PREOPERATIVE ANXIETY AND ITS ASSOCIATED FACTORS AMONG SURGICAL

PATIENTS IN MALAYSIA

Azura Abdul Halain1, Nyra Nabila Mat Bidin2, Salimah Japar1, Zarina Haron1, Santhi Yew Roan Nee1,
Kim Lam Soh1

1
Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, Universiti
Putra Malaysia.
2
Subang Jaya Medical Center,Subang Jaya , Selangor,Malaysia

Corresponding author e-mail: azurahalain@upm.edu.my

Keywords: Preoperative anxiety, Amsterdam Preoperative Anxiety and Information Scale (APAIS)

Abstract such distress among surgical patients at public

Background: Preoperative anxiety is a
challenging issue among patients awaiting surgical
procedures. Preoperative anxiety is derived from
stress responses towards perceived threat and risk
related to surgery. The purpose of this study is to
investigate factors that impact preoperative
anxiety among surgical patients at a public
hospital in Selangor, Malaysia.
Method: A cross-sectional study with universal
sampling was used in this study. A total of 98
preoperative patients from a public hospital in
Selangor were selected to participate in a self-
administered questionnaire carried out from June
until October 2018. The study instrument used in
this study was adapted from the Amsterdam
Preoperative Anxiety and Information Scale
(APAIS). The data obtained were analyzed by
descriptive analysis using frequencies and
percentages.
Results: Our findings showed that of the 98
respondents in this study, 57(58.2%) respondents
experienced preoperative anxiety while 41(41.8%)
experienced no anxiety prior to surgery. The two
most common reasons for anxiety were over the
outcome of their operation (51.0%) and
postoperative pain (49.0%), while insufficient
attention from caregiver (5.1%) was the factor
with the least impact on preoperative anxiety in
this study.
Conclusion: The majority of respondents
experienced preoperative anxiety prior to surgery.
Hence, intervention should be conducted by
healthcare providers, especially nurses, to reduce
hospitals.
`
Introduction
Preoperative anxiety is an unpleasant state of
tension, which can be considered as secondary
to a patient being concerned about a disease,
hospitalization, anaesthesia and surgery
(Ebirim & Tobin, 2010). Preoperative anxiety
is derived from stress responses towards
perceived threat and risk related to the surgery
and hospital environment (Alqefari et al.,
2017; Ting, Ng & Siew, 2013). According to
Ting et al. (2013), patients with preoperative
anxiety experience a variety of unpleasant
symptoms such as greater postoperative pain
and psychological distress. The level of
preoperative anxiety may adversely affect
different aspects of surgical recovery, selection
of anaesthesiological approach, and outcome
of surgery. Preoperative anxiety remains
common today despite advances in medicine
and surgical techniques. According to
Gangadharan, Feddah and Reemas (2014),
reducing preoperative anxiety may improve
surgical outcome, shorten hospital stay, and
minimize lifestyle disruption.
Surgery is a branch of medicine that deals with
the diagnosis, treatment of injury, deformity, and
disease by the use of instruments (WHO, 2017).
Nevertheless, from the patients’ perspective,
surgery may be perceived as a negative event
associated with fear, and even as a possible
threat to physical and mental integrity
(Ruhaiyem, Alshehri, Saade , Shoabi , Zahoor,
Tawfeeq, 2016). Thus, it is important to manage

