Preoperative information as predictor of the patient’s fear and anxiety before surgery Systematic review of qualitative and quantitative literature

Abstract

Background:

Between 10% and 80% of surgical patients experience some form of fear and anxiety before surgery. This is often attributed to inadequate or incorrect preoperative information.

Objectives:

This study aimed to critically evaluate and compile research that describes the impact of preoperative information on the patient's well-being before surgery.

Methods:

A systematic search was conducted on PubMed, Medline, CHINAL, Embase, and the Cochrane Library database for qualitative and quantitative literature regarding factors influencing patients' well-being before surgery. An inductive thematic analysis generated categories and subcategories. Nineteen studies were included.

Results:

Two main categories emerged from the thematic analysis of the included articles. These were the direct impact of information on fear and anxiety and the indirect impact of information on fear and anxiety. Information from healthcare professionals, alternative sources of information, shortage of healthcare professionals, music, and inability to receive information were some of the factors that can influence the well-being of patients before surgery. There are different reasons for the patient's fear and anxiety preoperatively, as well as the importance of direct and indirect information and other methods. For some patients, however, too much information could cause more fear and anxiety.

Conclusion:

The importance of the patient's discomfort being highlighted by the healthcare professionals emerges clearly and shows negative experiences in those cases where the patient feels his fears and concerns are not being addressed. More qualitative and quantitative research in the same theme, education and using person-centred care, and the right amount of information based on the patient's wishes are needed to improve the patient's well-being.

Introduction

In recent decades, the fear and anxiety of patients scheduled for surgery have become significant concerns. These emotions typically arise once surgery is required and persist until the patient enters the operating room. Between 10% and 80% of surgical patients experience some form of fear and anxiety before surgery.[1,2] The primary causes are fear of anesthesia and the surgical process itself.[3,4] Increased preoperative anxiety can complicate patient management, anesthesia control, surgical recovery, and overall outcomes.[5,6] This is often attributed to inadequate or incorrect preoperative information. Healthcare systems are required to inform patients about the procedure to ensure they understand the implications of surgery. Studies show that preoperative information and the time spent with patients significantly impact both the preoperative and postoperative phases. Patients receiving information a day before surgery fare better than those informed on the day of surgery, as they have time to discuss the information with relatives.[7] Patients who are not informed according to their needs tend to experience increased anxiety both pre- and postoperatively.[8,9] Comprehension of the provided information also plays a role; patients who understand the information feel better prepared and adhere more to preoperative guidelines.[10] Recent studies suggest that preoperative films can notably reduce fear and anxiety and improve patient well-being.[11] However, providing adequate information may extend the time needed for preoperative discussions, putting pressure on healthcare staff.[12,13] Information delivery should be tailored to each patient’s needs. The process is influenced by the competence, habits, and routines of healthcare providers.[14] A review of recent research into preoperative information helps understand its importance from the patient’s perspective and can inform clinical practice. Therefore, this study aims to synthesize both qualitative and quantitative research to evaluate the impact of preoperative information on patient well-being before surgery.

Inclusion and exclusion criteria

Inclusion criteria

1. English-language,

2. Qualitative approach,

3. Original studies,

4. Peer-reviewed publications.

Exclusion criteria

1. Mixed-method

2. Systematic review studies.

Search strategy

Using SweMeSH terms, we refined the search [Table 1]. Keywords like “influence,” “preoperative,” “information,” “patients,” “fear,” “anxiety,” “surgery,” “qualitative,” “quantitative,” and “review” were used. The searches were conducted in PubMed, Medline, CHINAL, Embase, and the Cochrane Library [Table 1].[15] Initially, titles were screened, followed by abstracts. Full texts of relevant studies were then analyzed. A total of 67 studies were reviewed, and 19 were included [Figure 1]. Authors independently screened abstracts for inclusion and exclusion. The final studies were analyzed using a five-step model process,[16] where key findings were identified, compared, and grouped into themes and subthemes according to Graneheim and Lundman. The analysis followed ethical guidelines for research [Table 2].[16]

Table 1.

