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 Epidemiology and Society Health Review| ESHR 
Vol. 3, No. 2, 2021, pp. 23-30 ISSN 2656-6052 (online) | 2656-1107 (print) 

 
 

      10.26555/eshr.v3i2.4301  

23  
 

     

Review Article 
 
Pre-operative Education to Reduce Anxiety: Literature 
Review 
 
Rissa Widyasworo Hartanti1,* and Lina Handayani1 
 

1 Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia  
 
* Correspondence: widyaswororissa@gmail.com Phone: +628562554570 
 
Received 26 June 2021; Accepted 9 August 2021; Published 10 August 2021 
 

ABSTRACT  

Background: Surgical procedure is one of the stressors that can end up with 
psychological disorders such as anxiety. Anxiety can lead to increased blood pressure 
and the risk of bleeding. Receiving detailed information on the surgical procedure is a 
patient's right. The information provided is expected to reduce patient anxiety and foster 
good relations between health workers and patients. Considering the importance of this 
step, we study the effect of pre-operative information before surgical procedures based on 
the published literature. This study aimed to summarize the previous research that 
elaborates on the relationship between education pre-operative and anxiety. 
Method: A literature review was used in this study. Google Scholar, PubMed, and 
ProQuest databases were chosen as data sources. We sough article published during 
2016-2021. In total, 450 articles were screened using inclusion and exclusion criteria for 
analysis.  
Results: Eight articles reported that there was an effect of education on patient anxiety. 
Conclusion: Providing education is an effective approach to reduce patient anxiety. 

Keywords: Education; Patient; Anxiety; Information 

INTRODUCTION 

Surgery is an invasive treatment action that displays body parts, makes an incision, then 
repairs and closes the wound with suturing (1). Surgery is a high-risk action that requires an 
operating room to minimize infection during surgery (2). The stages of surgery start from pre-
operative, intraoperative, and post-operative. Pre-operative preparation is one of the phases 
that determines the success of the surgery. Pre-operative preparation starts from the patient 
entering the treatment room until the patient arrives in the operating room (3). The readiness 
of the patient includes physical and mental readiness. Physical readiness examines physical 
health, nutritional, fluid, and electrolyte balance, gastric and colonic hygiene, personal 
hygiene, and bladder emptying. Mental/psychic pre-operation readiness is psychological 
readiness in dealing with surgery. Patients who do not have mental readiness will 
experience anxiety before surgery (4). Anxiety also has medical risks such as increased 



Hartanti (Pre-operation Education to Reduce Anxiety: Literature Review) 
 

 

Vol. 3, No. 2, 2021, pp. 23-30    10.26555/eshr.v3i2.4301 
  

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breathing, vasoconstriction of blood vessels, increased blood pressure which causes 
surgical bleeding. Several reasons can cause pre-operative anxiety, including fear of 
physical changes, uncertainty, surgery pain, death risk (5). 

The prevalence of anxiety disorder worldwide varies 2.5 to 7 percent by country (6). It is 
estimated that globally 284 million people experienced an anxiety disorder in 2017. About 63 
percent (179 million) are women, and 105 million are men. According to a survey in the 
United States, 18.1% or about 42 million people live with anxiety (7). In Indonesia, the 
results of Basic Health Research 2018 show that 6,2% of people aged 15-24 years and 
15.941-157.695 people in Indonesia experience anxiety (8). Causes of anxiety such as 
potential stressors, knowledge, social support, environmental adaptation process, and 
operating experience influence patient anxiety (9). To make s surgical procedure successful 
need psychology preparations cover the patients. Patients need to be educated, and all 
treatment alternatives should be explained (10). Mental or psychological support is required 
for patients who experience anxiety by providing information about the surgery to be 
conducted. Providing details on operating time, information on the operation site's situation 
or things experienced during the surgical procedure can reduce anxiety and make the 
patient more prepared to undergo surgical procedures. The role of the nurse as an advisor is 
vital to perform these actions (4). Accordingly, we want to know the effect of pre-surgery 
education on patient anxiety patients. This paper aims to summarize the previous research 
that elaborates on the relationship between education pre-operative and anxiety. 

METHOD 

Search Strategy 

This literature study searched research articles in reputable databases such as PubMed, 
ProQuest, and Google Scholar. A set of keywords, namely "education pre-surgery," "patient 
anxiety," "effect of education," and "effect of pre-surgery education," were used to search for 
articles. Title, keywords, abstracts, language, year of published and method were screened 
for the first step for relevant articles. In the second step, we screened the article according to 
the relevant variable, and last we selected the article based on the full-text availability. 
Figure 1 shows the flow chart of the article review employed in this paper.  

