Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries

doi:10.4236/ojanes.2013.39085

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Open Journal of Anesthesiology, 2013, 3, 402-407

Published Online November 2013 (http://www.scirp.org/journal/ojanes)

http://dx.doi.org/10.4236/ojanes.2013.39085

Open Access OJAnes

Balance of Concerns: Satisfactory Pre-Anesthetic Patient

Education and the Extent of Patient Worries

Joerg Schnoor*, Ulrike Reuter, Nils Engelmann, Ullrich Burkhardt

Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.

Email: *[email protected]

Received September 24th, 2013; revised October 17th, 2013; accepted October 29th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Controversy exists whether or not patient’s concerns regarding anesthetics can be reduced by face-to-face pre-asses-

sment with an anesthetist. Thus we were looking at concerns patients had before and after such a consultation. Patient

satisfaction was rated by a validated questionnaire. A four-staged Likert-scale was used to quantify the extent of pa-

tients concerns. The totaling 461 patients were overall highly satisfied. 448 patients had “nil” to “minimal” concerns.

After the assessment, 106 patients stated their concerns had been lessened (p < 0.001). Having gone through the anes-

thetic pre-assessment center, 99.1% of all patients reported no considerable concerns regarding anesthetics whatsoever.

A high level of patient satisfaction does not constitute a low level of concerns patients may hold over anesthetics, al-

though a pre-operative consultation mitigated these concerns by 23%, whilst for 9% of all patients this pre-assessment

led to a higher level of concerns.

Keywords: Patient Worries; Patient Concerns; Preoperative Patient Assessment; Resilience; Anxiolysis

1. Introduction

More and more hospitals take patient satisfaction into

consideration when evalu ating outcome of hosp ital stays.

But especially for pre-assessment centers such an ap-

proach is not always helpful. About 90% of all patients

are happy at the time of getting pre-assessed. However,

this can be too optimistic taking into consideration the

dependence on and subjection to the carer and treatment,

as demonstrated in the wellbeing paradox [1,2].

30% - 60% of all patients had concerns or even fears

prior to any operation [3]. Whilst concerns regarding the

operation and those regarding anesthetics are hard to

differ, a pre-aesthetic consultation can reduce these con-

cerns by up to 60% [4-9]. Unfortunately 30% of all pa-

tients saw their concerns soaring after such a consultation

[10]. Although patient satisfaction is more and more em-

braced by hospitals as another tool for measurement of

quality, patients concerns remain a somewhat unchar-

tered territory.

We aimed at quantifying the impact an anesthetic pre-

assessment had on patients concerns whilst otherwise

being satisfied. Therefore, a validated questionnaire had

to be filled out by patients prior and after the pre-asses-

sment rating patients’ worries.

2. Method

After approval from the local Ethics Commission we

conducted our study form July to September 2011 in the

anesthetic pre-assessment center of the University Hos-

pital Leipz ig. Writt en in formed consent was o btain ed p rio r

to the anesthetic consultation. Patients were recruited

from 12 different surgical specialties (Visceral-, Trans-

plant-, Thoracic- and Vascular Surgery, Trauma and

Plastic surgery, Orthopedics, Neuro surgery, OBs/ GYNE,

Urology, ENT, Maxillo Facial surgery, Dermatology,

Radiotherapy, Virology and Allergology). Patients being

bedbound or contagious were not included.

We included all patients from 18 years of age upwards,

ranging in ASA classification I-IV, presenting them at

that time in the anesthetic pre-assessment center. Selec-

tion of patients was conducted weekdays, depending on

availability of staff trained for this survey. Criteria for

dismissal of participation were aged below 18, missing

power of attorney, previous participation when undergo-

ing revision of surgery, lack of communication, and pa-

*Corresponding a uthor.

Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries 403

tients’ refusal to participate.

