The relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open heart surgery: a cross-sectional study

Abstract

Background

Open-heart surgery involves surgical fear as a frequently experienced condition in patients because of uncertainty, perception of death, pain, and intense stress. In this process, spiritual well-being and religious coping mechanisms stand out as important psychosocial resources that can influence how patients cope with fear and anxiety. The study aimed to determine the relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open-heart surgery.

Method

This was a cross-sectional descriptive correlational study. The study was conducted with patients scheduled for open-heart surgery in the cardiovascular surgery department of a university hospital in eastern Turkiye. Data were collected during the preoperative period between March and October 2025. Participants who met the inclusion criteria and agreed to participate were recruited using a convenience sampling method. The study was completed with 179 patients. The data were collected using the “Personal Information Form”, “Surgical Fear Questionnaire (SFQ)”, “3-Factor Spiritual Well-being Scale (3F-SWBS)”, and “Religious Coping Scale (RCS)”. Descriptive statistics (percentages, mean values, frequencies, and standard deviation values), t-test, and Pearson correlation analysis were used for analyses. Also, stepwise linear regression analysis was performed to identify factors influencing surgical fear.

Results

The average age of the patients was 64.99 ± 9.27 years. The mean SFQ score was 22.69 ± 19.79, the mean 3F-SWBS score was 124.78 ± 12.04, the positive religious coping score was 26.21 ± 2.87, and the negative religious coping score was 10.05 ± 3.59. 3F-Spiritual well-being (Beta = -0.282 ; p < 0.001) was significantly associated with surgical fear, followed by negative religious coping (Beta = 0.208; p=0.005 p) and having previous non-cardiac surgery (Beta = 0.166; p=0.019 p).

Conclusion

The study found that patients reported low levels of surgical fear, high levels of spiritual well-being, and positive religious coping, alongside low levels of negative religious coping. Higher spiritual well-being was associated with lower surgical fear, whereas higher negative religious coping and a history of previous non-cardiac surgery were associated with higher surgical fear.

Background

As one of the surgical methods employed in the treatment of heart diseases, open-heart surgery is a fundamental treatment method applied in conditions such as coronary artery disease, heart valve disease, repair of congenital heart lesions, and heart transplantation [1]. Heart surgeries aim to reduce physical symptoms and morbidity and improve quality of life. Although open-heart surgery is vital for patients, it creates high levels of physical, psychological, and emotional stress, such as anxiety, fear, depression, and pain [2]. Also, uncertainty about the disease and the future, lack of information about the surgical procedure, fear of not waking up from anesthesia, lifestyle changes, distorted body image, postoperative pain, disability, and fear of death are among the causes of preoperative anxiety and fear [3–6]. Surgical fear is not only a temporary emotional state in the pre-operative period, but also a significant problem that negatively affects the recovery process and can prolong hospital stays because of nausea, vomiting, increased pain, delayed wound healing, increased sensitivity to anesthesia, and increased analgesic requirements after surgery [1, 4, 7, 8]. Studies conducted in different countries have consistently reported moderate to high levels of preoperative fear and anxiety among patients scheduled for open heart surgery [5, 9–16].

Individuals experience fear and anxiety caused by major surgical procedures [5, 9–16] and use various coping mechanisms to cope with these stressful situations [17]. One of these mechanisms, religious coping, helps individuals make sense of their difficulties, maintain hope, and restore emotional balance [18]. Religious beliefs and practices such as prayer, reading sacred texts, seeking refuge in God, patience, and reliance on God can help individuals cope with feelings of fear and helplessness during challenging life experiences such as illness and surgery [17, 19]. Positive religious coping involves viewing difficulties as opportunities for growth and seeking strength and support through faith. It also includes establishing a secure relationship with God and coping with negative life events through spiritual support and religious beliefs. On the other hand, negative religious coping involves viewing problems/illness as divine punishment, and actions such as hopelessness, helplessness, guilt, anger, and resentment [18, 20, 21]. Positive religious coping can reduce guilt, reframe suffering, and bolster hope, whereas negative religious coping is associated with lower quality of life, impaired psychological adjustment, spiritual distress, and lower spiritual well-being [22, 23].

Spiritual well-being is one of the important psychosocial resources for coping with life-threatening health problems such as surgical interventions. Spiritual well-being is defined as an individual finding meaning in life, feeling inner peace, remaining strong in the face of traumatic events, and feeling connected to a transcendent power [24–26]. Spiritual practices such as prayer and meditation can help patients regain a sense of control and cope with the uncertainty surrounding the surgical process [27]. In a previous study, patients before cardiac surgery were found to rely on spirituality and faith in God as key resources for coping with stress and anxiety [28]. In addition, individuals with higher levels of spiritual well-being have been reported to experience lower levels of preoperative anxiety and fear [24, 26]. The literature also suggests that healthcare professionals must be aware of the impact of spiritual well-being on surgical fear and provide spiritual support to patients [26, 29]. Supporting spiritual well-being in the care of surgical patients can facilitate their adaptation to the surgical process, alleviate their anxiety, and accelerate the healing process [30].

