|Year : 2016 | Volume
| Issue : 3 | Page : 502-507
Evolving with modern technology: Impact of incorporating audiovisual aids in preanesthetic checkup clinics on patient education and anxiety
Haramritpal Kaur1, Gurpreet Singh1, Amandeep Singh2, Gagandeep Sharda1, Shobha Aggarwal1
1 Department of Anaesthesia, GGS Medical College and Hospital, Faridkot, Punjab, India
2 Department of Surgery, GGS Medical College and Hospital, Faridkot, Punjab, India
|Date of Web Publication||27-Sep-2016|
Department of Anaesthesia, GGS Medical College and Hospital, Faridkot, Punjab
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Aims: Perioperative stress is an often ignored commonly occurring phenomenon. Little or no prior knowledge of anesthesia techniques can increase this significantly. Patients awaiting surgery may experience high level of anxiety. Preoperative visit is an ideal time to educate patients about anesthesia and address these fears. The present study evaluates two different approaches, i.e., standard interview versus informative audiovisual presentation with standard interview on information gain (IG) and its impact on patient anxiety during preoperative visit.
Settings and Design: This prospective, double-blind, randomized study was conducted in a Tertiary Care Teaching Hospital in rural India over 2 months.
Materials and Methods: This prospective, double-blind, randomized study was carried out among 200 American Society of Anesthesiologist Grade I and II patients in the age group 18–65 years scheduled to undergo elective surgery under general anesthesia. Patients were allocated to either one of the two equal-sized groups, Group A and Group B. Baseline anxiety and information desire component was assessed using Amsterdam Preoperative Anxiety and Information Scale for both the groups. Group A patients received preanesthetic interview with the anesthesiologist and were reassessed. Group B patients were shown a short audiovisual presentation about operation theater and anesthesia procedure followed by preanesthetic interview and were also reassessed. In addition, patient satisfaction score (PSS) and IG was assessed at the end of preanesthetic visit using standard questionnaire.
Statistical Analysis Used: Data were expressed as mean and standard deviation. Nonparametric tests such as Kruskal–Wallis, Mann–Whitney, and Wilcoxon signed rank tests, and Student's t-test and Chi-square test were used for statistical analysis.
Results: Patient's IG was significantly more in Group B (5.43 ± 0.55) as compared to Group A (4.41 ± 0.922) (P < 0.001). There was significant reduction in total anxiety from the baseline values in both the groups. This reduction was significantly more in Group B (8.47 ± 1.861) as compared to Group A (9.29 ± 1.616) (P < 0.001). PSS was also more in Group B (29.27 ± 2.378) as compared to Group A (25.62 ± 1.745) (P < 0.001).
Conclusion: Audiovisual presentation provides unhurried, detailed, and reliable information about the perioperative environment and anesthesia procedure. This helps in significant IG and reduction of patient anxiety.
Keywords: Anxiety, audiovisual, information gain, patient satisfaction, preoperative visit
|How to cite this article:|
Kaur H, Singh G, Singh A, Sharda G, Aggarwal S. Evolving with modern technology: Impact of incorporating audiovisual aids in preanesthetic checkup clinics on patient education and anxiety. Anesth Essays Res 2016;10:502-7
|How to cite this URL:|
Kaur H, Singh G, Singh A, Sharda G, Aggarwal S. Evolving with modern technology: Impact of incorporating audiovisual aids in preanesthetic checkup clinics on patient education and anxiety. Anesth Essays Res [serial online] 2016 [cited 2020 Jul 6];10:502-7. Available from: http://www.aeronline.org/text.asp?2016/10/3/502/177187
| Introduction|| |
Patients awaiting surgery may experience high level of anxiety due to undue worries. A lack of knowledge about operative theater environment, surgical procedure, and anesthesia techniques may be the underlying cause., Incidence of perioperative anxiety has been reported to be as high as 92% in patients undergoing any surgical procedure.
