Educating patients about anaesthesia: effect of various modes on patient’s knowledge, anxiety and satisfaction Anna Lee and Tony Gin Purpose of review This review summarizes the current research on the effects of preoperative education about anaesthesia on patient knowledge, anxiety, and satisfaction. Recent findings Misconceptions about the process and the risks of general and regional anaesthesia are common. Information leaflets should be formally assessed to ensure that patient knowledge is increased. Patients should be surveyed to see what information they want, rather than just providing what healthcare professionals think is appropriate. The amount of information requested by patients can vary considerably. Providing detailed drug information leaflets for anaesthetic drugs was not thought necessary by many patients, but was not associated with increased preoperative state anxiety. Information sessions to small groups of patients by multidisciplinary healthcare professionals were useful for patients undergoing total hip arthroplasty, with a small reduction in preoperative state anxiety, but patient satisfaction levels remained unchanged. Patient satisfaction should be measured by a valid and reliable questionnaire. When this was done, the introduction of pamphlets did not improve patient satisfaction. The evidence for better patient outcomes after patient education interventions is not convincing. Summary Preoperative patient education should recognize that different patients have various misconceptions, expectations and needs. Multiple modes may be required to increase knowledge for informed consent and decrease patient anxiety. Patient satisfaction is generally high irrespective of the mode of patient education. Keywords anaesthesia, anxiety, knowledge, patient education, patient satisfaction Curr Opin Anaesthesiol 18:205–208. # 2005 Lippincott Williams & Wilkins. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China Correspondence to Anna Lee, PhD, MPH, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China Tel: +852 2632 2735; fax: +852 2637 2422; e-mail: email@example.com Current Opinion in Anaesthesiology 2005, 18:205–208 Abbreviation STAI State Trait Anxiety Inventory # 2005 Lippincott Williams & Wilkins 0952-7907 Introduction Preoperative patient education is a standard of care. Information is provided to patients to improve the knowledge of their medical management. This should enable them to participate in decision making and provide a sound basis for giving informed consent. It is important that everyone has realistic expectations to avoid dissatisfaction. Our previous systematic review of randomized controlled trials published up to May 2002 found that the use of video or printed information can decrease patient anxiety and increase patient knowledge . However, patient satisfaction with anaesthetic care was similar between media-based intervention and non-intervention groups . This review summarizes current research on the effect of various modes of patient education on knowledge, anxiety and patient satisfaction in patients undergoing elective surgery. For informed consent, patients need general information about the process and the risks of anaesthesia, and specific information about their management from the anaesthetist. Recent studies have shown that the public has many misconceptions about general and regional anaesthesia [2,3]. Concerns about rare events by the public are prevalent . Of the 1216 people in Alberta, Canada, surveyed, approximately 20% were very concerned about brain damage, waking up during surgery and memory loss during general anaesthesia . Twelve per cent were concerned about death during general anaesthesia . Approximately 27% were very concerned about permanent paralysis, back injury, pain, a needle in the back and seeing the procedure with regional anaesthesia . Although the survey [2,3] had limitations , these findings suggest that patients may be reluctant to use regional anaesthesia as a result of a lack of knowledge. The studies [2,3] also highlight the importance of the need for patient education about general and regional anaesthesia. 205 206 Ethics, economics and outcome Although it is unclear which mode of patient education is most cost-effective, a recent study showed that most parents indicated that they would like the preoperative information in the form of a pamphlet (90%), preoperative visit from the anaesthetist (80%), video (41%), meeting with play specialist (24%) and group information session (18%) . Irrespective of whether education interventions are used or not, most patients indicated that they would like to be seen by the anaesthetist before surgery [2,6]. Knowledge It is generally accepted that good preoperative education about anaesthesia should increase patients’ knowledge about the process and risks of anaesthesia. This may depend on the quality of the presentation, patient interest and motivation, and patients’ literacy skills. Factual knowledge of anaesthesia may improve compliance with perioperative instructions and facilitate informed consent. However, none of the recent studies examining