Patients were asked to choose from one of the follow-

ing 4 stages of concerns displayed on a four-staged Li-

kert-scale (4 = nil concerns, 3 = minimal concerns 2 =

many concerns, 1 = great concerns) before and after the

face-to-face consultation with an anesthetist [11]. Further

on we rated patients’ satisfaction regarding the anesthetic

pre-assessment consultation using a validated question-

naire (ZUF-8), which is the German adaptation to the

American CSQ-8 questionnaire (Table 1) [12-14].

Statistical analysis was computer based, using SPSS®

Statistics, Version 20, IBM®. The paired t-Test was util-

ized for pre-post comparison within any random sample.

Group comparison was conducted using both the Mann-

Whitney-U test and the Fisher’s exact test, respectively.

Data is displayed as an Arithmetic Mean and Standard

Deviation, unless stated otherwise. Level of Statistical

Significance was determined as 5% (p < 0.05).

3. Results

Of 587 patients, 461 (78.5%) completed records were ob-

tained. Median age was 52.4 ± 16.5 years, out of which

46.2% were of female gender. Median ASA classifica-

tion was II (Figure 1). Overall patient satisfaction was

high (ZUF-8: 29.4 ± 2.5; Minimum-Maximum 20 - 32,

Figures 2 and 3).

Prior to the anesthetic pre-assessments 448 (97.2%)

stated to have “nil” to “minimal” concerns regarding

anesthesia (Figure 4). This figure rose to 457 patients

(99.1%; 3.72 ± 0.47; t = 5.27; Degrees of Freedom = 460;

p < 0.001, Figure 5). Opposite to that the number of pa-

tients with “many” concerns (12 patients) was reduced

down to 4 patients. The single patient with, “great” con-

I II III

ASA-Classification

400

300

200

100

Number of Patients

Figure 1. Distribution of ASA classification.

20 22 23 24 25 26 27 28 29 30 31 32

ZUF-8 score

140

120

100

Number of Patients

Figure 2. Distribution of patient satisfaction according to

ZUF-8-score after anesthetic pre-assessment (ZUF-8-Ques-

tionnaire, 8 - 32 possible points summarized).

Table 1. Overall satisfaction with the anesthetic pre-assessment, determined by a modified questionnaire, adapted to the pre-

assessment center (ZUF-8 [12]).

1) To what extend has the anesthetic pre-assessment center catered for your need?

(4 = catered for almost all my need; 3 = catered for most of my need; 2 = catered for just a few of my need; 1 = has not catered for my need)

2) How would you rate the quality of your anesthetic consultation?

(4 = excellent; 3 = good; 2 = not so good; 1 = bad)

3) How satisfied were you with th e overall content of your pre-assessment?

(4 = satisfied; 3 = mostly satisfied; 2 = with reservations; 1 = not satisfied)

4) Has the anesthetics consultation helped you to revaluate your concerns regarding the anesthetics procedure?

(4 = yes, it has been very helpful; 3 = it helped a little; 2 = it did not help at all; 1 = no, it made it even more difficult to deal with)

5) Would y ou opt for this ane sthetics departme nt again if you had to undergo other anesthetics?

(4 = definitely; 3 = generally speaking, yes; 2 = generally speaking, no; 1 = absolutely not)

6) Would you recommend the anesthetic department to a friend if he or she needed an anesthetic?

(4 = definitely; 3 = generally speaking, yes; 2 = generally speaking, no; 1 = absolutely not)

7) Would you come back to the University Hospital Leipzig if you were in need of medical attention?

(4 = definitely; 3 = generally speaking, yes; 2 = generally speaking, no; 1 = absolutely not)

8) Would you recommend the University Hospital Leipzig to a friend if he or she nee de d medical attention?

(4 = definitely; 3 = generally speaking, yes; 2 = generally speaking, no; 1 = absolutely not)

he s u m of achieved points leads to the ZUF-8 rating (Minimum-Maximum: 8 - 32 points).

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Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries

404

ZUF-8 summarized pionts

ZUF-8 Distribution

Figure 3. Patient satisfaction (box plot) after the anesthetic

pre-assessment (ZUF-8-Questionnaire, 8 - 32 possible points

summarized).

