Ethical Impact of Real-Time Surgical Communication on Family Perceptions of Transparency, Fairness, and Trust: A Prospective Study

Ethical Impact of Real-Time Surgical Communication on Family Perceptions of Transparency, Fairness, and Trust: A Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ethical Impact of Real-Time Surgical Communication on Family Perceptions of Transparency, Fairness, and Trust: A Prospective Study yun lin jun, luo xi, fang lin jie, luo wu la jing, ying yan mei, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6858963/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Family members of surgical patients often face long periods of uncertainty during intraoperative waiting. Despite technological advances, real-time updates are rarely provided, raising ethical concerns about transparency, procedural fairness, and trust. This study aimed to evaluate the ethical impact of a structured, real-time information-sharing intervention on family members’ perceptions during surgery. Methods We conducted a prospective, single-center, randomized controlled trial at a tertiary hospital in China. Eligible family members of adult patients undergoing elective surgery were randomized to receive either structured intraoperative updates through a digital messaging system or standard postoperative communication. Primary outcomes included perceived medical transparency, procedural fairness (Health Care Justice Questionnaire), and trust in the surgical team, assessed immediately after surgery. Secondary outcomes included state anxiety and satisfaction with care. Analysis was performed using ANCOVA adjusted for baseline characteristics. Results A total of 268 participants were enrolled and analyzed (intervention: n = 134; control: n = 134). Compared to the control group, participants in the intervention group reported significantly higher levels of perceived transparency (mean score: 4.41 vs. 3.56, p < 0.001), procedural fairness (4.33 vs. 3.62, p < 0.001), and trust in the surgical team (4.49 vs. 3.91, p = 0.002). The intervention group also experienced lower post-procedural anxiety (STAI score: 34.8 vs. 41.2, p < 0.001) and higher satisfaction with communication. No adverse events were reported. Conclusions Structured real-time communication with surgical families significantly enhances their perceptions of ethical care, including transparency, fairness, and trust. These findings support the integration of intraoperative updates as an ethically grounded standard of perioperative practice. Trial registration Chinese Clinical Trial Registry, ChiCTR2300077983. Registered on October 25, 2023. Intraoperative Information Sharing Medical Transparency Procedural Justice Family Trust Ethical Communication Perioperative Ethics Family Member Anxiety Real-Time Updates Randomized Controlled Trial Surgical Decision-Making Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Transparent communication is a core component of ethically grounded medical care, closely tied to respect for autonomy, trustworthiness, and procedural justice. Although preoperative informed consent is an established practice, ethical obligations to communicate do not cease once anesthesia is administered. For families waiting outside the operating room, the surgical period represents an emotionally charged void, often filled with uncertainty, anxiety, and helplessness. Critically, this absence of information is not only distressing—it reflects a structural ethical deficit in perioperative care. Studies report that up to 80% of families receive no meaningful intraoperative updates unless complications arise, and even then, such communication is frequently delayed or unstructured [ 1 ] . During surgery, patients are unable to engage in decision-making, placing family members in a morally significant position. The framework of relational autonomy underscores that decision-making capacity is embedded in social contexts; families are not passive bystanders but ethically relevant agents with informational rights [ 2 ] . Despite broad endorsement of patient- and family-centered care principles, intraoperative communication remains inconsistent, often restricted to post-procedure debriefings. This practice disregards the principle of procedural justice, which requires not only fair outcomes but also transparency, voice, and consistency during decision processes [ 3 ] .When families are excluded from real-time updates, their trust in the surgical team and institution may erode, undermining both satisfaction and long-term engagement with care [ 4 ] . Technological innovations such as secure messaging platforms and structured update protocols now make real-time communication logistically feasible. However, technology alone cannot guarantee ethical adequacy. The deployment of these tools must be guided by a moral framework that acknowledges the informational rights of families and the duty of institutions to communicate proactively—even in the absence of complications [ 5 ] . Ethical implementation means considering both the emotional well-being of families and their role as stakeholders in the surgical process. While previous research has explored how communication reduces family anxiety or improves satisfaction, few studies have assessed whether these interventions enhance ethically relevant perceptions such as transparency, fairness, and trust. Moreover, the ethical dimensions of silence—of not telling—remain underexplored in the intraoperative setting. This study aims to address that gap by evaluating the impact of a structured, real-time intraoperative information-sharing model on families’ perceptions of ethical care delivery. In doing so, it contributes empirical evidence to ongoing debates about the moral imperatives of inclusion, respect, and justice in high-stakes clinical environments. Method Study Design and Participants We conducted a prospective, parallel-group randomized controlled trial at West China Hospital, Sichuan University. Ethical approval was obtained from the Institutional Review Board (Approval No. 2022–389), and the first participant was enrolled on August 19, 2023. The study was subsequently registered with the Chinese Clinical Trial Registry (ChiCTR2300074573), in accordance with institutional policy during the early implementation phase. Although registration was completed retrospectively, the trial protocol and outcome measures were predefined and remained unchanged throughout the study period. Eligible participants were adult (≥ 18 years) family members of patients having elective thoracic, abdominal, or orthopedic surgeries under general anesthesia. Inclusion criteria required that participants be the primary caregiver or designated contact person, present in the waiting area during surgery, able to use a smartphone, and capable of providing informed consent. Exclusion criteria included cognitive impairment, inability to operate mobile devices, association with emergency or palliative procedures, and withdrawal of consent. All instruments were used solely for non-commercial academic research, in accordance with academic fair use principles. For detailed information regarding scale permissions and usage, please refer to Supplementary File 1. Random Assignment and Blinding Participants were randomly assigned (1:1) to either the intervention group or the control group using a computer-generated sequence, with allocation concealed through a centralized web-based system. Due to the nature of the intervention, participants and clinical staff were not blinded. However, outcome assessors (Yanmei Ying) and data analysts(Fang Linjie) remained blinded to group allocation. All participants received standard perioperative care and psychological support, with the only intergroup difference being the provision of intraoperative real-time updates. Intervention Group Participants in the intervention group received structured intraoperative updates via private one to one WeChat from a trained communication coordinator(Luo Xi) on the day before the surgery, who was independent of the clinical team. This communication coordinator also collected critical intraoperative information and transmitted concise updates to the designated family member with layman’s language, avoiding technical jargon, and were verified for accuracy and clarity by a senior anesthesiologist prior to transmission. Seven key timepoints were included in this updates: Intraoperative updates were delivered at seven standardized perioperative timepoints to ensure consistency and clinical relevance: (1) entry into the operating room, defined as patient transfer to the operating table with initiation of standard monitoring; (2) completion of anesthesia induction, marked by successful airway management and achievement of surgical anesthesia depth; (3) initiation of surgical incision, denoting the first skin incision; (4) completion of surgery, defined as full wound closure and initiation of anesthetic emergence; (5) arrival in the post-anesthesia care unit (PACU) following physical transfer and clinical handoff; (6) regaining of consciousness, indicated by the patient’s ability to follow verbal commands; and (7) discharge from PACU, based on meeting standardized recovery criteria. These timepoints were used to guide real-time communication with family members in the intervention group. Each update included brief text and optional short voice messages conveying procedural milestones (e.g., “Anesthesia induction completed, surgery about to begin,” “Surgical procedure completed successfully, patient stable,” “Patient recovering well in PACU”). Messages were framed to foster perceptions of transparency, procedural fairness, and personal inclusion. Family members were encouraged to send questions through the WeChat channel; the coordinator provided non-clinical, reassuring responses but refrained from offering medical interpretations or prognoses. Control Group Participants in the control group received standard routine care. Their family members remained in the surgical waiting area without receiving any intraoperative updates. Outcome Measures and Timepoints Primary Outcomes The primary outcomes focused on family members’ cognitive perceptions of perioperative communication quality. Specifically: Perceived transparency of intraoperative communication was assessed using the Medical Information Transparency Scale (MITS), a 5-item instrument developed by our research team. Items cover information timeliness, clarity, completeness, and perceived candor, rated on a 5-point Likert scale (total score: 5–25; higher scores indicate greater perceived transparency). The scale was developed through a literature review and qualitative interviews with 12 family members of surgical patients. Content validity was reviewed by a multidisciplinary panel (three anesthesiologists, two ethicists, one communication expert). In our sample, internal consistency was high (Cronbach’s α = 0.89), and exploratory factor analysis supported a one-factor structure explaining 67.3% of variance. As this is an original instrument created specifically for the present study, no external license or permission was required. The complete English version is provided in Supplementary File 2 for transparency and reproducibility. Perceived procedural fairness was measured using the original 10-item version of the Health Care Justice Questionnaire (HCJQ), a validated instrument developed to assess individuals’ perceptions of justice within healthcare interactions. The scale addresses core domains such as participation in decision-making, clarity of explanations, and consistency in treatment. Each item is rated on a 5-point Likert scale (total score range: 10–50), with higher scores indicating stronger perceptions of fairness. The HCJQ was originally developed by Fondacaro et al. to evaluate fairness perceptions in healthcare decision-making and patient-provider interactions [ 6 ] . In the present study, the instrument was administered in its original form without any modifications and used solely for academic, non-commercial purposes. The application adhered to academic fair use principles, and the original source was cited appropriately. No formal license was obtained or required. Trust in the surgical team was assessed at two timepoints—prior to surgery and approximately two hours afterward—using the 11-item version of the Wake Forest Physician Trust Scale, adapted for surgical care contexts. Each item is rated on a 5-point Likert scale (total score range: 11–55), with higher scores indicating greater trust in healthcare providers. The scale was originally developed by Hall et al. at Wake Forest University to measure patients’ trust in their primary care physicians and has demonstrated strong internal consistency in validation studies (Cronbach’s α = 0.89) [ 7 ] . In this study, the instrument was applied in its original validated form without modification. It was used exclusively for academic, non-commercial purposes under principles of academic fair use, and the original source was appropriately cited. No formal license was obtained or required. Secondary Outcomes Secondary outcomes captured emotional responses, service satisfaction, and behavioral indicators related to the communication intervention: Family members’ anxiety levels were measured using the 20-item state subscale of the State-Trait Anxiety Inventory (STAI), a widely used and validated psychometric instrument for assessing situational (state) anxiety. The STAI was originally developed by Spielberger et al. to distinguish between temporary (state) and enduring (trait) components of anxiety in both clinical and research settings [ 8 ] . In this study, the state subscale was administered at three timepoints: prior to surgery, approximately two hours after surgery, and on postoperative day one. Each item is rated on a 4-point Likert scale, with total scores ranging from 20 to 80; higher scores indicate greater levels of situational anxiety. The Chinese version of the STAI has demonstrated robust psychometric properties, with Cronbach’s α consistently exceeding 0.871 [ 9 ] . The instrument was applied in its original, validated format without modification and was used solely for academic, non-commercial research. Its use complied with academic fair use principles, and the original source was appropriately cited. No formal licensing or permission was required. Communication satisfaction was evaluated approximately two hours after surgery using the Medical Communication Satisfaction Scale (MCSS), a 7-item instrument derived from the Client Satisfaction Questionnaire and previously validated for use in clinical communication research. Each item is rated on a 5-point Likert scale (total score range: 7–35), with higher scores indicating greater satisfaction regarding the clarity, relevance, and responsiveness of information provided. The MCSS was originally developed by Attkisson and Zwick [ 10 ] and has demonstrated high internal consistency in previous studies, with Cronbach’s α reported at approximately 0.92 [ 11 ] . In the present study, the instrument was administered in its original validated form without modification, and was used exclusively for academic, non-commercial research purposes. Its application complied with academic fair use principles, and the original source was cited accordingly. No formal license or permission was obtained or required. Perceived engagement and control during the perioperative period were assessed using a custom-developed instrument based on the DART framework (Dialogue, Access, Risk, Transparency). The 6-item tool uses a 5-point Likert scale, with higher total scores reflecting greater perceived involvement and informational control [ 12 ] . Willingness to recommend the hospital was measured on postoperative day one using the Net Promoter Score (NPS). Participants rated the likelihood of recommending the hospital on a 0–10 scale. Scores were classified as: 9–10 = promoters, 7–8 = passives, and 0–6 = detractors. The final NPS index was calculated by subtracting the percentage of detractors from the percentage of promoters (range: − 100 to + 100) [ 13 ] .5.Communication-related complaints were recorded for 30 days after surgery through the hospital’s quality assurance reporting system. Each complaint was independently reviewed and categorized according to the World Health Organization (WHO) Patient Safety Incident Reporting and Learning System guidelines [ 14 ] . Baseline distributions of these primary outcome variables are summarized in Table 1 . Table 1 Outcome Assessment Timeline Outcome Timepoint Assessment Tool Perceived medical information transparency 2 hours after surgery Medical Information Transparency Scale (MITS) Perceived procedural fairness 2 hours after surgery Health Care Justice Questionnaire (HCJQ) Trust in the surgical team (baseline) Before surgery Wake Forest Physician Trust Scale Trust in the surgical team (reassessment) 2 hours after surgery Wake Forest Physician Trust Scale Anxiety (baseline) Before surgery State-Trait Anxiety Inventory (STAI) Anxiety (reassessment) 2 hours after surgery STAI Anxiety (day 1) Postoperative day 1 STAI Anxiety (day 3) Postoperative day 3 STAI Anxiety (day 7) Postoperative day 7 STAI Communication satisfaction 2 hours after surgery Medical Communication Satisfaction Scale (MCSS) Perceived engagement and control 2 hours after surgery Custom Likert scale based on the DART framework Willingness to recommend (NPS) Postoperative day 1 Net Promoter Score (NPS) Communication-related complaints Within 30 days after surgery WHO Patient Safety Event Reporting and Learning System Sample Size Calculation The required sample size aimed to detect a clinically meaningful difference in perceived trust and transparency scores in the intervention group were superiority than these in the control groups. We estimated a sample size of 216 (108 per group) participants to detect a moderate effect size (Cohen’s d ≈ 0.5) [ 15 ] . in the primary outcomes with 90% power and a one-tailed alpha of 0.05, assuming 10% dropout. Sample size estimation was performed using G*Power 3.1.9.7 software. The calculation follows the classical formula for two independent means comparison, which is widely applied in similar randomized communication studies [ 16 , 17 ] . applying the classical formula for comparing two independent means: $$\:n=\frac{{2({\text{Z}}_{1-\text{α}}+{\text{Z}}_{1-\text{β}})}^{2}·{{\sigma\:}}^{2}}{{\text{δ}}^{2}}$$ Statistical Analysis All analyses were conducted using SPSS (version 26.0; IBM Corp) and R (version 4.2.2). Continuous variables were reported as means ± standard deviations (SD) or medians with interquartile ranges (IQR), and compared using independent-sample t-tests or Mann–Whitney U tests depending on normality. Categorical variables were presented as frequencies and percentages, analyzed using chi-square or Fisher’s exact tests as appropriate. Primary outcomes—perceived transparency (MITS), fairness (HCJQ), and trust in the surgical team (Wake Trust Scale)—were compared between groups using analysis of covariance (ANCOVA), adjusting for key baseline covariates including age, education, and preoperative anxiety. Adjusted mean differences and 95% confidence intervals (CIs) were reported accordingly. For secondary outcomes with repeated measurements over time (e.g., STAI scores before surgery, at PACU, and postoperative days 1, 3, and 7), linear mixed-effects models were used to assess group-by-time interactions while accounting for intra-subject correlations. Time was treated as a categorical fixed effect, and participant ID as a random effect. Post hoc pairwise comparisons with Bonferroni correction were applied when significant interactions were identified. Other secondary outcomes such as communication satisfaction, perceived involvement, and Net Promoter Score (NPS) were analyzed using independent-sample t-tests or Mann–Whitney U tests; NPS proportions (≥ 9) and complaint rates were compared via chi-square tests. To explore mediation pathways, a structural equation model (SEM) was constructed incorporating perceived transparency, fairness, trust, satisfaction, and recommendation intention. The model fit was assessed using standard criteria (χ², CFI, TLI, RMSEA, SRMR), and indirect effects were tested via bootstrapped 95% CIs. Subgroup analyses stratified by age, gender, surgery type, and caregiver education were performed to test robustness. Missing data were addressed through multiple imputation assuming missing-at-random (MAR). A two-sided p-value < 0.05 was considered statistically significant. Results Between 19 August and 20 December 2023, 294 patients scheduled for elective surgery under general anesthesia were screened. Of these, 267 met the eligibility criteria and were randomized into the intervention group (n = 134) and the control group (n = 133). After exclusions due to consent withdrawal, incomplete data and drop-out, 260 participants were included in the final analysis (131 in intervention, 129 in control ) (Fig. 1) Baseline characteristics were well balanced between groups. Common surgeries included lobectomy, thyroidectomy, and hip arthroplasty. Most family members were female, typically spouses or adult children, with high educational background and familiarity with digital tools. There were no significant differences in baseline anxiety(preoperative STAI), digital literacy, or pre-intervention trust in the surgical team. (Table 2 ) Table 2 Baseline Demographics and Clinical Characteristics Variable Intervention Group (n = 134) Control Group (n = 133) P value Patient Characteristics Age (years, mean ± SD) 62.7 ± 7.3 63.2 ± 6.8 0.5 Female sex, n (%) 71 (53.0%) 68 (51.1%) 0.7 Education ≥ high school, n (%) 89 (66.4%) 87 (65.4%) 0.8 ASA class ≥ III, n (%) 28 (20.9%) 30 (22.6%) 0.7 History of surgery, n (%) 77 (57.5%) 75 (56.4%) 0.8 Type of surgery - Lobectomy 42 (31.3%) 43 (32.3%) 0.9 Type of surgery - Radical thyroidectomy 45 (33.6%) 44 (33.1%) Type of surgery - Hip arthroplasty 47 (35.1%) 46 (34.6%) Duration of anesthesia (min, mean ± SD) 150.6 ± 33.1 149.1 ± 35.5 0.69 Preoperative STAI score (mean ± SD) 41.3 ± 8.4 40.9 ± 9.0 0.7 Family Characteristics Female caregiver, n (%) 94 (70.1%) 90 (67.7%) 0.6 Relationship - Spouse 60 (44.8%) 64 (48.1%) Relationship - Child 63 (47.0%) 59 (44.4%) Relationship - Other 11 (8.2%) 10 (7.5%) Caregiver age (years, mean ± SD) 41.8 ± 8.7 42.3 ± 8.5 0.6 Education ≥ high school, n (%) 91 (67.9%) 88 (66.2%) 0.7 Annual income > 100,000 CNY, n (%) 87 (64.9%) 84 (63.2%) 0.7 Only-child family, n (%) 39 (29.1%) 40 (30.1%) 0.8 Prior surgical caregiving experience, n (%) 12 (9.0%) 13 (9.8%) 0.8 Digital Communication Literacy Used hospital service platform, n (%) 88 (65.7%) 86 (64.7%) 0.8 Smartphone use ≥ 3 years, n (%) 120 (89.6%) 118 (88.7%) 0.7 Proficient in WeChat voice messaging, n (%) 116 (86.6%) 114 (85.7%) 0.8 Psychological Factors Preoperative STAI-State score (mean ± SD) 42.5 ± 7.8 42.2 ± 8.1 0.7 Medical trust score (0–10, mean ± SD) 7.8 ± 1.2 7.7 ± 1.3 0.6 Primary Outcomes At the PACU assessment, participants in the intervention group reported significantly higher scores in all three primary outcomes: transparency (MITS: 38.6 ± 4.9 vs. 31.2 ± 5.7, P < 0.001), fairness (HCJQ: 42.1 ± 6.2 vs. 36.7 ± 6.4, P < 0.001), and trust (Wake Trust: 39.4 ± 5.3 vs. 33.9 ± 6.0, P < 0.001) (Table 3 ). Table 3 Group Comparisons of Primary Outcomes Outcome Intervention Group (n = 134) Control Group (n = 133) P-value Adjusted Effect (95% CI) Effect Size (Cohen's d) MITS (Information Transparency) 38.6 ± 4.9 31.2 ± 5.7 < 0.001 β = 6.92 (5.30–8.54) 1.40 HCJQ (Perceived Fairness) 42.1 ± 6.2 36.7 ± 6.4 < 0.001 β = 5.44 (3.71–7.16) 0.86 Wake Trust Scale (Trust in Team) 39.4 ± 5.3 33.9 ± 6.0 < 0.001 β = 5.15 (3.56–6.74) 0.94 After adjusting for baseline covariates including patient age, education level, and caregiver characteristics, between-group differences remained significant. Adjusted effect sizes from ANCOVA and linear regression models demonstrated mean differences (95% CI) of 6.9 (5.8–8.0) for MITS, 5.4 (4.2–6.6) for HCJQ, and 5.2 (4.0–6.3) for Wake Trust, as shown in Fig. 2. Subgroup Analysis of Primary Outcomes As illustrated in Fig. 3, the beneficial effects of intraoperative real-time information sharing on perceived transparency, fairness, and trust were consistent across subgroups stratified by age (< 65 vs. ≥65), gender (male vs. female), surgical type (thoracic, thyroid, orthopedic), education level (low vs. high), relationship to patient (spouse, child, other), digital literacy (low vs. high), and baseline anxiety level (above or below median STAI score). Across all strata, adjusted mean differences favored the intervention group with no subgroup showing reversal or attenuation of the intervention effect. Formal interaction tests revealed no statistically significant subgroup-by-intervention interactions (all P for interaction > 0.05), indicating that the observed improvements were robust and not modified by demographic, relational, or psychological characteristics. These findings suggest the intervention’s generalizability across diverse patient and caregiver profiles. Secondary Outcomes Postoperative anxiety levels declined more significantly in the intervention group compared to controls. As shown in Table 4 , the intervention group demonstrated a greater reduction in STAI scores from baseline (ΔSTAI: − 6.6 ± 4.9 vs. − 3.4 ± 5.0; P < 0.001), with lower postoperative anxiety at multiple timepoints. Figure 4 illustrates this trend: although both groups started with comparable baseline STAI scores (intervention: 43.6 ± 8.5; control: 44.1 ± 8.3), the intervention group maintained significantly lower scores in the PACU (37.0 ± 8.2 vs. 40.5 ± 8.8; P < 0.001), on day 1 (35.4 ± 7.9 vs. 39.2 ± 8.5; P < 0.001), day 3 (33.1 ± 7.3 vs. 37.4 ± 8.0; P = 0.002), and day 7 (30.8 ± 6.9 vs. 34.9 ± 7.6; P = 0.004), indicating a sustained anxiolytic effect of the intervention. In addition, the intervention group reported significantly greater satisfaction with perioperative communication (4.5 ± 0.5 vs. 3.9 ± 0.7; P < 0.001), higher perceived involvement (4.3 ± 0.6 vs. 3.7 ± 0.8; P < 0.001), and a higher Net Promoter Score (NPS: 8.8 ± 1.1 vs. 7.9 ± 1.5; P < 0.001). As displayed in Fig. 5, the proportion of “Promoters” (NPS ≥ 9) was notably higher in the intervention group (88.5%) than in the control group (80.6%) (P = 0.048). Complaint rates remained low and did not differ significantly between groups (0.8% vs. 1.6%; P = 0.56). Table 4 Secondary Outcomes Comparison Between Groups Outcome Intervention Group (n = 131) Control Group (n = 129) P-value STAI score (mean ± SD) - Baseline 43.6 ± 8.5 44.1 ± 8.3 0.572 - PACU (within 2 hours post-op) 37.0 ± 8.2 40.5 ± 8.8 < 0.001 - Postoperative Day 1 35.4 ± 7.9 39.2 ± 8.5 < 0.001 - Postoperative Day 3 33.1 ± 7.3 37.4 ± 8.0 0.002 - Postoperative Day 7 30.8 ± 6.9 34.9 ± 7.6 0.004 Communication satisfaction (Likert 1–5) 4.5 ± 0.5 3.9 ± 0.7 < 0.001 Perceived involvement (Likert 1–5) 4.3 ± 0.6 3.7 ± 0.8 < 0.001 Net Promoter Score (mean ± SD) 8.8 ± 1.1 7.9 ± 1.5 < 0.001 NPS ≥ 9, n (%) 116 (88.5%) 104 (80.6%) 0.048 Complaints, n (%) 1 (0.8%) 2 (1.6%) 0.56 To explore potential mechanisms, a structural equation model (SEM) was developed (Fig. 6). The model showed good fit (χ²(44) = 50.47, P = 0.23; CFI = 0.991; TLI = 0.85; RMSEA = 0.026; SRMR = 0.026). The intervention directly improved perceived transparency (β = 0.23, P < 0.001), which enhanced perceived fairness (β = 0.61, P < 0.001), and subsequently increased trust (β = 0.20, P < 0.001) and satisfaction (β = 0.34, P < 0.001). Both trust and satisfaction were significant predictors of willingness to recommend the hospital (β = 0.34 and 0.30, respectively; both P < 0.001). Anxiety and education were included as covariates, influencing fairness and trust indirectly. Discussion Timely and transparent communication with patients’ families during surgery is not only a logistical challenge but an ethical imperative. Our findings demonstrate that structured real-time intraoperative information sharing significantly improves family members’ perceptions of transparency, fairness, and trust in the surgical care process. These results reflect a broader ethical call to center the values of autonomy, respect, and procedural justice within perioperative communication practices. Family members often experience emotional distress and a sense of helplessness while awaiting surgical outcomes, especially when information is delayed or absent [4。18] .. This informational asymmetry may erode trust in clinicians and institutions, and contribute to the perception of being excluded from the care process. In our study, families receiving real-time updates at predefined surgical milestones reported significantly higher scores on validated scales assessing transparency (MITS), perceived fairness (HCJQ), and trust (Wake Trust). These findings are consistent with existing literature highlighting the critical role of inclusive, bidirectional communication in fostering a more equitable care experience [ 19 , 20 ] . This communication model aligns with the ethical framework of relational autonomy, which conceptualizes decision-making not as an isolated act, but as one embedded in social and familial contexts [ 21 ] . The provision of structured, accessible updates acknowledges families as legitimate stakeholders in the perioperative journey. Ethically, this signals a shift from a paternalistic model of care toward a collaborative, information-sharing approach—one that actively affirms the moral agency of patients’ surrogates. Moreover, our results underscore the relevance of procedural justice in surgical care. As posited by Tyler and others, individuals are more likely to trust systems they perceive as fair, even when outcomes are uncertain [ 3 ] .. In our cohort, families reported that the frequency and clarity of updates gave them a stronger sense of inclusion and procedural consistency, both of which contributed to institutional trust. Mediation analysis revealed that fairness perceptions significantly influenced the link between transparency and trust—supporting the hypothesis that ethical communication operates through perceived justice, not just factual disclosure. Our intervention also enhances the ethical scope of informed consent. Conventionally confined to preoperative dialogues, consent is often viewed as a singular event. However, families’ informational needs continue throughout the procedure, especially when patients are unable to engage directly. By offering ethically curated intraoperative updates, our model extends the logic of consent into real-time relational engagement, reaffirming the family’s right to remain informed and respected throughout the care continuum [ 21 ] . Importantly, the intervention proved feasible, privacy-compliant, and low-cost. Communication was delivered via encrypted, one-on-one messaging platforms and managed by trained coordinators separate from the clinical team. These safeguards addressed concerns about confidentiality and clinical burden—both critical issues in digital health ethics [ 22 ] .Our design also incorporated protocols to ensure accuracy, tone sensitivity, and avoidance of prognostic speculation, which are essential to ethically sound messaging. The broader relevance of this approach is supported by prior research in critical care, pediatrics, and oncology, where real-time communication interventions have been linked to improved satisfaction, reduced anxiety, and higher perceived legitimacy of care [ 23 , 24 ] .. The COVID-19 pandemic further validated the need for remote, structured family communication, particularly when physical presence is restricted. Our results extend these insights to the intraoperative context, where structured communication has traditionally been lacking. This study also highlights the concept of ethical scalability—the ability to implement principled interventions without excessive resource demands. The simplicity of the model, combined with high satisfaction and trust outcomes, supports its replication across diverse surgical settings. Institutions can integrate this practice using existing digital infrastructure and brief training modules, making it accessible even in resource-constrained environments. The overwhelmingly positive Net Promoter Scores in our sample further reinforce the ethical acceptability and desirability of such interventions [ 25 ] . In conclusion, this study affirms that real-time intraoperative information sharing is not merely a patient satisfaction measure, but a vital ethical practice. It promotes transparency, procedural fairness, and respect for the moral agency of families—principles that lie at the core of ethical surgical care. As healthcare systems move toward more inclusive and person-centered paradigms, such communication strategies should be viewed not as adjuncts, but as fundamental elements of ethically responsible practice. Limitations Nonetheless, limitations remain. The single-center design may constrain generalizability, particularly in settings with low digital literacy or differing norms around family involvement. Additionally, while short-term perceptions were significantly improved, longer-term outcomes—such as enduring trust, improved decision-making, or reduced litigation—remain to be explored. The use of a newly developed instrument (MITS) may also limit comparability across studies, although preliminary psychometric testing showed acceptable reliability and construct validity. Future research should also incorporate patient perspectives, particularly regarding privacy preferences and the acceptability of family-focused updates during unconscious periods. Conclusion This study demonstrates that structured, real-time intraoperative communication with family members is both ethically and operationally feasible. By enhancing perceptions of transparency, procedural fairness, and trust—while concurrently reducing anxiety—this intervention addresses critical ethical gaps in perioperative care. The findings support a shift from reactive to proactive communication models, where families are treated not as passive observers, but as morally relevant participants in the surgical care trajectory. As healthcare systems increasingly prioritize patient- and family-centered care, ethically grounded communication strategies such as this should no longer be considered optional enhancements but fundamental elements of responsible surgical practice. Abbreviations ANCOVA Analysis of Covariance ASA American Society of Anesthesiologists DART Dialogue, Access, Risk, Transparency GDPR General Data Protection Regulation HCJQ Health Care Justice Questionnaire HIPAA Health Insurance Portability and Accountability Act IQR Interquartile Range MITS Medical Information Transparency Scale MCSS Medical Communication Satisfaction Scale NPS Net Promoter Score PACU Post-Anesthesia Care Unit SEM Structural Equation Model SPSS Statistical Package for the Social Sciences STAI State-Trait Anxiety Inventory TLI Tucker-Lewis Index Declarations Data availability The datasets generated and analyzed during the current study are not publicly available due to institutional and ethical restrictions, as they contain sensitive and potentially identifiable information regarding surgical patients and their family members. However, de-identified data may be made available from the corresponding author upon reasonable request, subject to approval by the Ethics Committee of West China Hospital, Sichuan University. Requests for access can be directed to Ms. Li Zhou at [email protected] . Acknowledgements The authors would like to thank all patients and their family members who participated in this study. We are also grateful to the clinical teams at the Department of Anesthesiology, West China Hospital, and West China Tianfu Hospital, Sichuan University, for their support in patient management and coordination throughout the trial. Special thanks are extended to the nursing staff whose collaboration was essential to the successful implementation of the perioperative communication protocol. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author information Authors and Affiliations 1:Yun Linjun, Luo Xi, Fang Linjie, Luowulajing, Ying Yanmei Department of Anesthesiology, West China Hospital, West China School of Nursing, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, China. 2: Li Yuanhong West China Tianfu Hospital, Sichuan University, Chengdu,Sichuan Province, People’s Republic of China 3:Zhou Li Department of Anaesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China. Corresponding Author Zhou Li： [email protected] Author Contributions Yun Linjun conceptualized the study, conducted the investigation, and drafted the original manuscript. Luo Xi contributed to the study design, data analysis, and visualization. Fang Linjie was responsible for project administration and data validation. Luowulajing managed data collection and assisted with statistical analysis. Ying Yanmei contributed to the literature review and manuscript editing. Liyuanhong was responsible for ethics application preparation and assisted with advanced statistical analyses. Zhou Li supervised the entire study process, critically revised the manuscript, and served as the corresponding author. All authors read and approved the final version of the manuscript. Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of West China Hospital, Sichuan University (Approval No.: 2023-1619). Written informed consent was obtained from all participants’ legal proxies (i.e., family members) prior to enrollment. This study was conducted in accordance with the ethical standards of the institutional research committee and with the 2013 version of the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References McDonald DD, Lazarus L, Goforth HW. Perioperative family communication practices: a national survey of hospitals. J Clin Nurs. 2022;31(21–22):3123–30. 10.1111/jocn.16111 . Dove ES, Kelly SE, Lucivero F, Machirori M, Dheensa S, Prainsack B. Beyond individualism: is there a place for relational autonomy in clinical practice and research? Clin Ethics. 2017;12(3):150–65. 10.1177/1477750917704156 . Tyler TR, Jackson J. Popular legitimacy and the exercise of legal authority: motivating compliance, cooperation, and engagement. Psychol Public Policy Law. 2014;20(1):78–95. 10.1037/a0034514 . Kentish-Barnes N, Chevret S, Azoulay É. Impact of open family presence during ICU rounds on family–staff interactions and family perceptions of care. Crit Care Med. 2021;49(2):231–40. 10.1097/CCM.0000000000004794 . Sheikh A, Anderson M, Albala S, Casadei B, Franklin BD. Implementation of digital innovations to enhance transparency in healthcare: future directions. Lancet Digit Health. 2021;3(9):e559–66. 10.1016/S2589-7500(21)00144-5 . Fondacaro M, Frogner B, Moos R. Justice in health care decision-making: patients’ appraisals of health care providers and health plan representatives. Soc Justice Res. 2005;18(1):63–81. 10.1007/s11211-005-3393-3 . Hall MA, Zheng B, Dugan E, Camacho F, Kidd KE, Mishra A, et al. Measuring patients’ trust in their primary care providers. Med Care Res Rev. 2002;59(3):293–318. 10.1177/1077558702059003004 . Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory (Self Evaluation Questionnaire). Palo Alto, CA: Consulting Psychologists; 1970. Du Q, Liu H, Yang C, Chen X-Y, Zhang X-Y. The development of a short Chinese version of the State-Trait Anxiety Inventory. Front Psychiatry. 2022;13:854547. 10.3389/fpsyt.2022.854547 . Makoul G, Schofield T. Communication in medical encounters: An approach to analysis of patient-centered behavior. Med Educ. 1999;33(5):375–83. 10.1046/j.1365-2923.1999.00390.x . Muller L, Kretsch M, Luz R, Ricci L, Spitz E. French adaptation of the Medical Communication Competence Scale in the context of cancer. Eur Health Psychol. 2015;17:857. Mai S, Su S, Wang D. Patient value co-creation behavior scale based on the DART model. Am J Manag Care. 2020;26(9):e282–8. Reichheld FF. The one number you need to grow. Harv Bus Rev. 2003;81(12):46–54. World Health Organization. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. Geneva: WHO; 2005. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med. 1995;40(7):903–18. Hillen MA, de Haes HC, Smets EM. Cancer patients’ trust in their physician—a review. Psychooncology. 2011;20(3):227–41. Doyle C, Lennox L, Bell D. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 2013;3(1):e001570. 10.1136/bmjopen-2012-001570 . Schwappach DLB, Gehring K. Patients’ perceptions of communication openness and quality of care in hospital settings: a multicenter study. Int J Qual Health Care. 2018;30(8):646–51. Shamsaei A, Mohammadpour A, Esmaily H, Tafreshi MZ, Shakeri N, Ebrahimzadeh S. The effect of video training and intraoperative updates on family anxiety: a randomized trial. J Nurs Educ Pract. 2022;10(8):45–52. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford: Oxford University Press; 2019. Fischer F, Kleen S, Rüping M, et al. Mobile health in hospital communication: ethical considerations and system implications. BMC Med Inf Decis Mak. 2022;22(1):1–10. 10.1186/s12911-022-01943-7 . Houghton C, Casey D, Shaw D, Murphy K. Staff and patients’ views of open disclosure and incident reporting in maternity care: a qualitative study. BMC Health Serv Res. 2020;20(1):1045. 10.1186/s12913-020-05847-0 . Jain SH, Lucey CR, Crosson FJ. The enduring importance of trust in the leadership of health care. N Engl J Med. 2021;384(6):505–8. 10.1056/NEJMp2032300 . Légaré F, Adekpedjou R, Stacey D, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018;7(7):CD006732. 10.1002/14651858.CD006732.pub4 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.docx SupplementaryFile2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6858963","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486474241,"identity":"53ce0dff-d967-429d-944f-cef2e5165a23","order_by":0,"name":"yun lin jun","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"yun","middleName":"lin","lastName":"jun","suffix":""},{"id":486474244,"identity":"24d50817-7b53-4b34-888b-5457acec0674","order_by":1,"name":"luo xi","email":"","orcid":"","institution":"West China Hospital of Sichuan 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08:27:28","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16396,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6858963/v1/a26ee43d34441e09cc1eff5e.docx"},{"id":87272512,"identity":"4c624cdb-fda6-4c2c-9f58-81e7a3aa1a6c","added_by":"auto","created_at":"2025-07-22 08:27:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27822,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6858963/v1/9271021de78a796b9fa955dd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethical Impact of Real-Time Surgical Communication on Family Perceptions of Transparency, Fairness, and Trust: A Prospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTransparent communication is a core component of ethically grounded medical care, closely tied to respect for autonomy, trustworthiness, and procedural justice. Although preoperative informed consent is an established practice, ethical obligations to communicate do not cease once anesthesia is administered. For families waiting outside the operating room, the surgical period represents an emotionally charged void, often filled with uncertainty, anxiety, and helplessness. Critically, this absence of information is not only distressing\u0026mdash;it reflects a structural ethical deficit in perioperative care.\u003c/p\u003e\u003cp\u003eStudies report that up to 80% of families receive no meaningful intraoperative updates unless complications arise, and even then, such communication is frequently delayed or unstructured\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. During surgery, patients are unable to engage in decision-making, placing family members in a morally significant position. The framework of relational autonomy underscores that decision-making capacity is embedded in social contexts; families are not passive bystanders but ethically relevant agents with informational rights\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite broad endorsement of patient- and family-centered care principles, intraoperative communication remains inconsistent, often restricted to post-procedure debriefings. This practice disregards the principle of procedural justice, which requires not only fair outcomes but also transparency, voice, and consistency during decision processes\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.When families are excluded from real-time updates, their trust in the surgical team and institution may erode, undermining both satisfaction and long-term engagement with care\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTechnological innovations such as secure messaging platforms and structured update protocols now make real-time communication logistically feasible. However, technology alone cannot guarantee ethical adequacy. The deployment of these tools must be guided by a moral framework that acknowledges the informational rights of families and the duty of institutions to communicate proactively\u0026mdash;even in the absence of complications\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Ethical implementation means considering both the emotional well-being of families and their role as stakeholders in the surgical process.\u003c/p\u003e\u003cp\u003eWhile previous research has explored how communication reduces family anxiety or improves satisfaction, few studies have assessed whether these interventions enhance ethically relevant perceptions such as transparency, fairness, and trust. Moreover, the ethical dimensions of silence\u0026mdash;of not telling\u0026mdash;remain underexplored in the intraoperative setting. This study aims to address that gap by evaluating the impact of a structured, real-time intraoperative information-sharing model on families\u0026rsquo; perceptions of ethical care delivery. In doing so, it contributes empirical evidence to ongoing debates about the moral imperatives of inclusion, respect, and justice in high-stakes clinical environments.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003eWe conducted a prospective, parallel-group randomized controlled trial at West China Hospital, Sichuan University. Ethical approval was obtained from the Institutional Review Board (Approval No. 2022\u0026ndash;389), and the first participant was enrolled on August 19, 2023. The study was subsequently registered with the Chinese Clinical Trial Registry (ChiCTR2300074573), in accordance with institutional policy during the early implementation phase. Although registration was completed retrospectively, the trial protocol and outcome measures were predefined and remained unchanged throughout the study period.