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The Fear of Surgery and Coronavirus in Patients Who Will Undergo a Surgical Intervention

      ABSTRACT

      Purpose

      The aim of this study was to determine the fear of surgery and Coronavirus in patients who will undergo a surgical intervention.

      Design

      A descriptive cross-sectional study.

      Methods

      This study was carried out with 103 patients who were hospitalized in the thoracic and cardiovascular surgery departments of a university hospital between July and December 2021 and underwent elective cardiac/thoracic surgery for various indications. The Patient Information Form, Surgical Fear Questionnaire, and Coronavirus (COVID-19) Fear Scale were used to collect data. One hundred three patients were reached within the scope of the study. Data were analyzed with the Mann Whitney U and Kruskal Wallis tests and Spearman's correlation analysis in IBM SPSS (V.22.0) program.

      Findings

      The mean age of the participants was 57.8 ± 14.0 years (19-82), 68.0% (n = 70) were male, and 78.7% (n = 81) underwent thoracic surgery. The total mean score of the patients on the Surgical Fear Scale was 26.9 ± 20.5 while the total mean score on the Coronavirus Fear Scale was 18.2 ± 7.5. A weak positive correlation was identified between the patients' total score averages on the Surgical Fear Scale and the Coronavirus Fear Scale (COVID-19) (P < .001).

      Conclusions

      Patients undergoing cardiothoracic surgery had a low fear of surgery and a close to moderate fear of Coronavirus. Patients' fears of surgery and Coronavirus should be determined before surgery, and psychological support should be provided to patients with high levels of fear.

      Keywords

      The World Health Organization (WHO) proclaimed the new Coronavirus disease (COVID-19) a pandemic on March 11, 2020, after its emergence in China at the end of 2019. Many countries, including Turkey, have been impacted by the pandemic. Turkey reported 12,237,610 confirmed cases and 88,734 deaths as of February 7, 2022.
      World Health Organisation (WHO)
      COVID 19 Homepage.
      The pandemic measures applied to reduce the spread rate and manage the process during the COVID-19 pandemic have greatly affected individuals socially, economically, and psychologically.
      • El Keshky MES
      • Basyouni SS
      • Al Sabban AM
      Getting through COVID-19: the pandemic's impact on the psychology of sustainability, quality of life, and the global economy – a systematic review.
      Health care services have also been affected by the pandemic. The COVID-19 pandemic has had a significant impact on patient safety, particularly in health care-associated illnesses, that is, nosocomial infections.
      • Hölscher AH.
      Patient, surgeon, and health care worker safety during the COVID-19 pandemic.
      COVID-19-related anxiety could influence patients' treatment decisions.
      COVIDSurg Collaborative
      Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans.
      Surgical interventions other than emergency surgeries have been postponed.
      • Koffman J
      • Gross J
      • Etkind SN
      • Selman L.
      Uncertainty and COVID-19: how are we to respond?.
      The surgery and the pandemic process have become a source of uncertainty and anxiety for patients, their relatives, and health care professionals.
      • Koffman J
      • Gross J
      • Etkind SN
      • Selman L.
      Uncertainty and COVID-19: how are we to respond?.
      ,
      • Shanafelt T
      • Ripp J
      • Trockel M.
      Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic.
      During the COVID-19 pandemic, 30.3% of neurosurgery patients undergoing non-urgent surgery felt state anxiety.
      • Doglietto F
      • Vezzoli M
      • Biroli A
      • et al.
      Anxiety in neurosurgical patients undergoing nonurgent surgery during the COVID-19 pandemic.
      During the COVID-19 pandemic, the number of surgical patients decreased significantly due to patients' aversion to going to the hospital for fear of infection.
      • Fersahoglu MM
      • Çiyiltepe H
      • Fersahoğlu AT
      • et al.
      A comparison of patients who have appendectomy during the COVID-19 pandemic period with the period before the pandemic.
      Patients have experienced anxiety and fear secondary to surgery and the pandemic due to long waiting times, fear of infection, and surgical procedure. This study aimed to determine the fear of surgery and Coronavirus in patients who underwent a surgical intervention.

