• Age, edu, hospital stay duration, surgery/anaesthesia type, malignant/benign disease, pre-op. pain, affecting factors 

The pre-operative identification of factors that would increase surgical fear would be helpful in planning out interventions that would be, per a local study, helpful in reducing anxiety and alleviating fear prior to surgery, and towards this end, pre-operative comprehensive patient information is important.

Further, age, educational level, the American Society of Anesthesiologists (ASA) grading, duration of the hospital stay, the type of surgery and anaesthesia, the malignant or benign nature of the disease, and the presence of pre-operative pain, are associated with a significantly higher level of surgical fear, according to the said study.

These findings were made in a scientific article on “A descriptive study on the assessment of fear of surgery in patients in a tertiary care centre” which was authored by S. Bandara (attached to the Postgraduate Institute of Medicine), and H.D.S. Niroshan and A. Pathirana (both are attached to the University of Sri Jayewardenepura) and published in the Sri Lanka Journal of Surgery's 41st Volume's First Issue in March, 2023.

According to the Oxford definition, fear is an emotional state evoked by the threat of danger. Fear of surgery among patients who are awaiting surgery is, per M. Theunissen, S. Jonker, J. Schepers, N.A. Nicolson, R. Nuijts, H-F. Gramke, M.A.E. Marcus and M.L. Peters's “Validity and time course of surgical fear as measured with the Surgical Fear Questionnaire (SFQ) in patients undergoing cataract surgery”, H.Y.V. Ip, A. Abrishami, P.W.H. Peng, J. Wong and F. Chung's “Predictors of post-operative pain and analgesic consumption: A qualitative systematic review”, and J. Celestin, R.R. Edwards and R.N. Jamison's “Pre-treatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: A systematic review and literature synthesis”, multi-factorial and associated with dire consequences such as the increased use of analgesia, poor post-operative recovery, poor physical function, and also poor mental health. A. Shafer, M.P. Fish, K.M. Gregg, J. Seavello and P. Kosek's “Pre-operative anxiety and fear: A comparison of assessments by patients and anaesthesia and surgery residents” and M. Koivula, M.T. Tarkka, M. Tarkka, P. Laippala and M. Paunonen-Ilmonen's “Fear and anxiety in patients at different time-points in the coronary artery bypass process” have identified multiple factors which inculcate fear in a patient awaiting surgery such as the surgery itself, the fear of anaesthesia, undergoing blood transfusions, anticipated operative and post-operative pain, previous experience with surgery, age, sex, etc.

The quantification of fear has been an issue worldwide. There are only a few validated study instruments available with regard to the assessment of fear and most of them are disease specific such as the Bypass Grafting Fear Scale (M. Koivula, M-T. Tarkka, M. Tarkka, P. Laippala and M. Paunonen-Ilmonen's “Fear and in-hospital social support for coronary artery bypass grafting patients on the day before surgery”) and the Surgery Stress Scale for knee surgery (P.H. Rosenberger, R. Kerns, P. Jokl and J.R. Ickovics's “Mood and attitude predict pain outcomes following arthroscopic knee surgery”). 

There are a few nonspecific scales such as the Hospital Anxiety and Depression Scale [HADS] (A.S. Zigmond and R.P. Snaith's “The HADS”), and the State – Trait Anxiety Inventory (C. Spielberger's “Assessment of state and trait anxiety: Conceptual and methodological issues”). The SFQ is, per M. Theunissen, M.L. Peters, E.G.W. Schouten, A.A.A. Fiddelers, M.G.A. Willemsen, P.R. Pinto, H-F. Gramke and M.A.E. Marcus's "Validation of the SFQ in adult patients waiting for elective surgery”, a generalised study instrument that is validated and tested in several populations and can be used across all types of surgical patients.

The assessment of surgical fear in patients is often an overlooked subsection of patient management worldwide which can be associated with dire consequences. The initial step in the management of surgical fear in an individual is the identification of the modifiable factors which are associated with surgical fear. 

Therefore, Bandara et al. used the SFQ to assess surgical fear among individuals awaiting surgery in a tertiary care centre in Sri Lanka for over eight months. Patients who were above 18 years of age and undergoing routine surgery from January to October, 2020, in the University Surgical Unit of the Colombo South Teaching Hospital in Kalubowila were recruited. Patients with known psychiatric disorders, ones who were unable to give a proper history, and patients who underwent emergency surgery were excluded. 

An interviewer administered questionnaire was used for data collection. The SFQ is an eight item study instrument for the assessment of surgical fear. All items are scored on an 11 point numeric scale ranging from zero (not at all afraid) to 10 (very afraid). The items, per S.M. Janković, G.V. Antonijević, S.N. Mirković, K.M. Raspopović, L.R. Radoičić, S.S. Putnik, M.N. Živković-Radojević, I.R. Vasić, B.V. Nikolić, D.R. Stanojević, S.D. Teofilov, K.V. Tomašević, and V.D. Opančina's “SFQ – Serbian cultural adaptation” are, being afraid of the operation, anaesthesia, post-operative pain, side effects, health deterioration, failed operation, incomplete recovery, and the long duration of rehabilitation.

