may not be a completely reliable measurement for some individuals. Furthermore, the patients in this sample varied in their health conditions post-surgery, with not all patients undergoing the same procedures.

In conclusion, the interplay between cardiovascular health and psychological well-being is a critical area of inquiry that warrants further exploration. By advancing our understanding of the psychological impacts of heart surgery, healthcare providers can better support patients holistically, ultimately leading to improved recovery experiences and quality of life. The integration of positive psychological frameworks into clinical practice not only has the potential to enhance patient outcomes but also to foster a more comprehensive approach to cardiac care that prioritizes mental health alongside physical health

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ekin Ilkeli

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