Videos for informed consent enable task shifting while enhancing patient safety and satisfaction: a retrospective study

Abstract

Background

Informed consent with video assistance provides patients with standardized information regarding complex clinical procedures. We explored the potential of completely replacing conventional face-to-face informed consent processes involving written documents with videos for informed consent (VIC) in the context of anesthesia.

Methods

A legally satisfactory VIC was developed to provide standardized information to patients and facilitate their understanding of anesthetic procedures, including their risks, benefits, and alternatives. In this single-center retrospective study, informed consent process-related data were extracted from two patient groups who underwent conventional informed consent and VIC. The opinions of the anesthesiologists were collected to evaluate workflow efficiency before and after VIC introduction. Statistical comparisons were performed using the Mann–Whitney U test.

Results

Before VIC implementation, bedside IC required a median total time of 45 [30–60] min, including 10 [5–10] min of travel time and 35 [25–50] min for anesthesia explanation. After VIC adoption, bedside IC was completely eliminated, and the median duration for outpatient IC decreased to 21 [14–30] min for conventional IC and 17 [12–22] min for VIC (p < 0.001). Approximately 97% of patients reported that VIC aided them in obtaining an explanation of the anesthesia, and 94% of patients who received VIC sufficiently understood the content of the informed consent. After the VIC introduction, 80% of patients reported that they would choose an outpatient clinic with a VIC over a conventional informed consent if given the option. Before and after 6 months of adopting VIC, 53% and 69% of anesthesiologists felt favorably about VIC, increasing to 86% after one year of VIC adoption.

Conclusions

VIC introduction successfully redistributed anesthesiologists’ workload and eliminated the need for bedside IC, while maintaining patient comprehension and satisfaction. These findings suggest that the standardized, repetitive components of the informed consent process are suitable candidates for digital transformation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-025-03536-7.

Background

Informed consent (IC) is an ethically and legally essential aspect of the process by which patients make legitimate decisions regarding invasive procedures [1]. IC provides information on procedure risks, benefits, disadvantages, alternatives, and treatment details. All patients must receive the same information and have a sufficient understanding of their medical procedures [2].

In universities and large hospitals in Japan, patients undergoing elective surgery under general anesthesia are rarely admitted on the day of surgery. The time to obtain consent for anesthesia is typically after admission for surgery. Generally, less discussion is involved in obtaining consent for anesthesia than for the surgical procedure, and less time is made available for consent conversation [1]. Written consent for surgery is typically obtained the day before surgery, and consent for anesthesia is obtained either on an outpatient basis or by an anesthesiologist visiting the patient’s bedside. In many Japanese facilities, explanatory documents or consent documents prepared by each facility are commonly utilized to unify the documents. However, the contents of oral explanations are left to the anesthesiologists or the person in charge and are not standardized. If the anesthesiologist seeking consent is not the one administering anesthesia, then they may be unable to provide the complete range of information on procedures or may share information that the administering anesthesiologist may consider is not in the patient’s best interests [1].

In our hospital, anesthetic IC is obtained verbally in writing on the business day immediately prior to surgery via two ways: bedside and outpatient clinic IC. At the time of this study, bedside ICs for approximately 15 patients per day were obtained by each assigned anesthesiologist. Similarly, ICs were obtained from approximately 15 patients per day at the anesthetic outpatient clinic. The anesthesiologist in charge must be replaced by another anesthesiologist for anesthesia management to visit the patient’s ward and perform IC. In contrast, in the anesthesia outpatient clinic, patients and/or their family members presented directly to the outpatient clinic, and IC was obtained by the anesthesiologist in charge of the outpatient clinic. Therefore, many anesthesiologist trainees perceive differences in explanation time and consistency and disadvantages of leaving the operating room during surgery, including a lack of experience in events occurring in their absence, lack of experience in improving communication with the operator, limited concentration on surgical anesthesia owing to preoccupation with IC preparations, and the inconvenience of setting a return visit in the absence of the patient.

Considering the changing ethical and legal contexts, the Association of Anesthetists has emphasized the need for an evidence-based online resource or leaflet for anesthetic consent that the patient can keep for future reference [3]. IC with video assistance has been reported to provide standardized information to patients. Video-assisted IC visually provides complex information, including relevant anatomy and complications, aiding patient understanding compared to verbal-only ICs in different clinical treatment scenarios [4, 5]. However, previous studies have explored the impact of adding an audio-visual assisted IC process as an adjunct, rather than a complete replacement for written IC forms.

As one of the first efforts to exclusively use video-assisted methods for obtaining IC, our institute developed a video presentation, which was a legally satisfactory document for IC, to provide standardized information to patients and facilitate their understanding of the anesthetic procedures, in addition to the risks, benefits, and alternatives. Moreover, we aimed to evaluate the efficiency of the IC process before and after the video for IC (VIC) introduction and examine the effectiveness of the work shift of anesthesiologists by the VIC.

