Perceived compassionate care and preoperative anxiety in hospitalized patients

Abstract

Background

Quality nursing care and ethical responses to patient pain and suffering are very important in the preoperative period. However, few studies have addressed these variables.

Objective

This study aimed to examine the relationship between compassionate care and preoperative anxiety from the perspective of hospitalized patients.

Methods

The current study was a cross-sectional descriptive one. The participants were selected using convenience sampling. The data were collected using a demographic questionnaire, Burnell Compassionate Care Tool, and Amsterdam Preoperative Anxiety and Information Scale (APAIS). The collected data were analyzed with SPSS software (version 22) through descriptive and inferential statistics at a significance level of 0.05 (p < .05).

Participants and setting

This study was conducted on 704 candidates for surgery in the internal and surgical wards of a large teaching hospital located in the south of Iran from December 2022 to March 2023.

Ethical considerations

The protocol for this study was reviewed and approved by the University Ethics Committee.

Findings

The patients’ average age was 36.61 ± 13.07. The average preoperative anxiety and need for information scores were 13.80 ± 2.66 and 7.44 ± 1.47, respectively. The average score of importance was 3.03 ± 0.19, and the average score of the extent of compassionate care provision was 1.22 ± 0.15. There was a significant relationship between preoperative anxiety with importance and the extent of compassionate care provision (r = 0.68, p < .001), r = −0.72, p < .001, respectively). A comparison of the demographic characteristics, need for information, importance, and provision of compassionate care showed that the extent of compassionate care provision had the greatest contribution in explaining preoperative anxiety (β = 0.50; p < .001).

Conclusion

Even though patients’ preoperative anxiety was high and providing compassionate care in the preoperative period had a great role in relieving their anxiety, many participants appear to have received little compassionate care. To this end, nursing managers should pay attention to the quality of compassionate care in the preoperative stage. Besides, healthcare staff should receive the necessary training in compassionate nursing care.

Keywords

Compassion nursing care anxiety patients surgical procedures operative

Introduction

Anxiety is an uncomfortable mental state or a feeling of helplessness caused by a threatening situation or the anticipation of an unknown threat to oneself or others.^1,2 Patients who need surgery are exposed to high levels of anxiety³ and the need to adapt to surgery physically, psychologically, and socially⁴ because any kind of surgery is considered a threat to the integrity of the body and life.⁵ The prevalence of preoperative anxiety has been reported to be 11%–22% in adults.^5,6 Preoperative anxiety can be attributed to different factors such as the fear of anesthesia and surgery or unknown factors can lead to changes in the patient’s vital signs,³ stress and delay in wound healing after surgery,¹ psychological and physiological changes, increased postoperative pain, and changes in the patient’s thoughts, feelings, and behaviors.⁴ Thus, it is important to use the correct nursing practices to reduce preoperative anxiety in patients to avoid postoperative complications.⁷

The preoperative nurses should have practice with compassion and respect for human dignity, especially in the context of their relationships with patients and taking into account the nature of patients’ health issues.⁸ Compassion-based care is one of the core values of the nursing profession. Compassionate care takes a patient’s innate need for connection and relationship, and improves health outcomes as well as the patient experience in the clinical care setting.⁹ Nurses have more contact with patients compared to other medical staff and are with them most of the time. Thus, when the patient complains of pain and suffering or is worried about his/her and his/her family’s health, the nurses are the ones who are with the patient most of the time. Hence, their response to the patient’s pain and suffering and the quality of nursing care are very important.¹⁰ To this end, the present study sought to examine the relationship between compassionate care and preoperative anxiety in hospitalized patients.