various modes of patient education addressed this issue directly. Written information helps patients make informed choices about their healthcare, and strengthens the process of informed consent . Standardized information leaflets are usually prepared by diverse groups and are distributed with the expectation that they will be useful. However, this is not often formally assessed. Nevertheless, the usefulness of the Obstetric Anaesthetists’ Association leaflet ‘Pain relief in labour’ on maternal knowledge was assessed in a British study . Pregnant women receiving the leaflet during the first trimester were more knowledgeable about various analgesic techniques than women in the control group . Although there is no standard method of measuring the level of patient knowledge, knowledge was assessed at full term gestation and was categorized as none, moderate or good according to a standardized scoring system, in which each question had a number of specific points of information associated with it . Regardless of the level of knowledge, most women (89%) thought that they would use some form of analgesia in labour . The authors concluded that all information leaflets should be formally assessed. Materials are often prepared from the healthcare professional’s perspective, but this may not be what patients want. In the paediatric anaesthesia setting, Wisselo et al.  used a questionnaire of parental attitudes towards information and anaesthesia to produce a useful video as part of their preoperative preparation programme. Most parents wanted information about premedication, the induction of anaesthesia, the side-effects of anaesthesia and postoperative pain management. Issues that were of most concern to parents were postoperative pain (88%), the process of anaesthesia (79%), recovery from anaesthesia (78%), nausea (78%) and induction of anaesthesia (70%) . Although the authors stated that the video was a success for patient education, the paper did not actually assess the effect of the video. Anxiety Reducing patient anxiety is one of the purposes of conducting a pre-anaesthetic consultation . Preoperative anxiety can be divided into three distinct dimensions: fear of the unknown; fear of feeling ill; and fear for one’s life . The incidence of high preoperative anxiety is approximately 25% [7,9] as measured by the State Trait Anxiety Inventory (STAI) , the current gold standard in measuring subjective anxiety. State anxiety refers to an acute situational-driven episode of anxiety. Trait anxiety refers to a personality trait that is stable over time. The level of patient knowledge about anaesthesia does not correlate with the level of state anxiety . A recent study from Brazil  assessed the effect of having any knowledge of the diagnosis, type of surgery and type of anaesthesia on anxiety levels, as measured by STAI. Twenty nine out of 149 patients were excluded for illiteracy. Patients who were unfamiliar with their surgical procedure had higher state anxiety than those who had adequate knowledge. Not knowing what type of anaesthesia they would receive did not affect state anxiety. There have been concerns about the amount of information that patients should be provided with because it is believed that too much information can cause anxiety. Patients have a right to request information about drugs that they are receiving. Patient information leaflets about drugs are available with drug packing in most countries, but most anaesthetists have probably not considered giving out such material to patients to read during the preoperative visit. The effect of providing patients with detailed information about anaesthetic drugs (propofol and remifentanil) was examined in a recent randomized controlled trial . Although more than 64% of patients did not wish to receive detailed anaesthetic drug information, the provision of such information did not significantly increase state anxiety . This suggests that patients should not have detailed information about the risks and process of anaesthesia withheld from them on the basis that they are likely to suffer adversely from such information. The amount of information that patients want may depend on the individual coping styles. ‘Monitors’ are patients who desire high levels of information. In contrast, ‘blunters’ are those patients for whom too much information can lead to increased anxiety. Using a validated questionnaire to assess individual coping styles, there was no difference between coping styles and the desire for information in the form of a video . This is Educating patients about anaesthesia Lee and Gin 207 surprising because it might reflect that having specific concerns about a procedure on a child overrides personal coping style for one’s personal life. Another mode of patient education is by multidisciplinary standardized information sessions to a small group of patients. Patients undergoing elective total hip arthroplasty were randomly allocated to a multidisciplinary (rheumatologist, surgeon, anaesthetist, physiotherapist, psychiatrist) information group that received verbal information and an information pamphlet or a control