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* From the Faculty of Nursing and
the Department Of Anesthesiology University of Montreal,
the Department Of Biostatistics, Montreal Heart Institute, and
the Department Of Psychology Université du Québec à Montréal, Montreal, Quebec, Canada.
Dr. Sylvie Le May, Faculty of Nursing, University of Montreal, C.P. 6128, Succursale Centre-Ville, Montreal, Quebec H3C 3J7, Canada. Phone: 514-343-6384; Fax: 514-343-2306; E-mail: sylvie.lemay{at}umontreal.ca
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Abstract |
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Methods: The scale of patients' perceptions of cardiac anesthesia services (SOPPCAS) is composed of 17 Likert-type and sociodemographic questions. Data collection was conducted on T-1 (fourth postoperative day) and T-2 (15 days postoperatively). In addition, we employed the Marlow-Crowne scale and a short form of the Psychological Symptoms Index to verify the influence of social desirability and psychological distress respectively. Data analysis included a principal component analysis (PCA).
Results: One hundred seventy patients answered the questionnaires at T-1 and 133 patients at T-2. Cronbach alpha of the SOPPCAS was 0.58. PCA revealed four perioperative factors: patient/anesthesiologist interactions, preoccupations related to anesthesia, experience with anesthesia and pain management. Global mean satisfaction was 4.45 ± 0.64 (maximum score 6.0). Main items related to satisfaction were: satisfaction with premedication, empathy from anesthesiologists, pain management. Main items related to dissatisfaction were: lack of information on blood transfusion and recall of endotracheal intubation. A score of 14/20 was obtained for social desirability. Social desirability did not influence the construct of the SOPPCAS.
Conclusion: We developed, using rigorous methods, an instrument to measure patients' perceptions of the quality of cardiac anesthesia services. Global mean satisfaction with anesthesia services was moderately high contrary to previous studies where it was high. Finally, the SOPPCAS should allow anesthesiologists to improve the quality of the care they provide.
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Introduction |
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What patients do know and can respond to is the manner in which a service is delivered (e.g., the behaviour of the individuals providing the service) and the consequences related to that service (e.g., morbidity). Omachonu4 mentions that an important aspect of the evaluation of services by patients is that technical or clinical expertise cannot compensate for a caregiver's poor interaction with patients. Conversely, good-quality interaction with the service provider may positively influence a patient, even when technical aspects are more or less adequate.
Development and testing of a questionnaire on patients' perceptions of anesthesia services requires rigorous methods since perceptions are subjective and considered difficult to measure. It is also essential to employ an instrument with specific questions concurrent with other measures to verify the impact of some of the major confounding variables such as social desirability (SD) and psychological distress. These variables may influence the results obtained from a survey on patient satisfaction. Further, every new instrument needs to be tested regarding its reliability and validity to establish some of its measurement properties.
Therefore, the primary objective of this pilot study was to develop an instrument to measure the perceptions of a group of patients regarding their experience with anesthesia and to verify the performance of our novel instrument. Secondarily, we report patients' perceptions of the anesthesia services provided by a group of cardiac anesthesiologists.
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Methods |
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Conceptual framework
In order to provide a structure to guide the study, we developed a conceptual framework5 depicting the proposed dimensions and interrelations of patients' perceptions of anesthesia services (Figure 1
). A conceptual framework is essential to present the interrelationships between the proposed variables of the concept being studied, and to guide the development of future testable hypotheses. Our framework presents perioperative factors and concomitant variables that might explain patients' perceptions of anesthesia services. These factors and variables were suggested from interviews with patients and health professionals and from our review of the literature.6–8
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Setting
The first part of the study (T-1) took place on the pre- and postoperative cardiac surgery unit of the Montreal Heart Institute (MHI), a teaching institution affiliated with the University of Montreal. The second part (T-2) consisted of a mailing to all participants of T-1.
Instruments
1) SCALE OF PATIENTS' PERCEPTIONS OF CARDIAC ANESTHESIA SERVICES (SOPPCAS)
An extensive review of the literature9 did not yield any appropriate instrument to collect data on patients' perceptions of anesthesia services. It was therefore deemed necessary to develop our own instrument. The SOPPCAS was designed after interviews with health professionals and patients pre- and postsurgery as well as from suggestions from the literature.7,8,10,11 The principal phases followed to develop the instrument and conduct the psychometric testing of the SOPPCAS are presented in Figure 2.
