The Spanish Journal of Psychology Copyright 2012 by The Spanish Journal of Psychology

2012, Vol. 15, No. 3, 1361-1370 ISSN 1138-7416

http://dx.doi.org/10.5209/rev_SJOP.2012.v15.n3.39421

Impact of Acceptance-Based Nursing Intervention

on Postsurgical Recovery: Preliminary Findings

María Dolores Fernández1, Carmen Luciano2, and Sonsoles Valdivia-Salas3

1Hospital Torrecárdenas (Spain)
2Universidad de Almería (Spain)
3Universidad de Zaragoza (Spain)

Research has shown that teaching individuals to experience pain and anxiety as inevitable products of the actions they freely
and responsibly undertake yields healthier reactions to suffering. This preliminary study assesses whether a brief acceptance-
based psychological intervention along with the usual presurgical protocol for a laparoscopic cholecystectomy will produce
healthier reactions to postsurgical pain, and will reduce anxiety, duration of postsurgical hospitalization, and demand of analgesics.
After admission, screening, and consent procedures, we assessed pain and anxiety. Patients in the experimental condition (n =
6) then received a brief acceptance-based nursing intervention addressing the individual meaning of surgery, and including a
metaphor and defusion practice, along with routine care. Patients in the control condition (n = 7) received routine care only.
Twenty-four hr following the intervention, surgery took place. Pain, anxiety, and patients’ demand for analgesics were assessed
24 hr or 48 hr after surgery. All six experimental patients, as compared to three of seven control patients, demanded fewer
analgesics and left the hospital within 24 hr or 48 hr from surgery even in the presence of frequent and/or intense pain. Anxiety
slightly decreased in the experimental patients. The brief acceptance-based intervention was effective in improving postsurgical
recovery. These preliminary findings support the potential of this type of intervention as a cost-effective strategy to be implemented
in the sanitary context.
Keywords: postsurgical recovery, acceptance, anxiety, pain, cholecystectomy.

Se ha demostrado que enseñar a los individuos a experimentar el dolor y la ansiedad como productos inevitables de las
acciones que ellos, libre y responsablemente, deciden emprender, produce menos sufrimiento. El estudio se llevó a cabo en
un hospital. Este estudio, preliminar, examina los efectos de un protocolo breve basado en la aceptación en la mejora de la
recuperación postquirúrgica tras una colecistectomía laparoscópica, entendida como: reacciones más saludables al dolor y
reducción de la ansiedad, duración de hospitalización y demanda de analgésicos. Una vez completada la admisión, selección
de participantes, y obtención del consentimiento, se tomaron medidas de dolor y ansiedad. Los pacientes experimentales (n
= 6) recibieron entonces el protocolo, que incluía la evaluación del significado individual de la cirugía, una metáfora y práctica
de defusion, junto con los cuidados rutinarios preoperatorios. Los pacientes controles (n = 7) recibieron cuidados rutinarios
preoperatorios solamente. La cirugía se llevó a cabo veinticuatro horas tras la implementación del protocolo. Pasadas 24 o 48
horas desde la cirugía, se tomó una segunda medida de dolor, ansiedad y demanda de analgésicos. El protocolo implementado
mejoró sensiblemente el postoperatorio de los pacientes experimentales: todos, en comparación con tres de los siete controles,
demandaron menos analgésicos, recibieron el alta a las 24 o 48 horas tras la cirugía, y puntuaron más bajo en ansiedad.
Estos resultados preliminares apoyan el potencial de este tipo de intervenciones para ser implementadas en el contexto sanitario.
Palabras clave: recuperación postquirúrgica, aceptación, ansiedad, dolor, colecistectomía.

Part of this material was presented at the I World Congress of the Association for Contextual and Behavioral Science, London,
July 2006. The research was conducted in partial fulfilment of Mª Dolores Fernández’s master degree (2005) under the supervision of
Carmen Luciano. Research for this paper was partially funded by project HUM-1093 and SEJ2008, granted to Carmen Luciano. The
authors thank the hospital staff for their assistance during data collection.
Corresponding concerning this article should be addressed to Sonsoles Valdivia-Salas. Departamento de Psicología y Sociología,
Universidad de Zaragoza. Campus Ciudad Escolar, Teruel 44003 (Spain). Phone: +34 978 645343. Fax: +34 978 618103. E-mail:
sonsoval@unizar.es - sonvaldivia@gmail.com

