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Information and its impact on satisfaction among surgical patients
Social Science & Medicine 51 (2000) 1817±1825
www.elsevier.com/locate/socscimed
Information and its impact on satisfaction among surgical patients Edward Krupat a,*, Marcella Fancey b, Paul D. Cleary c a
Massachusetts College of Pharmacy and Health Sciences, Health Psychology Program, Boston, MA 02115, USA b Department of Psychology, Boston University, Boston, MA 02215, USA c Department of Health Care Policy, Harvard Medical School, Cambridge, MA 02115, USA
Abstract This study investigates the association between patient characteristics, reported problems with obtaining information and global evaluations of care among surgical patients. Using data from a large scale study of hospital care, a factor analysis of 30 information-relevant items was conducted with data from a sample of 3602 surgical patients; and correlation and multiple regression analyses were conducted to identify the relationships among information, patient characteristics and global evaluations of care. Path analysis was also used to determine the extent to which perceived control mediates the information±evaluation relationship. Four information factors were identi®ed: surgical information, recovery information, general information and sensory information, and each was signi®cantly related to global evaluations. Desire for involvement interacted with information received in determining patients' evaluations; and partial support was found for perceived control as a mediator of the information±evaluation link. The data indicate that the relationship between information and evaluations of quality is generalizable across patients, conditions and hospitals; and should be de®ned more broadly to include that which is given by a variety of providers, to family, and about medications and home recovery. Desire for involvement and perceived control must also be considered in understanding the value and impact of information. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Hospitalization; Surgical patients; Patient satisfaction; Patient information
Introduction Hospital patients, especially those facing surgery, often experience considerable anxiety as the result of receiving too little information or information that they cannot understand. It has been noted that the
* Corresponding author. Tel.: +1-617-732-2901; fax: +1617-732-2801. E-mail address: [email protected] (E. Krupat).
nursing sta is generally unable to ful®ll the informational needs of patients once they are hospitalized (Meredith, 1993), that the majority of written pre-operative instructions could not be understood by patients (Livingston, 1989) and that only 60% of the cancer patients studied could correctly describe their treatment (Cassileth, Zupkis, Sutton-Smith & March, 1980). Byrne, Napier and Cuschieri (1988) found that more than one quarter of the patients who had had informed consent meetings with their surgeons were not even aware of the organ that was going to be
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involved in their surgery. In addition to these, a wide variety of informational problems and de®cits have been documented in several reviews (Horne, Vatmanidis & Careri, 1994; O'Halloran & Altmaier, 1995; Alberts, Lyons, Moretti & Erickson, 1989; Edwards, Lilford, Thornton & Hewison, 1998) and meta-analyses (Johnston & Vogele, 1993; Suls & Wan, 1989). To address informational problems such as these, many programs have been developed to improve communication and provide information to patients facing invasive procedures. Roach, Tremblay and Bowers (1995) trained the nursing sta to provide patients with information about joint replacements, and found that patients' length of stay was shortened and costs were reduced. Beddows (1997) provided information to elective surgery patients both before hospitalization and on their ®rst day, and found that levels of anxiety were lower than a control group that had not been provided with the additional information. In other intervention programs, the provision of information has resulted in reductions in anxiety (Wallace, 1984; Kendall, Williams, Pechaceck, Graham, Shisslak & Herzo, 1979), lower self-reported pain (Wilson, Moore, Randolph & Hanson, 1982; Langer, Janis & Wolfer, 1975), quicker return to normal activities (Kanto, Laine, Vuorisalo & Salonen, 1990) and greater patient satisfaction (Devine, 1992). In the development of interventions, researchers have often relied upon the distinction between sensory information, which involves patients' knowledge about the feelings and sensations they will experience, and procedural information, which involves the nature and sequence of events that patients will experience (Mathews & Ridgeway, 1984; Johnson, 1984). In their metaanalysis of this literature, Suls and Wan (1989) concluded that the provision of procedural information alone provided no greater bene®t than standard (i.e. control group) instruction, but that providing a combination of procedural and sensory information had a signi®cant impact on measures of aect, pain and general distress. In addition to the type of information from which patients bene®t, another key issue involves the mechanism by which information works; how or why information seems to have a salutory eect. In his classic research, Janis (1958) argued that pre-operative information allows patients to engage in the ``work of worrying''. He proposed that information is useful because it allows patients to anticipate and rehearse the stressful events they are about to encounter, and thereby to cope more successfully with them. Others (Mahler & Kulik, 1991; Viney, Benjamin, Clarke & Bunn, 1985) have noted, however, that the bene®ts of information may vary considerably depending on the personality and
demographic characteristics of the patient. Miller and Mangan (1983) report, for instance, that patients who engage in problem-focused coping may want a great deal of information, while those who utilize an avoidant coping style may prefer to have as little as possible. A second explanation for the eects of information revolves around the concept of mastery and perceived control (Oetker-Black, Teeters, Cukr & Rininger, 1997; Bedell, Cleary & Delbanco, 1994; Thompson, 1981). Taylor (1979) believes that patients experience a loss of control when hospitalized, noting that they become either dicult (in order to restore control) or passive (accepting of its loss), in both cases failing to direct cognitive resources toward the task of recovery. Proposing that patients fare better when they believe they can exercise some control over their illness and its treatment, intervention studies have demonstrated that patients who were given information and coping skills had a more positive view of their surgical experience, which was associated with a greater sense of perceived control and better post-operative outcomes (Pick, Pearce & Legg, 1990; Robins, 1987). In spite of the growing volume of research on information and surgery, the majority of these studies are limited in several ways. First, almost all have been based on small samples of patients with selected problems. Second, much of the research has been intervention-based, and therefore the information studied has been almost exclusively pre-surgical and focused narrowly on speci®c kinds of information of interest to the researcher. Third, general evaluations of the quality of hospital care have not been widely studied in this context. As a result, only limited conclusions can be drawn from these studies about the broader role that information plays in the experience of hospitalization. The present research takes a broader approach to the understanding of the role of information among surgical patients. To investigate a wide spectrum of information-related issues, we analyzed responses to a large nationwide survey of hospital patients, addressing informational issues both pre- and post-surgery. The speci®c goals of the research were to determine empirically the manner in which informational issues cluster (especially whether they are organized around the sensory-procedural distinction) and the relationship between patient characteristics and information received; to estimate the strength of the relationship between information and patient evaluations of quality across a wide variety of patients who had undergone a range of surgical procedures; and to explore the mechanisms mediating the relationship between information and quality evaluation, in particular the role of perceived control.