It is already known that the psychological state and emotional well-being of patients scheduled for surgery in the pre-operative period also affect physiological and psychological recovery in the post-operative period [3]. High levels of preoperative fear and anxiety have been reported to be associated with negative outcomes such as increased postoperative pain, delayed recovery, and decreased adherence to treatment [12, 31]. For this reason, nurses must adopt a holistic approach that includes considering the spiritual aspect of care to comprehensively address anxiety and fear in surgical patients. In line with the understanding that health services must be provided with a holistic approach, it is becoming increasingly important to evaluate not only the physical but also the psychological, social, and spiritual needs of patients [32]. Especially in nursing care, approaching the spiritual and religious needs of patients with sensitivity can reduce surgical fear and positively contribute to the treatment and recovery process. Previous studies have explored the relationship between surgical fear and spiritual well-being in various surgical populations, including patients scheduled for abdominal surgery, geriatric surgery, and liver transplantation [24, 26, 29, 33]. In addition, only limited evidence is available regarding the relationship between surgical fear and religious factors in surgical patients [34]. However, the relationship between surgical fear, spiritual well-being, and religious coping has not yet been examined in patients scheduled for cardiac surgery, and no study in our country has evaluated these variables together among patients scheduled for open-heart surgery. Therefore, this study was conducted to examine the relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open-heart surgery.

Aim

This study was conducted to examine the relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open-heart surgery.

Study questions

• What is the level of spiritual well-being of patients who are scheduled to undergo open-heart surgery?

• What are the levels of religious coping skills of patients who are scheduled to undergo open-heart surgery?

• What are the levels of surgical fear of patients who are scheduled to undergo open-heart surgery?

• Is there a relationship between surgical fear levels and spiritual well-being and religious coping of patients who are scheduled to undergo open-heart surgery?

• Is there a relationship between the level of surgical fear of patients who are scheduled to undergo open-heart surgery and their demographic and clinical characteristics?

Method

Study design

The study aimed to determine the relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open-heart surgery. This study was conducted using a cross-sectional descriptive correlational design. The aim was to determine the current levels of surgical fear, spiritual well-being, and religious coping in patients scheduled for open-heart surgery, and to examine the relationships between these variables over the same time period. This design is a suitable method for revealing the direction and level of the relationship between variables without any intervention. The study was conducted at the Cardiovascular Surgery Clinic of a university hospital in eastern Turkiye. Data were collected between March and October 2025. This study was reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guideline for observational studies.

Study population and sample

The study population consisted of patients scheduled for open-heart surgery at the Cardiovascular Surgery Clinic of a university hospital in eastern Turkiye. The sample consisted of patients who met the inclusion criteria and agreed to participate in the study and were recruited using a convenience sampling method. A power analysis was performed using the G-Power 3.1.9.7 software package to determine the sample size. Considering the mean surgical fear scores from Gacaner’s (2024) study [35], the effect size for the power analysis was found to be 0.570. Based on this effect size, a significance level of 0.05, and a power of 80%, the minimum number of patients that could be included in the study was 169 [36]. Because of the possibility of data losses, 179 patients were included in the study. Patients included in the study were over 18 years of age, scheduled to undergo open-heart surgery for the first time, had no communication problems, had no diagnosed psychiatric illness based on medical records and self-report, and agreed to participate in the study.

Data collection tools

The data were collected using the “Personal Information Form”, which was prepared by the researchers to question sociodemographic characteristics of the patients, the “Surgical Fear Scale”, the “3-Factor Spiritual Well-being Scale”, and the “Religious Coping Scale”.

Personal Information Form

This form consists of 11 questions regarding patients’ age, gender, marital status, education level, employment status, presence of chronic diseases, history of previous non-cardiac surgery, type of surgery performed, religious practices, and body mass index (BMI). Patients were also asked to indicate the factor they believed contributed most to the development of their illness (e.g., psychological reasons, risk factors, or accident), and these data were recorded based on self-reportThis form consists of 11 questions regarding patients’ age, gender, marital status, education level, employment status, presence of chronic diseases, history of previous non-cardiac surgery, type of surgery performed, religious practices, and body mass index (BMI). Patients were also asked to indicate the factor they believed contributed most to the development of their illness (e.g., psychological reasons, risk factors, or accident), and these data were recorded based on self-report.