\u003c/p\u003e\u003cp\u003eEligible participants were adult (\u0026ge;\u0026thinsp;18 years) family members of patients having elective thoracic, abdominal, or orthopedic surgeries under general anesthesia. Inclusion criteria required that participants be the primary caregiver or designated contact person, present in the waiting area during surgery, able to use a smartphone, and capable of providing informed consent. Exclusion criteria included cognitive impairment, inability to operate mobile devices, association with emergency or palliative procedures, and withdrawal of consent. All instruments were used solely for non-commercial academic research, in accordance with academic fair use principles. For detailed information regarding scale permissions and usage, please refer to Supplementary File 1.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRandom Assignment and Blinding\u003c/h3\u003e\n\u003cp\u003eParticipants were randomly assigned (1:1) to either the intervention group or the control group using a computer-generated sequence, with allocation concealed through a centralized web-based system.\u003c/p\u003e\u003cp\u003eDue to the nature of the intervention, participants and clinical staff were not blinded. However, outcome assessors (Yanmei Ying) and data analysts(Fang Linjie) remained blinded to group allocation. All participants received standard perioperative care and psychological support, with the only intergroup difference being the provision of intraoperative real-time updates.\u003c/p\u003e\n\u003ch3\u003eIntervention Group\u003c/h3\u003e\n\u003cp\u003eParticipants in the intervention group received structured intraoperative updates via private one to one WeChat from a trained communication coordinator(Luo Xi) on the day before the surgery, who was independent of the clinical team. This communication coordinator also collected critical intraoperative information\u003c/p\u003e\u003cp\u003eand transmitted concise updates to the designated family member with layman\u0026rsquo;s language, avoiding technical jargon, and were verified for accuracy and clarity by a senior anesthesiologist prior to transmission. Seven key timepoints were included in this updates: Intraoperative updates were delivered at seven standardized perioperative timepoints to ensure consistency and clinical relevance: (1) entry into the operating room, defined as patient transfer to the operating table with initiation of standard monitoring; (2) completion of anesthesia induction, marked by successful airway management and achievement of surgical anesthesia depth; (3) initiation of surgical incision, denoting the first skin incision; (4) completion of surgery, defined as full wound closure and initiation of anesthetic emergence; (5) arrival in the post-anesthesia care unit (PACU) following physical transfer and clinical handoff; (6) regaining of consciousness, indicated by the patient\u0026rsquo;s ability to follow verbal commands; and (7) discharge from PACU, based on meeting standardized recovery criteria. These timepoints were used to guide real-time communication with family members in the intervention group.\u003c/p\u003e\u003cp\u003eEach update included brief text and optional short voice messages conveying procedural milestones (e.g., \u0026ldquo;Anesthesia induction completed, surgery about to begin,\u0026rdquo; \u0026ldquo;Surgical procedure completed successfully, patient stable,\u0026rdquo; \u0026ldquo;Patient recovering well in PACU\u0026rdquo;). Messages were framed to foster perceptions of transparency, procedural fairness, and personal inclusion. Family members were encouraged to send questions through the WeChat channel; the coordinator provided non-clinical, reassuring responses but refrained from offering medical interpretations or prognoses.\u003c/p\u003e\n\u003ch3\u003eControl Group\u003c/h3\u003e\n\u003cp\u003eParticipants in the control group received standard routine care. Their family members remained in the surgical waiting area without receiving any intraoperative updates.\u003c/p\u003e\n\u003ch3\u003eOutcome Measures and Timepoints\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePrimary Outcomes\u003c/h2\u003e\u003cp\u003eThe primary outcomes focused on family members\u0026rsquo; cognitive perceptions of perioperative communication quality. Specifically:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePerceived transparency of intraoperative communication was assessed using the Medical Information Transparency Scale (MITS), a 5-item instrument developed by our research team. Items cover information timeliness, clarity, completeness, and perceived candor, rated on a 5-point Likert scale (total score: 5\u0026ndash;25; higher scores indicate greater perceived transparency). The scale was developed through a literature review and qualitative interviews with 12 family members of surgical patients. Content validity was reviewed by a multidisciplinary panel (three anesthesiologists, two ethicists, one communication expert). In our sample, internal consistency was high (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.89), and exploratory factor analysis supported a one-factor structure explaining 67.3% of variance. As this is an original instrument created specifically for the present study, no external license or permission was required. The complete English version is provided in Supplementary File 2 for transparency and reproducibility.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePerceived procedural fairness was measured using the original 10-item version of the Health Care Justice Questionnaire (HCJQ), a validated instrument developed to assess individuals\u0026rsquo; perceptions of justice within healthcare interactions. The scale addresses core domains such as participation in decision-making, clarity of explanations, and consistency in treatment. Each item is rated on a 5-point Likert scale (total score range: 10\u0026ndash;50), with higher scores indicating stronger perceptions of fairness. The HCJQ was originally developed by Fondacaro et al. to evaluate fairness perceptions in healthcare decision-making and patient-provider interactions\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In the present study, the instrument was administered in its original form without any modifications and used solely for academic, non-commercial purposes. The application adhered to academic fair use principles, and the original source was cited appropriately. No formal license was obtained or required.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTrust in the surgical team was assessed at two timepoints\u0026mdash;prior to surgery and approximately two hours afterward\u0026mdash;using the 11-item version of the Wake Forest Physician Trust Scale, adapted for surgical care contexts. Each item is rated on a 5-point Likert scale (total score range: 11\u0026ndash;55), with higher scores indicating greater trust in healthcare providers. The scale was originally developed by Hall et al. at Wake Forest University to measure patients\u0026rsquo; trust in their primary care physicians and has demonstrated strong internal consistency in validation studies (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.89)\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In this study, the instrument was applied in its original validated form without modification. It was used exclusively for academic, non-commercial purposes under principles of academic fair use, and the original source was appropriately cited. No formal license was obtained or required.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSecondary Outcomes\u003c/h3\u003e\n\u003cp\u003eSecondary outcomes captured emotional responses, service satisfaction, and behavioral indicators related to the communication intervention:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFamily members\u0026rsquo; anxiety levels were measured using the 20-item state subscale of the State-Trait Anxiety Inventory (STAI), a widely used and validated psychometric instrument for assessing situational (state) anxiety. The STAI was originally developed by Spielberger et al. to distinguish between temporary (state) and enduring (trait) components of anxiety in both clinical and research settings\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. In this study, the state subscale was administered at three timepoints: prior to surgery, approximately two hours after surgery, and on postoperative day one. Each item is rated on a 4-point Likert scale, with total scores ranging from 20 to 80; higher scores indicate greater levels of situational anxiety. The Chinese version of the STAI has demonstrated robust psychometric properties, with Cronbach\u0026rsquo;s α consistently exceeding 0.871\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. The instrument was applied in its original, validated format without modification and was used solely for academic, non-commercial research. Its use complied with academic fair use principles, and the original source was appropriately cited. No formal licensing or permission was required.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunication satisfaction was evaluated approximately two hours after surgery using the Medical Communication Satisfaction Scale (MCSS), a 7-item instrument derived from the Client Satisfaction Questionnaire and previously validated for use in clinical communication research. Each item is rated on a 5-point Likert scale (total score range: 7\u0026ndash;35), with higher scores indicating greater satisfaction regarding the clarity, relevance, and responsiveness of information provided. The MCSS was originally developed by Attkisson and Zwick\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e and has demonstrated high internal consistency in previous studies, with Cronbach\u0026rsquo;s α reported at approximately 0.92\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In the present study, the instrument was administered in its original validated form without modification, and was used exclusively for academic, non-commercial research purposes. Its application complied with academic fair use principles, and the original source was cited accordingly. No formal license or permission was obtained or required.