1361
1362 FERNÁNDEZ, LUCIANO, AND VALDIVIA-SALAS
Uncertainty, worries, and fears are common reactions to
an upcoming surgical procedure. The occurrence of this
conjoint of feelings and thoughts is common across
individuals, but particular individuals’ thoughts, fears, and
reactions will be different, and will affect differently the
postsurgical recovery. The role of psychological factors in
the recovery process is so well documented that psychological
preparation for surgery has become a usual practice.
In a landmark study, Egbert, Battit, Welch, and Bartlett
(1964), found that patients receiving presurgical instructions
and encouragement by a member of the medical team
reported less pain and demanded fewer narcotics than
controls. These initial findings stimulated further research
on the benefits of different coping strategies in terms of a
faster and smoother, hence less expensive, postsurgical
recovery. At present, the two main targets of pre-surgery
psychological preparation are pre-surgical anxiety and
postsurgical pain (e.g., Caumo, Hidalgo et al., 2002; Caumo,
Schmidt et al, 2002; Coll & Ameen, 2006; Lin & Wang,
2005; Roykulcharoen & Good, 2004), and the protocols
implemented derive from the cognitive-behavioral approach.
The prototypical intervention comprises three components,
namely: 1) information about the surgery and its physical
and emotional consequences; 2) emotional support and
cognitive strategies directed towards the expression of
emotions; and 3) training of coping skills (e.g., search for
emotional support, adequate compliance to medical advice,
etc.) and stress-reduction (e.g., relaxation, distraction,
cognitive restructuring). Within this perspective, there is
evidence suggesting that nursing interventions aimed at
decreasing presurgical anxiety and improving patients’ pain
attitude, may reduce postsurgical pain. For instance, Lin and
Wang (2005) examined the effects of presurgical nursing
intervention for pain on patients’ presurgical anxiety, pain
attitude and postsurgical pain as well as interference of pain
in daily activities, dosage of analgesics, start of out-of-bed
activities, and length of postsurgical hospitalization.
Approximately 24 to 72 hr before abdominal surgery, a nurse
presented a 20-30 min intervention to the patient and the
primary caregiver that (1) explained the causes of
postsurgical pain; (2) addressed the importance of pain
management and early out-of-bed activities; (3) taught how
to decrease pain with non-medicinal methods; (4) encouraged
demand of analgesics if pain was present; and (5) described
the importance of expressing feelings and concerns.
Compared to control participants, patients who received the
protocol showed a markedly decrease of presurgical anxiety,
postsurgical pain, and interference of pain. Likewise,
experimental patients showed better pain attitude, and started
1 A detailed description of how humans establish relations among events and derive worries, fears, and similar, exceeds the scope
of the present paper (interested readers might check the relational learning and transformation of functions literature, for example,
Hayes, Barnes-Holmes, & Roche, 2001).
out-of-bed activities sooner. Length of hospitalization and
demand of analgesics, did not differ between groups.
However, teaching patients to manage their pain and anxiety
to the point of leaving the hospital sooner and demanding
fewer analgesics is key to decrease surgery costs.
Having worries or fears when confronted to a stressful
or painful event is a natural product of being verbal
organisms (Hayes, Wilson, Gifford, Follette, & Stroshal,
1996; Luciano, Rodríguez, & Gutiérrez, 2004). In the case
of surgery, being verbal involves establishing life directions
which are personally meaningful (e.g., “I want to be part
of my children’s life”), establishing relations between such
life directions and the changes the surgery may bring along
(being able to engage in personally valued actions), and
deriving worries (e.g., “surgery might not go well,” or “after
surgery I might not be able to take good care of my
children”).1 Research has shown that trying not to have
worries and painful thoughts and emotions is extremely
difficult in some circumstances. Indeed, the very attempt to
somehow down-regulate them may turn them into highly
accessible contents amplifying its power (e.g., Wegner, 1994),
and hence increasing the patient’s suffering (Hayes et al.,
1996). Contrarily, accepting painful thoughts and emotions
yields positive results (for the latest review, see Ruiz, 2010).
In the clinical arena, acceptance means letting go of the
battle with thoughts, emotions, and memories that the person
experiences as aversive and barriers to action (Hayes, Luoma,
Bond, Masuda, & Lillis, 2006). Contrarily to toleration or
resignation, acceptance entails taking an active and
courageous stance that undermines the notion that one must
change what one thinks and feels in order to live better.
While recognizing that humans cannot control how they
think or feel in a particular moment (because the nature of
the mind or language is fundamentally about relating, sense
making, and deriving new relations), however, they can
control what they do in the presence of particular thoughts
and feelings. A central idea within the acceptance-based
interventions is that neither wanted or unwanted thoughts
are barriers to effective action and, in fact, can be present
while the person behaves in personally valued directions.
From this premise, the ultimate goal of acceptance-based
interventions is to alter rigid and inflexible patterns of
reacting to thoughts and feelings (e.g., suppression,
avoidance, distraction) in favor of flexible responding. The
choice about how to respond to thoughts and sensations
(either avoidance or acceptance) becomes a matter of
workability towards valued life goals and directions.
