Abstract
Background
The potential for preoperative anxiety to be negatively associated with postoperative recovery remains a current, increasingly important issue that warrants further investigation. The primary objective of this study was to assess the relationship between preoperative anxiety and postoperative recovery in patients.
Methods
Designed as a prospective observational cohort study, this research included patients who had surgeries in the general surgery department at a university hospital from September 15, 2020, to January 31, 2021. The study gathered data through the use of the Patient Information Form, the Anxiety Specific to Surgery Questionnaire, and the Postoperative Recovery Index. The analysis of the data was carried out using the SPSS (version25.0) software package.
Results
The study found that the average age of the patients was 54.28 ± 15.4 years, and 60.0% of them were women. The average score on the Anxiety Specific to Surgery Questionnaire was 27.9 ± 10.9. The average score on the Postoperative Recovery Index was 2.84 ± 0.86 for measurements taken on days 0–3 and 1.82 ± 0.64 for measurements taken on days 10–15. Upon examining each sub-dimension and the total scale scores, it was found that most patients reported favorable recovery outcomes. In addition, a statistically significant relationship was identified between preoperative anxiety levels and postoperative recovery scores.
Conclusion
Patients generally reported greater recovery difficulties during the early postoperative period (days 0–3) compared with days 10–15. It was also found that preoperative anxiety was significantly associated with postoperative recovery.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12893-026-03589-6.
Keywords: Anxiety, Recovery, Surgery, Preoperative, Postoperative
Introduction
Anxiety is characterized by varying degrees of tension, worry, irritability, discomfort, and increased autonomic activity, arising from an anticipation of danger [1]. Anxiety is a natural response developed by individuals in situations where they do not feel safe, and it is considered a universal emotion that plays a critical role in the perioperative period, influencing surgical outcomes and recovery processes [2, 3]. Recent studies indicate that various levels of anxiety and fear are observed in a significant proportion of patients during the preoperative process [4–6], with prevalence rates ranging from approximately 60% to 80% among surgical patients [7]. It is known that anxiety should exist up to a certain level and its positive features when it is functionally adequate [8]. However, disproportionate reactions in response to anxiety, leading to the formation of symptoms at pathological levels, negatively impact the patient [9]. As a result, it is anticipated that anxiety may have a negative impact on the surgical process [10, 11].
All surgical procedures are followed by postoperative recovery [12]. While the concept of recovery after surgery is widely utilized, defining it consistently has been challenging due to its multidimensional nature and the absence of a universally accepted definition [13]. The process of Recovery after surgery starts immediately and can span several months, continuing beyond discharge and involving various milestones [14]. It is noted that the recovery period may be lengthy, impacting both the physical and psychological well-being of the patient [14]. From a comprehensive standpoint, postoperative recovery encompasses a gradual enhancement in functional abilities and the individual’s subjective sense of recovery [15, 16].
The concern regarding the postoperative recovery process can create anxiety in patients, and the possibility of pre-existing anxiety adversely affecting postoperative recovery [11] remains a timely, increasingly important, and research-worthy issue. In line with this, this study was conducted to assess the relationship between preoperative anxiety and postoperative recovery in patients.
Materials and methods
The study was designed as a prospective observational cohort study conducted to examine the relationship between preoperative anxiety and postoperative recovery and was reported in accordance with the STROBE guidelines for cohort studies.
The study was conducted in the General Surgery Clinic of a university hospital in Turkey between September 15, 2020 and January 31, 2021. This clinic consists of 45 patient rooms and can accommodate 1–6 patients. The age of inpatients ranged from 18 to 99 years. Major procedures such as gastrointestinal tract surgery, hepatopancreatobiliary surgery, hernia surgery, breast surgery, thyroid-parathyroid surgery, and many minor procedures such as lipoma excision are performed here.
The study population consisted of those scheduled for surgery at the general surgery clinic between the specified dates. An a priori sample size was calculated using the “G. Power-3.1.9.2” based on an assumed medium effect size and a two-tailed significance level of 0.05, with a target power of 0.80. The calculation was performed for correlation analysis. Based on these parameters, a minimum sample size of 138 participants was estimated. All patients reached according to the calculated sample size agreed to participate in the study. The sample of the study consisted of 145 patients aged 18 years and over who were admitted to the general surgery clinic, scheduled for surgery, and who volunteered to participate in the study. Patients read and signed the informed consent form at the time of inclusion. During each process of patient contact, the information was obtained by the researcher personally. There was no loss of participants during the first, second and third interviews. These eligibility criteria were applied to reduce potential sources of selection bias and confounding. In addition, data were collected using validated instruments and administered in a standardized manner by the same researcher to enhance internal validity.
