Original article

Colloquial descriptions of
body image in older surgical
patients
Pat Deeny, Michael Kirk-Smith

Major surgery and associated experiences in critical care settings affect patients’ perceptions of
their body images. This paper discusses several colloquial terms related to body image used in
interviews by elderly patients following major surgery for abdominal aortic aneurysm. The terms
‘badly failed, and well mended’, and ‘out of sorts’, and ‘in tune with my body’ recurred. These
referred to perceptions related to body weight or strength and bodily competence and control,
respectively. Patients had difficulty explaining these colloquial terms in other words, i.e.
Pat Deeny RN, BSc
(Hons) Nursing,
synonyms were not readily available to them.
RNT, Advanced Therefore, discussions or assessment using conventional body image terms used in psychology
Diploma in
and nursing literature may be confusing, misunderstood or irrelevant to these patients. This may
Education for
Nurses; Lecturer in be true for other groups, not necessarily elderly patients, using other colloquialisms. Such terms
Critical Care may not correspond directly to conventional body image terms, so comparability must be
Nursing, University
of Ulster, Cromore ascertained before standard body image instruments can be justified for use in such
Road, Coleraine, populations.
Co. Londonderry,
BT52 1SA, Nurses and health care professionals need to be sensitive to such colloquial descriptions when
Northern Ireland, assessing need and interventions involving psychological perceptions of body image. It is
UK. Tel: +44
(0)2870 324390;
suggested that these colloquial terms, which patients naturally perceive as relevant, should be
Fax: +44 (0)2870 used to communicate, discuss, and assess therapy during recovery after major surgery that
324951; E-mail:
involves intensive care. © 2000 Harcourt Publishers Ltd
pg.deeny@ulst.
ac.uk
Michael Kirk-
Smith PhD, Reader
in Behavioural and Introduction concept) would be particularly relevant.
Health Sciences, However, there is little research in this area. Any
Institute of
Major surgery and intensive care are found to studies that do exist concentrate on functional
Postgraduate
Medicine and cause various psychological changes, e.g. status after surgery or are specific to patient
Health University following heart transplant, some patients were groups with breast cancer and stomas. The only
of Ulster,
found to deteriorate in psychosocial adjustment research describing and evaluating the
Newtownabbey,
Co. Antrim, BT37 and show an increase in mood disturbance psychological well-being of the elderly after
0QB, Northern (Bohachick et al. 1992), and to show increased abdominal aortic aneurysm surgery (Sandstrom
Ireland, UK.
anxiety and depression levels in the early post- et al. 1996) did not consider body image as part of
Tel: +44 (0)2890
280669; Fax: +44 transplant period (Dew et al. 1994); and some psychological well-being. However in other
(0)2890 366811; patients with coronary artery bypass developed a groups, findings that link body image with major
E-mail:
more fatalistic attitude and increased hostility surgery are noteworthy. Waters (1988) found that
mks@ulst.ac.uk
(Strauss et al. 1992). The changes to the body women who were eight weeks post-mastectomy
Requests for effected by major surgery suggest that the showed marked changes in evaluation of body
offprints to PD
psychological concept of ‘body image’ (See Price image and this, in association with social support,
Manuscript 1990; Newell 1991; Vamos 1993; Price 1995; strongly influenced overall psychosocial
accepted 2/5/00 Gardner 1996; Salter 1997 for reviews of the adjustment. Klopp (1990) found that individuals