Methods

Ethics statements

This study was a single-center, retrospective cohort study that used data collected in routine clinical practice and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Moreover, this study conformed to the standards of the Declaration of Helsinki and was approved by the Ethics Committee of the Nagoya University Hospital (approval number: 2023 − 0491, the study period: April 9, 2024, to December 31, 2025). Regarding the item related to consultation time, the Ethics Committee waived the requirement for written IC and approved opt-out IC, and IC from patients was obtained by opting out from the hospital website. Regarding the patient questionnaire and the consent of the study participants (anesthesiologists), written consent was obtained from each patient and anesthesiologist before filling out the questionnaire, and they then completed the questionnaire. Regarding patients who were minors, consent was obtained from their parents, and responses were obtained from both parents. There were no minors among the anesthesiologists.

Study design and population

Patient enrollment period was from January 1, 2023, to October 31, 2023. In our hospital, IC is performed on the business day immediately before the operation for all patients scheduled for surgery under the management of the anesthesiologist. To shift tasks for anesthesiologists and standardize anesthesia IC, we applied VIC instead of face-to-face IC (conventional IC) at the patient’s bedside by an anesthesiologist from May 2023. Therefore, patients who underwent elective surgery between January 2023 and April 2023 were included in the conventional IC group, and those assessed between May 2023 and October 2023 were included in the VIC group.

The study’s primary objective was to evaluate task shifting by comparing the time required for IC for each patient between the VIC and conventional IC groups. The time required for IC was defined as the sum of the anesthesiologist’s travel time between the operating room and ward, anesthesia explanation time, consultation/interview time, and question-and-answer time. Secondary outcomes included patient awareness and understanding of the IC contents in VIC or conventional IC, anesthesiologist awareness of VIC, and efficiency of the consent process. In both groups, the anesthesiologists were required to compile all relevant preoperative information—including electronic medical records, laboratory tests, electrocardiograms, ultrasound results, and imaging studies—into a standardized individual patient evaluation sheet prior to obtaining IC. This evaluation sheet served as the foundation for subsequent discussion with the patient and was used during the IC process in both groups. Thus, VIC introduction did not alter the underlying process of individualized preoperative assessment, risk stratification, and the consultation to obtain the consent form was conducted using this evaluation sheet at hand.

Anesthesiologists in the preoperative consultation unit are supported by trained nursing staff. These nurses assist by reviewing this evaluation sheet, confirming drug allergies, anesthesia history, and comorbidities, and supplementing missing information as needed. However, all legal and clinical responsibilities regarding anesthetic risk explanation and written IC acquisition lie solely with the attending anesthesiologist.

In both the VIC and conventional IC groups, anesthesia trainees (board-certification candidates) were responsible for reviewing the clinical data of specific patients for whom they would be providing anesthesia care and preparing individualized preoperative evaluation sheets. These sheets were subsequently reviewed and approved by supervising board-certified anesthesiologists to ensure accuracy and completeness. As part of their routine clinical duties, anesthesia trainees participated in the VIC outpatient consultation service under supervision, gaining hands-on experience in patient interviews, risk assessment, and the IC process. This rotation structure ensured continuity of educational opportunities across both VIC and conventional IC models, such as anesthesia in the operating room one day, IC outpatient clinic the next, and anesthesia in the operating room the next.

VIC

The video content was reviewed and approved by the Department of Patient Safety in Nagoya University Hospital (consisting of physicians specializing in patient safety, nurses, pharmacists, lawyers, clinical engineers, and office workers) and the IC Documentation Committee of our hospital. The video contained all the information to be explained by the anesthesiologist and satisfied all the elements to replace the explanation to the patient, considering Japanese law, patient safety, and medical ethics (Table 1).

Table 1.

Items that require explanation and consent from a legal perspective in Japan

What VIC can do	What physicians should do
Need for treatment or testing, prognosis, and effects of non-treatment	Diagnosis, medical condition
Contents and methods of treatment and examination	Affected body part (Left and right, top and bottom, etc.)
General progress, schedule, and precautions for treatment and examination	Sedation (methods of sedation, risks, complications, and problems associated with sedation)
Expected effect, success rate	About pain (types of pain expected, intensity, how to deal with it, etc.)
Possible risks, complications, and side effects, and how to deal with them	Cost
Availability of other treatment methods, comparison (advantages, disadvantages)	Respond to patient questions
Freedom to choose other treatment methods	Present the person responsible for the operation, examination, procedure, etc.
Second opinion
Consent may be revoked at any time.
To be able to ask questions without hesitation.

