Journal of Traumatic Stress, Vol. IS, No. 4. August 2002. pp. 329-332 (0 2002)

An Evaluation of Patient Satisfaction With an Information Leaflet for Trauma Survivors

Carol R0bertson,’7~ Susan Klein?y3 Heather Bullen,* and David A. Alexander29

A new leaflet that provided information about posttraumatic reactions and how to deal with them was distributed within 14 days of attendance at the Accident and Emergency Department (ED), Aberdeen Royal Infirmary, to a heterogeneous sample of trauma patients (N = 222). An evaluation form to assess satisfaction with the leaflet was also mailed with the leaflet. A sample of 98 (44%) of the initial patient group responded, and 96% of them reported the leaflet as either very helpful or helpful. Satisfaction with the leaflet was not affected by age, by gender, or by the type of trauma encountered. Overall, the findings confirmed that such a leaflet is well received by trauma patients attending an ED.

KEY WORDS: trauma; leaflet; information; patient satisfaction.

In the United Kingdom it has become widely ac- cepted in the national health service (NHS) that patients should be given information about their condition, its treat- ment and related matters (Gray, 1982). As a consequence, in the NHS there is a “leaflet culture”; no clinic or wait- ing area is complete without a large stand garlanded by leaflets on a miscellany of clinical topics.

Whilst written information may facilitate treatment compliance (Kitching, 1990), there is also the risk that patients are exposed to “information overload.” This is an important issue in view of the fact that patients absorb only a limited amount of information (Gray, 1982; Weinman, 1990). Moreover, leaflets are usually designed through group consensus, and they may be of poor quality (Smith, 1992).

For trauma patients, there is a particular risk of iatro- genic anxiety by heightening their awareness of the nature

I Royal Cornhill Hospital. Grampian Primary Care NHSTrust, Aberdeen. Scotland, United Kingdom.

’Department of Mental Health. University of Aberdeen. Aberdeen. Scotland, United Kingdom.

‘Resent address: Aberdeen Centre for Trauma Research, University of Aberdeen, Aberdeen, Scotland, United Kingdom.

‘To whom correspondence should be addressed at Royal Cornhill Hos- pital. Grampian Primary Care NHS Trust, Cornhill Road, Aberdeen AB25 2ZH. Scotland, United Kingdom; e-mail: cml.robertson@gpct. grampian.scot.nhs.uk.

and duration of posttraumatic symptoms and reactions. Staff working in trauma units have expressed concern that patients may develop symptoms if they are forewarned of the kind of reactions which can be expected after traumatic experiences (Alexander & Atcheson, 1998). Nevertheless, there is no lack of enthusiasm for distributing leaflets, particularly after a major catastrophe (Alexander, 1991 ; Raphael, 1986) and, more specifically, following motor vehicle accidents (Mayou, Bryant, & Duthie, 1993).

In contrast to the prevailing enthusiasm for producing and distributing leaflets, there is no obvious commitment displayed toward their evaluation in terms of what patients want to know.

This report presents the results of a systematic sur- vey of patient satisfaction with various aspects of a newly designed leaflet for survivors of trauma. No measure of later functioning or distress was used.

Method

The Draft Leaflet

The content of the leaflet was based on well- established features of posttraumatic reactions reported in the literature (e.g.. Alexander, 1999). Guidelines on leaflet design in relation to reading level, style, and other

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330 Robertson, Klein, Bullen, and Alexander

presentational issues were addressed (Albert & Chadwick, 1992; Flesch, 1949; Gray, 1982; Weinman, 1990).

A draft leaflet was subsequently piloted on 12 pa- tients attending the Aberdeen Traumatic Stress Clinic, Royal Cornhill Hospital. In addition, it was sent to 10 clinical staff comprising psychiatrists, surgeons, and gen- eral practitioners. The Leaflet Committee of the Aberdeen Royal Hospitals NHS Trust Patient Information Group also approved the draft publication.

The Final L.eq/let

The leaflet was professionally printed in muted blue and green colours on a single piece of A4 paper folded in three to give six sides of printed material.

The leaflet is entitled Surviving Trauma. On the cover there is a photograph of the ED, Aberdeen Royal Infirmary, with an approaching ambulance. There are five sections. These provide information on (i) for whom the leaflet is intended; (ii) what are the common short-term reactions to trauma, for example, numbness and overalertness (a defi- nition of flashbacks is included); (iii) the impact of trauma on relationships; (iv) the likely timescale of any effects (from hours to months depending on the situation); (v) ad- vice on how survivors can help themselves (e.g., by reduc- ing their intake of caffeine-containing drinks. tobacco, and alcohol), and (vi) from whom to seek further help (includ- ing a list of local voluntary organizations which provide care and/or advice for victims of trauma). The pervasive tone of the leaflet was intended to be nondramatic, reas- suring, and positive.