Surgical Fear Questionnaire (SFQ)

Developed in 2014 by Theunissen et al. to determine the level of fear of patients scheduled to undergo elective surgery regarding the short-term and long-term consequences of the surgical procedure [37]. Its Turkish validity and reliability were established by Bağdigen and Özlü (2016). The scale is an 11-point Likert scale consisting of 8 items and 2 sub-dimensions. Items 1 to 4 of the scale question the short-term consequences of surgery, while items 5 to 8 question the long-term consequences of surgery. Each item is scored between 0 and 10. A total score of 0 to 80 can be obtained from the scale, and a score of 0 to 40 from the sub-dimensions. A higher score indicates a high level of surgical fear. In the study where the validity and reliability of the scale were determined, the Cronbach’s Alpha internal consistency coefficient was found to be 0.93 [38]. Although the Turkish validity and reliability of the scale had previously been established, Cronbach’s Alpha was recalculated in the present study to confirm the internal consistency of the scale in this specific sample of patients scheduled for open-heart surgery. In this study, the Cronbach’s Alpha coefficient was calculated as 0.90.

3-Factor Spiritual Well-being Scale (3 F-SWBS)

The scale was developed by Ekşi and Kardaş (2017), and its Turkish version has established validity and reliability. The original validation study demonstrated satisfactory content validity, construct validity, and reliability. The scale is a 5-point Likert-type scale, consisting of 29 items and three sub-dimensions. The sub-dimensions are “Transcendence”, “Harmony with Nature”, and “Anomie”. The items for the Transcendence sub-dimension are 1, 4, 5, 8, 9, 12, 13, 16, 17, 20, 21, 24, 25, 27, 29; the items for the Harmony sub-dimension are 2, 6, 10, 14, 18, 22, 28; and the items for the Anomie sub-dimension are 3, 7, 11, 15, 19, 23, 26. The minimum score on the scale is 29, and the maximum is 145. Items in the anomia subscale of the scale are reverse-scored. As the score on the scale increases, spiritual well-being increases. While high scores on “transcendence” and “harmony with nature” are said to increase spiritual well-being, high scores on the “anomie” subscale are interpreted as negativity, meaning negative situations that lead to unhappiness and loneliness. In the original validation study, the Cronbach’s Alpha coefficients were reported as 0.95 for the transcendence subscale, 0.86 for the harmony with nature subscale, and 0.85 for the anomie subscale. The total Cronbach’s Alpha value of the scale is 0.88 [39]. In this study, the reliability coefficients of the subscales were found to be 0.74 for the transcendence subscale, 0.83 for the harmony with nature subscale, and 0.79 for the anomie subscale. The total Cronbach’s Alpha value of the scale in this study was determined to be 0.85

Religious Coping Scale (RCS)

The scale was developed by Pargament et al. (1998), primarily for use across a wide range of Judeo-Christian groups, although it has also been suggested to apply to other theocentric religions such as Islam [23]. The Turkish validity and reliability study of the scale was conducted by Ekşi (2001) [40]. It contains 14 questions of a four-point Likert type in 2 sub-dimensions: positive religious coping (questions 1, 2, 6, 8, 9, 11, and 13) and negative religious coping styles (questions 3, 4, 5, 7, 10, 12, and 14). A minimum score of 7 and a maximum score of 28 are obtained for each coping style. Low scores on the scale indicate that the religious coping style is used less, while high scores indicate that it is used more. As a result of the reliability analysis, Cronbach’s Alpha values were found to be 0.64 for the positive coping styles sub-factor and 0.63 for the negative coping styles sub-factor [40]. In this study, Cronbach’s Alpha values were calculated as 0.82 for positive religious coping and 0.74 for negative religious coping.

Data collection

After obtaining ethical committee approval and institutional permissions, the data were collected between March and October 2025 through face-to-face interviews conducted in the patients’ rooms one day before surgery. All data were collected by the same researcher. Each participant was interviewed individually, and the data collection process lasted approximately 15–20 min. Patients were informed about the purpose, content, and scope of the study, and after obtaining their consent, the data collection forms were administered.

To ensure consistency in the administration of the questionnaires and to accommodate participants with different literacy levels, all questions, scale items, and response options were read aloud to each participant by the researcher in a clear, neutral, and standardized manner. The same instructions were provided to all participants. Participants were given sufficient time to answer each question, and their responses were recorded exactly as stated. The researcher avoided providing explanations, examples, or interpretations that could influence the participants’ responses.

