This survey was part of a larger multi-center, multi-national quality improvement (QI) study (Ethical Committee MMA No. 8/2020 date 04.08.2020) (20). Research teams from 6 hospitals in one country (Republic of Serbia) participated in this survey during 3 months.

The sample included patients who underwent mixed surgical procedures, requiring overnight hospital stay. Inclusion criteria were: (i) providing consent for participation; (ii) age ≥18 years old; (iii) on the first day after surgery (POD1) and on the ward for at least 6 h, and (iv) ability to read in the native language. For family and/or friends present at the time patients were approached, consent was given orally. The medical staff sample consisted of consultant anesthesiologists and surgeons, anesthesiology and surgery residents, and nurses on the ward, who gave oral consent. Since this was an internal anonymous audit performed on a voluntarily basis, no consent was needed from medical staff and family members in line with local regulations at the time of survey performance.

The original tool “The Information Needs Questionnaire—Pain and Pain Management” (INQPP) was developed based on clinical guidelines, and analyzed and edited by the multidisciplinary committee [Pain Management Education Team (PMET)] dedicated to pain management education (17). PMET consisted of 22 physicians and nurses' experts in the pain field and “allied health professionals” from pharmacy and physiotherapy (17). The tool was tested by postsurgical patients during their hospitalization “for comprehensiveness of content areas and usability” [Kastanias (17), p. 24]. The initial version of the tool was corrected to increase sensitivity by changing the response format from a 5-point to 10-point Likert scale (17).

The original INQPP consisted of 19 questions grouped into 3 sections: (A) pain characteristics and management; (B) side effects of pain medications, and (C) management of pain and side effects once discharged from the hospital (17). We adapted the INQPP, with permission, for use in our patient population and modified the question ratings to an 11-point Likert scale from 0-not important to 10-extremly important. The adapted questionnaire underwent forward translation and back-translation from English to Serbian. Questions were added to assess preferences regarding timing (section D) and methods of presentation (section E) using dichotomous yes/no answers. The adapted questionnaire was then piloted on the national population in 9 patients-family member dyads in postoperative period (Supplementary file). No formal validation of the original or the adapted version of questionnaire was performed.

An investigator, who was not involved in the patient's clinical care, approached participants on the first postoperative day (POD1) to provide background regarding the survey and oral guidance on how to complete the questionnaire. The patients were provided with a printed version of questionnaire and left to complete the questionnaire independently without the investigators involvement. In each center, we aimed for a convenience sample, ≥20 patients, matched to a family member or friend. Medical staff consisted of anesthesiologists, surgeons, residents and medical nurses directly engaged in medical care of patients treated on the surgical wards and were invited to complete the survey. However, the medical staff on the ward did not participate as investigators in the survey to overcome potential researcher bias. No target number for staff members and percentage of kinds of professionals that participated was made.

Results are presented as count (%) or mean ± standard deviation, and 25th to 75th percentile range, depending on the data type and distribution. The evaluations reported by the groups were compared using one-way ANOVA, chi-squared, and independent samples t-test, depending on the type of data and analysis. All p-values less than 0.05 were considered significant. Data were analyzed using SPSS 29.0 (IBM Corp. Released 2022. IBM SPSS Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp., USA).

Of the subjects enrolled between August 2019 and March 2020, data from 143 patients, 130 family members or friends of the patient and 168 members of staff from 12 wards and 6 hospitals, were analyzed (Figure 1). The demographic characteristics of the study sample are presented in Table 1. Participants completed the survey in 10–15 min.

With regard to timing of providing information about perioperative pain (item 20), overall, the preferred time for providing information about perioperative pain was before surgery at the pre-operative clinic (Table 3). The second choice was different among the groups. Patients and medical staff opted for getting information after surgery, on the first day, while family members tended to prefer “before surgery, as a leaflet sent to my home” (Table 3). There was a significantly higher number of patients compared to family members and medical staff who expressed that they do not wish to have information about pain (Chi-squared, p = 0.001).

The preferred methods for receiving information (item 21) is shown in Table 4. All three groups, gave the highest preference to receiving the information orally by the anesthesiologists, followed by the surgeon and then nurse. The second most preferred option for patients and family members was a leaflet left on the ward, while for medical staff the second most preferred option was oral information presented by a nurse.

The content of the information provided is of the utmost importance. Irrelevant content information in concurrence with the vulnerable state of patients, particularly in conjunction with nonfamiliarity of the hospital environment may lead to increased patient stress and anxiety (21, 22). Although we as medical staff have constant communication with patients that does not necessarily mean that we are giving them the information of their interest (3). All groups were interested in knowing the person to whom they should speak with if they experience pain, which suggests that patients rely on communication with medical staff as this offers patients the possibility of taking an active role in their pain management (3, 23).

Patients rated information about postoperative pain duration and treatment during hospitalization lower than family members and staff, highlighting a potential area for further investigation in patient support mechanisms (3). Most patients and their family members ranked the questions regarding information after leaving the hospital as the most important. Similar findings were reported in previous studies (17, 18). Medical staff should be encouraged to provide patients and their families with realistic expectations for the recovery process which includes pain management (19); however, the lack of education for this type of conversation is noticeable in practice (3, 16).

