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International Journal for Quality in Health Care Advance Access originally published online on February 2, 2007
International Journal for Quality in Health Care 2007 19(2):113-119; doi:10.1093/intqhc/mzl075
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© The Author 2007. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Expectations and received knowledge by surgical patients

Sirkku Rankinen1, Sanna Salanterä1, Katja Heikkinen1,2, Kirsi Johansson1, Anne Kaljonen1, Heli Virtanen1 and Helena Leino-Kilpi1,3

1 University of Turku, Department of Nursing Science, Turku, Finland
2 Turku Polytechnics, Turku, Finland
3 Hospital District of Southwest Finland, Turku, Finland

Address reprint request to Sirkku Rankinen, Department of Nursing Science, 20014 University of Turku, Finland. Tel: +358 50 361 7651; Fax: +358 2 333 8400; E-mail: sirkku.rankinen{at}kolumbus.fi; sirkku.rankinen{at}utu.fi


   Abstract
Top
 Abstract
Methods
 Research questions
 Instruments
 Results
 Discussion
 References
 
Objective. Here, the aim is to compare surgical patients' knowledge expectations at admission with the knowledge they received during their hospital stay.

Design. The study used a descriptive and comparative design.

Setting. The study was conducted on surgical wards at one randomly selected university hospital in Finland.

Participants. The sample (n = 237) consisted of surgical patients (traumatological, gastroenterological, urological and heart and thorax surgery) admitted to hospital during a 2-month period in 2003.

Methods. The data were collected by two specially developed, parallel questionnaires: Hospital Patients' Knowledge Expectations and Hospital Patients' Received Knowledge. These 40-item instruments used a four-tier response scale and made a distinction between the bio-physiological, functional, experiential, ethical, social and financial dimensions of knowledge. The data were analysed statistically.

Results. Surgical patients received less knowledge than they felt they expected on the bio-physiological, functional, experiential, ethical, social and financial dimensions. Their knowledge expectations and the knowledge they received were related to age, gender and level of basic education.

Conclusions. The results highlighted the need for improved patient education. Surgical patients expect to receive more knowledge than they actually receive on all dimensions. The most problematic areas in the education of surgical patients are the experiential, ethical, social and financial dimensions of knowledge. In particular, younger patients, female patients and patients with a higher level of education require more attention.

Keywords: knowledge expectations, knowledge received, surgical patient

Surgical patients' hospital stays have become significantly shorter as a result of advances in medical technology and inadequate health care budgets. Nonetheless, all surgical patients should have access to a uniformly high quality of care [1]. For this reason, it is important that there is an ongoing effort to develop patient-centered education.

In this study, we compare surgical patients' knowledge expectations at admission with the knowledge they receive during their stay. Knowledge expectations and knowledge received are important components of quality improvement in patient education [2]. For the purposes of this study, we have divided knowledge into the bio-physiological (i.e. illness, symptoms, treatment and complications), functional (i.e. individual needs, mobility, rest, nutrition and body hygiene), experiential (i.e. emotions and hospital experiences), ethical (i.e. rights, duties, participation in decision-making and confidentiality), social (i.e. families, other patients and patient unions) and financial (i.e. costs and financial benefits) dimensions [2–4].

On the bio-physiological dimension, patients expect to receive knowledge on issues related to their diagnosis [5–9], risk factors [5, 10], symptoms [11–13] and the causes and effects of their illness and the surgical procedure [5–8, 10, 11, 14–16]. Furthermore, patients are interested in the treatment facilities [5, 8, 12, 15, 16], the technical details of the surgical procedure [12, 14] and possible complications [5, 9, 11, 12–16]. Most patients want to take part in decision-making about their health care [6, 7, 11] and be better prepared for self-care [7, 15–17]. On the functional dimension, patients want to know how they can cope with the illness [6, 12, 13, 18] and how to prepare for the surgical procedure [5, 10, 15]. Patients' knowledge expectations on the experiential, ethical, social and financial dimensions have received only little attention. However, prostate cancer patients have been reported to want to learn about the ethical aspects of decision-making [6]. Cardiac patients want to learn about emotional reactions [5] and stress [15]. Gastro-oesophageal reflux patients have expressed an interest in previous patients' experiences. Surgical patients with greater knowledge expectations also show better physical and social functioning as well as more effective pain relief [18] than those with low expectations.