      Materials and Methods

      Study Design and Sample

      This descriptive and cross-sectional study was carried out with 103 patients who were hospitalized in the thoracic and cardiovascular surgery departments of a university hospital between July and December 2021 and underwent elective cardiac/thoracic surgery for various indications. A convenience sampling method was employed in data collection, which was performed on a voluntary basis. Using the G*Power 3.1.9.4 software, the minimum number of people to be sampled was found to be 89, predicting effect size = 0.353 at a 95% confidence level and a 95% power ratio.
      • Kizilkaya MC
      • Somuncu E.
      Fear of Covid-19 in patients with obesity and the influence on bariatric surgery rates.
      One hundred three patients were reached within the scope of the study.
      The study population consisted of patients who were to undergo cardiac/thoracic surgery for various indications in thoracic surgery and cardiovascular surgery departments. Adult patients who were to undergo cardiac/thoracic surgery in thoracic surgery or cardiovascular surgery departments, had no neuropsychiatric diagnosis, were at least primary school graduates, had a negative preoperative COVID-19 test, and volunteered to participate in the study were enrolled in the study.

      Data Collection Tools

      The Patient Information Form, the Surgical Fear Questionnaire, and the Fear of Coronavirus (COVID-19) Scale were used to collect data.

      Patient Information Form

      The form included 10 questions prepared by the researchers in line with the literature on the subject.
      • Bağdigen M
      • Karaman Özlü Z.
      Validation of the Turkish Version of the Surgical Fear Questionnaire.
      ,
      • Theunissen M
      • Peters ML
      • Schouten EG
      • et al.
      Validation of the surgical fear questionnaire in adult patients waiting for elective surgery.
      The questions were aimed at identifying the patients' sociodemographic characteristics (age, sex, education level, smoking status, comorbidity), their experience with surgery (surgery to be performed, pain), their experience with COVID-19 (sources of information about COVID-19, COVID-19 infection status, and COVID-19 vaccination status).

      Surgical Fear Questionnaire

      The scale, which evaluates the fear levels of patients who will undergo a surgical intervention, was developed by Theunissen and others
      • Theunissen M
      • Peters ML
      • Schouten EG
      • et al.
      Validation of the surgical fear questionnaire in adult patients waiting for elective surgery.
      in 2014, and Bağdigen and Özlü
      • Bağdigen M
      • Karaman Özlü Z.
      Validation of the Turkish Version of the Surgical Fear Questionnaire.
      conducted its validity and reliability study for the Turkish population in 2018. The scale consists of eight items with a numerical scale of zero to 10. Items one to four on this scale, which consists of two subscales, measure the fear of the short-term consequences of surgery, while items five to eight measure the fear of the long-term consequences of surgery. These questions address fears of surgery, anesthesia, pain, side effects, worsening of health due to surgical intervention, unsuccessful surgical intervention, incomplete recovery after surgical intervention, and prolonged recovery. The lowest score that can be obtained from the scale is 0, and the highest score is 80. High scores on the Surgical Fear Questionnaire indicate high levels of fear. Cronbach's alpha coefficient of the scale was determined as 0.76 to 0.92 for the original scale and 0.93 in the study by Bağdigen and Özlü.
      • Bağdigen M
      • Karaman Özlü Z.
      Validation of the Turkish Version of the Surgical Fear Questionnaire.
      In this study, Cronbach's α value was calculated as 0.90.

      Fear of Coronavirus (COVID-19) Scale

      The scale consists of one dimension and seven items. It is a 5-point Likert-type scale, including (1) Strongly disagree, (2): Disagree, (3): Undecided, (4): Agree, and (5): Strongly agree. There is no reverse item on the scale. The total score obtained from all scale items reflects an individual's level of fear of Coronavirus (COVID-19). The scores that can be obtained from the scale vary between seven and 35. A high score on the scale means a high level of fear of Coronavirus.
      The scale was developed by Ahorsu et al
      • Ahorsu DK
      • Lin CY
      • Imani V
      • et al.
      The Fear of COVID-19 Scale: development and initial validation.
      in 2020, and Bakioğlu et al
      • Bakioğlu F
      • Korkmaz O
      • Ercan H.
      Fear of COVID-19 and positivity: Mediating role of intolerance of uncertainty, depression, anxiety, and stress.
      performed the validity and reliability study of the Turkish version in 2020. Cronbach's α value of the scale was found to be 0.88. In this study, Cronbach's α value was determined as 0.87.