Search Terms and Search Results of Databases

Database	Hits
PubMed	228
Medline	128
CHINAL	234
Embase	48
Cochrane Library	92
Total	730

Figure 1.

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines

Table 2.

PICO Framework

PICO Framework	Research question and facilitation of literature review
P – Population	The patient before surgery
I – Intervention	The patients experience of fear and anxiety before surgery
C – Comparison	Experience of preoperative information as a predictor on patients’ well-being
O – Outcome	Different kinds of results regarding patients’ well-being before surgery

Literature quality evaluation and data extraction

This systematic review followed the PRISMA guidelines.[17] We analyzed qualitative studies to address factors influencing patients’ fears and anxieties before surgery.[18] The search for relevant studies took place between January and October 2023, focusing on articles published between 2005 and 2021. We consulted an expert at the University Library in Gothenburg to refine the selection criteria. The selected studies focused on factors influencing patients’ preoperative fears and anxieties.[18] A Population, Intervention, Comparison, Outcome (PICO) model was used to guide the article selection process [Table 2]. Inclusion criteria included: English-language, qualitative approach, original studies, and peer-reviewed publications. We excluded mixed-method and systematic review studies.

Results

Literature search and study descriptions

The literature search shown in the PRISMA flow diagram [Figure 1] identified 730 articles, of which 67 were selected for full-text review. Ultimately, 19 articles[16,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36] were included, involving 358 informants. The search strategy yielded a total of 730 articles from the electronic databases after the removal of duplicates. A title and abstract sieve were conducted, and 67 articles were selected for a full-text review. Of these, a total of 19 articles were included [Figure 1]. The articles were published between 2005 and 2021, and data were largely collected the using semi-structured interviews and focus groups. Two main categories emerged from the thematic analysis of the included articles: the direct impact of information on fear and anxiety, and the indirect impact of information on fear and anxiety.

The direct impact of information on fear and anxiety

The studies included in the review highlighted several factors related to the direct impact of the preoperative information on patients’ fear and anxiety. These factors include information from healthcare professionals, the behavior of the healthcare team, different routes to the patient’s information, and the phenomenon that too much information can have the opposite effect.

Information from the healthcare professionals

According to many studies, lowering patients’ fear and anxiety preoperatively was not an easy task for healthcare staff. However, most patients in the studies indicated that the primary factor in alleviating fear and anxiety was the healthcare personnel.[16,19,20] A study that emphasized the importance of treating patients as individuals and responding to their feelings and questions reported that patients felt cared for, which reduced their fear and anxiety.[21,22] Serious meetings and open dialogue were also found to be effective in reducing fear and anxiety.[16]

Having touching and stimulating patients

The dialogue between healthcare staff and patients, as well as the flow of information, were considered essential in alleviating preoperative fear and anxiety. Healthcare personnel, who took the initiative in conversations, informed patients about surgical processes, and addressed patients’ concerns were successful in reducing fear and anxiety.[19] Additional factors identified in previous studies included hand massages, hand-holding, stress balls, and the comfort of the operating table, all of which contributed to reducing anxiety and lowering systolic blood pressure before surgery.[21,22,23,24]

Information from sound recording/film

Audio recordings and films were also found to directly reduce fear and anxiety. In previous studies, playing audio recordings or showing films chosen by the patients themselves helped calm patients and distract them from the surgical process.[24,25]

The indirect impact of information on fear and anxiety

In addition to direct factors, several factors were identified that indirectly influenced patients’ fear and anxiety. These included a shortage of staff to inform patients, patients who were too scared to receive information, and language barriers for foreign patients.

