Minor Surgery

1. 1

Study into the benefits of preparatory
information prior to minor surgery in
primary care settings and its
consequent effect on reducing
preoperative and peri-operative
anxiety.






James. D. Whyman
Submission date: 22.05.09 Word Count: 4,873

2. 2
Contents:


Title Page………………………………………………………………………………1

Abstract……………………………………………………………………………...3,4

Introduction…………………………………………………...……………………..4-6

Literature Review……………………………………………………………………7,8

Objectives……………………………………………………………………………...9

Method…………………………………………………………………………..…9,10

Results…………………………………………………………………………….11-14

Discussion……………………………………………………………………...…15-18

Strengths and limitations of study………………………………………………...19,20

Implications for future practice………………………………………………………21

Appendix 1…………………………………………………………………………...22

Appendix 2…………………………………………………………………………...23

Appendix 3…………………………………………………………………………...24

Appendix 4………………………………………………………………………..25,26

Appendix 5………………………………………………………………………..27,28

References………………………………………………………………………...29,30

3. 3
Abstract:

Objectives: To determine any significant link between patient anxiety and amount of
pre-operative information given with particular regard to gender and whether the
surgical unit is General Practitioner (GP) led or Surgeon led. This will involve the
identification of different anxieties relating to certain procedures. Design: This study
was a randomised controlled equivalency trial involving the distribution of
questionnaires to consenting adults undergoing minor surgical procedures. Setting:
Two surgical units, one surgeon/GP led (Surgery A) and one GP led unit (Surgery B)
in two neighbouring towns. Participants: Consenting patients over the age of 18
requiring elective minor surgery. Results: A total of 193 participants (96 surgery A:
53 males 43 females) (97 surgery B: 38 males 59 females) Surgery A: Most common
procedures performed were hand surgeries followed by skin procedures (39.5% and
20% respectively). The main anxieties for men were pain (33.3%), and success of
operation (31%).
Main anxieties for women were success of operation (48%) and pain (39%). Surgery
B: Most common procedures performed were skin operations (56.7%) followed by
joint injections (14.4%). Main anxieties for men were pain (57%), and success of
operation (31%). Main anxieties for women were the success of the operation (30%)
and anaesthetic (27%). Conclusions: The results show that there were higher levels of
satisfaction from patients undergoing minor surgical procedures in the surgeon led
unit. (100% satisfaction with the amount of preoperative information given) as
opposed to 84% from surgery B. This opinion was largely as a result of patients’
comments on the questionnaires regarding the information they had received
preoperatively and peri-operatively. (See appendix patients’ comments). Implications
for future practice: Minor surgical units could implement a basic patient satisfaction

4. 4
questionnaire so as to encourage better communication between the staff and the
patient therefore creating an informal patient-centred relationship. This proposed
survey can potentially identify and record any pre-operative anxieties and be easily
addressed at the time of the procedure allowing for better patient-centred care. This
implementation can be very useful for auditing purposes as well as patient
satisfaction.


Introduction:

Historically, minor surgery has been an important service offered by a general
practice. This was largely due to the implementation of the National Health Service
Plan (DoH 2002), which focused on patient choice of where they could go for
specialist clinics within their community. Since this time, General Practitioners (GP’s)
have been keen to promote minor surgery services to their patients as an alternative to
hospital admission. This could relieve the pressures on secondary care, their staff,
waiting times enabling instead, easier access, shorter waiting times and flexibility
(DoH 2006). Patients attending for minor surgery are often very anxious about the
procedure and educating the patient before surgery as to what to expect and how the
procedure is carried, out can reduce pain and aid relaxation postoperatively (Wilmore
and Kehlet 2001). This paper acknowledges this and supports the implementation of
preparatory assessment, a tool recommended by the Government (NICE 2003), which
is already being used in secondary (hospital) care.

The aim of this study was to determine the benefits of information given to patients
prior to minor surgery in primary care led units and its consequent effects on their
potential anxiety.

5. 5
Contributing factors, which may potentially influence anxiety, will be considered for
example gender and type of anxiety.
In addition by reading previous patient questionnaires from the surgeries illustrated,
underlying variables were identified and included in this study.
This in turn led to a more in-depth analysis of preoperative anxiety in patients, the
implications of which could be significant for improving patient centred care.
Distractions such as the provision of music during the procedure and the use of
educational videotapes prior to procedures will be briefly discussed.
The author’s study aims to examine these key principles with the intent of relating
them to general practice.