The study population consisted exclusively of patients scheduled for elective surgical procedures. Patients undergoing urgent or emergency surgery were not included. Individuals with a previously diagnosed anxiety disorder or other psychiatric conditions requiring active treatment were excluded from the study. In addition, patients who reported regular use of sedative medications, including benzodiazepines or similar anxiolytic agents, were excluded to minimize potential confounding effects on preoperative anxiety levels.
The data were collected through face-to-face and telephone interviews using the “Patient Information Form,” the “Anxiety Specific to Surgery Questionnaire (ASSQ),” and the “Postoperative Recovery Index (PoRI).” On the morning of the surgery day, the “Patient Information Form” and the “Anxiety Specific to Surgery Questionnaire” were administered to the patients through face-to-face interviews. After the surgery, the “Postoperative Recovery Index” was administered twice. The first administration (1st measurement) was conducted within the first three days after the surgery [17, 18]. The second administration (2nd measurement) took place on days 10–15 after the surgery [17, 18], during the patients’ first clinical follow-up either face-to-face or via telephone interview. The data collection time for each interview was approximately 10–15 min.
The “Patient Information Form” consists of a total of 15 questions, was developed specifically for this study by the researchers based on a review of the relevant literature to collect sociodemographic and clinical data [10, 19, 20]. The questionnaire has not been previously published elsewhere (Supplementary File 1).
The Anxiety Specific to Surgery Questionnaire (ASSQ), evaluates specific fears and concerns related to surgery. Developed by Karanci and Dirik (2003), the scale consists of 10 questions rated on a 5-point Likert scale [21]. Each question is rated on a scale from “5 = Strongly Agree” to “1 = Strongly Disagree.” Only item 8 is reverse-scored. The possible score range from the scale is between 10 and 50, where higher scores reflect greater anxiety about pain, death during surgery, complications, and limitations. In Karanci and Dirik’s study, the Cronbach’s Alpha value was found to be 0.79 [20], while in this study, it was determined to be 0.897.
The Postoperative Recovery Index (PoRI), developed by Butler and colleagues in 2012, is used to assess the quality of recovery in patients undergoing major surgical procedures shortly after surgery [17]. In a study conducted by Cengiz and Aygin (2019) in Turkey to establish its validity and reliability, the overall Cronbach’s Alpha value was found to be 0.967 [22]. In this study, the overall Cronbach’s Alpha value was determined to be 0.926 for the first measurement and 0.925 for the second measurement. The Cronbach’s Alpha values for the subscales range from 0.77 to 0.94.
The PoRI has been introduced into Turkish literature as a 25-item self-assessment scale. It includes three different 5-point Likert-type scales. For the first four questions, the options range from “none” to “extremely.” For items 5–12, the options range from “not at all limited” to “extremely limited,” and for the remaining items, from “not at all bothered” to “extremely bothered.” To score the PoRI, the item scores within each subscale are summed and averaged to determine the subscale score. For the total score, the sum of all 25 items is averaged. Higher scores indicate greater difficulty in postoperative recovery, while lower scores indicate easier recovery. As specified in the study by Cengiz and Aygin, the PoRI assessment was conducted in two stages: the first measurement within the first three days post-surgery, and the second measurement between days 15–30. The scoring system for the total and subscale scores of the PoRI is explained in Fig. 1 [17, 22]. In the present study, the second PoRI measurement was conducted between postoperative days 10 and 15 in order to capture the early post-discharge recovery period, which is considered a critical phase for functional and psychological adjustment. This timing was also selected to minimize loss to follow-up and to reflect routine clinical follow-up practices in the study setting.
Fig. 1.
