Cross-sectional survey: levels of engagement among surgical patients
Creators: name: Law, Rebecca
Publisher: name: RMIT University
Year: 2024
Subjects: classificationCode: 320221
subject: Psychiatry (incl. psychotherapy)
classificationCode: 320223
subject: Rheumatology and arthritis
classificationCode: 420803
subject: Traditional Chinese medicine and treatments

description: Patient engagement is a patient’s desire and capability to actively collaborate with healthcare providers to improve their health care. Engaged patients can access and process information, participate in decision-making and act on their health needs. These behaviours promote patient participation and contribute to patient recovery. Patient engagement starts with the ability to access and process information.

In Australia, 2.7 million surgeries are performed annually. For every 100 patients, 30 complications occur. Postoperative complications contribute to increased mortality, length of hospitalisation and risk of readmission. One way to reduce complications is to engage patients in their recovery. Current studies have yet to explore levels of capacity to engage amongst surgical patients and whether information processing and decision-making (components of patient engagement) are associated with capacity to engage. This study aimed to 1) understand how engagement is measured in surgical patients; (2) determine levels of surgical patient engagement; and (3) assess whether levels of engagement are associated with information processing and decision-making capabilities.
 
A scoping review was conducted to address aim 1 and written according to the framework proposed by Arksey and O’Malley and enhanced by Levac et al and The Joanna Briggs Institute. MEDLINE/PubMed, CINAHL, SCOPUS and Embase databases were searched. Eligible articles included those that presented results that assessed adult surgical patients during the perioperative period for engagement. Analysis from charting the data identified the measurement tools, levels of capacity to engage and relationships between engagement and surgical outcomes.
 
A cross-sectional survey was undertaken at a large metropolitan health service in Victoria, Australia. Participants involved were elective surgery patients aged 18 years and above. Recruitment planned to last for 12 months, with an aim to recruit 510 participants. The survey consisted of a demographic questionnaire, the Patient Activation Measure (PAM) to assess patient engagement, and a validated Post-operative Nausea and Vomiting (PONV) Risk Self-Reported Checklist to assess how well patients could process information and make decisions. Patients were recruited face-to-face one to three hours before surgery.
 
Descriptive analysis was conducted to assess the responses and to compare respondent characteristics with PAM levels and decision-making capability. Chi-squared or Fishers Exact test was used to compare between groups of categorical variables. Analysis was conducted using SPSS version 26, with a p-value of less than 0.05 indicating statistical significance.
 
The scoping review included 12 studies and identified three valid and reliable tools to measure patient engagement, with PAM being the most used. Engagement levels were primarily categorised into two (high/low) or four levels. High levels of engagement were associated with improved surgical patient satisfaction, and decreased pain and disability.
 
For the cross-sectional survey four hundred and forty-nine patients returned the survey over three months, with an overall response rate of 64.6% and a valid response rate of 56.3%. Respondents had a mean age of 48.4 ± 16.2 years, and were primarily female (58.1%, n= 259). The majority of participants held a secondary school (year 7-12)/TAFE/Diploma qualification as their highest educational level (68.6%, n = 306), were of Oceania ethnicity (42.4%, n= 182), and underwent a day procedure (84.1%, n= 375).

Of 391 respondents returning a valid PAM, 41.7% were categorised as low capacity (Levels 1 and 2). Respondents who did not speak English had a lower PAM score and were more likely to be of low level of capacity to engage. PAM scores or levels were not associated with age, education, gender or expected length of stay.
 
Only three quarters of respondents (75.6%, n= 319) demonstrated adequate information processing skills by correctly identifying their PONV risk level. Only half of the respondents (50.7%, n = 209) showed good decision-making capability. No association was found between levels of engagement and a patient’s information processing or decision-making capacity, suggesting those with the knowledge and skills to act may not necessarily have the mindset or ability to do so in the perioperative setting.

The scoping review identified PAM as a valid tool to assess capacity to engage amongst surgical patients. Subsequently, PAM was used in the cross-sectional hospital survey. Compared with previous studies on surgical patients and other Australian studies, this study observed a high proportion of patients having low levels of engagement (41.7%); compared with 20.2% in a study conducted in the United States of America among elective cervical and lumbar spinal surgery, 32% of Australian patients with chronic illness and 14.8% of South Eastern Sydney Medicare Local region residents. In this current study, those who did not speak English were at risk for low level of engagement. Furthermore, one in four respondents could not correctly interpret the information about PONV risk levels, and only one in two could make decision. Comparing with the populations included in the studies reviewed in this thesis, the population of this survey had low education attainment. Poor education has been found to inhibit patients’ ability to obtain, understand and use health information to make decisions. However, education was not associated with level of engagement, information processing or capacity to make decisions. Furthermore, no association was found between levels of engagement and information processing and decision-making.
   
The main weakness of this survey was that the planned sample size was not achieved due to pandemic-induced constraints and multiple lockdowns. Only 4% of the current sample had a non-English speaking background, which was lower than 25% based on the hospital sample. Further research is recommended including recruiting patients non-English speaking background to clarify the current findings. Future research should also explore whether information processing and decision-making relate to patient engagement.
 
Results from this survey emphasise the importance for healthcare providers to consider patient demographics (e.g., education) and their English proficiency, identify patients at risk of low engagement and tailor care accordingly. Patient engagement interventions such as motivational interviewing and information videos can be used to provide patients with the know-how to participate in their health care. Interpretation services and culture navigators can be employed to overcome language and cultural barriers experienced by culturally and linguistically diverse patients (CALD).