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British Journal of Anaesthesia 104 (3): 369–74 (2010)

doi:10.1093/bja/aeq002 Advance Access publication February 1, 2010

REGIONAL ANAESTHESIA
Effect of preoperative multimedia information on perioperative
anxiety in patients undergoing procedures under regional
anaesthesia
H. A. Jlala1, J. L. French2, G. L. Foxall2, J. G. Hardman1* and N. M. Bedforth2
1
Division of Anaesthesia and Intensive Care, University of Nottingham, Nottingham NG7 2UH, UK.
2
Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
*Corresponding author. E-mail: j.hardman@nottingham.ac.uk
Background. Provision of preoperative information can alleviate patients’ anxiety. However,
the ideal method of delivering this information is unknown. Video information has been shown
to reduce patients’ anxiety, although little is known regarding the effect of preoperative multi-
media information on anxiety in patients undergoing regional anaesthesia.
Methods. We randomized 110 patients undergoing upper or lower limb surgery under
regional anaesthesia into the study and control groups. The study group watched a short film
(created by the authors) depicting the patient’s in-hospital journey including either a spinal
anaesthetic or a brachial plexus block. Patients’ anxiety was assessed before and after the film
and 1 h before and within 8 h after their operation, using the Spielberger state trait anxiety
inventory and a visual analogue scale.
Results. There was no difference in state and trait anxiety between the two groups at enrol-
ment. Women had higher baseline state and trait anxiety than men (P¼0.02). Patients in the
control group experienced an increase in state anxiety immediately before surgery (P,0.001),
and patients in the film group were less anxious before operation than those in the control
group (P¼0.04). After operation, there was a decrease in state anxiety from baseline in both
groups, but patients in the film group were less anxious than the control group (P¼0.005).
Conclusions. Preoperative multimedia information reduces the anxiety of patients undergoing
surgery under regional anaesthesia. This type of information is easily delivered and can benefit
many patients.
Br J Anaesth 2010; 104: 369–74
Keywords: anaesthetic techniques, regional; equipment, videos; stress; surgery, preoperative
period
Accepted for publication: January 4, 2010

Many patients experience substantial anxiety before oper- improve surgical outcome, shorten hospital stay, and mini-
ation,1 – 7 and this is reported to affect 60 – 80% of surgical mize lifestyle disruption.14
patients.6 8 Increased anxiety before surgery is associated Provision of preoperative information can alleviate
with pathophysiological responses such as hypertension patients’ anxiety.15 – 17 The ideal method of delivering this
and dysrrhythmias9 and may cause patients to refuse information is unknown. Written information has been
planned surgery.10 Anxiety also increases the requirement used as an effective way for delivering information to
of anaesthetic drugs to produce unconsciousness9 11 and patients,18 19 but not all patients are literate enough to read
therefore may indirectly increase the risk of awareness. and understand an information sheet; in addition, patients
Anxiety may also worsen patients’ perception of pain and will retain information to a variable extent. Multimedia
increase requirements for postoperative analgesia.3 12 information (in the form of a video) has been the subject
Anxiety may decrease patients’ overall satisfaction with of randomized controlled studies, and the value of this
perioperative care.13 Reducing preoperative anxiety may form of information in decreasing patients’ anxiety before

# The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournal.org
Jlala et al.

surgery has been demonstrated,7 15 20 21 although these at all, somewhat, moderately so, and very much so). This
effects were small and not supported by other studies.22 23 form was used at all time points of the study for both
Conflicting results may have arisen because of differences groups. Statements in the STAI-T are also rated on a
in methodology, multimedia format, measurement tools, four-point scale (almost never, sometimes, often, and
and variability in study populations. No study has almost always). This form was used twice for each partici-
addressed the patient population undergoing surgery under pant: on entering the study and on exiting the study. The
regional anaesthesia. Therefore, we developed a short film overall (total) score for STAI ranges from a minimum of
depicting the patient journey through hospital (including 20 to a maximum of 80; STAI scores are commonly
regional anaesthesia) and examined the effect of this film classified as ‘no or low anxiety’ (20 – 37), ‘moderate
on patients’ perioperative anxiety. anxiety’ (38 – 44), and ‘high anxiety’ (45 –80).25

