Critical ischaemia of lower extremities is a serious social issue, as it is connected with a 20% annual risk of amputation and a 20% annual risk of death (Farber & Eberhardt, 2016; Norgren et al., 2007). Occurrence of critical ischaemia of lower extremities is estimated to be 500-1000 new cases per one million inhabitants per year (Criqui et al., 1992). Rest pain and presence of necrotic lesions in lower limbs force the patients to undergo aggressive surgical treatment to restore aortic blood flow in lower extremities. Revascularization of lower extremity arteries is connected with a significant (1-10%) risk of serious complications and perioperative death. Moreover, effective revascularization does not always result in saving the threatened limb, so the patient carries the risk of amputation throughout his or her life (Adam et al., 2005; Tunis et al., 1991).

The majority of patients suffering from critical ischaemia of lower extremities are also affected with other diseases of the cardiovascular system. Critical ischaemia of lower extremities tends to be accompanied by concurrent ischaemic heart disease, scattered ischaemic lesions in the brain and hypertension (Aronow & Ahn, 1994; Hirsch et al., 2001). The often identified concurrent diseases include tobacco related neoplasms (Armstrong & Lavery, 1998). Patients with concurrent diabetes constitute the greatest challenge, as in their case the risk of losing a limb is nearly 100 times greater (Moulik et al., 2003; Schillinger et al., 2002).

Despite technological progress being made, patients undergoing revascularization are exposed to restenosis in the area of the previously treated vessels (20-70% in five-year follow-up study), and to a 20% risk of developing new lesions in peripheral arteries (in five-year follow-up study) (Matsumura et al., 2013). A patient who regularly returns to the hospital to undergo revascularization realises the risk of recurrence and that each subsequent surgical procedure may fail. This may have an impact on his or her attitude to the surgery (Peters et al., 2019).

Each time the patient’s limb or life is at risk, it is necessary to activate his or her personal resources which comprise mental dispositions needed to effectively cope with a difficult situation in life, i.e. fighting a chronic disease (Antonovsky, 1984; Baum & Stewart, 1990; Steunenberg et al., 2016). The resources include particularly important dispositions such as self-efficacy and internal health locus of control, as they enable patients to cope with the stress related to the disease. A similar role is played by the desired life quality, which is both the cause and result and which reinforces the self-efficacy and internal health locus of control. The concept of self-efficacy, introduced to psychology by Albert Bandura (1977, 1982) refers to one’s conviction of having capabilities to achieve one’s goals, i.e. to implement tasks even in unforeseeable and stressful conditions. Health locus of control is understood as a generalised expectation that any events in life are a result of either external forces or one’s own efforts and personal control (Rotter, 1966). Internal health locus of control is connected with taking personal responsibility for one’s health. It may also happen that any given person shows an external health locus of control, thus indicating one’s dependence either on other people’s (especially health professionals’) influence or on one’s fate or chance (Wallston & Wallston, 1982; Wallston et al., 1994). As for their life quality assessment, it relates to a set of factors such as physical health, mental state, degree of independence, relations with the people around them, and functioning in their social and occupational roles (Pavot & Diener, 2008; Peterman & Cella, 2000).

The described psychological categories underlie the mechanisms of coping with life challenges such as a disease and a decision on undergoing surgery. Therefore, we decided: 1) to assess the correlation between the attitude to the surgery and self-efficacy, health locus of control and own life quality assessment in all patients with lower limb ischaemia; 2) 6 months after surgery, to extract and compare the results of the patients during that period regarding death and reinterventions.



With consent granted by the Research Ethics Committee (approval number: 55/14), the research study was conducted from May to the end of September 2014, involving 64 patients with critical lower limb ischaemia (Rutherford 4 and 5), including 26 women and 38 men, aged from 33 to 86 (M = 65.94, SD = 9.37). Among them, 24 patients had concurrent diabetes (10 women and 14 men). The assessing psychologist selected all patients with leg-threatening limb ischaemia who were admitted on one selected day of the week. All patients were able to give informed consent to the assessment. No cognitive assessment between the diabetic and non-diabetic groups was made prior to inclusion in the study. The data on other concomitant diseases were not collected.


In view of the purpose of the study and heterogenous group of patients, 4 simple scales were applied, which were completed – with the help of the researcher – by the patients awaiting elective revascularisation in the clinical hospital during primary admission.

  1. Generalized Self-Efficacy Scale (GSES; Schwarzer & Jerusalem, 1995; Polish adaptation by Juczyński, 2001), comprising 10 statements and measuring the level of general personal conviction regarding the individual’s efficacy in handling tough situations.

  2. Satisfaction with Life Scale (SWLS; Diener et al., 1985; Polish adaptation by Juczyński, 2001), composed of 5 statements and measuring the generalised feeling of satisfaction with life so far.

  3. Multidimensional Health Locus of Control Scale (MHLC; Wallston et al., 1978; Polish adaptation by Juczyński, 2001), composed of 18 statements and aimed at specifying their expectations in three aspects of health locus of control. Thus, the study participant indicates whether their own health is controlled: 1) by them (internal aspect); 2) by other individuals, especially health professionals (external personal aspect); 3) by fate/chance (external impersonal aspect).