Scoring system for the PoRI total score and subdimension scores
No measurement tool was developed specifically for the purposes of this study. Preoperative anxiety was assessed using the Anxiety Specific to Surgery Questionnaire (ASSQ), and postoperative recovery was evaluated using the Postoperative Recovery Index (PoRI), both of which are previously developed and validated instruments. Validated Turkish versions of both scales have demonstrated acceptable psychometric properties in prior studies. In the present study, internal consistency coefficients were recalculated to confirm the reliability of the scales within the current sample. No modifications were made to the original structure or item content of the scales.
The IBM Statistical Package for the Social Sciences (SPSS) version 25.0 was employed for data analysis. Descriptive statistics and the Chi-square test were used to evaluate the data. Reliability analyses of the scales were performed using Cronbach’s alpha coefficients. The normality of continuous variables was assessed using visual (histograms and Q–Q plots) and analytical methods (Kolmogorov–Smirnov test). In addition, multivariable linear regression analyses were performed to examine the association between preoperative anxiety and postoperative recovery at two time points (0–3 days and 10–15 days after surgery). The models were adjusted for age group, sex, education level, working status, previous surgical experience, presence of comorbid disease, having children, and type of surgery.
Prior to inferential analyses, the normality of continuous variables was assessed using visual methods (histograms and Q–Q plots) and analytical tests (Kolmogorov–Smirnov test). Descriptive statistics were presented as mean ± standard deviation or median (minimum–maximum), as appropriate. For comparisons between two independent groups, the Independent Samples t-test was used for normally distributed variables, while the Mann–Whitney U test was applied for non-normally distributed variables. Comparisons among more than two independent groups were performed using one-way ANOVA for normally distributed variables and the Kruskal–Wallis test for non-normally distributed variables. Post hoc Bonferroni correction was applied where appropriate to control for multiple comparisons. Associations between continuous variables, including ASSQ and PoRI total and subscale scores, were evaluated using Spearman correlation analysis. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant. A post-hoc power analysis was conducted based on the observed effect size of the correlation between the ASSQ total score and the PoRI total score (r = 0.222). With a two-sided alpha level of 0.05 and a final sample size of N = 145, the achieved statistical power was calculated as 1 − β = 0.77 (G. Power-3.1.9.2).
Ethics approval and consent to participate
Our study adhered to the Declaration of Helsinki. Human ethics and participation approval statements have been received. To conduct the study, approval was obtained from the medical research ethics committee of Ege University Medical Research Ethics Committee (Date: 15.09.2020, Decision No: 20-9T/12), as well as written permission from the general surgery clinic of the university hospital where the study was conducted. Additionally, permission to use the scales was obtained via email from the authors. All participants were informed about the purpose and procedures of the study and voluntarily provided written informed consent prior to participation.
Results
Based on descriptive analyses, the average age of the patients included in the study was 54.28 ± 15.4 years, with 35.9% falling between the ages of 50–64. Among them, 60.0% were female, and 79.3% were parents, with 69.0% of the parents having children aged 19 and older. Furthermore, 58.6% of the patients had a chronic illness, with 40.3% of them being hypertensive, and 43.5% having multiple chronic conditions. 35.9% of the patients had undergone gastrointestinal system surgery, 60.0% had previous surgical experience, 60.7% had been hospitalized before, and among those previously hospitalized, 67.6% had stayed in the hospital for less than 1 h (Table 1).
Table 1.