Visual analogue scale


Methods The visual analogue scale (VAS) has also been validated
Approval for the study was provided by the local research as an instrument for measuring anxiety.26 In our study, a
ethics committee. One hundred and ten consecutive scale of 0 – 100 mm was used to measure the anxiety level
patients undergoing upper limb (hand) or lower limb (knee of participants by asking them to quantify their anxiety by
and ankle) elective surgery at the Queen’s Medical Centre putting a mark on a VAS scale, which they felt represented
(Nottingham) from November 2007 to July 2008 were the degree of their anxiety at that moment. One end of the
invited on the day of their preoperative assessment visit (2 scale was labelled as ‘no anxiety’ and the other end as
weeks before surgery) to take part in the study. Invitation ‘maximum anxiety imaginable’. This was used at all time
letters along with the study information sheet had been points for both groups.
sent to the patients before this appointment. Inclusion cri-
teria were: adults aged 18 – 80 yr, ASA I and II, and under- Feedback questionnaire
going elective surgery under regional anaesthesia. This is a non-validated questionnaire designed for this
Anaesthesia was established under brachial plexus periph- study; it consisted of a series of closed statements
eral nerve block (PNB) for hand surgery or spinal anaesthe- answered ‘Yes’ or ‘No’. This was administered after
sia (SA) for knee or ankle surgery. Exclusion criteria watching the information film. Patients were asked directly
included the inability to read and understand English, sig- if they found the film to be an informative and valuable
nificantly impaired eyesight or hearing, and an existing source of information and scored their satisfaction with the
psychiatric disorder. The primary outcome measure was film. We also asked them if they felt watching the film
anxiety assessed immediately before operation by a self- made them calmer or more anxious.
reported psychological instrument, the Spielberger state
trait anxiety inventory (STAI). Patients were randomly allo- Pre-anaesthetic film
cated to a film group (watching the film) or a control group Film 1 (PNB)
(not watching the film), using computerized randomization. A 9 min film was made of a 55-yr-old man who was under-
The group allocations were sealed in serially numbered going hand surgery under regional block. The film begins
opaque envelopes (according to the generated sequence) with a ward-based preoperative consultation with the
prepared by a member of staff not involved in the study. anaesthetist; this was taken from an interview of an actual
Researchers and patients were blinded to group allocation patient before surgery. The discussion included: a descrip-
until after the completion of baseline anxiety scoring. Staff tion of the PNB process and the risks involved, specifically
members working in all study settings were unaware of the risk of nerve injury (1:5000 –10 000) and block failure
patients’ group allocations. The anaesthetists who carried (5%) possibly requiring conversion to general anaesthesia.
out the blocks were blinded to the patient group allocation. Discussion also included postoperative advice (wearing off
of the block and analgesic requirements). The next scene
Instruments shows the patient entering the anaesthetic room and the
State trait anxiety inventory entire brachial plexus block procedure. The patient is then
The STAI is a validated and widely used instrument to moved into the operating theatre and shown talking with
measure patients’ anxiety.24 The STAI-state (STAI-S) the anaesthetist next to him while the surgeons are carrying
form consists of 20 statements, and the answers to these out the procedure. The last scene shows the patient being
are used to determine a patient’s current anxiety level; the transferred to the recovery room.
STAI-trait (STAI-T) form consists of a different set of 20
statements, and the answers to these are used to determine Film 2 (SA)
a patient’s underlying (ongoing/personality) anxiety level. A 7 min film was made of a 77-yr-old woman who was
Each statement in the STAI-S is rated on a four-point undergoing a left knee arthroplasty under SA. The film
scale for the subject’s agreement with that statement (not begins with a ward-based preoperative consultation. The

