Table 2.

Patient feedback and item modifications from the first round of cognitive interviews.

Original items	Patient feedback	Item modifications	Modified items
Overall assessment of PREMs	① One patient (1-p6) remarked that the inclusion of temporal qualifiers (e.g., “during your admission”) across multiple items increased the cognitive load by requiring them to recall and verify the accuracy of time periods. This patient further noted that numerous items with similar content were distinguished only by time frames, suggesting the consolidation of such items to reduce respondent burden. ② Three patients (1-p5, 1-p8 and 1-p12) identified substantial item redundancy in the scale, recommending that semantically overlapping items be merged or removed.	Regarding the recommendation to remove temporal specifications, the expert panel concluded that deleting time qualifiers and consolidating identical items was methodologically justified. The consolidated item would assess patients' experiences throughout the surgical procedure, as response options were anchored to the frequency of occurrence. This approach permits holistic evaluation of the care continuum. Regarding item redundancy, the panel agreed that eliminating duplicative items would enhance the scale's discriminant validity, thereby streamlining the scale without compromising conceptual coverage.	Remove temporal qualifiers from the items; consolidate or eliminate semantically overlapping items.
R1-3. Operating theatre nursing staff maintained a neat and pretty appearance.	① Conceptual Ambiguity: Five patients (1-p2, 1-p3, 1-p4, 1-p5 and 1-p7) expressed concerns regarding the term “pretty appearance,” citing ambiguous evaluation criteria and explicitly asking “what constitutes the threshold for acceptable pretty appearance?” ② Content relevance: Three patients (1-p3, 1-p7 and 1-p11) questioned the item's clinical salience, stating that the appearance of nursing staff was a low-priority concern provided clinical dress code compliance was maintained.	Following panel deliberation, it was concluded that patients' primary concern regarding the appearance of nursing staff within the surgical context centred on adherence to professional dress codes. Consequently, the original descriptor “neat and pretty appearance” was revised to “adherence to professional dress codes.”	R2-3. Operating theatre nursing staff adhered to professional dress codes.
R1-4. Nursing staff provided detailed explanations of personnel, environment, surgical procedures, and relevant precautions during preoperative visits.	① Item interpretation: Four patients (1-p4, 1-p5, 1-p9 and 1-p10) contended that explanations of surgical process should be provided throughout the perioperative period, not solely during preoperative visits. They interpreted the item's wording as implying that such communication was exclusively required preoperatively, potentially neglecting intraoperative and postoperative education. ② Cultural context relevance: Five patients (1-p2, 1-p3, 1-p4, 1-p6 and 1-p10) emphasised familial inclusion in surgical communication, noting that within China's healthcare paradigm, (a) preoperative preparations often require family participation, and (b) intraoperative protocol modifications necessitate surgeon-family discussions to ensure informed comprehension.	Following panel deliberation, it was agreed that surgical process education should take place across all perioperative phases, with nurses providing phase-specific explanations. Consequently, temporal descriptors were eliminated to expand the item's applicability to the entire surgical journey, and the phase “to you/your family” was added.	R2-4. Nursing staff provided comprehensive explanations to you/your family regarding personnel, environment, surgical procedures and precautions.
R1-5. Did nursing staff provide psychological support and reassurance during your preoperative visit?	① Item redundancy: Five patients (1-p2, 1-p4, 1-p5, 1-p6 and 1-p7) identified substantial content overlap between these items and R1-20, noting that all aimed to assess nurses' caring behaviours towards patients. ② Presumptive condition bias: Two patients (1-p2 and 1-p12) raised concerns about an implicit assumption in the items: that preoperative anxiety was present and necessitated psychological intervention. They noted that this presumption excluded patients who felt calm and did not require such support, potentially introducing forced response bias.	Following panel deliberation, it was concluded that item R1-20—“did nursing staff proactively provide companionship and emotional support?”—adequately encompasses the constructs measured by both redundant items, while maintaining universal applicability across varying patient psychological states.	Delete two items.
R1-9. Did nursing staff provide psychological support and reassurance while awaiting surgery?