All the items in this table are proposed by Yoshimasa Nagao and Fumimasa Kitano to maintain and improve patient safety and medical care quality provided to patients [“Policy for creating videos to assist with informed consent”, Case reception number: C20230190H, September 15, 2023. The rights were transferred to Nagoya University]. All of these must be met in the IC document. Items that VIC can account for are shown on the left. This approval number is treated as intellectual property and is similar to a patent for know-how

IC informed consent, VIC video for informed consent

VIC was provided via tablets (Additional file 1) to patients who visited the anesthetic outpatient clinic for IC of anesthesia. The video demonstrated all actual and possible anesthetic procedures, including general and local anesthesia (epidural anesthesia, spinal anesthesia, nerve block anesthesia, and infiltration anesthesia), arterial line, central venous line, pulmonary artery catheter (Swan–Gantz catheter), transesophageal echocardiography, and blood transfusions. In addition to this procedure, the video covered all the required items listed in Table 1, including possible risks and adverse events. After the patients watched the video, they received a question–and–answer session with an anesthesiologist, including any inquiries/examinations. The outpatient department constituted one anesthesiologist, one trainee, one or two nurses, and a clerk (Fig. 1A). Regarding minors, parents/guardians watched the VIC and provided consent for anesthesia.

Fig. 1.

Comparison between VIC and conventional IC. A In VIC, no bedside IC in the OR was obtained, whereas IC was obtained for 30 patients each day among all anesthesia outpatients. In the conventional IC (B), the movement of individuals is shown by the arrows. When the operating anesthesiologist goes to the ward, another anesthesiologist is sent to the OR. Bedside IC was obtained by the anesthesiologist visiting during surgery for 15 patients, and the number of ICs obtained from outpatients was approximately 15. IC, informed consent; VIC, video for informed consent; Aprox, approximately; OR, operating room

Conventional IC

The anesthesiologist in charge of surgical anesthesia was assigned to the patient at least two days before the date of surgery. While the anesthesiologist was administering anesthesia in the operating room, another anesthesiologist temporarily assumed responsibility for intraoperative anesthesia management. This allowed the anesthesiologist to visit the ward and obtain IC at the bedside from a patient scheduled for surgery on the following day (Fig. 1B). If the anesthesiologist in charge was absent on the day before surgery, it was not possible to go to the ward to obtain IC; therefore, patients had the opportunity to obtain IC at the anesthesia outpatient clinic the day before surgery. The anesthesiologists explained all possible procedures regarding anesthesia and their possible risks and adverse events at both the patient’s bedside and the outpatient clinic. Subsequently, the patients underwent a question-answer session, inquiries, and examinations. Regarding minors, the anesthesiologists explained the procedure to their parents/guardians and obtained their consent for anesthesia.

Data extraction

The following information was obtained from the anesthesia recording system database (ORSYS; Philips Healthcare, Best, Netherlands) and electronic medical record system (HOPE/EGMAIN-GX; Fujitsu, Tokyo, Japan): age, height, weight, sex, and operative method. In the conventional IC phase from January 2023 to April 2023, the time required for IC was objectively measured using our institutional physician location-tracking and attendance management system (Dr. JOY, Dr. JOY K.K., Tokyo, Japan). All anesthesiologists carried a coin-sized personal Bluetooth beacon, which interacts with receivers installed throughout the hospital to record their location in real-time. Using this system, we extracted timestamped location data to identify when an anesthesiologist departed from the operating room, visited the ward, and returned. This automated approach ensured accurate, unbiased measurement of IC duration without reliance on self-reported data or manual observation. In the VIC phase from May 2023 to October 2023, the time required for IC in the anesthesiology preoperative outpatient clinic was calculated from entry into the patient’s call register. After the VIC introduction, an optional questionnaire was administered to all patients to improve the outpatient process, and the opinions of patients who received the VIC were extracted from the submitted questionnaires. Additionally, surveys were administered to the anesthesiologists as questionnaires (which can be filled out and submitted at any time) during monthly meetings for outpatient clinic process improvement. These surveys included both supervising anesthesiologists and anesthesia trainees who participated in the IC process under supervision. The survey of anesthesiologists was conducted from September 1 to October 31, 2023, and responses were anonymous and could only be submitted once by the same person. The opinions of anesthesiologists before and after the VIC introduction were extracted from the submitted questionnaires. The last access date for research purposes was January 31, 2025. Although accessing information that could identify participants was necessary to collect data, the data was collected in an anonymous state, and the anonymized data was used in subsequent data analysis to prevent individuals from being identified.

Statistical analysis

Demographic variables, such as age, sex, and clinical department, were summarized using descriptive statistics. The normality of the IC duration data was assessed using the Shapiro–Wilk test, which revealed significant deviations from normality in both the conventional IC and VIC groups (p < 0.001). Therefore, group comparisons of IC duration were conducted using the Mann–Whitney U test. Statistical significance was defined as p < 0.05. All statistical analyses were performed using Microsoft Excel (Microsoft, Redmond, WA) and Python (version 3.10).

Results

Overall, 5,730 patients underwent surgery during the study period. Among them, 718 patients received an IC method that differed from the definitions used in this study and were excluded. Consequently, 5,012 patients were considered eligible. Of these, patients with incomplete or missing data related to IC timing and/or questionnaire responses were further excluded. As a result, 477 patients in the conventional IC group and 324 in the VIC group had complete datasets and were included in the final analysis. A flow diagram illustrating patient inclusion and exclusion is provided in Fig. 2, and patient backgrounds are shown in Table 2.