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2) MARLOW-CROWNE SOCIAL DESIRABILITY SCALE (MCSD)
The MCSD scale, developed by Marlow-Crowne in 1960,12 describes culturally approved behaviours with a low probability of occurrence. It was used in the present study to control for respondent's eagerness to please the investigator while answering the SOPPCAS. The abridged form used herein contains 20 questions with a dichotomized choice of response (true-false). A reliable French version of the scale13 was used to collect data. An Alpha of 0.78 was previously obtained with the French version of the scale.13 Scores of the scale vary from 0 to 20. Each item related to a socially desirable behaviour is allotted one point. The higher the score, i.e., approaching 20, the higher is the tendency of the respondent to answer a questionnaire according to what he/she believes would please the investigator, thus showing a high level of SD.
3) PSYCHOLOGICAL DISTRESS ABBREVIATED FORM (SHORT FORM OF THE PSYCHIATRIC SYMPTOM INDEX– PSI OF ILFELD)
The PSI scale, created by Ilfeld in 1976,14 measures the psychological distress of respondents. We employed a shorter form of the PSI, the mini-questionnaire (MQ). A correlation of 0.69 was obtained between the original form and the shorter form of the PSI.15 The internal consistency of the MQ is 0.89.15 This form was validated in French15 and contains questions related to three factors (depression, anxiety and anger). It includes nine Likert-type questions from 0 (not at all) to 4 (very often or extremely). Mean scores equal or close to 4 reveal patients expressing a higher level of psychological distress.
Data collection
The same investigator (SLM) interviewed all 170 patients at T-1. We felt it important that someone outside the department of anesthesia, not one of the anesthesiologists, administer the questionnaires in order to allow patients to express themselves as freely as possible. After giving written informed consent, patients were asked to answer the SOPPCAS and the MQ on their fourth or fifth postoperative day (T-1). On average, each interview lasted about 15 min. The second part of data collection (T-2) involved a mailing of the SOPPCAS, the MQ and the MCSD along with a stamped return envelope to all patients recruited at T-1, approximately 15 days postdischarge from the hospital. T-2 was used to evaluate whether patients' responses regarding satisfaction remained the same after discharge from the hospital (stability of the content), not to evaluate the psychometric stability of the SOPPCAS since the concept of satisfaction is considered unstable over time. The MQ was administered twice to verify the impact of psychological distress on patients' perceptions of satisfaction at T-1 and T-2. The MCSD scale was only administered once at T-2 since SD is an attribute considered stable over time and not expected to vary during a period of 15 days.
Data analysis
The mean, variance, minimum and maximum were calculated for each item. Principal component analysis (PCA) was performed to determine the presence of a factorial structure among the items of the SOPPCAS. Correlations were performed between major significant variables and the SOPPCAS as well as between the SOPPCAS, the MQ and the MCSD scale. We used Cronbach's Alpha to estimate the internal consistency of the SOPPCAS. Data analysis was performed with the SAS release 6.12 software (SAS Institute, Cary, North Carolina, USA).
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Results |
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The mean age of patients was 62.8 ± 11.3 yr (95% CI, 61.11–64.52; Min: 23; Max: 81) with a majority of men (68.2 %). The predominant level of education was high school for 47.1% of the sample. For 22.4% of the patients, this was their first surgical experience and, for 85.9% of them, their first heart operation. Half of the respondents (50%) would have appreciated a postoperative visit by the anesthesiologist who took care of them in the operating room. Table I presents the major postoperative complaints expressed by patients. Most frequent postoperative problems were: nausea and vomiting, pain, sleep disorders and voice hoarseness. One patient reported awareness during surgery (0.6%) while five (2.9%) reported intraoperative dreaming. Finally, 32.9% of the respondents reported hallucinations and 30.0% experienced nightmares during the first two to three days after surgery.
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): 1) patient/anesthesiologist interactions; 2) preoccupations related to anesthesia; 3) experience with anesthesia; 4) pain management. Table II shows the distribution of the items according to each factor as well as the value of Cronbach's Alpha and percentage of variance explained by each factor. Total variance explained by the four perioperative factors was 55.94%. Item 12 displayed the weakest distinction in the distribution of the items among the four factors and, consequently, was removed.
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presents the mean score obtained for each question and reversed question and also the global score of the SOPPCAS at T-1. The mean global satisfaction score averaged 4.45 ± 0.64 (95% CI, 4.36–4.55; Min: 2.82, Max: 5.80 on a possible maximum of 6.0). A mean of 4.39 ± 0.73 (95% CI, 4.26–4.51; Min: 2.23; Max: 5.93) was obtained at T-2. Main items related to satisfaction (represented arbitrarily by scores over 50% for combination of positive responses 4, 5, 6 or 1, 2, 3 for reversed questions) were: satisfaction with premedication (95.8%), feeling of empathy from the anesthesiologist (92.1%), reassurance from the anesthesiologist (90.8%), pain management (86.5%), clarity of information provided by anesthesiologist (86.4%), sufficient information related to anesthesia (83.2%), sufficient information related to the side effects of the anesthetics (63%). Items related to dissatisfaction (represented arbitrarily by scores over 50% for combination of negative responses 1, 2, 3 or 4, 5, 6 for reversed questions) were: lack of information on risks related to blood transfusion (71.5%) and recall of endotracheal intubation (50.8%).
