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Keywords:

  • Hysteroscopy;
  • patient experience;
  • screen;
  • visualisation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Background  The introduction of patient screens for outpatient procedures is becoming increasingly common. To date, the impact on the patient of viewing the screen remains unknown.

Objectives  To explore how viewing the screen during a hysteroscopy procedure affects the patient’s experience.

Setting  The outpatient clinics at the Royal Surrey Hospital in Guildford and the Royal Infirmary in Bradford.

Design  A randomised control trial.

Sample  Women undergoing a hysteroscopy procedure were randomly allocated to see the screen (n = 81) or not to see the screen (n = 76).

Methods  A quantitative study with measures taken before and after the intervention.

Main outcome measures  Pain perception, mood, illness cognitions, communication.

Results  Seeing the screen or not had no impact on several measures of pain perception, mood, illness cognitions or communication. However, women who did not see the screen were more optimistic about the effectiveness of their treatment and felt that the health professional was more receptive to them during the consultation compared with those who saw the screen. After controlling for the use of a local anaesthetic, those who did not see the screen also reported a greater decrease in anxiety after the procedure. However, those who saw the screen described pain more positively (i.e. in terms of comfort, reassurance or encouragement) compared with those who did not see the screen.

Conclusion  Viewing the screen does not benefit the patient and may interfere with the patient–physician interaction.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

A hysteroscopy is most often prescribed following uterine problems such as bleeding or pain and can either be diagnostic or operative.1 A hysteroscopy can be carried out under a general anaesthetic although most are now carried out using a local or regional anaesthetic within the context of ‘one stop’ and ‘see and treat’ outpatient clinics.2 Research has explored women’s experiences of undergoing a hysteroscopy in these contexts and suggest that the although procedure is associated with raised anxiety and pain, most women state that they would still rather have the procedure in an outpatient clinic under the same conditions than be admitted into hospital.3–8

Contemporary gynaecological procedures including hysteroscopy use modern technology such as telescopes and monitors that allow clinicians to have a more precise understanding of what changes are occurring in a patient’s health.9 Many clinics now also enable the women to see the procedure either on their own screen or the clinician’s screen. Although such visual imaging has proved to be beneficial for the clinician as a means to carry out such procedures, there remains only limited evidence concerning the potential impact of seeing the procedure on the patient experience. For example, Sutton 10 provides a review of the hysteroscopy procedure and suggests that some women find viewing the screen during the procedure an interesting and informative experience, although some can find it unnerving. Morgan et al.11 carried out a small-scale descriptive study to explore women’s experiences of having a hysteroscopy that included a reference to the impact of seeing the screen. They analysed the data from 29 women and concluded that while 10 women had watched the screen as they were interested in the procedure and found it a distraction from their pain, 14 had chosen to look away for fear of becoming anxious through what they might see. Morgan et al.11 also described how those who did not see the screen reported more pain. A further five were unable to see the screen as it was positioned out of their line of sight.

This study therefore suggests that viewing a procedure on a screen may influence a number of different aspects of the woman’s experience. First, the results indicate a role for pain perception that is in line with research indicating that an individual’s attentional state through focus or distraction can exacerbate or minimise the pain they experience.12,13 Second, the results indicate that seeing the screen may influence an individual’s mood, particularly their level of anxiety that finds reflection in research illustrating how information about a medical procedure can either increase or decrease negative mood.14,15 Third, Morgan et al.11 also highlighted the importance of communication and the patient’s relationship with the clinician although the impact of the screen on this variable was not examined. It is possible that having a screen available for both the clinician and patient could change the communication between these two individuals. Research in Primary Care indicates that the increasing use of computers within the General Practice consultation has implications for the doctor–patient relationship 16,17. In line with this, the availability of the screen during a hysteroscopy may also have an impact upon the communication process although whether the presence of a screen is either positive or negative remains unclear.

Patients are therefore increasingly being given access to a screen to watch their hysteroscopy procedure. The impact of this remains unknown although preliminary exploratory research suggests that the screen may have an impact upon the patient experience in terms of pain perception, mood and communication. The present study therefore aimed to test these findings quantitatively using an experimental design with patients being randomly allocated to seeing or not seeing the screen during their procedure. Research within parallel areas also indicates a role for illness cognitions that are the ways in which a person makes sense of their health problem. In particular, Leventhal et al.18 argue that people make sense of their health problem in terms of a number of different dimensions such as beliefs about the cause of their problem and beliefs about the impact of the problem on their lives, and much research indicates that these dimensions are consistently held by women with a range of illnesses including coronary heart disease, diabetes, obesity and cancer.19,20 Furthermore, research also indicates that they can change following information, education, adverse effects of medication and symptom experience.21,22 It is possible that seeing a hysteroscopy procedure on a screen could change the ways in which patients makes sense of their health problem. Accordingly, the present study also explored the impact of viewing the screen on patients’ illness cognitions.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Design

The study involved a randomised trial with two conditions: seeing the screen versus not seeing the screen. Baseline mood and clinical variables were measured before the procedure. Aspects of the patients’ experience (mood, pain perception, illness cognitions and communication with the health professional) were assessed after the procedure.

