The relationship between perceived safety and postoperative recovery in patients undergoing surgery with regional anesthesia: a cross-sectional study

Abstract

Background

Patients’ emotional and psychological experiences during surgery can significantly affect postoperative recovery. In procedures performed under regional anesthesia, where patients remain conscious, the perception of safety may play a critical role in both intraoperative comfort and recovery outcomes.

Methods

This descriptive and correlational study was conducted between February 1 and June 30, 2025, in a public hospital in Istanbul. A total of 308 patients undergoing elective surgery under regional anesthesia were included. Data were collected using the Patient Information Form, Feeling Safe During Surgery Scale, and Postoperative Recovery Index. Descriptive statistics, the Mann–Whitney U test, the Kruskal–Wallis H test, and Spearman’s correlation analysis were used for data analysis.

Results

Patients reported a high level of perceived safety during surgery (M = 115.72 ± 10.50), while postoperative recovery was characterized by moderate levels of difficulty (M = 1.69 ± 0.36). Difficulties were most pronounced in the physical activity domain of recovery. A low but statistically significant negative correlation was identified between perceived safety during surgery and postoperative recovery scores (r = -0.157, p < 0.001).

Conclusions

Higher perceived safety during surgery may be associated with fewer difficulties in postoperative recovery among patients undergoing regional anesthesia. Providing structured preoperative information, maintaining clear communication, and offering supportive nursing care may help strengthen patients’ perceived safety and support postoperative recovery within the perioperative process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-026-03772-5.

Introduction

Patients’ perioperative perceptions of safety may play an important role in postoperative recovery. In addition, being hospitalized and undergoing surgery are commonly associated with increased perioperative anxiety, often related to uncertainty about the surgical procedure, anesthesia, and the overall treatment experience [1]. Preoperative anxiety is a well-documented phenomenon and has been shown to be influenced by various patient-related and clinical factors prior to surgery. In addition, perioperative anxiety is commonly experienced by surgical patients and may occur across different types of surgical procedures [2].

Patient safety in surgical care is closely related to the management of complex healthcare systems and the implementation of effective safety strategies within hospitals [3]. In the operating theatre, nurses’ non-technical skills such as communication, teamwork, and situational awareness play a critical role in maintaining patient safety during surgical procedures [4]. During the perioperative period, nurses also play a key role in supporting surgical patients through effective communication, provision of information, and professional care. These nursing-related factors, together with the organization of perioperative care and teamwork within the surgical environment, have been associated with patients’ experiences of care and satisfaction during the surgical process [4–6]. In this context, understanding patients’ experiences and emotional responses during the surgical process, particularly in the operating room environment, is of particular importance [7].

According to data from the General Directorate of Health Services, a total of 4,704,094 surgical procedures were performed in public, private, and university hospitals in Turkey in 2021 [8]. Surgical procedures conducted across different healthcare institutions and clinical environments may expose patients to varying perioperative care contexts. Institutional characteristics, communication with healthcare professionals, and differences in the organization of care processes may influence patients’ experiences during hospitalization and surgery. Therefore, perceived safety has been considered an important dimension of the healthcare experience. Kenward et al. reported that patients’ perceptions of safety in healthcare settings are influenced by factors such as communication with healthcare professionals, staff support, and the overall quality of care [9]. Similarly, Dahlberg et al. emphasized that feeling safe and supported by healthcare professionals is an important component of patients’ experiences throughout the surgical care and postoperative recovery process [10].

In surgeries performed under regional anesthesia, patients usually remain awake or only lightly sedated, and the temporary loss of normal movement and sensation may contribute to anxiety, discomfort, or fear during the surgical procedure [11, 12]. In addition, remaining conscious throughout the procedure, fear of intraoperative pain, and exposure to auditory or visual stimuli in the operating room may further intensify stress and anxiety [11, 13, 14]. For this reason, perceived safety may assume a particularly important role in surgical interventions performed under regional anesthesia. Patients’ subjective experiences related to anesthesia and the surgical environment shape their emotional responses, which may be associated with postoperative recovery outcomes [15, 16].