304 Intensive and Critical Care Nursing (2000) 16, 304–309 © 2000 Harcourt Publishers Ltd

with a faecal stoma have a poorer body image
and are very susceptible to depression after
surgery. Nordstrom et al. (1992), examining
psychosocial adjustment after major surgery for
urinary diversion and stoma formation, noted
that factors related to an altered body image were
the most common negative aspect reported by
female patients.
An ageing population means that more
patients who are elderly are having major
surgery that involves intensive care. This is
especially the case for repair of abdominal aortic
aneurysm (Stevens 1993; Pleumekers et al. 1994;
Nasim et al. 1995). Physical response to major
surgery is precipitated by the effects of the ageing
process and perhaps underlying illnesses
(Foreman 1992; Frezza et al. 1998). Moreover, it
has been suggested that all types of surgery have
a significantly decompensating impact on the
mental status of elderly patients (Cryns et al.
1990). These factors must affect recovery time, the
individual’s ability to regain previous energy
levels and the positive evaluation of self that is
required for rehabilitation. Therefore it is
possible, even likely, that the psychological
effects of such surgery may be greater in older
than in younger people. These changes are likely
to affect how they perceive themselves, and
particularly their perceptions of their bodies, i.e.
their ‘body image’. Consequently, understanding
how elderly patients feel and perceive their
bodies across the experience of major surgery and
intensive care is likely to be crucially important in
the planning of treatment during the immediate
post-operative period and during rehabilitation,
e.g. in facilitating communication and help with
counselling.
Despite this, there is a dearth of research
investigating how major surgery and the
intensive care experience changes perceptions of
body image in elderly patients. One group of
particular interest is patients undergoing elective
repair of an abdominal aortic aneurysm. Aside
from a large abdominal incision, this group has
no obvious exterior bodily changes compared to
patients with burns and amputations, where
gross physical changes are readily observable.
However, they may have affective responses to
the changes they perceive in their bodies due to
both fatigue and weight loss, e.g. the lowered
performance may result in a negative evaluation
of the body. Thus, it is the psychological effects
© 2000 Harcourt Publishers Ltd Intensive and Critical Care Nursing
Descriptions of body image
rather than physical perceptions that are most
relevant to this group. Understanding the nature
of these effects may be potentially useful in
informing the planning and monitoring of
nursing interventions during recovery.
How might this be approached? Some studies
have examined changes in perceptions of body
shape and size in the elderly during illness
(Janelli 1991; Miller et al. 1991; Hallinan &
Schuler 1993; Janelli 1993). However, they have
used standard ‘body image’ measurement
instruments developed outside the clinical
situation. The concepts and terms used in body
image research and the measurement instruments
are derived from predominantly young
populations in the USA. It is possible that such
terms (or even the term ‘body image’ itself) may
not be appropriate, or even meaningful in
interactions with older people. This will be
especially so if they are from a different culture
from which the body image instruments were
derived, e.g. a rural retired Irish farmer, whose
livelihood has depended on his physical strength,
is likely to have a very different world view,
understanding of his body image and vocabulary
from a young city dweller from the USA.
Given these contextual and cultural issues, the
aim of this paper is to investigate how a sample
of elderly patients in recovery from major
surgery for an abdominal aortic aneurysm,
understand the changes that they perceive in
their bodies, and, specifically, how they
expressed these perceptions, in colloquial
language. The argument underlying the study is
that therapy during recovery must be grounded
in, and sensitive to, the language of those who
live the experience.
Sample and access
Nine respondents (five male and four female, age
range 65–78 years) were drawn at random from
the annual surgical lists of three major hospitals
in Northern Ireland, two in the east of the region
and one in the west. The criteria for selection
centered on being aged over 65 and having had
elective surgery for abdominal aortic aneurysm
within the past six months. Due to the emphasis
on the collection of colloquial descriptions, it is
important to note that, while there is a
concentration of hospitals in the east of the
region, respondents were not concentrated in the
(2000) 16, 304–309 305
Intensive and Critical Care Nursing