Background

Compassion is one of the indicators of the quality of nursing care. It is a moral response to suffering that leads to care combined with comfort for the suffering person.¹¹ Compassion is a factor that can directly affect the quality of patient care and usually nursing service recipients’ assessment of the quality of the services they receive are based on the compassion shown by the nurse in providing care.¹²

Compassionate care is characterized by four factors including wisdom, humanity, love, and empathy. These characteristics may indicate an awareness of the vulnerable and suffering person’s position. Compassionate care is the inner feeling of another person’s suffering with the motivation to help and relieve suffering.¹³ As members of the care profession team, nurses are expected to establish a sincere relationship with patients through compassionate behaviors so that they can respond to their pain and suffering.¹¹

The available evidence shows that when care is provided based on compassionate behaviors, patients can easily express their symptoms and concerns. As a result, the medical staff can examine the patient’s condition thoroughly and provide accurate diagnoses.¹⁴ On the other hand, if the care is provided in a non-compassionate way, it will cause a decrease in the care standards and adversely affect the quality of care.¹¹ Thus, patients may feel that they have been forgotten and are not valued, ultimately leading to patient dissatisfaction.^11,15

Adugbire et al (2017) reported dissatisfaction, anger, and confusion among patients due to insufficient nursing care in the preoperative and intraoperative stages.¹⁵ However, the patient experiences a lot of anxiety from the moment of determining the surgery until the time of the surgery. Since the patient’s anxiety is affected by many factors such as age, level of education, adaptation pattern, and personality type of the person; thus, preoperative nursing care should be patient-centered.¹⁶ In many studies, various methods such as music therapy, guided imagery, audio-visual training, preoperative visits, psychological support, and educational and informational interviews have been used to reduce the anxiety of patients in the preoperative phase.^17–19 Previous studies have reported that active listening, preserving the patient’s privacy, discovering the patient’s anxiety, and trying to overcome this anxiety are examples of compassionate care¹¹ and compassionate clinical communication leads to a faster recovery of the patient from serious conditions.²⁰ Furthermore, anesthesiologists’ sympathetic attitudes in the preoperative stage reduce patients’ anxiety and increase patients’ satisfaction.²¹ However, no study has yet addressed the relationship between compassionate care and preoperative anxiety.

Given the key role of nurses in the preoperative phase and the importance of reducing preoperative anxiety, it is necessary to identify factors affecting preoperative anxiety. One of the factors affecting patients’ preoperative anxiety is nursing care. Compassionate nursing care is quality, patient-centered, and safe care that increases the patient’s satisfaction and recovery.^9,11

Methodology

Study design

This was a cross-sectional study. There were 704 participants who were candidates for elective surgery from December 2022 to March 2023.

Setting

This study was conducted in the medical- surgical wards of one of the large hospitals located in the south of Iran.

Participants

The target population consisted of all adult patients admitted to the medical- surgical wards. The inclusion criteria were willingness to participate in the study, the age range of 18–79 years, having at least reading and writing literacy, hospitalization for at least one night before the surgery, absence of mental disorders, absence of drug addiction, absence of use of anti-anxiety medications, and the patient’s consent. The patients who refused to continue the interview during the study or those with higher levels of anxiety due to unpredictable events occurring in the ward were excluded from the study.

Sample size

Following a similar study,²² the mean of the importance of compassionate care (3.27 ± 0.52), the mean of the extent of compassionate care provision (2.8 ± 0.64), α = 0.05, z = 1.96, d = 0.05, and using the sample size formula ( $\frac{{z 2 σ}^{2}}{d 2}$ ), the sample size was estimated to be around 414 persons for the importance of compassionate care and 640 for the extent of compassionate care provision. However, taking a 10% dropout possibility, 704 patients who were candidates for surgery and met the inclusion criteria were considered the participants in the research sample.

Data collection

In the present study, after obtaining permission from the hospital director and the supervisors of the medical- surgical wards of the hospital, the researcher’s main co-worker visited the medical- surgical wards in person and received a list of hospitalized patients waiting for surgery from the officials.

The questionnaires were completed by the participant on the morning of the operation day, immediately before transferring the patient to the operating room. The participants were selected using convenience sampling. All participants were informed of the objectives of the study, research procedure, and confidentiality of the data before completing the questionnaires. The questionnaires were completed through interviews with the participants conducted by a member of the research team.