Previous studies have demonstrated consistent associations between preoperative anxiety and postoperative outcomes. Higher anxiety levels have been associated with greater analgesic requirements and delayed recovery trajectories, while perioperative anxiety has also been linked to poorer patient-reported experiences such as lower satisfaction with perioperative care [15, 16]. Preoperative anxiety is also influenced by patient- and experience-related factors, including previous anesthesia experience, age, sex, and education [17]. In addition, perioperative stress and anxiety may adversely affect recovery trajectories, highlighting the need for targeted strategies to mitigate anxiety before and during surgery [15].

In the context of regional anesthesia, perceived safety may be shaped not only by fears related to the surgical procedure itself but also by patients’ understanding of the anesthesia process and the intraoperative environment. Being awake during surgery, fear of intraoperative pain, and exposure to auditory or visual stimuli may intensify anxiety and discomfort [11–14]. Evidence suggests that structured preoperative information and patient education can reduce anxiety and improve patient experiences and satisfaction with care [5]. Therefore, clear communication about anesthesia techniques, potential risks, and expected perioperative sensations, together with supportive nurse-patient interactions, may contribute to greater perceived safety and more favorable recovery experiences [4–6, 15].

Overall, the literature highlights a complex interaction between perceived safety, anxiety, and postoperative recovery among patients undergoing surgery with regional anesthesia. Understanding these interrelated factors is essential when developing interventions targeting both psychological and clinical dimensions of perioperative care. Educational approaches and effective communication strategies enable healthcare professionals to foster a more supportive and therapeutic environment. Such practices may enhance patients’ perceived safety and be associated with more favorable recovery experiences. Within this scope, the present study aimed to determine the relationship between perceived safety during surgery and postoperative recovery in patients undergoing surgery with regional anesthesia at a state hospital in Istanbul, Turkey.

Materials and methods

Ethical considerations

This study was conducted in full accordance with the ethical principles outlined in the Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Non-Interventional Clinical Studies Ethics Committee of Marmara University Faculty of Health Sciences (Decision No: 18, Date: 29 January 2025). Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were clearly informed that they could withdraw from the study at any stage without any effect on their medical treatment or nursing care. Permission to use the Feeling Safe During Surgery Scale was obtained from the original scale developers, and permission to use the Postoperative Recovery Index was obtained from the authors of the Turkish validity and reliability study.

Study design

This study was designed as a descriptive, correlational study.

Research questions

The study addressed the following research questions:

• How safe do patients undergoing surgery with regional anesthesia perceive themselves to be during the surgical process?

• What are the postoperative recovery levels of patients undergoing surgery with regional anesthesia?

• Is there an association between perceived safety during surgery and postoperative recovery levels in patients undergoing surgery with regional anesthesia?

Setting and study period

The study was conducted in all surgical clinics (neurosurgery, general surgery,orthopedics and traumatology, urology and cardiovascular surgery) of a state hospital in Istanbul, Turkey, between February 1 and June 30,2025.

Population and sample

According to institutional records, a total of 1,077 patients underwent surgery under regional anesthesia at the study hospital in 2024. Since the present study was designed as a descriptive and correlational study, the sample size was calculated using the known population sample size formula to obtain a representative sample of the study population. With a 95% confidence level, a 5% margin of error, and assuming maximum variability (p = 0.5), the minimum required sample size was calculated as 284 participants.

A census approach including all eligible patients was not feasible due to the limited study period; therefore, sampling was performed to obtain a representative sample of the study population. The study was completed with 308 patients, exceeding the calculated minimum sample size. In addition, the achieved sample size (n = 308) provides adequate statistical power to detect small associations between the variables examined in this study [18, 19].

Eligibility criteria

Inclusion criteria were: elective surgical patients undergoing surgery under regional anesthesia without additional sedation (including neurosurgical procedures such as lumbar disc herniation surgery; general surgical procedures such as stoma closure, cholecystectomy, appendectomy, and hernia repair; urological procedures such as cystoscopy; and orthopedic-traumatologic procedures such as arthroscopy, carpal tunnel release, and trigger finger surgery), individuals aged 18 years or older, patients with clear consciousness, those able to read and write Turkish, and those who agreed to participate in the study.

Exclusion criteria were: patients undergoing surgery under general anesthesia, emergency surgical procedures, patients diagnosed with cognitive or psychiatric disorders, patients who were hemodynamically unstable and required postoperative admission to the intensive care unit, and patients who withdrew from the study.