Participants

Consecutive patients attending the hysteroscopy outpatient clinics at the Royal Surrey County Hospital in Guildford and the Bradford Royal Infirmary were invited to take part in the study. Women were excluded if they did not speak sufficient English to complete the questionnaire (or did not have someone with them who could translate) or if they ended up not having a hysteroscopy. Women who did not wish to be randomised were also excluded from the study. Approximately 60 women were approached in Bradford and 132 were approached in Surrey (these numbers are approximate because of some data not being recorded). Completed questionnaires were received from 117 women from the Royal Surrey and 40 from Bradford. Data collection took place in two blocks with the Bradford component occurring in 2006 and the Royal Surrey occurring in 2007. The project was approved by the Bradford and Royal Surrey Local Research Ethics committees. Because of this being the first trial in this area and the absence of any existing data on the impact of seeing the screen during a hysteroscopy, no formal sample size calculation was carried out. However, it was calculated that with alpha set at 5% and beta set at 80% a sample size of 150 (n = 75 in each arm) should be sufficient to detect a medium effect size.

Procedure

On the day of appointment all women attending the hysteroscopy clinic were invited to take part in the research. Those who agreed were further informed about the purpose of the study and provided with the information sheet and consent form. The patients were advised that 50% of women would see the screen during the procedure and 50% would not see the screen depending on the number on the questionnaire. Patients who agreed to continue signed the consent form and completed the baseline questionnaire. The follow-up questionnaire was completed by women after the hysteroscopy had been carried out. The questionnaire was anonymous and not linked to the woman’s notes.

Randomisation

Randomisation was carried out using a random number generator. An odd number on the questionnaire meant that the woman was not able to see the screen during the procedure, and an even number indicated that the person was able to see the screen during the procedure. All participants were asked to pick the top questionnaire from a randomly ordered pile.

Measures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Baseline

The baseline questionnaire consisted of the following list below.

Demographics

Participants described their age, occupation, ethnicity, whether they were a parent (excluding fostering and adoption), method of delivery (‘vaginal, ‘caesarean’ or ‘both’) and first language.

Mood (prehysteroscopy)

Participants completed an adapted version of the Profile of Mood States questionnaire (POMS23) to describe their mood in terms of anxiety (8 items), depression (14 items), fatigue (4 items) and vigour (6 items) rated on a 5-point Likert scales ranging from ‘Not at all’ (1) to ‘Very much’ (5).

Follow up

The follow-up questionnaire consisted of the following listed below.

Mood (posthysteroscopy)

The POMS questionnaire was completed for a second time. Change scores for each mood subscale were computed (follow up—baseline) for the analysis.

Pain perception

Perceived pain was assessed using an adapted version of the McGill Pain Questionnaire24 to evaluate two aspects of pain: sensory (e.g. flickering, quivering and pulsing [6 items]) and affective (e.g. punishing and gruelling [5 items]). In addition, positive pain items (e.g. interesting, reassuring and comfortable [4 items]) and negative pain items (e.g. painful, frightening and worrying [4 items]) were added to the scale and checked for internal reliability. Women rated these constructs on a 5-point Likert scale ranging from ‘not at all’ (1) to ‘extremely’ (5). All items has Cronbach’s alphas >0.6.

Illness cognitions

These were assessed using an adapted version of the Illness Perception Questionnaire (IPQR25,26) to assess different dimensions of illness cognitions each of which was rated using three items: cause of problem (e.g. ‘stress or worry’, ‘My own behaviour’ and ‘hereditary—it runs in the family’), its consequences (e.g. ‘my problem has major consequences on my life’), time line (e.g. ‘my problem will last a short time’), treatment effectiveness (e.g. ‘my treatment can control my problem’), affect (e.g. ‘my problem is a misery to me’) and sense making (e.g. ‘my problem is puzzling to me’). Women rated dimensions of the IPQ on a 5-point Likert type scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). The causal items were summated to create a variable reflecting psychological causes (e.g. ‘My own behaviour’) and one reflecting a belief in biological causes (e.g. ‘hereditary—it runs in the family’).