      Data Collection

      The Patient Information Form, Surgical Fear Questionnaire, and Fear of Coronavirus (COVID-19) Scale were used to collect data. The researcher informed the patients who met the inclusion criteria in the surgical units about the study's objective. Data collection forms were given to the patients who volunteered to participate in the study, and they were asked to answer all the questions in the data collection forms. After the data collection process, which took about 15 minutes, the forms were received by the researcher. During the data collection process, mask, distance, and hygiene rules were followed.

      Ethical Considerations

      Ethics committee approval and institutional permission required for the study were obtained with the decision dated June 14, 2021, protocol no. TUMF-SREC 2021/290 (decision no. 13/28). The patients participating in the study were informed about the study, and their written consent for participation was obtained. It was explained to the patients that their answers would be kept confidential and the information provided would only be used within the scope of the study. They were told that participation in the study was voluntary and they could leave the study whenever they wanted. Throughout the process, the ethical principles of protecting patient rights, patient confidentiality, privacy, and informed consent were respected.

      Data Analysis

      Data were analyzed using the IBM SPSS Statistics version 22.0 (IBM, Armonk, NY, USA) packaged software. The descriptive data of the study were evaluated by number, percentage, mean and standard deviation calculations. The Kolmogorov-Smirnov test was used to investigate the compatibility of the data with the normal distribution, and the Mann-Whitney U and Kruskal-Wallis tests were used to evaluate the data that did not show normal distribution. Spearman's correlation test examined the relationship between the total scale score and age. A statistical significance value was accepted as P < .05.

      Findings

      The participants’ mean age was 57.8 ± 14.0 years (19-82), 68.0% (n = 70) were male, 70.9% (n = 73) were primary school graduates, 50.5% (n = 52) did not have a chronic disease, and 78.7% (n = 81) underwent thoracic surgery. It was revealed that 7.8% (n = 8) of the patients had had COVID-19 infection and 89.3% (n = 92) had been vaccinated against COVID-19 (Table 1).
      Table 1Comparison of the Mean Scores of the Surgical Fear Questionnaire and the Coronavirus Fear (COVID-19) Scale According to the Individual Variables of the Patients (N = 103)
      Variablesn (%)Surgical Fear Questionnaire (Mean ± SD)Statistical ValueFear of Coronavirus (COVID-19) Scale (Mean ± SD)Statistical Value
      26.9 ± 20.518.2 ± 7.5
      Sex
       Female33 (32.0)29.8 ± 19.8P = .31419.6 ± 7.5P = .189
       Male70 (68.0)25.6 ± 20.8U = 980.50017.6 ± 7.5U = 969.500
      Education level
       Primary school73 (70.9)26.5 ± 21.0P = .77419.3 ± 7.7P = .048
       High school16 (15.5)27.8 ± 20.1KW = 0.08314.6 ± 6.0KW=6.090
       University14 (13.6)28.1 ± 19.416.5 ± 7.0P1-2 = .021
      Comorbidity
       Yes51 (49.5)30.8 ± 20.6P = .04319.4 ± 7.3P = .097
       No52 (50.5)23.2 ± 19.8U = 998.00017.0 ± 7.6U = 1075.000
      Smoking status
       Yes18 (17.5)34.7 ± 23.3P = .10618.5±8.9P = .865
       No85 (82.5)25.2 ± 19.6U = 572.00018.1 ± 7.3U = 745.500
      Surgery to be performed
       Thoracic81 (78.7)27.0 ± 20.5P = .98017.9 ± 7.5P = .451
       Cardiovascular22 (21.3)26.6 ± 20.8U = 877.00019.3 ± 7.7U = 797.500
      Pain
       Yes63 (61.2)19.6 ± 7.5P = .85219.6 ± 7.5P = .691
       No40 (38.8)17.6 ± 7.5U = 1201.50017.6 ± 7.5U = 1201.500
      Sources of information about COVID-19
       Mass media86 (83.5)29.6 ± 20.2P = .52319.1 ± 7.6P = .775
       Others17 (16.5)27.5 ± 22.1U = 293.50018.5 ± 7.6U = 323.000
      COVID-19 infection status
       Yes8 (7.8)20.6 ± 13.1P = .48521.0 ± 8.0P = .246
       No95 (92.2)27.5 ± 20.9U = 320.00018.0 ± 7.5U = 286.000
      COVID-19 Vaccination status
       Yes92 (89.3)27.3 ± 20.6P = .57118.4 ± 7.7P = .401
       No11 (10.7)23.9 ± 20.0U = 448.00016.4 ± 5.2U = 427.500
      Age (in years)57.8 ± 14.0 (19-82)P = .778P = .796
      rs = -0.028rs=0.026
      U, Mann Whitney U test; KW, Kruskal Wallis H test; rs, Spearman correlation analysis
      The total mean score of the patients on the Surgical Fear Questionnaire was 26.9 ± 20.5, and the mean score on the Fear of Coronavirus (COVID-19) Scale was 18.2 ± 7.5. The total mean score of the Surgical Fear Questionnaire varied according to the presence of chronic disease (P = .043), while the total mean score of the Fear of Coronavirus (COVID-19) Scale varied according to educational status (P = .021) (Table 1).
      A weak positive correlation was identified between the total mean scores of the patients on the Surgical Fear Questionnaire and the Fear of Coronavirus (COVID-19) Scale (P < .001) (Table 2).
      Table 2Relationship Between Surgical Fear Questionnaire and Fear of Coronavirus (COVID-19) Scale (N = 103)
      ScaleFear of Coronavirus (COVID-19) Scale
      Surgical Fear QuestionnaireP = .000