Data collection methods and instruments

A structured self-report data collection approach was used. Data were collected by the researchers through face-to-face interviews conducted in the patients’ rooms within the first 24 h after surgery, at a time that did not interfere with routine treatment or nursing care. The instruments used for data collection were the Patient Information Form, the Feeling Safe During Surgery Scale (FSDS), and the Postoperative Recovery Index (PoRI).

Patient information form

The Patient Information Form consisted of 11 items developed by the researchers in line with the literature to describe patients’ sociodemographic and clinical characteristics, including age, sex, educational level, employment status, type of surgical procedure, anesthesia method, history of previous surgery, anesthesia method used in previous surgeries, number of previous surgeries, and presence of a companion [9, 20–24].

Feeling safe during surgery scale

The Feeling Safe During Surgery Scale (FSDS) was developed by Larsson et al. in 2021 to assess patients’ perceived sense of safety during surgical procedures performed under regional anesthesia. The scale is a one-dimensional instrument consisting of 13 items. Each item is scored on a 10-point Likert-type scale ranging from 1 (completely negative) to 10 (completely positive), resulting in a total score ranging from 13 to 130. Higher scores indicate a higher level of perceived safety during surgery. The original study reported good internal consistency with a Cronbach’s alpha coefficient of 0.88 [21], and the Turkish validity and reliability study reported a Cronbach’s alpha value of 0.83 [22]. In the present study, the Cronbach’s alpha coefficient was 0.80.

Postoperative recovery index

The Postoperative Recovery Index (PoRI), developed by Butler et al. in 2012, is a multidimensional instrument designed to assess patients’ subjective perceptions of postoperative recovery during the early recovery period following surgery, typically within the first 30 days. The original scale consists of 37 items grouped into five domains: psychological symptoms, physical activities, general symptoms, bowel symptoms, and appetite-related symptoms. Items are rated on Likert-type response options reflecting the severity or limitation experienced by the patient, and scores are calculated as the mean of item responses across domains. Higher scores indicate greater difficulty in postoperative recovery. The original study reported excellent internal consistency with a Cronbach’s alpha coefficient of 0.95 [23]. The Turkish validity and reliability study also demonstrated high internal consistency (Cronbach’s α = 0.96) [24]. In the present study, the Cronbach’s alpha coefficient was 0.85.

The measurement instruments used in this study, including their characteristics and psychometric properties, are presented in Supplementary Material Table 1.

Data collection procedure

Regional anesthesia procedures were categorized as central blocks, peripheral nerve blocks, and local anesthesia techniques. At the study hospital, patients undergoing surgery with regional anesthesia typically had a one-day hospital stay, provided no complications occurred. The suitability of the first 24-hour postoperative period for data collection was evaluated in consultation with the patient and the responsible nurse, taking into account pain level, sedation status, and level of consciousness. This early period was considered appropriate to capture patients’ immediate perceptions of the surgical experience. Both scales used were methodologically compatible with the study population and data collection timing [21–24]. The FSDS was administered postoperatively because it was originally developed to evaluate patients’ retrospective perceptions of safety during the surgical experience [21]. Assessing perceived safety shortly after surgery allows patients to reflect on the intraoperative experience while the events are still recent in memory. In addition, collecting data during the early postoperative period is commonly used in studies evaluating perioperative patient experiences and recovery processes [25]. Therefore, the first 24-hour postoperative period was considered appropriate to capture patients’ immediate experiences while minimizing the potential risk of recall bias.

Statistical analysis

Descriptive statistics were used to summarize the data. Continuous variables were presented as mean ± standard deviation or median (minimum–maximum), while categorical variables were presented as numbers and percentages. Normality was assessed using the Kolmogorov–Smirnov test, and non-parametric statistical methods were applied accordingly. Associations between continuous variables were examined using Spearman’s rho correlation coefficient. Group comparisons were conducted using the Mann–Whitney U test and Kruskal–Wallis H test, with Bonferroni correction applied for post hoc analyses. Statistical analyses were performed using SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA) and statistical significance was set at p < 0.05.

Clinical trial number

This study was not registered as a clinical trial because it was a descriptive and correlational study; therefore, a clinical trial number is not applicable.