Socio-demographic characteristics of patients
| Characteristics | X ± SD | Min. - Max. |
|---|---|---|
| Age | 54.28 ± 15.4 | 18–89 |
| Number (n) | Percentage (% ) | |
| Age | ||
| 18–29 | 11 | 7.6 |
| 30–49 | 35 | 24.1 |
| 50–64 | 52 | 35.9 |
| 65 and over | 47 | 32.4 |
| Gender | ||
| Female | 87 | 60.0 |
| Male | 58 | 40.0 |
| Education Level | ||
| Illiterate | 19 | 13.1 |
| Literate | 12 | 8.3 |
| Primary/Secondary School | 43 | 29.7 |
| High School | 39 | 26.9 |
| University | 32 | 22.1 |
| Employment Status | ||
| Yes | 50 | 34.5 |
| No | 95 | 65.5 |
| Parenthood Status | ||
| Yes | 115 | 79.3 |
| No | 30 | 20.7 |
| Presence of Chronic Disease | ||
| Yes | 85 | 58.6 |
| No | 60 | 41.4 |
| If Yes; | ||
| Diabetes Mellitus | 33 | 24.6 |
| Hypertension | 54 | 40.3 |
| Renal Insufficiency | 6 | 4.5 |
| Heart Diseases | 13 | 9.7 |
| Thyroid Diseases | 10 | 7.5 |
| Others (COPD, other cancers, psychiatric problems) | 18 | 13.4 |
| Number of Chronic Diseases | ||
| 1 | 48 | 56.5 |
| 2 | 27 | 31.7 |
| 3 | 9 | 10.6 |
| 4 | 1 | 1.2 |
| Type of Surgery | ||
| Gastrointestinal System Surgery | 52 | 35.9 |
| Hepatopancreatobiliary Surgery | 33 | 22.8 |
| Hernia Surgery | 11 | 7.6 |
| Breast Surgery | 21 | 14.5 |
| Thyroid-Parathyroid Surgery | 28 | 19.3 |
| Previous Surgery Status | ||
| Yes | 87 | 60.0 |
| No | 58 | 40.0 |
| Previous Hospitalization Status | ||
| Yes | 88 | 60.7 |
| No | 57 | 39.3 |
| Length of Hospital Stay | ||
| Less than 1 h | 98 | 67.6 |
| 1–24 h | 18 | 12.4 |
| 25–72 h | 12 | 8.3 |
| 73 h and over | 17 | 11.7 |
| Total | 145 | 100 |
Data are presented using descriptive statistics
X Mean, SD Standard Deviation, Min Minimum, Max Maximum
Descriptive analyses showed that, in Table 2, the mean score of the patients on the ASSQ was found to be 27.9 ± 10.92 (min: 10.00 - max: 50.00).
Table 2.
Mean scores of patients on the ASSQ
| Scale | n | Min. | Max. | Mean | SD |
|---|---|---|---|---|---|
| ASSQ Total | 14 | 10,0 | 50,0 | 27,903 | 10,9222 |
| Score | 5 | 0 | 0 | 4 | 8 |
Data are presented using descriptive statistics
Min.Minimum, Max. Maximum, SD Standard Deviation
Using descriptive statistics, postoperative recovery was assessed at two time points: early postoperative period (days 0–3) and post-discharge period (days 10–15). Overall, patients reported greater recovery difficulties during the early postoperative period compared with the later assessment. In the first measurement, the mean score for the Psychological Symptoms subscale was 2.2 ± 0.9, for the Physical Activities subscale was 3.2 ± 1.2, for the Appetite Symptoms subscale was 2.5 ± 1.3, for the Bowel Symptoms subscale was 2.8 ± 1.2, for the General Symptoms subscale was 2.9 ± 1.3, and the total mean score of the index was 2.8 ± 0.8. In the second measurement, the mean score for the Psychological Symptoms subscale was 1.4 ± 0.5, for the Physical Activities subscale was 2 ± 0.9, for the Desire-Symptoms subscale was 1.6 ± 0.9, for the Bowel Symptoms subscale was 1.6 ± 0.7, for the General Symptoms subscale was 2.1 ± 1.1, and the total mean score of the index was 1.8 ± 0.6 (Table 3). When PoRI sub-dimensions were examined, the highest mean scores were observed in the Physical Activities sub-dimension, whereas the lowest mean scores were found in the General Symptoms sub-dimension. No statistically significant differences were observed between PoRI total or sub-dimension scores and sociodemographic characteristics (p > 0.05).
Table 3.