      rs = 0.102
      rs, Spearman correlation analysis

      Discussion

      Overall, patients had a low level of surgical fear. Lai et al
      • Lai E
      • Grimes C
      • Kasoff M
      • et al.
      Assessment of level of fear in adult patients undergoing elective urogynecologic and gynecologic procedures and surgeries during the COVID-19 pandemic using the validated surgical fear questionnaire.
      reported that patients who underwent urogynecological surgery during the pandemic period had a low level of surgical fear, and Çolak and Vural
      • Çolak S
      • Vural F.
      Determination of surgical fear levels of patients undergoing day surgery.
      reported that patients who underwent outpatient surgery had a low level of surgical fear. The study conducted by Theunissen et al
      • Theunissen M
      • Jonker S
      • Schepers J
      • et al.
      Validity and time course of surgical fear as measured with the surgical fear questionnaire in patients undergoing cataract surgery.
      with patients undergoing cataract surgery reported low surgical fear levels. Victoria et al
      • Victoria W
      • Melinda L
      • Zoltan H
      • et al.
      Complex supportive care of patients with breast cancer.
      revealed that patients who would undergo mastectomy surgery had a low level of surgical fear. Taylan and Çelik
      • Taylan S
      • Çelik GK.
      The effect of preoperative fear and related factors on patients' postcataract surgery comfort level: a regression study.
      determined that patients who would undergo cataract surgery had a low level of surgery fear. Another study by Çetin and Yılmaz
      • Çetin F
      • Yılmaz E.
      The effects of health literacy levels of patients in surgical clinic on health perception and surgical fear.
      reported that fear of surgery in surgical patients was at a low level. Mete and Işık
      • Mete Z
      • Işık SA.
      Determination of the relationship between surgical fear levels and postoperative pain levels in patients undergoing total knee prosthesis surgery.
      determined that patients who underwent total knee prosthesis surgery experienced moderate surgical fear. Patients who have undergone cardiac or thoracic surgery can be mobilized earlier and more frequently and become independent in activities of daily living more quickly.
      • Dığın F
      • Ü Yıldız Fındık
      The effect of nurse telephone consultation after coronary artery bypass on the autonomy level of elderly patients: A quasi-experimental study.
      Additionally, the different characteristics of patients forming the sample of studies (eg, perceived social support, motivation, surgical experience) may also cause different results.
      The patients' fear of Coronavirus was close to moderate. Likewise, Keskin et al
      • Keskin E
      • Celik S
      • Kostekli S.
      Surgical process anxiety from the perspective of neurosurgery patients in Covid-19 pandemic.
      reported that neurosurgery patients experienced moderate fear of COVID-19. Another study by Kurtgöz and Avcı
      • Kurtgöz A
      • Avcı S.
      Determination of COVID-19 fear of patients applying to emergency department.
      reported that fear of COVID-19 in patients admitted to the emergency department was at a moderate level. Montalto et al
      • Montalto F
      • Ippolito M
      • Noto A
      • et al.
      Emotional status and fear in patients scheduled for elective surgery during COVID-19 pandemic: a nationwide cross-sectional survey (COVID-Surgery).
      revealed that 55% of patients who underwent elective surgery during the pandemic were afraid of being infected with SARS-CoV-2. Doğan et al
      • Doğan R
      • Kaplan Serin E
      • Bağci N.
      Fear of COVID 19 and social effects in liver transplant patients.
      found that liver transplant patients had a high level of fear of Coronavirus. Another study revealed that fear of infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) affected 65% of solid organ transplant recipients.
      • Reuken PA
      • Rauchfuss F
      • Albers S
      • et al.
      Between fear and courage: Attitudes, beliefs, and behavior of liver transplantation recipients and waiting list candidates during the COVID-19 pandemic.