Patient surveys from two local medical practices within neighbouring towns were
selected. One practice has a dedicated surgical centre whose consultants are qualified
surgeons from secondary care acting in partnership with the GP (Surgery A), also a
qualified surgeon. The other practice has a small in-house minor surgical unit run by
GP’s experienced in minor operative procedures, (Surgery B). Both practices see
patients prior to the date of surgery, to inform, consent and document the procedure,
which is a compulsory requirement of their regulatory body (GMC 2004) , but no
formal pre-operative assessment is undertaken, as is encouraged in secondary care
(NICE 2003).
The results will illustrate areas of patient anxiety, for example, pain, recovery, time
off work and if there is a link between either practices. This may prove of interest in
establishing whether a practice with qualified surgeons is more effective at allaying
anxiety than a GP led minor surgical unit.

6. 6
A large study, the MiSTIC trial (George et al 2005) compared minor surgery in
primary and secondary care (hospitals) and concluded that patient satisfaction was
greater in primary care and therefore reduced patient anxiety. (See appendix 1).
However the same study suggested that while it was more cost effective to perform
minor surgery in hospitals, due to a more successful surgery (for example complete
cyst excision) this may not be a popular option as it would increase workload and
inconvenience patients.

Gilmartin (2004) suggested that nurses are well suited to assess patients pre-
operatively because they are very good at giving information.. Patients clearly felt
prepared and assessed adequately by nurses, although a minority felt their needs were
not addressed leaving them feeling anxious. This study was designed within
secondary care surgical units, but demonstrates that communication skills and
knowledge of procedures is essential, which is the case in the primary care setting.
Gilmartin and Wright (2007) explain that information given should be wholly patient-
centred to alleviate anxiety and that communication skills are therefore vital for
General Practitioners (GP’s) specialising in minor surgery to support the pre-
assessment process.
GP surgeries undertake regular audits to establish patient satisfaction regarding the
services available. This is a requirement through clinical governance (NICE 2008)
whereby NHS organisations are accountable for maintaining the provision of high
standards of services . This often involves the distribution of patient questionnaires.
The results of the questionnaires or surveys are essential for ongoing clinical practice,
thus changes can be made through auditing to ensure best practice and therefore
patient satisfaction.

7. 7
Literature review:

Nice Guidelines – CG3 – Preoperative tests.
These government guidelines form the basis of patient consent before surgery. They
address the importance ethically and legally of consent, and, in addition include the
guideline that states that “patients should have access to sufficient information about
risks, benefits and alternatives to be able to make an informed decision about whether
to consent”.
www.nice.org.uk/nicemedia/pdf/CG3NICEguidelineposter.pdf

Patient anxiety and modern elective surgery: a literature review.
This report states that although there has been a significant rise in day-surgeries i.e.
elective surgery, preoperative psychological care has remained fairly static. “A
considerable number of patients are very anxious prior to elective surgery and little
formal care is undertaken to address this major issue”. This study involved reviewing
the key fears of patients undergoing elective surgery and identifying any interventions
that primarily address said anxieties.
Mitchell M 2003 Journal of clinical nursing – Volume 12, issue 6 p.806-815

A prospective randomised comparison of minor surgery in primary and secondary
care. The MiSTIC trial.
This study’s aims were to collect data on the quality of the surgery undertaken
alongside patient satisfaction, safety and cost in primary and secondary care.
The results of this study showed that the safety of the patient is of paramount
importance and that primary care is not safe as it is currently practised. The MiSTIC
trial highlighted that hospital based minor surgery would be more cost effective but
there is not the capacity to undertake the workload. Alongside this, it was established
that secondary care minor surgery was unpopular with patients due to waiting times
and that they preferred primary care.
George S et al NHS National Library for Health 2005.

Direct Access Minor Surgery service--patient satisfaction and effectiveness.
D. Bandyopadhyay, B. Turnpenny, and E. P. Dewar.
This study analysed patient satisfaction with direct access minor surgery services in
secondary care centres i.e. hospitals. Direct access meant that no prior outpatient
appointment was attended. The results showed that the service was favourable among
patients and that 90% were satisfied with the preoperative information given. This
study with regard to the MiSTIC trial conforms to the same conclusions, though the
patient satisfaction level was surprisingly high given the allegedly unpopular service
due to long waiting times.
Ann R College of Surgery England. 2005 July; 87(4): 248–250.