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Overall, men (4.53 ± 0.59) and women (4.29 ± 0.73) were equally satisfied (P <0.05). Yet, men (5.14 ± 1.00, P=0.0002) and women (4.45 ± 1.34, P=0.001) differed regarding preoccupations related to anesthesia (factor 2; P=0.0002) at T-1.
At T-1, other variables correlated significantly with the mean global score or with the perioperative factors of the SOPPCAS. Thus, age correlated with preoccupations related to anesthesia, (factor 2; r=0.16, P=0.04) and patient/anesthesiologist interactions (factor 1; r=-0.23, P=0.003). Global satisfaction with anesthesia services correlated significantly with the number of postoperative problems (r=-0.19, P=0.02), and pain management (factor 4; r=0.36, P=0.0001).
d) SD and psychological distress
Global mean score of this group of respondents to the MCSD scale was 14.24 ± 3.16 (95% CI,13.69–14.80, Min: 5; Max: 20). 11.8% of respondents obtained a score of 10 or less, indicative of a weak influence of SD. SD was correlated with psychological distress (r=-0.34, P=0.0005) and preoccupations with anesthesia (factor 2; r=0.18, P=0.04). Questions of the SOPPCAS were not correlated with the MCSD scale (r values below 0.13 with P-values above 0.05), indicating that the SOPPCAS measures elements unrelated to SD.
At T1, respondents obtained a mean psychological distress score of 0.55 ± 0.64 (95% CI, 0.44–0.62, Min. 0; Max 4.0) and a mean of 0.99 ± 0.84 (95% CI, 0.84–1.13, Min: 0; Max: 3.78) at T-2. Psychological distress correlated with: number of postoperative problems (physical and psychological problems; r=0.24, P=0.005) and global satisfaction with anesthesia services (r=-0.25, P=0.004).
e) Open-ended questions
Following is a summary of the main results obtained for each of the open-ended questions of the SOPPCAS. Respondents recalled principally the environment of the operating room (39.9%) or leaving their room (26.6%). Fourteen percent did not appreciate being conscious of the operating room just before surgery. Most of the respondents (46.1%) remembered the voice of a nurse telling them that the surgery was over. Others recalled the tube in their throat (13.3%) or a family member standing at their bedside and talking to them (12.6%).
A majority of patients (56.5%) mentioned that they were very satisfied by the care they received from the anesthesiologist. But, for close to 37% of the respondents, the most painful recollection of their experience was the presence of the endotracheal tube and the related pain. Several patients (28%) mentioned that they had to wait more than an hour, awake, alert, intubated and not allowed to receive sedation (for fear of retarding extubation), until the anesthesiologist visited them.
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Discussion |
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To our knowledge, no previous study had attempted to measure correlations between the questionnaire used to measure satisfaction and SD, a variable which could, theoretically at least, strongly influence patients' responses.29,30 Our group of patients scored moderately high (14/20) on the MCSD scale, indicating that they were, to some extent, eager to please the interviewer, despite all the precautions taken to allow them to respond freely. Originally, we had hoped to be able to minimize the effect of SD by eliminating all respondents scoring over 10.0 on the MCSD scale. Obviously, we could not proceed accordingly since only 11.8% of the respondents obtained a low SD score. In such cases, Norman and Streiner30 recommend that caution be exercised when interpreting the overall result on mean satisfaction.
A more detailed analysis of the results shows that the items of the SOPPCAS were not related to SD (r <0.13), indicating that the validity of the questionnaire was not affected. Rather, SD should be viewed as an inherent characteristic of a majority of patients, a characteristic that tends to shift their responses towards more favourable scores in general.