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Methods Study sample The data set used for this study came from a survey conducted by the Picker/Commonwealth Fund Program for Patient-Centered Care. The study sample was selected in two stages, ®rst by hospital and then by patients. Hospitals were chosen using the American Hospital Association hospital survey database, selecting a strati®ed probability sample of public and private nonpro®t hospitals in the continental United States that had a general medical and surgical service. Hospitals with fewer than 100 beds as well as for-pro®t, federal and osteopathic hospitals and all long-term hospitals (de®ned as those with 30 or more days length of stay for more than half of the patients) were excluded. Small hospitals were not included in the sample because they would not have a sucient number of recent discharges, and for-pro®t hospitals were not considered because one focus of the project was on supporting change in nonpro®t institutions. Specialty and long-term care facilities were not sampled because the patient mix and process of care in such facilities is usually very dierent from those in general hospitals. All eligible hospitals were strati®ed by ownership, region and teaching status, and a disproportionate random sample from each stratum was selected using sampling probabilities that would yield a similar number of hospitals in each stratum. Thus, certain types of hospital such as academic health centers were oversampled. Of the 141 hospitals contacted, 62 participated in the survey. Reasons for not participating included inadequate administrative sta or resources to compile a list of eligible patients in the hospital; lack of interest in patient reports; diculties selecting a sample of patients because of limited or changing computer systems; concerns that the identity of the hospital would be revealed; logistical problems with data; potential confusion with internal marketing surveys; unwillingness to comply with the protocols; and medical board refusal. Participating and nonparticipating hospitals were compared with respect to ownership, teaching status, region of the country, midsize number of yearly admissions, average daily census and average occupancy rate. Participation rates were somewhat higher among academic health centers and larger hospitals and somewhat higher in the midwest and south, but none of these dierences were statistically signi®cant. For the patient sample, we attempted to interview approximately 100 eligible patients from each hospital as close as possible to three months after discharge. Patients were contacted by phone by a professional telephone interview ®rm (Louis Harris and Associates).
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The interviewer explained the purposes of the study and if the patient agreed, proceeded to question the respondent. The interview was conducted using a Computer Assisted Telephone Interview (CATI). We contacted a total of 8728 patients or someone in their household. Of these, 239 were not eligible for the study because they had been readmitted to a hospital or nursing home. Of the 8489 eligible patients, 6455 (76%) completed a telephone interview. Of these, 56% had had surgery and the remainder were medical patients. Interview content and measures used The interview questions were generated by compiling a list of the features of high quality care most often cited in the literature (see Cleary, Edgman-Levitan, Roberts, McMullen, Walker & Delbanco, 1991; Cleary & McNeil, 1988; Mechanic, Weiss & Cleary, 1983); no eort was made either to include or exclude questions that referred to issues related to procedural or sensory information. Patients were asked about problems with care in each of nine areas: communication, emotional support, patients, needs and preferences, family involvement, education, physical comfort and care, pain management, discharge preparation and ®nancial issues (Gerteis, Edgman-Levitan, Daley & Delbanco, 1993; Cleary et al., 1991). The questions were designed to focus on speci®c actions of the hospital sta rather than broad aspects of care. This was done to minimize the likelihood that factors such as expectations and gratitude, or response tendencies related to gender, class or ethnicity might confound the responses. Most of the questions were asked with dichotomous response options (yes or no), using follow up questions to elicit further information. The survey instrument was reviewed to identify every question in the interview that speci®cally pertained to information-related problems (e.g. ``Were the results of your surgery explained . . . '', ``Were you told the purpose of each medicine. . .'') as opposed to other aspects of care (e.g. ``Was there one particular doctor in charge of your care . . . '', ``Did you experience any pain . . . ''). Thirty-two such items were identi®ed and these were used for purposes of further analysis, although two had to be deleted because a signi®cant proportion of responses (greater than 10%) were missing. Patients also responded to several other interview questions designed to elicit their preferences and evaluations of care. ``Desire for information'' was based on patients' responses to three items (on a four point strongly agree to strongly disagree scale) asking them how much they believed that patients should be fully informed about their care; and ``desire for involvement'' was based on their responses to two items (on a
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Table 1 Characteristics of the hospital patient sample and the surgical patient sub-sample Hospital patients
Surgical patients
Hospital patients
Surgical patients
Age: 18±40 41±64 65±74 75+
23 42 22 13
25 42 22 11
Gender: Male Female
45 55
45 55
Race: White Black Other
86 11 3
84 11 5
Education: Some high school High school graduate Some college College graduate or more
26 37 19 18
23 38 20 18
Marital status: Married or cohabitating Divorced Widowed Single
66 9 14 11
69 9 11 11
Insurance: Private HMO Medicare Medicaid None
57 8 25 5 5
59 9 23 4 5
Income: $15,000 or less $15,001±35,000 $35,001+
37 36 27
32 38 30
Health status: Excellent Good Fair or poor
22 44 34
26 47 27
similar four point scale) asking the extent to which they believed that patients should be part of the decision making process. Both of these ``desire'' measures were adapted from the Autonomy Preference Index developed by Ende and colleagues (Ende, Kazis, Ash & Moskowitz, 1989). Patients were asked whether they had had ``enough say'' about their medical treatment, and responses to this were taken as an index of the extent to which felt they had ``perceived control'' within the context of their treatment. Evaluation of their hospital stay was operationalized using a ®ve item satisfaction index (Cleary et al., 1991) in which patients indicated their evaluation of the courtesy and helpfulness of doctors and nurses, availability of nurses and the organization of the hospital services and sta (using a ®ve point scale from excellent to poor). These items were based on questions used in previous studies (Cleary & McNeil, 1988; Mechanic, Greenley, Cleary, Hoeper & Wenzel, 1980; Mechanic et al., 1983), and have been shown to be related to patients' reported problems with care (Cleary, Edgman-Levitan, McMullen & Delbanco, 1992). Finally, patients answered a 1 Requests for any of the materials used in this project should be made to Paul Cleary, Harvard Medical School, Department of Health Care Policy, 180 Longwood Ave., Boston, MA 02115, USA.
series of questions about their perceived health status and personal and demographic characteristics1.