The benefits of acceptance over control rationales have
been demonstrated in coping with laboratory induced panic-
 ACCEPTANCE IN POST-SURGERY RECOVERY
like symptoms (Eifert & Heffner, 2003; Levitt, Brown,
Orsillo, & Barlow, 2004; Spira, Zvolensky, Eifert, &
Feldner, 2004) and pain (e.g. Gutiérrez, Luciano, Rodríguez,
& Fink, 2004; Hayes, Bissett et al., 1999; Masedo & Esteve,
2007; McMullen et al., 2008; Páez-Blarrina, Luciano,
Gutiérrez, Valdivia-Salas, Ortega et al., 2008; Páez-Blarrina,
Luciano, Gutiérrez, Valdivia-Salas, Rodríguez et al., 2008).
Research has also moved from analogue laboratory studies
to clinical settings. The efficacy of acceptance based
protocols has been demonstrated in the treatment of such
diverse medical conditions as chronic pain (e.g. McCracken,
Vowles, & Eccleston, 2005; Vowles & McCracken, 2008;
Wicksell, Melin, Lekander, & Olsson, 2009), diabetes
(Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007), obesity
(e.g., Forman, Butryn, Hoffman, & Herbert, 2009),
decreasing self harm in women with borderline personality
disorder (Gratz & Gunderson, 2006), smoking cessation
(Gifford et al., 2004; Hernández-López, Luciano, Bricker,
Roales-Nieto, & Montesinos, 2009), improving the quality
of life for individuals with epilepsy (Lundgren, Dahl, &
Hayes, 2008; Lundgren, Dahl, Melin, & Kies, 2006) and
breast cancer (Páez-Blarrina, Luciano, & Gutiérrez, 2007),
and undermining the believability of delusions and
decreasing the frequency of rehospitalization in individuals
with schizophrenia (Bach & Hayes, 2002; Gaudiano &
Herbert, 2006). There is no evidence, however, of the
efficacy of acceptance-based strategies in the context of
post-surgical recovery. The present study aims at filling
this gap by examining the benefits of incorporating a brief
acceptance-based nursing intervention to routine care 24
hr prior to a laparoscopic cholecystectomy (LC). LC is the
surgical removal of the gallbladder, and requires several
small incisions in the abdomen to allow the insertion of
operating ports through which surgical instruments and a
video camera are placed into the abdominal cavity. LC is
the first-choice of treatment for gallstones and inflammation
of the gall bladder, conditions that are accompanied by
intense pain in the abdomen. This procedure yields fewer
complications than open cholecystectomy and most patients
return to their daily routine in about one week.
In our study, the benefits of the brief acceptance-based
nursing intervention on LC post-surgical recovery are assessed
in terms of duration of postsurgical hospitalization, postsurgical
pain, demand of analgesics, and anxiety. It is hypothesized
that discharge will be earlier and analgesic demand will
decrease regardless of the participants’ level of pain and
anxiety, in those who received the nursing intervention.
Method
Participants
We screened all patients who were scheduled to undergo
LC during the week the protocol was to be implemented.
1363
A total of 20 patients were initially recruited. Five of them
did not meet the inclusion criteria (see Procedure) and were
excluded, and two refused to participate in the trial. The
final sample included 13 patients, 11 women, aging 29 to
70 years (M = 52.4, SD = 13.4).
Experimental Setting, Design, and Measures
All data were collected in the patient room. Given the
reduced number of scheduled LC during the week the
treatment was to be implemented and in order to ensure
that enough patients received the intervention, patients were
assigned to either the experimental or the control condition
by order of admission. The first six eligible patients were
assigned to the experimental condition. The remaining seven
patients were assigned to the control condition. To ensure
consistency in the interventions, the same nurse attended
all recruited patients and implemented the nursing
intervention following training in acceptance-based
interventions with the second author.
We first assessed self-reported frequency and intensity
of pain, and anxiety (admission assessment). Patients in the
control condition then received treatment-as-usual (TAU)
while patients in the experimental condition also received
an acceptance-based nursing intervention (ANI). Surgery
took place 24 hr after the nursing intervention. Twenty four
or 48 hr after surgery, we assessed self-reported frequency
and intensity of pain, anxiety, and analgesics consumed
(post-surgery assessment). The same measures were
collected at discharge if patients stayed hospitalized beyond
48 hr. A detailed description of these and other measures
is provided next.
Self-reported frequency and intensity of pain. Frequency
was measured by using a visual analogue scale (VAS)
consisting of a 10 cm horizontal line from 0 (never pain)
to 10 (constant pain). A 10 cm VAS ranging from 0 (no
pain) to 10 (severe pain) was used to assess pain intensity.
Anxiety. State Trait Anxiety Inventory (STAI, Spielberger,
Gorsuch, & Lushene, 1970) was used. The STAI includes
two 20-item self-report scales that assess state (STAI-S) and
trait (STAI-T) levels of anxiety. Respondent indicates how
much each statement reflects how s/he feels at the present
moment (STAI-S), or how s/he generally feels (STAI-T) on
four-point Likert-type scales (Roemer, 2001). Scores range
from 0 to 60 on each scale.
Duration of postsurgical hospitalization. The number
of days of hospitalization from surgery to discharge was
collected from each patient’s medical records. Discharge
was notified by the physicians, who were blinded to the
condition patients were assigned to.
Believability of pain. Believability has been established
as a good differential variable between acceptance-based
and cognitive control-based protocols in the literature on
coping with pain (Gutiérrez et al., 2004; Hayes et al.,
2006; McCracken et al., 2005; Wicksell, Dahl, Magnusson,
& Olsson, 2005). In those studies, believability was
1364 FERNÁNDEZ, LUCIANO, AND VALDIVIA-SALAS