Data sources/measurement

The demographic questionnaire

The demographic questionnaire was administered to assess the participants’ age, gender, marital status, education level, hospitalization department, average length of stay, the number of admissions, type of surgical intervention, and history of previous surgeries.

Amsterdam preoperative anxiety and information scale

The patient’s preoperative anxiety was measured using Amsterdam Preoperative Anxiety and Information Scale (APAIS). APAIS has six items that measure anxiety and the need for information based on a five-point Likert scale from 1 (not at all) to 5 (extremely). The anxiety score ranges from 4 to 20 and the need for information is measured with a score ranging from 2 to 10. The items in the scale are completed by the respondents themselves. Since APAIS is a short instrument that specifically measures preoperative anxiety, it seems to be more useful for administration in clinical settings than the Spielberger State-Trait Anxiety Inventory (STAI). The cut-off scores for the anxiety subscale and the need-for-information subscale are 11 and 5, respectively. A score higher than 11 indicates high anxiety. A score of 2–4 on the need-for-information subscale indicates a need for little information, a score of 5–7 indicates a need for moderate information, and a score of 8–10 indicates a need for a lot of information.²³

The APAIS was translated by Nikandish et al. (2007) for use in Iran. The APAIS contains six items that measure patients’ anxiety levels and information requirements in the preoperative phase on a five-point Likert scale. The total score on the scale ranges from 6 to 30. The Iranian version of the APAIS was normalized for preoperative anxiety with Cronbach’s alpha of 0.84 and the need for preoperative information with Cronbach’s alpha of 0.82. The correlation between the preoperative subscale of the APAIS and the Spielberger State-Trait Anxiety Inventory (STAI) was 0.68 (p < .001) and the correlation between the information subscale and the Spielberger State-Trait Anxiety Inventory (STAI) was 0.5 (p < .001), confirming the concurrent validity of the APAIS.²⁴ The reliability index of the APAIS was found to be 0.8 in the present study.

Compassionate care assessment tool

The Compassionate Care Assessment Tool (CCAT) was developed by Burnell and Agan (2013).²⁵ The CCAT was translated and localized in Iran by Vaisi-Raygani et al. (2021).²⁶ This 20-item tool measures the importance and the extent of providing compassionate care. The score on each subscale of the tool ranges from 20 to 80. Each subscale measures meaningful connection, patient expectation, caring attributes, and capable practitioner. Each statement is designed based on Likert’s four-point scale for important of compassionate care “not important = 1” to “very important = 4”. The statements about the extent of services are scored from never = 1 to most of the time = 4. To obtain the score for each factor, the total score of the related statements is divided by the number of statements. A higher score in this tool indicates more compassionate care. The patients expressed their opinions in two fields of importance and extent or providing compassionate cares.^22,25 The construct validity of the tool was assessed and confirmed through confirmatory factor analysis ( $X^{2}$ = 76.2, df = 2.46, RMSEA = 0.07 and 0.083). The Cronbach’s alpha values for the importance and extent of compassionate care provisions were 0.91 and 0.93, confirming the reliability of the tool. Moreover, the corresponding values for the two subscales through the test-retest method in two consecutive weeks were 0.84 and 0.9, respectively.²⁶ The reliability indicators for the two subscales of the importance and the extent of providing compassionate care were 0.9 and 0.89 in the present study.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki. The present study has been approved by the Research Ethics Committee of Hormozgan University of Medical Sciences (IR.HUMS.REC.1401.280). The participants were informed about the objectives of the study, their anonymity and confidentiality of their information, and the role of the researcher. Written informed consent was obtained from all the participants before participation in present study.

Statistical methods

The collected data were analyzed with SPSS software (version 22) through descriptive statistics including frequency and mean and inferential statistics including t-test, ANOVA, Pearson correlation test, and multiple linear regression analysis. A significance level of 0.05 was considered for data analysis.

