Attachment toward the informal caregiver and perception of the amount of support received after elective surgery

Abstract

This study investigated the relationship between attachment representations and help received from informal caregivers after elective surgery. In total, 98 respondents reported on their attachment toward their informal caregiver before surgery and on the amount of help they received from the caregiver after surgery. We found that anxious attachment was negatively related to all types of support except for ensuring and explaining medical care, whereas avoidant attachment was negatively related to emotional types of support. This study extends previous findings by demonstrating the influence of attachment representations on help received in the context of the unique help provided after elective surgery.

Keywords

attachment hospitalization informal caregiver social support surgery

Surgery is an intense and stressful event (Mitchell, 2003), and most patients need emotional as well as informational support afterward (Krohne and Slangen, 2005; Kulik and Mahler, 1989). Although hospital staff provide some of this help, informal caregivers who accompany patients during hospitalization provide a substantial portion of it (Auslander, 2011). However, we know little about the effect of the quality of the patient’s relationship with his or her informal caregiver and the amount of various types of support received. In this study, we hypothesized that the quality of a patient’s attachment toward the informal caregiver accompanying him or her during hospitalization for elective surgery affects the amount of support the patient receives after surgery.

Informal caregiving support during hospitalization

Most patients are accompanied by informal caregivers during hospitalization, ranging from 69 to 87 percent of all inpatients (Auslander, 2011; Cho and Kim, 2006) and reaching 96 percent in older adult populations (Gur-Yaish et al., 2013). This is a global and expanding phenomenon related to social norms, health policy issues, and hospital nursing-staff shortages (Cho and Kim, 2006; Lavdaniti et al., 2011; Li et al., 2000, 2003, 2004). Informal caregivers are usually the significant others in a patient’s life, and most patients report that parents, spouses, or adult children accompanied them during hospitalization (Auslander, 2011; Gur-Yaish et al., 2013; Levine et al., 2010).

Informal support during hospitalization is different from support provided in the community setting since it is limited in time and occurs in a setting unfamiliar to both patient and caregiver (Auslander, 2011). Four dimensions of informal support were identified in a study of older adults hospitalized in internal medical units: instrumental support (IS), or help with basic activities of daily living such as eating and drinking; supervision of instrumental support (SIS), provided by hospital staff; ensuring and explaining medical care (EEMC), or communication with the health-care team; and psychological support (PS), or attending to emotional needs and distress (Gur-Yaish et al., 2011). Because elective surgery is a painful and emotionally charged situation that disrupts regular functioning at least temporarily, we assumed that the same dimensions of support would also be relevant after elective surgery and with a population representing a broader age range.

Attachment and caregiving support

According to attachment theory, a basic strategy for coping with a stressful situation is to turn to one’s significant others for reassurance and comfort (Bowlby, 1988). However, past experience with significant others (generalized to the internal working model of attachment) causes some individuals to deactivate or hyperactive this strategy and to bias the perception of support. In particular, individuals with a more avoidant internal working model try to cope independently and to distance themselves from their attachment figures in emotionally charged situations (Mikulincer and Shaver, 2003). This theoretical postulation was supported in a study of avoidant individuals coping with war-related stress (Mikulincer et al., 1993), with romantically involved couples in a community setting (e.g. Fraley and Shaver, 1998; Mikulincer and Florian, 1995) and in laboratory experiments (e.g. Collins and Feeney, 2000; Simpson et al., 1992). Individuals with a more anxious attachment representation, on the other hand, are more likely to hyperactive their attachment system and to seek support from significant others (Mikulincer and Shaver, 2003). However, results regarding the anxiety dimension are mixed, with anxiously attached soldiers found to seek more support in times of stress (Mikulincer and Florian, 1995) but romantically involved anxious respondents found to seek less PS in times of stress (Simpson et al., 2002).

In this study, we investigated the relationships between attachment representations and the perception of the amount of support received from the informal caregiver in the stressful situation of the unfamiliar hospital setting after elective surgery. Most studies on attachment and support received have been conducted in laboratory settings where partners discuss personal problems (Fletcher et al., 2013) and with romantically involved couples (but see Kafetsios and Sideridis (2006), who studied attachment and social support in middle-aged and older adults). Our research is unique in studying support received in a real-life situation with various types of informal caregivers and various kinds of support. Because respondents who are higher in avoidant attachment distance themselves from emotionally charged situations, we assumed that they would report less support regarding the psychological type of support only and that we would find no relationships between the more “technical,” instrumental types of support. As for individuals higher in anxious attachment, because results from previous research are mixed, we hypothesized that we would find relationships with all kinds of support, but we did not hypothesize their direction. We also did not hypothesize the directionality of the relationships between attachment avoidance and EEMC because we did not know whether this kind of support is regarded as more “technical” or more emotional. In particular, we hypothesized the following:

Hypothesis 1. Attachment anxiety will be related to IS.

