Addressing preoperative anxiety in surgical patients: A qualitative exploration of coping mechanisms and healthcare support

Abstract

BACKGROUND:

This study aims to identify strategies for managing preoperative anxiety among patients and explore the role of healthcare professionals in supporting its management before elective surgery.

METHODS AND MATERIAL:

Participants were purposively selected based on their preoperative anxiety experiences between September and October 2024. Semi-structured interviews explored anxiety causes, coping strategies, and interactions with healthcare professionals.

RESULTS:

The dominant sources of pre-operative anxiety were fear of anaesthesia, pain after surgery, and the possibility of a long recovery period. Family support was one of the coping mechanisms used by patients, as well as religious practice and seeking help through social media and films. One of the circumstances that helped patients alleviate their anxiety was clear and comfortable communication with healthcare professionals, although some patients felt that this could have been more detailed.

CONCLUSIONS:

Social support, particularly family involvement, and clear communication with medical staff are essential in reducing preoperative anxiety. Integrating these strategies into routine pre-surgery preparation can enhance patient well-being and improve surgical outcomes.

Introduction

Preoperative anxiety is one of the documented phenomena that can indeed affect several patients who are about to undergo surgery. Several investigations in this area have revealed that approximately 40–60% of pediatric patients and 11–80% of adult patients also experience preoperative anxiety.[1] The problem of preoperative anxiety is twofold in terms of manifestations both in psychological and physiological terms where symptoms include the appearance of mild nervousness to severe states including rapid heartbeat, high blood pressure, large amounts of cortisol, and others which are all detrimental to surgery.[2] Anxiety and its physiological effects can affect the performance of surgical procedures, prolong the duration of recovery, and consequently prolong hospitalization.[3]

In addition to the effects it has on the body, preoperative anxiety can lead to more pain after surgery, a higher need for pain medication, and a longer recovery. Preoperative anxiety can also affect patient compliance and cooperation during surgical procedures, which can make it difficult for medical personnel to perform the required care. Several studies have shown it to be a temporary psychological burden while to some extent increasing the likelihood of failure in the surgical process, prolonged hospitalization, and financially burdening the healthcare delivery system.[4] The management of preoperative anxiety is very important, so it is necessary to know the factors behind it.

There are several sources of preoperative anxiety: fear of imminent surgery, fear of anaesthesia, concern about possible outcomes, and the possibility of being away from home or work responsibilities.[5] Of these fears, fear of anesthesia is prominent as it is mostly seen in patients’ concerns of unwanted events such as anesthetic side effects or not waking up, especially in older adults with co-morbid conditions.[6] Fear of returning to functional ability is largely placed on the duration of postoperative recovery; patients often worry about how long it will take to return to daily life.[7] This creates anxiety for many patients, especially for those who have dependents or have other issues at work, waiting for the results of the surgery and whether they can work after surgery.[8]

Despite advances in medical care, preoperative anxiety has been recognized since the early days of medicine. However, the management of preoperative anxiety has largely relied on drug-based aids such as sedatives and anxiolytics. Although beneficial, these types of drugs have negative side effects, such as drowsiness that can affect postoperative care and slow down recovery.[1] Acknowledging the inadequacy of pharmacological interventions, methods other than drugs that include multi-faceted approaches such as psychological support, music therapy, guided imagery and relaxation have gained popularity as useful methods to reduce anxiety without side effects.[9] These innovations make patients feel that they have more control over their surgery, which affects their psychological status positively and improves postoperative recovery.

However, despite the increasing appreciation given to non-pharmacological approaches, the literature shows that gaps still exist. Firstly, there is insufficient data on patient attitudes towards these types of interventions. How can an intervention or treatment be offered if it is not clear which methods patients find effective or are prepared to undertake? Secondly, not much research has attempted to understand how nurses and other healthcare providers understand and utilize non-pharmacological approaches. Thirdly, little research has been done on individualized approaches aimed at reducing preoperative anxiety. There is no understanding of how different types of anxiety centers are addressed and the different anxiety control strategies that can be applied to diverse patient populations.