370
Preoperative video and perioperative anxiety

discussion included a description of the SA and the (a¼0.05, power¼0.80, SD¼8.9). Data are presented as
risks involved, specifically the risk of nerve injury median and inter-quartile range (IQR). Baseline character-
(1:5000 – 10 000), block failure (5%) possibly requiring istics were analysed with Student’s t-test for continuous
conversion to general anaesthesia, headache (1:100), data and x2 test for categorical variables. STAI data were
itching and nausea (very rare), urinary retention (very lumped and tested for normality of distribution
rare), and necessity of having a urinary catheter. (Kolmogorov–Smirnov); the data demonstrated good
Discussion also included postoperative advice (wearing off approximation to normal distribution, so two-way repeated-
of the block and analgesic requirements). The next scene measures analysis of variance was used to analyse the sig-
shows the SA placement. The last scene shows the patient nificance of changes in anxiety scores over time between
being transferred to the recovery room and having a drink. groups (group vs time interaction). Statistical analysis was
The same person filmed and edited both films. The performed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).
same anaesthetist appeared in both films. In both films, the
anaesthetist provides the patient with information about
the risks, benefits, alternatives, and technical details of the
regional anaesthesia procedure. The same investigator Results
showed the films to the participants and oversaw question- Of 187 patients approached, 12 returned incomplete ques-
naire completion. tionnaires and 42 patients declined or were not suitable for
participation (12 patients because they feared viewing the
Intervention film would be distressing; 10 patients, who had had the
same operation in the past, did not think it would add any
Written informed consent was obtained in the preoperative
information; 20 patients were undergoing general anaes-
assessment clinic. On enrolment and before the patients’
thesia). Twenty-three patients were excluded for other
formal preoperative consultation with the nurse and
reasons (e.g. converted to general anaesthesia, changes to
surgeon, anxiety was assessed using STAI-S, STAI-T, and
theatre schedule, cancelled operations). In total, 110
VAS. We did not aim to separate anxiety related to anaes-
patients completed all questionnaires and were included in
thesia and surgery; therefore, we gave clear instructions to
our analysis. Random allocation resulted in 55 patients
the patients on how to rate their overall level of anxiety
assigned to the film group and 55 to the control group.
using both tests. Patients in the film group then watched the
The two groups did not differ in age, gender, weight,
film using a laptop computer equipped with headphones.
anaesthetic techniques, history and type of previous anaes-
STAI-S and VAS were then repeated after the film. Any vol-
thesia, and time from enrolment to surgery (Table 1).
unteered feedback regarding the video was recorded.
There was no difference in state or trait anxiety scores
Patients in both groups then underwent routine consultations
between the two groups at enrolment. The control group
with the admitting nurse and surgeon but not the anaesthe-
experienced an increase in state anxiety score from base-
tist; as per our normal practice, patients met their anaesthe-
line immediately before surgery (P,0.001), whereas the
tist on the day of surgery. The patients in both study arms
film group showed a non-significant increase in anxiety
received our standard care at this point (an interview with
(Fig. 1). Patients in the film group were significantly less
an anaesthetist before surgery on the day of operation).
anxious before operation than those in the control group
Three consultant anaesthetists performed all the preopera-
(P¼0.04; Fig. 1). After operation, there was a significant
tive, routine visits; they were not told specifically how to
decrease in state anxiety compared with baseline in both
explain procedures before operation, as we wished to repli-
groups; again patients in the film group were less anxious
cate our standard practice for risk disclosure and make the
than those in the control group (P¼0.005). Anxiety levels
study applicable to real practice. Patients were not specifi-
in the film group immediately after watching the film were
cally informed of the risk of rare complications (e.g. para-
reduced compared with the baseline anxiety scores, but
plegia, death). On the day of surgery, patients arrived 2–3
this did not reach statistical significance (P¼0.07; Fig. 1).
h before their surgery. All patients completed STAI-S and
VAS 1 h before surgery. Routine preoperative visits by the
patient’s anaesthetist were completed before STAI-S and Table 1 Baseline characteristics. *Time from baseline measurement to day of
surgery. Where appropriate, data are presented as median (IQR)
VAS measurement. Between 2 and 8 h after operation,
patients completed our last set of STAI and VAS. Film group (n555) Control (n555)