Results

Of a total of 721 patients waiting for surgery, 17 patients were excluded from this study due to cancellation of surgery or unwillingness to attend the study. This study was conducted on 704 patients admitted to the medical-surgical wards of the hospital. The patients’ average age was 36.61 ± 13.07 with an age range of 18–79 years. Most of the participants were male (50.9%) and married (58.6%). The average length of stay was 2.69 ± 1.53 days. Table 1 shows other demographic characteristics of the patients in this study.

Table 1.

Demographic characteristics of the hospitalized patients waited to operation (n = 704).

Variables		N (%)	Variables		N (%)
Gender	Male	371 (54%)	Type of surgeries	Nephrostomy	40 (5.68%)
	Female	333 (46%)		Percutaneous nephrolithotomy (PCNL)	27 (3.83%)
	Female	333 (46%)		Open stone surgery	11 (1.56%)
Age	18–28	189 (28.9%)		Transurethral resection of the prostate (TURP)	58 (8.23%)
	29–39	201 (31.3%)		Myringotomy	5 (0.71%)
	40–50	145 (19.8%)		Rhinoplasty	34 (4.82%)
	51–60	82 (9.9%)		Surgery for retinal detachment	32 (4.54%)
	>61	87 (10.1%)		Colorectal surgery	45 (6.39%)
Marital status	Single	295 (41.4%)		Cholecystectomy	52 (7.38%)
	Single	295 (41.4%)		Laparoscopy	21 (2.98%)
	Married	409 (58.6%)		Herniorrhaphy	32 (4.54%)
Educational level	Primary school	81 (6.6%)		Mastectomy	9 (1.27%)
	Secondary school	107 (15.6%)		Surgical removal of an abdominal mass	15 (2.13%)
	High school diploma	170 (28.5%)		Vascular surgery	17 (2.41%)
	Bachelor degree	258 (43.1)		Pilonidal cyst excision	9 (1.27%)
	Postgraduate degree	88 (7.2%)		Open reduction and internal fixation (ORIF)	95 (13.62%)
	Postgraduate degree	88 (7.2%)		Arthroplasty	35 (4.94%)
Wards	Urological surgery ward	125 (17.75%)		Craniotomy for brain abscess excision	15 (2.13%)
	General surgery ward	282 (40.09)		Craniotomy for brain tumor excision	8 (1.13%)
	Orthopedic surgery ward	130 (18.45%)		Neck and lumbar open discectomy	72 (10.22%)
	Neurosurgical units	95 (13.49%)		Diabetic foot ulcer amputation	61 (8.66%)
	General medicine ward	72 (10.22%)		Surgical debridement of bed sores	11 (1.56%)
Previous surgery	Yes	84 (11.93%)
Previous surgery	No	620 (88.07%)

The mean scores for preoperative anxiety, need for information, the importance of compassionate care, and the extent of compassion care provision were 13.80 (2.66), 7.44 (1.47), 3.03 ± 0.19, and 1.22 ± 0.15, respectively.

The results of the Pearson correlation test showed a significant relationship between preoperative anxiety and need for information (r = 0.3; p < .05), and the importance of compassionate care (r = 0.68; p < .001) and the extent of compassionate care provision (r = −0.72; p < .001). Table 2 shows the correlations between the dimensions of compassionate care and preoperative anxiety.

Table 2.

The relationships between the dimensions of compassionate care and preoperative anxiety.