R1-6. Upon entering the operating theatre, did the nurse staff promptly introduce themselves to you?	Item Redundancy: Three patients (1-p3, 1-p6, 1-p10) identified conceptual duplication between this item and R1-7 (“upon entering the operating theatre, did operating room nurses provide a patient reception including preoperative process orientation”). They noted that self-introduction constitutes an integral initial component of the reception process within routine clinical practice.	Following expert panel deliberation, the patient feedback was endorsed. Consequently, item R1-7 was retained, and the duplicate item was deleted.	Delete item
R1-10. Did nurse staff provide adequate informational support to alleviate anxiety while you awaited surgery?	① Conceptual ambiguity: Four patients (1-p4, 1-p6, 1-p10 and 1-p11) reported difficulty understanding the term “informational support,” requesting simplified phrasing. ② Item redundancy: Two patients (1-p5 and 1-p9) raised concerns about the item's inherent evaluation bias, noting that patients may lack a clear standard for judging “adequacy.” they emphasised that timely response to patient inquiries should suffice as an indicator of sufficient information provision.	Following expert panel deliberation, conceptual ambiguity in this item was confirmed. As corroborated by patient feedback, the content queried is sufficiently addressed by existing items: R1-19 (“were your questions addressed thoroughly and patiently by nursing staff?”) and R1-23 (“did nursing staff respond promptly when assistance was required?”).	Delete item
R1-12. Did nursing staff ensure you were aware of and comprehended their procedural actions during clinical procedures?	① Conceptual ambiguity: Five patients (1-p5, 1-p8, 1-p9, 1-p10 and 1-p12) reported difficulty understanding the term the term “clinical procedures.” Three patients (1-p6, 1-p8 and 1-p9) expressed that they were unable to evaluate “procedural competence” owing to a lack of professional expertise, and suggested reframing the item to focus on observable behaviours. ②: Content relevance concerns: Two patients (1-p6 and 1-p8) questioned R1-15's clinical salience, noting that certain interventions, such as venipuncture or electrode placement, inherently cause discomfort. They cautioned against misattributing inherent procedural discomfort to nursing quality and instead proposed measuring aspects such as procedural fluidity and attentiveness to prevent technique-related discomfort. ③: Item redundancy and burden: Three patients (1-p5, 1-p8, 1-p12) identified conceptual overlap between R1-12 and R1-13 and recommended consolidating them into a single item.	Following comprehensive team deliberation on patient feedback, the four items addressing clinical procedures were deemed excessive. To address issues of terminological ambiguity and questionable clinical relevance raised by patients, the research team conducted a literature review and referenced the inpatient nursing service experience questionnaire. Consequently, content related to procedural explanations, procedural competence, and discomfort experience was consolidated into a single item assessing the technical proficiency of clinical techniques.	R2-7. How would you rate the technical proficiency of nursing staff during clinical procedures?
R1-13. Did nursing staff explain clinical procedures to you while performing them?
R1-7. Did nursing staff demonstrate procedural competence during clinical procedures?
R1-15. Did any clinical procedures performed by nursing staff cause you to experience physical discomfort?
R1-26. Did operating room nursing staff facilitate your active participation in postoperative rehabilitation activities?	Content relevance concerns: Five patients (1-p3, 1-p4, 1-p5, 1-p8 and 1-p10) emphasised that postoperative rehabilitation should be primarily managed by ward nurses. They noted that ward nurses possess a comprehensive understanding of patients' perioperative health status, making them optimally positioned to lead rehabilitation activities. While acknowledging potential involvement from operating room nurses, they advocated for a supporting rather than primary role in postoperative recovery guidance.	Following expert panel deliberation on patient feedback, the unique intraoperative insights of operating room nurses (e.g., blood loss dynamics, skin integrity status and intraoperative thermoregulation) were acknowledged as clinically significant to postoperative recovery. However, under China's accelerated recovery after surgery framework, postoperative rehabilitation remains primarily coordinated by ward nursing teams. Given that ward nurses systematically incorporate intraoperative vital metrics into recovery planning, the panel concluded that postoperative follow-up counselling by operating room nurses should focus specifically on surgery-specific health guidance, rather than providing general rehabilitation instruction.	R2-18. During postoperative follow-up, did nursing staff provide tailored postoperative care instructions?

Note: 1-Px = Patient x in Round 1 interviews, R1-x = Item x in Round 1 interviews, R2-x = Item x in Round 2 interviews.