  4. A simple scale was applied to find the attitude to the surgery, where –10 stands for the maximally negative attitude, 0 for neutral, and +10 for maximally positive.

Scales 1, 2, 3 were used for measuring mental dispositions (self-efficacy, health locus of control, life quality assessment), and scale 4 to specify the kind and intensity of one’s attitude to the surgery. The statistical analysis of the results was performed using IBM SPSS Statistics 22 software. To assess the normality of distribution of the analysed variables, the Shapiro-Wilk test was used. To determine the strength of correlation between the variables, Pearson’s correlation coefficient (r) was applied.


Six months after primary admission the following outcomes were noted: a) died – 4 persons, b) no readmission during follow-up – 43 persons, c) returned to the reinterventions several times – 17 persons.

It was found that during primary admission on average the attitude to the surgery was highly positive (M = 8.50) at the whole group level as well as in relation to men and women. The lowest grades were given by those hospitalised several times (M = 8.30), and particularly low grades came from women (M = 7.70), whereas the patients who were hospitalised only once assessed their attitude to the surgery similarly as the whole group (M = 8.60), and particularly high grades were given by women (M = 9.10).

For the totality of patients, a strong, statistically significant and positive correlation was found between the positive attitude to the surgery and self-efficacy (p = .012), internal health locus of control (p = .041) and its external locus (p = .026). The other correlations proved to be statistically insignificant. In the case of the patients who died within six months from the baseline study, no statistically significant correlations were found. As for the patients who were hospitalised once within that period, a correlation was found between the positive attitude to the surgery and the external personal health locus of control (p = .023). The other correlations proved to be statistically insignificant. Regarding the patients who were hospitalised several times within that period, a correlation was found between the originally positive attitude to the surgery and self-efficacy (p = .009). The other correlations proved to be statistically insignificant, as presented in Table 1.

Table 1

Main psychological factors contributing attitude to surgery in patients with lower limb ischaemia (categorized results)

Psychological factor/AttitudeTotalDeceasedOne hospitalisationMultiple hospitalisations
  Pearson correlation.
  Significance (2-tailed).0101.00.117.009
Internal locus of control
  Pearson correlation.
  Significance (2-tailed).040.457.059.540
External locus of control
  Pearson correlation.
  Significance (2-tailed).
Locus – fate/chance
  Pearson correlation–.01.38–.07.22
  Significance (2-tailed).903.616.624.388
Quality of life
  Pearson correlation.03–.71–.05.37
  Significance (2-tailed).799.295.723.140


The study results show that in the case of patients with lower limb ischaemia who make decisions on surgery, special attention must be paid to their personal resources, especially mental dispositions such as self-efficacy and health locus of control, and, in that context, to their relations with the attending physician and other members of the therapeutic team. This is because it has been proved that the patients’ assessment of their pro-health actions expressed by their attitude to the surgery is the more positive, the higher their self-efficacy and internal health locus of control are. At the same time it was found that a positive attitude to the surgery depends on the level of trust to health professionals and other significant persons (family), i.e. on external health locus of control. Similar results were obtained in other research studies (Ruffin et al., 2012; Rzepa & Stanisić, 2012; van Dijk et al., 2013; Zotti et al., 2007).

These findings were confirmed by subsequent analyses carried out 6 months after performing the baseline study. It turned out that among the patients who had successfully completed their surgical treatment, as they were not hospitalised in the said period, their positive attitude to the surgery mainly depended on their trust in the medical staff (external health locus of control). It also turned out that the patients who had returned to the clinical hospital originally had related their positive attitude to the surgery mainly to their self-efficacy, without referring to such an important personal resource as health locus of control. Finally, as for the patients who died within 6 months from the surgery, it turned out that during the baseline study they did not strengthen their attitude to the surgery by activating any mental dispositions. The status of a patient with critical limb ischaemia cannot be compared to other life-threatening diseases such as stroke (Xu et al., 2021). The high possibility of readmission should also be taken into account in the psychological assessment of the patients.

It can be assumed that preoperative psychological assessment may identify the group of patients with critical limb ischaemia, being at risk of early failure of the primary intervention. Most likely poor personal resources may induce poor compliance with the postoperative medication and training programme, resulting in reintervention or death. These findings should be confirmed in a larger group of patients.

These findings may be explained by the correlation of the said dispositions with a strong motivation to improve one’s health status, built on its accurate cognitive evaluation, reinforced with an appropriate medical diagnosis (Heszen & Sęk, 2007; Kościelak, 2010).

Concluding our study results, we would like to emphasise some study limitations: mainly the explorative character of the study with a heterogeneous group of patients regarding age and concomitant disease. However, the present study should ease the communication pathway between the medical professional and patient with limb-threatening ischaemia.


Patients with weak mental dispositions cannot cope with difficult situations and show a tendency to experience strong emotions, concentrating on their deficiencies. This approach results in decreased motivation and thus feeble engagement in personal health problems, as was found in the case of the deceased patients.