Results

As shown in Table 1, the mean scores of the scales used in the study were as follows: the FSDS (mean ± SD: 115.72 ± 10.50), the PoRI (1.69 ± 0.36), and its subscales-Psychological Symptoms (1.32 ± 0.54), Physical Activities (2.63 ± 0.88), General Symptoms (1.21 ± 0.39), Bowel Symptoms (1.30 ± 0.45), and Appetite Symptoms (1.14 ± 0.38). The internal consistency coefficients of the overall scales and their subscales ranged between 0.671 and 0.931. These findings indicate acceptable to high internal consistency for the measurement instruments used in the study.

Table 1.

Descriptive statistics of the scales used in the study (N = 308)

Scales	Mean ± SD	Median	Min.-Max.	Cronbach’s Alpha
Feeling Safe During Surgery Scale	115.72 ± 10.50	121.00	64–130	0.802
Postoperative Recovery Index	1.69 ± 0.36	1.60	1.00-2.96	0.850
Psychological Symptoms Subscale	1.32 ± 0.54	1.00	1.00-4.25	0.671
Physical Activities Subscale	2.63 ± 0.88	2.63	1.00–5.00	0.931
General Symptoms Subscale	1.21 ± 0.39	1.00	1.00-3.25	0.715
Bowel Symptoms Subscale	1.30 ± 0.45	1.00	1.00–3.00	0.817
Appetite Symptoms Subscale	1.14 ± 0.38	1.00	1.00-4.25	0.829

Mean Arithmetic average, SD Standard deviation, Min Minimum score, Max Maximum score

As shown in Table 2, 57.1% of the participants were male, 35.7% were aged between 66 and 75 years, and 51.9% were primary school graduates. 71.1% were not employed, 48.1% had undergone orthopedic surgery, and 86.4% received spinal/epidural anesthesia. In addition, 71.8% had a history of previous surgery, 31.8% had undergone surgery once, and 84.1% were accompanied by first-degree relatives.

Table 2.

Comparison of descriptive characteristics with overall scores of the feeling safe during surgery scale and the postoperative recovery index (N = 308)