Communication

The interaction with the health professional was assessed using a measure of patient centeredness developed by Ogden et al.27 This focuses on four dimensions of the interaction with the health professional each of which is assessed using three items: patient involvement (e.g. ‘my clinician allowed me to speak freely’), emotional interaction (e.g. ‘my clinician was aware of my feelings in the consultation’), information giving (e.g. ‘my clinician explained the possible consequences of my problem’) and doctor receptiveness (e.g. ‘I felt my doctor acknowledged my views when discussing the cause of my problem’). Each item was rated on a 5-point Likert scale ranging from ‘Not at all’ (1) to ‘Very much’ (5).

Clinical variables

Women were also asked if this was their first experience of having a hysteroscopy and if not they were asked to indicate how many previous hysteroscopies they had had and to describe the gender of the health professional who had carried out their current procedure. The researcher noted what type of hysteroscopy they had (‘diagnostic’, ‘operative’ or ‘coil’), and the qualification of a health professional that carried out the procedure (nurse versus doctor versus consultant). In addition, whether or not they had been administered a local anaesthetic during the procedure was recorded for 116 women. The missing data for this variable was because of a change in researcher and could not be obtained after the patient had left the clinic as the data collection process was anonymous.

Data analysis

The data were analysed to describe the participants’ demographic and clinical variables and to explore differences in these variables between the two conditions using either t tests (for scale data) or χ2 for (dichotomous data). The data were then analysed to assess the impact of the intervention (screen on versus screen off) on aspects of the patient’s experience (change in mood, pain perception, illness cognitions and communication with the health professional) using analysis of variance (ANOVA). Finally, this analysis was repeated using the presence or absence of a local anaesthetic as a covariate using analysis of covariance (ANCOVA). Partial eta2 is reported for the analyses of the impact of the intervention as a measure of effect size.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Participants’ demographic and clinical variables

Participants’ demographic and clinical variables and differences in these factors by condition are shown in Table 1.

Table 1.  Differences in demographics and clinical variables by condition
VariablenScreen on (n = 81)Screen off (n = 76)t or χ2P
Location of the hospital157Guildford = 62Guildford = 55χ2= 0.360.55
Bradford = 19Bradford = 21
Age (years)119Mean = 45.5Mean = 47.7t =−1.040.30
SD = 12.61SD = 10.76
Ethnicity132White = 64White = 62χ2= 1.230.54
Asian = 2Asian = 3
Other = 0Other = 1
First language132English = 65English = 62χ2= 1.870.17
Other = 1Other = 4
Children?120No = 11No = 11χ2= 0.030.86
Yes = 47Yes = 51
Type of delivery118Vaginal = 36Vaginal = 39χ2= 2.400.49
Caesarean = 7Caesarean = 4
Both = 3Both = 7
No children = 11No children = 11
No. of hysteroscopies154None = 62None = 55χ2= 2.180.54
One = 13One = 17
Two = 3Two = 1
Procedure157Diagnostic = 78Diagnostic = 70χ2= 4.480.11
Operative = 0Operative = 4
Coil = 3Coil = 2
Qualification of health professional117Nurse = 7Nurse = 6χ2= 0.040.98
Doctor = 17Doctor = 16
Consultant = 38Consultant = 33
Gender of a health professional157Male = 39Male = 35χ2= 0.260.88
Female = 39Female = 39
Both = 3Both = 2
Local anaesthetic116No = 45No = 47χ2= 0.400.52
Yes = 10Yes = 14
Occupation110Housewife = 11Housewife = 8χ2= 5.190.16
Employed = 44Employed = 35
Unemployed = 0Unemployed = 3
Retired = 3Retired = 6

The sample consisted of 157 women aged between 21 and 74 years. The majority of women were white whose first language was English. The majority of women had children, with the most common type of delivery being vaginal delivery followed by caesarean delivery. Most had not had a hysteroscopy before, although a number of women reported that they have had one hysteroscopy in the past and a minority of women reported having two or three previous hysteroscopies. The majority of women underwent the hysteroscopy for diagnosis and did not receive a local anaesthetic. Of the 157 women undergoing a hysteroscopy procedure, 81 had the screen on while 76 had the screen off.

The results showed that the two conditions were comparable for all demographic and clinical variables.