1
and reduce preoperative anxiety among patients
who are awaiting surgery.
Method
This study was conducted in a public hospital
in Selangor. It was a cross-sectional study
carried out over 6 months from December
2017 until May 2018. A total of 98
preoperative patients were selected to
participate in a self-administered questionnaire
modified from Moerman, Dam, Muller and
Oosting (1996) and from Zakariah, Lai and
Loh (2015). A Malaysian version of the
Amsterdam Preoperative Anxiety and
Information Scale (APAIS) was used in this
study with permission from the authors
Zakariah, Lai and Loh (2015) to measure the
anxiety level among respondents. The APAIS
portion of the questionnaire contained 6 items,
with items 1, 2, 4 and 5 determining the score
for preoperative anxiety. Items 3 and 6 were
concerned with ‘need-for information’. The
scoring system using APAIS had a cut-off
point of 13, where ≥ 13 would be considered
anxiety, whereas scores <13 would not be
considered anxiety. The maximum score was
60 while the minimum score was 6. The
respondents, aged 18 years and above, were
awaiting elective surgeries.
The questionnaire was written in English and
Malay to facilitate comprehension by
respondents with different language
proficiencies. There were three sections.
Section A was aimed at soliciting socio-
demographic data such as age, gender,
educational level, history of previous surgery
and types of surgery. Section B consisted of
questions which rated anxiety according to
APAIS, while Section C consisted of 8
questions that were related to factors which
contributed to preoperative anxiety among
respondents awaiting surgery; these questions
required ‘yes’ or ‘no’ responses.
After obtaining ethical approval from the
University Ethic Committee, the
questionnaires were distributed to preoperative
respondents in selected surgical wards.
Patients about to undergo emergency surgery
or medically diagnosed with psychiatric
2
problems were excluded from this study.
Ninety eight respondents participated in this
study (44 males and 54 females). An
information sheet and consent form was given
to the participants before they answered the
questionnaire. They were also informed about
the aims of the study and were guided on how
to respond to the questionnaire.
After the completed questionnaires were
collected, they were reviewed to identify errors
before being analysed. The data were
subjected to descriptive analysis using the
Statistical Analysis Package for Social
Sciences Version 20. Frequency tables were
generated for age, gender, educational status,
previous surgical history, factors responsible
for preoperative anxiety, and comparison of
respondents with preoperative anxiety from
different surgical wards.
Results
Table 1 shows the socio-demographic
characteristics of the respondents.
Among the 98 respondents, 57(58.2%)
experienced preoperative anxiety while 41
(41.8%) did not experience anxiety prior to
surgery (Table 2). The results indicated that
elderly respondents (60 years and above)
showed less anxiety, with only 30.6% affected
by such distress. This compared with younger
respondents aged below 60 years, among
whom 45.9% between 31 to 59 years and
23.5% below 30 years showed preoperative
anxiety. A majority of female respondents
(55.1%) experienced preoperative anxiety
compared to male respondents (44.9%). It was
found that the respondents who had no formal
education (16.3% showing anxiety) were less
affected compared to respondents with
primary (20.4%), secondary (34.7%), and
tertiary (28.6%) education. A comparison of
preoperative anxiety among patients from six
(6) surgical wards showed that those with the
highest anxiety level were from the
ophthalmology ward and orthopaedic ward
with 35.7% and 29.6% respectively. Anxiety
levels were lower among respondents in the
gynaecology ward (14.3%), general surgery
(10/2%) and ear-nose-throat ward (10.2%).
These differences might be because of the least concern was insufficient attention from
different management of preoperative patients caregiver (5.1%).
in each ward.

Table 3: Reasons for preoperative anxiety among

surgical patients (N=98)
Table 1: Respondents’ socio demographic
profiles (N=98) Variables n %

Variables n (%) Fear of death

Yes 23 (23.5)
Age No 75 (76.5)
30 years and below 23 (23.5) Fear of the unknown
31 to 59 years old 45 (45.9) Yes 10 (10.2)
60 years and above 30 (30.6) No 88 (89.8)

Gender Awareness during anaesthesia

Male 44 (44.9) Yes 14 (14.3)
Female 54 (55.1) No 84 (85.7)
Result of operation
Educational Status
No formal Yes 50 (51.0)
education 16 (16.3) No 48 (49.0)
Primary education 20 (20.4) Postoperative pain
Secondary 34 (34.7) Yes 48 (49.0)
education No 50 (51.0)
Tertiary education 28 (28.6)
Insufficient attention from
Previous surgery caregiver
Yes 41 (41.8) Yes 5 (5.1)
No 57 (58.2)
No 93 (94.9)
Postponed surgery
Table 2: Preoperative anxiety among Yes 47 (48.0)
respondents No 51 (50.0)
Preoperative anxiety n (%)
Financial loss due to hospitalization
No anxiety 41 41.8
Clinically significant anxiety 57 58.2 Yes 8 (8.2)
No 90 (91.8)

Factors responsible for preoperative anxiety:

The most common cause for anxiety was
concern about the result of the operation,
which was the factor most commonly cited
(51%) by the respondents, this was followed
by postoperative pain (49.0%), and postponed
surgery (48.0%). Next was fear of death
(23.5%), awareness during anaesthesia
(14.3%), fear of the unknown (10.2%),
financial loss due to hospitalization (8.2%), of
Discussion
This study finding showed that 58.2% of the
respondents experienced preoperative anxiety.
Study by Zakariah et al. (2015) on preoperative
surgical patients at the University Malaya Medical
Centre, Kuala Lumpur, showed that 80% of the
200 respondents experienced preoperative anxiety
prior to surgery. However, preoperative anxiety

3
among respondents in their study was associated
more with lack of information regarding
anaesthesia. Meanwhile, a study on anxiety prior
to surgery among surgical patients that was
performed in 2013 by Ting et al., (2013) at the
Hospital Kuala Lumpur (HKL) showed that 92%
of the 88 patients experienced anxiety. The
incidence of anxiety prior to surgery in their study
was associated with insufficient preoperative
information. It is found that information regarding
surgery was ranked as the highest with 84(97.5%)
followed by information of nursing care
66(83.3%). The results from Saini and Dayal
(2016) were consistent with this study finding
whereby 58.7% of their 129 preoperative
respondents experienced preoperative anxiety.
Influence of Socio-demographic characteristics
of the respondents
Findings in this study showed that respondents
who were aged 60 years and above experienced the
least anxiety. Older adults were more able to
identify, and seek appropriate treatment for
common psychiatric symptoms than younger
adults (Wetherell, 2009). This study also found
that female patients awaiting surgery were more
anxious compared to men. According to Howard
(2016), the differences in brain chemistry and
hormonal fluctuations could be the factor that
influencing coping with stress between men and
woman.
The results of this study also showed that
respondents with no experience of surgical history
had more anxiety, this finding being supported by
Ebirim and Tobin (2010). It may be related to the
conditioned learning model where many
unconditioned fear stimuli repeatedly occur at
short intervals during the perioperative period.
According to Caumo et al. (2001) the patient’s
with surgical and medical history may reduce fear
conditioning, making the quality of the experience
a crucial aspect.
Factors responsible for preoperative anxiety
The factor most frequently associated with
preoperative anxiety in this study was the result or
outcome of the operation. People believe changes
4
resulting from surgery might affect their daily
routine physically, emotionally, and financially
(Millán, Barrera Serrano and Ornelas Aguirre,
2010; Jawaid, Mushtaq, Mukhtar & Khan, 2007).
Besides, social stigma may have a considerable
impact emotionally due to changes prior to the
outcome of surgery (Anxiety and Depression
Association of America, 2016). Postoperative pain
ranked second among the factors as a cause for
preoperative anxiety in this study. This was
consistent with the earlier finding that respondents
were worried about pain after their surgery
(Nigussie et al., 2014). The factor that least
impacted preoperative anxiety among surgical
patients at the public hospital in Selangor was
insufficient attention from their caregiver. This
finding might not be applicable to preoperative
patients in other countries because in Malaysia, the
local set-up is family oriented, where family values
are accorded importance (Mansor, 2013).
Unlike the findings of this study, a study by
Nigussie et al., (2014) found that fear of death
drove up the anxiety level among preoperative
patients. While Ebirim and Tobin (2010) showed
that the leading factor of preoperative anxiety in
their study population was the fear of having
postoperative pain. The different findings from
various studies could be influenced by cultural and
demographic differences among patients awaiting
surgery (Saini & Dayal, 2016).
Conclusion
In conclusion most patients who are undergo
surgery experience varying levels of preoperative
anxiety. In this study, majority of the respondents
at the public hospital in Selangor had anxiety prior
to surgery. The younger female patients, patients
with no formal education, and those who had no
experienced previous surgery had high anxiety
level prior to surgery. Meanwhile, concern with
the outcome of the operation was the most
common factor influencing preoperative anxiety
among respondents. Hence, appropriate
intervention such as preoperative orientation could
be implemented in the ward prior to surgery to
reduce preoperative anxiety among surgical
patients.
Acknowledgements

All patients in surgical wards at Selangor for

their cooperation, we are very thankful to them.

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