Data analysis

The analysis of the study data was performed using the Statistical Package for the Social Sciences (SPSS) 20.0 software package (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov Test was used to determine whether the data were normally distributed, and the results indicated that the data were normally distributed at the 95% confidence level (p > 0.05). Descriptive statistics (frequency, percentage, mean, and standard deviation) were used for the analysis of demographic data. Categorical variables were evaluated using numbers and percentages, and continuous variables using mean and standard deviation. Cronbach’s Alpha value was calculated for the scales, and Pearson Correlation Analysis was performed to determine the relationship between some variables and scales. In addition, Stepwise Linear Regression Analysis was performed to determine the factors affecting surgical fear, and the Dummy Coding Method was used to include categorical variables in the model. According to the multiple regression results, when more than one independent variable was identified as a significant predictor, the stepwise regression method was used to determine the explanatory contribution of each variable to the model. Statistical significance of the data was evaluated at the p < 0.05 level.

Results

The results imply that 55.9% of the participating patients were over 65 years old, 68.2% were male, 78.8% were married, 50.8% did not have a chronic disease, and 31.3% had completed primary education. 80.4% were unemployed, 64.2% had undergone CABG surgery, 59.8% had not had previous non-cardiac surgery, 50.2% developed the disease because of risk factors, and 57.5% performed their religious rituals. The mean BMI of the patients was determined to be 28.48 ± 3.60 and the mean age was 64.99 ± 9.27 years. The difference between the patients’ descriptive characteristics and their mean scores on the surgical fear scale was not statistically significant (p > 0.05, Table 1).

Table 1.

Comparison of mean surgical fear scale scores according to patients’ demographic characteristics (N = 179)

Variables	n %		Surgical Fear Questionnaire	Test and p-value
			X ± SD
Age
40–64 years old	79	44.1	21.37 ± 20.29	t=-0.787
65 and over	100	55.9	23.74 ± 19.42	p = 0.432
Sex
Female	57	31.8	24.63 ± 21.31	t = 0.893
Male	122	68.2	21.79 ± 19.06	p = 0.373
Marital status
Married	141	78.8	23.82 ± 20.15	t = 1.478
Single	38	21.2	18.50 ± 18.01	p = 0.141
Chronic Disease
Yes	88	49.2	22.68 ± 19.30	t=-0.011
No	91	50.8	22.71 ± 20.36	p = 0.991
Educational Status
Illiterate	40	22.3	17.80 ± 12.00
Literate	28	15.6	26.21 ± 22.27	F = 1.446
Primary education	56	31.3	24.00 ± 21.40	p = 0.215
High school	49	27.4	24.53 ± 21.82
University and above	6	3.4	11.83 ± 8.84
Employment status
Yes	35	19.6	20.82 ± 18.12	t=-0.622
No	144	80.4	23.15 ± 20.21	p = 0.509
The surgery performed
CABG	115	64.2	21.48 ± 20.00	F = 0.806
Valve surgery	48	26.8	23.95 ± 19.05	p = 0.448
CABG and valve surgery	16	9	27.62 ± 20.65
Previous non-cardiac surgery
Yes	72	40.2	25.04 ± 19.39	t = 1.580
No	107	59.8	20.36 ± 19.32	p = 0.116
Causes of disease development
Psychological reasons	64	35.8	21.76 ± 19.41	F = 0.169
Presence of risk factors	90	50.2	23.55 ± 20.26	p = 0.844
Accident	25	14.0	22.00 ± 19.67
Performing religious rituals
Yes	103	57.5	23.09 ± 19.52	F = 0.054 p = 0.948
Partially	68	38.0	22.23 ± 20.60
No	8	4.5	21.50 ± 18.41
	Min	Max	± SD
BMI	18.52	35.86	28.48 ± 3.60	r = 0.132 p = 0.077
Age	40.0	81.0	64.99 ± 9.27	r = 0.082 p = 0.275

Note: X: Mean, SD: Standard Deviation, CABG: Coronary Artery Bypass Graft, BMI: Body Mass Index

Table 2 shows the mean scores of patients on the 3 F-SWBS and its sub-dimensions, the sub-dimensions of the RCS, and the SFQ. The mean surgical fear score of the patients was 22.69 ± 19.79. The mean total 3 F-SWBS score was 124.78 ± 12.04, while the mean scores for the transcendence, harmony with nature, and anomie sub-dimensions were 70.02 ± 4.91, 32.64 ± 3.96, and 22.11 ± 6.65, respectively. The mean positive religious coping score was 26.21 ± 2.87, whereas the mean negative religious coping score was 10.05 ± 3.59.

Table 2.

