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The Impact of Information Videos on Patient Satisfaction for Patients Undergoing Radiation Therapy
Radiation Therapy
The Impact of Information Videos on Patient Satisfaction for Patients Undergoing Radiation Therapy By: John French, DCR(T), ACT, CMS, BSc(Hons), FCAMRT and Mackenzie Yu, DCR(T), RTT
ABSTRACT A video was produced using digital imagery technology for the purpose of demonstrating specific information regarding radiation therapy treatment for patients with head and neck cancer. The effectiveness of the video as a patient education tool was evaluated by use of a satisfaction survey, which was delivered immediately before the first mould room appointment and again at the first post treatment follow up appointment. The patients that had seen the video prior to the first mould room appointment had higher satisfaction ratings with their radiation treatment than those that did not see the video at all. This effect was repeated, but with less statistical significance, at the time of the post treatment follow up appointment.
RÉSUMÉ On a produit une bande vidéo au moyen de l’imagerie numérique portant expressément sur la radiothérapie administrée à des patients souffrant du cancer de la tête et du cou. L’efficacité de la bande comme outil d’information du patient a été évaluée par un sondage satisfaisant utilisé immédiatement avant le premier rendez-vous dans la salle de moulage puis, au moment du premier rendez-vous de suivi du traitement. Les patients qui avaient vu la bande avant leur premier rendez-vous dans la salle de moulage étaient beaucoup plus satisfaits de leur traitement que ceux qui ne l’avaient pas vue. L’effet de satisfaction se répétait, bien qu’à un degré moindre, au moment du rendez-vous de suivi du traitement.
INTRODUCTION The education of radiation therapy patients regarding procedural aspects of their treatment, treatment related side effects and management of those side effects is an important aspect of overall care. A recent large study from the United Kingdom found that the vast majority of patients with cancer want a great deal of very specific information about their disease and treatment (1), but several other studies have demonstrated that patient education needs are not well met. Many studies provide evidence that patients do not receive enough detailed information, in an appropriate format to meet their needs (2-11). The role of video style productions as a method of providing information to patients has been previously evaluated. In a literature review on the efficacy of the use of video in general patient education, Gagliano summarized 19 randomized controlled clinical trials, finding that video programs consistently increase short term knowledge, and they instruct as well as, and often better, than written materials, lectures or even individual counselors. Several of the studies showed that video interventions could decrease anxiety and increase overall coping ability (12). 2
Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
Additional work done by several researchers in the 1980’s did find that audio-visual style productions had an impact in increasing knowledge and understanding and decreasing anxiety amongst patients receiving radiation therapy (13-18). However, long-term knowledge retention and compliance were as much a problem after video interventions when compared to other methods of education. More recently, a study evaluating a computer generated information video produced in Canada was found by patients to be useful and informative, and was perceived by patients to be better than other forms of information, such as information given verbally or in writing (19). A well designed randomized study conducted in 2000 in the United Kingdom found that a commercially produced orientation video increased satisfaction and decreased treatment related anxiety and depression for both radiation therapy and chemotherapy patients (20). The available literature demonstrates that education needs of radiation therapy patients are extensive, are not well met, and that methods of improving patient education should be explored and evaluated further. Video-based productions may be of use in delivering information to patients. This study was designed to evaluate the efficacy, in terms of patient satisfaction with information delivery, of a video produced using digital imagery technology, and identify other variables that may impact on satisfaction with information for a cohort of patients prescribed radiation therapy for cancers of the head and neck.
