The effect of video-assisted learning on pre-operative knowledge and satisfaction for total knee arthroplasty surgery: a randomised-controlled study

Abstract

Introduction

Traditionally, surgical procedures are explained through consultations between the surgeon and the patient to ensure informed consent. Patient education enhances engagement and knowledge, aiding informed decision-making. This study aimed to assess the effect of an educational video on preoperative patient knowledge and satisfaction in the context of total knee arthroplasty (TKA) as an adjunct to the consent process.

Methods

A prospective randomized controlled study involving 100 patients in dedicated elective orthopedic units in UK-based hospitals was conducted. After consultation with a dedicated knee surgeon and a preoperative education day for TKA run by dedicated orthopedic nurse specialists, patients were randomized into one of two limbs (video vs no video) at a 1:1 ratio. The treatment group (video group) was shown a video about the principles and steps of the procedure, including the recovery time. Following this, a 10-point knowledge test was completed, and patients rated their satisfaction with the preoperative education on a scale of 0–10.

Results

Patients in the video limb group had a significantly greater mean knowledge score and greater satisfaction with preoperative education than patients who did not view the video. The video group (n = 49) had a mean knowledge score of 8.73 +/− 0.159 compared to 7.68 +/− 0.281 for the nonvideo limb (n = 50) (p < 0.05). The video group had a mean satisfaction score of 9.00 +/− 0.123 compared to 8.40 +/− 0.121 for the nonvideo limb group (p < 0.05).

Conclusion

Video-assisted consent in total knee arthroplasty improves preoperative knowledge and patient satisfaction when used as an adjunct in the consent process. A simple, standardized video, either pre- or post-consultation could reinforce information that the patient receives in a simple effective manner, allowing for true informed consent.

Introduction

Traditionally, surgical procedures are explained through consultations between the surgeon and the patient. This ‘consultation’ is of paramount significance because it allows a surgeon to make the patient aware of the implications of surgery, including the intended benefits, associated risks and possible alternatives. The goal is to create an environment where the patient can acquire all the necessary information for informed consent to be obtained. Although in theory this process seems robust, the transfer of knowledge at this stage is arguably very limited and may not be entirely retained [1]. Krupp et al. asked patients to write down all the disclosed risks associated with neurosurgery that they could recall two hours after the consent interview. On average, only four risks out of 32 and six risks out of 25 were recalled by participants for cranial and spinal surgery, respectively [1]. A lack of information or education related to the procedure and associated outcomes has also been shown to increase preoperative anxiety [2].

Patient education can promote patient engagement within the perioperative period and can help enhance knowledge to make informed choices, cope with anxiety preoperatively and improve health behavior [3]. Some UK-based elective orthopedic units have adopted a program known as “Joint School”. Such programs aim to disseminate procedure specific, tailored information to patients. The goal is to improve overall education pertaining to the journey from arriving preoperatively to the surgery itself and the postoperative period. A variety of other modalities have also been used, including printed materials, visual aids and computer-based programs [4].

There has been a notable increase in the use of video-assisted learning within surgery to provide preoperative patient-centered information, with the aim of improving patient understanding [3, 5]. Research has demonstrated an improvement in recall by patients who use multimedia modalities [4, 6, 7].

The objective of our study was to assess the efficacy of a TKA-specific educational video on patient knowledge and retention specific to the procedure when it was used as an adjunct in the consultation process. We hypothesized that the video would improve knowledge regarding the procedure and improve overall satisfaction from the experience surrounding preoperative education.

Methods

A prospective randomized controlled study was conducted involving 100 patients in two dedicated elective orthopedic units in UK-based hospitals from June to October 2017. Patients who required TKA for osteoarthritis were identified and enrolled in the study. Patients who were younger than 18 years old, who did not have the capacity or who were unable to fully comprehend the study’s instructions or associated media, who had previously undergone any arthroplasty or who were medical personnel with professional knowledge regarding knee arthroplasty were excluded.