Impact of the intervention on patient outcomes

The data were analysed to assess the impact of the intervention (screen on versus screen off) on aspects of the patient’s experience (change in mood, illness cognitions, pain perception, communication with the health professional) using one-way ANOVA.

Mood

Differences in changes in mood from baseline to follow up by condition are shown in Table 2. The results showed no impact of the intervention on patients’ change in mood.

Table 2.  Impact of intervention on mood at follow up
VariableScreen on (n = 81)Screen of (n = 75)FPPartial eta2
Change in anxietyMean =−0.18Mean =−0.393.240.070.03
SD = 0.68SD = 0.76
Change in depressionMean =−0.09Mean =−0.080.0010.980.0001
SD = 0.41SD = 0.41
Change in vigourMean =−0.19Mean =−0.120.410.520.0001
SD = 0.70SD = 0.70
Change in fatigueMean = 0.14Mean = 0.100.090.770.001
SD = 0.83SD = 0.70
Pain perception

Differences in pain perception by condition are shown in Table 3. The results showed no significant impact of the intervention on women’s perception of pain.

Table 3.  Impact of intervention on pain perception
VariableScreen on (n = 81)Screen off (n = 75)FPPartial eta2
Sensory painMean = 1.61Mean = 1.630.350.850.0001
SD = 0.70SD = 0.73
Affective painMean = 1.30Mean = 1.360.320.570.003
SD = 0.69SD = 0.69
Negative painMean = 2.19Mean = 2.351.030.310.01
SD = 0.92SD = 1.00
Positive painMean = 2.81Mean = 2.553.630.060.05
SD = 0.91SD = 0.75
Illness cognitions

Differences in illness cognitions by condition are shown in Table 4. The results showed no impact of the intervention on patients’ beliefs about the cause, consequences, meaning or time line of their problem. However, those who had the screen on reported feeling less optimistic about the effectiveness of their treatment.

Table 4.  Impact of the intervention on illness cognitions
VariableScreen on (n = 81)Screen off (n = 75)FPPartial eta2
  • *

    Significant impact of intervention.

Consequences of illnessMean = 2.46Mean = 2.550.500.480.003
SD = 0.85SD = 0.76
Treatment effectivenessMean = 3.50Mean = 3.775.440.02*0.04
SD = 0.80SD = 0.59
Sense makingMean = 2.23Mean = 2.220.010.970.0001
SD = 0.90SD = 0.85
Biological causeMean = 2.02Mean = 2.050.040.830.001
SD = 0.80SD = 0.68
Psychological causeMean = 1.92Mean = 2.000.350.560.0001
SD = 0.83SD = 0.74
Time line of illnessMean = 2.61Mean = 2.600.010.920.0001
SD = 0.89SD = 0.74
Communication with the health professional

Differences in perceptions of communication with the health professional are shown in Table 5. The results showed that the intervention had no impact upon patients’ experiences of communication with the health professional in terms of patient involvement, affect and information giving. However, those who did not see the screen felt that the health professional was more receptive to them during the consultation.

Table 5.  Impact of the intervention on communication with the health professional
VariableScreen on (n = 81)Screen off (n = 75)FPPartial eta2
  • *

    Significant impact of the intervention.

Patient’s involvementMean = 3.61Mean = 3.680.390.530.003
SD = 0.68SD = 0.66
Emotional interactionMean = 4.29Mean = 4.270.050.830.002
SD = 0.59SD = 0.64
Information givingMean = 3.98Mean = 3.821.510.220.02
SD = 0.80SD = 0.74
Doctor’s receptivenessMean = 3.94Mean = 4.164.120.04*0.03
SD = 0.65SD = 0.68

Impact of the intervention (controlling for the use of a local anaesthetic)

Because of the potential impact of receiving a local anaesthetic on the patient experience, the above analysis was repeated using local anaesthetic as a covariate in those participants for whom this was assessed (n = 116: screen on, n = 51; screen off, n = 54). In line with the analysis described above, the results showed that those women who did not see the screen during the procedure were more optimistic about the effectiveness of the treatment they were offered (F104,1 = 6.93, eta2 = 0.06, P = 0.01) and felt that the health professional was more receptive to them during the consultation (F104,1 = 3.83, eta2 = 0.04, P = 0.05). In contrast to the above results however, those who saw the screen described pain in more positive terms (e.g. comfort, reassurance and interesting) (F104,1= 6.09, eta2= 0.06, P = 0.02) but showed a smaller decrease in their anxiety levels than those who did not see the screen (F104,1= 5.09, eta2= 0.05, P = 0.03).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

The present study aimed to assess the impact of viewing the screen during a hysteroscopy on the patient’s experience.