The reading level was assessed by means of a com- puter generated Flesch Reading Ease (FRE) rating. The leaflet achieved a FRE score of 58.94 which falls just be- low the average reading level when compared with the standard FRE score of between 60 and 70.

Participants

These comprised a total of 222 patients who had att- ended the ED. Participants were recruited over a &month period if they had experienced a significant trauma (e.g., a motor vehicle accident, an assault, or an industrial accident).

Exclusion criteria were (i) patients admitted to other departments at Aberdeen Royal Infirmary such as the Or- thopaedic Trauma Unit or the Bums and Plastics Unit (be- cause they would probably have been referred to one of the authors for clinical reasons), (ii) patients with a reported history of alcohol or substance abuse or whose trauma

were alcohol and/or drug related, (iii) patients whose in- juries were deliberately self-inflicted, and (iv) patients with more severe head injuries which required care by the neurosurgical teams.

Prior to the start of the survey, meetings were held with the ED staff to inform them of the protocol. To ensure nursing and medical staff continued to recruit appropriate patients, the selection criteria were displayed in the depart- ment. In addition, one of the authors (Heather Bullen) reg- ularly visited the ED for the duration of the survey to col- late data on those patients meeting our inclusion criteria.

Assessment

Demographic Characteristics

These included age, gender, type of trauma, and time that had elapsed since the trauma.

Leaflet Evaluation Form

This assessed patients’ satisfaction with the features of the leaflet and perceived helpfulness of the information contained in the leaflet.

Features of the leaflet were measured in terms of (i) the appearance and design (very good, good, poor, very poor), (ii) the length (too long, about right, too short), (iii) the quality and volume of the information (too much, about right, too M e ) , and (iv) how easy the information was to understand (very dificult, quite dificult, quite easy, very easy).

Patients were also asked to indicate, by endorsing either a Yes or a No response option, whether they had found helpful the information related to (i) common short- term reactions to trauma, (ii) impact of trauma on relation- ships, (iii) what others can do to help, (iv) what reactions are most likely to occur, (v) advice on how survivors can help themselves, and (vi) from whom further help can be sought. Respondents were also asked to indicate, in general terms, how helpful they found the content of the leaflet by means of a Liken-type scale of 1 (very helpful) to 4 (very unhelpful).

Dichotomous categories were computed for each helpfulness or satisfaction rating. Thus, ratings of very helpful or helpful were classified as helpful. Ratings of unhelpful or very unhelpful were reclassified as indicating unhelpful. Similarly. ratings of very good or good were collapsed to indicate satisfaction with the leaflet design. A rating of about right as opposed to ratings of too long or roo short were used to indicate a rating of satisfied ver- sus dissatisfied regarding the length of the leaflet and the

Patient Satisfaction With a lhuma Leaflet 331

volume of information provided. With regard to the un- derstandability of the information. very diflcult and quite diflcult were classified as dissatisfaction, and quite easy and very easy as satisfaction.

This approach is recognised as an acceptable measure of patient satisfaction (Fitzpatrick, 1991).

Procedure

Within 14 days of their trauma, patients were sent by mail a package containing a covering letter, the leaflet, a stamped addressed envelope, and an evaluation form.

Statistical Analysis

SPSS for Windows (Version 9.0) software was used to input and to analyse the data. Nonparametric meth- ods were used in the face of skewed distribution and het- erogeneity of variance. Associations were measured by means of the Spearman’s rank correlation coefficient and the chi-square test. The Fisher’s exact probability test was reported for all 2 x 2 contingency tables containing more than 20% of cells with expected frequencies of less than five.

All tests were two-tailed, and statistical significance was assumed at p < .05.

Results

Of the 222 patients from the ED who were sent the survey material 98 replied, representing a response rate of 44%.

The age range for the sample was 16-82 years (M = 39.1, SD = 16.2). Approximately half (n = 52; 53%) of the sample were male. Although respondents had been exposed to a miscellany of trauma, the majority (n = 78; 80%) had experienced a motor vehicle accident when com- pared with assaults (n = 4; 4%). Only one patient had ex- perienced an industrial accident. The remainder (n = 15; 15%) had experienced fires, electric shocks, and other mis- cellaneous trauma. The time that had elapsed from trauma to reply ranged from 8 to 64 days (Mdn = 24 days) with the majority of the respondents (n = 69; 70%) having completed the evaluation form within 1 month posttrauma.

Table 1 displays the number and percentage for those patients who were satisfied with the five aspects of the leaflet as listed. Satisfaction with all five of these aspects was endorsed by the majority of respondents.

