Open Journal of Anesthesiology, 2013, 3, 402-407
Published Online November 2013 (
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: *
Received September 24th, 2013; revised October 17th, 2013; accepted October 29th, 2013
Copyright © 2013 Joerg Schnoor et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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-
Number of Patients
Figure 1. Distribution of ASA classification.
20 22 23 24 25 26 27 28 29 30 31 32
ZUF-8 score
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).
Open Access OJAnes
Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries
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
Number of Patients
1 = great 2 = many 3 = minmal 4 = nil
Degree of Worries
Figure 4. Patients concerns prior to anesthetic pre-asses-
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 =
4. Discussion
In line with expectations, the results demonstrate a high
min i ma l
Degree of Worries
re post
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,
Open Access OJAnes
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
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
Open Access OJAnes
Balance of Concerns: Satisfactory Pre-Anesthetic Patient Education and the Extent of Patient Worries
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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