Anxiety is known to trigger stress response which can be extremely harmful to the patients., Stress can have both physiological and psychological impact on the patients. Stress is known to cause deranged blood sugars, inhibit cellular immune response, increased oxidative demand, tachycardia, arrhythmias, elevated blood pressure, delayed surgical healing, myocardial ischemia, posttraumatic stress disorder, depression, etc.,
Anesthesia and analgesia requirements in an anxious patient are much higher. Anxious patients require larger doses of induction agents, need a longer hospital stay, and have a higher incidence of perioperative complications.,
Managing anxiety is an important but an extremely difficult task. The preanesthetic consultation serves as an ideal platform to establish a good patient–doctor relationship. It can be utilized for providing insight about surgery and anesthesia techniques. This results in better educated and informed patients, which can help reduce patient's anxiety. The most common concerns elicited during preanesthetic visit include queries regarding operation theater (OT) environment, pain, intraoperative awareness, risks associated with anesthesia, and surgical outcome.,
With current multimedia technologies becoming an essential part of our present day-to-day life, it becomes ever eminent to incorporate these elements effectively in our standard health care services. This can ensure a more efficient, accurate, authentic acceptable flow of information.
A number of studies have tried to assess the patient satisfaction after preanesthetic visit, comparing different methods, e.g., face-to-face interviews, brochures, audio tapes, preoperative video information, with varying results., However, very little consideration has been given to patient education, information gain (IG), and patient anxiety levels.
The present study evaluates two different approaches to patient education, i.e., standard interview versus informative audiovisual presentation with standard interview on patient's IG and its impact on patient's anxiety.
| Materials and Methods|| |
After Institutional Ethical Committee approval, this prospective, double-blind, randomized study was carried out over 2 months among 200 American Society of Anesthesiologist (ASA) Grade I and II patients in the age group 18–65 years to undergo elective surgery under general anesthesia. Exclusion criteria included prior exposure to any anesthesia technique, patients having psychiatric disorders, patients not well oriented to time, place, and person, patients having significant medical background (e.g., doctors/medical interns/staff nurses and medical technicians aware of operative environment), and ASA Grade >II.
Patients were allocated to one of the two equal-sized groups through computer-generated randomization. Due to nature of the intervention, participants could not be blinded to the study group intervention. To counteract this potential, it was ensured that the resident doctor collecting the forms or making patients record was unaware to which group patient was allocated and was not the same who had delivered the preoperative information to the patient. During analysis, the observer was blinded to the study group allocations. Blinding was opened at the end of the study.
Patient anxiety and information desire were assessed using 6-item, Amsterdam Preoperative Anxiety and Information Scale (APAIS).
A departmental-approved audiovisual presentation was prepared in the common vernacular of our region (Punjabi) showing OT environment, general anesthesia techniques, and common equipment. Baseline patient anxiety and information desire scores were assessed using APAIS-1 and recorded for both Group A and Group B.
Group A then received preanesthetic interview with the anesthesiologist, and their anxiety and information desire was reassessed.
Group B patients were shown the audiovisual presentation about OT and anesthesia procedure followed by preanesthetic interview, and their anxiety and information desire was reassessed.
Patient satisfaction and IG were assessed using standard questionnaire  among both groups at the end of preanesthetic interview.
The APAIS consisted of four questions (1, 2, 4, and 5) concerning patients anxiety about anesthesia and surgery and two questions (3 and 6) evaluating the need or desire for information.
- I am worried about the anesthetic
- The anesthetic is on my mind continually
- I would like to know as much as possible about the anesthetic
- I am worried about the procedure
- The procedure is on my mind continually
- I would like to know as much as possible about the procedure.
All questions were scored on a 1–5 Likert scale. This 6-item questionnaire had been subgrouped into 3 components:
Anesthesia-related anxiety (sum A) = Sum of questions 1 and 2.
Surgery-related anxiety (sum S) = Sum of questions 4 and 5.
Total anxiety (sum C) = (sum A + sum S).
Information desire component (IDC) (sum IDC) = Sum of questions 3 and 6.
After the procedure, patient satisfaction was judged by a standard questionnaire given below:
- The preanesthetic visit took place under time pressure
- The explanation could be understood easily
- Some of my questions were not answered during preanesthetic visit
- After the preanesthetic visit, I was informed about the procedure of anesthesia
- The form of preanesthetic visit should have been clearer
- I was content with the preanesthetic visit.