METHODOLOGY Using digital imagery technology, a video was produced outlining the steps involved in radiation therapy treatment for head and neck cancer. The information in the video was specific to the treatment techniques and support programs used at the centre in question. The computer generated video consists of a series of still images joined together with transition effects and accompanied by text, narration and music. The video was 30 minutes in length and covered the following topics: description of head and neck cancer; radiation therapy; the mould room and simulation process; the plan, production and treatment process. Also included was information about reactions to treatment and care of reactions, including images of actual treatment reactions, information regarding appointment times and treatment review clinics and a description of the psychosocial support services available to patients. The video was made available to patients who had been referred for a course of radiation therapy for head and neck cancer at the time of the initial consultation with a Radiation Oncologist (when patients were determined eligible for radiation therapy). Patients were given the option of seeing the video at the centre or taking a copy home to view. To evaluate the video, a satisfaction survey was designed by the authors with input from a multi-disciplinary team. Prior to use, the survey questionnaire was reviewed by staff members and tested on a group of volunteer helpers at the centre. The survey collected basic demographic data and data relating to patient
perception of the amount and detail of information provided. Satisfaction ratings were collected on specific aspects of treatment, namely, satisfaction with information about the mould room procedure, simulation procedure, treatment planning procedures, reactions to treatment, appointment times for treatment, what happens after treatment is completed and overall satisfaction. A single survey item measured the degree of nervousness about treatment. Likert scales were used to measure responses. Patients were also provided an opportunity to add comments on the survey. The survey was administered twice, initially on the day of the first mould room appointment (the first appointment in the radiation therapy department), immediately before any information was given to them on that day (PRE MR survey). The second survey was administered on the first follow up appointment, 6 weeks after the final radiation therapy treatment (POST XRT survey). A quasi-experimental study design was used, with the surveys initiated before the video was made available and continuing after the video was released. No assistance was given to patients to complete the survey, and the survey was not given to patients who did not speak English. This was the only exclusion criteria. The data were collected from June 1997 to March 1999. Completed data were entered into a spreadsheet and analyzed. The study was primarily designed to test the efficacy of the videos in relation to patient satisfaction with information. Other variables analyzed included patient age group, gender, waiting time for appointments, written material received and verbal information received. T-tests were used to determine statistical differences. P values of less than 0.05 were deemed significant.
RESULTS Fifty-three completed surveys were obtained. Seventy percent of the respondents were male, 30% female. Most were aged over 61 (49%), with 23% aged between 51 and 60 and 28% less than 50 years old. In general, the results demonstrated increased satisfaction at the time of the PORT XRT survey compared to the PREMR survey for all facets. No change in nervousness or apprehensiveness was detected between surveys, with 32% of all patients reporting that they were somewhat nervous or apprehensive about their treatment and 17% reporting that they were either very or extremely nervous. The majority of patients felt that staff spent a reasonable amount of, or more than enough, time explaining their treatments to them, but up to 36% of patients felt they were not given enough detail about their treatments. Nobody reported getting too much information, or too much detail, and Figure 1. Satisfaction ratings - PRE MR survey
23% of respondents, at both survey points, thought that they should have been given more information. In general patients exhibited higher satisfaction with information about their reactions to treatment than with other procedural aspects of treatment such as mould room, simulator or planning. A large number of patients reported receiving no information at the PRE-MR survey, but all patients had received this information by the time of the POST-XRT survey. Thirty-four percent saw the video, (VIDEO SEEN group) 66% did not (VIDEO NOT SEEN group). No differences were detected in responses about nervousness about the treatment or in regard to the perceived amount of time spent with the patient. No respondents indicated that they received too much information, or too many details, while an average of 20% from both groups indicated that they would have liked more information. This was consistent for both the PRE MR and POST XRT surveys. The VIDEO SEEN group was more likely to state that they received just the right amount of detail about their treatments on the PRE MR survey (p<0.005). There were no differences noted on the POST XRT survey for this item. In regard to satisfaction with specific items the VIDEO SEEN group expressed higher satisfaction on the PRE MR survey with information about the simulation procedure, (p<0.01), planning procedures (p<0.01) reactions to treatment (p<0.05) appointment times (p <0.05) what happens after their treatment is complete (p<0.05) and overall satisfaction (p<0.05). See Figure 1. At the time of the POST XRT survey there were no significant differences between the groups, although the VIDEO SEEN group that saw the video had consistently higher ratings. See Figure 2. At the PRE MR survey a proportion of the VIDEO NOT SEEN group stated that they received no information at all for all items, ranging from 9% for information about reactions to 40% about information about simulation and appointment times. Some of the VIDEO SEEN group stated that they received no information for about mould room (5%) appointment times (17%) and what happens after their treatment is complete (22%). Differences were significant for information about simulation and the planning process (p<0.05). See Figure 3. No respondents indicated that they received no information on the POST XRT survey. With regard to the other variables no significant difference was detected for gender or age group. Fifteen patients waited more than 2 weeks between their initial appointment and first mould room appointment, but had similar ratings to those that Figure 2. Satisfaction ratings - POST XRT survey 100 Percentage expressing satisfaction