Healthcare professionals’ shortage

A shortage of healthcare staff tasked with informing patients was linked to increased fear and anxiety. In some studies, patients reported more anxiety because the information they received was incomplete. Forty-seven percent of patients felt the information was insufficient to alleviate their anxiety, and 86% wanted information 4 weeks before surgery.[26,27,28,29] Additionally, patients who had undergone previous surgeries reported higher levels of anxiety compared to those who had not.[29,30,31,32] In another study, it was found that women were more likely to experience more fear and anxiety and desired more information than men.[28,29]

Music

Music was identified as an indirect way to reduce fear and anxiety when traditional methods of informing patients were ineffective. Studies showed that patients who were allowed to listen to music before and during surgery reported lower levels of anxiety.[31,32,33,34] In a study, involving patients with pronounced fear and anxiety, music was particularly effective in calming them.[35] In an intervention study, although some patients experienced increased anxiety, those allowed to listen to music had the least increase in anxiety.[36]

Language difficulties

Language barriers were found to significantly increase fear and anxiety. Patients who could not communicate in the language of the country in which they were receiving care experienced more anxiety both preoperatively and during the surgery. A study by Jiwanmall et al. (2019)[28] found that language difficulties, a lack of time for information delivery, and the complexity of the disease prevented patients from understanding the information provided to them.[27] Furthermore, 40% of staff in another study felt that language problems prevented patients from expressing their emotional concerns.[30]