Hypothesis 2. Attachment anxiety will be related to SIS.

Hypothesis 3. Attachment anxiety and attachment avoidance will be related to EEMC.

Hypothesis 4. Attachment anxiety will be related to PS, and attachment avoidance will be related to lower levels of PS.

We assumed that all these relationships will remain significant after controlling for previously identified precursors of informal support during hospitalization: health status, time the caregiver stayed in the hospital, and number of children (Gur-Yaish et al., 2011). In addition, we controlled for length of hospital stay, category of caregiver, age, and gender.

Method

The study used a time-sequenced correlational design and was conducted from October to June 2012 in three surgery units in a large tertiary-care medical center in central Israel. Patients were recruited for the study at the preoperative clinic or in the surgery unit prior to undergoing their operations.

Participants were Hebrew-speaking, at least 40 years old, cognitively capable of signing a consent form, and scheduled for a surgical procedure requiring an estimated hospital stay of 24–72 hours. Only those who were accompanied by an informal caregiver and who planned to have that same caregiver with them after the surgery were invited to participate in the study.

Measurements

Level of attachment toward the informal caregiver was measured with a shortened version of the Experience in Close Relationships–Revised (ECR-R) instrument (Fraley et al., 2000).The shortened version includes eight statements from each dimension (avoidance and anxiety) that had the highest discrimination value in the original item–response analysis by Fraley et al. (2000) (discrimination values ranged from 1.74 to 2.79). Items include statements such as “I often worry that the informal caregiver doesn’t really love me” (anxiety dimension), and “I prefer not to show my informal caregiver how I feel deep down” (avoidance dimension). Responses were recorded on a scale of 1 (strongly disagree) to 7 (strongly agree). In a previous study, the shortened version had good reliability scores (.86 for the anxiety scale and .81 for the avoidance scale; Mandelman-Edry, 2011). Reliability in the present analysis was adequate, with .74 for the avoidance score and .75 for the anxiety score (minus two items that dropped the reliability for the anxiety score: “I often wish that my informal caregiver’s feelings for me were as strong as my feelings for him or her” and “I rarely worry about my informal caregiver leaving me”).

Informal caregiver support was measured with the Informal Assistance and Support for Hospitalized Older Adults (ICHOA) instrument (Gur-Yaish et al., 2011). Responses were scored using a Likert scale ranging from 1 (did not receive any help) to 5 (received help all the time). The ICHOA contains four subscales: (1) IS, (2) SIS, (3) EEMC, and (4) PS. Participants were instructed to report about help they received from the primary informal caregiver that they had specified in the preoperative stage of the study. Reliability for the subscales was good and ranged from .84 to .96.

Controls

Health status was assessed using Charlson’s comorbidity index (Charlson et al., 1987), which weights the number and severity of health conditions in patients. The index relies on information from patients’ medical files assessing 20 health conditions, each carrying a weighted score ranging from 1 to 6. Predictive validity of the index was shown to be high, using criteria such as likelihood of death and correlations with other established predictive systems and measures (Charlson et al., 1994).

Time the informal caregivers stayed in the hospital was measured in hours (average per day).

Length of hospital stay was measured in hours.

Caregivers were categorized according to whether they were spouses, children, or others.

Procedure

One of the researchers approached patients who were about to undergo one of the following surgeries: laparoscopic cholecystectomy, laparoscopic or open hernia repair, carotid artery endarterectomy, lumpectomy, or arteriovenous (AV) fistula. The potential participants were informed that the study was about informal caregiving and recovery after surgery. Of 122 eligible participants, 10 refused because they were not interested and 5 because they were too tensed before the surgery, which left 107 participants. After signing the consent form, participants filled out a form with background information and the attachment questionnaire. They filled it out privately, without the informal caregiver, other family members, or staff members being present. There were no significant differences in the main study variables between participants recruited in the preoperative unit (n = 24) and participants recruited in the surgical units (n = 83).

The data on amount of caregiver support received by participants using the ICHOA measure were collected 10–22 hours after surgery (M = 15.9 hours, standard deviation (SD) = 3.17 hours). The questionnaire was again filled out privately.

The final sample included 98 participants: 5 patients did not have a surgery date until data collection was to end, 2 had a new diagnosis that changed the proposed treatment, the informal caregiver of one respondent did not show up, and one refused to answer the questionnaires after surgery. Participation in the study was voluntary, and no compensation was offered.