Subscales and total score means of the PoRI
| Scale and Subscales | n | Min. | Max. | Mean | SD | |
|---|---|---|---|---|---|---|
| 1st Measurement (0–3 days) | Psychological Symptoms Mean Score | 145 | 1.00 | 5.00 | 2.2190 | 0.92650 |
| Physical Activities Mean Score | 145 | 1.00 | 5.00 | 3.2759 | 1.21540 | |
| Appetite Symptoms Mean Score | 145 | 1.00 | 5.00 | 2.5052 | 1.31414 | |
| Bowel Symptoms Mean Score | 145 | 1.00 | 5.00 | 2.8469 | 1.23018 | |
| General Symptoms Mean Score | 145 | 1.00 | 5.00 | 2.9431 | 1.32607 | |
| Total Score Mean of PoRI | 145 | 1.20 | 5.00 | 2.8444 | 0.86296 | |
| 2nd Measurement (10–15 days) | Psychological Symptoms Mean Score | 145 | 1.00 | 3.50 | 1.4017 | 0.53546 |
| Physical Activities Mean Score | 145 | 1.00 | 5.00 | 2.0560 | 0.97738 | |
| Appetite Symptoms Mean Score | 145 | 1.00 | 5.00 | 1.6310 | 0.95520 | |
| Bowel Symptoms Mean Score | 145 | 1.00 | 4.00 | 1.6690 | 0.79351 | |
| General Symptoms Mean Score | 145 | 1.00 | 5.00 | 2.1362 | 1.15957 | |
| Total Score Mean of PoRI | 145 | 1.00 | 4.24 | 1.8188 | 0.64234 |
Data are presented using descriptive statistics
SD Standard Deviation
A statistically significant positive correlation was identified between the ASSQ total score and the PoRI total score at both postoperative measurements (Spearman correlation, r = 0.222, p < 0.05) (Table 4).
Table 4.
The relationship between PoRI and ASSQ scores
| Scale Correlation |
Psychological Symptoms | Physical Activities | Appetite Symptoms | Bowel Symptoms | General Symptoms | PoRI Total Score | ASSQ Total Score | |
|---|---|---|---|---|---|---|---|---|
| Psychological Symptoms | rs | 1.000 | ||||||
| Physical Activities | rs | 0.385*** | 1.000 | |||||
| Appetite Symptoms | rs | 0.431*** | 0.347*** | 1.000 | ||||
| Bowel Symptoms | rs | 0.217** | 0.196* | 0.269** | 1.000 | |||
| General Symptoms | rs | 0.276** | 0.198* | 0.299*** | 0.300*** | 1.000 | ||
| PoRI Total Score | rs | 0.596*** | 0.735*** | 0.636*** | 0.609*** | 0.561*** | 1.000 | |
| ASSQ Total Score | rs | 0.163 | 0.152 | 0.197* | 0.102 | 0.097 | 0.222* | 1.000 |
rs = Spearman’s rank correlation coefficient
***p<0.001, **p<0.01, *p<0.05
As shown in Table 5, multivariable linear regression analyses showed that preoperative anxiety was independently associated with postoperative recovery at both assessment time points after adjustment for demographic and clinical covariates. The association was stronger in the early postoperative period (PoRI-1, 0–3 days; standardized β = 0.406, p < 0.001; adjusted R² = 0.166) compared with the post-discharge period (PoRI-2, 10–15 days; standardized β = 0.386, p < 0.001; adjusted R² = 0.115). Although the magnitude of the association attenuated over time, preoperative anxiety remained statistically significant in both models. None of the examined covariates, including type of surgery, were independently associated with postoperative recovery outcomes in either model (all p > 0.05) (Table 5).
Table 5.
Multivariable linear regression analyses examining the association between preoperative anxiety and postoperative recovery at two postoperative time points
| PoRI-1 (0–3 days) | PoRI-2 (10–15 days) | |
|---|---|---|
| Adjusted R² | 0.166 | 0.115 |
| ASSQ (standardized β) | 0.406 | 0.386 |
| ASSQ (p value) | < 0.001 | < 0.001 |
| Covariates† (all p > 0.05) |
PoRI Postoperative Recovery Index, ASSQ Anxiety Specific to Surgery Questionnaire
†Covariates included in the multivariable models were age group, sex, education level, working status, previous surgical experience, presence of comorbid disease, having children, and type of surgery. None of these covariates were independently associated with postoperative recovery outcomes (all p > 0.05)
A statistically significant difference was found between ASSQ total scores across educational status groups (Kruskal–Wallis test, p < 0.05). Post hoc Bonferroni analysis revealed significant differences between university graduates and patients who were illiterate, literate, or had primary/middle school education (p = 0.022, p = 0.025, and p = 0.005, respectively), with higher ASSQ scores observed among patients with lower educational levels.
In addition, ASSQ total scores were significantly higher among patients with children compared with those without children (Mann–Whitney U test, p < 0.05).
Discussion
It is known that preoperative anxiety not only is closely related to the entire surgical process but also is associated with postoperative recovery measures [10, 11]. Postoperative recovery is an energy-demanding process that begins shortly after surgery and extends beyond discharge. The intended outcome is to return to preoperative levels of physical, psychological, customary, and social states, achieving optimal well-being and preoperative levels of independence/dependence in daily life activities [1, 15, 23].