300

200

100

Number of Patients

1 = great 2 = many 3 = minmal 4 = nil

Degree of Worries

Figure 4. Patients concerns prior to anesthetic pre-asses-

sment.

cerns felt relief and subsequently downgraded his con-

cerns to the “many” concerns level.

A total of 42 patients announced an increase in con-

cerns felt after the anesthetic consultation. 41 of these

patients went from “nil” to a “minimal” concerns level.

A single patient went from “nil” concerns to “great” con-

cerns after having been pre-assessed by an anesthetist.

The group of patients show ing an increase in concerns (n

= 42) simultaneously displayed a slightly higher level of

overall satisfaction (ZUF-8: 30.5 ± 1.6 vs. 29.3 ± 2.6; p=

0.01). Other than that no statistically significant differ-

ence was found regarding the variables of gender (Fis-

cher’s exact test, p = 0.303), age, BMI, and ASA (Mann-

Whitney-U test with p = 0.907, p = 0.802, and p =

0.737).

4. Discussion

In line with expectations, the results demonstrate a high

nil

min i ma l

many

great

Degree of Worries

re post

167

281 335

1 95

1 122

Figure 5. Summary of concerns of individual patients prior

and after anesthetic pre-assessment. Numeric characters

und sizes of circle display number of patients. Green arrow s

indicate a reduction in concerns, a red arrow an increase in

concerns patients had. Numeric characters of arrows dis-

play number of patients as net movement.

level of patient satisfaction regarding the anesthetic pre-

assessment consultation. The overwhelming number of

patients had nil to minimal concerns regarding the up-

coming anesthetic, and this number increased by 6% up

to 99% of all patients after consulting an anesthetist. 13

patients with “many” to “great” concerns could be com-

forted, whilst 9% of all patients had their level of con-

cerns raised, one even comprehensively.

Having concerns and fear are primeval feelings. The

roots of these can be found in man’s perception of his life

span limiting his existence. Vulnerability of body and

soul, a sense of imperfection, and finally, the prospect of

inevitable death all fuel doubt, concerns, and fears. Out-

side of Psychopathology definition of these is subject to

debate. However, psychologically ordinary patients per-

ceive “concerns” as disconcerting forethoughts, without

any reassurances whether the anticipated realistic or un-

realistic scenarios can be dealt with accordingly or not.

Fear, in its true meaning, is perceived as imminence or

even intimidation, un idirectional, even unmotivated, with

or without a comprehensible so urce of this, whilst “Fear”

has a present source and magnitude [15].

4.1. Patients’ Perspective

Patients favor a reduction of pre-operative concerns, no-

tably by consulting a doctor [16]. A previous study

though found an unintentional increase in patients’ con-

cerns in up to 30% after such a consultation [10]. Our

study showed a lower rate than this; still despite a high

level of patient satisfaction almost every 10th patient

voiced an increased level of concerns after the anesthetic

pre-assessment. However, previous studies found other,

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Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries 405

non anesthetic related sources, notably being away from

home and relatives, waiting time on operation, loss of

autonomy, as well as ensuing physical and psychological

ramifications from prospective surgery [17,18].

Opposingly, multiple factors can reduce pre-operative

concerns of patients. An empathetically conducted pre-

assessment, an adequate amount of information, as well

as the manner of the consultation all attribute positively

towards reducing patients’ concerns [19,20]. A religious

or spiritual background, a supportive social network, vi-

siting relatives, acupressure and music are perceived as

alleviating and comforting. A patient’s cultural back-

ground contributing to his coping strategies must be ta-

ken into consideration as well [21-23].

Individual coping strategies seem to be of great im-

portance. “Resilience” describes an individual’s ability to

utilize ones own resources as well as those of relatives

and other social networks, to cope and overcome stress

and adversity, and possibly even gain posttraumatic

growth [2 4, 25].