The effect of music on preoperative anxiety in day surgery
Cooke M et al 2004
This study showed that the use of music in day surgery significantly reduces patient
anxiety levels. The study also concluded that there was no clinical relationship
between clinical variables such as gender or type of surgery.

8. 8
The nurse’s role in day surgery; a literature review.
Gilmartin J, Wright K.
This study showed that patient anxiety was significantly reduced by the use of music,
story telling and distraction. In addition the deficits included poor preoperative
information giving resulting in high anxiety. The conclusion was that adequate
preparation and psychological support was necessary in obtaining high patient
satisfaction levels.
International Nursing Review. 2007 Jun; (5492):183-90

Day surgery: patient’s perceptions of a nurse-led preadmission clinic.
Gilmartin J.
This study concluded that a nurse-led clinic was effective, and “most patients felt they
were adequately assessed and prepared for day surgery”. The results showed that
there was a high level of patient satisfaction due to conveyance of comprehensive
information and the opportunity to ask questions about the procedure.
Clin Nurs. 2004 Feb;1392):243-50

The effect of detailed, video-assisted anaesthesia risk education on patient anxiety and
the duration of the pre-anaesthetic interview: A randomised trial.
This study focuses on educating patients in pre-anaesthetic clinics by showing
informative videos regarding anaesthetics and risks. They concluded that patient
anxiety remained static but led to better understanding of the procedure itself.
Salzwedel C et al. 2008 Anaesthetic and analgesia Jan; 106 (1): 202-209

Angela Coulter and Jo Ellins
Effectiveness of strategies for informing, educating, and involving patients.
BMJ Jul 2007; 335: 24 - 27; doi:10.1136/bmj.39246.581169.80

Douglas W Wilmore and Henrik Kehlet
Recent advances: Management of patients in fast track surgery.
BMJ Feb 2001; 322: 473 - 476; doi:10.1136/bmj.322.7284.473

E Hunt Raleigh, M Lepczyk, C Rowley - Journal of Advanced Nursing, 1990 -
Blackwell Synergy
Significant others benefit from preoperative information.


Shuldham - International Journal of Nursing Studies, 1999 - ncbi.nlm.nih.gov
A review of the impact of pre-operative education on recovery from surgery.

Krupat, E. Fancey, M and Cleary P.D.(2000) Information and its impact on
satisfaction among surgical patients. Social Science & Medicine - Elsevier

9. 9
Objectives:
The main aim of this study was to discover any possible correlation between patient
anxiety and the amount of pre-operative information given. There are very few
published studies relating to this area although the author found there to be large
amounts of anecdotal evidence mainly applied to minor surgical units in general
practice. It is therefore also the author’s intention to clarify the relationship between
anxiety levels and information giving.

Method:
A patient questionnaire was designed to explore the anxieties people felt prior to their
minor surgery, their chief anxieties afterwards, and if there was a link between the
type of surgical procedure, age group and gender. Patient comments were encouraged.
In order to do this, the author sat in on pre-assessment clinics with a doctor and
observed the level of information given, how it was relayed and the patient’s
reactions. The doctor encouraged patients to ask questions so he could explain the
surgery in detail and at a level they could understand.
A survey was designed in conjunction with the structure of previous medical
questionnaires (see appendix 2) with particular reference to patient anxiety questions.
Using previous experience in observing minor surgical consultations, a list of
common procedures was devised so as to limit the results to purely quantitative
answers so as to avoid confusion during data analysis.

The initial pilot study was undertaken at the College of West Anglia to identify any
problems with the survey. It was decided that the ethnicity section of the survey was
redundant in the sense that it was of no significance in the results. The amended

10. 10
questionnaire was then distributed to the neighbouring GP practices. The author
consulted the doctors at each practice to gain permission and to ensure there were no
problems regarding the structure of the survey.
The questionnaires were given to each patient at the first clinic appointment and
collected either on the same day, or at the follow up assessment, usually after two
weeks. The results were obtained over a period of a several weeks and collated in a
database for analysis at a later date.