This study examined the relationship between preoperative anxiety and postoperative recovery at two different time points in patients undergoing general surgery. The findings indicate that higher levels of preoperative anxiety were statistically associated with poorer postoperative recovery, particularly during the early postoperative period. However, the strength of this association was modest and attenuated over time, suggesting that postoperative recovery is influenced by multiple interacting factors rather than a single determinant.
The mean score of the ASSQ in the preoperative period was found to be 27.9 ± 10.9 for the patients. According to some similar studies in the literature, Bulut (2017) reported a mean score of 28.6 ± 7.82 on the ASSQ [19], while Çevik Acar and Yıldız Fındık (2015) found a mean score of 28.5 ± 7.06 in their study [24]. Yıldız Fındık and Yıldızeli Topçu (2012) reported mean scores of 23.76 ± 7.12 for planned surgical interventions, 28.55 ± 7.15 for emergency surgical interventions, and 28.03 ± 8.20 for day surgery interventions [25]. In the study by Karancı and Dirik (2003), who developed the ASSQ, the mean score was reported to be 36.50 ± 17.55 [21]. Oflaz and Vural (2010) stated that the anxiety levels of patients in surgical clinics were higher than those in other clinics and that these levels increased even more when they focused on the surgery [25]. These findings suggest that the level of anxiety specific to surgery experienced by surgical patients is above average. Based on the literature, it is observed that preoperative anxiety still exists but shows a decrease in measured results and scores over time. Factors such as preoperative information, patient education, and patient-centered approaches have been discussed in the literature in relation to this decrease [20].
Nurses are an essential part of the preoperative period. They are responsible for monitoring and identify surgical risk factors, assessing patients’ needs, managing patients’ expectations, and understand their sensitivities [26]. In a study evaluating the quality of perioperative nursing care, Çevik Acar and Yıldız Fındık (2015) emphasized the importance of patient satisfaction and noted that the perceived quality of care may be associated with patients’ preoperative anxiety levels [20]. Widiyawati et al. (2024) reported that hand relaxation and progressive muscle relaxation techniques applied before cesarean section were associated with lower preoperative anxiety levels The authors also discussed that interventions targeted during the preoperative period may be related to improvements in postoperative recovery [27]. In addition, İnce and Özlü (2024) reported an association between higher preoperative anxiety levels and less favorable postoperative recovery experiences. These findings highlight the importance of nurses taking a more proactive role in the assessment and management of preoperative anxiety [28].
A statistically significant difference was identified between ASSQ mean scores and sociodemographic characteristics, particularly with respect to education level. Lower ASSQ scores were observed among patients with higher levels of education. This finding is consistent with the study by Bulut (2017), who examined characteristics related to preoperative anxiety and reported that the scores of patients who were illiterate or had only completed high school were statistically significantly higher than those of patients who had graduated from university [19].
A statistically significant difference was found in the mean scores of the ASSQ based on whether patients had children (p < 0.05). Higher ASSQ scores were observed among patients with children compared with those without children. Similarly, another study examining preoperative anxiety reported higher anxiety scores among patients with a greater number of children [20].
The recovery status and difficulties in recovery of the patients participating in the study were examined based on the total score and sub-dimensions of the PoRI. In the first measurement, moderate difficulties were identified in Psychological Symptoms, while significant difficulties were experienced in other areas and overall. In the second measurement, patients experienced mild difficulties in Psychological Symptoms and moderate difficulties in other areas and overall.
Furthermore, when examining the measurements of the PoRI, it was observed that patients had the highest mean scores in the Physical Activities sub-dimension and the lowest mean scores in the General Symptoms sub-dimension [29]. These results suggest that surgical intervention impacts physical activities more significantly and that general symptoms are less pronounced. In this study, no statistically significant differences were found between the PoRI and sociodemographic data. The difference between these results and those reported by Dığın and Kızılcık Özkan may be related to the exclusively elderly population in their study [29].