Variable		Mean	SD	r, p value
Total score	Importance	3.03	0.19	r = 0.68, p < .001
Total score	Providing	1.22	0.15	r = −0.72, p < .001
Meaningful connection	Importance	3.92	0.37	r = 0.62, p < .001
Meaningful connection	Providing	1.52	0.25	r = −0.70, p < .001
Patient expectation	Importance	3.63	0.44	r = 0.56, p < .001
Patient expectation	Providing	1.52	0.24	r = −0.68, p < .001
Caring attributes	Importance	3.78	0.3	r = 0.64, p < .001
Caring attributes	Providing	1.47	0.29	r = −0.71, p < .001
Capable practitioner	Importance	3.7	0.42	r = 0.61, p < .001
Capable practitioner	Providing	1.370.46	0.46	r = −0.72, p < .001

Furthermore, preoperative anxiety had significant correlations with age (r = −0.18; p < .001), hospitalization frequency (r = −0.24; p < .001), and average length of stay (r = −0.26; p < .001). There was a significant difference in the average preoperative anxiety in terms of education level (p < .001; F = 3.06). However, the average preoperative anxiety did not show any significant differences in terms of gender (p = .43; t = 0.67), marital status (p = .32; t = 0.46), kind of surgery (p = .46; F = 0.58), previous surgery (p = .36; t = 0.41), and hospital wards (p = .57; F = 0.67).

The data from multivariate linear regression analysis indicated that factors such as the importance and extent of compassionate care provision, need for information, age, education level, frequency of hospitalization, and the average length of stay explained 0.44% of the variances in preoperative anxiety. In addition, compassionate care provision followed by the average significance of compassionate care had a greater contribution in explaining preoperative anxiety (β = 0.50, p < .001) (Table 3).

Table 3.

Multiple linear regression analysis predicting pre operation anxiety in patients (n = 704).

Coefficientsa
Model	Unstandardized coefficients		Standardized coefficients	t	p value
Model	B	Std. error	Beta	t	p value
(Constant)	14.841	1.411	—	10.521	<0.001
Importance of compassionate care	0.192	0.030	0.331	3.181	<0.001
Provision of compassionate care	−0.372	0.026	−0.50	−6.924	<0.001
The need for information	0.522	0.062	0.315	8.377	<0.001
Age	0.005	0.098	0.002	0.053	0.958
Education level	0.208	0.111	0.073	2.166	0.05
Number of hospital stays	−0.202	0.161	−0.056	−1.251	0.211
Length of stay	−0.338	0.069	−0.178	−4.906	<0.001

^aDependent Variable: Pre operation anxiety, Adjusted R² = 0.44.

Discussion

The present study investigated the relationship between perceived compassionate care and preoperative anxiety in hospitalized patients. The results showed that the patients assessed preoperative anxiety to be severe, compassionate care had high importance, and the extent of compassionate care provision was low.

Surgery is always considered a serious experience for patients and their family members, and anxiety is a reaction to natural adaptation to surgery.²⁷ Preoperative anxiety has been moderate to severe in patients who underwent various types of surgery,^28–31 as was confirmed in the present study. Rastgarian et al. (2020) also showed that preoperative anxiety in hospitalized patients was moderate.⁴ Ferede et al. (2022) investigated the prevalence and risk factors for preoperative anxiety in pregnant patients who underwent cesarean section and reported that the overall prevalence of preoperative anxiety was high.²⁸ A huge bulk of evidence from the literature confirms the vital role of nurses and anesthesiologists in reducing patients’ anxiety in the preoperative phase through psycho-educational and individual interventions. It is necessary for the personnel of health organizations to plan effective measures based on the patient’s preferences to reduce their anxiety in the preoperative stage and provide psychological support for the patients.

One of the issues that have recently been addressed with an emphasis on moral and human values and patient-centeredness in care and have become a global issue is the provision of compassionate care.³² A review of the literature also showed that compassionate care is an inseparable part of nursing care.³³ The patients in the present study reported that the importance of compassionate care was high and the extent of compassionate care provision was low. According to the patients in the present study, all dimensions of compassionate care, including meaningful connection, patient expectation, caring attributes, and capable practitioner were very important in reducing preoperative anxiety. In compassionate care, the nurse establishes a constructive interaction with the patient to discover the patient’s concerns and does her best to resolve those concerns. Hence, the first requirement for providing compassionate care is to establish an effective relationship between the nurse and the patient.¹¹