Sample

The sample consisted of 44 men (45%) and 54 (55%) women; their mean age was 64.1 years (SD = 11.79 years, range 40–84 years). Of them, 40 percent had a high-school education (n = 39) and 46 percent (n = 45) had an academic degree (14% reported having an elementary school education); 77 percent (n = 76) were married or lived with a partner, and the vast majority had children (97%, n = 95). All participants lived in the community. In all, 57 percent reported that their spouse would accompany them after surgery and act as their primary caregiver, 35 percent were escorted by a child, 4 percent by a sibling, and 4 percent by others, such as a friend or a neighbor.

Ethical considerations

The study was approved by the Ethics Review Boards of the hospital and the Ministry of Health. All participants signed informed consent forms, and participation was voluntary and confidential.

Results

Table 1 presents means and SDs for all study variables.

Table 1.

Means and standard deviations for all study variables.

Study variables	Mean	SD	Range
Attachment anxiety	1.84	.87	1–5.5
Attachment avoidance	2.17	.77	1–5.1
Health status	1.90	2.03	0–10
Time the informal caregiver spent in the hospital	8.8	3.3	1–12
Number of children	3.41	2.06	1–12
Instrumental support (IS)	3.26	1.67	1–5
Supervision of instrumental support (SIS)	2.92	1.70	1–5
Ensuring and explaining medical care (EEMC)	3.80	1.30	1–5
Psychological support (PS)	4.15	.96	1.2–5

Respondents were in good health and reported that they experienced low levels of attachment avoidance and anxiety toward their informal caregiver, that they received medium to high levels of all types of support, and that their informal caregiver stayed with them most waking hours each day (see Table 1).

Preliminary correlational analyses between the controls (i.e. health status, time the caregiver stayed in the hospital, number of children, length of hospital stay, category of caregiver, age, and gender) and the attachment and caregiving variables revealed that age was related to PS and that the number of children and the number of hours the caregiver spent in the hospital were related to all types of support (see Table 2). In addition, univariate analyses of variance indicated that category of informal caregiver affected SIS (F(2, 98) = 3.79, p < .05), EEMC (F(2, 98) = 5.44, p < .05), and PS (F(2, 98) = 9.69, p < .0001). Scheffe post hoc comparisons revealed that others provided less of these types of support than did a spouse or a child. No differences were found between amounts of support received from a spouse or a child.

Table 2.

Correlational matrix with all study variables.

	1	2	3	4	5	6	7	8	9	10
1. Attachment anxiety
2. Attachment avoidance	.54***
3. Instrumental support (IS)	−.34**	−.20*
4. Supervision of instrumental support (SIS)	−.25*	−.02	.43***
5. Ensuring and explaining medical care (EEMC)	−.35**	−.34**	.45***	.58***
6. Psychological support (PS)	−.41***	−.40***	.40***	.41***	.66***
7. Health status	−.02	.08	−.04	.07	.00	.00
8. Time the informal caregiver spent in the hospital	−.18	−.09	.49***	.47***	.51***	.57***	−.03
9. Number of children	−.13	−.05	.24*	.31**	.26**	.20*	.06	.23*
10. Length of hospital stay	.13	−.04	.01	.04	−.02	.09	.00	.09	.18
11. Age	−.03	.00	−.04	.18	.10	.22*	.28**	.02	.06	.29**

To verify whether we can use parametric statistics, we investigated the normativity of the study variables. The analysis revealed that skewness (range −1.5 to 1.7) and kurtosis (range −1.1 to 3.6) of all study variables were acceptable (Afifi et al., 2007). To test the main study hypotheses, we ran four regression analyses for each kind of support (IS, SIS, EEMC, and PS). The first block of each regression contained the controls that were statistically significant in the preliminary analyses: age for PS, caregiver category (a dummy variable: 0 = spouse or a child; 1 = other) for all types of support except IS, and the number of children and number of hours caregiver spent in the hospital for all types of support. The second block contained levels of attachment anxiety and attachment avoidance toward the informal caregiver.

Hypothesis 1, asserting relationships between anxious attachment and IS, was supported by regression analysis (b = −.24, p < .05), indicating negative relationships. Regression analysis results also indicated that the number of hours the informal caregiver spent in the hospital was related to this type of support (b = .42, p < .0001).

Hypothesis 2, asserting relationships between anxious attachment and SIS, was supported by regression analysis (b = −.26, p < .05), indicating negative relationships. Regression analysis results also indicated that the number of hours the informal caregiver spent in the hospital was related to this type of support (b = .36, p < .0001).

Hypothesis 3, asserting relationships between anxious attachment and avoidant attachment and EEMC, was partially supported by regression analysis, with negative relationships found between avoidant attachment and EEMC (b = −.20, p < .05), but no significant relationships between anxious attachment and EEMC. The regression analysis results also indicated that the number of hours the informal caregiver spent in the hospital was related to this type of support (b = .41, p < .0001).