The scales’ min-max, mean scores, and standard deviation values

Scales	Min-Max	X̅ ± SD
3 F-SWBS-Transcendence	48–75	70.02 ± 4.91
3 F-SWBS - Harmony with Nature	13–35	32.64 ± 3.96
3 F-SWBS-Anomie	7–35	22. 11 ± 6.65
3 F-SWBS	89–145	124.78 ± 12.04
RCS - Positive religious coping	17–28	26.21 ± 2.87
RCS - Negative religious coping	7–25	10.05 ± 3.59
SFQ	0–73	22.69 ± 19.79

Note: X: Mean, SD: Standard Deviation, Min: Minimum, Max: Maximum, 3 F-SWBS: 3-Factor Spiritual Well-being Scale, RCS: Religious Coping Scale, SFQ: Surgical Fear Questionnaire

Based on the correlation analysis, a significant negative relationship was detected between the SFQ and the 3 F-SWBS (r = − 0.326, p < 0.001). Similarly, a significant negative relationship was found between the SFQ and the sub-dimensions of transcendence, harmony with nature, and anomie (p < 0.05). In contrast, a significant positive relationship was found between the SFQ and negative religious coping (r = 0.295, p < 0.001; Table 3).

Table 3.

Correlation values of some variables and scales (N = 179)

	1	2	3	4	5	6	7	8
1. Age	1
2. 3 F-SWBS-Transcendence	r = 0.117 p = 0.118		1
3. 3 F-SWBS - Harmony with Nature	r = 0.056 p = 0.458	r = 0.414 p = 0.000***	1
4. 3 F-SWBS-Anomie	r=-0.034 p = 0.650	r = 0.356 p = 0.000***	r=0.406 p = 0.000***	1
5. Total 3 F-SWBS	r=-0.047 p = 0.529	r = 0.741 p = 0.000***	r = 0.722 p = 0.000***	r = 0.832 p = 0.000***	1
6. RCS - Positive religious coping	r=0.171 p = 0.022*	r = 0.561 p = 0.000***	r=0.360 p = 0.000***	r = 0.199 p = 0.008**	r = 0.457 p = 0.000***	1
7. RCS - Negative religious coping	r=-0.017 p = 0.826	r=-0.301 p = 0.000***	r=-0.158 p = 0.035*	r=-0.283 p = 0.000***	r=-0.331 p = 0.000***	r=-0.440 p = 0.000***	1
8. SFQ	r = 0.082 p = 0.275	r=-0.322 p = 0.000***	r=-0.214 p = 0.004**	r=-0.225 p = 0.003**	r=-0.326 p = 0.000***	r=-0.205 p = 0.006**	r = 0.295 p = 0.000***	1

Note: 3F-SWBS: 3-Factor Spiritual Well-being Scale, RCS: Religious Coping Scale, SFQ: Surgical Fear Questionnaire, r: Pearson’s Correlation

Analysis, p: significance level, *p < 0.05, ** p < 0.01, ***p < 0.001

A stepwise multiple regression analysis was conducted to identify factors predicting patients’ fear of surgery. Multicollinearity assumptions were evaluated using tolerance and VIF values. Tolerance values ranged between 0.859 and 1.000, and VIF values ranged between 1.000 and 1.164, indicating no multicollinearity problem.

Variables that could influence surgical fear (age, sex, marital status, chronic disease, educational status, employment status, type of surgery performed, previous surgery history, causes of illness, and performing religious rituals), the total and subdimension scores of the 3-Factor Spiritual Well-being Scale (transcendence, harmony with nature, anomie), and the subdimensions of the Religious Coping Scale (positive religious coping and negative religious coping) were included in the model. In the stepwise regression analysis, the independent variable showing the highest correlation with the dependent variable was the total score of the 3-Factor Spiritual Well-Being Scale (r = -0.326; p < 0.001), which was entered into the model first (Table 4). Using this method, the total variance explained in surgical fear was obtained after three stages (models).

Table 4.

Stepwise multiple linear regression models for predicting surgical fear

Model	Predictor Variables	ß	Beta	t	Tolerance	VIF	p
1	Spiritual Well-being	-0.517	-0.322	-4.492	1.000	1.000	0.000
2	Spiritual Well-being	-0.400	-0.249	-3.352	0.891	1.122	0.001
	Negative Religious Coping	1.192	0.221	2.976	0.891	1.122	0.003
3	Spiritual Well-being	-0.454	-0.282	-3.781	0.859	1.164	0.000
	Negative Religious Coping	1.124	0.208	2.834	0.886	1.128	0.005
	Having had non-cardiac surgery before	6.551	0.166	2.358	0.964	1.037	0.019

Abbreviations: B: coefficient B; βeta: standardized beta coefficient

Model 1 suggests that the spiritual well-being variable explained 10.3% of the variance in surgical fear (R² = 0.103; F-change = 20.174; p < 0.001). In other words, it was found that the spiritual well-being variable was the strongest predictor of the surgical fear variable. There was a negative relationship between spiritual well-being and surgical fear (Beta = -0.322; Table 4).