Variables	N	Feeling Safe During Surgery Scale				Postoperative Recovery Index Scale
		Mean	SD	Med	M.R.	Mean	SD	Med	M.R.
Gender
Female	132	116.73	11.23	121.00	168.41	1.69	0,39	1.68	157,00
Male	176	114.96	9.88	117.00	144.07	1.68	0,34	1.56	152,62
Statistical Analysis		U: 9780.5 p: 0.017 / d: 0.273				U:1 1285.5 p: 0.669 ---
Age Groups
a- Between 26 and 35	29	118.38	7.85	121.00	174,43	1.49	0,35	1.40	101,36
b- Between 36 and 45	34	114.76	9.00	116.50	143,18	1.68	0,45	1.54	149,54
c- Between 46 and 55	53	114.64	10.02	116.00	141,17	1.67	0,30	1.60	156,67
d- Between 56 and 65	82	117.94	10.06	121.00	176,93	1.68	0,36	1.62	150,81
e- Between 66 and 75	110	114.18	11.76	117.50	142,45	1.76	0,35	1.70	171,75
Statistical Analysis / Comparison Results		X2 : 10.50 p: 0.033 / d: 0.296 d > c;d > e				X2 : 14.75 p: 0.005 / d: 0.384 a < c-a < d-a < e
Education Level
a- Literate (No formal education)	13	120.31	4.87	121.00	190.12	1.92	0.38	1.84	207.69
b- Primary School	160	114.88	11.14	118.00	147.50	1.70	0.34	1.60	158.55
c- Secondary School	32	114.34	11.24	116.00	147.53	1.73	0.39	1.66	163.86
d- High School	64	116.70	9.41	121.00	158.18	1.58	0.32	1.60	131.22
e- Bachelor’s Degree	39	117.18	9.92	121.00	171.01	1.69	0.47	1.52	150.69
Statistical Analysis/ Comparison Results		X2 : 4.75 p:0.313 ---				X2 : 9.78 p: 0.044 / d: 0.279 a > d
Employment
Not working	219	115.88	10.83	121.00	156.25	1.71	0.36	1.64	159.37
Working	89	115.34	9.70	117.00	150.19	1.64	0.37	1.56	142.51
Statistical Analysis		U: 9362.0 p: 0.587				U: 8678.0 p:0.132
Surgical Procedure/Operation
a-Orthopedic Surgery	148	117.20	9.14	121.00	164.07	1.71	0.41	1.68	156.31
b-Urologic Surgery	92	114.14	11.82	117.00	143.79	1.76	0.31	1.66	176.94
c-General Surgery	33	113.45	13.52	121.00	149.64	1.65	0.22	1.56	151.56
d- Cardiovascular Surgery	35	115.74	8.18	121.00	146.77	1.42	0.24	1.44	90.61
Statistical Analysis/ Comparison Results		X2 : 3.43 p: 0.330 ---				X2 : 3.99 p: 0.001 / d: 0.114 d < a-d < b-d < c
Type of Anesthesia Used
Spinal/Epidural Anesthesia	266	115.43	11.03	120.00	154.71	1.74	0.36	1.68	169.60
Nerve Block	42	117.55	5.87	121.00	153.18	1.35	0.09	1.36	58.89
Statistical Analysis		U: 5530.5 p: 0.917				U: 1570.5 p:0.000 / d: 0.943
Previous Surgery
Yes	221	115.73	10.79	121.00	154.77	1.72	0.34	1.68	164.55
No	87	115.70	9.77	121.00	153.82	1.61	0.41	1.52	128.98
Statistical Analysis		U: 9554.5 p: 0.933				U: 7393.0 p: 0.002 / d: 0.366
Anesthesia Method Used in Previous Surgery
a-General Anesthesia and Spinal Anesthesia	61	114.15	12.98	121.00	147.93	1.74	0.39	1.68	165.75
b-General Anesthesia	76	116.03	8.56	118.00	148.59	1.77	0.32	1.72	177.22
c-Spinal Anesthesia	67	116.57	9.74	121.00	160.33	1.67	0.33	1.64	153.38
d-Epidural Anesthesia	17	116.76	14.85	122.00	185.00	1.63	0.25	1.64	147.59
e-No Previous Surgery and No Anesthesia Received	87	115.70	9.77	121.00	153.82	1.61	0.41	1.52	128.98
Statistical Analysis/ Comparison Results		X2 : 2.98 p: 0.561 ---				X2 : 13.20 p: 0.010 / d: 0.354 e < a;e < b
Number of Previous Surgeries, if Applicable
a-Once	98	115.74	9.17	118.50	146.24	1.69	0.34	1.60	157.02
b-Twice	69	114.39	13.10	121.00	153.78	1.69	0.35	1.64	157.99
c-Three Times or More	54	117.41	10.20	121.00	171.49	1.81	0.33	1.86	186.59
d- No Previous Surgery and No Anesthesia Received	87	115.70	9.77	121.00	153.82	1.61	0.41	1.52	128.98
Statistical Analysis/ Comparison Results		X2 : 2.84 p: 0.417 ---				X2 : 14.36 p: 0.002 / d: 0.394 d < a;d < c
Presence of a Companion
a-Companion Present (First-Degree Relative)	259	115.00	10.86	120.00	147.96	1.69	0.35	1.60	156.80
b-Companion Present (Second-Degree Relative / Friend)	38	121.87	6.13	122.00	216.58	1.73	0.46	1.68	162.42
c-No Companion	11	111.45	5.09	109.00	94.00	1.40	0.13	1.40	73.09
Statistical Analysis		X2 : 25.16 p: 0.001 / d: 0.573 b > a;b > c				X2 : 9.68 p: 0.008 / d: 0.321 c < a;c < b

Bonferroni correction was applied for intergroup comparisons. X² denotes the Kruskal–Wallis H test and U denotes the Mann–Whitney U test

SD Standard deviation, Med Median, MR Mean rank. Cohen’s d values of 0.20–0.59 indicate a medium effect size, and values ≥ 0.60 indicate a large effect size

Based on demographic characteristics, a statistically significant difference was observed between gender and FSDS scores (U = 9780.5; p = 0.017), with higher scores reported by female participants. A significant difference was also found among age groups (χ² = 10.50; p = 0.033); post hoc analyses indicated that participants aged 56–65 years had higher scores than those aged 46–55 years (U = 1656.5; p = 0.016) and 66–75 years (U = 3515.5; p = 0.009). No statistically significant differences were found in FSDS scores according to educational level (p > 0.05). Participants accompanied by second-degree relatives or friends had significantly higher scores compared with those accompanied by first-degree relatives (U = 2724.5; p < 0.001) and those without companions (U = 46.5; p < 0.001; χ² = 25.16; p < 0.001). No statistically significant differences were observed according to employment status, type of surgery, or previous surgical history.

