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Patient perception regarding preoperative information to anxiety towards surgery.

INTRODUCTION: Anxiety is a constant motivating aspect in life that can warn people when their wellbeing is threatened. It can be a reply to or a cause of tension. Anxiety due to hospital organization leads to imbalances in homeostasis which elicit a physiological & psychological response that can compromise recovery. Anxiety is the uneasiness and apprehension the patient feels without being able to identify the precise cause. [1]

Preoperative anxiety is derived from pressure perceived due to threat and risk related to the hospital environment. The incidence of preoperative anxiety reaches up to the level of 92% among patients in surgical wards. [2] Patients having preoperative anxiety were reported to practice a variety of unpleasant symptoms such as postoperative pain & distress. High level of preoperative anxiety obstructs healing process and it is associated with morbidity and mortality. [3]

Preoperative teaching is a vital aspect during before surgery. Preoperative teaching facilitates coping by enhancing the sense of self-respect and psychological well-being of patients. 78% of surgical patients had reported the effectiveness of preoperative teaching in reducing anxiety. [4]

Studies showed that psychological preparation could not accomplish everything. However psychological relaxation techniques such as distraction and imagery have significantly reduced the anxiety level. [5]

The degree to which each patient manifests anxiety related to future experiences depends on many factors as age, gender, type and extent of surgery, and previous surgical experience.^ Thus this paper evaluates the perception of patients regarding anxiety prior to surgery according to different factors.

METHODS: The study was conducted from February to May 2015 among 273 patients attending the outpatient department of Hospital, Bilaspur. Out of total subjects 105 were males and 168 were females. The study sample was selected by simple random sampling technique. Ethical clearance was obtained from the Head of the Institute. All the patients were aged 20-60 years. Patients who declined to give informed consent and who were suffering from any anxiety disorders were excluded from the study.

The demographic information was obtained as age, gender, educational status, history regarding previous surgery. A self-structured questionnaire was used to measure the level of anxiety. It was administered in both Hindi and English language and all the patients filled the forms in the waiting hall. Those patients who were uneducated and were unable to read were helped by investigator. The anxiety was measured by means of 11 different questions like fear of surgery, pain due to surgery, postoperative complication, preoperative information of surgery etc.

DATA ANALYSIS: The data were analyzed using number-percentage distributions, averages, Student's t-test, one-way ANOVA was performed to obtain the mean values of anxiety using SPSS 16.0 for Windows. Step-wise multiple linear regression analysis was used to assess the independent variables that significantly influenced the variance in the dependent variables (Anxiety). The p value of 0.05 considered as statistically significant.

RESULTS: All the 273 participants were was divided into four groups according to their educational level: illiterate; up to primary education; graduation; and post-graduation. Similarly age was divided into four groups as follows: 20 to 30 years; 31 to 40 years; 41 to 50 years; and 51 to 60 years.

It was found that all of the patients received preoperative information about the surgery to be done and most of them obtained information from doctors (27.6%). Hospital management staff also informed the patients regarding surgry (24.3%), followed by nurses (22.5%), family members(12.6%) and anesthetist (9.8%). Very few patients got information about their procedure from the internet (3.2%) (Graph 1).

Graph 2 showed that fear of surgery (18.6%) and pain (17.4%) are most common factors among study participants. Some cases were insequre of post operative complications(14.6%), 13.8% think that being in hospital during treatment is a major headache. 12.3% thaink that they will get weakness after surgery. Less number of participants were having the fear of anesthesia(3.5%).

The study showed that female patients were significantly more anoxious during treatment as compared to male patients (p=0.000) as mentioned in Table 1. Educational level showed a significant corelation with anxiety; with upgrading of education the anxiety scores were lowering (Table 2). But the results were opposite in relation of age, showing that almost the anxiet level was increasing with advancing age as illustrated in Table 3.

It presents a step-wise multiple linear regression analysis in which the dependent variables was Anxiety level. The anxiety level showed significant association with all independent variables as educational level, sex and age in descending order (Table 4).