Percentage expressing satisfaction
100 80 60 40 20 0
80 60 40 20 0
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
OVERALL
Item
Item VIDEO SEEN
OVERALL
VIDEO NOT SEEN
VIDEO SEEN
VIDEO NOT SEEN
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Percentage receiving no information
Figure 3. Patients receiving no information - PRE MR survey 40 35 30 25 20 15 10 5 0
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
OVERALL
Item VIDEO SEEN
VIDEO NOT SEEN
waited less than 2 weeks. Nineteen percent of patients reported that they did not receive any written information, and were more likely to state that staff did not spend enough time with them, and that they received no information (p<0.01). Nine percent received no written information, and were more likely to state that staff did not spend enough time with them, and that they received no information (p<0.01). Three oncologists were responsible for the care of all patients surveyed. No differences in responses were detected depending on the oncologist. Forty-six separate comments were received on the PRE MR survey. The most frequent comments expressed concern relating to undergoing a new experience or identifying specific information that was not given to them. In many cases patients identified that they did not get specific information that they wanted, often relating to potential side effects of treatment. Fifteen percent of the comments received were positive about staff at the centre. Fourteen percent indicated some level of stress or anxiety about the treatment, diagnosis or disease, and a further 14% of comments related to the wait for treatment or concern regarding appointment times. Forty-seven separate comments were received on the POST XRT survey. Forty percent of these were positive comments about the RT staff. Thirteen percent referred to concern over side effects, 11% to fear of the unknown, 9% requesting specific information and 9% relating to worry or stress about the treatment, diagnosis or disease.
DISCUSSION The results support the notion that the format in which information is given can impact patient satisfaction with information, and that a video format appears to be effective. Certainly those patients that saw the video had significantly increased satisfaction scores on the survey. It appears that patient information is not given to consistently the same standard, in that several patients reported receiving no verbal or written information, despite a practice in the centre of giving both verbal and written information as part of the consultation and consent process. This discrepancy may occur given the fact that providing information does not necessarily mean that information is received. Verbal information may be misheard, misunderstood or not heard at all, and written information may be not read, lost or not understood. Those patients that stated that they received no information were less satisfied than those that did receive information. Also, many patients did not receive, or exhibited dissatisfaction with, information about, the procedural aspects of radiation therapy, such as
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Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
planning procedures, appointment times, and post treatment procedures. This study reinforces the notion that patient education requires providing information in a format that is readily understandable and also suggests that ensuring information is received and understood is an important part of the process. It is of note that no one responded that they received too much information or too much detail about their treatments, or that staff spent too much time with them. The use of videos as an educational tool is attractive in radiation therapy. Previously the cost of producing these videos might have been a limiting factor, however computer technology can drastically reduce costs. Meade quotes an approximate budget of $1000 US per edited minute of video (21). The video in this study was produced on multi-media computers and at very little cost after acquiring the equipment. Video production is normally time consuming and requires assistance from outside contractors. However, this video was produced entirely in-house with very little production time involved. Based on the significant variation in satisfaction scores between the group that saw the video compared to those that did not, it is a reasonable conclusion that the video was of benefit in increasing satisfaction with information between the initial consultation and first mould room appointment. The effect was diminished by the time of the first follow-up appointment, when satisfaction ratings for both groups were generally higher than previous and possibly because of the increased amount of education and information given by health care providers during the course of treatment. However, satisfaction ratings at this point were consistently higher for those that saw the video, and a larger study may have revealed more significant differences. A large proportion of patients that did not see the video indicated that they received no information at all about aspects of their forthcoming treatment, while no respondents indicated they received too much information. Comments received by patients were complimentary about the care they received and the staff at the centre. The comments also reinforced the fact that patients are concerned about their diagnosis and prognosis, and their treatment and side effects to treatment. Patients also expressed a desire for more information, often specific to their needs.
CONCLUSION This study adds weight to previous studies demonstrating the benefits of providing information in a video format. This is probably because patients may find information about new and complex experiences provided in written or verbal formats hard to understand. New technology means that videos can be produced non-commercially, and at little cost (19). This enables health care providers to produce videos that clearly explain the exact process that a patient will undergo, which may be of benefit when explaining complex procedures, such as radiation therapy delivery, to patients. Without the use of videos it appears that in many cases patients are not receiving information about certain aspects of their treatments, supporting the argument that verbal or written information may be of limited efficacy. The study also supports research indicating that patients want a large amount of specific information (1). It is also a reasonable conclusion that while we may not be providing enough information, in no cases is too much information or too much detail given to patients. The results of this study have enabled the video producers and study authors to obtain additional funding for producing more videos.