Results The analysis plan involved several steps: (1) a determination of whether the surgical sample was representative of the larger patient group sampled; (2) an attempt to identify and interpret the structure of information problems experienced by patients using factor analysis, along with the calculation of correlations between patient variables and information factors; (3) investigation of the relationship between information received and evaluations of care using simple correlation and multiple regression; (4) investigation of those variables that might modify and mediate the relationship between information and satisfaction using analysis of variance and path analysis. Characteristics of the sample For the analyses presented herein, we used data from only those patients who indicated that they had surgery performed, a total of 3602. Table 1 presents the characteristics of the surgical sample studied as well as the larger sample from which they were drawn, indicating that overall they were remarkably similar to
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one another. The surgical patients, the majority of whom were white (89%) and married (69%), varied widely in age (18±81), education and income. Compared to the total sample, surgical patients were slightly less likely to be over 65 years of age (33% vs. 35%), more likely to be married (69% vs. 66%), less likely to not have at least a high school education (23% vs. 26%) or an income of $15,000 or less (32% vs. 37%), and more likely to rate their health as excellent (26% vs. 22%). The gender and racial distribution of the surgical and medical patients was almost identical.
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the patient's recovery; (3) general information, a factor which included items about medication usage as well as communication with nurses and family; (4) sensory information, speci®cally dealing with explanations about pain, discomfort and anxiety from tests and surgery. The correlations among the four factors were all positive and ranged between 0.35 and 0.53. Internal consistency (coecient alpha) for the four factors was 0.73, 0.69, 0.66 and 0.76, respectively. These represent relatively low yet acceptable levels of alpha (DeVellis, 1991).
Factor structure of information problems
Relationship between patient characteristics and information problems
To identify the patterning of information problems experienced by patients, we analyzed the 30 items using principal factors factor analysis with an oblique rotation. Four signi®cant factors were identi®ed. Items were then eliminated if they did not load at least 0.3 on any of those factors, or if they loaded at least 0.3 on more than one factor. A second factor analysis was performed. This procedure was repeated twice more until a ®nal solution was obtained. Four interpretable factors, containing 21 items, were identi®ed (see Table 2). These were labeled: (1) surgical information, involving questions about the surgery, its risks and bene®ts; (2) recovery information, involving questions about what to do and not do at home to aid
Scale scores for each subject were created by taking the sum of the patient's score on all items included in each factor. Simple correlations of these scores with several demographic variables (age, education, income race, insurance coverage) were calculated. None of the factors was associated strongly with any of the demographic variables (in all cases, r < 0.09). Patients' selfreported health status showed a slightly higher association with each of the types of information received, ranging from a correlation of 0.13 for recovery information to 0.19 for sensory information. Correlations were also calculated between the scale scores and the two brief individual dierence indices, desire for information and desire for involvement.
Table 2 Questionnaire items and factor loadings Factor 1 Surgeon answered all questions? Results of surgery explained? Surgeon explained risks and bene®ts? Surgeon explain what would be doing? Got answers could understand from doctor? Told what activities at home? Told what to do to help recovery at home? Told when to resume regular activities? Told danger signals at home? Told what foods at home? Family given information for at home? Purposes of medications explained? Answers could understand from nurses? Side eects of medications explained? Family given enough information? Explained why tests being done? Told purposes of medications at home? Surgeon explained discomfort? Discomfort of tests explained? Surgeon told how feel after surgery? Surgeon discussed anxieties and fears? Eigen value
0.69 0.57 0.56 0.49 0.31
Factor 2
Factor 3
0.60 0.57 0.48 0.42 0.40 0.60 0.49 0.42 0.42 0.39 0.32
4.82
Factor 4
0.85
0.80
0.68 0.53 0.53 0.39 0.45
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Patient desire for information correlated 0.07 or less with each of the scales, while patient desire for involvement had equally low correlations with three of the four. Only one scale, general information, showed a slightly higher correlation with desire for involvement (r=ÿ0.11). The more patients desired involvement with their care, the less likely they were to report that they received adequate information. Only one patient variable, our measure of perceived control, showed a strong and consistent relationship with the information factors. Patients' responses on this measure were most strongly related to general information (r = 0.37), with surgical information (r = 0.35) and sensory information (r = 0.31) also showing a strong correlation. Recovery information, which refers to information given to patients primarily at the end of their hospital stay and is therefore less likely to aect how much say patients felt they had in their treatment, showed a somewhat lower correlation (r = 0.23).
received, was also found to be strongly correlated with satisfaction (r = 0.36). To investigate the relative strength of association of the information factors as well as the individual dierence and demographic factors on satisfaction, a multiple regression analysis was performed. The second column of Table 3 contains the standardized regression coecients when only the four information factors were entered as predictors of satisfaction; the third column presents the results of the regression analysis when age, gender, perceived health status and perceived control were entered as well. The four factors alone accounted for a combined 25% of the variance in satisfaction, while the addition of the other variables accounted for an extra 5%, yielding an r 2 of 0.30. General information remained the strongest predictor of satisfaction in both of these analyses, while perceived control was the most powerful of the personal predictors, even more strongly predictive of satisfaction than any of the remaining information factors.
The relationship of information to satisfaction
Desire for involvement and satisfaction
In order to determine the relationship between satisfaction and information received, zero-order correlations were ®rst calculated between satisfaction and each of the four factors, as well as age, gender, health status, desire for information, desire for involvement and patients' perceived control over their care. As indicated in the ®rst column of Table 3, a weak, but statistically signi®cant relationship was found for age (r = 0.10), and a stronger relationship was found for health status (r=ÿ0.23), indicating that older and healthier patients were more satis®ed with the care they received. The association between each of the information factors and satisfaction was considerably stronger, with the strongest correlation between general information and satisfaction (r = 0.41). Perceived control, which was positively associated with information
In light of past research indicating that patients may be satis®ed with greater or lesser information depending on their individual characteristics and coping styles, the relationship of information to satisfaction was also tested for patient sub-groups with diering preferences. Based on the ®nding in this study that patients' perceived control was related to satisfaction, we asked whether patients who desired more or less involvement in their care were dierentially satis®ed as a function of the information they reported receiving. To do this, we divided patients at the median based on their score on the desire for involvement index and a separate median split was also generated for each of the four information scales. Then, using patient satisfaction as the dependent variable, four separate twoway analyses of variance (two levels of desire for invol-
Table 3 Predictors of satisfaction with care Multiple regression standardized regression coecients
Surgery information General information Sensory information Recovery information Perceived control Age Gender Health status
p < 0.05;
p < 0.001.