DISCUSSION: The reported incidence of preoperative anxiety in many studies ranges from 60% to 92% among surgical patients. [2,7] The anxiety level of subjects was examined by gender, and female participants were found to be higher than males with significant differences. This consequence is consistent with other studies conducted in different countries showed females have more anxiety of surgery than males. [8,9] Egbert et al showed that on an average, 57% of patients felt anxious before operation and female patients were more likely to be anxious. [10] However, the results of study conducted by Ozdemir et al showed higher anxiety and fear level among males. [11]

The present data showed that the anxiety level was almost increasing with advancing age, older patients were more anxious than younger ones. Locker et al also showed same results that the values were higher in older ages. [12] Similar results were seen by Arslan and Erten in their study in 2009. [13] However some studies reported lower anxiety values at 55 years of age and over. [14,15]

The study also demonstrated the relationship of education status with anxiety and found that significantly more educated patients were having not as much of fear of treatment than less educated. Spielberger et al, also mentioned same relationship between patients and reported that patients with higher levels of education have developed efficient skills in reducing stress. [16] Similarly, Doerr et al & Elter et al mentioned that as the education increased, anxiety diminished [14,15] Whereas, a study done by Gorgun et al. found that the highest level of anxiety was in those who had postgraduate education. [17] Some researchers did not reveal any relationship between anxiety of surgery and education. [9,18]

This consequence may indicate that those with a low level of education have insufficient information about the treatment and those with a high level of education have too much information before the treatment. So, it may be advisable to give general explanations to patients before any operation without going into too much detail.

Patients should use relaxation and breathing techniques that successfully reduce the fear of receiving treatments. A common method is Jacobsen's progressive muscular relaxation is used, which relaxes patients by reducing muscle tension, and makes them more aware of their stress. Their greater feeling of control over the situation and over their anxiety symptoms should translate into greater ability in coping with the stress of dental treatment. A simple scheme for progressive muscular relaxation involves tensing and relaxing groups of muscles in turn, for example from the feet through the lower body and abdomen to the thorax and then the head and neck. [19]

In the present study, most of the subjects were anxious of surgery and post-operative pain. However in some studies patients were mostly afraid of equipment and instruments were found in 38% of the sample but only 8.5% reported high fear. These results are within the range reported by previous studies. [20,21]

The present study found that all of the patients received preoperative information about the surgery to be done and most of them obtained information from doctors (27.6%), hospital management staff (24.3%) and nurses (22.5%). However, Kelly et al mentioned that 97.5% (N=78) of the patients agreed that they received preoperative information but only 10% (N=8) noted receiving the information from the nurses. 1.3% claimed that details of operation theatre were inadequately told and another 3.8% claimed that details of surgical procedure were insufficiently provided. [5]

CONCLUSION: The results revealed that all the patients got information prior to the surgery and main source of information were doctors, hospital management staff and nurses. Mostly patients were anxious of surgery and post-operative pain.

Female patients were having more anxiety that males and their anxiety level was increasing with age and decreasing with education. Still, health professionals should plan and implement correct and appropriate procedures to help patients against this fear.

DOI: 10.14260/jemds/2015/1281


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[2.] Perks A, Chakravarthi S, Manninen P. Preoperative anxiety in neurosurgical patients. Neurosurg Anesthesiol 2009; 21: 127-30.

[3.] Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE & McClain BC. Preoperative anxiety, postoperative pain, and behavioural recovery in young children undergoing surgery. Pediatrics 2006; 118: 651-8.

[4.] Chetty M & Ehlers VJ. Orthopaedic patients' perceptions about their preoperative information. Curationis 2009; 32: 55-60.

[5.] Kelly Ee Lu Ting, Maria SauSim Ng, Wei Fern Siew. Patient perception about preoperative information to allay anxiety towards major surgery. IeJSME 2013; 7(1): 29-32.

[6.] Ping G, Linda E, Antony A. A preoperative education intervention to reduce anxiety and improve recovery among Chinese cardiac patients: a randomized controlled trial. Int J Nurs Stud 2012, 49(2):129-137.

[7.] Frazier SK, Moser DK, Daley LK, McKinley S, Riegel B, Garvin BJ, An K: Critical cre nurses' beliefs about and reported management of anxiety. Am J Crit Care 2003; 12(1):19-27.

[8.] Koroglu A, Durkan R. Evaluation of treatment methods and dental anxiety syndrome serologic in practice of dentistry. Ataturk University Faculty of Dentistry Journal 2010; 20: 205-12.

[9.] Gonzalez-Lemonnier S, Bovaira-Forner M, Penarrocha-Diago M, Penarrocha-Oltra D. Relationship between preoperative anxiety and postoperative satisfaction in dental implant surgery with intravenous conscious sedation. Med Oral Patol Oral Cir Bucal 2010; 15: 379-82.

[10.] Egbert LD, Battit GE, Tumdorf H, Beecher HK. The value of the preoperative visit by the Anaesthetist. JAMA 1963; 185: 553.