In Model 2, the negative religious coping sub-variable was added to the model after the spiritual well-being variable and tested. Adding this variable increased the explained variance in surgical fear scores from 10.3% to 14.7% (R² = 0.147; F-change = 8.855; p < 0.001). It was determined that the negative religious coping variable contributed approximately 4% to the explained variance. The relationship between negative religious coping scores and surgical fear scores is positive (Beta = 0.221; Table 4).

In Model 3, after the variables of spiritual well-being and negative religious coping, the variable of having previous non-cardiac surgery was added to the model, and with the addition of this variable, the explained variance in surgical fear score increased from 14.7% to 17.3% (R² = 0.173; F-change = 5.562; p < 0.001). Although the contribution of the previous non-cardiac surgery variable to the explained variance was significant, an increase of approximately 3.0% was determined. The relationship between the previous non-cardiac surgery and the surgical fear score is positive (Beta = 0.166; Table 4).

	R2	Adjusted R2	R2 change	F	F-change	P	Durbin Watson
Model 1	0.103	0.098	0.103	20.174	20.174***	0.000 a	1.918
Model 2	0.147	0.137	0.043	14.967	8.855***	0.000 b
Model 3	0.173	0.159	0.027	12.094	5.562***	0.000 c

^aPredictors in the Model: (Constant), 3-Factor Spiritual well-being

^bPredictors in the Model: (Constant), 3-Factor Spiritual well-being, Negative religious coping

^cPredictors in the Model: (Constant), 3-Factor Spiritual well-being, Negative religious coping, having had non-cardiac surgery before

Abbreviations: R²: R‐square (the coefficient of determination) ^*** p < .001

Note: Dummy coded: Previous non-cardiac surgery (yes = 1, no = 0)

Discussion

To the best of current knowledge, this study is the first to examine the relationship between surgical fear, spiritual well-being, and religious coping in patients scheduled for open heart surgery, and the results were evaluated in accordance with the literature data.

The results suggest that patients had relatively lower mean SFQ scores. Işıklı et al. (2023), in their study on patients hospitalized in thoracic and cardiovascular surgery departments and scheduled for elective surgery, found that patients had relatively lower surgical fear scores [41]. Similarly, studies conducted with different samples have reported relatively lower preoperative fear scores [3, 42–46]. Unlike the findings of the present study, a study conducted on patients scheduled for coronary artery bypass surgery determined that 64.7% of patients experienced moderate-to-high levels of anxiety [47]. Also, some studies reported that preoperative surgical fear is at a moderate-to-high level in patients scheduled for surgical procedures [4, 6, 15, 16, 26]. In the literature, it is seen that there are different levels of surgical fear in patient groups scheduled for surgical operations. The differences in results between studies can be explained by the demographic characteristics of the sample, cultural structure, individual coping mechanisms, the level of information patients receive about the surgical procedure, the type of surgical intervention, the perceived risk level, and the high average age of patients scheduled for open heart surgery. There are studies in the literature indicating a relationship between age and fear, with lower fear levels being associated with older age [3, 45, 48]. Furthermore, the relatively lower levels of surgical fear found in patients in this study can be explained by Mishel’s Uncertainty in Illness Theory. This theory considers the uncertainty individuals experience regarding illness, treatment, and outcomes as a cognitive stressor and explains how such uncertainty affects psychological adjustment. According to the theory, uncertainty arises from a lack of information about the illness, unpredictable events, and ambiguous situations [49]. Higher perceptions of uncertainty are associated with higher levels of fear and anxiety, whereas sufficient information, support, and effective coping resources may reduce uncertainty and strengthen psychological adaptation. In this study, the high levels of spiritual well-being and positive religious coping among patients may be associated with perceiving the surgical process as more meaningful, manageable, and controllable. This may be associated with lower perceptions of uncertainty and relatively low levels of surgical fear observed in the study.

Individuals resort to spirituality to cope with conditions such as illness that increase anxiety and stress levels [18]. The literature indicates that spiritual well-being is associated with patients’ ability to make sense of the difficulties they experience and with greater psychological resilience [33, 50]. The results of this study support the literature, showing that patients had high levels of spiritual well-being. Similarly, studies conducted with patients scheduled for heart surgery have found high levels of spiritual well-being [51]. In one study, patients awaiting cardiac surgery reported relying on spirituality and faith in God as important resources for coping with stress and anxiety [28]. Previous studies conducted with patients scheduled for different surgical procedures also determined that patients had high levels of spiritual well-being [22, 26, 29, 50, 52]. Unlike the findings of the present study, Bezerra et al. (2018) reported that patients scheduled for heart surgery had moderate levels of spiritual well-being [53]. In another study conducted with surgical patients, it was similarly reported that the patients’ levels of spiritual well-being were moderate [25]. These findings demonstrate that spiritual well-being is an important internal resource supporting patients’ psychological adaptation to the surgical process. Especially in surgical procedures such as open-heart surgery, where uncertainty, perceived life-threatening situations, and feelings of loss of control can be prominent, spirituality is thought to contribute to patients’ ability to make sense of the process and cope with stress. However, the differences in spiritual well-being levels reported in studies may stem from cultural structure, religious beliefs, the meaning attributed to the illness, and individual experiences. Therefore, the high levels of spiritual well-being found in patients in the present research may be related to the cultural and spiritual characteristics of the sample and their ways of understanding the surgical process.