With regard to the PoRI scores, no statistically significant difference was found according to gender (p > 0.05). However, a significant difference was observed among age groups (χ² = 14.75; p = 0.005); scores in the 26–35 age group were lower than those in the 46–55 (U = 603.5; p = 0.004), 56–65 (U = 816.0; p = 0.012), and 66–75 age groups (U = 859.0; p < 0.001). According to educational level, participants who were literate without formal education had higher scores than high school graduates (U = 211.5; p = 0.005; χ² = 9.78; p = 0.044). Participants who received spinal/epidural anesthesia had higher scores than those who underwent nerve block anesthesia (U = 1570.5; p < 0.001). Participants with previous surgical experience had higher scores than those without such experience (U = 7393.0; p = 0.002). Regarding previous anesthesia type, participants who had received general or spinal anesthesia had higher scores than those who had not received anesthesia (χ² = 13.20; p = 0.010). In addition, participants who had undergone surgery three or more times had higher scores than those with no previous surgical history (χ² = 14.36; p = 0.008). Participants without companions had lower scores than those accompanied by first-degree relatives (U = 98.0; p = 0.008) or second-degree relatives/friends (U = 640.0; p = 0.002; χ² = 9.68; p = 0.008) (Table 2).

As presented in Table 3, a low-level, negative, statistically significant correlation was identified between overall FSDS scores and both overall PoRI scores (r = − 0.157; p < 0.001) and the physical activities subscale (r = − 0.228; p < 0.001). No statistically significant correlations were observed between FSDS scores and the psychological symptoms, general symptoms, bowel symptoms, or appetite symptoms subscales of the PoRI (p > 0.05).

Table 3.

Correlations between perceived safety during surgery and overall and subscale scores of the postoperative recovery index (N = 308)

Variables	1.	2.	3.	4.	5.	6.	7.
1. Perceived Safety during Surgery Scale	1.00
2. Postoperative Recovery Index Scale	− 0.157**	1.00
3. Psychological Symptoms Subscale	0.029	0.298**	1.00
4. Physical Activities Subscale	− 0.228**	0.835**	− 0.027	1.00
5. General Symptoms Subscale	− 0.029	0.495**	0.127*	0.229**	1.00
6. Bowel Symptoms Subscale	0.049	0.468**	0.302**	0.093	0.444**	1.00
7 Appetite Symptoms Subscale	− 0.096	0.404**	0.133*	0.120*	0.336**	0.265**	1.00

Spearman’s rho correlation coefficient was used to assess the relationships between variables. * p < 0.05, ** p < 0.001

According to Tables 4 and 64.9% of participants rated their overall postoperative recovery as moderately difficult, while 0.6% reported no difficulty and no participants reported extreme difficulty. Regarding psychological symptoms, 63.0% reported no difficulty, whereas 0.6% reported extreme difficulty. For physical activity, 38.0% reported severe difficulty and 2.9% reported no difficulty. In terms of general symptoms, 65.6% reported no difficulty and 2.3% reported severe difficulty. For bowel symptoms, 57.8% reported no difficulty and 2.9% reported severe difficulty. Finally, regarding appetite symptoms, 85.7% reported no difficulty and 0.3% reported extreme difficulty.

Table 4.