conceptualized as the degree to which pain served as a
barrier to continue performing the pain task. In the present
study, we calculated believability of pain by assessing
duration of post-surgery hospitalization (24 or 48 hr) in
the presence of self-reported moderate to high frequency
and/or intensity of pain (i.e., 7 or higher in the VAS)
Demand of analgesics. Non-steroidal anti-inflammatory
drugs (NSAID) are the usual treatment of choice for
postoperative pain in cases when it is not highly resistant.
The grams (gr) of NSAID diluted in physiological saline
intravenously administered 24 hr after surgery (in the case
patient was discharged one day after surgery) or during the
second day after surgery were collected from the medical
records.
Treatment-As-Usual
Patients in the control condition received routine care,
or treatment-as-usual (TAU). This involved the provision of
basic information about the surgery, its potential risks, and
the usual course of recovery. It lasted 10 min approximately
and was introduced right after the admission assessment.
Acceptance-based nursing intervention
Patients in the experimental condition received the
acceptance-based nursing intervention (ANI), in addition
to TAU. The intervention was an adaptation of the main
components of Acceptance and Commitment Therapy (ACT;
Hayes, Strosahl, & Wilson, 1999, 2011; Wilson & Luciano,
2002) to the treatment of the pain and worries about the
surgical procedure, and included: (a) clarification of the
personal meaning of undertaking surgery, (b) normalization
of fears and worries about the surgery, and (c) exposure
practice to such fears and worries to potentiate the
differentiation between the person who is having the fears
from the fears and worries themselves. The whole
intervention took about 30 minutes to complete. The main
components of the protocol are summarized below (a literal
transcript is available from the authors):
(a) Making explicit the personal meaning of undertaking
surgery. The purpose of this component was identifying
the aspects in the patient’s life that were “stuck” because
of the side effects of a dysfunctional gall bladder. In other
words, why undergoing surgery was important for the
patient; what personal “doors” would the surgery open;
which were the things that the patient saw himself doing
weeks or months from the surgery; which were the most
affected areas and how did the patient believe they would
improve upon recovery.
(b) ormalization of fears, worries and pain. The nurse
proceeded making explicit that the surgery had pros and
cons and used a metaphor to depict what going through
surgery might feel like. The nurse said: “This process is like
walking a road that is important for you, still it has stuff
you do not like, such as stones, sand, nails, etc. You want
to take the road because of all the things you will probably
get later in that direction, however, going through the road
involves having to face the stuff you do not like. Your fears
and worries are like those stones, they are part of the surgery,
of the road, that will probably allow you to get the things
you value in your life.” Following the same argument, pain
was presented as another stone in the road. “If the pain is
there when you open your eyes after the surgery, then it
means that everything has gone as expected, the effects of
the anaesthesia have disappeared, and you are progressing
through the normal postsurgical process.” The nurse then
asked the patient to say out loud their fears and worries so
that s/he might watch them. She said: “Similar to when we
are planning to cook, before going through surgery it is
important to take a look at the ingredients we have. You tell
me, what do you fear about the surgery? What are you
worried about?” The nurse wrote each fear in a piece of
paper and put them all on a table in front of the patient.
(c) Exposure to and defusion from fears and worries.
The nurse then asked the patient to close their eyes, breath
deeply and notice the first fear/worry that came to their
minds. If the fears about the surgery did not show up, the
nurse read the first fear that she had written on the pieces
of paper. Then she said, “Stay with that thought for a
moment, picture it written in a big stone, and look at it…
Notice all the feelings and emotions this thought brings
along. Stay with those feelings for a moment while you
ask yourself what you want and why you are here… Now
let other fear come, stay with it, picture it written in a big
stone, look at it while you ask yourself what you want and
why you are here…” The same followed with three more
thoughts. When the exercise finished, the patient was
encouraged to repeat it every time a fear/worry came and
disturbed her before and after the surgery.
Procedure
Admission procedures, pre-screening, and informed
consent. We obtained the hospital Ethics Committee’s
approval for the proposed study. After admission, and when
the patient was already in his/her room, the nurse
administered a screening interview. For inclusion in this
study, it was necessary that patients (1) did not present any
infectious disease (e.g., tuberculosis, hepatitis, AIDS),
autoimmune diseases, allergies, asthma, immune
deficiencies, transplants, haemophilia, and blood diseases;
and (2) did not present any developmental disability. The
nurse described to eligible patients the possibility of
participating in a study to help them deal with their worries
about the surgery, as well as their right of refusal. The study
started only upon obtaining informed consent to participate.
Admission assessment, protocol implementation, and
post-surgery assessment. Patients completed the STAI (both
scales), and the two VAS measures (intensity and frequency
of pain). When finished, the nurse proceeded to provide
the patient with basic information about the surgical
 ACCEPTANCE IN POST-SURGERY RECOVERY 1365