The study also found that patients had a high average score for positive religious coping and a low average score for negative religious coping. A qualitative study conducted in the northern region of Ghana reported that surgical patients largely attributed successful surgical outcomes to divine intervention and faith, while the emphasis on the competence of healthcare professionals remained limited [54]. Demirbağ et al. (2025) reported that patients with oncological surgery had positive religious coping strategies in their study [22]. Similarly, in another study conducted with elderly surgical patients, it was found that positive religious coping scores were high and negative religious coping scores were low [20]. In the study conducted by Ravishankar et al. (2014), most patients reported that religion was an effective coping mechanism that provided them with strength, comfort, and hope throughout the surgical process [55]. These findings are consistent with Pargament’s Religious Coping Theory. According to Pargament, positive religious coping enables individuals to find meaning in stressful life events, develop hope, and strengthen their perception of spiritual support, whereas negative religious coping is associated with negative cognitive processes such as feelings of punishment, spiritual conflict, and abandonment [56]. These results show that patients extensively use positive religious coping strategies in dealing with stressful situations, while adopting negative religious coping approaches to a limited extent. Similar results obtained in different cultures and patient groups indicate that religious coping may be a universal support mechanism. Also, the cultural and religious context of Turkiye, where a significant proportion of the population is Muslim, may be associated with the greater use of positive religious coping strategies.

The present study further revealed that spiritual well-being was the variable that predicted surgical fear at the highest level, with a significant negative correlation. It was concluded that higher spiritual well-being was associated with lower levels of surgical fear in patients scheduled for open heart surgery. Kayaoğlu et al. (2023) determined that liver transplant candidates with high levels of spiritual well-being had lower levels of surgical fear [26]. Kapıkıran et al. (2021) found a significant negative correlation between spiritual well-being and surgical fear in abdominal surgery patients [24]. In a study conducted by Jamalimoghadam et al. (2022), it was reported that there was a significant negative relationship between spiritual health and depression, anxiety, and stress in general surgery patients, and that these psychological symptoms decreased as the level of spiritual health increased [57]. Spiritual well-being increases individuals’ expectations, energy, and motivation for life, strengthens the feeling of hope, and facilitates their adaptation to disease conditions [33]. The literature indicates that spirituality is related to physical and mental health [39]. Studies have found that spiritual therapies reduce preoperative anxiety [58, 59]. The finding that higher spiritual well-being is associated with lower anxiety through the ability to give meaning to one’s life, develop hope, and accept the situation is consistent with the literature.

In contrast to the results of this study, another study indicated that although spiritual well-being (religiosity and spirituality) was presented as a coping strategy and tool for psychological adaptation, they were not effective in reducing anxiety and depression levels in patients before heart surgery [60]. Considering that the role of spirituality and spiritual care in reducing anxiety and facilitating the treatment process might vary depending on individuals’ cultural, religious, and personal belief systems, the differences in the results obtained in the studies can be considered natural and expected.

The study identified negative religious coping as another variable for predicting surgical fear. Religious coping encompasses how individuals deal with stressful life events within the framework of religious beliefs and practices, including cognitive, emotional, and behavioral responses [32]. In negative religious coping, individuals interpret the difficulties they experience as punishment from the creator, leading to an intensification of negative emotions such as hopelessness, guilt, and anger [17, 21]. The findings of the present study indicate a positive and significant relationship between negative religious coping and surgical fear. In this context, higher levels of negative religious coping are associated with higher levels of surgical fear. This result largely coincides with the literature. Since no study examining the relationship between religious coping and surgical fear in surgical patients was found in the literature review, the results were discussed with studies conducted with different samples. One study found a positive relationship between negative religious coping and anxiety, with an increase in worry and anxiety levels as the negative religious coping score increased [18]. Previous studies reported that negative religious coping is associated with life satisfaction and psychological resilience, with life satisfaction and psychological resilience decreasing as the frequency of negative religious coping increases [61–63]. Another study reported that individuals who used negative coping strategies had higher stress levels [64]. In parallel, Muslu et al. (2020) revealed that individuals’ belief levels were an influential factor in preoperative.

e anxiety [65]. These findings support Pargament’s theory of religious coping. According to the theory, individuals who use negative religious coping strategies may interpret their health problems within the framework of divine punishment, abandonment, or spiritual conflict [56]. Since surgical procedures also involve intense sources of stress such as uncertainty, loss of control, and fear of death, these factors may be associated with higher levels of surgical fear among individuals with a tendency toward negative religious coping.