11. 11
Results:
Surgeon led surgical unit:
Sample (n = 96 patients)


Summary of results from a surgeon led unit
53
43
15
52
29
20
7
0
6
38
13
7
12
38
19
34
24
18
9
0 0
96
0
20
40
60
80
100
120
mal e
fema le 16- 35 36- 60
61+ skin
toen ail
c ry otherapy
in jec tion s
han d su rge ry
v asec tomy
othe r
ana esth esi a
s ucc ess of op era tion
ope rati on
pai n
wor k c ommi tments fami ly co mmitme nts
othe r
too much info
not enough info
ju st rig ht inf o
Variables
number of patients

Chart to show most common anxieties in women prior to minor surgery in surgery A
43
5
21
4
17
12
15
0
5
10
15
20
25
30
35
40
45
50
Anxiety
number of patients
Series1 43 5 21 4 17 12 15
Females anaesthesia
success of
operation
operation pain work commitmentsfamily commitments

12. 12
Chart to show most common anxieties in men in Surgery A (surgeon led)
54
18
12
17
4
7
15
0
10
20
30
40
50
60
Anxieties
Number of patients
Series1 54 18 12 17 4 7 15
Males Pain Work
Success of
operation
Family Anaesthetic Operation itself


Variable No. Patients Percentage of Patients (%)
Male 53 55
Female 43 45
16-35 15 16
36-60 52 54
61+ 29 30
Skin 20 21
Toenail 7 7
Cryotherapy 0 0
Injections 6 6
Hand surgery 38 40
Vasectomy 13 14
Other 7 7
Anaesthesia 12 13
Success of operation 38 40
Operation itself 19 20
Pain 34 35
Work commitments 24 25
Family commitments 18 19
Other 9 9
Too much information 0 0
Not enough information 0 0
Just right information 96 100

13. 13
GP led surgical unit:
Sample (n = 97 patients)

Sumary of results from questionnaires from GP led surgical unit
38
59
29
47
14
55
7
14
0 0
9
26
30
21
35
12
3
12
2
10
82
0
10
20
30
40
50
60
70
80
90
ma le
fem ale 16-35 36-60
61+ skin
toen ail
i njec ti ons
hand surger y
v as ectom y
othe r
anae sthes ia
s uc ces s of o perati on
operati on
pain
work com mitme nts
fam il y c om mi tme nts
othe r
too m uch info
not e nough i nfo
j ust rig ht info
Variable
No. Patients

Chart to show most common anxieties in men in surgery B (GP led)
38
10
12
11
22
5
1
0
5
10
15
20
25
30
35
40
Anxieties
Number of patients
Series1 38 10 12 11 22 5 1
men anaesthesia
success of
operation
operation pain work commitmentsfamily commitments

14. 14


Chart to show main anxieties of women in surgery B (GP led)
59
16
18
10
13
7
2
0
10
20
30
40
50
60
70
Anxieties
Number of patients
Series1 59 16 18 10 13 7 2
Females anaesthesia
success of
operation
operation pain work commitmentsfamily commitments

Variable No. Patients Percentage of Patients (%)
Male 38 39
Female 59 61
16-35 29 30
36-60 47 49
61+ 14 14
Skin 55 57
Toenail 7 7
Injections 14 14
Hand surgery 0 0
Vasectomy 0 0
Other 9 9
Anaesthesia 26 27
Success of operation 30 31
Operation itself 21 22
Pain 35 36
Work commitments 12 12
Family commitments 3 3
Other 12 12
Too much information 2 2
Not enough information 10 10
Just right information 82 85

15. 15
Discussion:
The response rate from Surgery A (Surgeon led) was less than that of Surgery B. This
was most likely due to the fact that patients were asked to return their completed
questionnaires at their follow up appointments and many forgot to do so. The
response rate was calculated to be 80%. Having distributed 120 questionnaires and a
return of 96. (Surgery A). The response rate of Surgery B was approximately 98% as
questionnaires were completed on the day of the procedure.
The findings suggest that there were higher levels of satisfaction from patients
undergoing minor surgical procedures in the surgeon led unit. (100% satisfaction with
the amount of preoperative information given) as opposed to 84% from surgery B.
This opinion was largely as a result of patients’ comments on the questionnaires
regarding the information they had received preoperatively and peri-operatively. (See
appendix patients' comments).
Surgery A
The most common procedures performed were hand surgeries including carpal tunnel
decompression and trigger finger release followed by skin procedures including cyst
excision and removal of naevi. (39.5% and 20% respectively).
The main anxieties for men were pain (33.3%), and success of operation (31%).
The main anxieties for women were success of operation (48%) and pain (39%).
Surgery B
The most common procedures performed were skin operations including excisions,
cryotherapy (56.7%) followed by joint injections (14.4%).
The main anxieties for men were pain (57%), and success of operation (31%).
The main anxieties for women were the success of the operation (30%) and
anaesthetic (27%).