Inclusion and Exclusion Criteria 

In our analysis, the article should fulfill the following inclusion criteria: article published in 
English or Indonesian, the article discussed Indonesia or globally, published 2016-2021, 
abstract and the full text is freely accessible, the research sample was elective surgery 
patient (planned surgery). While the exclusion criteria were qualitative research, the article 
did not mention the instrument used for measuring anxiety, study in the emergency setting, 
full text not freely available. 

RESULTS 

Based on the results of a literature search, eight articles were found that matched the 
criteria. The research article identifies patient education and anxiety in various hospitals in 
Indonesia and outside Indonesia. Eight articles were published as review articles, five from 
Indonesia, and three journals were published outside Indonesia (Polandia, Iran, and 



Hartanti (Pre-operation Education to Reduce Anxiety: Literature Review) 
 

 

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Taiwan). The most significant number of samples used was 213, and the smallest number of 
samples was 15. A research instrument is a tool used to collect or obtain data in conducting 
research. A total of 3 articles used State-Trait Anxiety Inventory (STAI) anxiety instrument, 
three articles used the HARS (Hamilton Anxiety Rating Scale) instrument, 1 article used 
Zung Self-Rating Anxiety Scale (SAS/ZRAS), and 1 article used T-MAS. 

 

 

 

 

 

 

 

 

 

 

 

Figure 1. The flow chart of the article review 

There are differences in the research design used, 6 studies using quasi-experiments and 2 
studies using pre-experiments. All articles explain that educating and providing information 
to patients can reduce patient anxiety. We found that five articles using Wilcoxon signed-
rank test, and three studies using the T-test for analysis purposes. All articles explained that 
educating and providing information to patients before getting an operation can reduce 
patient anxiety. 

Table 1. Literature search synthesis 

No Title, 
Author 

Method Sample 
 

Instrument and 
analysis used. 

Result 

1 The Effect of 
Health 
Education on 
Changes in 
Anxiety of Pre 
Elective Surgery 
Patients in 3rd 
Class of RSUD 
City of Madiun 
 
Widyaningrum. 
(2017) 
 

Pre-
experiment   

The number of 
samples was 35 
respondents, one 
group without 
control by 
consecutive 
sampling. 

Data collection 
used Zung Self-
Rating Anxiety 
Scale (ZSAS) 
Data were 
analyzed using 
a T-test 

Before being given health 
education, the average 
anxiety level of respondents 
was in the moderate 
anxiety category, 24 
respondents (68.6%). After 
being given health 
education, most of the 
respondents' anxiety levels 
were in the non-anxious 
category were 19 
respondents (54.3%). 
Statistical test results show 
p-value = 0.000 (p-value< = 
0.05), there is an effect of 
education in patients with 

Potentially relevant studies were identified by searching 
in Google scholar (n=241), PubMed (n=62), ProQuest 

(n=147)  
Total n=450 

 

Studies were selected by title and keyword  
(n=105) 

245 articles were excluded because 
published in other than English and 

Indonesian, not mentioned the instrument 
used for anxiety measure, published before 

2016, using a qualitative approach 
 
 
 
 

Studies were selected for more detailed evaluation 
(full-text articles were retrieved, and abstracts were 

read) (n=25) 

17 articles were excluded because 
the full text was not freely available 

Potentially relevant studies  
(n=8) 

 

80 articles were excluded due to variables 
not relevant to the research purpose 

 
 
 
 



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Vol. 3, No. 2, 2021, pp. 23-30    10.26555/eshr.v3i2.4301 
  

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No Title, 
Author 

Method Sample 
 

Instrument and 
analysis used. 

Result 

pre-elective surgery in 3rd 
Class of General Hospital 
of Madiun District. 

2 Effect of an 
Orientation Tour 
on Preoperative 
Anxiety in 
Candidates for 
Coronary Artery 
Bypass Grafting: 
A Randomized 
Clinical Trial 
 
Reyhaneh 
Niknejad, 
Mohsen 
Mirmohammad 
Sadeghi, 
Mohammad 
Akbari, Ahmad 
Ghadami (2019) 
 

Quasi 
Experiment  

The number of 
samples is 70 
(control group= 35 
Respondens and 
intervention group= 
35 respondents), 
randomized clinical 
trial study.  

Anxiety 
instrument with 
State-Trait 
Anxiety 
Inventory(STAI)
Data was 
analyzed using 
T-test. 

Anxiety levels were 
significantly lower in the 
intervention group (35.40 ± 
10.24) compared to the 
control group (46.91 ± 9.51) 
(P < 0.001). So the pre-
operative orientation 
overview has a positive 
impact on the anxiety level 
of the prospective CABG 
patient. 
 