Fig. 2.

Patients flow diagram

Table 2.

Patient backgrounds

	Conventional IC N = 477	VIC N = 324
Age (year)	51.3 ± 24.7 (57.0, 0.0–94.0)	54.5 ± 23.2 (60.0, 0.0–93.0)
Sex (male : female)	246 : 231	159 : 165
Clinical department
Gastrointestinal Surgery	91	69
Orthopedic Surgery	84	36
Cardiovascular Surgery	44	24
Thoracic Surgery	23	24
Urology	27	31
Neurosurgery	29	21
Pediatric Surgery	22	21
Obstetrics and Gynecology	55	24
Plastic Surgery	21	11
Breast and Endocrine Surgery	29	23
Oral and Otolaryngologic Surgery	35	26
Other Specialties	17	14

Values are presented as mean ± standard deviation (median, range) for age, and as counts for sex and surgical departments. Other Specialties include Psychiatry, Dermatology, and Ophthalmology. IC informed consent, VIC video for informed consent

Table 3 summarizes the time required by the anesthesiologists to obtain IC. The mean withdrawal time of anesthesiologists during surgical management with bedside IC was approximately 50.1 ± 24.9 min. The average IC time per patient for ambulatory anesthesia in the outpatient clinic for conventional IC was 23.2 ± 10.7 min, whereas that for VIC was 19.1 ± 10.0 min. A comparison of IC duration between the conventional IC and VIC groups using the Mann–Whitney U test showed that the VIC group required significantly less time than the conventional IC group (U = 96,530.5, p < 0.001).

Table 3.

Average required duration for IC

	Conventional IC		VIC
	Bedside IC	Outpatient clinic	Outpatient clinic
IC duration (min)	35 [25–49.5]	21.0 [14.1–30.0]	17 [12–22]
Travel time (min)	10 [5–10]	0	0
Total (min)	45 [30.3–60]	21.0 [14.1–30.0]	17 [12–22]
p-value	< 0.001	< 0.001	-

Conventional IC was the form of IC before the VIC introduction. This included bedside IC, where the anesthesiologist who manages the surgical anesthesia goes to the patient in the ward, and outpatient IC, where the patient arrives at the outpatient clinic

VIC is a method of providing anesthesia descriptions using video

IC duration included anesthetic explanation time, patient interview time, and consultation time

The p-value is the Mann–Whitney U test value when compared to VIC

IC informed consent, VIC video for informed consent

Figure 3 shows the patient’s understanding of VIC from the patient questionnaire. The content of each survey item is directly displayed within the figure panels, with the question text placed above each corresponding pie chart. This format is intended to facilitate visual association between each question and its response distribution.

Fig. 3.

Questionnaire-based response on patient’s understanding of VIC. The opinions of patients who received the VIC were extracted from the submitted questionnaires. IC, informed consent; VIC, videos for informed consent

The number of valid questionnaire responses was 219. According to the patient questionnaire results, approximately 94% of patients who received VIC sufficiently understood the IC content. On the other hand, approximately 5% of patients reported that the explanation was difficult or difficult to understand. Moreover, 96% of patients understood the risks of anesthesia, whereas 2% reported that these were difficult or difficult to understand.

Results of patient convenience and comfort with VIC from the patient questionnaires are shown in Fig. 4. Approximately 97% of the patients reported that VIC aided them in obtaining an explanation of anesthesia. In addition, 87% of the patients had no concerns about receiving scheduled anesthesia after undergoing VIC, 1% were anxious about receiving anesthesia, and the remaining 12% reported being unsure of any concerns.

Fig. 4.

Questionnaire-based response on patient's convenience/comfort with VIC. The opinions of patients who received the VIC were extracted from the submitted questionnaires. IC, informed consent; VIC, videos for informed consent

Figure 5 shows the results of a questionnaire survey of anesthesiologists at our institution regarding the IC system before and after VIC introduction. The questionnaire was sent to 32 anesthesiologists in our hospital who worked in the operating rooms before and during the time of VIC administration. Fifteen (46.9%) responses were collected. Before the VIC introduction, 53% of anesthesiologists reported feeling favorable and/or positive about VIC, 35% felt skeptical and/or negative about VIC, and the remaining 12% were neutral. Six months after the VIC introduction, 69% of anesthesiologists favored VIC, and 26% disliked it. The remaining 5% were neutral. A questionnaire survey of anesthesiologists one year after VIC introduction revealed that 92% of anesthesiologists expressed positive sentiments about VIC, and 4% expressed negative sentiments.

Fig. 5.

Questionnaire survey of anesthesiologists at our institution regarding the IC system before and after six months and one year of VIC introduction. The opinions of anesthesiologists before and after the VIC introduction extracted from the submitted questionnaires. IC, informed consent; VIC, videos for informed consent

After the VIC introduction, 80% of patients reported that they would choose an outpatient clinic with a VIC over a conventional IC if given the option, as shown in Fig. 6. The remaining 20% answered that conventional IC was better.