procedure, and then implemented the protocol in the ANI

Individual scores and average calculation of self-reported pain intensity (Int) and frequency (Freq), analgesics administered in grams (gr), and duration of post-
condition. In the TAU condition, the nurse provided the

Median

5.50
7.00
4.50
7.00
—
—
6.00
6.00
12.00
72.00
patient with basic information about the surgical procedure
and left the room.
Within 24 hr if the patient was discharged, or 48 hr
following surgery, all patients completed the STAI-S and

4.71
6.78
5.78
6.78
1.50
2.37
6.0 5.14
6.0 5.14
12.0 10.28
72 92.57
M
the VAS for the assessment of intensity and frequency of
pain. The same measures were collected at discharge when

P13

0.0
0.0
10.0*
5.0*
3.0
3.0
it occurred beyond 48 hr following surgery. All patients
were fully debriefed at the moment of discharge.

P12

5.5
5.5
1.5
9.0*
—
—
2.0
2.0
4.0
48
Reliability and data analysis
The acceptance-based protocol was scripted word-for-

TAU

P11

7.5
5.0
2.5 10.0*
7.0* 5.0*
0.0
0.0
6.0
6.0
12.0
168
word, and the protocol administration was audio-taped. Two
independent observers rated nurse adherence by means of

P10

0.0
10.0

1.0
4.5
4.0
4.0
8.0
72
a 0-10 scale. Mean adherence was 9.5 (SD = ,51), with an
inter-observer agreement of 95% (kappa [w] = .91).

P9

2.0
10.0
2.0
7.0*
2.0
2.0
6.0
6.0
12.0
192
SPSS for Windows 16.0 software was used for statistical
analyses. Descriptive statistics such as mean (M), median,
standard deviation (SD), and frequencies were calculated.

P8

8.0 10.0
7.0 10.0
4.5 10.0*
4.5 10.0*
—
—
6.0
6.0
12.0
48
We ran Mann-Whitney U tests to test for differences between
conditions in assessments of self-reported pain, anxiety,

P7

—
—
6.0
6.0
12.0
48
duration of postsurgery hospitalization, and analgesics
consumed. We ran Wilcoxon Rank tests to test for differences
between pre and post assessments of pain and anxiety on
each condition. Lastly, Fischer’s exact tests were run to
Median

assess for differences between conditions in the percentage 2.50

9.00
6.25
10.00
—
—
6.00
4.00
7.00
36.00
of participants showing a reduction in anxiety.

Results
3.17
7.75
5.92
8.58
—
—
5.33
4.00
7.33
48 36.00
M

Pain reports. Table 1 shows that at admission, patients’

* 7 or higher in the VAS. — Patients were discharged 24 or 48 h after surgery.