There are many individual and organizational obstacles to providing compassionate care.^34,35 Loss of self-compassion, fatigue, personal life problems such as lack of well-being in personal life, and patient-reactive behaviors like aggression have been reported as individual obstacles to compassionate care.³⁶ Moreover, high workload, paperwork, crowded ward, shortage of medical staff, disrespect for compassionate care, low salaries, the failure to value compassionate care, and lack of management support have been highlighted as organizational factors affecting compassionate care.³⁵

Despite the importance of compassionate care in increasing patient satisfaction, facilitating the discharge process, and reducing treatment costs,³⁷ there are some obstacles to the nurse-patient relationship.³⁵ Effective nurse-patient interaction is one of the important indicators of compassionate care that can be influenced by the culture of the community.¹¹ In Iranian communities, nurses are mostly considered healers and caregivers, and the supportive and professional role of nurses is less acknowledged. In Islamic societies such as Middle Eastern countries, religion plays an important role in the quality of nursing care. Compliance with the religious and cultural norms of the community in the care of patients is also mandatory.³⁸ The studies conducted in this field in Iran have confirmed that gender is a determining factor and is considered a cultural barrier for the compassionate behavior of nurses. Traditionally, nursing care measures in Iran are based on Islamic standards and policies governing treatment and care.³⁸ Previous studies (e.g., Zaidi, 2015; Jahromi et al., 2014) have indicated that if the gender of the nurse and the patient are the same, the nurse is more motivated and makes more efforts to talk about the patient’s issues.^39,40 However, nurses try to support patients and their families by spending time with them and providing culture-based care.³⁴ Cultural and religious differences in Islam and other cultures can justify these differences. For example, some loving behaviors such as touching the opposite sex are inappropriate and forbidden in Islam, and Muslim nurses should avoid such behaviors.

Accordingly, other studies addressing compassionate care in Iran have shown that nurses emphasize their therapeutic role without considering the psychological and emotional aspects of the care provided. The participants reported that sharing feelings, understanding the concerns of patients who need intimate interactions, intimacy and friendly communication, physical intimacy, and touch are not approved by the Iranian culture and community.³⁸ Babaei et al. (2022) showed that compassionate care is usually context-based and there is no single theory to explain the process of compassionate care. This finding also indicates the importance of observing cultural norms in the community.⁴¹ Most Iranian nurses are Muslims. Muslim tradition encourages all people, including nurses, to help others and be compassionate as human beings. Thus, Muslim nurses are expected to provide compassionate care in their profession.⁴² As such, nursing managers and health care officials should improve the knowledge and skills of nurses by holding training workshops and develop the organizational culture to focus on compassionate care. In addition, to reduce time spent on paper work, computerized documentation should be promoted in the organization.³⁴ Moreover, paying attention to nurses’ individual problems, ensuring their well-being, and creating a supportive work environment by managers are helpful in promoting compassionate care.

Accordingly, ethical and human issues are among the other aspects of compassionate care, as confirmed in previous studies.⁴³ Therefore, it can be acknowledged that compassionate care is a moral virtue that should be used along with other moral principles in providing nursing care.³⁶ In addition, one of the important requirements for providing compassionate care is establishing effective communication between the nurse and the patient, and most studies have highlighted the importance of establishing a sincere and friendly relationship with the patient to discover the patient’s problems and solve them.⁴⁴ Moreover, the available evidence shows that the nurse’s conversation with the patient and their family members and even with colleagues is very important regarding how to provide care. Dewar et al. (2014) have called this process caring conversations.⁴⁵ Proctor also considered active listening, protecting the patient’s privacy, discovering the patient’s anxiety, and trying to alleviate this anxiety as examples of compassionate care.⁴⁶

The data in the present study showed a significant relationship between preoperative anxiety and providing compassionate care. In other words, the more compassionate care was provided, the less preoperative anxiety. Preoperative anxiety is an integral part of surgery and bothers the patient. However, various studies have shown that the use of non-pharmacological treatment methods, such as education and sometimes listening to the patient, listening to music, as well as counseling and clinical staff’s effective verbal communication with patients who are candidates for surgery are effective in reducing preoperative anxiety and stress.^50,51