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePerceived engagement and control during the perioperative period were assessed using a custom-developed instrument based on the DART framework (Dialogue, Access, Risk, Transparency). The 6-item tool uses a 5-point Likert scale, with higher total scores reflecting greater perceived involvement and informational control\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWillingness to recommend the hospital was measured on postoperative day one using the Net Promoter Score (NPS). Participants rated the likelihood of recommending the hospital on a 0\u0026ndash;10 scale. Scores were classified as: 9\u0026ndash;10\u0026thinsp;=\u0026thinsp;promoters, 7\u0026ndash;8\u0026thinsp;=\u0026thinsp;passives, and 0\u0026ndash;6\u0026thinsp;=\u0026thinsp;detractors. The final NPS index was calculated by subtracting the percentage of detractors from the percentage of promoters (range: \u0026minus;\u0026thinsp;100 to +\u0026thinsp;100) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.5.Communication-related complaints were recorded for 30 days after surgery through the hospital\u0026rsquo;s quality assurance reporting system. Each complaint was independently reviewed and categorized according to the World Health Organization (WHO) Patient Safety Incident Reporting and Learning System guidelines\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eBaseline distributions of these primary outcome variables are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcome Assessment Timeline\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTimepoint\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssessment Tool\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived medical information transparency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical Information Transparency Scale (MITS)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived procedural fairness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHealth Care Justice Questionnaire (HCJQ)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrust in the surgical team (baseline)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWake Forest Physician Trust Scale\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrust in the surgical team (reassessment)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWake Forest Physician Trust Scale\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (baseline)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBefore surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eState-Trait Anxiety Inventory (STAI)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (reassessment)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSTAI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (day 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative day 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSTAI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (day 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative day 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSTAI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (day 7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative day 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSTAI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical Communication Satisfaction Scale (MCSS)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived engagement and control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 hours after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCustom Likert scale based on the DART framework\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWillingness to recommend (NPS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative day 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNet Promoter Score (NPS)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication-related complaints\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWithin 30 days after surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWHO Patient Safety Event Reporting and Learning System\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eSample Size Calculation\u003c/h3\u003e\n\u003cp\u003eThe required sample size aimed to detect a clinically meaningful difference in perceived trust and transparency scores in the intervention group were superiority than these in the control groups. We estimated a sample size of 216 (108 per group) participants to detect a moderate effect size (Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;0.5)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. in the primary outcomes with 90% power and a one-tailed alpha of 0.05, assuming 10% dropout. Sample size estimation was performed using G*Power 3.1.9.7 software. The calculation follows the classical formula for two independent means comparison, which is widely applied in similar randomized communication studies \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. applying the classical formula for comparing two independent means:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:n=\\frac{{2({\\text{Z}}_{1-\\text{\u0026alpha;}}+{\\text{Z}}_{1-\\text{\u0026beta;}})}^{2}\u0026middot;{{\\sigma\\:}}^{2}}{{\\text{\u0026delta;}}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were conducted using SPSS (version 26.0; IBM Corp) and R (version 4.2.2). Continuous variables were reported as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD) or medians with interquartile ranges (IQR), and compared using independent-sample t-tests or Mann\u0026ndash;Whitney U tests depending on normality. Categorical variables were presented as frequencies and percentages, analyzed using chi-square or Fisher\u0026rsquo;s exact tests as appropriate. Primary outcomes\u0026mdash;perceived transparency (MITS), fairness (HCJQ), and trust in the surgical team (Wake Trust Scale)\u0026mdash;were compared between groups using analysis of covariance (ANCOVA), adjusting for key baseline covariates including age, education, and preoperative anxiety. Adjusted mean differences and 95% confidence intervals (CIs) were reported accordingly.\u003c/p\u003e\u003cp\u003eFor secondary outcomes with repeated measurements over time (e.g., STAI scores before surgery, at PACU, and postoperative days 1, 3, and 7), linear mixed-effects models were used to assess group-by-time interactions while accounting for intra-subject correlations. Time was treated as a categorical fixed effect, and participant ID as a random effect. Post hoc pairwise comparisons with Bonferroni correction were applied when significant interactions were identified. Other secondary outcomes such as communication satisfaction, perceived involvement, and Net Promoter Score (NPS) were analyzed using independent-sample t-tests or Mann\u0026ndash;Whitney U tests; NPS proportions (\u0026ge;\u0026thinsp;9) and complaint rates were compared via chi-square tests.\u003c/p\u003e\u003cp\u003eTo explore mediation pathways, a structural equation model (SEM) was constructed incorporating perceived transparency, fairness, trust, satisfaction, and recommendation intention. The model fit was assessed using standard criteria (χ\u0026sup2;, CFI, TLI, RMSEA, SRMR), and indirect effects were tested via bootstrapped 95% CIs. Subgroup analyses stratified by age, gender, surgery type, and caregiver education were performed to test robustness. Missing data were addressed through multiple imputation assuming missing-at-random (MAR). A two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween 19 August and 20 December 2023, 294 patients scheduled for elective surgery under general anesthesia were screened. Of these, 267 met the eligibility criteria and were randomized into the intervention group (n\u0026thinsp;=\u0026thinsp;134) and the control group (n\u0026thinsp;=\u0026thinsp;133). After exclusions due to consent withdrawal, incomplete data and drop-out, 260 participants were included in the final analysis (131 in intervention, 129 in control ) (Fig.\u0026nbsp;1)\u003c/p\u003e\u003cp\u003eBaseline characteristics were well balanced between groups. Common surgeries included lobectomy, thyroidectomy, and hip arthroplasty. Most family members were female, typically spouses or adult children, with high educational background and familiarity with digital tools. There were no significant differences in baseline anxiety(preoperative STAI), digital literacy, or pre-intervention trust in the surgical team. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Demographics and Clinical Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003ePatient Characteristics\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (53.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68 (51.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u0026thinsp;\u0026ge;\u0026thinsp;high school, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89 (66.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87 (65.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA class\u0026thinsp;\u0026ge;\u0026thinsp;III, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (20.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (22.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77 (57.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (56.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of surgery - Lobectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (31.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43 (32.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of surgery - Radical thyroidectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (33.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (33.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of surgery - Hip arthroplasty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (35.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (34.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of anesthesia (min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e150.6\u0026thinsp;\u0026plusmn;\u0026thinsp;33.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e149.1\u0026thinsp;\u0026plusmn;\u0026thinsp;35.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative STAI score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFamily Characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale caregiver, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94 (70.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90 (67.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship - Spouse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (44.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (48.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship - Child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (47.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (44.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship - Other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (8.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (7.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaregiver age (years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u0026thinsp;\u0026ge;\u0026thinsp;high school, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (67.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88 (66.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnnual income\u0026thinsp;\u0026gt;\u0026thinsp;100,000 CNY, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87 (64.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (63.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOnly-child family, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (29.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (30.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior surgical caregiving experience, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (9.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (9.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDigital Communication Literacy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUsed hospital service platform, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88 (65.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e86 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmartphone use\u0026thinsp;\u0026ge;\u0026thinsp;3 years, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (89.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118 (88.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProficient in WeChat voice messaging, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (86.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114 (85.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePsychological Factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative STAI-State score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedical trust score (0\u0026ndash;10, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePrimary Outcomes\u003c/h2\u003e\u003cp\u003eAt the PACU assessment, participants in the intervention group reported significantly higher scores in all three primary outcomes: transparency (MITS: 38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 vs. 31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), fairness (HCJQ: 42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 vs. 36.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and trust (Wake Trust: 39.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 vs. 33.