Fig. 6.

Questionnaire-based response regarding patient’s sentiments about outpatient clinic with VIC over conventional IC. The opinions of anesthesiologists before and after the VIC introduction extracted from the submitted questionnaires. IC, informed consent; VIC, videos for informed consent

Discussion

We first present the background, rationale, and educational and institutional aspects of VIC implementation, building toward the discussion of time efficiency and operational sustainability, which represent the central focus of this study.

Background and institutional rationale for VIC implementation

The joint statement issued by the World Health Professions Alliance in 2008 emphasized the need to continuously evaluate the impact of task shifting on healthcare quality and efficiency [6]. In this study, we implemented the VIC system as a task-shifting intervention in anesthetic care. The primary aim was not to reduce costs but to optimize workflow and ensure that all legally required elements of IC—outlined under Japanese law—were delivered consistently and comprehensibly. Our findings demonstrated that VIC improved efficiency, preserved intraoperative continuity, and enhanced patient safety, without compromising the legal or ethical standards of IC. As such, VIC should be regarded as a supportive tool for standardized, patient-centered communication that aligns with institutional accountability and global strategies for sustainable healthcare delivery.

Limitations of conventional consent and advantages of VIC

Previous studies have demonstrated multiple shortcomings of conventional IC processes. These include variability in explanation quality depending on the physician, inconsistent inclusion of legally required elements, and reliance on subjective patient satisfaction as an outcome measure [4, 7–10]. Many interventions lack standardization and fail to quantitatively assess improvements in workflow efficiency or institutional burden. A recent Cochrane review further emphasized that shared decision-making tools often fail to address the structural and legal adequacy of the consent process, particularly in time-constrained clinical environments [11]. In our study, the VIC model provided a standardized, legally vetted explanation that addressed these limitations. The VIC ensured delivery of uniform content—including the nature and purpose of anesthesia, associated risks, and institutional protocols—to all patients, thereby reducing provider-dependent variability and minimizing the risk of legal insufficiency. This approach not only enhanced the clarity and completeness of patient education but also contributed to institutional accountability by meeting legal standards for disclosure across all cases. In addition to these legal and procedural benefits, the VIC system demonstrated operational advantages. VIC significantly reduced the explanation time in our outpatient clinic compared to conventional IC, while maintaining high levels of patient comprehension. Approximately 94% of patients reported adequate understanding of the IC content, and 96% understood the associated anesthetic risks. These findings are consistent with previous reports showing that audiovisual consent formats improve patient understanding, reduce anxiety, and are generally preferred over traditional paper-based approaches [4, 7, 12, 13]. Furthermore, by incorporating video footage of key procedures—including airway management and catheter placement—our VIC provided realistic visualization, ensuring that even unplanned intraoperative interventions were adequately explained in advance. This comprehensive and reproducible format supported not only informed decision-making but also institutional risk management and patient safety initiatives.

Educational implications of task-shifting

In conventional IC workflows, anesthesiology residents were often required to leave the operating room to obtain patient consent. Although this practice ensured that patients received necessary explanations, it disrupts the intraoperative learning environment and compromises the continuity of clinical education. During these absences, a substitute anesthesiologist had to be dispatched to maintain intraoperative care, leading to fragmented communication and potentially reduced quality of supervision for both patients and trainees. Such discontinuity has been associated with increased postoperative complications in other studies examining handover quality in anesthetic care [14]. In contrast, the implementation of VIC eliminated the need for residents to interrupt their operating room duties for consent-related tasks. This allowed anesthesia trainees to remain involved in critical intraoperative decision-making and emergency responses under direct supervision, thereby preserving the quality and continuity of their anesthetic education. The VIC system thus supported not only patient-centered care but also a more structured and uninterrupted clinical learning experience—an aspect of task-shifting that is often underappreciated in evaluations of procedural efficiency. Importantly, anesthesia trainees (board-certification candidates) remained actively engaged in the IC process through their participation in the VIC outpatient rotation. In both IC and VIC models, they were responsible for drafting individualized preoperative evaluation sheets prior to the IC process based on a thorough chart review of the patients undergoing anesthetization. These sheets were subsequently reviewed and approved by supervising anesthesiologists. This structure ensured that anesthesia trainees gained essential experience in preoperative assessment, risk stratification, and patient communication, thereby preserving educational opportunities regardless of task-shifting modifications.

Comparison with previous studies and broader applicability

Our findings are congruent with prior studies demonstrating the efficacy of VIC approaches in other clinical domains. Randomized trials in general surgery [15], endourology [16], and outpatient urologic procedures [12] have reported that audiovisual consent formats improve patient comprehension, alleviate anxiety, and are generally preferred to traditional paper-based methods. However, these studies frequently lacked an explicit focus on institutional workflow optimization or legal standardization.