16. 16

From observing minor surgery in both areas and from patient’s comments, the author
concluded that the surroundings were an important factor for example comfort, music
and the reassuring professional attitude from the staff. Musical distraction is clearly
an important factor to reduce anxiety as suggested by Augustin and Hains 1996 and
Gilmartin and Wright 2007 who noted that music alleviated some anxiety particularly
if personal choice of music was considered. This is evident in the surgeon led unit
where nurses ask patients what their preference of music is. Surgery B provided radio
for patients to listen to in the waiting room but not in the theatre itself.
An older study by Augustin and Hains (1996) indicated that watching television prior
to and during operative procedures had a significant impact on the reduction of patient
anxiety. This was supported by a later study (Salzwedel 2008), which suggested the
use of educational videos representing surgery (in particular cataracts) was of benefit.
This could be implemented into modern minor surgical practice to ensure low anxiety
levels as a form of distraction therapy. Patients could view programmes of their
choice, although this may also prove too distracting for the surgeon.

Government guidelines recommend thorough pre-assessment and that as much
information should be given as possible, for example medication, past health history,
risks, benefits and alternatives to surgery enabling the patient to make an informed
decision about consenting for surgery. (DoH 2002). But what do patients want?
Oshodi (2007) discusses that surgery can be physically and psychologically stressful
and that pre-operative education can lessen pain post-operatively. From the results
obtained, patients from both practices have a clearly significant level of anxiety
towards pain, both during the operation and afterwards. Shuldham (1999) concludes

17. 17
that the use of pre-operative education has a beneficial effect on patient anxiety both
peri-operatively and post-operatively. Anxieties relating to pain can be potentially
resolved with a written information leaflet on analgesia prior to the surgery to reduce
pain levels and what medication would be of benefit afterwards. This is a fairly
common practice in some surgeries but should be considered in all minor surgery
units. With regard to anaesthesia related anxiety, more pre-operative information can
be given on the effects of local anaesthetic and what to expect in the hours after
surgery. It was noted that both men and women were concerned about work
commitments; Medical Certificates could be issued to allow recovery time before
returning to work.

Risk assessment is obviously important in pre-op assessment clinic but overall
patients liked the friendliness, careful explanation, information and the opportunity to
ask questions. Coulter’s study (2005) demonstrated that good interpersonal care that
is, good communications skills and practitioners with excellent clinical knowledge
have a profound effect on reducing patient anxiety. People want to be involved in
decisions around their care and continuity of their care; her article is based on a large
study by the Health Commission (2005), which implied that patients were generally
very positive about their primary care services. Although Coulter’s article applied to
all aspects of primary care, it can also be valuable in the minor surgery setting,
because people want an approachable friendly doctor who is able to communicate
well (Little et al 2005).

18. 18
Good communication skills from a doctor are vital for allaying anxiety in any
situation. (Silverman, Kurtz et al 2005) discuss the necessity for this because without
these essential skills, “all knowledge and intellectual efforts can easily be wasted”.
The author noted during observing doctors in both practices that although there was a
limited time spent with each patient, there was a clear understanding of the procedure
given and information around consent. The survey reflected this by the positive
comments from patients; the doctor helped them to feel comfortable and less nervous.
Patients need to know if the procedure will be painful, what sort of anaesthetic they
will be given, if there will be bleeding, how to care for the dressing if it leaks through,
and who to contact should there be a problem. Patients also seemed to like having the
appointment times for follow up care given there and then.
The results of this study agreed with those from the MiSTIC trial by George et al
(2008), in that patients within primary care were more concerned about success of the
operation or satisfaction with the wound and pain. In addition, according to George et
al, patients were more satisfied in primary care settings due to convenience, comfort
and privacy.

19. 19
Strengths and limitations of the study:
The pilot study identified any weaknesses in survey structure, for example, a large
section of the initial questionnaire included ethnicity which was irrelevant as the study
focused primarily on gender, type of surgery and nature of anxiety. Previous surveys
within the practices helped in restructuring the author’s questionnaire to make it easier
to read and analyse.
Time constraints were an issue prior to analysis of the results due to questionnaires at
surgery A being returned at follow-up appointments one to two weeks later. This was
not a problem with surgery B as the questionnaires were returned the same day.