group that received the usual verbal information from the surgeon and the anaesthetist and the standard information pamphlet . Patients in the intervention group were significantly less anxious before surgery than patients in the control group ( 5, 95% confidence interval 9 to 1 by STAI) . Although these results were statistically significant, the clinical significance is minimal given the intense programme. However, this may be worthwhile because rehabilitation is an important part of the overall preoperative and postoperative management of patients undergoing orthopaedic surgery. There is some evidence that a reduction in preoperative anxiety levels is associated with better outcomes . Patients in the multidisciplinary standardized information session group who were less anxious before surgery experienced less pain before and after surgery, and were able to stand sooner than those in the control group who had higher levels of preoperative anxiety . Therefore, it appears that a reduction in state anxiety levels from patient education interventions may also improve the quality of recovery. Patient satisfaction Patient satisfaction is a complex psychological phenomenon, and it is an important outcome measure. In reviewing patient satisfaction studies, there needs to be a clear distinction between satisfaction with preoperative information, satisfaction with the overall anaesthetic management, and satisfaction with the surgical process and outcome. More importantly, patient satisfaction should be assessed by multi-item questionnaires that have been shown to be reliable and valid instead of commonly using a single global assessment . Although information and involvement in decisionmaking is the most important dimension in explaining patient satisfaction with anaesthetic care [15,16], it is often difficult to show a difference in patient satisfaction between different modes of patient education. For example, the level of patient satisfaction (not specifically defined by the authors) was similar between the multidisciplinary information group and the control group (92 16 versus 91 22, respectively) using a single global measure of patient satisfaction . When patient satisfaction is measured by a reliable and validated questionnaire, information campaigns and the introduction or improvement of pamphlets alone did not improve patient satisfaction with anaesthesia care . The percentage of patients who thought that information and involvement in decision-making were a problem remained unchanged between 2000 (31%) and 2002 (28%) . A possible explanation for this finding is that the leaflet had not been formally assessed for its effect on patient knowledge. To show a positive effect on patient satisfaction, multiple modes of patient education and an improvement in communication skills by anaesthetists are probably needed in combination. There was some evidence that training anaesthetists in communication skills can increase patient satisfaction with the preoperative anaesthetic visit, but this was not statistically significant . Using complex modeling, training decreased patient anxieties about anaesthesia and surgery, but the effect was small given the intense programme . A preoperative interview may influence anaesthetic outcome. Reurer et al.  conducted a study in 710 patients using a complex structural equation path analysis modeling approach. They assessed the causal relationships between satisfaction with the preoperative interview and postoperative events (postoperative nausea and vomiting, difficulties in recovering from anaesthesia, experience of postoperative pain, physical discomfort and satisfaction with convalescence). The results were extremely difficult to understand. They concluded that the anaesthetist’s efforts to improve the interview by more patient reassurance and information would result in fewer side-effects from anaesthesia and better recovery from surgery . However, it appears that satisfaction with the preoperative interview was significantly related only to satisfaction with convalescence. It is not certain that this is a strong causal relationship. Satisfaction with the preoperative interview was not significantly correlated with anaesthetic side-effects . A limitation of the study was that patient satisfaction was measured by a tool without sound psychometric properties. Discussion Effective patient education requires good communication skills, consideration of adult learning and teaching principles, and selecting the mode to suit the individual patient’s needs. None of the recent studies have compared pamphlets, videos and multidisciplinary information sessions directly with each other on outcome measures. Therefore, the most cost-effective mode of patient education remains unclear. Written information is not always successful because it requires basic literacy skills and the motivation to read 208 Ethics, economics and outcome the material provided. Videos are useful in that patients learn by seeing a demonstration of the perioperative process , but misunderstandings cannot be clarified unless there is an opportunity for patients to discuss issues of