Each question was assigned one to six points. Total patient satisfaction ranged from a minimum of 6 to maximum of 36. The difference of two points in sum score reflects a relevant improvement in patient satisfaction.
The second part of the questionnaire consisted of six multiple choice specific questions on IG  given below:
- Who is an anesthesiologist?
- A nurse
- A doctor (correct answer)
- A medical technician
- I do not know/I cannot remember
- Where is the anesthesiologist staying during your operation?
- He is with me all the time to check my vital signs (correct answer)
- He leaves the operating room as the surgeon is monitoring the anesthesia
- He is looking after several patients at a time
- I do not know/I cannot remember
- How do you breathe during general anesthesia?
- I am mechanically ventilated by a tube (correct answer)
- I am breathing normally
- During surgery, I do not need to breathe
- I do not know/I cannot remember
- What do you know about strong pain after surgery?
- Severe pain can be prevented (correct answer)
- Severe pain is a necessary part of recovery
- Severe pain has to be endured
- I do not know/I cannot remember
- What is true about the duration of anesthesia?
- The duration of anesthesia is determined before surgery and cannot be altered thereafter
- The duration of anesthesia can be prolonged as desired during surgery (correct answer)
- The duration of anesthesia cannot be predicted or be influenced
- I do not know/I cannot remember
- Why cannot you eat or drink before anesthesia?
- So that the anesthesia can take effect
- To thicken the contents of the stomach
- To prevent the contents of the stomach getting into the lungs (correct answer)
- I do not know/I cannot remember.
Each correct answer was assigned one point, wrong answers or the response “I do not know/I cannot remember” were given no points. IG values ranged between a minimum of zero and a maximum of six score.
Sample size calculation and analysis of data
The sample size was calculated using data from the previous studies. To ensure 80% power of the study, 77 participants were needed in each group. The data collected were entered into an Excel spreadsheet and then converted into IBM SPSS, version 17.0 for further analysis. Kruskal–Wallis, Mann–Whitney, and Wilcoxon signed rank tests, Student's t-test, and Chi-square test were used for statistical analysis. P < 0.05 was considered statistically significant, and P < 0.001 was considered highly significant.
| Results|| |
Totally, 200 patients were enrolled in the study. Random allocation resulted in 100 patients assigned to Group A (interview alone) and 100 patients assigned to Group B (interview and audiovisual presentation).
There was no significant difference in demographic data and educational status among the two groups [Table 1]. Baseline anxiety and information desire score were recorded as APAIS-1 [Table 2]a. Anxiety and information desire scores after interview and audiovisual presentation were recorded as APAIS-2 [Table 2]b. Patient satisfaction score (PSS) were recorded [Table 3]. IG was recorded [Table 3] and the frequency of correct answers to each question in IG is shown in [Table 4].
| Discussion|| |
With daycare/outpatient-based surgical practice becoming the need of the day, anesthesiologists get very little time to interact with patients. In such time-restrained situations, patient's fears regarding anesthesia and surgical outcome may not be properly addressed. Patient education often suffers. A short informative audiovisual presentation can help improve this.
Anxiety is the normal human response particularly when people are facing a serious life-threatening situation. Patient awaiting surgery may experience different levels of anxiety. Incidence of perioperative anxiety in adults may vary from 11% to 80%. Lack of knowledge is a known contributor to patient anxiety.
Although anxiolytic drugs help in relieving anxiety, they carry their own limitations and disadvantages. Various distraction and relaxation techniques, i.e., yoga, therapeutic massage, or music, have been used to reduce anxiety with variable outcome.,, Information can be an important tool in reducing patients anxiety and improving their hospitalization experience. Video presentations are high-impact tools for providing information. Visuals cause a faster and stronger reaction than words. They help users engage with the content and such emotional reactions influence information retention. Visual memory is far superior to verbal memory and can persist for a longer time., Previous studies have shown reductions in anxiety scores when using video or broacher as information tool during preoperative visit.,,
This study is an attempt to evaluate the usefulness of informative audiovisual presentation and its impact on patient education and anxiety.
This study was carried out in 200 patients to assess IDC, anxiety, IG and PSS. It was hypothesized that video presentation would result in more informed and less anxious patients, thus increasing patient satisfaction, which was proven to be true in this study. Patients' anxiety, information desire, and IG were assessed as primary outcome and patient satisfaction score was assessed as secondary outcome.