Research on the recovery experiences of patients after colorectal surgery reveals severe physical weakness and a high need for caregiver support in the postoperative period [30, 31]. These findings emphasize that the recovery process involves not only physical but also psychological and social dimensions. Similarly, in this study, a negative association was observed between preoperative anxiety and postoperative recovery. In particular, greater recovery difficulties were observed during the first three days of the postoperative period, indicating a need for psychological support in this process. Importantly, the observed association between preoperative anxiety and postoperative recovery persisted after adjustment for multiple demographic and clinical variables, suggesting that this relationship was not explained by differences in surgical type or patient characteristics. It is frequently reported in the literature that preoperative anxiety may be associated with less favorable surgical outcomes and postoperative recovery experiences [32]. The difficulties experienced by patients after colorectal surgery indicate that this process includes not only physical recovery but also psychological and social needs. In this context, it is suggested that nurses may adopt a more holistic approach in the postoperative support process by taking into account the psychological status of patients. Xiangting et al. (2023) stated that providing more support psychological support by nurses may be associated with more favorable recovery experiences [31]. These findings highlight that not only physical but also psychological and social needs of patients should be taken into consideration in the postoperative period. In this context, developing intervention strategies for patients with anxiety in the preoperative period may support the postoperative recovery process.
A study evaluating postoperative recovery via a mobile application on the 7th and 14th days revealed that the recovery criteria in the experimental group (sleep difficulties, general discomfort, feeling unwell, dizziness, headache, difficulty in eating, pain, or edema at the surgical incision site) were better compared to the control group, which did not receive nurse intervention [33]. Similarly, in this study, recovery was assessed using similar criteria postoperatively, and all patients were followed up by a nurse on days 10–15. Based on these findings, it can be suggested that interaction with a nurse during the post-discharge period may be associated with more favorable recovery experiences.
Postoperative recovery is a subjective, multidimensional, long-term, and complex process; therefore, using only objective findings to explain it may not be sufficient [34]. This highlights the importance of understanding the role of psychological factors before and after surgery. In a study on the Enhanced Recovery After Surgery (ERAS) approach in laparoscopic urology surgery, more favorable recovery outcomes were observed in the experimental group where nursing interventions were conducted. The study results suggest that the concept of rapid rehabilitation surgery, combined with psychological nursing stress interventions and nursing guidance, may be associated with better regulation anxiety and depression, reduced postoperative stress responses, improve immune function, and a more favorable recovery process [35].
In study investigating sleep quality, anxiety, and perceived stress levels in patients scheduled for surgery, it has been reported that longer preoperative hospital stays are associated with increased stress and anxiety levels. In particular, studies conducted in patients undergoing cardiac surgery have shown that prolonged preoperative hospitalization is associated with higher preoperative anxiety levels, which may be related to postoperative stress responses [36]. The results of a study examining preoperative anxiety and its relationship with postoperative sleep quality indicated that as patients’ preoperative anxiety increased, their postoperative sleep quality and comfort levels tended to decrease [37]. Similarly, other studies have reported that higher levels of preoperative anxiety are associated with increased postoperative pain and sleep disturbances [37, 38]. In another study examining postoperative outcomes related to preoperative anxiety, it was found that higher anxiety levels were associated not only with increased postoperative pain but also with a higher incidence of nausea and vomiting [39]. The findings of this study indicate that higher preoperative anxiety levels are associated with poorer postoperative recovery. Although the correlation between preoperative anxiety and postoperative recovery was statistically significant, the magnitude of this association was modest. This finding suggests that preoperative anxiety represents one of multiple factors related to postoperative recovery rather than a dominant determinant. Implementing appropriate psychological support and stress management strategies in the preoperative period may support patients’ postoperative recovery process. Postoperative psychological support and stress intervention may help alleviate the negative experiences associated with preoperative anxiety and contribute the recovery. These findings highlight the importance of preoperative anxiety management and the potential role of psychological support strategies on postoperative recovery. Therefore, providing psychological evaluation and appropriate interventions during the preoperative period may help patients experience a more favorable recovery outcomes. However, more research and individualized nursing interventions are needed to better address patients’ personal needs and anxiety levels [40].
Strengths and limitations
Despite the strengths of the study, several limitations should be acknowledged. Data collection was conducted during the COVID-19 pandemic, which prolonged the data collection period. During the early stages of the pandemic, elective surgeries were suspended for extended periods, and after resumption, patients were frequently referred to day surgery settings. This may have limited opportunities for preoperative counselling and contributed to constraints on sample size. In addition, major surgical procedures were postponed as much as possible during this period.
