ABSTRACT
Objective
Surgical fear, which is common before abdominal surgery, adversely affects postoperative recovery and prolongs hospital stay. This study was conducted to determine the effect of preoperative fear level on recovery after abdominal surgery. This study employed a prospective, correlational design.
Methods
The researcher conducted the study involving 200 patients undergoing abdominal surgery. Data were collected using the patient information form, Surgical Fear Questionnaire, and postoperative recovery index.
Results
The mean preoperative total surgical score among patients was 27.22±22.73. Analyses of univariate linear regression models found that fear of surgery complicates patients’ postoperative recovery [(T1, β=0.234; p=0.001; R2=0.055); (T2, β=0.195; p=0.006; R2=0.038)].
Conclusion
The study showed that preoperative fear of abdominal surgery increased patients’ difficulty during postoperative recovery.
INTRODUCTION
Emergency or elective abdominal surgery constitutes a controlled trauma that affects patients both physiologically and psychologically. Despite advances in technology and surgical techniques, patients undergoing surgery today may experience problems such as fear of pain and anesthesia, separation from family, and interventions that alter body image, which can lead to fear of surgery (1-4). In patients undergoing abdominal surgery, Factors that may cause fear of surgery—unlike in other types of surgery—include the possibility of impairing the functions of vital organs, such as digestion and excretion, and concern that abdominal pain will restrict movement. Surgical fear is defined as the excessive fear experienced by a person anticipating surgical interventions (5). This condition, which varies from patient to patient, may negatively affect patient outcomes during and after surgery (6). Studies have reported that preoperative fear negatively affects the patient’s recovery, increases the use of anesthetic drugs during surgery, and causes surgical complications (5, 7). In addition, surgical fear may lead to increased postoperative pain, delayed wound healing, and increased need for analgesics. It may prolong hospital stays and adversely affect recovery (8, 9). In the preoperative period, each patient should be carefully evaluated for surgical anxiety, and postoperative recovery should be supported by nursing care tailored to the patient’s needs (10). Delayed recovery is associated with problems such as delayed return to home and work activities, difficulty moving, fatigue, the belief that more time is needed for recovery, loss of appetite, nausea, and pain (10, 11). The majority of studies on anesthesia and postoperative recovery have focused on physiological parameters, recovery time, and rates of adverse outcomes, including serious complications and mortality. It has been emphasized in the literature that fear of surgery negatively affects postoperative recovery (1, 8, 11, 12). Unlike other studies, it aimed to answer how fear-induced stress before abdominal surgery would affect the patient and their recovery. We aimed to evaluate the effect of preoperative fear on postoperative recovery.
METHODS
Study Design, Population, and Sample Size
The study was conducted the general surgery departments of a training and research hospital in Türkiye from March to August 2024. This study employed a descriptive, relational design. The population comprised patients undergoing abdominal surgery in the general surgery department of a training and research hospital in Türkiye from March to August 2024. The sample size was determined to be 196 patients using G*Power 3.1, with a margin of error of 0.05, an 80% confidence level, and a power of 80%. A total of 205 patients who met the inclusion criteria were enrolled to account for potential withdrawals or exclusions during the study. During data collection, two patients had previously used antipsychotic and antidepressant drugs, two had speech problems and one refused to participate; therefore, the study was completed with 200 patients. This study addressed the following questions.
Study Inclusion Criteria
Participants aged 18-70 years who underwent elective abdominal surgery (appendectomy, cholecystectomy, total gastrectomy, hemicolectomy) and had no hearing or speech problems impairing communication or psychiatric illness were included.
Exclusion Criteria
Patients with psychiatric disorders who underwent emergency surgery were excluded from the study.
Instruments
Research data were collected using the patient identification form, the Surgical Fear Questionnaire (SFQ), and the postoperative recovery index (PoRI).
Patient Identification Form
The researcher developed the patient information form based on data from the literature (1, 2, 13). It consists of 11 questions assessing age, gender, education, profession, marital status, type of surgery, previous hospitalizations, previous surgeries, chronic diseases, preoperative pain, and current medications.
Surgical Fear Questionnaire
Theunissen and colleagues designed this scale to examine levels of surgical fear in patients undergoing surgery. The original scale’s Cronbach’s alpha was 0.87 (14). Construct validity and internal consistency for Turkish were assessed by Bağdigen and Karaman Özlü (15). It is a Likert-type scale consisting of eight items. The questionnaire is scored on a scale from 0 to 10 (0=not at all; 10=very afraid). Scores range from 0 to 80, depending on the patient’s level of fear. A higher score indicates a higher level of fear. The Cronbach’s alpha coefficient for the adapted scale is 0.93 (15). In this study, Cronbach’s alpha was determined to be 0.98.