This study sought to fulfil this aim by examining patients’ understanding of preoperative anxiety and sought to explore the use of non-pharmacological strategies in reducing the condition. To advance knowledge in this discipline, it seeks methods to control patient anxiety and implement them before surgery. This research seeks to identify patient factors and less invasive treatments that target healthcare professionals under a collaborative patient to build a less invasive model for patients, which minimizes preoperative anxiety and improves surgical outcomes. It will also help to understand the possible role of the healthcare team in managing patients through non-pharmacological initiatives, which will then contribute to the understanding of appropriate interventions based on the specific characteristics of each patient.

This particular study aims to focus specifically on patients, their perceptions and experiences, with particular emphasis on the reasons behind their pre-operative anxiety. The focus is also on how to create a non-pharmacological intervention model that is acceptable to patients and practical for clinicians to reduce anxiety and improve surgical outcomes.

Materials and Methods

Study design and setting

This research utilized a qualitative research design focusing on the phenomenon of preoperative anxiety among patients undergoing elective surgery. The study was conducted in two hospitals in Surakarta, Central Java, Indonesia, between September and October 2024.

Study participants and sampling

Participants were selected using purposive sampling, targeting individuals who could provide relevant insights into their experience with preoperative anxiety. Inclusion criteria included participants aged 18 years and above, scheduled to undergo elective surgery within the study period, and willing to provide informed consent. A total of eight participants were interviewed, achieving data saturation with no new themes or information emerging. Individuals with sensory disabilities such as vision and hearing impairments were excluded to ensure active participation in the interviews.

Data collection tool and technique

Data collection was conducted through in-depth, semi-structured interviews, allowing participants to share their experiences freely while the interviewer guided the discussion using open-ended questions. The interviews explored triggers of preoperative anxiety, coping mechanisms, and interactions with healthcare professionals. Privacy and participant needs were prioritized throughout the process. Additional interviews with healthcare professionals were conducted to gain insights into the institutional approaches to managing preoperative anxiety. Interviews were audio-recorded and video-recorded, with subsequent transcription for analysis.

Ethical consideration

Ethical approval for the study was obtained from the Institutional Review Board (IRB) of Universitas Sebelas Maret under protocol number 163/UN27.06.11/KEP/EC/2024. Informed consent was obtained from all participants, and their confidentiality was ensured through data anonymization. Interviews were conducted with respect for the psychological and emotional well-being of participants, with particular care taken to minimize distress during discussions about preoperative anxiety.

Statistical analysis method

The analysis involved a multi-step qualitative approach. Initially, all audio and video recordings were transcribed verbatim. The transcriptions were then coded, with recurring phrases and ideas grouped into themes and sub-themes. Broad conceptual categories, such as fear of anesthesia, fear of surgical outcomes, and fear of burdening family members, were developed. Emerging patterns were tracked and analyzed until saturation was reached. Findings were cross-validated with interviews from healthcare professionals to ensure the credibility and reliability of the results.

Results

Demographic data of participants have been added in the following sections, including age, gender, causes of anxiety, ways to cope with anxiety, and feedback from healthcare professionals [Table 1]. For the sake of confidentiality, all participants’ identities have been replaced with anonymous comments.

Table 1.