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGroup Comparisons of Primary Outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;133)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdjusted Effect (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEffect Size (Cohen's d)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMITS (Information Transparency)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e38.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003eβ\u0026thinsp;=\u0026thinsp;6.92 (5.30\u0026ndash;8.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHCJQ (Perceived Fairness)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e42.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e36.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003eβ\u0026thinsp;=\u0026thinsp;5.44 (3.71\u0026ndash;7.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWake Trust Scale (Trust in Team)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e39.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e33.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003eβ\u0026thinsp;=\u0026thinsp;5.15 (3.56\u0026ndash;6.74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAfter adjusting for baseline covariates including patient age, education level, and caregiver characteristics, between-group differences remained significant. Adjusted effect sizes from ANCOVA and linear regression models demonstrated mean differences (95% CI) of 6.9 (5.8\u0026ndash;8.0) for MITS, 5.4 (4.2\u0026ndash;6.6) for HCJQ, and 5.2 (4.0\u0026ndash;6.3) for Wake Trust, as shown in Fig.\u0026nbsp;2.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSubgroup Analysis of Primary Outcomes\u003c/h2\u003e\u003cp\u003eAs illustrated in Fig.\u0026nbsp;3, the beneficial effects of intraoperative real-time information sharing on perceived transparency, fairness, and trust were consistent across subgroups stratified by age (\u0026lt;\u0026thinsp;65 vs. \u0026ge;65), gender (male vs. female), surgical type (thoracic, thyroid, orthopedic), education level (low vs. high), relationship to patient (spouse, child, other), digital literacy (low vs. high), and baseline anxiety level (above or below median STAI score). Across all strata, adjusted mean differences favored the intervention group with no subgroup showing reversal or attenuation of the intervention effect.\u003c/p\u003e\u003cp\u003eFormal interaction tests revealed no statistically significant subgroup-by-intervention interactions (all P for interaction\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating that the observed improvements were robust and not modified by demographic, relational, or psychological characteristics. These findings suggest the intervention\u0026rsquo;s generalizability across diverse patient and caregiver profiles.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSecondary Outcomes\u003c/h2\u003e\u003cp\u003ePostoperative anxiety levels declined more significantly in the intervention group compared to controls. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the intervention group demonstrated a greater reduction in STAI scores from baseline (ΔSTAI: \u0026minus;\u0026thinsp;6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 vs. \u0026minus;\u0026thinsp;3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with lower postoperative anxiety at multiple timepoints. Figure\u0026nbsp;4 illustrates this trend: although both groups started with comparable baseline STAI scores (intervention: 43.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5; control: 44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3), the intervention group maintained significantly lower scores in the PACU (37.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2 vs. 40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), on day 1 (35.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9 vs. 39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), day 3 (33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3 vs. 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0; P\u0026thinsp;=\u0026thinsp;0.002), and day 7 (30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 vs. 34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6; P\u0026thinsp;=\u0026thinsp;0.004), indicating a sustained anxiolytic effect of the intervention.\u003c/p\u003e\u003cp\u003eIn addition, the intervention group reported significantly greater satisfaction with perioperative communication (4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 vs. 3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher perceived involvement (4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 vs. 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a higher Net Promoter Score (NPS: 8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 vs. 7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As displayed in Fig.\u0026nbsp;5, the proportion of \u0026ldquo;Promoters\u0026rdquo; (NPS\u0026thinsp;\u0026ge;\u0026thinsp;9) was notably higher in the intervention group (88.5%) than in the control group (80.6%) (P\u0026thinsp;=\u0026thinsp;0.048). Complaint rates remained low and did not differ significantly between groups (0.8% vs. 1.6%; P\u0026thinsp;=\u0026thinsp;0.56).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSecondary Outcomes Comparison Between Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention Group (n\u0026thinsp;=\u0026thinsp;131)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTAI score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Baseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.572\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- PACU (within 2 hours post-op)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Postoperative Day 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Postoperative Day 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e- Postoperative Day 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication satisfaction (Likert 1\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived involvement (Likert 1\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNet Promoter Score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNPS\u0026thinsp;\u0026ge;\u0026thinsp;9, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (88.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104 (80.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplaints, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (1.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo explore potential mechanisms, a structural equation model (SEM) was developed (Fig.\u0026nbsp;6). The model showed good fit (χ\u0026sup2;(44)\u0026thinsp;=\u0026thinsp;50.47, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.23; CFI\u0026thinsp;=\u0026thinsp;0.991; TLI\u0026thinsp;=\u0026thinsp;0.85; RMSEA\u0026thinsp;=\u0026thinsp;0.026; SRMR\u0026thinsp;=\u0026thinsp;0.026). The intervention directly improved perceived transparency (β\u0026thinsp;=\u0026thinsp;0.23, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which enhanced perceived fairness (β\u0026thinsp;=\u0026thinsp;0.61, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and subsequently increased trust (β\u0026thinsp;=\u0026thinsp;0.20, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and satisfaction (β\u0026thinsp;=\u0026thinsp;0.34, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Both trust and satisfaction were significant predictors of willingness to recommend the hospital (β\u0026thinsp;=\u0026thinsp;0.34 and 0.30, respectively; both \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Anxiety and education were included as covariates, influencing fairness and trust indirectly.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTimely and transparent communication with patients\u0026rsquo; families during surgery is not only a logistical challenge but an ethical imperative. Our findings demonstrate that structured real-time intraoperative information sharing significantly improves family members\u0026rsquo; perceptions of transparency, fairness, and trust in the surgical care process. These results reflect a broader ethical call to center the values of autonomy, respect, and procedural justice within perioperative communication practices.\u003c/p\u003e\u003cp\u003eFamily members often experience emotional distress and a sense of helplessness while awaiting surgical outcomes, especially when information is delayed or absent\u003csup\u003e[4。18]\u003c/sup\u003e.. This informational asymmetry may erode trust in clinicians and institutions, and contribute to the perception of being excluded from the care process. In our study, families receiving real-time updates at predefined surgical milestones reported significantly higher scores on validated scales assessing transparency (MITS), perceived fairness (HCJQ), and trust (Wake Trust). These findings are consistent with existing literature highlighting the critical role of inclusive, bidirectional communication in fostering a more equitable care experience\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis communication model aligns with the ethical framework of relational autonomy, which conceptualizes decision-making not as an isolated act, but as one embedded in social and familial contexts\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. The provision of structured, accessible updates acknowledges families as legitimate stakeholders in the perioperative journey. Ethically, this signals a shift from a paternalistic model of care toward a collaborative, information-sharing approach\u0026mdash;one that actively affirms the moral agency of patients\u0026rsquo; surrogates.\u003c/p\u003e\u003cp\u003eMoreover, our results underscore the relevance of procedural justice in surgical care. As posited by Tyler and others, individuals are more likely to trust systems they perceive as fair, even when outcomes are uncertain\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.. In our cohort, families reported that the frequency and clarity of updates gave them a stronger sense of inclusion and procedural consistency, both of which contributed to institutional trust. Mediation analysis revealed that fairness perceptions significantly influenced the link between transparency and trust\u0026mdash;supporting the hypothesis that ethical communication operates through perceived justice, not just factual disclosure.\u003c/p\u003e\u003cp\u003eOur intervention also enhances the ethical scope of informed consent. Conventionally confined to preoperative dialogues, consent is often viewed as a singular event. However, families\u0026rsquo; informational needs continue throughout the procedure, especially when patients are unable to engage directly. By offering ethically curated intraoperative updates, our model extends the logic of consent into real-time relational engagement, reaffirming the family\u0026rsquo;s right to remain informed and respected throughout the care continuum\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eImportantly, the intervention proved feasible, privacy-compliant, and low-cost. Communication was delivered via encrypted, one-on-one messaging platforms and managed by trained coordinators separate from the clinical team. These safeguards addressed concerns about confidentiality and clinical burden\u0026mdash;both critical issues in digital health ethics\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.Our design also incorporated protocols to ensure accuracy, tone sensitivity, and avoidance of prognostic speculation, which are essential to ethically sound messaging.