Following the findings of this study, a review of the literature indicated that preoperative interventions through internal connection and empathetic and patient-centered approaches to care are the most effective interventions to reduce the anxiety of patients before surgery. The patient-centered approach focuses on concerns, expectations, informational needs, spiritual-emotional needs, and life issues.⁵² Dias et al. (2022) showed that a standardized preoperative nursing discussion helped reduce preoperative anxiety in patients undergoing major visceral surgery.⁵² Pereira et al. (2016) studied the effect of an empathic patient-centered approach on preoperative anxiety and surgical outcomes in ambulatory surgery patients and showed that an empathetic patient-centered intervention can reduce preoperative anxiety, improve surgical outcomes, and increase wound healing and patient satisfaction.⁵³ Xu et al. (2020) found that preoperative nursing visits reduce postoperative anxiety and complications in laparoscopic cholecystectomy candidates.⁵⁴

Lee and Seomun (2016) reported that nurses considered compassionate nurses to be sensitive to patients’ conditions and be able to interpret or predict their needs. Such a nurse communicates with patients with an open attitude and has the basic and up-to-date professional knowledge to provide compassion-based services.⁵⁵ Compassionate nurses are seen as competent and skilled nurses in their jobs and act professionally.^25,56

Another study showed that knowledge-based care and specialized skills of the nurse, intuition in diagnosing problems, time management in care, and maintaining moral values during care combined with moral virtues are indicators of the nurse’s professionalism in line with compassion in performance.¹¹ Research has also shown that professional and capable nurses tend to provide compassionate care.⁵⁷ Although compassion can be one of the main factors contributing to improving the quality of nursing care, other factors such as the professionalism and competence of the nurse are also effective in the development of the quality of nursing care.

The findings from the present study revealed a significant correlation between preoperative anxiety and the need for information. Ju et al. (2023) showed that preoperative anxiety was common in lung cancer patients scheduled for video-assisted thoracoscopic surgery, and meeting the patient’s informational needs was one of the key protective factors for preoperative anxiety.⁵⁸ Various factors are associated with preoperative anxiety, including demographic factors, psycho-social variables, and factors related to surgery and anesthesia such as previous surgical experiences, and having information about the surgical procedure and anesthesia.^59,60 The information given to the patient should be simple, understandable, and reliable, avoid misunderstandings, and help the patient to understand the medical goal pursued and the proposed procedures. The demand for receiving information is very variable according to the patient’s condition. In general, patients who demand more information have a higher level of anxiety.⁶¹ Providing sufficient information is necessary for proper management and coping with the disease and reducing stress and fear caused by the disease and surgery.⁵⁸ Compassionate nurses are also expected to meet the comprehensive needs of the patient, including meeting the needs of information and training for their care to help alleviate the suffering and concerns of patients and their families.¹¹

The present study found a significant relationship between preoperative anxiety and age. In other words, with increasing age, the level of preoperative anxiety decreased. This finding was consistent with the results of previous studies.^31,62 Another study showed that the age of patients less than 30 years, education, and previous exposure to anesthesia and surgery were also highly correlated with preoperative anxiety.²⁸ Age appears to be a protective factor against preoperative anxiety. However, some studies showed that elderly patients experience higher levels of preoperative anxiety than younger patients due to comorbidities.^63,64 In contrast, a study showed that age is not an important factor in preoperative anxiety.⁵⁰ These conflicting results can be attributed to different sample sizes in studies. However, to reduce patients’ preoperative anxiety, healthcare staff should consider patient-centered care and take educational and support measures according to the unique characteristics of the patient.