Summary of patient anxiety and coping mechanisms

Participant ID	Age	Gender	Source of Anxiety	Coping Mechanisms	Role of Healthcare Professionals
P1	29	Male	Fear of surgery failure, postoperative pain, and extended recovery	Family support, prayer	Reassuring but seeking more details
P2	59	Male	Minimal concern, high trust in the surgical team	No specific coping needed	Strong trust in healthcare team
P3	67	Male	Fear of anesthesia, postoperative complications, and age-related concerns	Prayer, family support	Supportive communication
P4	20	Female	Anxiety from online research about surgery risks	Distraction (social media)	Desire for more detailed explanations
P5	25	Female	Fear of anesthesia and potential postoperative pain	Music, entertainment	Moderate support from doctors
P6	26	Female	Concerns about surgery success, anesthesia, and the impact on family responsibilities	Watching dramas, prayer	Clear communication from healthcare team
P7	41	Female	Balancing anxiety with family responsibilities, particularly related to children	Family support, breathing exercises	Reassuring communication
P8	62	Female	General fear of anesthesia and complications related to age	Prayer, family support	Supportive but limited in details

Fear of the Unknown

Surgery often causes tremendous anxiety as there is a fear of the unknown. For example, other participants expressed reservations about anesthesia or other unexpected events P1 (29 years old, male). P5 and P3, a 29-year-old male participant said, ‘I’m scared about how long the recovery will take, and once it’s done, will I feel pain? I just want the pain to go away. Another participant, P4 (20 years old, female) said, ‘I am nervous about the anesthesia and whether I can tolerate the pain after the surgery, I want to know what will happen’.

On the other hand, P2 (59 years old, male) showed calmness and had great trust in his healthcare team members ‘I am not worried. I trust the doctors, and I feel they have explained everything very well to me’. This trust greatly reduced preoperative anxiety. However, P8 (62 years old, female) indicated that trusting the medical team did not eliminate anxiety. ‘But I was afraid, I still prayed. Even though I trusted the doctor. The anxiety is still there’.

Concerns about recovery and pain

There were concerns regarding pain after surgery and recovery time. Participant P1 had concerns about how the surgery would affect her: ‘I am afraid that I will take a long time to recover and my capacity to work will be affected. This is because I need to get back to normal in the shortest time possible. Another participant, P5 (25 years old, female), said that the physical pain of the surgery scared her: ‘I am afraid that the anesthesia will not be effective and there will be suffering during the operation or afterwards’.

In addition, participants also targeted those who had experienced anesthesia and surgery before, such as P6 (26 years old, female), who seemed particularly apprehensive recalling painful feelings related to previous surgical interventions: ‘I felt pain after the last surgery and especially during the recovery period, that’s what I still feel today. Thinking about it makes me sick.

Impact on family and responsibilities

Concerns not only about the health of many participants but also how their surgery would impact their families. A 41-year-old mum, P7, had mixed feelings about recovery and household management, saying: ‘I'm worried about how my children will cope while I'm in recovery. I need to be there for them, but now I'm not. I should be there for them, but now I can't.

Some participants, such as P1, also had concerns regarding the economics of their operation, commenting: ‘I think about how long I will be out of work’. It is hard to explain because money is not everything, but still, this situation will affect my family.

Coping mechanisms

The participants demonstrated a variety of coping mechanisms used to deal with anxiety. P5 reported increasing useless activities on social media that mesmerized: ‘I don’t want to think about the operation, so I play games on my mobile phone, watch TikTok or YouTube’. In addition to playing games, P6 said that she also watched dramas to ease her anxiety: ‘I go to YouTube and Korean dramas to relieve anxiety’.

On the other hand, some participants also engaged in family support and religious practices. P1 revealed that reassurance from his wife helped ease his panic: ‘My wife said that I have to go through this, and that helped me a lot.’ P8 explained how he worried about himself and turned to prayer: ‘I usually pray a lot. It is the only thing that calms me down before the operation.

Role of healthcare professionals

Healthcare professionals are key actors in managing and reducing patients’ preoperative anxiety. P7 commented: ‘The details were explained by the surgeon, and it was very calming for me as a patient.’ Good communication with the medical team evokes active patient participation and lowers their stress levels.

However, some participants still wished for additional information. P4 stated that although the medical staff was very good, she would have liked to know more about the invasive details of the surgery itself: ‘I wish they would have explained more about the surgery. It would have helped me feel more prepared and less anxious.’

