JSUR Journal

Notably, one-fourth (40/163, 24.5%) of the surveyed patients said that they had no role in their own perioperative safety (Table 1). Among these 40 patients, eight patients believed that the perioperative outcomes were entirely the ‘hands of God’, whereas 32 patients (32/163, 19.6%) felt that the perioperative outcomes were the ‘hands of the doctors’ (Table 2). Notably, 20%, which is one-fifth of the patients surveyed, believed that their safety lies entirely in the ‘hands of doctors’. This cohort can potentially turn hostile to the medical team in the event of unfavourable perioperative outcomes, which could be misrepresented through social media. Therefore, it is important to talk with the patients’ community and on social media platforms about PFPS awareness. The preoperative period does offer a ‘teachable’ moment when these patients and their families can be identified and educated on shared patient responsibility for perioperative safety.

In our study, we found that despite having had prior exposure to anesthesia and surgery, patients were not aware of the concept of participation in their own perioperative safety. This may reflect the lack of effective communication by the perioperative team.

Therefore, effective communication by the perioperative team can have a significant impact, as revealed by a study by Wolter CB et al [11] on patients’ perspectives on patient engagement in safety. They reported that during communication regarding patient safety, patients related more to terms such as ‘your safety’ instead of ‘patient safety’ and thought that engagement in healthcare decisions was their ‘right’. However, they believed that the ultimate responsibility of their safety should still lie in the hands of healthcare professionals. [12] This finding resonates with our study population, who thought/believed that patient safety lies entirely in the ‘hands of doctors’.

Our study aligns with the findings of Gobbo et al [12], who noted that patients value preadmission contact, specific education, effective communication, continuity of care, and privacy during the perioperative period. Our study revealed that these are crucial factors for enhancing patient satisfaction and safety [12].

Like our study, Dixon and Tillman [13] did not find a correlation between education level and patients’ perceptions of their safety.

Neither did modern patient safety initiatives directly influence patients’ perceptions. Before surgery, physician trust and patient communication were found to have the greatest impact on patients’ feelings of safety. Patients who had more trust in their doctor and had better communication with health care workers were 30% less likely to complain against the doctor [13,14].

Awareness About Anesthesia

We found that more than 80% of the surveyed patients were aware that they would experience some kind of numbness or unconsciousness before their surgery; however, the majority were oblivious about anesthesia being administered by specialized doctors (Table 1). Similar findings have been reported in previous studies. Despite a high level of awareness (82-92%) regarding the need for some type of anesthesia for surgery, [8,15,16] the knowledge of anesthesia being a separate specialty and anesthesiologists being specialized doctors was found to be limited (30-50%) [6,8,15].

In contrast, some studies have reported high levels of awareness among anesthesiologists. A survey conducted with visitors to a health fair in Bangalore, India, in [14,16-20] revealed very high awareness (75% of participants) that anesthesiologists are doctors. This could be because the survey was conducted in a specific cohort of educated industry workers, and the questionnaire design had leading questions with a binary response format. Similarly, a high level of awareness among patients about anesthesiologists as ‘specialized doctors’ was reported in a study from Ghana.[17] This was attributed to the fact that 88% of the surveyed patients were educated and were referred to a ‘special doctor’ (anesthetist) by the surgeon. This highlights the role of team communication, including that of surgical colleagues, in creating anesthesia awareness.

*Significant at p<0.05, 1: Chi-Squared Test

Table 5: Association between ‘Educational Level’ and Parameters.

In our study, only 24% of patients knew the word ‘anaesthesia’ (Table 1); however, most of the patients related to the more commonly used term ’behoshi’, which in the local language means ‘unconsciousness’. Similarly, unawareness of the term ‘anesthesiologist’ was observed compared with ‘physicians’ and ‘surgeons’ by Prasad et al.¹⁶ We believe that this lack of awareness of specific terminology for unconsciousness might have impacted awareness of anesthesia as an independent specialty and that anesthesiologists, as independent doctors, are at par with surgery and surgeons. Surprisingly, in a study conducted in 2009, awareness about the spectrum of anesthesia procedures available to patients was found to be lacking not only in the general population but also among educated people, including medical undergraduate students [18]. Additionally, in our study, educated patients were significantly more aware of term anesthesia and the need for anesthesia for surgery and were more engaged in their after-care requirements than uneducated patients were (Table 5). A positive correlation between education and anesthesia awareness is well known [6,8,15,19,20].

The lack of effective communication by the anesthesia team is reflected in the findings of our study. Previous experience with surgery did not result in increased awareness of anesthesia. Although all patients had undergone Preanaesthesia Evaluation (PAE), one-third of them were not aware that they had completed PAE. Fewer than 4% of patients knew that the recommended Nil Per Oral (NPO) status is vital for safe anesthesia delivery (Table 1). Many patients believe that preoperative fasting is a requirement for abdominal surgeries only. This lack of awareness could lead to noncompliance with preoperative NPO instructions in patients postabdominal surgeries, leading to adverse anesthesia outcomes. A lack of correlation between anesthesia awareness and a history of previous surgery has also been reported in earlier studies. [6,15] The need to improve patient communication by the anesthesia team, particularly during preoperative visits, can be an effective measure [6,8,19,20].