ACKNOWLEDGEMENTS The authors wish to thank Susie Lytwyn, Tracey Warner, Nadia Kutowy and all who participated in the production of the video.
REFERENCES 1. Jenkins V., Fallowfield L., Saul J. Information Needs of Patients with Cancer: Results from a Large Study in UK Cancer Centres. British Journal of Cancer. 2001; 84(1): 48-51. 2. Brewin T.B. The Cancer Patient: Communication and Morale. British Medical Journal. 1977; 2; 1623-1627. 3. Cassileth B.R., Volckman D., Goodman R.L. The Effect of Experience on Radiation Therapy Patients’ Desire for Information. International Journal Radiation Oncology, Biology and Physics. 1979; 6: 493-496. 4. Eardley A., Patients and Radiotherapy. Radiography. 1986; 52: 19-22. 5. Fieler V.K., Wlasowicz G.S., Mitchell M.L., Jones L.S., Johnson J.E., Information Preferences of Patients Undergoing Radiation Therapy. Oncology Nursing Forum. 1996; l23 (10): 1603-1608. 6. Frith B. Giving Information to Radiotherapy Patients. Nursing Standard. 1991; 5(34): 33-35. 7. Hinds C., Streater A., Mood D. Functions and Preferred Methods of Receiving Information Related to Radiotherapy - Perceptions of Patients with Cancer. Cancer Nursing. 1995; 18(5): 374-384. 8. Hubert A., Kantor G., Dilhuydy J.M., et al. Patient Information about Radiation Therapy: A Survey in Europe. Radiotherapy and Oncology. 1997; 43: 103-107. 9. Mitchell G.W., Glicksman A.S., Cancer Patients: Knowledge and Attitudes. Cancer. 1977; 40: 61-66. 10. Northouse P.G., Northouse L.I. Communication and Cancer: Issues Confronting Patients, Health Professionals and Family Members. Journal of Psychosocial Oncology. 1987; 5:17-46.
11. Wiggers J.H., Donovan K.O., Redman S., Sanson Fisher R.W. Cancer Patient Satisfaction with Care. Cancer. 1990; 66: 610-116. 12. Gagliano M.E. A Literature Review on the Efficacy of Video In Patient Education. Journal of Medical Education. 1988; 63: 785-792. 13. Cassileth B.R., Hieberger R.M., March V., Sutton-Smith K. Effect of Audiovisual Cancer Programs On Patients and Families. Journal of Medical Education. 1982; 57: 54-59. 14. Chang B.L., Hirsch M. Videotape Intervention: Producing Videotapes for Use in Nursing Practise and Education. The Journal of Continuing Education in Nursing. 1994; l25 (6): 263-267. 15. Israel M.J., Mood D.W. Three Media Presentations For Patients Receiving Radiation Therapy. Cancer Nursing. 1982; 57-63. 16. Mood D.W., Cook C.A., Chadwell D.K. Increasing Patients Knowledge of Radiation Therapy. Int J. Radiation Oncology, Biol. Phys. 1988; 15: 989-993. 17. Poroch D. The Effect of Preparatory Patient Education on the Anxiety and Satisfaction of Cancer Patients Receiving Radiation Therapy. Cancer Nursing. 1995; 18(3): 206-214. 18. Rainey C.R., Effects of preparatory Patient Education for Radiation Oncology Patients. Cancer. 1985; 56: 1056 – 1061. 19. French J.G., Yu M., Samant R.S. Production and Evaluation of LowCost Patient Education Videos Using Digital Imagery. Journal of Cancer Education. 1999; 14(4); 204 – 7. 20. Thomas R., Daly M., Peryman B., Stockton D. Forewarned is Forearmed – Benefits of Preparatory Information on Video Cassette for Patients Receiving Chemotherapy or Radiotherapy – a Randomised Controlled Trail. European Journal of Cancer. 2000; 36: 1536-1543. 21. Meade C.D. Producing Videotapes for Cancer Education: Methods and Examples. Oncology Nursing Forum. 1996; 23(5): 837-846.
Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
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The Impact of Information Videos on Patient Satisfaction for Patients Undergoing Radiation Therapy By: John French, DCR(T), ACT, CMS, BSc(Hons), FCAMRT and Mackenzie Yu, DCR(T), RTT
ABSTRACT A video was produced using digital imagery technology for the purpose of demonstrating specific information regarding radiation therapy treatment for patients with head and neck cancer. The effectiveness of the video as a patient education tool was evaluated by use of a satisfaction survey, which was delivered immediately before the first mould room appointment and again at the first post treatment follow up appointment. The patients that had seen the video prior to the first mould room appointment had higher satisfaction ratings with their radiation treatment than those that did not see the video at all. This effect was repeated, but with less statistical significance, at the time of the post treatment follow up appointment.
RÉSUMÉ On a produit une bande vidéo au moyen de l’imagerie numérique portant expressément sur la radiothérapie administrée à des patients souffrant du cancer de la tête et du cou. L’efficacité de la bande comme outil d’information du patient a été évaluée par un sondage satisfaisant utilisé immédiatement avant le premier rendez-vous dans la salle de moulage puis, au moment du premier rendez-vous de suivi du traitement. Les patients qui avaient vu la bande avant leur premier rendez-vous dans la salle de moulage étaient beaucoup plus satisfaits de leur traitement que ceux qui ne l’avaient pas vue. L’effet de satisfaction se répétait, bien qu’à un degré moindre, au moment du rendez-vous de suivi du traitement.
INTRODUCTION The education of radiation therapy patients regarding procedural aspects of their treatment, treatment related side effects and management of those side effects is an important aspect of overall care. A recent large study from the United Kingdom found that the vast majority of patients with cancer want a great deal of very specific information about their disease and treatment (1), but several other studies have demonstrated that patient education needs are not well met. Many studies provide evidence that patients do not receive enough detailed information, in an appropriate format to meet their needs (2-11). The role of video style productions as a method of providing information to patients has been previously evaluated. In a literature review on the efficacy of the use of video in general patient education, Gagliano summarized 19 randomized controlled clinical trials, finding that video programs consistently increase short term knowledge, and they instruct as well as, and often better, than written materials, lectures or even individual counselors. Several of the studies showed that video interventions could decrease anxiety and increase overall coping ability (12). 2
Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
Additional work done by several researchers in the 1980’s did find that audio-visual style productions had an impact in increasing knowledge and understanding and decreasing anxiety amongst patients receiving radiation therapy (13-18). However, long-term knowledge retention and compliance were as much a problem after video interventions when compared to other methods of education. More recently, a study evaluating a computer generated information video produced in Canada was found by patients to be useful and informative, and was perceived by patients to be better than other forms of information, such as information given verbally or in writing (19). A well designed randomized study conducted in 2000 in the United Kingdom found that a commercially produced orientation video increased satisfaction and decreased treatment related anxiety and depression for both radiation therapy and chemotherapy patients (20). The available literature demonstrates that education needs of radiation therapy patients are extensive, are not well met, and that methods of improving patient education should be explored and evaluated further. Video-based productions may be of use in delivering information to patients. This study was designed to evaluate the efficacy, in terms of patient satisfaction with information delivery, of a video produced using digital imagery technology, and identify other variables that may impact on satisfaction with information for a cohort of patients prescribed radiation therapy for cancers of the head and neck.
METHODOLOGY Using digital imagery technology, a video was produced outlining the steps involved in radiation therapy treatment for head and neck cancer. The information in the video was specific to the treatment techniques and support programs used at the centre in question. The computer generated video consists of a series of still images joined together with transition effects and accompanied by text, narration and music. The video was 30 minutes in length and covered the following topics: description of head and neck cancer; radiation therapy; the mould room and simulation process; the plan, production and treatment process. Also included was information about reactions to treatment and care of reactions, including images of actual treatment reactions, information regarding appointment times and treatment review clinics and a description of the psychosocial support services available to patients. The video was made available to patients who had been referred for a course of radiation therapy for head and neck cancer at the time of the initial consultation with a Radiation Oncologist (when patients were determined eligible for radiation therapy). Patients were given the option of seeing the video at the centre or taking a copy home to view. To evaluate the video, a satisfaction survey was designed by the authors with input from a multi-disciplinary team. Prior to use, the survey questionnaire was reviewed by staff members and tested on a group of volunteer helpers at the centre. The survey collected basic demographic data and data relating to patient
perception of the amount and detail of information provided. Satisfaction ratings were collected on specific aspects of treatment, namely, satisfaction with information about the mould room procedure, simulation procedure, treatment planning procedures, reactions to treatment, appointment times for treatment, what happens after treatment is completed and overall satisfaction. A single survey item measured the degree of nervousness about treatment. Likert scales were used to measure responses. Patients were also provided an opportunity to add comments on the survey. The survey was administered twice, initially on the day of the first mould room appointment (the first appointment in the radiation therapy department), immediately before any information was given to them on that day (PRE MR survey). The second survey was administered on the first follow up appointment, 6 weeks after the final radiation therapy treatment (POST XRT survey). A quasi-experimental study design was used, with the surveys initiated before the video was made available and continuing after the video was released. No assistance was given to patients to complete the survey, and the survey was not given to patients who did not speak English. This was the only exclusion criteria. The data were collected from June 1997 to March 1999. Completed data were entered into a spreadsheet and analyzed. The study was primarily designed to test the efficacy of the videos in relation to patient satisfaction with information. Other variables analyzed included patient age group, gender, waiting time for appointments, written material received and verbal information received. T-tests were used to determine statistical differences. P values of less than 0.05 were deemed significant.