Discussion

The results of this study focused on several aspects of pre-operative anxiety experienced by patients about to undergo surgery and the strategies needed to overcome this multi-faceted anxiety. This particular study found that patients’ fears were mostly related to ignorance about the surgery, fear of anaesthesia, and issues related to recovery after surgery. This finding relates to the general observation noted by other authors that in surgical patients, fear of the unknown and fear related to anesthesia are some of the commonly observed reasons for anxiety.[2,10] Participants in this study also feared pain after surgery and a long recovery, which is also consistent with previous studies showing that anxiety is related to concerns about pain and disruption of normal activities.[11]

An important insight from this study was how family support and spirituality were incorporated into the patients’ anxiety management process. Some participants reported that their families helped reduce the fear they experienced before undergoing surgery. This is also supported by attachment theory, which states that one can get through anxiety and stress with the help of comforting relationships.[12] On a similar note, the tendency to use religious practices, in this case prayer, illustrates the place of spirituality as an established practice towards psychological comfort in the treatment of anxiety.[13] This mechanism provides patients with the necessary psychological control, which is important in an environment that seems likely to be overwhelming.

Another dimension that is equally relevant to this study is the focus on the healthcare provider component of addressing preoperative anxiety. Participants whose surgeons and nurses took the time to explain the procedure to them felt more confident about themselves. This finding highlights patient-centred care practices that advocate communication and active patient participation as important for reducing preoperative anxiety.[14] Previous research suggests that when patients articulate their anxiety to their healthcare providers, especially during communications that lack medical explanations, they relieve anxiety by evoking strategies to reduce uncertainty and improve the status of care information.[15] However, other participants in this study stated that they needed to be given more information than what they got about their procedure. This suggests that although communication was helpful, it could be further improved to alleviate most patients’ concerns.

Limitations and recommendations

Even with its various strengths, there are many shortcomings in this study. Qualified confidence was reasoned that the sample size of the eight participants who participated in the study was rather small, although sufficient to reach. By using a small sample, this study made it possible to investigate how people with anxiety perceive their experiences in hospital admission situations. However, this study proposes the inclusion of a more representative sample population in future studies to test the generalizability of these results. A related limitation is that the data collection was conducted in only one setting, as the findings will only relate to the specific clinical environment in which the study was conducted. The way patients perceive anxiety may differ from one hospital to another, one region to another, or even one healthcare system to another, and this may affect the findings of the study.

In addition, the study used a self-report technique, which has risks and sources of error as participants may under- or over-report their anxiety levels, depending on their interpretation of their experience or how they think the interviewer wants them to react. In the case of patients, integrating qualitative interviews with quantitative methods, such as psychological tests aimed at anxiety (e.g. Hospital Anxiety and Depression Scale), may help overcome some of the other limitations.

Implications for the field

The study underscores the critical role of effective communication and non-pharmacological interventions in managing preoperative anxiety. Healthcare providers should prioritize empathetic, patient-centered communication to address patients’ informational needs and reduce anxiety. Non-pharmacological strategies, such as spiritual guidance, family involvement, relaxation techniques, and cognitive-behavioral methods, offer promising alternatives to pharmacological treatments. Future research should evaluate these interventions’ effectiveness and explore longitudinal impacts of preoperative anxiety on recovery, aiming to develop standardized protocols for integrating psychological support into surgical care.

Conclusion

The findings of this study conclude that preoperative anxiety is significantly influenced by fear of anesthesia, surgical outcomes, and recovery, with family support, spiritual practices, and clear communication from healthcare professionals serving as effective coping mechanisms. It is recommended that healthcare providers prioritize patient-centered communication and integrate non-pharmacological interventions such as guided relaxation, family involvement, and spiritual guidance into preoperative care to reduce anxiety and improve surgical outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

The research was supported by the Institute for Research and Community Service, Universitas Sebelas Maret, Surakarta, Indonesia, under the agreement number 194.2/UN27.22/PT.01.03/2024.