      In their study conducted in the first 6 months of the pandemic, Güven et al
      • Guven DC
      • Sahin TK
      • Aktepe OH
      • et al.
      Perspectives, knowledge, and fears of cancer patients about COVID-19.
      found that 90% of oncology patients experienced moderate or severe fear of being infected with COVID-19 and the disruption of their treatment due to the COVID-19 pandemic. The study by Raslan et al,
      • Raslan HA
      • Abu Salem EM
      • AbdElaal A
      • Mahmoud O
      • Almanzlawi HA
      Preoperative anxiety level and fear of covid 19 among adult patients undergoing elective surgery.
      which examined the fear of surgery in elective surgery patients, found that patients had a high level of fear during the pandemic. Sisto et al
      • Sisto A
      • Vicinanza F
      • Tuccinardi D
      • et al.
      The psychological impact of COVID-19 pandemic on patients included in a bariatric surgery program.
      determined that 59% of patients awaiting bariatric surgery or undergoing bariatric surgery experienced anxiety about the pandemic. The study results revealed that patients experienced different levels of fear of Coronavirus, especially in the early days of the pandemic. It is known that patients are afraid of going to pandemic hospitals.
      • Pereira X
      • Lima DL
      • Moran-Atkin E
      • Malcher F.
      Where have the surgical patients gone during the COVID-19 pandemic?.
      However, the fact that the university hospital where the data were collected was not a pandemic hospital, that suspected and confirmed COVID-19 cases were treated in another public hospital in the same city, and the high vaccination rates of patients (89.3%) may explain the low level of fear of Coronavirus among the patients.
      Patients with a chronic disease experienced more surgical fear than patients without it. Furthermore, the perceived stress levels of oncology patients who underwent elective surgery during the pandemic were higher than those without an oncologic disease.
      • Del Zingaro M
      • Cochetti G
      • Maiolino G
      • et al.
      Influence of COVID-19 pandemic on stress levels of urologic patients.
      Al Rahimi et al
      • Al-Rahimi JS
      • Nass NM
      • Hassoubah SA
      • Wazqar DY
      • Alamoudi SA.
      Levels and predictors of fear and health anxiety during the current outbreak of COVID-19 in immunocompromised and chronic disease patients in Saudi Arabia: A cross-sectional correlational study.
      found that during the pandemic, fear and health anxiety were more common in patients taking immunosuppressants or those with chronic diseases (Crohn's disease, cardiovascular diseases). Kapıkıran et al.
      • Kapıkıran G
      • Demir B
      • Bülbüloğlu S
      • Sarıtaş S.
      The effect of spiritual well-being on surgical fear in patients scheduled to have abdominal surgery.
      revealed that patients' surgical fear varied according to the presence of chronic disease in patients undergoing abdominal surgery. The fact that the presence of chronic disease poses a risk to the surgical process may have caused patients with comorbidities to fear surgical procedures.
      • Zehri AH
      • Peterson KA
      • Lee KE
      • et al.
      National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014.
      The fear of Coronavirus was higher among primary school graduates than among high school graduates. Raslan et al
      • Raslan HA
      • Abu Salem EM
      • AbdElaal A
      • Mahmoud O
      • Almanzlawi HA
      Preoperative anxiety level and fear of covid 19 among adult patients undergoing elective surgery.
      determined that patients with low education levels who underwent elective surgery experienced more COVID-19-related anxiety than patients with high education levels. Al Rahimi
      • Al-Rahimi JS
      • Nass NM
      • Hassoubah SA
      • Wazqar DY
      • Alamoudi SA.
      Levels and predictors of fear and health anxiety during the current outbreak of COVID-19 in immunocompromised and chronic disease patients in Saudi Arabia: A cross-sectional correlational study.
      revealed that fear and health anxiety were more common in patients with low education levels during the pandemic. The study by Cerda and Garcia