Zero order correlation
Information factors only
Information and patient characteristics
0.27 0.41 0.33 0.29 0.36 0.10 0.03 0.23
0.10 0.30 0.13 0.14
0.05 0.23 0.11 0.12 0.18 0.09 0.04 0.13
E. Krupat et al. / Social Science & Medicine 51 (2000) 1817±1825 Table 4 Satisfaction by desire for involvement and recovery informationa Level of recovery information High Low Desire for involvement High 1.75 Low 1.70 a
2.16 1.95
Lower means indicate greater satisfaction.
vement two levels of information received on each information scale) were performed. As expected, strong main eects for information received on satisfaction were found for each of the factors; however, for two of the scales, recovery information and general information, a signi®cant interaction was detected with desire for involvement (recovery information desire for involvement F = 8.37, general information desire for involvement F = 6.26; for each df = 1, 3411, p < 0.0001). In both cases, the pattern for the means was highly similar. As indicated in Table 4 for recovery information, among patients who received much information there was little dierence in their evaluation of care depending on their preference for involvement. Among those who received little information, however, those who preferred to be involved in their care were notably less satis®ed than those who expressed a stronger interest in being involved. Perceived control as a mediator Next, we investigated whether the relationship between information and satisfaction was mediated by
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patients' feelings that they had had enough say in their care. To test the role of perceived control as a mediator variable, a path analysis was conducted. Since the distribution of the variables was skewed, we added 1 to each score to reduce kurtosis. A chi-square of 0.46 was obtained for the overall model, indicating that the overall model ®t the data well. As indicated in Fig. 1, the path coecients relating the sensory, recovery and general information factors as well as perceived control to satisfaction were found to be signi®cant. However, of the paths from the factors to perceived control, only the path coecient relating general information to control was signi®cant. In this model, the predictor variables explained a total of 22% of the variance in satisfaction. To determine whether these relationships remained the same among patients who desired greater vs. lesser involvement in their treatment, patients were divided into quartiles on the index of desire for involvement. In separate analyses using only the upper and the lower quartiles, it was found that for those patients who were least interested in being involved in their own care, the combined variables accounted for 17% of the variance; whereas for those patients who desired the greatest amount of involvement, the combined variables accounted for more than twice the variance, 37%.
Discussion The ®ndings of this study are consistent with the literature, indicating that the fewer informational problems that surgical patients report having, the more positively they evaluate their experience of hospitaliz-
Fig. 1. Path model showing relationships of information factors, perceived control and satisfaction with care.
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ation. However, this research extends previous work because it diers considerably in its approach to the information±satisfaction link. Not only does it contain a very large and diverse sample of patients, conditions and hospitals within a single study, but also it addresses a wider variety of types of information than most studies do. This is because the research itself was not designed to assess the impact of a speci®c intervention, but rather to investigate patients' overall perceptions of their hospital experience. In this manner, it constitutes a broad based, naturalistic test concerning the impact of information received by surgical patients on satisfaction and also allows us to deal with several questions not addressed in previous research. For instance, while each of the separate factors was signi®cantly correlated to satisfaction, the regression analysis suggests that the largest contributor was general information, the one hybrid factor in the factor solution. This cluster of information items involving medications, family involvement and nursing care constitute a set of issues that are sometimes overlooked in the literature. The results of the factor analysis are also enlightening concerning the manner in which the informational issues are structured. For instance, the second factor derived, involving discharge and continuity of care beyond the hospital setting, does not ®t neatly into the procedural vs. sensory distinction made by prior researchers, nor has it often been addressed in many studies dealing with information provision. We believe that this element of information has often been overlooked for two reasons: (1) the research has focused almost exclusively on information given prior to surgery; (2) patient satisfaction data are often collected while patients are still in the hospital, before they can be aware of or anticipate the role of discharge and home recovery information. The presence of this factor suggests that information and coping ought to be de®ned more broadly and assessed from a greater temporal perspective. The factor labeled sensory information received clearly resembles one of the two kinds of information identi®ed in past research, con®rming the signi®cance of informing patients about how they will feel physically and emotionally. However, the other two factors are neither procedural nor sensory, and the several informational items in the original pool that referred to procedural issues were not part of the ®nal factor solution. In light of prior research focusing on loss of control as a key mediator, the association between perceived control and satisfaction as well as its association with the information factors suggested that the route through which information was linked to satisfaction might be patient empowerment. Testing this possibility through the use of path analysis, we found that there
was a signi®cant goodness of ®t for the model as a whole, but for three of the four factors the direct relationship between information and satisfaction was stronger than the relationship between information and control, providing suggestive but not strong support for this hypothesis. Interpretation of these ®ndings, however, should be made with caution as our measure of perceived control was based on a single item; and future research on control as a mediating variable ought to be done using previously validated, multi-item measures of this concept.
Conclusions These ®ndings oer clear support for the hypothesis that the information received by surgical patients is an important determinant of patient satisfaction, and suggest that more attention should be devoted to this area. In addition, they argue strongly for a broadening and possible re-conceptualization of the nature of relevant information that surgical patients need and value to include medication, family, other providers such as nurses and post±hospitalization information. Finally, while our results oer only tentative support for the mediating role of perceived control, they nonetheless suggest that information may be empowering, especially to those who desire it, and indicate that its eect on satisfaction is generally quite positive.
Acknowledgements The authors thank the Picker Institute for making these data available, and acknowledge the collaboration, support and assistance of Jan Walker during the course of this project.
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aration for surgery. In A. Steptoe, & A. Mathews, Health care and human behavior (pp. 231±259). London: Academic Press. Mechanic, D., Greenley, J. R., Cleary, P. D., Hoeper, E., & Wenzel, F. (1980). A model of rural health care: consumer response among users of the Marsh®eld Clinic. Medical Care, 18, 597±606. Mechanic, D., Weiss, N., & Cleary, P. D. (1983). The growth of HMOs: issues of enrollment and disenrollment. Medical Care, 21, 338±347. Meredith, P. (1993). Patient satisfaction with communication in general surgery: problems of measurement and improvement. Social Science and Medicine, 37, 591±602. Miller, S. M., & Mangan, C. E. (1983). Interacting eects of information and coping style in adapting to gynecological stress: should the doctor tell all? Journal of Personality and Social Psychology, 45, 223±236. Oetker-Black, S. L., Teeters, D. L., Cukr, P. L., & Rininger, S. A. (1997). Self-ecacy enhanced preoperative instruction. AORN Journal, 66, 860±861. O'Halloran, C. M., & Altmaier, E. M. (1995). The ecacy of preparation for surgery and invasive medical procedures. Patient Education and Counseling, 25, 9±16. Pick, B., Pearce, S., & Legg, C. (1990). Cognitive responses and the control of postoperative pain. British Journal of Clinical Psychology, 29, 409±415. Roach, J. A., Tremblay, L. M., & Bowers, D. L. (1995). A preoperative assessment and education program: implementation and outcomes. Patient Education and Counseling, 25, 83±88. Robins, P. M. (1987). Coping responses and adaptational outcomes of children undergoing orthopaedic surgery. Journal of Clinical and Child Psychology, 16, 251±259. Suls, J., & Wan, C. K. (1989). Eects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis. Journal of Consulting and Clinical Psychology, 57, 372±379. Taylor, S. E. (1979). Hospital patient behavior: reactance, helplessness, or control? Journal of Social Issues, 35, 156± 184. Thompson, S. C. (1981). Will it hurt less if I can control it? A complex answer to a simple question. Psychological Bulletin, 90, 89±101. Viney, L. L., Benjamin, Y. N., Clarke, A. M., & Bunn, T. A. (1985). Sex dierences in the psychological reactions of medical and surgical patients to crisis intervention counseling: sauce for the goose may not be sauce for the gander. Social Science and Medicine, 20, 1199±1205. Wallace, L. M. (1984). Psychological preparation as a method of reducing the stress of surgery. Journal of Human Stress, 10, 62±77. Wilson, J. F., Moore, R. W., Randolph, S., & Hanson, B. J. (1982). Behavioral preparation of patients for gastrointestinal endoscopy: information, relaxation, and coping style. Journal of Human Stress, 8, 13±23.