Due to the observational design of the study, causal relationships between preoperative anxiety and postoperative recovery cannot be inferred. Although multivariable analyses adjusting for clinical and demographic variables were conducted during the thesis phase of the study, these analyses did not demonstrate statistically significant independent associations. Therefore, they were not included in the present manuscript, which focuses on the primary descriptive and correlational findings.
Furthermore, a substantial proportion of the study sample (approximately 60%) had previously undergone at least one surgical procedure. Prior surgical experience may influence patients’ perceptions of the perioperative process and may be associated with lower levels of preoperative anxiety. This may have contributed to an underestimation of anxiety prevalence and may limit the representativeness and generalizability of the findings.
The inclusion of patients undergoing a wide range of surgical procedures with varying levels of invasiveness and recovery trajectories may have contributed to heterogeneity in postoperative recovery outcomes and may also have influenced the interpretation of the ASSQ and PoRI, despite their established validity. This heterogeneity should be taken into consideration when interpreting the results.
Although the achieved statistical power was slightly below the conventional 0.80 threshold (1 − β = 0.77), it was considered sufficient to detect small-to-moderate associations; however, weaker relationships may have remained undetected.
Finally, the timing of the second PoRI measurement (postoperative days 10–15) differed from that used in some original validation studies (postoperative days 15–30), which may limit the direct comparability of recovery scores across studies.
Conclusion
Postoperative recovery tended to be poorer among patients with higher levels of preoperative anxiety. These findings suggest that preoperative anxiety may be associated with postoperative recovery outcomes alongside other clinical and psychosocial factors. Given the observational design of the study, causal inferences cannot be made, and the observed association may be influenced by surgical and patient-related characteristics. Accordingly, a multidisciplinary and multimodal approach may be considered, including comprehensive evaluation patients’ anxiety levels, provision of appropriate professional support for patients experiencing anxiety, efforts to minimize preoperative hospital stay where feasible, routinely assessment of postoperative recovery, and tailoring of nursing care to individual patient needs. Additionally, future prospective studies with larger samples and comprehensive multivariable analyses across different surgical populations are warranted to further clarify this relationship and inform clinical practice.
Psychological care and targeted interventions in nursing
This study highlights the psychological dimension of nursing by underscoring nurses’ role in assessing preoperative anxiety levels and in informing the development of tailored patient education and psychosocial support approaches that take patients’ educational background and parental status.
Timely, evidence‑based recovery monitoring
By systematically evaluating postoperative recovery at early (days 0–3) and later (days 10–15) intervals using the PoRI, this research offers evidence‑based insights that may inform care planning and the timing of supportive interventions.
Holistic surgical nursing approach
Through the concurrent examination of preoperative anxiety and postoperative recovery across a heterogeneous surgical cohort, the study provides a comprehensive perspective to the general surgery literature and supports the integration of nursing practice within multidisciplinary care pathways.
Supplementary Information
Acknowledgements
We would like to thank the participations who participated in this study. All participants were informed about the purpose and procedures of the study and voluntarily provided written informed consent prior to participation.
Authors’ contributions
All authors of this paper meet the authorship criteria according to the International Committee of Medical Journal Editors guidelines. Study design: NET, YCD. Data collection: NET. Data analysis: NET, YCD. Study supervision: NET, YCD. Manuscript writing: NET, YCD. Both authors read and approved the final version of the manuscript.
Funding
During this study, no financial or spiritual support was received neither from any pharmaceutical company that has a direct connection with the research subject, nor from a company that provides or produces medical instruments and materials which may negatively affect the evaluation process of this study.
Data availability
The datasets produced and investigated during this study are available from the relevant author upon reasonable request (Corresponding Author Email: candanyelda@hotmail.com).
Declarations
Ethics approval and consent to participate
Our study adhered to the Declaration of Helsinki. Ethical approval for this research was received from Ege University Medical Research Ethics Committee (Date: 15.09.2020, Decision No: 20-9T/12). All participants were informed about the purpose and procedures of the study and voluntarily provided written informed consent prior to participation.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets produced and investigated during this study are available from the relevant author upon reasonable request (Corresponding Author Email: candanyelda@hotmail.com).