Pre-operative knowledge has been received mostly on the bio-physiological and functional aspects of care [14, 19–26]. For example, pre-operative knowledge has been reported to increase surgical patients' knowledge about their illness [23, 25, 26], side effects, symptoms [9, 14, 26], recovery [19, 20, 23, 26, 27] and their knowledge when to contact their physician [14]. Pre-operative knowledge also facilitates patients' adjustment to post-operative complications [18, 25, 26] and reduces anxiety [20, 23, 27], pain, stress [27], the need for physiotherapy and occupational therapy [20], as well as the length of hospital stays [23, 27]. Pre-operative knowledge, on the other hand, did not reduce the hospital stay of hip or knee replacement patients [23]. Patients have, however, also reported receiving inadequate bio-physiological [17, 19, 28, 29], functional [8, 17, 28–30], ethical [29, 30], social [8, 19, 28–30] and financial knowledge [30].

Studies comparing patients' knowledge expectations and knowledge received have shown that staff collect data on those expectations of patients pre-operatively [9, 18] or post-operatively [6, 14]. Gender and age have been found to be related to what patients want to know and what knowledge they receive, but the results are partly inconsistent. Women have greater knowledge expectations before the surgical procedure than men [11, 12], but after discharge no gender differences have been detected [11]. Other studies have reported no gender differences at all [15, 24]. Men seem to be more interested in receiving conventional knowledge than women. However, no gender differences were found in pre-operatively received written knowledge [25]. Men rate themselves higher in terms of their overall preparation for returning home [20]. Older patients have reported receiving sufficient financial, ethical, experiential and social knowledge [26], whereas younger and well-educated patients said they received less knowledge than they expected [14, 26].


   Methods
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 Abstract
 Methods
Research questions
 Instruments
 Results
 Discussion
 References
 
Aim
The aim of this study was to compare surgical patients' knowledge expectations at admission with the knowledge they received during their hospital stay. In addition, we were interested in exploring the relationship between demographic variables and patients' knowledge expectations and knowledge received.


   Research questions
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 Abstract
 Methods
 Research questions
Instruments
 Results
 Discussion
 References
 
We had the following research questions: (i) What knowledge expectations did surgical patients have at admission? (ii) What knowledge did surgical patients receive during their hospital stay? (iii) Did surgical patients receive the knowledge they had expected? and (iv) How were demographic variables associated with patients' knowledge expectations and with the knowledge they received?

Sample and data collection
The study population consisted of all surgical patients (i.e. traumatological, gastroenterological, urological and heart and thorax surgery) from one randomly selected university hospital in Finland during a 2-month period in 2003. The inclusion criteria were: surgical hospital stay, age over 15 years, Finnish speaking, no cognitive disabilities, capable of completing the questionnaire and informed consent. The nurses on the surgical wards attached the first questionnaires concerning patients' knowledge expectations to the appointment letter. The patients returned these questionnaires at admission. The second questionnaires concerning knowledge received during the hospital stay were administered at discharge. The patients filled in the questionnaires and handed them in sealed envelopes to the nurses. Altogether 362 patients were recruited; 45 patients declined to participate, and 80 patients replied to only one questionnaire or returned empty questionnaires; 237 patients completed both questionnaires. Only these responses were included in the analysis. The final response rate was 65%.

Ethical issues
The study protocol was approved by the research committee of the university hospital. Patients were informed of the purpose of the study and about the principles of voluntary and anonymous participation. The patients gave their informed consent prior to replying to the questionnaires.


   Instruments
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 Abstract
 Methods
 Research questions
 Instruments
Results
 Discussion
 References
 
Two parallel scales were developed for this study, based on a literature review, an expert panel and close cooperation with practicing nurses: Hospital Patients' Knowledge Expectations and Hospital Patients' Received Knowledge. These 40-item instruments measured 6 summative variables: the bio-physiological (8 items), functional (8), experiential (3), ethical (9), social (6) and financial (6) dimensions of knowledge [2–4]. For example, the patients were asked what knowledge they expected to receive on the bio-physiological dimension (I wish to receive knowledge about symptoms related to my illness) and on the ethical dimension (I wish to receive knowledge about the rights I have in hospital). At discharge, the patients were asked, for example, about the functional knowledge (I received knowledge about when I can have a shower) and social knowledge they had received (I received knowledge about social benefits). The items were rated by the respondent on a four-point scale, ranging from fully agree (1) to fully disagree (4); a does not apply (0) option was also provided. Lower scores reflect higher knowledge expectations and more knowledge received.