P6

4.5
9.5
8.0*
10.0*
—
—
6.0
4.0
10.0
reported pain intensity in the ANI condition ranged from 0
as in patient 4 (P4) to 8.5 (P3) (M = 3.17, SD = 3.04), and
P5

2.0
10.0 10.0
2.0
10.0* 10.0*
—
—
6.0
2.0
8.0
48
from 0 (P10 and P13) to 10 (P8) (M = 4.71, SD = 4.06) in
the TAU condition. As for the reported frequency of pain,
ANI

in the ANI condition it ranged from 4 (P2) to 10 (P4, P5)

P4

0.0

10.0

—
—
2.0

2.0
24

(M = 7.75, SD = 2.77), and in the TAU condition it ranged

from 0 (P13) to 10 (P9, P10) (M = 6.78, SD = 3.69). Mann-
P3

8.5
8.5
9.0*
9.0*
—
—
6.0

6.0
24

Whitney U tests revealed no significant differences between

conditions in pain intensity (p = .61) or frequency (p = 1.0)
P2

3.0
4.0
2.0
2.5
—
—
6.0

6.0
24

at admission. As also shown in Table 1, 24 hr or 48 hr after

surgery, patients in both conditions reported a slight increase
of pain intensity. In the ANI condition, it ranged from 2
surgical hospitalization (Discharge)

P1

1.0
4.5
4.5
10.0*
—
—
6.0
6.0
12.0
48

(P5) to 10 (P4) (M = 5.92, SD = 3.55). In the TAU condition,

pain intensity ranged from 1.5 (P12) to 10 (P8, P11, and
P13) (M = 5.78, SD = 4.05). Regarding frequency of pain,
Total at 48h
2nd day

in the ANI condition it increased slightly (M = 8.58, SD =

Freq

Freq

Freq
24h
Int

Int

Int

3.0) with scores ranging from 2.5 (P2) to 10 (P1, P4, P5,
and P6); while it remained the same as at admission for
patients in TAU condition (M = 6.78, SD = 2.12), with scores
Admission

24 or 48hr

Discharge (hr)
Discharge

ranging from 4.5 (P7) to 10 (P8). Wilcoxon Rank tests

Drugs (gr)

revealed non-significant changes from admission to post-

Table 1

Pain at

surgery in any of the variables in both conditions (ps > .16).

1366 FERNÁNDEZ, LUCIANO, AND VALDIVIA-SALAS

Likewise, Mann-Whitney U tests revealed that the average
intensity and frequency of pain 24/48 hr following surgery
did not differ significantly (p = .88, and p = .12, respectively)
between conditions.
Anxiety. Table 2 includes patients’ level of anxiety
(as measured with the STAI), across procedural phases
(scores of P1 were not available due to procedural
problems). Overall, responses to the STAI-T were within
normal limits for a nonclinical sample. Patients 6 and 8
constituted the only exceptions, with scores falling above
percentile 96 (46 and 44, respectively). The reported
levels of state anxiety, as measured with the STAI-S, were
within normal limits for all patients except for P6 (36),
whose score fell above percentile 80. Mann-Whitney U
tests did not revealed significant differences between
conditions in the STAI-T (p = .87) nor in the STAI-S at
admission (p = .57). Twenty-four or 48 hr following
surgery, all patients, except for P6 (ANI condition) and
P8 (TAU condition), scored within normal limits in the
STAI-S. However, we note that four of five patients (80%)
in the ANI condition (P2, P3, P4, and P5), and three of
seven patients (42.86%) in the TAU condition (P7, P9,
and P13) reported less anxiety than at admission (p =
.29, Fischer’s exact test). At discharge, except for
participants 6 and 8, who had shown high levels of
anxiety during the whole process, all patients showed
anxiety levels within normal limits, not differing
significantly between conditions (p = .42).
Duration of post-surgical hospitalization. None of the
patients in either condition presented complications related
to the surgical procedure that could have affected the
duration of post-surgery hospitalization. On average, ANI
patients stayed in the hospital for 36 hr after surgery while
TAU participants stayed for 92.57 hr. This difference
reached statistical significance (p = .01). As shown in Figure
1 (see also Table 1), three (P2, P3, and P4) out of six
patients (50%) in the ANI condition left the hospital within
24 hr from the surgery and the rest were discharged within
48 hr from the surgery. In the TAU condition, however, no
patient left the hospital within 24 hr, and only three (P7,
P8, and P12) out of seven (42.8%) were discharged 48 hr
from the surgery.
Believability of pain. As shown in Table 1, of the five
patients in the ANI condition who reported high levels of
pain intensity and/or frequency after surgery (i.e., 7 or
higher in the VAS), two left the hospital within 24 hr (P3
and P4) (40%) and three left the hospital 48 hr after surgery
(P1, P5, and P6) (100%). In the TAU condition, however,
no patient left the hospital 24 hr after the surgery and only
two (P8 and P12) out of six patients (33.3%) who reported
high levels of pain were discharged after 48 hr had passed
since the surgery.
Analgesics. Table 1 shows the grams of intravenous
NSAID that patients in ANI and TAU conditions consumed
during the first 24 hr after surgery (if discharged at 24 hr) or
during the second day after surgery. On average, the amount
of analgesics did not differ during the first 24 hr (M = 5.33
and M = 5.14, respectively for the ANI and TAU conditions,
p = .70). Considering the total amount of pain medication at
48 hr after surgery (when all ANI patients left the hospital),
ANI patients had consumed 44 gr (M = 7.33) while TAU
patients had consumed 72 gr (M = 10.28) (p = .09).