      Cerda A, Garcia L. Factors explaining the fear of being infected with COVID-19. Health Expect. 25:506-512. doi:10.1111/hex.13274

      determined that educated people experienced less fear. The study conducted by Doğan and Düzel
      • Doğan MM
      • Düzel B.
      Fear-anxiety levels in Covid-19.
      with individuals in society revealed that high school graduates experienced more fear of Coronavirus than individuals with university degrees. The study by Kasapoğlu
      • Kasapoğlu F.
      Examining the relationship between fear of COVID-19 and spiritual well-being.
      reported that primary school graduates experienced more fear of Coronavirus than high school graduates. The transformation of access to information during the pandemic
      • Varışlı B.
      Transformation of education in the pandemic era: sociological reflections of online education.
      may have caused individuals with higher education levels to access and adapt to information more easily.
      A positive correlation was revealed between patients' surgical fear and fear of Coronavirus. Doglietto et al
      • Doglietto F
      • Vezzoli M
      • Biroli A
      • et al.
      Anxiety in neurosurgical patients undergoing nonurgent surgery during the COVID-19 pandemic.
      determined that one of the important predictors of preoperative anxiety in patients who underwent brain and nervous system surgery during the pandemic was the fear of being infected with Coronavirus. Another study found that 26.8% of patients with high anxiety feared being infected with COVID-19 during their hospital stay.
      • Aloweidi A
      • Abu-Halaweh S
      • Almustafa M
      • et al.
      Preoperative anxiety among adult patients undergoing elective surgeries at a tertiary teaching hospital: a cross-sectional study during the era of COVID-19 vaccination.
      Shih et al
      • Shih CL
      • Huang PJ
      • Huang HT
      • et al.
      Impact of the COVID-19 pandemic and its related psychological effect on orthopaedic surgeries conducted in different types of hospitals in Taiwan.
      reported that surgical procedures decreased by 20% to 30% due to the fear of Coronavirus in patients. Vanni et al
      • Vanni G
      • Materazzo M
      • Pellicciaro M
      • et al.
      Breast cancer and COVID-19: The effect of fear on patients' decision-making process.
      stated that surgical procedures were postponed in patients who were planned to undergo surgical treatment for breast cancer on the grounds of the fear of infection due to the pandemic. A study conducted with patients who underwent elective urological surgery found that those who had fear of Coronavirus infection had higher levels of perceived stress in the preoperative period.
      • Del Zingaro M
      • Cochetti G
      • Maiolino G
      • et al.
      Influence of COVID-19 pandemic on stress levels of urologic patients.
      Another study shows that fear of viruses can affect the decision-making process of patients and may have negative consequences on patient outcomes.
      • Wang TT
      • Wang SW.
      Applying behavioral economics to address covid-19 fear among oral and maxillofacial surgery patients.
      The study results reveal that the fear of surgery is related to the fear of Coronavirus.

      Conclusion

      The pandemic continues to make its effects felt in the health system, as in many areas. At least one third (33%) of patients are very afraid of COVID-19. Perioperative nurses should identify patients' fears of surgery and Coronavirus and support them. Particularly, patients with low education levels and chronic diseases should be carefully evaluated.

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