In addition, the following background factors were included: gender, age, level of education, present employment, employment in social and health care, long-term illness, type of admission, reason for present hospital stay, earlier treatment in this hospital and length of present hospital stay.

Data analysis
Summative variables were constructed on the six dimensions of knowledge, bio-physiological, functional, experiential, ethical, social and financial, by calculating the mean values of the corresponding items. In addition, a total index of knowledge was calculated from the mean values of the six summative variables. The response category 0 = does not apply was excluded. The summative variable was accepted if the patient had responded to at least 50% of the items. Descriptive statistics (i.e. frequency, mean, standard deviation and range) were considered with sample characteristics. The effect of socio-demographic variables (age, gender and basic education) on patient's knowledge expectations and knowledge received was examined by the t-test for independent samples or by one-way analysis of variance when appropriate. The difference between knowledge expectations and knowledge received was calculated by analysis of variance for repeated measurements, first without and later with a grouping variable (i.e. age, gender and basic education). The Pearson correlation coefficient was calculated between knowledge expectations and knowledge received for each scale. In all tests, the level of statistical significance was set at P < 0.05 [31]. Only results with statistical significance are reported. Computations were done using the SAS System for Windows, release 8.2/2001.


   Results
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 Abstract
 Methods
 Research questions
 Instruments
 Results
Discussion
 References
 
Characteristics of the sample
The sample comprised 237 surgical (i.e. traumatological, gastroenterological, urological and heart and thorax surgery) patients aged 16–84 (mean = 53, SD = 16.9); most of them were male (Table 1). Over one-third had completed primary education, almost half of the patients had completed secondary education and 2 in 10 had taken the matriculation examination. Four in 10 were employed and the same proportion were retired. About one-sixth were employed in social or health care. Most were elective patients and had visited this hospital earlier (range 1–50 times, mean = 6.6, SD = 7.6). Most of the patients had a surgical procedure during the present hospital stay (range 1–30 days, mean = 5.1, SD = 3.95), and half of them had some chronic illness.


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  		Table 1 Characteristics of the sample (n = 237)

 
Knowledge expectations and knowledge received
The patients' knowledge expectations were mainly focused on bio-physiological and functional issues. They had the least knowledge expectations on the experiential and social dimensions (Table 2).


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  		Table 2 Knowledge expectations and received knowledge

 
Surgical patients' knowledge expectations correlated with their level of basic education: patients with only a primary education had greater knowledge expectations than those who had matriculated.

Patients received most knowledge on the bio-physiological and functional and least knowledge on the social and financial dimensions.

Received knowledge correlated with age, sex and level of basic education. Older surgical patients received more knowledge than younger patients, and male patients received more knowledge than female patients. Patients with a primary education received most knowledge, those who had taken the matriculation examination least.

Differences between knowledge expectations and knowledge received
The differences seen between patients' knowledge expectations and knowledge received pointed at a shortfall of knowledge on all dimensions. In other words, patients had more expectations for knowledge than they actually received, and the differences were statistically significant. The difference was the smallest on the functional and bio-physiological dimensions and the greatest on the social and financial dimensions. (Table 2).

The difference between patients' knowledge expectations and knowledge received was related to age, sex and level of basic education. Male and female patients had the same kinds of knowledge expectations at the overall level as well as on the bio-physiological, functional, experiential, ethical, social and financial dimensions (Table 3). Female patients received statistically significantly less knowledge than male patients overall as well as on bio-physiological, functional, experiential, ethical and social dimensions. The difference between patients' overall knowledge expectations and knowledge received was greater among women than among men. The difference was the greatest on the social dimension and the smallest on the functional dimension.


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  		Table 3 Differences between knowledge expectations and received knowledge by sex

 
Younger patients had lower knowledge expectations than older patients on the total scale and on the bio-physiological dimension (Table 4). Younger patients received less knowledge overall and on the bio-physiological dimension than any other group of patients. Younger patients also showed greater differences than older patients between knowledge expectations and knowledge received on the total scale and on the bio-physiological dimension.


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  		Table 4 Differences between knowledge expectations and received knowledge by age

 
Patients with a higher basic education have less knowledge expectations than patients with a lower basic education on the total scale as well as on the bio-physiological, experiential, social and financial dimensions (Table 5). Patients with a higher basic education received less knowledge overall and also on the bio-physiological, experiential, social and financial dimensions than patients with a lower education. The higher the level of basic education, the greater the differences between patients' knowledge expectations and knowledge received overall. The difference was the greatest on the financial dimension and the smallest on the bio-physiological dimension.