All enrolled patients had a consultation with a dedicated knee surgeon and a preoperative education day for TKA run by dedicated orthopedic nurse specialists. All participants received the same standard of care at this point.

Patients were then randomized into one of two groups (video vs no video) at a 1:1 ratio using a block randomization method. The patients in the treatment group (video group) were brought to an adjacent room and shown a video approved by the National Health Service (NHS) about the principles and steps of the procedure, including the recovery time [8]. The control group (no video group) was not shown this video. The surgeons were blinded to the allocation of these groups.

A 10-point knowledge test (including multiple-choice questions and ‘true or false’ questions) was used to evaluate the patients’ comprehension and retention of information preoperatively (Table 1).

Table 1 10-point knowledge test used to assess knowledge pre-operatively

This procedure was completed by both groups preoperatively. A rating (from 0 to 10, with 0 being not satisfied at all and 10 being very satisfied) was also given by the patients to assess their satisfaction with the preoperative education.

Graphical and numerical summary measures were used to display the information gathered. The mean knowledge and satisfaction scores for each group were compared with independent two-sample t tests. A p value of < 0.05 was considered to indicate statistical significance, and all procedures were two-sided.

Results

A preliminary power calculation indicated that the required sample size to achieve greater than 80% power was n = 72. Given the availability of patients, this number was rounded to 100, with 50 in each limb of the study. Out of 123 patients assessed for eligibility, 100 were included in the study. Among the recruited patients, there were 42 males and 58 females, with a mean age of 66 ± 7.82 years. The video limb subsequently had 50 patients randomized to it, with all but one patient completing the preoperative questionnaire (n = 49). Fifty patients with nonvideo limbs were also included. This is summarized in Fig. 1.

Fig. 1

Comprehensive flowchart of patient allocation and data analysis in total knee arthroplasty surgery research

Patients who were in the video limb showed a significantly greater mean knowledge score than patients who did not view the video (Fig. 2). Table 2 shows a mean knowledge score of 8.73 +/− 0.159 for the video limb compared to 7.68 +/− 0.281 for the nonvideo limb (p = 0.0016).

Fig. 2

Patient satisfaction ratings comparing video and conventional groups

Table 2 Comparison of knowledge and satisfaction scores between video and non-video groups

Regarding the subjective self-assessment of the patients’ satisfaction with the knowledge provided, patients who were in the video limb showed significantly greater satisfaction with the preoperative education than did those who did not view the video. The video limb had a mean satisfaction score of 9.00 +/− 0.123 compared to 8.40 +/− 0.121 for the nonvideo limb (p = 0.0008) (Table 2).

Discussion

After providing informed consent for an operation, the surgeon needs to present all the relevant information in an impartial manner for patients to understand and make decisions. Finding a suitable adjunct to the consultation to ensure true informed consent is gained has proven much more difficult than one might envisage. The study we conducted intended to show that patient education videos can aid traditional face-to-face consultation by assisting the informed consent process for total knee arthroplasty. We found that showing patients a short animated educational video some time prior to surgery significantly improved their knowledge about the surgery.

Our results are consistent with other studies examining the use of multimedia, more specifically, video, to improve patient knowledge. Rossi et al. demonstrated improved patient recall of information with the use of video for consent for arthroscopic procedures. In his study, 73 patients were shown a video for consent purposes versus 77 who were only provided with verbal consent. The video group scored 78.5% on comprehension, while the control group scored 65.4% (p < 0.001) [9]. An increase in knowledge with the use of multimedia has been demonstrated for a number of orthopedic procedures, including metatarsophalangeal joint arthrodesis [10], plantar fasciitis [11] and shoulder arthroscopy [4].

Studies have shown that patients who attend educational classes prior to surgery have better postoperative pain control, more realistic expectations of surgery, and an increased understanding of their surgery [12, 13]. Similarly, clinical pathways incorporating a preoperative education program for elective hip and knee arthroplasty lead to shorter hospital stays, higher rates of discharge to home, lower rates of readmission, and overall increased costs [14,15,16].