[11.] Ozdemir AK, Ozdemir HD, Coskun A, Tasveren S. Investigation of a patient's anxiety in other clinics with denture clinic in faculty of dentistry. Cumhuriyet University Faculty of Dentistry Journal 2001; 4: 71-4.

[12.] Locker D, Lidell A, Burman D. Dental fear and anxiety in older adult population. Community Dent Oral Epidemiol 1991; 19: 120-4.

[13.] Arslan ZZ, Erten H. Dental fear and anxiety. Journal of Hacettepe Faculty of Dentistry 2009; 33: 62-8.

[14.] Doerr PA, Lang P, Nyquist LV, Ronis DL. Factors associated with dental anxiety. J Am Dent Assoc 1998; 129: 1111-9.

[15.] Elter JR, Strauss, RP, Beck JD. Assessing dental anxiety, dental care use and oral status in older adults. J Am Dent Assoc 1997; 128: 591-7.

[16.] Spielberger CD, Gorsuch RL, Lushene RE. STAI Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, USA: Consulting Psychologists Press; 1970.

[17.] Gorgun S, Yazioglu B, Oztas B. Determination of scale dental anxiety in patients admitted to Ankara University Faculty of Dentistry. Ataturk University Faculty of Dentistry Journal 1993; 20: 217-22.

[18.] Ragnarsson E. Dental fear and anxiety in an adult Icelandic population. Acta Odontol Scand 1998; 56: 100-4.

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[21.] Eli I, Uziel N, Blumensohn R, Baht R. Modulation of dental anxiety-the role of past experiences, psychopathologic traits and individual attachment patterns. Br Dent J 2004; 196: 689-94.

Devpriya Lakra (1), Shanti Prakash Kujur (2)


(1.) Devpriya Lakra

(2.) Shanti Prakash Kujur


(1.) Associate Professor, Department of Medicine, Jawaharlal Nehru Medical College, Raipur, Chhattisgarh.

(2.) Associate Professor, Department of General Surgery, Chhattisgarh Institute of Medical Sciences, Bilaspur. Chhattisgarh.



Dr. Devpriya Lakra, Associate Professor, Department of Medicine, Jawaharlal Nehru Medical College, Raipur, Chhattisgarh.


Date of Submission: 16/06/2015.

Date of Peer Review: 17/06/2015.

Date of Acceptance: 19/06/2015.

Date of Publishing: 23/06/2015.
Table 1: Showing mean scores of anxiety according to gender

SEX         No    Mean    Std. Deviation     Sig.

Males      105    6.10         1.121        0.000
Females    168    6.60         .752

Table 2: Showing mean scores of anxiety according to education status

Education           No    Mean    Std. Deviation       F       Sig.

Illiterate          63    7.50         .475         137.281    .000
Primary             91    7.00         .711         366.079    .000
Graduation          84    6.00         .711         404.289    .000
Post-graduation     35    5.33         .506          3.777     .024
Total              273    6.38         1.005

Table 3: Showing mean scores of anxiety according to age

Age       No    Mean    Std. Deviation       F       Sig.

20-30     42    5.67         .506         148.821    .000
31-40     63    5.50         .475         323.349    .000
41-50     80    6.25         .834         394.251    .000
51-60     88    6.50         .503          26.106    .000
Total    273    6.29         1.005

Table 4: Step wise multiple linear regression analysis with Anxiety
level as a dependent variable

Model        R         R Square     Adjusted    Std. Error
                                    R Square      of the

1         .771(a)        .594         .592         .642
2         .786(b)        .618         .615         .623
3         .790(c)        .625         .620         .619

a. Predictors:(Constant), Education.

b. Predictors:(Constant), Education, sex.

c. Predictors:(Constant), Education, sex, Age.

Graph 1: Frequency of obtaining preoperative
instructions from different sources

Doctors                   27.60%
Nurses                    22.50%
Anesthetist                9.80%
Internet                   3.20%
Hospital management       24.30%
Family members            12.60%

Note: Table made from bar graph.

Graph 2: Frequency of fear among patients due to
different factors

Weakness                          12.30%
Work loss                          5.60%
Finicial Loss                      6.70%
Being in hospital                 13.80%
Post operative complication       14.60%
Anesthesia                         3.50%
Diff environment of hospital       7.50%
Pain                              17.40%
Surgery                           18.60%

Note: Table made from bar graph.
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Author:Lakra, Devpriya; Kujur, Shanti Prakash
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jun 25, 2015
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