same way. As it is common practice for referrals upset but this option remained throughout.
to be made from the west to the larger hospitals Minimal biographical data are presented and all
in the east, there was a geographical spread in the discourses have been modified to exclude
sample. Equally there was an appropriate reference to places and names of individuals.
distribution between rural areas, small towns and
cities.
Results
All respondents were written to by the
researchers and invited to participate. After a Two bipolar dimensions consistently emerged
returning a consent form including telephone from the first interviews in relation to body
number, they were contacted in order to discuss image.
the purpose of the research and arrange an
interview. Arrangements for the follow-up
Badly failed and well mended
telephone interview on colloquial descriptions of
body image were made after the researchers The most common term used by respondents
identified pieces of relevant discourse in the referring to themselves was ‘badly failed’ and,
interview transcript. This involved the less frequently, its opposite ‘well mended’.
interviewer telephoning the respondent’s home Examples from the discourses (with code
and asking if he/she could answer more numbers indicating male and female
questions. respondents), which illustrate their use, are as
follows,
Procedure M1: I suppose I have lost an awful lot of weight
but I am starting to pick up now. I was failed
Data were collected using a combination of open-
when I came out of the hospital.
ended interviews and follow-up telephone calls.
M2: I didn’t realize that I was so failed, that I had
The interviews were conducted in each elderly
lost that much weight until I came out of the
person’s home, three to six months after
hospital. More or less my face had fallen in, here
discharge from hospital. Respondents were
and again around the neck area. I could put my
invited to recount experiences associated with
fingers down my collar. The clothes were
having the surgery. Salient points related to body
hanging off me. I had to get them taken in before
image were selected from the discourse. The
I could go out.
follow-up telephone interviews occurred
M4: Oh, I’m badly failed since the hospital. I used
approximately three weeks after the first
to be as strong as a bull. Three months home
interview and focused specifically on the
today and I’ve mended a very little. I’ve lost at
colloquial descriptions related to body image.
least two stone weight.
Questions such as ‘What do you mean by that
F2: I was always nine stone and now I am only
term?’ ‘What would be the opposite of that?’ and
seven and a half. Oh, I noticed myself that I have
‘how is that related to how you see your body?’
lost weight. No one said to me that you’re failed,
were commonly used. Initial interviews lasted
but you know yourself when you stand in front
from one to two-and-a-half hours. Follow-up
of the mirror. There is no point in them saying to
telephone interviews lasted for no more than ten
you ‘you’re well mended after the operation’
minutes.
because you’re not.
Aside from the usual ethical considerations of
F3: Oh, I went down a hell of a lot after the
freedom of choice to participate, anonymity and
operation because I remember putting on my
confidentiality, other aspects required sensitivity.
clothes and two of the girls (daughters) were in
There was a risk that respondents might have
and I noticed one doing that to the other
become anxious or upset when considering
(nodding) and I said nothing but I knew what
experiences that have been traumatic. It was
they were on about … that I had lost so much
made clear in the letter of invitation that
weight, so badly failed in my arms and legs.
respondents had the right to withdraw from the
study at any time without having to give a Some did expand on how they felt as a whole
reason. Fortunately, it was not necessary to stop and related this to the terms ‘failed’ and
the interviews as a result of respondents being ‘mended’. They also introduced the idea of