Table 2
Individual scores in the State-Trait Anxiety Inventory for patients in AI and TAU conditions throughout the procedure
STAI-T STAI-S

Admission Admission 24/48h Discharge

P1 (ANI)a – – – = –
P2 (ANI) 15 23 14 14
P3 (ANI) 19 20 10 = 10
P4 (ANI) 8 30 19 = 19
P5 (ANI) 30 18 15 = 15
P6 (ANI) 46 36 47 = 47
P7 (TAU) 6 21 2 = 2
P8 (TAU) 44 29 38 = 38
P9 (TAU) 31 22 5 29
P10 (TAU) 28 26 27 17
P11 (TAU) 10 19 19 10
P12 (TAU) 25 14 16 = 16
P13 (TAU) 30 25 22 4
aDue to procedural issues, no STAI data were collected from P1.
STAI-T = State Trait Anxiety Inventory –Trait scale.
STAI-S = State Trait Anxiety Inventory –State scale.
 ACCEPTANCE IN POST-SURGERY RECOVERY
Figure 1. Percentage of patients in the ANI condition (n = 6, solid line) and TAU condition (n = 7, dotted line) who were discharged
within 24 hr or 48 hr from the surgery. The percentage of patients reporting 7 or above in the VAS for pain are also shown. ANI =
Acceptance-based Nursing Intervention. TAU = Treatment As Usual.
Discussion
The purpose of the present study was to examine the
benefits of incorporating brief acceptance-based pre-surgical
nursing intervention to routine care on postsurgical recovery.
The most salient and relevant result is that all patients in
the ANI condition, as compared to the TAU condition, left
the hospital within 48 hr after the surgical procedure (half
of them did it 24 hr after surgery). Also relevant, all but
one patient in ANI left the hospital in spite of being in
moderately intense and frequent pain. In contrast, although
TAU patients reported less post-surgical pain, none left the
hospital within 24 hr after surgery and only three of seven
patients (42.8%) did it within 48 hr. Another finding is that
more patients in the ANI condition, as compared to TAU
condition, reported lower levels of anxiety during post-
surgical recovery. Although the decrease in the level of
anxiety was not a goal in this study, a possible explanation
for this reduction is provided below. Lastly, 48 hr after
surgery when all ANI patients were discharged, they had
demanded fewer analgesics than TAU patients (on average,
7.33 vs 10.28 gr per patient, respectively).
We may conclude that a brief intervention focused in
clarifying what is personally meaningful for a particular
goal in the long run, and accepting what cannot be changed
in the process (e.g., worries about the surgery and pain)
have an impact on postsurgical recovery, as indicated by
these preliminary findings. Duration of postsurgical
hospitalization and demand of analgesics were the two
aspects that more clearly differed between conditions,
contrarily to what Lin and Wang (2005) found. This reveals
that psycho-education as usually implemented may not
make any difference on these measures unless it explicitly
incorporates, at the least, the clarification of the life
1367
directions and the mid and long-run goals the surgery
targets.
As mentioned in the Introduction, emotion regulation
strategies that promote focusing on emotions to somehow
alter their content and diminish discomfort quickly (e.g., from
“I’m anxious” to “I’m not too anxious”), may have a
boomerang effect. In our study, we asked patients to notice
their fear and worries but with a very different purpose. We
just wanted them to differentiate the person from their fears
and to see their fears for what they really are, i.e. inevitable
parts of going through surgery as the choice the patients made.
The immediate effect of detaching from events that cannot
be controlled (such as worries, fearful thoughts or feelings
during the surgery process), and focusing individuals’
attention on what they can really control (i.e., doing what is
relevant to the chosen goal any time such thoughts show up)
is the engagement in valued actions. It is important to note
that research has also revealed that engaging in valued actions
may, as a side effect, decrease anxiety in the short and, more
likely, in the long run although it is not the goal (Branstetter,
Wilson, Hildebrandt, & Mutch, 2004; Hayes et al., 2006;
McCracken et al., 2005; Ruiz, 2010). This is probably the
reason why ANI patients as compared to TAU patients in our
study scored lower in anxiety.
This is the first study showing the benefits of using
brief acceptance-based interventions to improve post-surgical
recovery. For ANI patients, the whole surgical process lasted
only two or three days, and the pain, fears and worries that
came along with it were experienced neither as barriers to
leave the hospital nor as reasons to demand analgesics.
Beyond the impact on patients’ life, the protocol here
implemented has a strong potential to drastically decrease
the economic costs of the surgical procedures, one of the
ultimate goal of studies on pre-surgery preparation.
1368 FERNÁNDEZ, LUCIANO, AND VALDIVIA-SALAS
Considering that reducing surgery costs without giving up