A total of 130 patients were interviewed. The age range was 25 to 74 years with 86 being males. A total of 35.4% had a university education, and 18.5% had education below the General Certificate of Education (GCE) Ordinary Level (O/L) while 46.1% had education up to the GCE Advanced Level. A total of 29.2% had either one or multiple comorbidities of bronchial asthma, diabetes, and hypertension. A total of 13.6% were smokers. A total of 23.1% had had previous surgery. A total of 96 had chronic pre-operative pain while 61.5% used regular analgesics to alleviate pain. 

There was no statistical significance in the SFQ scores between males and females. A significant difference in the mean SFQ scores was noted between patients who were above 40 years and less than 40 years. A statistical significance of the SFQ scores was noted between patients with an education level of below the GCE O/L and patients with university education. When comparing the ASA grading of patients and their SFQ scores, the SFQ of ASA I patients was significantly lower than in ASA II and III patients. However, there was no statistical significance of the SFQ between patients of ASA II and III. 

A statistical significance was noted between the duration of the pre-operative hospital stay (one day, more than one day) and the SFQ score. Patients who had pre-operative pain had a significantly higher SFQ score than the patients who did not have pre-operative pain. Patients awaiting surgery for malignancies had a statistically significant higher SFQ score than patients awaiting surgery for benign conditions. The individual question which had the highest mean fear score was “I am afraid of the long duration of rehabilitation after the operation” for patients who had both benign and malignant conditions. Patients who were planned for complex surgeries had a statistically higher SFQ score than patients who were planned for minor surgeries. Patients who were planned for general anaesthesia had a significantly higher SFQ score than patients who were planned for surgery under local or spinal anaesthesia. However, there was no statistical significance between the patients awaiting surgery under local or spinal anaesthesia. No statistical significance was identified between the SFQ scores of patients who were non-smokers and smokers and the use of alcohol.

In view of an intervention to alleviate the fear of surgery, 64% opted for no intervention or treatment, while 13.8% appreciated some sort of treatment, and 65% stated that more information about the surgery would be helpful.

Surgical fear is an often-overlooked area by surgical professionals all over the world. The assessment of surgical fear needs the quantification of fear, which has been an issue. There have been attempts to quantify surgical fear. The SFQ is a tool that is used to quantify surgical fear and has been validated in many different languages and used in many research publications worldwide (a Czech study, a Hungarian study, and a Turkish study). M. Bağdigen and Z.K. Özlü's “Validation of the Turkish version of the SFQ”, which was a study done on patients who were awaiting cataract surgery showed a SFQ which is low compared to the studies which were done on patients who are awaiting general surgical procedures, which implies that the patients' fear of surgery depends on the procedure that they undergo. No significant difference was noted between the male and female patients. However, R. Zelenikova, K. Kovarova, P. Bujok and M. Theunissen's “The Czech version of the SFQ: Measuring validity and reliability” observed an increase in fear associated with the female gender. Increasing age was found to be a factor which increases the fear of surgery. 

Patients with higher education had lower fear-related scores than patients with lower levels of education. However, Koivula et al. found that there was no effect of the educational level on the fear of surgery. A statistically significant reduced level of fear was seen in patients with a lower ASA grading than patients with a higher ASA grading, which can be because, per Bandara et al., the presence of comorbidities, which makes the patients more anxious and prone to develop a fear of surgical procedures. 

The duration of the hospital stay inversely affected the fear of surgery significantly, where the lower the number of days in the hospital, the lower the fear. Hence, reducing the number of pre-operative in-hospital days where possible is important in relation to reducing the fear of surgery in patients. Patients who had pre-operative pain had a higher fear score than patients who did not have pre-operative pain. Hence, addressing persistent pre-operative pain might be helpful in alleviating the fear of surgery in patients. Patients who were awaiting surgery for malignant diseases and who were planned for complex major surgeries had a significantly higher fear score than patients who were awaiting benign surgeries. 

According to Shafer et al., patients who are awaiting complex surgeries and surgeries for malignant diseases have high anxiety levels which can contribute to the high fear scores. Therefore, Bandara et al. suggested that this cohort of patients can be considered for pre-operative counselling and other interventions which help to alleviate anxiety and the fear of surgery. Patients who planned to undergo surgeries under general anaesthesia had a higher fear score than patients who were to undergo surgeries under spinal or local anaesthesia. This can be, according to Bandara et al., due to the anxiety found in the community with regard to recovery from general anaesthesia. There was no correlation between smoking and the use of alcohol and the fear of surgery. There was no significant correlation between the history of previous surgery and the fear of surgery. There was no statistical significance between the group of patients that had previous surgery and the group of patients that did not have previous surgery. 

However, Theunissen et al. have observed a reduced fear amongst patients who have undergone previous surgery which was attributed to the fact that facing surgery once would reduce the anxiety of a second surgery. Even though there was no statistical difference between the two groups, the instant study shows a higher mean SFQ in patients who have had previous surgery, which is contradictory to the findings of previous studies. This can, according to Bandara et al., be due to the unpleasant experience of the previous surgeries or can be due to the lack of a proper sample size. A total of 65% of the patients stated that more information regarding the surgery and the procedure would have been helpful in terms of alleviating the associated fear. 

Proper comprehensive patient information prior to surgery would reduce the anxiety and fear amongst patients but it is often an overlooked area in the Sri Lankan medical setting. The pre-operative identification of factors that would increase surgical fear would be helpful in planning out interventions that would be helpful in alleviating this fear prior to surgery. Pre-operative comprehensive patient information might be important in reducing the fear amongst patients awaiting surgery, Bandara et al. concluded.