With regard to sample size, the number of participants was 193. This could be seen to
be too small a sample and not reflect the general population, although other studies
(George et al 2008) had a sample size of 568, this had similar results.
There have been certain limitations with this study mostly involving data analysis due
to the initial questionnaire design. Retrospectively, a numerical scoring system
implemented into the questionnaire might have enabled a larger range of statistical
testing. For example a Chi Squared Test to measure significance between observed
values and expected values.
The particular method of analysis (i.e. histograms) was chosen as they can be read and
understood easily and require no prior mathematical or statistical knowledge to
interpret them.
The author was able to form a list of the most common surgical procedures due to
being able to sit in on surgical consultations with both practices and liasing with the
doctors and staff concerned. This was valuable as it formed the basis for the
questionnaire.

20. 20
The excellent feedback and comments from replies to questionnaires were obtained
allowing for a more thorough understanding of individual anxieties. In addition,
good relationships with the doctors and nurses involved in minor surgery enabled the
author to distribute the questionnaire easily and efficiently.

Pre-operative assessment and information giving is pivotal in promoting patient
satisfaction. Mitchell (1996) recognised that patients are individuals and prefer to be
given a choice regarding the information they require.
His study implied that levels of information could be developed according to their
level of understanding and needs. This information can be broken down to encompass
all areas that patients are likely to encounter. For example, pre-operative information,
peri-operative information (details of the operation itself while it is being performed),
and post-operative information. Mitchell also suggests there should be a choice of
accuracy regarding information, because some patients may require in depth
information, whilst others may prefer simpler terminology.
On observation at surgery A, it is apparent that these different levels of accurate
information are portrayed to the patients. For example, for those undergoing carpal
tunnel decompression, the surgeon draws the incision on the wrist and explains the
basic anatomy and what he is going to do. Patients appear to be in favour of this as is
illustrated in the feedback comments.

21. 21
Implications for future practice:
The implementation of written patient information, which covers all aspects of fears,
expectations, wound care and healing times should be common practice in all minor
surgery units when patients attend their first pre-assessment appointment. This would
encourage better communication between the patient and doctor because it promotes a
good, informal relationship that is patient centred. Effective communication skills are
vitally important in maintaining a good relationship with the patient undergoing a
minor operation. The ability to field questions from a nervous patient and understand
their perspective can be essential in alleviating anxiety. Being able to establish a good
rapport with a patient can be seen as highly professional yet comforting as observed in
both surgeries during the pre-operative assessment.
The proposed information would identify and record anxieties mentioned and have
these addressed at the time of the operation. A patient questionnaire returned at the
follow-up appointment would also prove a useful tool for auditing purposes as well as
ongoing patient satisfaction.
Annual audits and surveys remain an important part of general practice because it can
help to identify any problems, for example standards of care and treatment,
accessibility to services and general satisfaction. This is a good way to involve
patients as it gives feedback, both positive and negative, and the results can
potentially benefit those who require these services.

22. 22
Appendix 1
A prospective randomised comparison of minor surgery in primary and secondary
care. The MiSTIC trial.
S George et al Health Technology Assessment 2008.

23. 23
Appendix 2
Previous patient satisfaction questionnaire from one of the practices in the study.

24. 24
Appendix 3
Patients Comments

Surgery A
• Doctor talked me through operation so I did not get nervous
• Very anxious but Dr and nurses made me feel better and calm. Very good.
• Couldn’t wish for better service from NHS.
• Well looked after making me feel welcome.
• Very easy going, very professional.
• Dr put me at ease, explained everything.
• Worried about being able to walk and work afterwards, hoped that anaesthetic
would be enough and that pain would go quickly.
• Good information from Dr made me feel at ease.


Surgery B
• Very nervous about having procedure, fear of unknown.
• Very professional service, Dr made me feel at ease.
• Was very anxious but staff explained everything.
• Very happy about service provided.
• Unhappy with cosmetic scarring.

25. 25
Appendix 4

The author’s questionnaire (after alterations).