service quality standards is a core in the health system, we
believe further exploration of the conditions in which
acceptance-based nursing interventions work deserves
researchers’ attention.
One of the strengths of our procedure is its low costs
and large benefits: it was implemented by a nurse as part
of her daily admission routine, took about half an hour to
complete, and it yielded early discharge and fewer demand
of analgesic. At this stage of research development,
however, we urge some caution before generalizing the use
of acceptance-based protocol as part of the usual preparation
for surgery, first, because its benefits have been
demonstrated with a limited number of patients; second,
because not all patients will need this type of intervention.
The acceptance-based model of psychological intervention
explicitly assumes that underlying problems such as
responding fused with unwanted private events and
inflexible patterns of avoidance, are common to many forms
of human suffering (Hayes et al., 1996). Hence, targeting
these problematic repertoires may have an impact on the
alleviation of suffering, regardless of where it comes from
(fear of the future, regrets from the past, worries about the
present). We did not include a systematic assessment of
problematic repertories of this type because our goal was
solely to take a first step in the examination of the impact
of an acceptance-based protocol in the recovery process of
those patients who agreed to participate. Further studies,
however, may examine how problematic repertoires such
as fused and inflexible avoidance may modulate the
recovery process and the impact of acceptance-based nursing
interventions.
Our intervention included two elements: (a) connecting
the surgery process with a personally valued life direction
(by using a metaphor that was coherent with the process),
and (b) practice of being present with the worries and fearful
thoughts and feelings connected to the surgery process.
Although this study was not conceived to isolate any of
these elements, previous research has shown that both
components are typically necessary (for a review, Hayes et
al., 2006, and Ruiz, 2010). The results obtained are coherent
with those obtained with acceptance-based protocols in the
health area (e.g., Dahl, Wilson, & Nilsson, 2004; Lundgren
et al., 2008; Lundgren et al., 2006; Wicksell et al., 2005;
Wicksell et al., 2009) and might be considered as a step
forward in extending the use of acceptance-based
interventions to postsurgical recovery.
Finally, there are a number of caveats regarding the
broader importance of the present work. One is that
acceptance-based intervention was compared to a condition
in which no alternative treatment was delivered but routine
care. This implies that ANI participants were given 30
minutes of additional attention by the nurse. In order to
examine whether this could have accounted for the
differences in outcomes, future studies may compare ANI
vs TAU plus additional attention, or ANI vs cognitive-
behavioral nursing intervention. We also recommend the
incorporation of additional nurses to deliver the treatment/s
who were blind to the purpose of the research. Although
there is evidence that acceptance-based strategies may be
superior to cognitive-behavior treatment, especially in the
long run, and that the process of change is different (for a
review, see Hayes et al., 2006; and Ruiz, 2010), however
no study has shown this superiority in postsurgical recovery.
In addition, to the extent that this was an exploratory
study, participants were not randomly allocated to the study
conditions (i.e., ANI vs TAU). As a result, our sample included
11 women and two men who were assigned to the ANI
condition by order of admission. Regarding gender, although
gender differences in pain perception are equivocal (e.g., see
Robinson, Wise, Riley III, & Atchison, 1998), Uchiyama et
al., (2006) found that postoperative pain after LC is more
severe for women than for men. Our findings may then pose
a more conservative test of the observed superiority of the
acceptance-based nursing intervention vs TAU for LC
postoperative pain management. Still, randomization during
sample recruitment and allocation to the treatment conditions
is strongly recommended in future studies.
To summarize, the incorporation of an acceptance-based
nursing intervention into routine care may be a cost-effective
intervention to reduce the negative impact of pain intensity,
pain frequency, and situational anxiety, while diminishing
postsurgical costs. In this preliminary study, participants
who received the acceptance-based nursing intervention
showed healthier reactions to pain and anxiety, with earlier
discharges and a decreased demand for analgesics compared
to a control group.
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Accepted September 27, 2011