Video-assisted preoperative education results in higher knowledge scores and higher satisfaction ratings with the consent process [17, 18]. Interestingly, Johnson et al. demonstrated that adjuncts to surgical consultation did not improve patient recall or satisfaction. However, patients voiced greater satisfaction when more adjunctive modalities were employed in the consent process. [19]. Hoppe et al. showed that the video group and control group had comparable satisfaction rates, but subjectively, the video group felt that the video had prepared them better for different stages of the surgical experience [4].

It is evident that adjuncts need to be employed in the traditional consent process, and studies have been conducted on the use of handouts and nurse educators with variable results. Handouts are widely used not only in secondary care but also in primary care; however, there are conflicting studies regarding their benefits. There are studies demonstrating increased understanding of the risks of cosmetic, head and neck and maxillofacial surgery with the receipt of additional written information [20]; however, Turner and William showed that even with written information provided, patient information was still very poor [21]. Sonne et al. found that when comparing video-assisted informed consent to paper-format informed consent, participants preferred video-assisted consent to paper formats, as they felt that videos were particularly helpful in describing procedures [22].

Preoperative videos regarding surgery allow patients to receive information in a controlled, well-organized manner that is simple to understand and repeatable. This could facilitate long-term learning prior to obtaining formal consent. This is of prime importance because individuals need to appreciate and assimilate information regarding the nature of their surgery, potential complications, and the pathway to recovery to provide informed consent [17, 18, 22]. Moreover, preoperative video-assisted education can significantly protect surgeons from medico-legal and documentation perspectives. Numerous complaints and litigation in orthopedic surgery have been attributed to poor patient‒doctor communication, and good patient education has been shown to greatly reduce the number of such proceedings [23].

The strengths of our study include the block randomization of patients into the two limbs and the use of a structured animated NHS-validated video that was specific to the procedure. There are several study limitations to consider. When testing retained knowledge, factors such as existing knowledge of the procedure and level of education were not taken into account. Therefore, it is difficult to attribute increased knowledge scores to the video alone, as in this day and age, it is not unexpected for patients to have already looked through the myriads of resources available on the internet. Patients in the video limb of the study would have had a face-to-face consultation followed by an animated video, and one could suggest that repetition of the facts is what led to an increase in knowledge. In addition, the level of information retention after the consultation was never assessed. This is important since patient education and informed consent contain information relevant to the postoperative period, including the rehabilitation period. Finally, although our sample size is greater than that of some other studies that examined similar parameters, it is not large enough to generalize these findings to other procedures or specialties.

Patient education levels play a major role in their ability to understand and recall information, regardless of how this information is presented to them. We did not specifically check for the level of education of the patients in our study; however, Rossi et al. showed that videos increased comprehension levels to a greater extent in those who had less than 12 years of formal education [9]. This has potential implications when trying to introduce patient education methods. Challenges include the patient’s ability to retain vast amounts of information delivered to them during their limited interaction with health professionals, as well as ensuring that information is delivered in a way that is understandable to those with lower literacy rates, poor English proficiency, and increased learning needs [24,25,26,27].

Conclusion

Overall, our study demonstrated that the implementation of an educational TKA-specific video prior to the procedure was associated with both higher scores in retained knowledge and higher satisfaction rates—a finding that is supported by many but not all previous studies. These findings have potential implications for all the physicians and patients involved. Referring physicians are reassured that when they are referring patients for joint replacement surgery, the patients are going through a rigorous and appropriate consent process. Moreover, preoperative video-assisted education can significantly protect surgeons from medico-legal and documentation perspectives.

A simple, standardized video either pre- or post-consultation could reinforce the information that the patient receives in a simple effective manner. Future studies are required to evaluate the balance between the cost and time demands of introducing additional adjuncts to the consent process against their benefits. Nevertheless, since the COVID-19 pandemic, numerous consultations have moved away from face to face. This makes the addition of adjunct methods, such as educational videos, to the consent process even more important than ever before.