Patients were satisfied with their interactions with the anesthesiologist, the content and amount of information given, the reassurance offered by the anesthesiologist and the management of their pain. Moreover, half of the respondents expressed a need to meet with the anesthesiologist after the operation, an infrequent occurrence in this institution and definitely an area for improvement. Postoperative visits give the anesthesiologist an opportunity to answer questions, seek evidence for injuries or complications related to anesthesia, and document completion of care.31
Overall, men are more satisfied with anesthesia services than women, a finding consistent with the literature. This may also be interpreted as a gender bias in response style, i.e., men have a lesser tendency to express emotion, dissatisfaction, etc.32–36
Contrary to the general literature on satisfaction, our results show that older patients seem to report less satisfaction than younger ones with respect to their interactions with anesthesiologists. Young people, usually under 50 yr of age, are found to be more critical of the care they receive.2,37 They are usually more educated and more aware of the standards of care they should receive. Apparently this was not the case in the present sample. A possible explanation is that older patients do not verbalize their dissatisfaction, being afraid to bother their care providers with questions or that they do not need the same type of information than younger people. The SOPPCAS, by allowing them to express themselves more easily, was able to reveal their lack of satisfaction with anesthesia services. Anesthesiologists should be aware of such issues related to age, gender, etc., when performing their preoperative evaluation, in order to allow them to personalize their interview.
Postoperatively, respondents were concerned mainly about the endotracheal tube and the resulting pain and discomfort. Currently, patients having cardiac surgery are most often extubated eight to 12 hr postoperatively, depending on their condition. Despite the ever-shortening time period between the end of surgery and extubation, the discomfort related to the endotracheal tube remains a serious concern. Similar concerns were also reported in another study38 in which 101 respondents rated the gagging on the endotracheal tube as the second most undesirable outcome after vomiting. Such problems can be avoided or prevented by adequate sedation39 and/or rapid intervention by the anesthesiologist when required.
Besides proposing elements to improve anesthesia patient care, the SOPPCAS will, implicitly, promote public recognition of anesthesiologists. Close to 22% of the respondents did not remember meeting the anesthesiologist before their surgery. As mentioned in a recent publication:31 "anesthesiologist-patient communication must span many gaps. It is tempting to discount communication if keeping patients alive and waking them up again are the only professional goals. Because anesthesiologist' interactions with conscious, verbal patients are within compressed time frames and narrow clinical conditions, clear, succinct, respectful communication is essential. Facility with a variety of communication skills signifies highly developed professionalism. Conversely, poor communication skills may increase litigious actions and malpractice suits."40 Further, patient satisfaction is also dependent on the anesthesiologist designing an anesthesia regimen that closely fits the patient's preference as identified during the preanesthesia assessment visit.38
Psychometric characteristics
Our results explain some of the relationships between the variables suggested in the conceptual framework (Figure 1
) and patient satisfaction. Nevertheless, since correlations (r) between the main variables are weak (despite being significant), we are cautious not to imply that the variables presented in the framework are the only ones explaining patient's perceptions of anesthesia services.
The internal consistency of the global score of the SOPPCAS is low. This can be explained by the distinctive difference between the four perioperative factors of the SOPPCAS. Items distributed themselves among the four factors with the exception of item 12. It will be removed in the next version of the SOPPCAS. The four factors obtained acceptable Alpha's (close to 0.70)30 with the exception of the fourth factor (pain management). This result is probably related to the presence of only two items associated to this factor, thus generating less variance and the dependency of one of the items (16) over the previous item (15). We decided not to remove the factor (and both items) since it covered what we felt to be an important aspect of anesthesiology care. Further, we would like to mention a measurement issue that was overlooked in the calculation of the global score of the SOPPCAS. The weight attributed to questions 11 and 16 should not have been the same as for the other 15 Likert questions of the SOPPCAS since both questions are dependent on the answers provided on the preceding question respectively, thus question 10 and question 15. For instance, if a patient answers (1=not at all) at question 10 ("do you remember having a tube down your throat"), then question 11 ("was the tube in your throat a painful experience") becomes irrelevant in a measurement perspective. The same applies for questions 15 and 16. Therefore, since we consider that the information generated by both questions (11 and 16) are essential, we recommend to keep both questions in the SOPPCAS but to remove them in the calculation of the global score and factor analysis of the SOPPCAS. The results obtained with questions 11 and 16 should be presented apart from the other Likert questions.
In another order of ideas, it is important to specify that this is the SOPPCAS' first trial and that the results were obtained on a homogenous sample of postoperative cardiac surgery patients. Data collected from our patients relate to their experience with a major surgical intervention requiring intensive care postoperatively. These results cannot be generalized to the broad population of postoperative patients. More studies are needed to confirm or invalidate the relationships between the variables presented in the conceptual framework (Figure 1) since the four perioperative factors of the SOPPCAS explained only 56% of the total variance on satisfaction. Yet, this result does not come as a surprise: the SOPPCAS is a novel instrument, the data was collected on an homogenous sample and, above all, research on the concept of "satisfaction with anesthesia services" is still in its infancy.
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Acknowledgments |
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Footnotes |
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Revision received July 23, 2001. Accepted for publication February 15, 2001.
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References |
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