By extending the VIC approach to the anesthesiology setting and incorporating both operational and regulatory dimensions, our study offers a more comprehensive model that addresses previously unmet needs. The integration of VIC into standard perioperative workflows—and its ongoing use even at present—highlights its practical feasibility and translational relevance. Taken together, these findings support VIC as a scalable and generalizable strategy for enhancing the quality, efficiency, and legal adequacy of informed consent across diverse clinical contexts.

Patient understanding and satisfaction

Despite the inherent subjectivity of patient-reported outcomes, patient understanding and satisfaction remain indispensable metrics in evaluating IC quality. In our study, approximately 94% of the patients who received VIC reported adequate comprehension of the IC content, and 96% understood the anesthetic risks. These findings are consistent with those of prior research showing that video-assisted IC improves patient understanding and is generally preferred over conventional formats [4, 7, 10, 12]. In one study, 78.7% of the participants favored the video-assisted process over the traditional paper-based method, and 96.7% reported an improved understanding of the described procedures [10]. Similarly, VIC formats for elective hand and skin cancer surgeries yielded satisfaction rates above 90%, with most patients reporting enhanced comprehension and willingness to recommend the videos to others [17, 18].

Our VIC format included video footage of anesthesiologists performing real procedures, such as induction, intubation, and central venous catheter insertion—interventions that may not be planned preoperatively but must be explained due to institutional requirements. By presenting realistic visual content, VIC supported patient-centered communication while standardizing the provided information. While our study did not directly assess reading level or surgical experience, prior research has indicated that conventional IC documents often exceed recommended readability thresholds, rendering them difficult to comprehend, particularly for patients undergoing surgery for the first time [19]. The standardized audiovisual format of VIC may help bridge this gap by presenting essential information in a more accessible and patient-friendly manner.

Initial challenges and shifting acceptance of VIC

Implementation of VIC at our institution demonstrated significant challenges. Initially, 35% of the anesthesiologists expressed negative sentiments toward the VIC process. Some reported operational confusion, such as uncertainty regarding the introduction of video content on a tablet device or logistical delays in incorporating VIC into daily routines. Others preferred direct, in-person communication, emphasizing the clinical value of seeing the patient in advance to assess factors, such as IV access difficulty or airway management considerations. These sentiments reflected both habitual practices and professional identity, as many anesthesiologists consider direct patient interaction essential for building trust and tailoring perioperative plans. Nevertheless, these concerns diminished over time. The rate of negative sentiment declined to 26% after 6 months, suggesting increased familiarity and acceptance of the VIC system among staff. After 1 year, the rate of negative sentiment declined to only 4%. This shift was facilitated by departmental training, standardization of procedures, and growing recognition that VIC complemented—rather than replaced—clinical judgment and patient interaction that anesthesiologists value. Thus, although the initial adoption phase required workflow adjustments and cultural adaptation, the long-term trajectory indicated growing support for VIC as a practical and legally robust solution for IC in anesthetic care. In practice, operational challenges, such as tablet handling logistics or uncertainty regarding the best timing to show the video contributed to initial reluctance. Additionally, some anesthesiologists expressed a preference for personally meeting patients before surgery to assess factors, such as vascular access or airway difficulty. While these concerns were valid, they diminished over time as the VIC process became more integrated into routine practice.

Additionally, implementing the VIC system requires initial investment in video production and tablet devices. The total cost depends largely on whether real footage or illustrations are used. Moreover, each institution must ensure that VIC meets national legal standards for IC and obtain approval from the institutional patient safety or risk management department. In our hospital, the Department of Patient Safety supervised the entire development and validation process. Once established, the VIC system can be operated by anesthesiologists and nurses with minimal additional cost, and its framework can be easily adapted for use in other clinical departments.

Time efficiency and operational sustainability

In addition to improving the quality and consistency of IC, the implementation of VIC significantly enhanced time efficiency and clinical sustainability. In our study, the average time required for IC using VIC was significantly shorter than that for conventional methods. These findings align with previous research demonstrating that video-assisted IC formats reduce the time burden on clinicians while maintaining patient comprehension [4, 7, 12, 20]. At our institution, preoperative IC is obtained after hospital admission, typically on the day before surgery. Prior to VIC implementation, anesthesiology residents were often required to leave the operating room to obtain IC from inpatients, disrupting intraoperative supervision and educational continuity. After introducing VIC, all ICs were conducted in the outpatient preoperative clinic by a dedicated anesthesiologist assigned to that role for the day. This system allowed operating room teams to focus solely on intraoperative care, preserving clinical efficiency and minimizing workflow interruptions.

Notably, VIC implementation unintentionally created temporal flexibility in the outpatient workflow. The same anesthesiologist responsible for obtaining IC in the morning was now able to secure discretionary time from around 3:00 PM onward. This newly available time was utilized for conducting postoperative pain rounds for all patients who had undergone surgery the previous day. As illustrated in Additional File 1, this contributed to the formation of a consistent, qualified acute pain team that could oversee both preoperative explanations and postoperative follow-up. This continuity not only enhanced patient-centered care but also promoted sustainable staffing by reducing fragmented tasks and mitigating after-hours workload.