www.elsevier.com/locate/socscimed
Information and its impact on satisfaction among surgical patients Edward Krupat a,*, Marcella Fancey b, Paul D. Cleary c a
Massachusetts College of Pharmacy and Health Sciences, Health Psychology Program, Boston, MA 02115, USA b Department of Psychology, Boston University, Boston, MA 02215, USA c Department of Health Care Policy, Harvard Medical School, Cambridge, MA 02115, USA
Abstract This study investigates the association between patient characteristics, reported problems with obtaining information and global evaluations of care among surgical patients. Using data from a large scale study of hospital care, a factor analysis of 30 information-relevant items was conducted with data from a sample of 3602 surgical patients; and correlation and multiple regression analyses were conducted to identify the relationships among information, patient characteristics and global evaluations of care. Path analysis was also used to determine the extent to which perceived control mediates the information±evaluation relationship. Four information factors were identi®ed: surgical information, recovery information, general information and sensory information, and each was signi®cantly related to global evaluations. Desire for involvement interacted with information received in determining patients' evaluations; and partial support was found for perceived control as a mediator of the information±evaluation link. The data indicate that the relationship between information and evaluations of quality is generalizable across patients, conditions and hospitals; and should be de®ned more broadly to include that which is given by a variety of providers, to family, and about medications and home recovery. Desire for involvement and perceived control must also be considered in understanding the value and impact of information. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Hospitalization; Surgical patients; Patient satisfaction; Patient information
Introduction Hospital patients, especially those facing surgery, often experience considerable anxiety as the result of receiving too little information or information that they cannot understand. It has been noted that the
* Corresponding author. Tel.: +1-617-732-2901; fax: +1617-732-2801. E-mail address: [email protected] (E. Krupat).
nursing sta is generally unable to ful®ll the informational needs of patients once they are hospitalized (Meredith, 1993), that the majority of written pre-operative instructions could not be understood by patients (Livingston, 1989) and that only 60% of the cancer patients studied could correctly describe their treatment (Cassileth, Zupkis, Sutton-Smith & March, 1980). Byrne, Napier and Cuschieri (1988) found that more than one quarter of the patients who had had informed consent meetings with their surgeons were not even aware of the organ that was going to be
0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 1 3 - 1
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involved in their surgery. In addition to these, a wide variety of informational problems and de®cits have been documented in several reviews (Horne, Vatmanidis & Careri, 1994; O'Halloran & Altmaier, 1995; Alberts, Lyons, Moretti & Erickson, 1989; Edwards, Lilford, Thornton & Hewison, 1998) and meta-analyses (Johnston & Vogele, 1993; Suls & Wan, 1989). To address informational problems such as these, many programs have been developed to improve communication and provide information to patients facing invasive procedures. Roach, Tremblay and Bowers (1995) trained the nursing sta to provide patients with information about joint replacements, and found that patients' length of stay was shortened and costs were reduced. Beddows (1997) provided information to elective surgery patients both before hospitalization and on their ®rst day, and found that levels of anxiety were lower than a control group that had not been provided with the additional information. In other intervention programs, the provision of information has resulted in reductions in anxiety (Wallace, 1984; Kendall, Williams, Pechaceck, Graham, Shisslak & Herzo, 1979), lower self-reported pain (Wilson, Moore, Randolph & Hanson, 1982; Langer, Janis & Wolfer, 1975), quicker return to normal activities (Kanto, Laine, Vuorisalo & Salonen, 1990) and greater patient satisfaction (Devine, 1992). In the development of interventions, researchers have often relied upon the distinction between sensory information, which involves patients' knowledge about the feelings and sensations they will experience, and procedural information, which involves the nature and sequence of events that patients will experience (Mathews & Ridgeway, 1984; Johnson, 1984). In their metaanalysis of this literature, Suls and Wan (1989) concluded that the provision of procedural information alone provided no greater bene®t than standard (i.e. control group) instruction, but that providing a combination of procedural and sensory information had a signi®cant impact on measures of aect, pain and general distress. In addition to the type of information from which patients bene®t, another key issue involves the mechanism by which information works; how or why information seems to have a salutory eect. In his classic research, Janis (1958) argued that pre-operative information allows patients to engage in the ``work of worrying''. He proposed that information is useful because it allows patients to anticipate and rehearse the stressful events they are about to encounter, and thereby to cope more successfully with them. Others (Mahler & Kulik, 1991; Viney, Benjamin, Clarke & Bunn, 1985) have noted, however, that the bene®ts of information may vary considerably depending on the personality and
demographic characteristics of the patient. Miller and Mangan (1983) report, for instance, that patients who engage in problem-focused coping may want a great deal of information, while those who utilize an avoidant coping style may prefer to have as little as possible. A second explanation for the eects of information revolves around the concept of mastery and perceived control (Oetker-Black, Teeters, Cukr & Rininger, 1997; Bedell, Cleary & Delbanco, 1994; Thompson, 1981). Taylor (1979) believes that patients experience a loss of control when hospitalized, noting that they become either dicult (in order to restore control) or passive (accepting of its loss), in both cases failing to direct cognitive resources toward the task of recovery. Proposing that patients fare better when they believe they can exercise some control over their illness and its treatment, intervention studies have demonstrated that patients who were given information and coping skills had a more positive view of their surgical experience, which was associated with a greater sense of perceived control and better post-operative outcomes (Pick, Pearce & Legg, 1990; Robins, 1987). In spite of the growing volume of research on information and surgery, the majority of these studies are limited in several ways. First, almost all have been based on small samples of patients with selected problems. Second, much of the research has been intervention-based, and therefore the information studied has been almost exclusively pre-surgical and focused narrowly on speci®c kinds of information of interest to the researcher. Third, general evaluations of the quality of hospital care have not been widely studied in this context. As a result, only limited conclusions can be drawn from these studies about the broader role that information plays in the experience of hospitalization. The present research takes a broader approach to the understanding of the role of information among surgical patients. To investigate a wide spectrum of information-related issues, we analyzed responses to a large nationwide survey of hospital patients, addressing informational issues both pre- and post-surgery. The speci®c goals of the research were to determine empirically the manner in which informational issues cluster (especially whether they are organized around the sensory-procedural distinction) and the relationship between patient characteristics and information received; to estimate the strength of the relationship between information and patient evaluations of quality across a wide variety of patients who had undergone a range of surgical procedures; and to explore the mechanisms mediating the relationship between information and quality evaluation, in particular the role of perceived control.