Results of patients’ postoperative recovery index scale total scores and subscale scoring system (N = 308)

Variables	No Difficulty		Mild Difficulty		Moderate Difficulty		Severe Difficulty		Extreme Difficulty
	n	%	n	%	n	%	n	%	n	%
Postoperative Recovery Index Scale	2	0.6	105	34.5	200	64.9	0	0.0	0	0.0
Psychological Symptoms Subscale	194	63.0	13	4.2	82	26.6	17	5.5	2	0.6
Physical Activities Subscale	9	2.9	24	7.8	97	31.5	117	38.0	61	19.8
General Symptoms Subscale	202	65.6	44	14.3	55	17.9	7	2.3	0	0.0
Bowel Symptoms Subscale	178	57.8	55	17.9	66	21.4	9	2.9	0	0.0
Appetite Symptoms Subscale	264	85.7	5	1.6	37	12.0	1	0.3	1	0.3

n Number, % Percentage

Discussion

In this study, patients who underwent surgery with regional anesthesia were found to report a high level of perceived safety during the surgical process, and the internal consistency coefficient of the scale was within an acceptable range (Table 1). This finding is consistent with the reliability reported in the original study of the FSDS developed by Larsson and colleagues and supports the use of the scale as a reliable measurement tool in surgical nursing research [21]. Similarly, the Turkish validity and reliability study conducted by Katran et al. reported a comparable Cronbach’s alpha value, indicating cross-cultural consistency of the FSDS [22]. Larsson and colleagues emphasized that patients’ feelings of safety during the surgical process are closely associated with their relationships with nurses and their sense of control. In line with this perspective, the present findings suggest that nursing care and nurse–patient interactions are important components of perceived safety during surgery [12].

The present study showed that the overall postoperative recovery level measured by the PoRI was generally characterized by low to moderate difficulty, while difficulties related to physical activities were more prominent compared to other subscales (Table 1). This pattern may be related to the relatively high proportion of participants who underwent orthopedic surgery, as limitations in mobility are commonly observed during postoperative recovery in this group. Nilsson et al. reported that although regional anesthesia has several advantages, physical fatigue and unexpected postoperative symptoms may complicate the recovery process [25]. Similarly, qualitative findings by Larsson et al. indicated that patients often experience challenges such as loneliness, difficulty balancing activity and rest, and insufficient information during recovery [26]. Together, these findings highlight the importance of individualized postoperative nursing care, particularly in addressing physical activity–related challenges, and underscore the potential role of adequate information and supportive care in shaping patients’ recovery experiences.

The findings further emphasize the interplay between postoperative recovery, perceived safety during surgery, and individual, environmental, and care-related factors. PoRI scores varied according to several sociodemographic and clinical characteristics. Patients who received peripheral nerve block anesthesia reported lower PoRI scores than those who received spinal or epidural anesthesia, indicating fewer difficulties in postoperative recovery (Table 2). Because higher PoRI scores represent greater recovery difficulties, this finding suggests relatively better recovery in the peripheral nerve block group. Previous research has also suggested that postoperative recovery experiences may vary according to the type of anesthesia administered [25]. Individuals with prior surgical experience and those accompanied during hospitalization also showed differences in recovery scores. Previous surgical experience may increase familiarity with the healthcare environment and perioperative procedures, while the presence of a companion may provide emotional and social support during hospitalization. Supportive perioperative environments and social support have been reported to influence patients’ experiences of postoperative recovery [6, 26]. Previous studies using the FSDS have shown that perceived safety during surgery is influenced particularly by nurse–patient interactions and the perioperative care environment [21, 22]. Effective communication and the visible presence of nurses appear to be particularly relevant in shaping patients’ sense of safety.

Consistent with these findings, Bergman et al. (2012) reported that perceived safety among patients undergoing orthopedic surgery under regional anesthesia was closely related to nurses’ professional conduct, a calm operating room atmosphere, and the information provided throughout the perioperative period [11]. Accordingly, the results of the present study align with existing qualitative evidence and support the psychometric validity of the Turkish adaptation of the FSDS [22]. From a nursing perspective, these findings reinforce the importance of patient-centered care approaches in promoting perceived safety and supporting recovery, particularly through communication and emotional support before and after surgery.

In examining the relationship between perceived safety during surgery and postoperative recovery, the present study identified a weak but statistically significant negative correlation between FSDS scores and both the overall PoRI score and the physical activity subscale (Table 3). This association suggests that higher perceived safety may be related to fewer reported recovery difficulties, particularly in the domain of physical activity. Similar findings were reported by Larsson et al. (2024), who showed that patients’ feelings of safety in the perioperative period were shaped by having someone nearby and by having a sense of control, particularly through supportive staff relationships and participation in care [12]. Likewise, Katran et al. reported associations between FSDS scores and patient satisfaction with the surgical experience [22]. Taken together, these findings indicate that patients’ emotional experiences during surgery may be linked to their postoperative recovery perceptions.