Pre$operative+and+post+operative+survey+
1. Are+you:+
Male% %
Female% %
%
2. What+age+range+do+you+belong+to?+
16*25%%26*35%%36*45%%46*60%%61+%%
+
%
3. Have+you+ever+undergone+a+minor+operation?+(Minor+meaning+local+anaesthetic)+and+performed+at+an+NHS+
practice.+
Yes%
%
No+
+

4. If+yes,+what+was+the+procedure(s)?+
Cyst%excision%(having%a%cyst%removed)% %
Removal%of%naevi%(moles)% %
Toenail%operations/procedures% %
Removal%of%skin%tumours% %
Cryotherapy%(freezing%treatment)% %
Injections%for%tennis%elbow/joints% %
Hand%surgery%including%Carpal%Tunnel%and%Trigger%Finger% %
Vasectomy% %
Other%
……………………………………………………………………………………………………………………………………………………%
%
%
%
%
%
%
%
%
%
%
%
%

26. 26
Questionnaire+Continued:+
+
5.+What+were+your+main+anxieties+about+the+procedure?+
Anaesthesia% %
Success%of%the%operation% %
The%operation%itself% %
Pain% %
Work%commitments% %
Family%commitments% %
Other%
……………………………………………………………………………………………………………………………………………………%
%
%
5. How+do+you+feel+about+the+information+given+to+you+prior+to+and+after+your+minor+operation?+
Too%much%
%
Not%enough%
%
Just%right%
%
+
6. Any+other+comments?+
……………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………..%
Thank you for completing this questionnaire, all information will remain confidential and anonymous. Please do not write your
name on this questionnaire.

27. 27

28. 28

29. 29
References:

Augustin P. & Hains A. (1996) Effect of music on ambulatory surgery patients'
preoperative anxiety. Association of Operating Room Nurses Journal 63, 750–758

Coulter, A and Ellins, J (2007) Effectiveness of strategies for informing, educating,
and involving patients. British Medical Journal. Jul; 335: 24 – 27 Retrieved March
11th 2009 from www.bmj.com

Coulter, A (2005) What do patients want from primary care? British Medical Journal.
2005, 331: Retrieved March 11th 2009 from www.bmj.com

Department of health (2006) Our Health, Our Care, Our Say: A new direction. (6)
136-162. London. Crown Copyright.

Department of health (2002) Delivering the NHS Plan. London. Crown Copyright

Department of health (2002) Good practice in consent implementation guide: consent
to examine or treatment. Available from: www.doh.gov.uk/consent.

General Medical Services Contracts Statutory Instrument (2004) The National Health
Services Schedule 2 (8) Additional Services Regulation. Crown Copyright.

Gilmartin, J and Wright, K. (2007) The nurse’s role in day surgery; a literature
review. International Nursing Review. Jun; 5492:183-90

Gilmartin, J. (2004) Day surgery: patient’s perceptions of a nurse-led preadmission
clinic. Clinical nursing. Feb; 1392:243-50

Healthcare Commission. Primary care trust survey of patients 2005. London: Healthcare
Commission, 2005

Little P, Everitt H, Williamson I, Warner G, Moore M, and Gould, C, (2001) Preferences of
patients for patient centred approach to consultation in primary care: observational study.
British Medical Journal, 322: 468-72.

Mitchell, M (1996) Patients’ perceptions of pre-operative preparation for day surgery.
Journal of Advanced Nursing. 1997, (26), 356-363.

National Institute of Clinical Excellence (2008) Principles for best practice in clinical
audit – Clinical audit in the NHS. pviii Radcliffe Medical Press, Oxon
Retrieved March 20th 2009 from
www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf

National Institute of Clinical Excellence (2003) Preoperative tests. CG3 guideline.
http://www.org.uk/nicemedia/pdf/CG3NICEguidelineposter.pdf
Oshodi, T O. (2007). The impact of preoperative education on postoperative pain.
British Journal of Nursing. vol. 16, no12, pp. 706-710.

30. 30

Salzwedel, C. (2008) The effect of detailed, video-assisted anaesthesia risk education
on patient anxiety and the duration of the pre-anaesthetic interview: A randomised
trial. Anaesthetic and analgesia Jan; 106 (1): 202-209

Shuldham (1999) A review of the impact of pre-operative education on recovery from
surgery. International Journal of Nursing Studies, vol. 36, no2, pp. 179-187.

Silverman J., Kurtz, S., and Draper J (2005) Teaching and Learning Communication
Skills in Medicine. 2nd ed. Oxford. Radcliffe Publishing.

Wilmore, D.W and Kehlet, H (2001) Pre-operative evaluation and education:
Management of patients in fast track surgery, British Medical Journal, February
2001; 322: 473 - 476; doi:10.1136/bmj.322.7284.473. Retrieved March 12th 2009
from http://www.bmj.com:/content/full/322/7284/473 sec2