E. Krupat et al. / Social Science & Medicine 51 (2000) 1817±1825
Methods Study sample The data set used for this study came from a survey conducted by the Picker/Commonwealth Fund Program for Patient-Centered Care. The study sample was selected in two stages, ®rst by hospital and then by patients. Hospitals were chosen using the American Hospital Association hospital survey database, selecting a strati®ed probability sample of public and private nonpro®t hospitals in the continental United States that had a general medical and surgical service. Hospitals with fewer than 100 beds as well as for-pro®t, federal and osteopathic hospitals and all long-term hospitals (de®ned as those with 30 or more days length of stay for more than half of the patients) were excluded. Small hospitals were not included in the sample because they would not have a sucient number of recent discharges, and for-pro®t hospitals were not considered because one focus of the project was on supporting change in nonpro®t institutions. Specialty and long-term care facilities were not sampled because the patient mix and process of care in such facilities is usually very dierent from those in general hospitals. All eligible hospitals were strati®ed by ownership, region and teaching status, and a disproportionate random sample from each stratum was selected using sampling probabilities that would yield a similar number of hospitals in each stratum. Thus, certain types of hospital such as academic health centers were oversampled. Of the 141 hospitals contacted, 62 participated in the survey. Reasons for not participating included inadequate administrative sta or resources to compile a list of eligible patients in the hospital; lack of interest in patient reports; diculties selecting a sample of patients because of limited or changing computer systems; concerns that the identity of the hospital would be revealed; logistical problems with data; potential confusion with internal marketing surveys; unwillingness to comply with the protocols; and medical board refusal. Participating and nonparticipating hospitals were compared with respect to ownership, teaching status, region of the country, midsize number of yearly admissions, average daily census and average occupancy rate. Participation rates were somewhat higher among academic health centers and larger hospitals and somewhat higher in the midwest and south, but none of these dierences were statistically signi®cant. For the patient sample, we attempted to interview approximately 100 eligible patients from each hospital as close as possible to three months after discharge. Patients were contacted by phone by a professional telephone interview ®rm (Louis Harris and Associates).
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The interviewer explained the purposes of the study and if the patient agreed, proceeded to question the respondent. The interview was conducted using a Computer Assisted Telephone Interview (CATI). We contacted a total of 8728 patients or someone in their household. Of these, 239 were not eligible for the study because they had been readmitted to a hospital or nursing home. Of the 8489 eligible patients, 6455 (76%) completed a telephone interview. Of these, 56% had had surgery and the remainder were medical patients. Interview content and measures used The interview questions were generated by compiling a list of the features of high quality care most often cited in the literature (see Cleary, Edgman-Levitan, Roberts, McMullen, Walker & Delbanco, 1991; Cleary & McNeil, 1988; Mechanic, Weiss & Cleary, 1983); no eort was made either to include or exclude questions that referred to issues related to procedural or sensory information. Patients were asked about problems with care in each of nine areas: communication, emotional support, patients, needs and preferences, family involvement, education, physical comfort and care, pain management, discharge preparation and ®nancial issues (Gerteis, Edgman-Levitan, Daley & Delbanco, 1993; Cleary et al., 1991). The questions were designed to focus on speci®c actions of the hospital sta rather than broad aspects of care. This was done to minimize the likelihood that factors such as expectations and gratitude, or response tendencies related to gender, class or ethnicity might confound the responses. Most of the questions were asked with dichotomous response options (yes or no), using follow up questions to elicit further information. The survey instrument was reviewed to identify every question in the interview that speci®cally pertained to information-related problems (e.g. ``Were the results of your surgery explained . . . '', ``Were you told the purpose of each medicine. . .'') as opposed to other aspects of care (e.g. ``Was there one particular doctor in charge of your care . . . '', ``Did you experience any pain . . . ''). Thirty-two such items were identi®ed and these were used for purposes of further analysis, although two had to be deleted because a signi®cant proportion of responses (greater than 10%) were missing. Patients also responded to several other interview questions designed to elicit their preferences and evaluations of care. ``Desire for information'' was based on patients' responses to three items (on a four point strongly agree to strongly disagree scale) asking them how much they believed that patients should be fully informed about their care; and ``desire for involvement'' was based on their responses to two items (on a
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Table 1 Characteristics of the hospital patient sample and the surgical patient sub-sample Hospital patients
Surgical patients
Hospital patients
Surgical patients
Age: 18±40 41±64 65±74 75+
23 42 22 13
25 42 22 11
Gender: Male Female
45 55
45 55
Race: White Black Other
86 11 3
84 11 5
Education: Some high school High school graduate Some college College graduate or more
26 37 19 18
23 38 20 18
Marital status: Married or cohabitating Divorced Widowed Single
66 9 14 11
69 9 11 11
Insurance: Private HMO Medicare Medicaid None
57 8 25 5 5
59 9 23 4 5
Income: $15,000 or less $15,001±35,000 $35,001+
37 36 27
32 38 30
Health status: Excellent Good Fair or poor
22 44 34
26 47 27
similar four point scale) asking the extent to which they believed that patients should be part of the decision making process. Both of these ``desire'' measures were adapted from the Autonomy Preference Index developed by Ende and colleagues (Ende, Kazis, Ash & Moskowitz, 1989). Patients were asked whether they had had ``enough say'' about their medical treatment, and responses to this were taken as an index of the extent to which felt they had ``perceived control'' within the context of their treatment. Evaluation of their hospital stay was operationalized using a ®ve item satisfaction index (Cleary et al., 1991) in which patients indicated their evaluation of the courtesy and helpfulness of doctors and nurses, availability of nurses and the organization of the hospital services and sta (using a ®ve point scale from excellent to poor). These items were based on questions used in previous studies (Cleary & McNeil, 1988; Mechanic, Greenley, Cleary, Hoeper & Wenzel, 1980; Mechanic et al., 1983), and have been shown to be related to patients' reported problems with care (Cleary, Edgman-Levitan, McMullen & Delbanco, 1992). Finally, patients answered a 1 Requests for any of the materials used in this project should be made to Paul Cleary, Harvard Medical School, Department of Health Care Policy, 180 Longwood Ave., Boston, MA 02115, USA.
series of questions about their perceived health status and personal and demographic characteristics1.