concern with anaesthetic staff. Although multidisciplinary information sessions with small groups of patients allow interactive discussion, this type of intervention is more difficult to undertake and is expensive. We found no recent studies examining the effect of patient education using interactive CD-ROM programs or by the Internet in the anaesthetic setting. Conclusion Preoperative patient education should recognize that different patients have various misconceptions, expectations and needs. Effective modes of patient education about regional anaesthesia in the non-obstetric setting are needed if we are to decrease the fears associated with regional anaesthesia and increase the public’s acceptance of this type of anaesthetic technique. Multiple modes may be required to increase knowledge for informed consent and decrease patient anxiety. Patient satisfaction is generally high irrespective of the mode of patient education. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest 1 Lee A, Chui PT, Gin T. Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions. Anesth Analg 2003; 96:1424–1431. 2 Matthey P, Finucane BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth 2001; 48:333–339. Matthey PW, Finegan BA, Finucane BT. The public’s fears about and perceptions of regional anesthesia. Reg Anesth Pain Med 2004; 29:96– 101. This study is a survey on the attitudes of the general public in Canada towards a number of commonly perceived fears about regional anaesthesia. 3 4 Birnbach D. The public’s perception of regional anesthesia: why don’t they get ‘‘the point’’? Reg Anesth Pain Med 2004; 29:86–89. An editorial on reference , which outlines areas that need to be addressed to change the public’s perception of regional anaesthesia and improvements to be made by anaesthetists to increase the use of regional anaesthesia. Wisselo TL, Stuart C, Muris P. Providing parents with information before anaesthesia: what do they really want to know? Paediatr Anaesth 2004; 14:299–307. This study outlines the results of a questionnaire to determine parental attitudes towards information before producing a video for patient education. 5 6 Stewart A, Sodhi V, Harper N, Yentis SM. Assessment of the effect upon maternal knowledge of an information leaflet about pain relief in labour. Anaesthesia 2003; 58:1015–1019. Oldman M, Moore D, Collins S. Drug patient information leaflets in anaesthesia: effect on anxiety and patient satisfaction. Br J Anaesth 2004; 92:854– 858. A randomized controlled trial of 85 patients to examine the effect of anaesthetic drug patient information leaflets on anxiety and patient satisfaction. 7 8 Klafta JM, Roizen MF. Current understanding of patients’ attitudes toward and preparation for anesthesia: a review. Anesth Analg 1996; 83:1314–1321. 9 Kindler CH, Harms C, Amsler F, et al. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesth Analg 2000; 90:706–712. 10 Spielberger CD. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press; 1983. 11 Miller KM, Wysocki T, Cassady JF, et al. Validation of measures of parents’ preoperative anxiety and anesthesia knowledge. Anesth Analg 1999; 88:251–257. 12 Kiyohara LY, Kayano LK, Oliveira LM, et al. Surgery information reduces anxiety in the pre-operative period. Rev Hosp Clin Fac Med Sao Paulo 2004; 59:51–56. A Brazilian study assessing anxiety levels on the day before surgery and accurate information about diagnosis, surgical procedure and anaesthesia. 13 Giraudet-Le Quintrec JS, Coste J, Vastel L, et al. Positive effect of patient education for hip surgery: a randomized trial. Clin Orthop 2003; 414:112– 120. 14 Brull R, McCartney CJ, Chan VW. Do preoperative anxiety and depression affect quality of recovery and length of stay after hip or knee arthroplasty? Can J Anaesth 2002; 49:109. 15 Heidegger T, Husemann Y, Nuebling M, et al. Patient satisfaction with anaesthesia care: development of a psychometric questionnaire and benchmarking among six hospitals in Switzerland and Austria. Br J Anaesth 2002; 89:863–872. 16 Heidegger T, Nuebling M, Germann R, et al. Patient satisfaction with anesthesia care: information alone does not lead to improvement. Can J Anaesth 2004; 51:801–805. This study uses a valid and reliable questionnaire to measure patient satisfaction about anaesthesia care (see Ref. 15). The authors examine the effectiveness of various types of information interventions before and after implementation in three different hospitals. 17 Harms C, Young JR, Amsler F, et al. Improving anaesthetists’ communication skills. Anaesthesia 2004; 59:166–172. This paper examines the effectiveness of training anaesthetists in communication skills on preoperative anxiety and patient satisfaction. 18 Reurer M, Hueppe M, Klotz KF, et al. Detection of causal relationships between factors influencing adverse side-effects from anaesthesia and convalescence following surgery: a path analytical approach. Eur J Anaesthesiol 2004; 21:434–442. A difficult paper to read. The authors used complex statistics to model causal relationships and mediator effects of the influence of the preoperative interview on the recovery after anaesthesia.