 The Indian Society of Anaesthesiologists designed an ‘ISA Public Awareness Flier’ (Supplementary file). It has two sections, ‘Know your Anaesthesia’ and ‘Know your Anaesthesiologist’, and is a very useful tool for spreading anesthesia awareness among patients and their families. This can be made available in PAE clinics, surgical outpatient clinics, and wards.

Things to be Informed About Before Surgery

Sixty-four percent of patients were aware of the importance of informing the doctor’s medical history preoperatively, particularly their current comorbidities and previous surgeries (Table 1, Table 2). Notably, only one patient in our study (1 out of 163; 0.6%) (Table 2) said that the correct site of surgery must be emphasized. Although patients are aware that wrong-site surgeries can occur, they also need to be educated about the role of patient participation in reducing such errors.

Concerns regarding the Perioperative Period

The main concerns of patients during the perioperative period included successful surgery outcomes, unconsciousness during surgery, waking up after surgery, pain management after surgery, resumption of diet, and normal activities after surgery. A substantial proportion of the patient population that comes to our hospital are daily wage workers; therefore, the resumption of a normal diet and activities also reflects returning to work early and earning. Notably, half of the patients (80/163; 49%) were mainly concerned about unconsciousness during surgery (24/163), waking up after surgery (27/163) and pain management after surgery (29/163) (Table 2), all of which are ‘anesthesia related’ outcomes.

In our study, almost half (42.9%) of the patients were confident regarding their surgery and did not have any perioperative concerns or fears. An important factor for patients’ confidence is their faith in the surgeon. As noted by Dixon and Tillman, [13] physicians’ trust and patient communication strongly affect patients’ ability to feel safe before surgery.

Previous studies have reported similar findings of fear of unconsciousness during surgery, not waking from anaesthesia after surgery, pain during and after surgery, and fear of death. [6,19] The role of public health education programs and the use of media for education has been suggested. [6,18,19] Our study highlights the importance of integrated programs for improved communication in PAEs, which can alleviate such patient fears and encourage patient empowerment.

In our study, educated patients were found to be generally more aware of anesthesia; they were  more concerned about the perioperative period and knew that they needed to tell their relevant medical history to the doctor before surgery (Table 5). Despite this increased awareness of anesthesia and perioperative care, educated patients were unaware of patient participation in enhancing perioperative safety. As noted by Wolter CB et al., [11] although patients demand engagement in healthcare decisions, the ultimate responsibility for their safety still lies in the hands of healthcare professionals only, which is also reflected in our study. One limitation of our study is the small sample size; therefore, the outcome represents the perception of a small cohort of patients. This study serves as a pilot study for larger studies on patient engagement in perioperative safety.

In conclusion, it was encouraging to note in our study that the general awareness of the requirement of anesthesia for surgery was widely acknowledged. Nonetheless, perceptions of anesthesia as a separate specialty and anesthesiologists as specialized doctors are lacking. The inadequate awareness of anesthesia, as found in our study, might not be a true reflection of a wider population, which calls attention to investing in ‘anesthesia awareness programs’. This should be addressed globally through academia, professional societies, public health, and social platforms. To the best of our knowledge, no previous studies have explored patients’ perceptions of ‘Patients for Patient Safety’ in the perioperative period. Our study revealed a very promising initial step in patient empowerment in that the majority of patients were amenable to participation in their own perioperative safety. Regardless of education status, the population in general needs to be familiarized with the shared patient responsibility in enhancing patient safety, similar to other public health programs. High-quality surgical services that ensure patient safety are essential to achieve the health-related targets of the United Nations Sustainable Development Goals.²¹ Our study also aligns with the proposed concrete interventions for improving the quality of perioperative care at a global stage towards achieving universal health coverage [22].

Declarations

Ethics approval and consent to participate: Ethics approval was given by the Jamia Hamdard Institutional Ethics Committee (JHIEC 01/20), and the study was registered prospectively with the Clinical Trials Registry- India. All the participants provided written informed consent before taking part in the study. This cross-sectional observational study was conducted in accordance with the principles outlined in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist.

Consent for publication: This was a questionnaire-based observational study with no experiments conducted on human participants. Ethical approval and informed consent were obtained from all participants, and no identifiable personal data was collected or published.

Availability of data and materials: All data generated or analyzed during this study are included in this published article and are publicly available for unrestricted use.

Competing interests & Funding: The authors declare that there are no conflicts of interest and no external funding was received for the study.

Authors’ contributions

• Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND
• Drafting the work or revising it critically for important intellectual content; AND
• Final approval of the version to be published; AND
• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
• All the authors-Jyotsna Agarwal, Meena Nathan Cherian, Sana Yasmin Hussain, Pratibha Panjiar, Santosh Kumar, and Davy Cheng-have contributed to the aforementioned four criteria of authorship.

Acknowledgements: Not applicable

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