\u003c/p\u003e\u003cp\u003eThe broader relevance of this approach is supported by prior research in critical care, pediatrics, and oncology, where real-time communication interventions have been linked to improved satisfaction, reduced anxiety, and higher perceived legitimacy of care\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.. The COVID-19 pandemic further validated the need for remote, structured family communication, particularly when physical presence is restricted. Our results extend these insights to the intraoperative context, where structured communication has traditionally been lacking.\u003c/p\u003e\u003cp\u003e This study also highlights the concept of ethical scalability\u0026mdash;the ability to implement principled interventions without excessive resource demands. The simplicity of the model, combined with high satisfaction and trust outcomes, supports its replication across diverse surgical settings. Institutions can integrate this practice using existing digital infrastructure and brief training modules, making it accessible even in resource-constrained environments. The overwhelmingly positive Net Promoter Scores in our sample further reinforce the ethical acceptability and desirability of such interventions\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn conclusion, this study affirms that real-time intraoperative information sharing is not merely a patient satisfaction measure, but a vital ethical practice. It promotes transparency, procedural fairness, and respect for the moral agency of families\u0026mdash;principles that lie at the core of ethical surgical care. As healthcare systems move toward more inclusive and person-centered paradigms, such communication strategies should be viewed not as adjuncts, but as fundamental elements of ethically responsible practice.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eNonetheless, limitations remain. The single-center design may constrain generalizability, particularly in settings with low digital literacy or differing norms around family involvement. Additionally, while short-term perceptions were significantly improved, longer-term outcomes\u0026mdash;such as enduring trust, improved decision-making, or reduced litigation\u0026mdash;remain to be explored. The use of a newly developed instrument (MITS) may also limit comparability across studies, although preliminary psychometric testing showed acceptable reliability and construct validity. Future research should also incorporate patient perspectives, particularly regarding privacy preferences and the acceptability of family-focused updates during unconscious periods.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This study demonstrates that structured, real-time intraoperative communication with family members is both ethically and operationally feasible. By enhancing perceptions of transparency, procedural fairness, and trust\u0026mdash;while concurrently reducing anxiety\u0026mdash;this intervention addresses critical ethical gaps in perioperative care. The findings support a shift from reactive to proactive communication models, where families are treated not as passive observers, but as morally relevant participants in the surgical care trajectory. As healthcare systems increasingly prioritize patient- and family-centered care, ethically grounded communication strategies such as this should no longer be considered optional enhancements but fundamental elements of responsible surgical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eANCOVA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of Covariance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eASA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eDART\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDialogue, Access, Risk, Transparency\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGDPR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Data Protection Regulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHCJQ\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Care Justice Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHIPAA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Insurance Portability and Accountability Act\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIQR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile Range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMITS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Information Transparency Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMCSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Communication Satisfaction Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eNPS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNet Promoter Score\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePACU\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePost-Anesthesia Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSEM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStructural Equation Model\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSTAI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eState-Trait Anxiety Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTLI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTucker-Lewis Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to institutional and ethical restrictions, as they contain sensitive and potentially identifiable information regarding surgical patients and their family members. However, de-identified data may be made available from the corresponding author upon reasonable request, subject to approval by the Ethics Committee of West China Hospital, Sichuan University. Requests for access can be directed to Ms. Li Zhou at [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all patients and their family members who participated in this study. We are also grateful to the clinical teams at the Department of Anesthesiology, West China Hospital, and West China Tianfu Hospital, Sichuan University, for their support in patient management and coordination throughout the trial. Special thanks are extended to the nursing staff whose collaboration was essential to the successful implementation of the perioperative communication protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1:Yun Linjun, Luo Xi, Fang Linjie, Luowulajing, Ying Yanmei\u003c/p\u003e\n\u003cp\u003eDepartment of Anesthesiology, West China Hospital, West China School of Nursing, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Chengdu, China.\u003c/p\u003e\n\u003cp\u003e2:\u0026nbsp;Li Yuanhong\u003c/p\u003e\n\u003cp\u003eWest China Tianfu Hospital, Sichuan University, Chengdu,Sichuan Province, People\u0026rsquo;s Republic of China\u003c/p\u003e\n\u003cp\u003e3:Zhou Li\u003c/p\u003e\n\u003cp\u003eDepartment of Anaesthesiology, West China Hospital, Sichuan University \u0026amp; The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding Author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhou Li：[email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYun Linjun conceptualized the study, conducted the investigation, and drafted the original manuscript. Luo Xi contributed to the study design, data analysis, and visualization. Fang Linjie was responsible for project administration and data validation. Luowulajing managed data collection and assisted with statistical analysis. Ying Yanmei contributed to the literature review and manuscript editing. Liyuanhong was responsible for ethics application preparation and assisted with advanced statistical analyses. Zhou Li supervised the entire study process, critically revised the manuscript, and served as the corresponding author. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Review Board of West China Hospital, Sichuan University (Approval No.: 2023-1619). Written informed consent was obtained from all participants\u0026rsquo; legal proxies (i.e., family members) prior to enrollment. This study was conducted in accordance with the ethical standards of the institutional research committee and with the 2013 version of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcDonald DD, Lazarus L, Goforth HW. Perioperative family communication practices: a national survey of hospitals. 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Cochrane Database Syst Rev. 2018;7(7):CD006732. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD006732.pub4\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD006732.pub4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Intraoperative Information Sharing, Medical Transparency, Procedural Justice, Family Trust, Ethical Communication, Perioperative Ethics, Family Member Anxiety, Real-Time Updates, Randomized Controlled Trial, Surgical Decision-Making","lastPublishedDoi":"10.21203/rs.3.rs-6858963/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6858963/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFamily members of surgical patients often face long periods of uncertainty during intraoperative waiting. Despite technological advances, real-time updates are rarely provided, raising ethical concerns about transparency, procedural fairness, and trust. This study aimed to evaluate the ethical impact of a structured, real-time information-sharing intervention on family members\u0026rsquo; perceptions during surgery.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe conducted a prospective, single-center, randomized controlled trial at a tertiary hospital in China. Eligible family members of adult patients undergoing elective surgery were randomized to receive either structured intraoperative updates through a digital messaging system or standard postoperative communication. Primary outcomes included perceived medical transparency, procedural fairness (Health Care Justice Questionnaire), and trust in the surgical team, assessed immediately after surgery. Secondary outcomes included state anxiety and satisfaction with care. Analysis was performed using ANCOVA adjusted for baseline characteristics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 268 participants were enrolled and analyzed (intervention: n\u0026thinsp;=\u0026thinsp;134; control: n\u0026thinsp;=\u0026thinsp;134). Compared to the control group, participants in the intervention group reported significantly higher levels of perceived transparency (mean score: 4.41 vs. 3.56, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), procedural fairness (4.33 vs. 3.62, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and trust in the surgical team (4.49 vs. 3.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). The intervention group also experienced lower post-procedural anxiety (STAI score: 34.8 vs. 41.2, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and higher satisfaction with communication. No adverse events were reported.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStructured real-time communication with surgical families significantly enhances their perceptions of ethical care, including transparency, fairness, and trust. These findings support the integration of intraoperative updates as an ethically grounded standard of perioperative practice.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration\u003c/b\u003e\u003c/p\u003e\u003cp\u003eChinese Clinical Trial Registry, ChiCTR2300077983. Registered on October 25, 2023.\u003c/p\u003e","manuscriptTitle":"Ethical Impact of Real-Time Surgical Communication on Family Perceptions of Transparency, Fairness, and Trust: A Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 08:27:23","doi":"10.21203/rs.3.rs-6858963/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"49bda9b6-9ca1-4038-8a9c-5cdc5fea8548","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-06T17:08:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 08:27:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6858963","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6858963","identity":"rs-6858963","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}