The present study found no significant relationship between preoperative anxiety and gender. Rastgarian et al. (2020) and Navarro-Gastón and Munuera-Martínez (2020) found no significant difference between the average anxiety level of women and men.^4,65 Contrary to the present study, some studies have shown that gender is an independent predictor for preoperative anxiety and women tend to experience higher levels of anxiety compared to men due to higher emotional sensitivity in women as well as fluctuations in sex hormones that lead to mood disorders and anxiety. Another reason is that women express their anxiety more easily than men.^29,66,67 Melchior et al. (2018) reported that men had a higher level of anxiety than women, and it is believed that men are more concerned about maintaining their homes and family because many patients were the sole breadwinners and were in informal or unemployed jobs, whose income depended on their independence and maintaining their health.³⁰

The findings of the present study showed that preoperative anxiety was significantly different in patients with different levels of education. Previous studies have also shown the variable effect of patients’ education on preoperative anxiety. Some of these studies, in line with the present study, have shown the negative effect of higher education on preoperative anxiety.²⁹ It has been stated that more educated people have an information-seeking personality and are more willing to receive medical information from their doctors.⁶⁸ On the contrary, some studies have reported a higher level of preoperative anxiety among illiterate patients and have associated it with “fear of the unknown” in this population.⁶³

The present study also showed a significant relationship between preoperative anxiety and the frequency of hospitalization, and the average length of stay. Previous exposure to surgery and anesthesia reduced preoperative anxiety compared to patients who had no exposure, as reported in various studies.^28,69 One possible reason is that patients who are exposed to surgery and anesthesia have fewer misconceptions and fear of unknown complications. However, in some studies, patients who had undergone previous surgery and anesthesia reported higher levels of anxiety.^29,70 To justify this finding, the researcher stated that patients may suffer stressful complications such as death due to previous anesthesia and surgical exposure. Additionally, such association may be contributed to negative experiences such as complications, infections, unresolved fears, or even low trust in the medical staff.^29,30

Given that anxiety is a frequent problem during the preoperative period both for patients and medical professionals, it is necessary to identify anxious patients in time and take effective measures to reduce the occurrence of preoperative anxiety and its possible consequences. Since cultural and social factors are also effective in how to care for patients and provide compassionate care, nurses must find effective strategies based on the cultural norms of the community. Furthermore, nursing managers need to consider compassionate care as a safe and secure technique for providing preoperative care to patients by taking into account the cultural-religious conditions of the community and the role of nurses in providing compassionate care. Besides, they should provide necessary training about this type of care to employees in health organizations and incorporate concepts related to compassionate care in nursing curricula.

One of the strengths of this study was the use of a quantitative design in the research setting. Most studies on compassionate care have been conducted qualitatively. Thus, this quantitative study can contribute to conducting future studies. One of the main limitations of the present study was the use of a cross-sectional design, making it difficult to establish a cause-and-effect relationship. Furthermore, this study addressed some types of surgery. In addition, the data were collected only immediately in the preoperative phase. Collecting the data in the postoperative phase is likely to provide more and richer information in this field.

Conclusion

The present study showed that compassionate nursing care was very important from the point of view of hospitalized patients in the preoperative period. However, this quality care, which is provided based on understanding the comprehensive needs of the patient and in line with ethical codes and professional values has received less attention. In addition, the patients in this study reported a high level of preoperative anxiety, which was associated with compassionate care in the preoperative phase. Thus, all nursing staff need to consider this type of care in their care behavior during the patient’s surgery, and the officials of health organizations should highlight the necessity of providing this care and its characteristics by holding workshops. A few studies have addressed compassionate care using quantitative approaches. Moreover, authorities need quantitative evidence to evaluate the performance of nurses and give them feedback. Thus, future studies should address compassionate care in other cultures and also a wide range of patients waiting for surgery, especially patients with long-term diseases, heart patients, cancer patients, and patients who need palliative care in the postoperative phase.

Footnotes

Acknowledgements

The authors would express their gratitude to all patients of the various wards of teaching hospitals under the authority of Hormozgan University of Medical Sciences for their participation.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Samaneh Bagherian

Banafsheh Tehranineshat

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