Baseline anxiety and IDC were recorded as APAIS-1 and were similar (P > 0.05) in both the groups [Table 2]a.
Anxiety and IDC postinterview and audiovisual presentation were recorded as APAIS-2.
On analysis, we could appreciate a significant reduction in IDC component from 6.76 ± 1.545 to 5.65 ± 1.192 in Group A (P< 0.001) and from 6.88 ± 1.565 to 4.80 ± 1.271 in Group B (P< 0.001 from the baseline IDC values [Table 2]b.
Group A recorded a decrease in total anxiety (sum C) from 11.42 ± 2.417 to 9.29 ± 1.616 (P< 0.001). Group B recorded a decrease in total anxiety (sum C) from 11.77 ± 2.494 to 8.47 ± 1.861 (P< 0.001) [Table 2]b.
On intergroup comparison [Table 2]a, Group B recorded a highly significant decrease in IDC component (4.80 ± 1.271) as compared to Group A (5.65 ± 1.192) (P< 0.001).
Total anxiety (sum C) recorded a similar decrease in Group B (8.47 ± 1.861) as compared to Group A (9.29 ± 1.616) (P = 0.001).
PSS and IG [Table 3], patient in the video Group B were more satisfied (PSS = 29.27 ± 2.378) as compared to Group A (PSS = 25.62 ± 1.745) (P < 0.001).
IG was significantly higher in Group B (5.43 ± 0.55) as compared to Group A (4.41 ± 0.922) (P < 0.001) correlating well with decrease in IDC as shown above.
Frequency of correct answers to each question in IG questionnaire is shown in [Table 4].
Question 1 (Who is an anesthesiologist?) and question 2 (Where does the anesthesiologist stay during your operation?) did not show any intergroup significant variations (P > 0.05). Out of 100, 98% patients in both groups correctly answered the question 1 while 89% and 94% patients in Groups A and B, respectively, correctly answered question number 2.
Question 3 (How do you breathe during general anesthesia?), question 4 (What do you know about strong pain after surgery?), question 5 (What is true about the duration of anesthesia?) and question 6 (Why can't you eat or drink before anesthesia?) recorded significant variations, with Group B recording a higher rate of correct response as compared to Group A (P < 0.001). Pertaining to these questions, Group B was better informed. Question 4, about perception of pain showed worst results in both groups (44% in Group A and 70% in Group B). Pain is an important and difficult topic for patients to understand and needs to be addressed specifically and separately.
A study by Done and Lee  revealed similar results when they used a video to convey preanesthetic information to patient undergoing ambulatory surgery and by Snyder-Ramos et al. in their study comparing patient satisfaction and IG using face-to-face interviews, brochure, and video during preanesthetic visit.
Our results correlate well with Done and Lee and Snyder-Ramos et al. Audiovisual presentation is a better information tool than interview alone. It results in much higher IG. Patients shown an informative audiovisual presentation before surgery have lesser anxiety. A better informed patient has a significantly higher satisfaction score. Audiovisual presentation helps in preparing patients better for their hospital experience and significantly adds to patient comfort.
Although this study highlights the benefits of audiovisual presentation, it has a few limitations. This study included only ASA Grade I and II patients in a relatively rural population. Patient socioeconomic status, education level, cultural and language diversities can influence the outcomes. Patient's diagnosis, type of surgery, duration of surgery and expected surgical outcomes can all affect the patients' anxiety levels. Video was made as per se emed necessary from the prospective of anesthesiologist (IG required) but not as per the actual needs or queries of the patients. A further study can be conducted taking into consideration patient queries as a basis. With the consensus of society, a standard video addressing the needs of both patients and anesthesiologist can be framed and made readily available to the general public and its impact can be assessed on a larger population base. Information about pain is often misinterpreted and needs to be addressed separately.
| Conclusion|| |
A better IG results in a lesser desire for further information which results in reduced anxiety. Video is a better tool than interview alone for imparting information. Its potential in providing education regarding lesser known areas of health services should be explored and utilized.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Matthias AT, Samarasekera DN. Preoperative anxiety in surgical patients – Experience of a single unit. Acta Anaesthesiol Taiwan 2012;50:3-6.