Age (yr) 58 (40, 63) 59 (42, 69)


Statistics Gender (F:M) 21:34 27:28
Weight (kg) 78 (67, 90) 77 (70, 88)
Data from a pilot study involving 20 patients were used to Baseline* to surgery (days) 15 (8, 21) 15 (8, 30)
perform an a priori power analysis to estimate the required Anaesthetic technique (SA:PNB) 26:29 31:24
sample size. We calculated that 52 subjects were required in History of anaesthesia (Yes:No) 37:18 45:10
Previous anaesthesia (GA:RA) 29:8 32:13
each group to detect a clinically significant difference in Trait anxiety (STAI-T) 34 (26, 42) 34 (26, 43)
patients’ anxiety scores between groups of .5 points

371
Jlala et al.

80 100
Film group
Film group 90
STAI (values range 20–80)

VAS (values range 0–100)


70 Control group
Control group 80
60 70
60
50 * 50
40
40 30
* 20
*
30
10
20 0
Baseline Post-film PreOp PostOp Baseline Post-film PreOp PostOp

Fig 1 State anxiety scores (STAI). Op, operative. *P,0.05 between the Fig 2 VAS scores. Op, operative. *P,0.05 between the groups. Error
groups. Error bars represent the standard error of mean (SEM). Note: bars represent the SEM.
Twenty is the lowest possible value of STAI.

Trait anxiety scores (STAI-T) were smaller after operation


than at enrolment in both groups (P,0.05), but no differ- The prevalence of ‘high’ anxiety among patients having
ence was found between the groups [median preop (IQR), surgery under regional anaesthesia was 17% in the assess-
median postop (IQR): film group 34 (26 – 42), 23 (21 – 29); ment clinic 2 weeks before surgery. Immediately before
control group 34 (26 – 43), 25 (21, 32)]. surgery, this increased to 27% among those who watched
The prevalence of anxiety in our study population is the film and 36% among those who did not. After oper-
summarized in Table 2. Women had higher baseline ation, only 2% reported high anxiety in the film group
anxiety scores (median¼36, IQR¼27, 46) than men compared with 5% among controls. These differences
(median¼32, IQR¼24, 39; P¼0.02). The anxiety scores demonstrate the effectiveness of our intervention. Anxiety
measured by VAS correlated positively with the STAI-S scores were generally higher in female patients awaiting
scores (r¼0.52, P,0.05). VAS did not differ significantly surgery. In agreement with previous studies,2 3 23 27 28 this
between the film and the control groups before operation, may suggest that more attention needs to be directed
but did after operation (Fig. 2). There was a significant towards women to alleviate anxiety.
correlation between anxiety scores 2 weeks before surgery In this study, we found a significant, positive correlation
and immediately before surgery (r¼0.68, P,0.001). between the two anxiety-measuring instruments (STAI and
Feedback from the film group indicated that 90% were VAS), consistent with previous reports.26 29 30 Although
satisfied with the film and felt it to be a valuable source of VAS did not show a difference in anxiety between the
information. Approximately 70% reported feeling calmer groups in the preoperative period, it was sensitive enough
immediately after the film when directly questioned to detect a significant change after operation, and showed
(although STAI-S did not demonstrate a significant differ- a consistent pattern throughout the course of the study.
ence before and after the film). Before operation, patients This might be attributed to the ‘central tendency bias’, in
voiced concerns over the pain of the anaesthetic procedure, which patients may avoid using extreme scores (due to
urinary retention, nerve damage, and noises during unfamiliarity of this method) when they are not sure of
surgery. how to respond.31 This may show the superiority of the
Spielberger STAI in detecting more subtle changes in
anxiety; VAS may retain some usefulness in assessing
Discussion patients with reading or comprehension difficulties or in
In this prospective, randomized, controlled study, we have situations of extreme anxiety.
demonstrated that viewing a short information film before Previous studies have shown that patients’ anxiety the
operation reduced the anxiety of patients undergoing elec- day before surgery correlates with that immediately before
tive surgery under regional anaesthesia. This effect was operation.3 32 We found that anxiety 2 weeks before
sustained into the postoperative period. surgery was also correlated with that occurring