Results The analysis plan involved several steps: (1) a determination of whether the surgical sample was representative of the larger patient group sampled; (2) an attempt to identify and interpret the structure of information problems experienced by patients using factor analysis, along with the calculation of correlations between patient variables and information factors; (3) investigation of the relationship between information received and evaluations of care using simple correlation and multiple regression; (4) investigation of those variables that might modify and mediate the relationship between information and satisfaction using analysis of variance and path analysis. Characteristics of the sample For the analyses presented herein, we used data from only those patients who indicated that they had surgery performed, a total of 3602. Table 1 presents the characteristics of the surgical sample studied as well as the larger sample from which they were drawn, indicating that overall they were remarkably similar to
E. Krupat et al. / Social Science & Medicine 51 (2000) 1817±1825
one another. The surgical patients, the majority of whom were white (89%) and married (69%), varied widely in age (18±81), education and income. Compared to the total sample, surgical patients were slightly less likely to be over 65 years of age (33% vs. 35%), more likely to be married (69% vs. 66%), less likely to not have at least a high school education (23% vs. 26%) or an income of $15,000 or less (32% vs. 37%), and more likely to rate their health as excellent (26% vs. 22%). The gender and racial distribution of the surgical and medical patients was almost identical.
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the patient's recovery; (3) general information, a factor which included items about medication usage as well as communication with nurses and family; (4) sensory information, speci®cally dealing with explanations about pain, discomfort and anxiety from tests and surgery. The correlations among the four factors were all positive and ranged between 0.35 and 0.53. Internal consistency (coecient alpha) for the four factors was 0.73, 0.69, 0.66 and 0.76, respectively. These represent relatively low yet acceptable levels of alpha (DeVellis, 1991).
Factor structure of information problems
Relationship between patient characteristics and information problems
To identify the patterning of information problems experienced by patients, we analyzed the 30 items using principal factors factor analysis with an oblique rotation. Four signi®cant factors were identi®ed. Items were then eliminated if they did not load at least 0.3 on any of those factors, or if they loaded at least 0.3 on more than one factor. A second factor analysis was performed. This procedure was repeated twice more until a ®nal solution was obtained. Four interpretable factors, containing 21 items, were identi®ed (see Table 2). These were labeled: (1) surgical information, involving questions about the surgery, its risks and bene®ts; (2) recovery information, involving questions about what to do and not do at home to aid
Scale scores for each subject were created by taking the sum of the patient's score on all items included in each factor. Simple correlations of these scores with several demographic variables (age, education, income race, insurance coverage) were calculated. None of the factors was associated strongly with any of the demographic variables (in all cases, r < 0.09). Patients' selfreported health status showed a slightly higher association with each of the types of information received, ranging from a correlation of 0.13 for recovery information to 0.19 for sensory information. Correlations were also calculated between the scale scores and the two brief individual dierence indices, desire for information and desire for involvement.
Table 2 Questionnaire items and factor loadings Factor 1 Surgeon answered all questions? Results of surgery explained? Surgeon explained risks and bene®ts? Surgeon explain what would be doing? Got answers could understand from doctor? Told what activities at home? Told what to do to help recovery at home? Told when to resume regular activities? Told danger signals at home? Told what foods at home? Family given information for at home? Purposes of medications explained? Answers could understand from nurses? Side eects of medications explained? Family given enough information? Explained why tests being done? Told purposes of medications at home? Surgeon explained discomfort? Discomfort of tests explained? Surgeon told how feel after surgery? Surgeon discussed anxieties and fears? Eigen value
0.69 0.57 0.56 0.49 0.31
Factor 2
Factor 3
0.60 0.57 0.48 0.42 0.40 0.60 0.49 0.42 0.42 0.39 0.32
4.82
Factor 4
0.85
0.80
0.68 0.53 0.53 0.39 0.45
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Patient desire for information correlated 0.07 or less with each of the scales, while patient desire for involvement had equally low correlations with three of the four. Only one scale, general information, showed a slightly higher correlation with desire for involvement (r=ÿ0.11). The more patients desired involvement with their care, the less likely they were to report that they received adequate information. Only one patient variable, our measure of perceived control, showed a strong and consistent relationship with the information factors. Patients' responses on this measure were most strongly related to general information (r = 0.37), with surgical information (r = 0.35) and sensory information (r = 0.31) also showing a strong correlation. Recovery information, which refers to information given to patients primarily at the end of their hospital stay and is therefore less likely to aect how much say patients felt they had in their treatment, showed a somewhat lower correlation (r = 0.23).
received, was also found to be strongly correlated with satisfaction (r = 0.36). To investigate the relative strength of association of the information factors as well as the individual dierence and demographic factors on satisfaction, a multiple regression analysis was performed. The second column of Table 3 contains the standardized regression coecients when only the four information factors were entered as predictors of satisfaction; the third column presents the results of the regression analysis when age, gender, perceived health status and perceived control were entered as well. The four factors alone accounted for a combined 25% of the variance in satisfaction, while the addition of the other variables accounted for an extra 5%, yielding an r 2 of 0.30. General information remained the strongest predictor of satisfaction in both of these analyses, while perceived control was the most powerful of the personal predictors, even more strongly predictive of satisfaction than any of the remaining information factors.