306 Intensive and Critical Care Nursing (2000) 16, 304–309 © 2000 Harcourt Publishers Ltd

different degrees of being failed. Being ‘badly
failed’ pertained to having lost a lot of weight
and looking very gaunt and having fatigue. One
respondent stated that being ‘badly failed’ relates
to an overall feeling that includes tiredness and
depression. Another respondent stated that it was
like ‘losing your spirit’ ‘losing heart in life’.
Someone who is ‘well mended’ is looking good
and feeling good.
‘Out of sorts with my body’ and ‘in tune
with my body’
These terms were not used as frequently as ‘badly
failed – well mended’. The following examples
from the first interviews illustrate their use:
M1: Oh, you be out of sorts. You’re all over the
place. Especially with the pain, you don’t what
end of you is up.
M3: I was not my usual self. You be out of sorts. I
was always fairly fit but I am not as good as I
used to be. The operation knocks you back
you’re no longer in tune with the body.
F1: I remember looking out over the fields before
I went to the hospital and thinking, will I ever be
back again? I’ll tell you that it’s a big operation.
You don’t know if you ever make it. It certainly
can set you back, especially if you’re someone
like me, always out and about, stuck in
everything (laughs). You want to be on top of
things but the ould body won’t respond. You’re
no longer in tune with it. You feel that it’s letting
you down.
F2: Oh, you just be out of sorts. Sick, you know,
and off your food.
In the second interview, respondents again
had difficulty explaining what was meant by
these terms, but could easily provide more
detail on how they felt. ‘Being in tune with the
body’ was further developed to include
knowing what is happening to the body. Some
respondents did not fully understand the
reasons for the surgery and having no
symptoms from the aneurysm precipitated this.
This was disconcerting for them. On the one
hand, they were told that they had a life-
threatening problem with ‘the large artery
coming from the heart’ and that it could rupture
at any moment. On the other hand, they had no
pain or bodily sensations to support this. Most
patients monitored their body for new
© 2000 Harcourt Publishers Ltd
Descriptions of body image
sensations, especially at night before going to
sleep. Some respondents described this period
of anxiety as being ‘out of sorts’ and ‘not in tune
with the body’. These terms were related to not
knowing what was happening prior to the
surgery. Moreover, during the time in the
intensive care unit postoperatively there was
also a feeling of ‘not being in tune with the
body’ as monitoring instruments or central
venous catheters that were not fully understood
were being inserted into the body. One
respondent vividly described the feeling.
M2: How would you be in tune with your body
when they are sticking things in every hole they
see. I had a thing in my neck, I couldn’t see what
it was, it was like brush shaft, what ever it was.
Discussion
While it is difficult to determine exactly what is
meant by these terms, it appears that they relate
to judgements of the body and perhaps body
function with general regard to size, competence
and sociability. However, it is difficult to
establish if these elderly patients see the body in
isolation from the total self, as opposed to the
body incorporated as part of the total self. The
psychological processes associated with how the
body is perceived in relation to the total self
require further investigation.
From the context of the first interview and the
explanations from the second interview, the
terms ‘badly failed’ and ‘well mended’
describe a dimension or state where patients
perceive themselves as having lost a lot of
weight, looking pale and tired or having gained
weight and looking healthy. Being ‘failed’
primarily appears to centre on an evaluation of
the face, usually meaning that face has ‘fallen in’
or is no longer looking good. Clothes are usually
too big, meaning that adjustments are required
in order to mitigate the image of ‘looking very
thin’. The description extends to include the
arms and legs, particularly in men who value
muscular strength. The terms may also include
an evaluation of sociability because references
were made to ‘going out’. There was a natural
scaling of judgements from badly failed to
well mended, and it may be that the terms judge
both the body and an overall evaluation of
health.
Intensive and Critical Care Nursing (2000) 16, 304–309 307
Intensive and Critical Care Nursing
The dimension underlying ‘out of sorts’ and
‘in tune’ appears to describe how the body is
perceived as being integral to health and how
after the surgery it feels as though the body is not
in unison with the rest of the individual. The
context of these terms suggest that they are
associated with a dimension related to an
evaluation of body competence, physical strength
and stamina and also, perhaps, to perceptions of
control over the body given the intrusions of
medical instruments.
As in previous studies of body image in the
elderly (e.g. Janelli 1991, 1993; Miller et al. 1991),
images of the body in illness emerge as being
important. Unlike those studies, in this one
patients were not presented with words or
concepts from conventional body image
instruments. Instead, they spontaneously and
naturally used colloquial terms to describe body-
related changes resulting from their surgery and
did not use terms found in body image
instruments. Significantly, they found it difficult
to explain their colloquial terms in other ways,
i.e. these terms ‘stand-alone’ as representatives of
the underlying dimensions, and did not have
readily available synonyms to mind. A
consequence is that alternative terms for the
colloquial expressions are unlikely to be as
readily understandable.
Elderly patients are likely to be less cognisant
of modern psychological jargon (such as ‘body
image’), and actively use colloquial terms.
Therefore, it might be both psychologically and
clinically more appropriate to use these colloquial
terms in diagnosis and post-operative therapy
than the terms used in body image instruments.
The present findings suggest that the use of
conventional body image terms and synonyms
may be confusing, misunderstood or irrelevant to
these patients.
This issue may be generally applicable since it
is likely that many other groups, not necessarily
old or rural, may have their own colloquialisms,
and may similarly use them in preference to
formal body image terms. The existence of such
colloquial descriptions points to the need for
nurses and health care professionals to be
sensitive to them as a basis for assessment of
need and interventions related to the
psychological response and body image.
The relation of these colloquial terms to
conventional body image terms needs to be made
308 Intensive and Critical Care Nursing (2000) 16, 304–309
with caution. It cannot be assumed, a priori, that
these local terms and their underlying
dimensions correspond directly to existing body
image terms and dimensions. Comparability
must be therefore be ascertained before the use of
standard body image instruments can be justified
within diagnosis and therapy in populations of
people such as those interviewed here.
If comparability of colloquial terms with
conventional body image cannot easily be
ascertained, an approach that is both sensitive to
patients’ own language and pragmatic might be
to elicit the colloquial terms patients perceive as
relevant to their body images (by interview, as
done here). These terms may then be used in
communication with patients in discussing and
planning their recovery therapy and used within
a rating scale. By using the patients’ own
language, such ratings will be both contextually
and culturally relevant to the patients’ own
concerns. This approach could be used both
before surgery to plan post-surgery nursing
interventions and to evaluate changes during the
recovery period so that progress can be tracked
and rehabilitation modified as required.
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