RESULTS Fifty-three completed surveys were obtained. Seventy percent of the respondents were male, 30% female. Most were aged over 61 (49%), with 23% aged between 51 and 60 and 28% less than 50 years old. In general, the results demonstrated increased satisfaction at the time of the PORT XRT survey compared to the PREMR survey for all facets. No change in nervousness or apprehensiveness was detected between surveys, with 32% of all patients reporting that they were somewhat nervous or apprehensive about their treatment and 17% reporting that they were either very or extremely nervous. The majority of patients felt that staff spent a reasonable amount of, or more than enough, time explaining their treatments to them, but up to 36% of patients felt they were not given enough detail about their treatments. Nobody reported getting too much information, or too much detail, and Figure 1. Satisfaction ratings - PRE MR survey
23% of respondents, at both survey points, thought that they should have been given more information. In general patients exhibited higher satisfaction with information about their reactions to treatment than with other procedural aspects of treatment such as mould room, simulator or planning. A large number of patients reported receiving no information at the PRE-MR survey, but all patients had received this information by the time of the POST-XRT survey. Thirty-four percent saw the video, (VIDEO SEEN group) 66% did not (VIDEO NOT SEEN group). No differences were detected in responses about nervousness about the treatment or in regard to the perceived amount of time spent with the patient. No respondents indicated that they received too much information, or too many details, while an average of 20% from both groups indicated that they would have liked more information. This was consistent for both the PRE MR and POST XRT surveys. The VIDEO SEEN group was more likely to state that they received just the right amount of detail about their treatments on the PRE MR survey (p<0.005). There were no differences noted on the POST XRT survey for this item. In regard to satisfaction with specific items the VIDEO SEEN group expressed higher satisfaction on the PRE MR survey with information about the simulation procedure, (p<0.01), planning procedures (p<0.01) reactions to treatment (p<0.05) appointment times (p <0.05) what happens after their treatment is complete (p<0.05) and overall satisfaction (p<0.05). See Figure 1. At the time of the POST XRT survey there were no significant differences between the groups, although the VIDEO SEEN group that saw the video had consistently higher ratings. See Figure 2. At the PRE MR survey a proportion of the VIDEO NOT SEEN group stated that they received no information at all for all items, ranging from 9% for information about reactions to 40% about information about simulation and appointment times. Some of the VIDEO SEEN group stated that they received no information for about mould room (5%) appointment times (17%) and what happens after their treatment is complete (22%). Differences were significant for information about simulation and the planning process (p<0.05). See Figure 3. No respondents indicated that they received no information on the POST XRT survey. With regard to the other variables no significant difference was detected for gender or age group. Fifteen patients waited more than 2 weeks between their initial appointment and first mould room appointment, but had similar ratings to those that Figure 2. Satisfaction ratings - POST XRT survey 100 Percentage expressing satisfaction
Percentage expressing satisfaction
100 80 60 40 20 0
80 60 40 20 0
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
OVERALL
Item
Item VIDEO SEEN
OVERALL
VIDEO NOT SEEN
VIDEO SEEN
VIDEO NOT SEEN
Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
3
Percentage receiving no information
Figure 3. Patients receiving no information - PRE MR survey 40 35 30 25 20 15 10 5 0
MOULD ROOM
SIMULATION
PLANNING
REACTIONS
APPT. TIMES
POST TREATMENT
OVERALL
Item VIDEO SEEN
VIDEO NOT SEEN
waited less than 2 weeks. Nineteen percent of patients reported that they did not receive any written information, and were more likely to state that staff did not spend enough time with them, and that they received no information (p<0.01). Nine percent received no written information, and were more likely to state that staff did not spend enough time with them, and that they received no information (p<0.01). Three oncologists were responsible for the care of all patients surveyed. No differences in responses were detected depending on the oncologist. Forty-six separate comments were received on the PRE MR survey. The most frequent comments expressed concern relating to undergoing a new experience or identifying specific information that was not given to them. In many cases patients identified that they did not get specific information that they wanted, often relating to potential side effects of treatment. Fifteen percent of the comments received were positive about staff at the centre. Fourteen percent indicated some level of stress or anxiety about the treatment, diagnosis or disease, and a further 14% of comments related to the wait for treatment or concern regarding appointment times. Forty-seven separate comments were received on the POST XRT survey. Forty percent of these were positive comments about the RT staff. Thirteen percent referred to concern over side effects, 11% to fear of the unknown, 9% requesting specific information and 9% relating to worry or stress about the treatment, diagnosis or disease.