The findings of the present study also imply that one of the important variables predicting surgical fear is having undergone surgery before. Having undergone surgery before was associated with higher levels of surgical fear. There are studies in the literature that support this finding. In the study conducted by Karabulut et al. (2023), it was found that the preoperative perceived stress and surgery-specific anxiety scores of geriatric surgery patients were higher in patients with previous surgical experience [66]. In the study conducted by Dimitriadou et al. (2025), it was determined that individuals’ previous surgical and anesthesia experiences were significant predictors of surgical fear [4]. Similarly, another study reported that surgery-specific anxiety is higher in patients with previous surgical experience [67]. This association may be related to previous negative or stressful experiences with medical interventions and greater sensitivity to subsequent surgical interventions. Indeed, Prado-Olivares et al. (2019) reported that previous negative intervention experiences were associated with higher surgical fear [10].

However, the literature also contains different findings. While some studies conducted with surgical patients indicate no significant relationship between surgical fear and having undergone previous surgery [31, 68], the studies by Kapıkıran et al. (2021) and Kuşçu et al. (2025) reported that patients without prior surgical experience had higher levels of surgical fear [24, 69]. These differences suggest that previous surgical experience may not only be related to its presence, but also to how the experience was perceived by the individual, the type of surgery, any pain or complications experienced in the previous process, the level of information received, and individual coping characteristics.

Limitations

Some limitations of the study merit consideration. The study was limited to patients who were scheduled to undergo open heart surgery in the cardiovascular surgery clinic of a university hospital in Turkiye. This restricted the generalizability of the results to a wider population. The study was limited to the measurements obtained from the study and the self-reports of the participants. Since the study was conducted in a predominantly Muslim society, the findings may be more applicable to Muslim communities; however, participants’ religious affiliation was not directly assessed, and this assumption was based on the sociocultural characteristics of the study population.

Conclusion

The study found relatively lower surgical fear scores among patients scheduled for open heart surgery. Patients showed high levels of spiritual well-being and positive religious coping, while negative religious coping was low. Spiritual well-being was found to be the variable showing the strongest correlation with surgical fear. Also, negative religious coping and previous non-cardiac surgery were significantly associated with patients’ levels of surgical fear. These results suggest that spiritual well-being and religious coping styles are important determinants in assessing surgical fear in patients before open-heart surgery. The results highlight the importance of addressing patients’ physical, psychosocial, and spiritual needs through a holistic approach during the preoperative care process. Spiritual support interventions and the enhancement of positive religious coping mechanisms may help reduce surgical fear. Therefore, assessing patients’ spiritual needs and integrating appropriate support mechanisms into the care process may represent an important component of clinical practice for healthcare professionals.

Relevance for clinical practice

In clinical practice, integrating spiritual assessments and supportive interventions into the preoperative care process by nurses and healthcare professionals can contribute to reducing surgical fear and supporting the postoperative recovery process. This approach has the potential to improve patient outcomes by strengthening a holistic care understanding. Finally, studies examining the relationship between surgical fear, spiritual well-being, and religious coping in surgical patients are limited in the literature. It is believed that new studies in this area will contribute more to the literature.

Author contributions

TK, AY, and AE contributed to conceptualisation; TK, AY, and AE contributed to methodology; AE, contributed to data collection; TK and AY contributed to data analysis; TK, AY, and AE contributed to administration; TK, and AY contributed to writing of initial draft; all authors contributed to writing, review and editing of final draft; all the authors listed were involved in the writing of the final draft, and all the authors agreed to be responsible for the outcome of the manuscript.

Funding

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

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Declarations

Ethics approval and consent to participate

Before the study, ethical approval was obtained from the Ethics Committee of Atatürk University Faculty of Medicine (Date: 28.02.2025, Decision No: 2/11), and written permission was obtained from the institution where the study would be conducted for data collection. All patients included in the study were informed of the purpose and importance of the study before data collection, and their written and verbal consent was obtained. Voluntary patients were included in the study, and their personal information was kept confidential. The Helsinki Declaration of Human Rights was adhered to throughout the study.

Consent for publication

Not applicable. This manuscript does not include identifying images or personal or clinical details of participants that compromise anonymity.

Conflict of interest

The authors have no conflicts of interest to disclose.

Authorship statement

All listed authors meet the authorship criteria, and all authors are in agreement with the content of the manuscript.

Competing interests

The authors declare no competing interests.