While VIC implementation generated workflow efficiencies and incidental financial benefit, it is important to note that economic outcomes were not a primary focus of this study. Therefore, no formal cost analysis or financial modeling was conducted. Our findings should thus be interpreted within the context of clinical workflow optimization rather than financial performance assessment. Notably, more than 2 years have passed since the implementation of VIC, and it remains in continuous use across our institution. Its integration into routine clinical workflows has been sustained without disruption, underscoring its practical feasibility and value as a standard component of preoperative anesthesia care.

Although VIC facilitates standardized explanations, the IC process remains a collaborative effort. In our institution, nurses in the preoperative consultation clinic support anesthesiologists by helping gather supplemental patient information and verifying critical medical history. This collaborative approach improves efficiency and data completeness while maintaining clear role boundaries: only anesthesiologists are authorized to provide the formal explanation and obtain written IC. This division of responsibility complies with institutional policy and medical-legal standards in Japan. In the conventional IC workflow, coordinating consent acquisition amidst unpredictable surgical schedules often resulted in trainees being pulled away from intraoperative duties, particularly when patients were temporarily unavailable for consent due to preoperative procedures or personal needs. The VIC system eliminated the need for such real-time coordination, enabling smoother scheduling, uninterrupted supervision, and reduced administrative burden for attending anesthesiologists.

Legal validity and standardization benefits of VIC

Our VIC system was developed under the longstanding guidance of our institution’s Department of Patient Safety and legal counsel, with the primary goal of ensuring procedural standardization and legal compliance. The videos incorporated video footage of anesthesiologists performing procedures, such as general and regional anesthesia, intubation, central venous catheter insertion, and transfusion—all interventions that may become necessary during surgery, even if not initially planned. This comprehensive approach reflects our institutional policy that all elective surgical patients must receive explanations for every potential anesthetic intervention and provide consent for transfusion prior to entering the operating room. By replacing variable, time-constrained verbal explanations with a legally validated, visually structured format, VIC ensured that all patients received consistent and complete information aligned with national legal requirements.

In addition to improving standardization and legal defensibility, VIC addressed a practical institutional challenge: the burden of obtaining consent during routine surgical hours. Although cost analyses, such as time-driven activity-based costing (TDABC), were beyond the scope of this study, VIC implementation offered sustainable operational benefits by streamlining consent delivery without compromising ethical or legal standards.

In this context, patient safety refers not to the frequency of complications but to the assurance that every patient receives a standardized, high-quality explanation of anesthetic risks and procedures, regardless of provider experience or communication variability. By guaranteeing uniform and complete disclosure, VIC promotes fairness, transparency, and trust in the IC process, which are essential components of patient safety and satisfaction. Furthermore, the results of this study demonstrated that patient understanding and satisfaction were well maintained, confirming that the quality of informed consent was preserved even as efficiency improved. On the provider side, VIC enabled anesthesiology trainees to remain in the operating room, while outpatient VIC teams successfully managed all consent cases, indicating a measurable improvement in workflow efficiency and human resource utilization.

Beyond these operational and legal benefits, VIC is not intended to replace the moral responsibility of anesthesiologists toward their patients. Maintaining empathy, understanding, and patient trust remains a fundamental duty that transcends efficiency. The time saved through VIC should not diminish human interaction but rather enable anesthesiologists to devote that time to more meaningful communication and shared decision-making.

Study limitations

This study had certain limitations. First, its single-center design limits the generalizability of the findings. Future studies should include multiple centers with diverse institutional structures to assess broader applicability. Additionally, because workflow structures and the delegation of anesthesiologists differ across healthcare systems—particularly outside Japan—the generalizability of the observed time-saving effects should be interpreted within the context of local organizational and cultural practices. Second, the retrospective nature of the study, although sufficient to provide preliminary insights, may introduce selection or information bias. A prospective randomized controlled trial with blinded outcome assessment and multicenter design is necessary to confirm our findings. Third, the non-concurrent comparison periods (January–April for conventional IC and May–October for VIC) may have introduced secular or seasonal biases. Although no institutional, staffing, or policy changes occurred during this time, we cannot exclude the possibility that patient attitudes or clinical workflow were subtly affected by temporal factors. Other limitations include the absence of data on how many times patients replayed the video and the lack of adjustment for potential confounding variables, such as age, educational background, or prior anesthetic experience.

Because the patient questionnaire was administered only after VIC introduction, comparable pre-VIC data were unavailable. Conventional IC consisted of direct verbal explanations generally regarded as sufficient; however, direct comparison with VIC was not feasible because the same patients could not experience both methods.