3 The Effect of 
Health 
Education on 
Anxiety Levels 
in Pre-Major 
Surgery Patients  
 
Fadli, Irmayanti, 
Kassaming, 
(2019) 

Quasi 
experiment 

The number of 
samples is 15 
respondents, one 
group without 
control by purposive 
sampling. 

Anxiety 
instruments with 
HARS (Hamilton 
Anxiety Rating 
Scale). Wilcoxon 
signed-rank test 
was used to 
analyze the 
data. 

There was a significant 
change in the average level 
of anxiety before and after 
health education to patients 
with pre-major surgery 
(23.67 to 17.93). So the 
average difference before 
and after is 5.73. The 
results showed p = 0.001. 
So there is deferent before 
and after education, it can 
be concluded that there is a 
significant effect of health 
education on reducing the 
level of anxiety in pre-major 
surgery 

4. Influence of Pre-
operative 
Information 
Support On 
Anxiety, Pain, 
and Satisfaction 
with post-
operative 
analgesia in 
children and 
adolescents 
after thoracic 
surgery: a 
randomized, 
double-blind 
study 
 
Lucyna 
Tomaszek, 
Grazyna 
Cepuch, Dariusz 
Fenikowski 
(2018) 
 

Quasi-
experiment  

The number of 
samples is 112 
consist control 
group subjects=56 
who the nurse gave 
routine pre-
operative 
information, and the 
experimental 
group=56 offered 
additional 
psychological 
consultation by 
randomized, double-
blind study. 

Anxiety 
instrument with 
State-Trait 
Anxiety 
Inventory 
(STAI). Wilcoxon 
signed-rank test 
was used to 
analyze the 
data. 

In the experiment group, 
the level of state anxiety 48 
hours post-surgery was 
significantly lower, <7/10 
sten to the procedure. In 
the control group, the level 
of post-operative anxiety 
was substantially higher ³ 7 
sten to the procedure. So, 
information support 
psychologists before 
thoracic surgery reduce 
post-operative anxiety 
levels.  

5. The Effect of 
Health 
Education on 
Preoperative 
Physical 
Preparation in 

This 
research 
used Quasi 
experiment  

The number of 
samples in this 
study amounted to 
32 consists 16 
respondents as 
intervention group 

Questionnaire 
used T-MAS. 
Data were 
analyzed using 
Wilcoxon 
signed-rank test 

There is a different level of 
anxiety in the treatment 
group and control group p-
value: 0.00 (p-value <0.05), 
meaning the effect of health 
education about physical 



Hartanti (Pre-operation Education to Reduce Anxiety: Literature Review) 
 

 

Vol. 3, No. 2, 2021, pp. 23-30    10.26555/eshr.v3i2.4301 
  

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No Title, 
Author 

Method Sample 
 

Instrument and 
analysis used. 

Result 

Reducing 
Anxiety in 
Hernia Patients 
  
Puspita, 
Miftahus (2017) 

and 16 respondents 
as control groups by 
consecutive 
sampling approach. 
 

and the Mann 
Whitney test. 

preparation on anxiety in 
hernia patients. 

6. The Effect of 
Cardiac Pre-
Catheterization 
Health 
Education on 
Patient Anxiety 
Levels at the 
Cardiac Service 
Installation  
 
Lily Misriani, 
Feriana Ira, 
Agnis (2020) 

This study 
used a pre-
experiment  

The number of 
samples is 16 
respondents. one 
group without 
control by purposive 
sampling approach. 

Anxiety 
instrument with 
HARS (Hamilton 
Anxiety Rating 
Scale) 
questionnaire. 
Data were 
analyzed using 
Wilcoxon 
signed-rank test. 

The result shows anxiety 
before being given health 
education was severe 
anxiety (19%), moderate 
anxiety (62%), mild anxiety 
(19%), whereas after health 
education, it became mild 
anxiety (75%) and no 
anxiety (25%). A P-value of 
0.0001 (< 0.05) means 
providing cardiac pre-
catheterization health 
education on the patient's 
anxiety level. 
 

7. The Effect  
Health 
Education Using 
The Leaflet 
Media Reduce 
Anxiety Levels 
In Pre 
Operations 
 
Fitria Anisa,Mugi 
Hartoyo,Sudiart
o (2019) 

This study 
used a 
quasi-
experiment  

The number of 
samples is 30 
respondents 
consisting of 15 
respondents in the 
intervention group 
and 15 respondents 
in the control group 
by consecutive 
sampling approach. 

The anxiety 
questionnaire 
used HARS 
(Hamilton 
Anxiety Rating 
Scale). Data 
were analyzed 
using Wilcoxon 
signed-rank test. 