Sagün A, Birbiçer H, Yapici G. Patients', who applied to the anesthesia clinic, perceptions and knowledge about anesthesia in Türkiye. Saudi J Anaesth 2013;7:170-4.
Jawaid M, Mushtaq A, Mukhtar S, Khan Z. Preoperative anxiety before elective surgery. Neurosciences (Riyadh) 2007;12:145-8.
Nigussie S, Belachew T, Wolancho W. Predictors of preoperative anxiety among surgical patients in Jimma University Specialized Teaching Hospital, South Western Ethiopia. BMC Surg 2014;14:67.
Zvara DA, Mathes DD, Brooker RF, McKinley AC. Video as a patient teaching tool: Does it add to the preoperative anesthetic visit? Anesth Analg 1996;82:1065-8.
Andersen BL, Farrar WB, Golden-Kreutz D, Kutz LA, MacCallum R, Courtney ME, et al.
Stress and immune responses after surgical treatment for regional breast cancer. J Natl Cancer Inst 1998;90:30-6.
Pritchard MJ. Identifying and assessing anxiety in pre-operative patients. Nurs Stand 2009;23:35-40.
Jafar MF, Khan FA. Frequency of preoperative anxiety in Pakistani surgical patients. J Pak Med Assoc 2009;59:359-63.
Maranets I, Kain ZN. Preoperative anxiety and intraoperative anesthetic requirements. Anesth Analg 1999;89:1346-51.
Klafta JM, Roizen MF. Current understanding of patients' attitudes toward and preparation for anesthesia: A review. Anesth Analg 1996;83:1314-21.
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;48:333-9.
Lee A, Chui PT, Gin T. Educating patients about anesthesia: A systematic review of randomized controlled trials of media-based interventions. Anesth Analg 2003;96:1424-31.
Snyder-Ramos SA, Seintsch H, Böttiger BW, Motsch J, Martin E, Bauer M. Patient satisfaction and information gain after the preanesthetic visit: A comparison of face-to-face interview, brochure, and video. Anesth Analg 2005;100:1753-8.
Prabhakar AR, Marwah N, Raju OS. A comparison between audio and audiovisual distraction techniques in managing anxious pediatric dental patients. J Indian Soc Pedod Prev Dent 2007;25:177-82.
Berth H, Petrowski K, Balck F. The Amsterdam preoperative anxiety and information scale (APAIS) – The first trial of a German version. Psychosoc Med 2007;4:Doc01.
Snyder-Ramos SA, Seintsch H, Böttiger BW, Motsch J, Martin E, Bauer M. Development of a questionnaire to assess the quality of the preanesthetic visit. Anaesthesist 2003;52:818-29.
Wilkinson SM, Love SB, Westcombe AM, Gambles MA, Burgess CC, Cargill A, et al.
Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: A multicenter randomized controlled trial. J Clin Oncol 2007;25:532-9.
Subramanya P, Telles S. Effect of two yoga-based relaxation techniques on memory scores and state anxiety. Biopsychosoc Med 2009;3:8.
Sherman KJ, Ludman EJ, Cook AJ, Hawkes RJ, Roy-Byrne PP, Bentley S, et al.
Effectiveness of therapeutic massage for generalized anxiety disorder: A randomized controlled trial. Depress Anxiety 2010;27:441-50.
Bailey L. Strategies for decreasing patient anxiety in the perioperative setting. AORN J 2010;92:445-57.
Standing L, Conezi J, Haber RN. Perception and memory for pictures: Single-trial learning of 2500 visual stimuli. Psychon Sci 1970;19:73.
Cohen MA, Horowitz TS, Wolfe JM. Auditory recognition memory is inferior to visual recognition memory. Proc Natl Acad Sci U S A 2009;106:6008-10.
Salzwedel C, Marz S, Bauer M, Schuster M. Video-assisted patient education in anaesthesiology: Possibilities and limits of a new procedure for improvement of patient information. Anaesthesist 2008;57:546-54.
Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010;104:369-74.
Done ML, Lee A. The use of a video to convey preanesthetic information to patients undergoing ambulatory surgery. Anesth Analg 1998;87:531-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]