Analysis by means of the Fisher’s exact probability test confirmed that satisfaction with the helpfulness of the

Table 1. Satisfaction With Features of the Leaflet and Perceived Helpfulness of the Information Provided

Satisfied Features n %

Presentational style Length Easy to understand Correct amount of information Helpfulness of information

90/97 93 78/93 84 92/93 99 76/92 83 85/89 96

Leaflet sections

~~~

Helpful n %

Common short-term reactions to trauma 81/84 96 Impact of trauma on relationships 63/77 82 What others can do to help 51/79 12 When reactions are most likely to occur 72/82 88 Advice on how survivors can help themselves 76/81 94 From whom further help can be sought 53/74 12

~ ~ ~ ~~~~~ ~

Nore. n = b e number of respondents who fell into the Helpful or Satisfied category according to the total number of responses received for each item.

leaflet, in general terms, was not significantly related to gender ( p = .13) or to type of trauma ( p = 1 .OO). More- over, age (rs = -.005, ns) and the time since the survey was completed (r, = -. 13, ns) were also found to be un- related to this aspect of the leaflet.

The extent to which patients perceived the specific aspects of the information contained in the leaflet as be- ing helpful is also presented in Table 1. Information about common short-term reactions to trauma was reported as particularly helpful by the majority of patients. Informa- tion concerned with seeking help from others was deemed the least helpful.

Discussion

Following the injunction of Alexander (1996) that, whenever possible, advances in the trauma field should be evidence-based, this study evaluated patients’ views on a carefully designed information leaflet. The feedback obtained was analysed to assess patient satisfaction.

Survivors of trauma clearly welcome the provision of written information within weeks of experiencing a trauma as indicated by the high level of satisfaction with all as- pects of the leaflet. Moreover, patients’ perception of the helpfulness of the information contained within the differ- ent sections indicates that patients subjectively found the information about common short-term reactions as partic- ularly helpful.

The preparatory work on enhancing the overall com- prehensibility of the leaflet was justified in that 99% of patients reportedly found it easy to understand. The broad

332 Robertson, Klein, Bullen, and Alexander

appeal of the leaflet was confirmed by the finding that per- ceived helpfulness of the leaflet was not affected by age, by gender, or by type of trauma experienced.

There are three limitations to this study. First, the design did not permit conclusions to be drawn about non- responders. There is a possibility that these patients were not satisfied with the leaflet and therefore did not reply. Second, efficacy of the leaflet information in terms of re- ported levels of distress or functioning was not assessed. Although patients reported the leaflet to be helpful, it is unclear whether the use of such material has a positive effect on posttrauma adjustment. Rose and Bisson (1998). in a review of brief early psychological intervention fol- lowing trauma, reported that subjective satisfaction with an intervention does not necessarily correlate with out- come as determined by other means. Moreover, although problems have been identified with the measurement of patient satisfaction (Cam-Hill, 1992), several of these is- sues have h e n addressed in this study, for example, stan- dardized tools for the measurement of satisfaction were avoided as the context and objectives of these differ. Third, it would not be possible from this study to identify if such a leaflet would be generalizable to a wider trauma population.

Specific strengths of this study are its scientific de- sign, and the size and variety of patients sampled. The thorough preparation and piloting of the leaflet produced a document that was very acceptable to the target pop- ulation; a population which was carefully defined in ad- vance. The response rate of 44% for ED patients was ac- ceptable for a postal survey, and it compares favorably with response rates obtained from other studies that have used trauma samples attending an ED. For example, Rose, Brewin, Andrews. and Kirk (1999) reported a response rate as low as 1 1%. Moreover, some patients, as a result of their injuries, may not have received their postal question- naire because they may not have returned to their index address following their recent trauma.

Although previous studies have included the provi- sion of information as part of an early intervention (Rose & Bisson, 1998). to the best of our knowledge, this is the first study to report an evidence-based approach in the provision of a leaflet for trauma patients attending an ED.

The authors advocate that the use of this leaflet can- not be a substitute for adequate psychological care for

patients who have undergone traumatic events but it may be a useful adjunct for a considerable proportion of pa- tients if additional efficacy support its usefulness. Further research would need to include an assessment of posttrau- matic adjustment to establish its efficacy in terms of an early intervention following trauma.

Acknowledgments

This survey was funded by the Leaflet Committee of the Aberdeen Royal Hospitals NHS Trust. We thank Karen Conn (Quality Development Manager); Mr. Alistair Matheson (Senior Consultant) and colleagues of the Ac- cident and Emergency Department, Aberdeen and the pa- tients of Grampian for their cooperation.

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