The relationship of information to satisfaction
Desire for involvement and satisfaction
In order to determine the relationship between satisfaction and information received, zero-order correlations were ®rst calculated between satisfaction and each of the four factors, as well as age, gender, health status, desire for information, desire for involvement and patients' perceived control over their care. As indicated in the ®rst column of Table 3, a weak, but statistically signi®cant relationship was found for age (r = 0.10), and a stronger relationship was found for health status (r=ÿ0.23), indicating that older and healthier patients were more satis®ed with the care they received. The association between each of the information factors and satisfaction was considerably stronger, with the strongest correlation between general information and satisfaction (r = 0.41). Perceived control, which was positively associated with information
In light of past research indicating that patients may be satis®ed with greater or lesser information depending on their individual characteristics and coping styles, the relationship of information to satisfaction was also tested for patient sub-groups with diering preferences. Based on the ®nding in this study that patients' perceived control was related to satisfaction, we asked whether patients who desired more or less involvement in their care were dierentially satis®ed as a function of the information they reported receiving. To do this, we divided patients at the median based on their score on the desire for involvement index and a separate median split was also generated for each of the four information scales. Then, using patient satisfaction as the dependent variable, four separate twoway analyses of variance (two levels of desire for invol-
Table 3 Predictors of satisfaction with care Multiple regression standardized regression coecients
Surgery information General information Sensory information Recovery information Perceived control Age Gender Health status
p < 0.05;
p < 0.001.
Zero order correlation
Information factors only
Information and patient characteristics
0.27 0.41 0.33 0.29 0.36 0.10 0.03 0.23
0.10 0.30 0.13 0.14
0.05 0.23 0.11 0.12 0.18 0.09 0.04 0.13
E. Krupat et al. / Social Science & Medicine 51 (2000) 1817±1825 Table 4 Satisfaction by desire for involvement and recovery informationa Level of recovery information High Low Desire for involvement High 1.75 Low 1.70 a
2.16 1.95
Lower means indicate greater satisfaction.
vement two levels of information received on each information scale) were performed. As expected, strong main eects for information received on satisfaction were found for each of the factors; however, for two of the scales, recovery information and general information, a signi®cant interaction was detected with desire for involvement (recovery information desire for involvement F = 8.37, general information desire for involvement F = 6.26; for each df = 1, 3411, p < 0.0001). In both cases, the pattern for the means was highly similar. As indicated in Table 4 for recovery information, among patients who received much information there was little dierence in their evaluation of care depending on their preference for involvement. Among those who received little information, however, those who preferred to be involved in their care were notably less satis®ed than those who expressed a stronger interest in being involved. Perceived control as a mediator Next, we investigated whether the relationship between information and satisfaction was mediated by
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patients' feelings that they had had enough say in their care. To test the role of perceived control as a mediator variable, a path analysis was conducted. Since the distribution of the variables was skewed, we added 1 to each score to reduce kurtosis. A chi-square of 0.46 was obtained for the overall model, indicating that the overall model ®t the data well. As indicated in Fig. 1, the path coecients relating the sensory, recovery and general information factors as well as perceived control to satisfaction were found to be signi®cant. However, of the paths from the factors to perceived control, only the path coecient relating general information to control was signi®cant. In this model, the predictor variables explained a total of 22% of the variance in satisfaction. To determine whether these relationships remained the same among patients who desired greater vs. lesser involvement in their treatment, patients were divided into quartiles on the index of desire for involvement. In separate analyses using only the upper and the lower quartiles, it was found that for those patients who were least interested in being involved in their own care, the combined variables accounted for 17% of the variance; whereas for those patients who desired the greatest amount of involvement, the combined variables accounted for more than twice the variance, 37%.
Discussion The ®ndings of this study are consistent with the literature, indicating that the fewer informational problems that surgical patients report having, the more positively they evaluate their experience of hospitaliz-
Fig. 1. Path model showing relationships of information factors, perceived control and satisfaction with care.
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ation. However, this research extends previous work because it diers considerably in its approach to the information±satisfaction link. Not only does it contain a very large and diverse sample of patients, conditions and hospitals within a single study, but also it addresses a wider variety of types of information than most studies do. This is because the research itself was not designed to assess the impact of a speci®c intervention, but rather to investigate patients' overall perceptions of their hospital experience. In this manner, it constitutes a broad based, naturalistic test concerning the impact of information received by surgical patients on satisfaction and also allows us to deal with several questions not addressed in previous research. For instance, while each of the separate factors was signi®cantly correlated to satisfaction, the regression analysis suggests that the largest contributor was general information, the one hybrid factor in the factor solution. This cluster of information items involving medications, family involvement and nursing care constitute a set of issues that are sometimes overlooked in the literature. The results of the factor analysis are also enlightening concerning the manner in which the informational issues are structured. For instance, the second factor derived, involving discharge and continuity of care beyond the hospital setting, does not ®t neatly into the procedural vs. sensory distinction made by prior researchers, nor has it often been addressed in many studies dealing with information provision. We believe that this element of information has often been overlooked for two reasons: (1) the research has focused almost exclusively on information given prior to surgery; (2) patient satisfaction data are often collected while patients are still in the hospital, before they can be aware of or anticipate the role of discharge and home recovery information. The presence of this factor suggests that information and coping ought to be de®ned more broadly and assessed from a greater temporal perspective. The factor labeled sensory information received clearly resembles one of the two kinds of information identi®ed in past research, con®rming the signi®cance of informing patients about how they will feel physically and emotionally. However, the other two factors are neither procedural nor sensory, and the several informational items in the original pool that referred to procedural issues were not part of the ®nal factor solution. In light of prior research focusing on loss of control as a key mediator, the association between perceived control and satisfaction as well as its association with the information factors suggested that the route through which information was linked to satisfaction might be patient empowerment. Testing this possibility through the use of path analysis, we found that there
was a signi®cant goodness of ®t for the model as a whole, but for three of the four factors the direct relationship between information and satisfaction was stronger than the relationship between information and control, providing suggestive but not strong support for this hypothesis. Interpretation of these ®ndings, however, should be made with caution as our measure of perceived control was based on a single item; and future research on control as a mediating variable ought to be done using previously validated, multi-item measures of this concept.
Conclusions These ®ndings oer clear support for the hypothesis that the information received by surgical patients is an important determinant of patient satisfaction, and suggest that more attention should be devoted to this area. In addition, they argue strongly for a broadening and possible re-conceptualization of the nature of relevant information that surgical patients need and value to include medication, family, other providers such as nurses and post±hospitalization information. Finally, while our results oer only tentative support for the mediating role of perceived control, they nonetheless suggest that information may be empowering, especially to those who desire it, and indicate that its eect on satisfaction is generally quite positive.
Acknowledgements The authors thank the Picker Institute for making these data available, and acknowledge the collaboration, support and assistance of Jan Walker during the course of this project.
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