The result showed an effect 
of health education using 
media leaflets on the level 
of anxiety (p=0.001). The 
post-test score of the 
intervention group was 
9.13, and the control group 
15.27, meaning health 
education with leaflets can 
reduce anxiety. 

8. A Study on the 
Effects of a 
Health 
Education 
Intervention on 
Anxiety and 
Pain During 
Colonoscopy 
Procedures 
 
Feng-Chi Hsueh 
& Chih-Mei 
Chen & Chien-
An Sun & Yu-
Ching Chou 
Szu-Mei Hsiao & 
Tsan Yang, 
(2016) 

This study 
used a 
quasi-
experiment  

The study sample 
was 213 consist of 
103 patients in the 
intervention group 
and 110 in the 
control group. 

The 
questionnaire 
used a 
questionnaire 
State-Trait 
Anxiety 
Inventory 
(STAI). 
Data were 
analyzed using a 
T-test. 

The anxiety score in the 
intervention group before 
health education was 48.7 
+ 11.6 and after health 
education 39.2 + 8.7. This 
study shows that 
multimedia health 
information about 
colonoscopy procedures 
effectively reduces anxiety 
and pain in colonoscopy 
patients. 

 
DISCUSSION 

The education program is vital in the pre-operative period. It is one of the alternative 
programs that can reduce patient anxiety (11). Anxiety mostly comes from operation effects; 
therefore, increasing patients' pre-operative education can relieve their anxiety and stabilize 
their emotions (12). Mental intervention in pre-operative patients can relax, promote the 
operation's success, improve the recovery and finally improve patients and their families (9).  

According to the analysis, almost all of the articles report that education effectively reduces 
anxiety before surgery. In Madiun regional hospital, the study followed the research 
expectations; health education can decrease anxiety patients. Communication is established 



Hartanti (Pre-operation Education to Reduce Anxiety: Literature Review) 
 

 

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between health workers and patients, so health education makes the patient feel cared (13). 
In coronary artery bypass grafting, patients with intervention had significantly lower anxiety 
than other groups without orientation. The reason is that the patients who participated in 
orientation education before surgery became familiar with operating room conditions, which 
helps them adapt to the new environment and feel secure. Health education had positive 
effects on anxiety in coronary artery bypass grafting candidates. It can be used effective 
technique for relieving anxiety (14). Primary surgery patients show that health education with 
leaflets can reduce anxiety. Health education intervention was succeeding. A patient who 
experienced severe anxiety became anxiety mildly, felt moderate anxiety became mild 
anxiety and felt mild anxiety became less anxiety (15). 
 
At the thoracic surgery, the previous study showed that the patient whose preparation for 
surgery needs the information to support psychology. These results advocated training for 
the nurse to provide individually tailored information support to patients before thoraces 
surgery. Patients with elevated levels of trait anxiety should be identified before surgery, and 
offers a dedicated educational program to prepare them for the surgical procedure 
adequately tho their emotional status (16). Previous research mentioned that health 
education affects the anxiety of hernia surgery patients. Health education is one of the non-
medical therapies that reduce pre-operative anxiety. Education intervention is an additional 
intervention, especially for nurses, in reducing patient anxiety (17). According to Masriani's 
research, the result showed an effect of health education on the anxiety level of pre-cardiac 
catheterization patients at the hearth service installation in Syaiful Anwar hospital. Health 
education is an effort to change the respondent’s behavior, including change in thinking and 
acting to reduce anxiety. The research found an anxiety decrease after received health 
education (18). 
 
Rizki found that there was an effect of health education with leaflet media. The intervention 
group has been shown to decrease anxiety compared to before the health education was 
given. The provision of health education using leaflet media can be used as an alternative 
for presenting information to prepare patients before surgery to decrease anxiety levels (19). 
Hence, Hsueh stated that education is necessary for patients with a certain characteristic. 
Medical staff may design multiple healthcare programs for a patient with different 
characteristics. This study showed that multimedia health information about colonoscopy 
procedures effectively reduces anxiety and pain in colonoscopy patients (20). 
 
CONCLUSION 

Anxiety is an unpleasant psychological condition caused by the surgery that the patient will 
experience. Non-pharmacological interventions with comprehensive and structured 
education can be applied as an intervention to reduce patient anxiety. Providing education 
and adequate information is effective in reducing patient anxiety.  

Authors' contribution 

RWH was responsible for research design, data collection, analysis, and drafting the first 
manuscript. LH monitored the research course and reviewed the manuscript. 

 



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Funding 

This research has not received external funding 

Conflict of interest 

There is no conflict of interest in this research.  

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