Postoperative Recovery Index
The PoRI, whose validity and reliability were tested by Butler et al. (16) in 2012, consists of five subdimensions: psychological symptoms, physical activities, general symptoms, bowel symptoms, and appetite symptoms. Scores for items included in each subdimension are summed, averaged, and used to determine their subdimension scores. The statistical validity and reliability of the Turkish adaptation of PoRI were assessed by Cengiz and Aygin (17). The scale consists of 25 items. Items 1-4 of the scale include psychological symptoms; items 5-12 include physical symptoms; and items 13-25 include general symptoms, bowel symptoms, and desire symptom (17). High scores on the scale indicate difficult postoperative recovery, whereas low scores indicate easier postoperative recovery. Cronbach’s alpha reliability coefficient was calculated as α=0.967.
In this study, Cronbach’s alpha (α) values for the total PoRI score at the first and second postoperative evaluations were 0.932 and 0.935, respectively.
Ethical Considerations
Ethics committee approval was obtained prior to data collection from İstanbul Atlas University Non-Interventional Scientific Research Ethics Committee (approval no: 02/08, date: 08.02.2024). Before surgery, patients were provided with necessary explanations about the study. Both verbal and written consent were obtained. This scientific study was completed in accordance with the Declaration of Helsinki.
Data Collection
Before surgery, the researcher administered the patient identification form (SFQ) to the patients. Postoperatively, PoRI was administered to evaluate both early and late recovery outcomes. The scale was administered face-to-face by the researcher on postoperative day 2 to evaluate early recovery, and once by phone between postoperative days 15 and 30 to evaluate late recovery. All patients were given research information and informed that they could withdraw from the study at any time. Data entry was performed by a researcher not involved in data collection.
Statistical Analysis
SPSS 27.0 was used to analyze the data. Normality was assessed using the skewness and kurtosis coefficients, which ranged from -1.5 to +1.5. Categorical data are presented as frequencies and percentages, and continuous data are presented as means and standard deviations. Independent-samples t-tests were used for two-group comparisons, one-way analysis of variance was used for more than two groups, paired t-tests were used for repeated measures, and Pearson correlation analysis was used for inter-variable relationships. The effect of fear of surgery on postoperative recovery was examined using linear regression analysis.
RESULTS
The mean age of patients in the study was 53.75±12.35 years. Of the participants, 55.5% were female, 81% were married, 60% were high school graduates, and 44.5% had chronic diseases. 62% of participants had prior surgical experience, and 137 (68.5%) had been hospitalized for at least one day. No statistically significant differences were found in mean PoRI scores among patients according to their descriptive characteristics (p>0.05). Female patients (t=2.225; p=0.027) and patients with no previous hospitalization experience (t=2.653; p=0.009) had significantly higher levels of surgical fear (Table 1).
A statistically significant positive correlation was found between the patients’ PoRI level and their total [(T1, r=0.234; p=0.001); (T2, r=0.195; p=0.006)], short-term [(T1, r=0.222; p=0.002); (T2, r=0.186; p=0.008)], and long-term [(T1, r=0.242; p=0.001); (T2, r=0.202; p=0.004)] surgical fear levels. A statistically significant positive correlation was found between the patients’ PoRI levels and their long-term surgical fear levels. A statistically significant but weak positive correlation was observed between patients’ level of surgical fear and the PoRI (Table 2).
The patients’ PoRI scores had a mean of 2.88±0.55 (range, 1.3-4.2) at the first measurement and 1.74±0.43 (range, 1-3) at the second measurement. A statistically significant improvement of approximately 39.6% in patients’ postoperative recovery difficulty was observed at the second measurement compared with the first (t=39.468; p<0.001). Findings for the PORI subscales paralleled those obtained from the total scale score (Table 3). According to the results of the univariate linear regression analysis, preoperative surgical fear increased the level of difficulty experienced by patients during postoperative recovery (T1: β=0.234; p=0.001; R2=0.055; T2: β=0.195; p=0.006; R2=0.038). When subgroup analyses were examined, surgical fear was identified as causing the greatest difficulty experienced by patients in recovery with respect to psychological symptoms [(T1, β=0.273; p<0.001; R2=0.074); (T2, β=0.307; p<0.001; R2=0.094)] (Table 4).
