вход по аккаунту



код для вставкиСкачать
Educating patients about anaesthesia: effect of various
modes on patient’s knowledge, anxiety and
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
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.
anaesthesia, anxiety, knowledge, patient education, patient
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:
Current Opinion in Anaesthesiology 2005, 18:205–208
State Trait Anxiety Inventory
# 2005 Lippincott Williams & Wilkins
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 [1]. However, patient
satisfaction with anaesthetic care was similar between
media-based intervention and non-intervention groups
[1]. 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 [2]. 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 [2]. Twelve
per cent were concerned about death during general
anaesthesia [2]. Approximately 27% were very concerned
about permanent paralysis, back injury, pain, a needle in
the back and seeing the procedure with regional anaesthesia [3]. Although the survey [2,3] had limitations
[4], 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.
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%) [5]. 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].
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
Written information helps patients make informed choices
about their healthcare, and strengthens the process of
informed consent [7]. 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 [6]. Pregnant women receiving
the leaflet during the first trimester were more knowledgeable about various analgesic techniques than women in the
control group [6]. 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 [6]. Regardless of
the level of knowledge, most women (89%) thought that
they would use some form of analgesia in labour [6]. 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.
[5] 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%) [5]. Although the authors stated that the
video was a success for patient education, the paper did
not actually assess the effect of the video.
Reducing patient anxiety is one of the purposes of conducting a pre-anaesthetic consultation [8]. Preoperative
anxiety can be divided into three distinct dimensions:
fear of the unknown; fear of feeling ill; and fear for one’s
life [9]. The incidence of high preoperative anxiety is
approximately 25% [7,9] as measured by the State Trait
Anxiety Inventory (STAI) [10], 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 [11]. A recent
study from Brazil [12] 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 [7]. 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 [7]. 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
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 [5]. 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 [13]. 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) [13]. 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 [14].
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 [13]. 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 [1].
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 [13].
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 [16].
The percentage of patients who thought that information
and involvement in decision-making were a problem
remained unchanged between 2000 (31%) and 2002
(28%) [16]. 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 [17].
Using complex modeling, training decreased patient
anxieties about anaesthesia and surgery, but the effect
was small given the intense programme [17].
A preoperative interview may influence anaesthetic outcome. Reurer et al. [18] 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 [18]. 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 [18]. A limitation of
the study was that patient satisfaction was measured by a
tool without sound psychometric properties.
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 [1], 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.
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
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
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.
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–
This study is a survey on the attitudes of the general public in Canada towards a
number of commonly perceived fears about regional anaesthesia.
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 [3], 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;
This study outlines the results of a questionnaire to determine parental attitudes
towards information before producing a video for patient education.
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–
A randomized controlled trial of 85 patients to examine the effect of anaesthetic
drug patient information leaflets on anxiety and patient satisfaction.
Klafta JM, Roizen MF. Current understanding of patients’ attitudes toward and
preparation for anesthesia: a review. Anesth Analg 1996; 83:1314–1321.
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;
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;
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–
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;
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.
Без категории
Размер файла
70 Кб
00001503, 00017, 200504000
Пожаловаться на содержимое документа