The results showed that whether the women saw the screen or not had no impact upon their pain perception, which is in contrast to the suggestion made by Morgan et al.11 Furthermore, it does not support research which indicates that distraction and or focus can ameliorate the pain experience.12,13 The results also showed no impact of seeing the screen on changes in mood, several aspects of illness cognitions and the woman’s experience of communication with the health professional. However, the results indicated that having the screen off resulted in the women reporting greater confidence in the effectiveness of their treatment and describing improved communication with the health professional in terms of the clinician’s receptiveness to their views. Furthermore, when controlling for the use of a local anaesthetic, the results also showed that those not seeing the screen reported a greater decrease in anxiety compared with before the procedure. These results support previous studies indicating that illness cognitions can be changed by information,22 that the presence of a screen may be detrimental for communication 16,17 and that seeing a procedure may exacerbate anxiety.11 The results from the present study, however, indicate that the impact of the screen was not entirely negative with women who saw the screen being more likely to use terms such as ‘interesting’ and ‘reassuring’.

To conclude, although the use of patient screens is becomingly common practice for a number of outpatient procedures, these results indicate that it may not be a benign intervention and may have a number of implications for the patient experience. In the main, the results indicate that having a screen on while having a hysteroscopy has a negative impact in terms of mood, cognitions and communication with the health professional. These results not only have implications for the use of screens for women undergoing a hysteroscopy but also for the increasing number of other outpatient-based procedures where screens are being introduced. Further research is needed to support the results from the present study both in the context of having a hysteroscopy and also for other similar procedures. In addition, how patients from different cultures, social classes and with different patient histories differentially experience viewing a screen could also be examined.

Contribution to authorship

J.O. was responsible for designing the study, analysing the data and writing the paper. C.P. and M.H. were responsible for data collection and gave input into data analysis and writing the paper. S.J. and A.K. provided access to the patients and supported the study.

Conflict of interest

None.

Funding

None.

Ethical approval

Ethical approval was granted by the Bradford and Royal Surrey Ethics Committees.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Measures
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Commentary on ‘The impact of viewing a hysteroscopy on a screen on the patient’s experience: a randomised trial’

Innovations in health technology have the potential to improve the service provision of gynaecological practice. Ambulatory hysteroscopy is becoming more acceptable and widely practised, with low incidence of serious complications and a small failure rate (Bakour et al., Best Pract Res Clin Obstet Gynaecol, 2006;20:953–75). However, it can make the patient anxious, which increases the likelihood of intolerance for the outpatient procedure (Gupta et al., Surg Endosc 2004;18:1099–104).

Enabling the woman to see the procedure on a monitor is becoming increasingly common, but it is not known whether this reduces or increases her anxiety. Ogden’s randomised trial examining the impact of a woman watching her own hysteroscopy is not only interesting, it also reports unexpected results. These show that women who did not watch the procedure were more optimistic about the effectiveness of the treatment and felt that the health professional was more receptive to them during the consultation compared with those who watched it. Their conclusions are that viewing the procedure does not benefit the patient and may interfere with the patient–physician interaction. The study also concludes that women from different cultures, social classes and with different histories may experience viewing the procedure differently and therefore further research should be carried out.

Very few studies have examined the effects of recent technological developments on communication and patient–physician relationship, and those that have were not based on a randomised design. Randomised controlled trials are considered the gold standard for research methodology. Ogden’s paper had an adequate sample size to detect a medium size effect of the differing approaches. Accordingly, I would expect this study to have an impact on other areas of ambulatory surgery, not only gynaecological, as many services are moving from the hospital into the community setting. With advances in technology, there will be more handheld devices that can only be viewed by the operator, using wireless technology and with smaller screens. The study highlights the importance of creating a bond and interacting positively with the woman. There may also be implications for resource allocation. If viewing screens do not confer significant benefit, the money saved can be used more productively elsewhere. In a world with decreasing health resources, decisions should be based on a patient-centred view and the most up to date available evidence.

Declaration of interests

The author is the Treasurer of the European Society of Gynaecological Endoscopists (ESGE), which is a charity, Clinical Director of the IPI (Institute of Pharmaceutical Innovation) Bradford University and Director of the MERIT Centre, Bradford Teaching Hospitals.

Both Bradford University and Bradford Teaching Hospitals have received funding from Karl Storz, Johnson and Johnson and Femcare in the last 5 years.

Peter O’Donovana, H Muddada Bradford Royal Infirmary, Bradford, UK