Individual levels of resilience determine how success-

ful a patient copes with stress. A hospital stay or sched-

uled operation can instigate serious thoughts regarding

ones own mortality. However, in a busy hospital sched-

ule time to dwell on these thoughts and finding answers

to these question s is naturally rather limited . Add ition ally,

ones concept of life previously taken for granted may

now become acutely destabilized.

Furthermore, some patients may realize the full ac-

count of surgical ramifications for the first time after an

anesthetic pre-assessment, with little to no time to ap-

prehend this in detail. Being unprepared and left with

aspects threatening their future wellbeing, concerns and

even fear may develop despite any empathetically con-

ducted anesthetic consultation.

4.2. Corporate Perspective

In the German health care system patients are seen as

customers shopping for services. However, in health care

markets a patient seldom approaches a medical profes-

sional on an even level, as his medical condition puts him

in a position of need and dependency. Furthermore, due

to the nature of illnesses, patients neither have time nor

in-depth knowledge to compare or even “choose” from a

variety of independently operating health care providers,

whilst being in need of medical atten tion.

German anesthetic pre-assessment centers operate un-

der a strict time frame, and the pre-assessment is con-

ducted under considerable time pressure, worsened by

ever increasing new legislative requirements for docu-

mentation. A personalized consultation, that has to be

conducted obeying all legal aspects, guidelines and re-

cord keeping requ irements, leaves little room to instigate

trust. Given the fact that in Germany the pre-assessing

anesthetist seldom performs the anesthetic himself, as

theatre and pre-assessment allocation happens on a day

to day basis, the patient is deprived of any chance to get

to know “his” anesthetist, to be there on the day of sur-

gery. This modern fragmentation of work, saving GBP

5.62 per patient each, is significantly working against

building trust between doctors and patients, hampering

bonding on a profession al level, and subsequently reduc-

ing the ability of medical professionals to mitigate pa-

tients’ concerns [26,27].

Quality Management utilizes patient satisfaction as a

tool to measure outcome. In this respect patients can only

measure and hence rate direct medical interaction, which

is exclusively rendered by doctors and nurses. From a

patient’s point of view, friendly and professional staff

makes all the difference, and inter-personal communica-

tion helps to reduce patients concerns. Staff under con-

siderable amount of pressure cannot contribute to build-

ing trust and confidence, nor help mitigate patients’ con-

cerns. The question arises how a modern day hospitals

schedule can accommodate for the need to build trust by

spending more time with patients.

4.3. Limitations of This Study

This study demonstrates various limitations. An addi-

tional person presents for recording the pre-assessment

study and the advanced information of all participants

limits comparison to real life pre-assessment.

Patient’s concerns were rated by the Likert-scale. To

not further interfere with clinical routine we dismissed

the use of standardized rows of questions, displaying the

routine appr oach of pre-assessment instead. This leads to

a stinted comparability with bibliographical references.

The validated ZUF-8 score rated the degree of satis-

faction. Nevertheless, this score is not one of the recently

recommended scores for rating satisfaction with pre-

assessment [28]. Consequently, the comparability of our

results might be limited in the future.

The individual coping strategies and reasons for con-

cerns of patients were not surveyed. Thus, an individual

cause-effect relationship could not be displayed.

The manner of each anesthetist’s assessment was not

taken into consideration. Whether these conversations

fulfilled criteria such as appreciation, authenticity, em-

pathy, and active listening, was not considered [29]. The

results of pre-assessment do not conclude on empathy

and patient centered communication displayed by each

anesthetist.

Altogether, a high level of patient satisfaction does not

conclude to a low level of concerns patients may hold.

Nevertheless, mitigation of patient concerns was achie-

ved one forth of all patients, whilst nearly 1 out of 10

patients emerged from pre-assessment with more con-

cerns than before. The reasons for concerns leading to a

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Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries

406

negative balance of these seem to be multi-factorial, and

as such are difficult to identify. However, a patient cen-

tered approach to presenting information relevant for gi-

ving informed consent should be sought, helping patients

to adapt an optimistic manner of dealing with their con-

cerns. To achieve this, more time spent with each patient

is desirable; something a DRG based system will have a

hard time to generate.

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