The present study also found a statistically significant negative correlation between perceived safety and difficulties related to physical activity (Tables 3 and 4). This finding suggests that challenges in physical recovery may be reflected in patients’ perceptions of safety, particularly in the early postoperative period. Larsson et al. emphasized that perceived safety during surgery is closely associated with nursing care and physical comfort [21]. Therefore, nursing interventions that support patient comfort and physical well-being may contribute to strengthening patients’ perceived safety and facilitating postoperative recovery experiences [6, 21, 26]. However, the absence of significant associations between perceived safety and psychological, bowel, or general symptoms highlights the multidimensional nature of postoperative recovery, indicating that perceived safety alone does not account for all aspects of recovery.

This study has several strengths. First, it examines patients’ perceptions of safety during surgery under regional anesthesia using a validated measurement instrument. Second, the relatively large sample size and the inclusion of patients undergoing different types of surgical procedures across multiple surgical specialties provide a broader perspective on perioperative patient experiences. In addition, examining the relationship between perceived safety and postoperative recovery adds to the growing evidence emphasizing the importance of patient-centered care in the perioperative setting.

Nevertheless, several limitations should be considered when interpreting the findings. The study was conducted in a single public hospital, which may limit the generalizability of the results to other healthcare settings. Furthermore, the cross-sectional design does not allow causal inferences regarding the relationship between perceived safety and postoperative recovery. In addition, the use of self-reported measurement instruments may introduce response bias.

Future research using qualitative approaches may provide deeper insight into the environmental, communication-related, and care-related factors that shape patients’ perceptions of safety during surgery under regional anesthesia. In addition, interventional studies could evaluate strategies aimed at enhancing perceived safety, such as structured preoperative information, patient education, and supportive nursing communication, and examine how interventions aimed at enhancing perceived safety may influence postoperative recovery. Such research may help identify practical perioperative approaches that strengthen patients’ sense of safety, improve patient experience, and support the delivery of patient-centred surgical care.

From a clinical perspective, these findings highlight the importance of interventions aimed at strengthening patients’ perceived safety during the perioperative process. Providing structured preoperative information, maintaining clear communication, and offering supportive nursing care may help reduce uncertainty and enhance patients’ sense of safety during surgery under regional anesthesia. Strengthening patients’ perceived safety may contribute to more positive postoperative recovery experiences and support the delivery of patient-centred perioperative care [6, 26].

Conclusion

This study examined the relationship between perceived safety during the surgical process and postoperative recovery in patients undergoing surgery under regional anesthesia. The findings suggest relatively high levels of perceived safety during surgery and low to moderate levels of difficulty during postoperative recovery, with physical activity–related difficulties being more prominent than other recovery domains. Fewer difficulties in postoperative recovery were observed particularly among patients who received peripheral nerve block anesthesia, as well as among those with prior surgical experience and those accompanied during hospitalization. A low but significant association was identified between perceived safety during surgery and postoperative recovery difficulty, suggesting that higher perceived safety during surgery may be associated with fewer postoperative recovery difficulties. These findings suggest that providing preoperative information, maintaining clear and effective communication, and offering nursing support may help strengthen patients’ perceived safety during the perioperative process. Developing nursing approaches that support patients’ perceived safety throughout the surgical care process may contribute to improving the quality of patient-centered perioperative care.

Authors’ contributions

**NA: ** Conceptualization, Methodology, Data curation, Visualization, Writing – original draft, Writing – review & editing.**GÖG: ** Conceptualization, Investigation, Methodology, Project administration, Data curation, Formal analysis, Writing – original draft, Writing – review & editing.**HBK: ** Conceptualization, Investigation, Methodology, Formal analysis, Supervision, Project administration, Writing – original draft, Writing – review & editing.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Non-Interventional Clinical Studies Ethics Committee of Marmara University Faculty of Health Sciences (Decision No: 18, Date: 29 January 2025). Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and participants were informed that they could withdraw from the study at any time without affecting their treatment or care.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.