Hypothesis 4, asserting relationships between anxious attachment and PS and negative relationships between avoidant attachment and PS, was supported by regression analysis, with negative relationships between anxious attachment and PS (b = −.21, p < .05), and approaching significant negative relationships between avoidant attachment and PS (b = −.17, p = .06). The regression analysis results also indicated that the number of hours the informal caregiver spent in the hospital was related to this kind of support (b = .38, p < .0001) and that respondents received less of this support from others (e.g. friends, neighbors, or siblings; b = −.28, p < .001).

Discussion

Surgery is a stressful life event that challenges individuals both physiologically and psychologically. Support from informal caregivers might help individuals meet this challenge successfully. In this study, we investigated whether the quality of a patient’s attachment to informal caregivers affects his or her perception of the amount of help received. We found that anxious attachment to the informal caregiver was related to reporting of less IS, less SIS, and less PS from the informal caregiver. Avoidant attachment toward the informal caregiver was related to reporting less EEMC and PS. These relationships were significant after controlling for the potentially intervening variables.

Our findings regarding anxious attachment support the notion that individuals are predisposed to appraise the support they receive in ways that are consistent with their relationship history and past experiences (Collins and Feeney, 2004). This distortion of perception can operate in three different ways. First, anxiously attached respondents may be inefficient in signaling their needs, especially in this unusual situation and context. Second, because of their inefficient signaling of distress, their informal caregivers may not provide help efficiently. Finally, anxiously attached respondents may exaggerate the inefficiency of their informal caregivers and translate their disappointments to reporting less support provided. Future study that observes the actual help exchange and its efficiency could further investigate these potential explanations in detail and further elucidate the relationships between perceived and actual support.

The tendency of avoidant respondents to avoid reassurance and support in times of emotional need (Simpson et al., 1992) was supported in this study: respondents higher in avoidant attachment reported receiving less PS. Interestingly, avoidant attached individuals also reported less EEMC, which suggests that this type of support may also put them in an emotionally needy position, which they try to avoid. We found no relationship between avoidant attachment and IS. Similar to laboratory experiments (Simpson et al., 2007), respondents higher in avoidant attachment were found to feel more comfortable with the more “technical” IS.

The findings that only a few respondents were accompanied by “other” informal caregivers (i.e. not a partner or child) and that they reported that other informal caregivers provided less support in all domains except IS were not the main focus of this study; however, they are congruent with past research suggesting that in adulthood and old age, spouses and older children are the preferred informal caregivers (Alsafran et al., 2013; Gur-Yaish et al., 2013). This suggestion should be studied in a bigger sample, taking a close look at different age groups with more “other” informal caregivers.

This study also contributes to the validity of the ICHOA. The fact that respondents reported high level of all types of support after surgery demonstrates the relevancy of the ICHOA as a measure of informal caregiving in different contexts in the hospital setting.

Past research revealed the relationships between attachment representations and support received (Collins and Feeney, 2000; Mikulincer et al., 1993, Mikulincer and Florian, 1995; Simpson et al., 1992, 2002). Our study extended previous research by demonstrating the relevance of attachment representations to support received in a real-life situation. In addition, our findings were obtained from a diverse-aged population with different informal caregivers and different surgeries. The heterogeneity of our sample as well as the use of controls for intervening demographic and health variables emphasizes the importance of attachment representation to the perception of receiving support.

Limitations

The sample was a convenience sample from one medical center in Israel, a country with a familial culture with close geographical proximity and contact between family members (Katz and Lavee, 2005). Past research has demonstrated the importance of cultural context to social support (Park et al., 2013) Therefore, the study should be replicated in different cultures, especially in more individualistic ones with higher divorce rates and fewer children.

In this study, we investigated only patients’ reports of their relationships with their informal caregivers and the amount of support provided, even though previous research has suggested that attachment relationships are dyadic in nature and that the informal caregiver’s attachment style might play a significant role in the amount of help exchanged (Collins and Feeney, 2000). Thus, future research that takes into account the perspective of informal caregivers might provide a more complex picture of the relationships between attachment and support. In addition, children and adults form multiple attachment relationships (Howes and Spieker, 2008), and therefore, it is important to study attachments to networks of informal caregivers and their effect on the amount of support they provide. A closer look at different age groups of respondents and informal caregivers could also be an area for future research.

Conclusion

This study extends previous research that pointed out the relevance of attachment representations to health-related outcomes (Schmidt et al., 2012) and demonstrated the importance of attachment representations to help received during hospitalization after elective surgery. Future research could study actual health outcomes such as pain after surgery and time to recover.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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