Discussion

The present study aims to synthesize qualitative and quantitative research and critically evaluate and compile research that describes the impact of preoperative information on the patient’s well-being before surgery. Because of that, a literature review of qualitative and quantitative articles was chosen as the method. A systematic literature review has been carried out with the aim of answering the research question regarding healthcare staff’s strategies and ways of handling and treating patients with fear and anxiety before a surgical procedure. This is to lay the foundation for safe care and detailed planning for the preoperative process. Through the search of various qualitative and quantitative studies, evidence has been accumulated to answer the research question. Since the presented study has several authors who had discussed which studies should be taken and which not, there may be biases that affect the choice of studies. Choosing different studies is a subjective process, and each author in the study has their own interpretations that can affect the process. A possible weakness to choosing a systematic literature review study could be the limited amount of qualitative or quantitative studies that were available within the specific subject; therefore, an interview study or a statistical study could arguably have been a suitable alternative to generate deeper results. The result of the present study showed two main themes emerged from the thematic analysis of the included articles. These were the direct impact of information on fear and anxiety and the indirect impact of information on fear and anxiety. In the direct impact of the information on lowering the level of fear and anxiety in the patient, results show different approaches. Having time to inform the patient, that the patient is receptive to the information, to talk calmly and calmly with the patient, hold the patient’s hand and sit next to the patient, and finally show a film to the patient preoperatively and also during the operation manifests itself in many studies that help mothers with fear and anxiety.[16,19,20,21,22,23,24,25] Results in the presented study are in line with other studies that show that the need and desire from patients and current preoperative information about anesthesia type and the operative process were great. When information was not provided, this caused feelings of uncertainty, fear, and anxiety in patients. This in turn means that patients do not become receptive to information and do not become involved in their care process.[37,38] Another study shows that it is so simple that healthcare professionals do not value and focus on the same kind of information that the patient does. While the staff focuses on the pre- and perioperative information, the patient usually focuses on the type of anesthesia and the anesthesia process.[39] This is in contrast to a study on person-centered care, where the patient is the focus of care and is listened to base on their wishes and needs. For this, it is important that the organization applies the theory and that this is used in daily care. The same applies to working according to the preoperative dialogue where dignity is preserved and suffering is alleviated.[40] Applying this in a preoperative context, meeting the patient the day before the operation, having a dialogue with them, holding them in the hand and having a calm and composed discussion, answering the patient’s questions, showing different films about the patient’s operation, and following the patient throughout the operation would have been perfect care today. What is very important, and for which there is no risk in today’s host healthcare, is to “overdose” with preoperative information. Previous studies show that preoperative information not only alleviates fear, worry, and anxiety but can instead cause worsening anxiety and create a feeling of having received too much detailed information, which once again highlights the importance of using person-centered care.[41] In those cases where the healthcare staff had to have other options for preoperative information, the indirect impact on fear and anxiety in patients was relevant. When the healthcare staff was not sufficient, they worked twice, and the stress increased. They applied other methods, such as having music before and during the operation process, but there were also registered patients who were difficult to inform due to the language barrier. One of the good ways to use when there is a shortage of personnel and other methods must be applied is music before and during the operation. The music in this case has more of a role to guide the patient and take their thoughts on a different path than fear and anxiety. It has proven to be a good and efficient way. However, it is important to identify already at the pre-operative interview those patients who have highly pronounced worry and anxiety because they have the greatest need and respond best to music therapy.[42] In the study on the impact of music on fear and anxiety suppression, the authors believe that extended information and music were the easiest to apply. Some parts of this film and music, patients could choose themselves and watch and play several times. Because patients with high levels of unspoken fear and anxiety experience a significant reduction in worry and anxiety, it is important to have a close dialogue and close cooperation between healthcare personnel and the patient. Through a dialogue and good collaboration, it makes it possible to identify the level of fear, worry, and anxiety in patients and which nursing measures can possibly work for the specific patient.[42] Another challenge that healthcare professionals face on a daily basis and throughout the world is patients who are immigrants in the respective countries and who do not have a native language like individuals born in the respective countries. In many cases, and to make things easier for themselves, researchers exclude such informants in their studies who do not make things easier. It is precisely those patients who may have access to the most important information and who could do better both for future patients and the healthcare system. In some modern and rich countries, it is possible for such patients to communicate with the healthcare system via an interpreter. In today’s healthcare in Sweden, where everything is paid and calculated according to the minutes of work performed, a pre-operative meeting takes between 5–8 min, which is just enough for an interpreter to come to the room, sit down, and everyone introduces themselves, and then it’s time to come out for those minutes that are “spent.”[9,43,44,45] In all the studies read, referenced, and used, and regardless of whether direct or indirect use and impact of the information on patient fear, worry, and anxiety “ghosts” healthcare professionals shortages. All this that healthcare professionals did in the past and are doing today is possible to do if there are enough healthcare professionals. In today’s healthcare in Sweden, however, this is not the case. In the situation where the staff is missing from assistant nurse to the chief doctor, it is necessary to organize in a different way and use other methods to “save” the situation. The reason for all of this should be that the healthcare professionals are poorly paid and not paid the same as people who have studied for the same length of time and do not work in healthcare. The whole process results in it being difficult to attract and persuade younger people to study and train in healthcare. The only question is whether we dare to continue doing it and risk that in the near future there will be no one to take care of us, because we are getting older and older, unfortunately. Our study has some limitations. Firstly, most selected studies in the results of our study are of quantitative nature. This can cause the writing and results of the upcoming study to be based on the numbers instead of informant’s experiences and thus not so much on the objective picture of the issue and based on questions and answers at different kinds of widowhood. Secondly, when it comes to coding data in the process where the data text was analyzed, we only let two of the most experienced researchers do the job, instead of all the authors doing the work. This contributes to the risk of the analyzed data to be poorer as fewer researchers did the job.

In conclusion, the results of the presented study show that there are different reasons for the patient’s fear and anxiety preoperatively, as well as the importance of direct and indirect information and other methods. For some patients, however, too much information could cause more fear and anxiety. The importance of the patient’s discomfort being highlighted by the staff emerges clearly and shows negative experiences in those cases where the patient feels his fears and concerns are not being addressed. Keeping this in mind and treating all patients according to person-centered theory can help to support and enrich the staff’s work in an effort towards a more person-centered spring that is based on the individual’s needs and resources. To further investigate preoperative fear and anxiety and the importance of the information, further qualitative and quantitative research is needed in the area and based on the patient’s experiences. More education in transcultural care, as well as translated information in several different languages would have helped both patients seeking care and also those caring for the patients.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.