Table 2 Prevalence of state anxiety of regional anaesthesia

Baseline Preoperative Postoperative

Film Control Film Control Film Control

Low anxiety (STAI 37) 32 (58%) 35 (64%) 32 (58%) 21 (38%) 53 (96%) 49 (89%)
Moderate anxiety (STAI 38– 44) 12 (22%) 13 (24%) 8 (15%) 14 (25%) 1 (2%) 3 (5%)
High anxiety (STAI 45) 11 (20%) 7 (13%) 15 (27%) 20 (36%) 1 (2%) 3 (5%)

372
Preoperative video and perioperative anxiety

immediately before surgery, indicating that high anxiety (iv) Viewing an educational video about anaesthesia
levels immediately before operation may be predicted at can improve patients’ knowledge and understand-
early preoperative assessment. ing;23 33 – 35 however, we did not examine how much
There is no consensus on what constitutes a clinically information our study group retained. Such knowl-
significant change in the anxiety scoring system; however, edge acquisition may have been a mechanism in
previous studies using the Spielberger STAI have quoted reducing anxiety in our study group. This needs to be
significant changes between 3 and 5 points,7 15 33 one explored further in patients undergoing surgery under
study pointed out that an important clinical change in state regional anaesthesia.
anxiety levels is 10 points.14 We have shown a positive (v) Anaesthesia is just one cause of anxiety; we did not
effect of our intervention. We think that our intervention explore the effect of other potential sources of
(audioþvisual) is a supplementary tool and not a substi- anxiety such as surgical techniques, success of the
tute to other methods of providing anaesthetic information, operation, fear of any anticipated complications, or
for example, written information (leaflet), or verbal/spoken amount of information provided to patients.
information ( physician). (vi) Twenty-two patients who were eligible for our study
We agree that the reduction in anxiety could have been declined to participate; these patients may have been
either due to a specific effect of the film or due to the the most anxious and so our population may have
larger amount of information received; in either case, our been skewed during recruitment.
intention was to compare this process (of showing patients
Approximately one-third of patients having surgery under
a video) with our current standard of care, which is a pre-
regional anaesthesia are highly anxious before surgery,
operative assessment visit during which the patient is
with a higher incidence in women. This anxiety can affect
assessed by a nurse and seen by the surgeon, but not by an
patients’ understanding and recall of information, and their
anaesthetist. Therefore, the potential benefit of this type of
ability to give informed consent.36 – 38 Audiovisual infor-
intervention is a very efficient method of conferring infor-
mation reduces pre- and postoperative anxiety and can be
mation to patients, in addition to any visits made by an
particularly useful to those with reading, comprehension
anaesthetist.
difficulties, or both.39 40 Economic issues are a continual
There were limitations to our study.
pressure on healthcare. An information film is an efficient
and convenient way to inform patients and reduce their
(i) The pre-anaesthetic film was shown to participants in
anxiety. This can easily be carried out in the preoperative
the preoperative assessment clinic 2 weeks before the
assessment clinic, allowing adequate time for reflection
day of surgery; we could not control information
before surgery, which might make the information
received by the patients in the interval leading up to
received more effective.
surgery, which could have affected the results.
(ii) Patients undergoing upper and lower limb surgery
could differ in their anxiety responses and we chose Acknowledgements
to merge these two groups in order to provide a We thank Professor C.D. Spielberger for his advice on use of the STAI
tool. We would also like to thank Dr D.M. Levy for his contribution in
cross-section of patients undergoing regional anaes- filming and editing the films.
thesia, rather than one specific type. Despite these
possible differences between the groups, we feel that
this makes the study results more applicable to a
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