DISCUSSION The results support the notion that the format in which information is given can impact patient satisfaction with information, and that a video format appears to be effective. Certainly those patients that saw the video had significantly increased satisfaction scores on the survey. It appears that patient information is not given to consistently the same standard, in that several patients reported receiving no verbal or written information, despite a practice in the centre of giving both verbal and written information as part of the consultation and consent process. This discrepancy may occur given the fact that providing information does not necessarily mean that information is received. Verbal information may be misheard, misunderstood or not heard at all, and written information may be not read, lost or not understood. Those patients that stated that they received no information were less satisfied than those that did receive information. Also, many patients did not receive, or exhibited dissatisfaction with, information about, the procedural aspects of radiation therapy, such as
4
Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
planning procedures, appointment times, and post treatment procedures. This study reinforces the notion that patient education requires providing information in a format that is readily understandable and also suggests that ensuring information is received and understood is an important part of the process. It is of note that no one responded that they received too much information or too much detail about their treatments, or that staff spent too much time with them. The use of videos as an educational tool is attractive in radiation therapy. Previously the cost of producing these videos might have been a limiting factor, however computer technology can drastically reduce costs. Meade quotes an approximate budget of $1000 US per edited minute of video (21). The video in this study was produced on multi-media computers and at very little cost after acquiring the equipment. Video production is normally time consuming and requires assistance from outside contractors. However, this video was produced entirely in-house with very little production time involved. Based on the significant variation in satisfaction scores between the group that saw the video compared to those that did not, it is a reasonable conclusion that the video was of benefit in increasing satisfaction with information between the initial consultation and first mould room appointment. The effect was diminished by the time of the first follow-up appointment, when satisfaction ratings for both groups were generally higher than previous and possibly because of the increased amount of education and information given by health care providers during the course of treatment. However, satisfaction ratings at this point were consistently higher for those that saw the video, and a larger study may have revealed more significant differences. A large proportion of patients that did not see the video indicated that they received no information at all about aspects of their forthcoming treatment, while no respondents indicated they received too much information. Comments received by patients were complimentary about the care they received and the staff at the centre. The comments also reinforced the fact that patients are concerned about their diagnosis and prognosis, and their treatment and side effects to treatment. Patients also expressed a desire for more information, often specific to their needs.
CONCLUSION This study adds weight to previous studies demonstrating the benefits of providing information in a video format. This is probably because patients may find information about new and complex experiences provided in written or verbal formats hard to understand. New technology means that videos can be produced non-commercially, and at little cost (19). This enables health care providers to produce videos that clearly explain the exact process that a patient will undergo, which may be of benefit when explaining complex procedures, such as radiation therapy delivery, to patients. Without the use of videos it appears that in many cases patients are not receiving information about certain aspects of their treatments, supporting the argument that verbal or written information may be of limited efficacy. The study also supports research indicating that patients want a large amount of specific information (1). It is also a reasonable conclusion that while we may not be providing enough information, in no cases is too much information or too much detail given to patients. The results of this study have enabled the video producers and study authors to obtain additional funding for producing more videos.
ACKNOWLEDGEMENTS The authors wish to thank Susie Lytwyn, Tracey Warner, Nadia Kutowy and all who participated in the production of the video.
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Summer / été 2003 • Volume 34 • Number 2 / Numéro 2
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