Importantly, the replacement of conventional verbal explanations with video-based consent was not intended to compromise ethical or legal standards. On the contrary, the VIC script was developed based on the same hospital-approved IC documents used in conventional practice, with input from the Department of Patient Safety and legal counsel. This ensured that all legally mandated elements—such as the nature and purpose of anesthesia, risks and alternatives, and institutional safety policies—were fully covered. Thus, the time savings observed with VIC were achieved without reducing the legal or informational integrity of the IC process. Importantly, while our institution mandates a uniform explanation of all major anesthetic procedures regardless of the ASA classification or surgical specialty, certain subgroups—such as patients undergoing highly complex procedures or those with significant comorbidities—may benefit more from personalized, face-to-face interaction.

Although subgroup analysis was not feasible in this study due to uniform IC protocols, future research should explore whether tailoring VIC content or delivery based on patient characteristics improves outcomes such as satisfaction, comprehension, and trust. Additionally, incorporating frameworks such as Time Driven Activity Based Costing (TDABC) may help evaluate the broader institutional impact and economic sustainability of VIC implementation. This study did not include a formal assessment of patient anxiety, such as through using validated instruments, including the State-Trait Anxiety Inventory (STAI). Although VIC was designed to improve patient understanding and streamline the consent process, its psychological impact—particularly on perioperative anxiety—was not quantitatively measured. Future studies incorporating anxiety assessment tools such as the STAI could provide further insight into the emotional and cognitive benefits of video-assisted IC [12].

Future directions and legal integrity of VIC

IC is not merely a procedural formality, but a legally and ethically grounded process intended to protect patient autonomy and ensure shared decision-making. As outlined in Table 1, the IC process must include all core components—such as the nature and purpose of anesthesia, foreseeable risks and complications, available alternatives, expected outcomes, and institutional safety policies. The omission of any of these elements undermines the legitimacy of consent and may have legal ramifications under Japanese law. VIC was designed not to replace face-to-face interaction but to standardize and augment the quality of the explanation provided during that interaction.

Therefore, it is essential to underscore that VIC alone—without subsequent physician-patient dialogue—does not constitute valid IC in the context of current Japanese legal and ethical standards. The video serves as a preparatory tool that promotes patient comprehension and enables more meaningful conversations during the actual consent encounter. This two-step approach helps prevent variability in explanation quality and ensures that patients are fully informed prior to anesthesia.

As VIC systems gain wider adoption, institutions must be cautious to ensure that these tools are not employed in isolation. Instead, they should be integrated into a structured clinical pathway that guarantees both legal compliance and patient safety. At our hospital, VIC has already been expanded beyond anesthesiology to other specialties, and similar approaches could potentially support digital task-shifting in areas such as admission guidance and ward orientation. Future studies should explore best practices for integrating VIC with face-to-face consultation workflows and evaluate outcomes such as patient trust, anxiety, long-term satisfaction, and clinical parameters, including postoperative pain control, length of stay, and opioid consumption. Ultimately, VIC should be recognized as a legally sound, ethically robust, and patient-centered adjunct—not a substitute—for comprehensive IC. Moreover, while VIC can be adapted to other clinical settings and institutions, its implementation must always comply with each country’s legal and ethical regulations. Equally important, the irreplaceable value of human empathy, trust, and real-time communication should always be preserved in every patient interaction.

Conclusions

In this study, VIC implementation effectively facilitated task-shifting among anesthesiologists, without compromising the quality or legal integrity of the IC process. VIC enabled the delivery of consistent, standardized explanations while reducing the need for anesthesiologists to leave the operating room, thereby preserving intraoperative continuity and enhancing trainee supervision. By eliminating the need for complex scheduling and real-time bedside ICs, VIC reduced workflow disruptions and alleviated the managerial burden on attending anesthesiologists. Importantly, patient comprehension and satisfaction were maintained at high levels throughout the transition. The majority of the anesthesiologists reported positive experiences and favored continued use of VIC. These findings suggest that VIC is a broadly applicable and sustainable tool that enhances both provider efficiency and patient-centered communication in diverse clinical settings.

Abbreviations

VIC

videos for informed consent

IC

Informed consent

TDABC

time-driven activity-based costing

STAI

State-Trait Anxiety Inventory

Authors’ contributions

AH, AS, and TT helped in study conception and design, material preparation, data collection and analysis, and writing the first draft of the manuscript. FK, being a lawyer working in the patient safety department, determined whether the VIC could be used as an alternative to paper documents and physician explanations based on Japanese law. HY, MK, TU, and YN (physicians affiliated with the Patient Safety Department) discussed and approved the content of the VIC, determining whether it could be used as a substitute for paper documentation and physician explanations. KN helped in study conception and design and supervised the study. All authors read and approved the final manuscript.

Funding

The authors declare no funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study conformed to the standards of the Declaration of Helsinki and was approved by the Ethics Committee of the Nagoya University Hospital (approval number: 2023 − 0491, the study period: April 9, 2024, to December 31, 2025).

Consent for publication

We declare “Not applicable”. Only anonymized data was used in this paper, and no personally identifiable data was included.

Competing interests

The authors declare no competing interests.