DISCUSSION
Multiple reasons underlie patients’ fear of surgery, which often begins when they decide to undergo the procedure. These reasons include anticipation of surgery, risks of surgery, fear of disability, fear of pain, distorted body image, and previous surgical experiences. Fear of surgery leads to postoperative morbidity and prolonged hospital stay, which negatively impact postoperative recovery (18). Postoperative recovery is defined as patient-centered care aimed at improving an individual’s quality of life. Therefore, surgical fear and its impact on postoperative recovery should be considered fundamental factors in the care of patients undergoing surgery (19).
The findings of this study indicate that pre-surgery fear levels were not elevated. Based on the average scores obtained from the scale, patients exhibited low levels of fear. This may be attributed to differences in levels of surgical fear according to the extent of the surgical procedure. When the literature was reviewed, no studies were found investigating the level of surgical fear among patients undergoing abdominal surgery. Kapıkıran et al. (20) reported moderate levels of surgical fear among patients undergoing gastrectomy, cholecystectomy, hepatectomy, and excision of liver cysts. The results differ from those reported in this study. The sociodemographic characteristics of the patients in the sample group differed. Scientific studies conducted with various sample groups using the same scale have also found surgical fear scores similar to those in this study (19, 21-24). Taylan and Çelik (5) highlighted surgical fear scores among patients undergoing cataract surgery. A study of patients undergoing urological surgery found that their levels of surgical fear were low (7).
Despite advancements in technology, surgical fear remains a significant problem. Surgical fear varies according to the patient’s personality, age, gender, type of anesthesia, previous surgical experience, extent of surgery, and sociocultural factors (1, 23, 25-28). In this study, levels of surgical fear in women were found to be significantly higher than those in men (p<0.05). In previous studies, preoperative surgical fear was found to be higher in women, similar to this study (1, 3, 7, 19, 24, 25, 27). This result is consistent with the literature. Biochemical changes in estrogen and progesterone hormones in women can cause women to become more sensitive and have difficulty coping with stress (29). Because they are more sensitive and emotional, they experience surgical fear when away from their loved ones and families and when anxious about not being able to return to their roles in the family. Patients’ experiences in the preoperative period are also among the factors affecting surgical fear. In the relevant study, higher levels of surgical fear were found among patients without prior hospitalization. No study in the literature has investigated the surgical fear scores of patients who underwent abdominal surgery and were hospitalized. However, studies of patients undergoing elective surgery found high levels of surgical fear among those with no prior hospital experience, as observed in this study (27, 29).
The postoperative recovery process begins when the patient decides to undergo surgery. Postoperative recovery is a process involving physical, psychological, and social dimensions. Fear of surgery heightens the body’s stress response, leading to elevated levels of hormones such as cortisol and adrenaline and rendering the individual more psychologically vulnerable. The results of this study showed that the higher the patients’ preoperative surgical fear levels, the more difficult it was for them to recover after surgery. Similarly, Gümüs (11) investigated fear of surgery in 80 patients who underwent abdominal surgery and emphasized that recovery quality was lower in patients with high anxiety levels than in patients with lower anxiety levels.
Surgical fear, which affects psychological well-being, may impair postoperative recovery and delay the healing process. A scientific study has shown that fear of surgery causes delayed recovery due to psychological symptoms. A study evaluating the effect of anxiety levels on the quality of recovery in patients undergoing abdominal surgery emphasized that anxiety and recovery quality should be investigated (11). The postoperative recovery status of patients who underwent elective major surgery in the general surgery, orthopedics, and traumatology clinics was evaluated, and these patients experienced substantial difficulty in their postoperative recovery (30). A study using a different sample group showed that preoperative patient anxiety negatively affected the emotional-state dimension of the quality of recovery three days after surgery (12). A patient-centered approach for patients undergoing surgical intervention may accelerate postoperative recovery and reduce the fear and anxiety they experience.
Study Limitations
Given these limitations, this study was conducted among patients undergoing abdominal surgery in the general surgery department at a single hospital. Therefore, future multicenter studies including patients undergoing major abdominal surgery may be important to increase the generalizability of the findings.
CONCLUSION
The results indicate that preoperative fear of abdominal surgery increases the difficulty experienced by patients during postoperative recovery.
Future research should focus on developing effective nursing care to reduce patients’ fear prior to abdominal surgery. Possible causes of preoperative fear should be identified and addressed, and measures should be taken to improve patients’ psychological state.