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  		Table 5 Differences between knowledge expectations and received knowledge by basic education

 

   Discussion
Top
 Abstract
 Methods
 Research questions
 Instruments
 Results
 Discussion
References
 
The aim of this study is to compare surgical hospital patients' knowledge expectations at admission and the knowledge they received during their hospital stay. We were also interested in the relationship between demographic variables and knowledge expectations and knowledge received.

Surgical patients had the greatest knowledge expectations on the bio-physiological, functional and ethical dimensions. The results concerning patients' bio-physiological and functional knowledge expectations are consistent with earlier findings [5–8, 10, 12, 13, 15, 16, 25]. This is not surprising in view of the nature of the surgical procedure. Patients often experience symptoms (i.e. pain and nausea) after their operation and difficulties with activity and mobility. As for ethical knowledge, patients were interested in the rights and responsibilities of different staff members during their hospital stay. Patients' knowledge expectations were lowest on the experiential and social dimensions. These results lend support to earlier findings [6, 16].

Our patients received more knowledge on the bio-physiological, functional and experiential dimensions. This is again consistent with earlier results [9, 17, 19–24]. There are also some findings according to which surgical patients do not receive enough bio-physiological knowledge about their illness [19, 29]. According to our results, patients received least financial and social knowledge [26].

Our results show that the differences between knowledge expectations and knowledge received were the smallest on the bio-physiological and functional dimensions. For example, the difference in functional knowledge of 0.22 corresponds to about a third of standard deviation, which would be a moderate difference. This difference may cause clinically significant adverse events on patients' recovery phase.

For surgical patients, due to operations, bio-physiological and functional aspects of knowledge are very important for recovery process. Thus, nurses can emphasize more these aspects and also patients expect to know about them. Short hospitalizations make these issues important.

Surgical patients' knowledge expectations are not met on all dimensions, as has been reported earlier [6, 9, 14, 18]. Younger patients and patients with a higher education have less knowledge expectations. Younger patients, patients with a higher education, and women received insufficient knowledge [14, 26]. In addition, the differences between knowledge expectations and knowledge received were greater among men, younger patients and patients with higher education. The nurses seem to be unaware about patients' expectations.

This study has some limitations that warrant attention. Two parallel instruments were developed for this study because no existing useful tools were available. Their reliability for internal consistency was estimated by Cronbach's alpha coefficient, which was 0.91 for the total 40-item Hospital Patients' Knowledge Expectations scale and 0.87–0.90 for the subscales; and 0.93 for the total Hospital Patients' Received Knowledge scale and 0.90–0.93 for the subscales. The Pearson correlation coefficient was calculated between knowledge expectations and received knowledge for each scale. It was statistically significant, with the exception of the bio-physiological knowledge scale (Table 2). Content validity was estimated on the basis of the theoretical literature and by an expert panel which was composed of researchers, doctors and nurses working in the surgical wards. The questionnaires, were piloted in a sample of 40 surgical patients. Patients had no difficulties filling in the questionnaires, and no changes were made. The instruments' psychometric properties need to be further examined, and they need to be tested with other patient groups.

The study was carried out in one university hospital in Finland, and the study sample consisted of surgical patients. Had we had information about the procedures and treatments provided for our surgical patients, we would also have been able to compare knowledge expectations and knowledge received in these different subgroups. The response rate was satisfactory. We have no knowledge on the reasons for non-response. Male patients outnumbered female patients in the sample. It is clear that additional research is needed (i) with other patient groups and in other settings; (ii) on the ethical, financial and social dimensions of knowledge; (iii) on the relationships between patients' demographic characteristics and their knowledge expectations and knowledge received; (iv) to test patient education interventions with patients undergoing surgical treatment.

Our most important finding is that patients do not seem to receive as much knowledge as they expect to. This clearly attests to the need to further develop and improve patient education. [26].

Not all surgical patients necessarily need the same knowledge, and therefore it is important that education for patients is individually tailored as far as possible. If we had a clearer understanding of what patients want to know, we could also target our education effort more carefully. There are some groups of patients whose knowledge expectations are not met, but the reasons for this may differ. The expectations of some groups may be neglected simply because they do not demand to know more, whereas the expectations of others may be overlooked because it is thought they already know quite a lot.


   References
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 Methods
 Research questions
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 Discussion
 References
 

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Accepted for publication December 6, 2006.


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