Of note is that addiction to analgesics was of low interest for all participants in our survey similar to Kastanias (17), Kastanias (18). However, patients expressed concerns regarding medication side effects after discharge from hospital which was similar to studies that explored opioid analgesic use during that period (24). The difference regarding perception of opioid addiction during the immediate postoperative period and post-discharge period might be the result of treatment duration i.e., short opioid application for postoperative pain management while patient is in the hospital. The literature has also discussed the possibility that information on pain treatment could raise patients' expectations for pain reduction, potentially leading to a higher demand for postoperative opioids (25, 26). The question remains whether our results indicated a greater confidence in receiving appropriate medical care and the belief that pain will be treated with adequate medications when necessary, thus, sparing opioid use (20) or if our results simply reflect lack of awareness toward the addiction in the population we studied. A recently published review concluded that limited data are available about adult patients “perceptions and experiences” with opioid use during surgery and the immediate postoperative period (27). Therefore, additional investigations are recommended as patient perceptions and experience have an influence on opioid prescription (27). Apart from opioids, the awareness about side effects related to non-opioid analgesics and adjuvants if used for longer periods of time, must be addressed to patients.

Providing information at the pre-operative clinic gives patients the opportunity to think and prepare, and it is therefore unsurprising that all groups preferred for this timing. In our survey, patients and medical staff preferred receiving information on the first day after surgery as a second option, while family members tended to receive information before surgery, as a leaflet sent to their home. Education and providing information to patients should be considered as a continuous process, and not just be limited to the preoperative period.

Surprisingly, a sizable portion of patients (21.7%) and family members (17.8%) in our survey opted that they do not wish to receive information. This might be a consequence of patients not identifying their role and its function in pain management, as was noticed in qualitative interpretive phenomenological research in patients from single cardiac rehabilitation center by Walton at al (28). However, the patients presented this role through different terms including the discussion of the subjective nature of pain and the importance of using a pain assessment tool (28), which may similarly reflect the desire for perioperative pain-related information, found in our study. Additionally, ignoring deeper knowledge about pain might be culturally related to the belief that surgery is supposed to be painful and that they will deal with the pain. This phenomenon has been previously described as the “positive social appraisal of ability to cope with pain” [Eshete (29), p.10), which may stem from patients being unaware of their situation and thus disregarding the information they receive, either because they do not fully understand it or due to fear of being perceived as “weak” by society for acknowledging their pain. The concept of patients' medical ignorance or their “right not to know” (Davies, 2020, p.300) was recently discussed, suggesting that in stressful situations, such as awaiting surgery or a diagnosis, information might be distressingly overwhelming for patients (30). However, this data necessitates further exploration so that medical professionals can be properly guided.

While our surveyed groups preferred orally delivered information, other cohorts opted for a combination of oral and written forms (23, 31). The difference in our patients' opinion and results from other studies might be due to cultural differences. Both forms of information presentation have their benefits and shortcomings. Providing information orally facilitates interactive communication between patients and the medical staff (“face to face”) and can be more effective in improving postoperative pain outcomes compared to video presentations (7). However, receiving information orally might be overwhelming and difficult to memorize in potentially stressful circumstances such as when waiting for surgery, while the written form offers a format that can be referred to repeatedly (23). Additionally, if the information is delivered in the preoperative clinic, patients have time to absorb and process the information, offering the opportunity to ask additional questions. Similarly, to other studies, our participants found physicians i.e., anesthesiologist as a valuable source of information (3, 23).

Our study has several limitations. The first limitation is that study took place in single country, and therefore cultural differences in how pain is perceived and managed, as well as healthcare practices, could limit the generalizability of the findings to other settings or countries. However, our study offers valuable information regarding patients' and family members' needs in middle income countries, particularly that patients from middle- and low-income countries are less frequently presented in pain outcome standardization initiatives (11). Secondly, the survey relied on reports by patients and their families without including information from patient's medical records and we were, therefore, unable to evaluate associations with factors such as reasons for surgery (e.g., cancer-related vs. not or acute vs. chronic condition) which might influence the nature of information that patients request.

The third limitation is the lack of medical staff breakdown in types or years of experience in our survey might impact the survey results, therefore we advocate for future studies to explore this topic. The fourth limitation worth noting is the exclusion of pharmacists from the survey. While the role of pharmacists varies between countries, many of the questions relate to side effects and pain management after discharge—areas where pharmacists could play an important role.

The participants were asked about their information needs and preferences after the surgery on POD1, and patients' experiences may change over time. It is worth noting that participating patients were fully alert and willing to take part in the survey, they also filled the questionnaire without assistance. Additionally, we relied on a convenience sample which may not fully represent the broader population of postoperative patients, leading to potential biases in the findings. For example, patients who volunteered to participate might have different experiences of pain (i.e., less pain) or attitudes than those who did not. To the best of our knowledge there is no formally validated questionnaire for exploration of patients' needs regarding information on postoperative pain management. For our survey we adapted the original INQPP tool, which had only been used in surgical contexts in previous studies (17, 18). With development of core outcome sets for acute pain which includes pain (intensity and duration), pain influence on physical functioning, quality of recovery and analgesics use (11) there is a need to develop a validated tool for assessing patients' needs regarding information on postoperative pain management, that will enable the comparison over healthcare settings and populations.

We suggest that future studies should include additional parameters in the evaluation such as presence of comorbidities, preoperative diagnosis, and history of previous surgeries. Furthermore, it is important to take into consideration the country's economic level and type of healthcare system model (i.e., national health insurance vs. private) as there could be a difference in findings.

The findings of this study could contribute to development of educational programs for healthcare providers on effective communication with patients and their families regarding pain and its management. Future directions should focus on improving methods for information transfer by actively involving patients as partners in the co-creation of educational materials that are understandable to both patients and their family members (32). At this point during the patient information development phase, priority should be given to continuous perioperative information about pain with information given predominantly in the preoperative clinic preferably by an anesthesiologist or surgeon. None of the previous studies evaluated the time needed to provide patients and family information about postoperative pain. This is noteworthy as information presentation, which is of the highest importance to patients, proper timing, and methods might streamline delivery. Future studies should assess the generic topics of interests in patients to aid in the further development of a more applicable education materials.