Surgical Science, 2011, 2, 303-311
doi:10.4236/ss.2011. 26065 Published Online August 2011 (http://www.SciRP.org/journal/ss)
The Impact on the Level of Anxiety and Pain of the
Tr aining before Operation Given to Adult Patients
Neziha Karabulut1, Funda Cetinkaya2
1Department of Surgical Nursing, School of Nursing, The Faculty of Health Science, Ataturk University,
Erzurum, Turkey
2Department of Surgical Nursing, School of Nursing, Aksaray University, Erzurum, Turkey
Received April 3, 2011; revised May 13, 2011; accepted July 9, 2011
Abstract
Aim: the aim oh this study was to detrmine the effects of different training programs implemented before
inguinal hernia operation on the pre- and post-operation anxiety level of and pain level the patient. Material
and Method: this quasi experimental study was carried out with inguinal hernia patients 18 - 60 years who
were hospitalized in the General Surgery Clinic of Hospital of Atatürk University and Süleyman Demirel
Medical Centre in Erzurum for inguinal hernia operation. The study data were collected between November
2007-May 2008 from a total of 90 patients. 30 patients were in the control group, 30 were in the video (VCD)
training group, and 30 were in the booklet training group. Data were collected by means of a questionnaire
about the patients and the inventory of state anxiety fort he adult. In collecting data, patient introduction form
and Spielberger’in State-Trait Anxiety Inventory, and visual analogue scale (VAS) were used. In data
assessment, T-test, Pearson correlation test, Mauchly’s variance analysis, Anova for repeated measures tests
and Bonferroni Correction Analysisi were used. Results: in control, booklet and VCD groups, in group
Situational Constant Anxiety score average was found significant in each three time periods (p < 0.001).
When the pain situations of the patients after operation was considered, the distinction in Visual Analogue
Scale and Verbal Rating Scala values of two groups in all measurement times was found significant (p <
0.001). Conclusion: in the conclusion of the study, it was found out that the given education effective on
level of pain and anxiety score for experimental groups of patients.
Keywords: Preoperative, Preparing, Patient, Anxiety, Pain, Operation
1. Introduction
Being healthy is defined not only as the absence of di-
sease and disability, but also as a complete well being in
terms of physical, social and mental state. The continuity
of the inner environment of the human organism is de-
pendent on the individual’s physiological and psycho-
logical balance. The main objective of nursing care is to
provide maintenance of the state of health, by preserving
the continuity of the inner environment, and to help in
restoring the balance lost in the state of illness [1,2].
People sometimes have to be hospitalized for the
maintenance and continuity of their health [3,4]. The
process of hospitalization, regardless of the reason,
causes different reactions in different people, including
adverse reactions such as anxiety, fear, and depression.
The patient feels anxiety as a result of the physical ef-
fects imposed by the disease as well by the change of
environment imposed by hospitalization. These factors,
which may cause anxiety in the hospitalized individual,
include the anxiety of receiving painful treatment, being
away from his/her family, losing his/her job, being in an
alien environment, and encountering unknown devices
and procedures. The anxiety of undergoing an operation
also feeds into this list of factors and constitutes a sig-
nificant source of anxiety [3,5,6]. Anesthesia, operation,
and some invasive interventions invoke real and unreal
fears. For the patient, an operation implies pain, loss of
independence, and distortion of body image, and each of
these factors is perceived as a threat. The individual feels
anxiety when he/she faces this type of threat that is -
rected to the order of his/her body or life [7,8].

N. KARABULUT ET AL. 304
Anxiety is defined as a state that emerges as a result of
a response against threats that may disrupt bodily bal-
ance, or a failure in restoring the lost balance [9]. Anxi-
ety has several negative effects on an organism, and one
of these effects is pain. Pain is an abstract concept and
affects the life quality of the individual in a negative way
by preventing the individual from carrying out daily ac-
tivities. The degree or nature of pain can only be de-
scribed by the individual affected by this state [10-13].
Pain is the primary complaint of post-operative patients
[10]. Severity of postoperative pain is related to several
factors. Operation type is one of these [14-16]. Pain is an
individual and subjective experience, and anxiety is the
most important determinant of postoperative pain. Acute
pain and acute anxiety are usually seen together, with
decreasing pain reducing the severity of the pain re-
sponse [17]. Studies have shown that anxiety increases
pain and the need for pain killers in the postoperative
period, and also reduces pain resistance [18]. In research
carried out by Özalp et al. [19]. on 99 female patients,
patients with depression and high anxiety levels were
found to experience more pain and to need more pain
killers.
Intense anxiety experienced in the pre-operative pe-
riod increases the intensity of pain in the postoperative
period and makes pain control difficult [20]. As high
levels of pain are associated with the anxiety and fear
level of the patient, providing education is one of the
most important strategies that can be used by the nurse
for reducing postoperative pain [21]. Research has de-
monstrated that anxiety levels of the patient and his/her
family, and the information required by each, are com-
parable [22,23]. Anxieties of patients in general have
been found to be associated with lack of information.
Since education reduces anxiety, preoperative education
and informing is the first step in the psychological
preparation of patients [21,24]. Pre-operative patient
education reduces patient anxiety and helps in overall
pain control [17].
In research carried out in a general surgery clinic, it
was determined that 31% and 14% of the patients were
not informed about pre-operative and post-operative
processes, respectively, whereas 95% of the patients
wanted to receive information about the processes to be
performed [25].
In a study carried out by Luck et al. examined the ef-
fect of pre-colonoscopy video-modeled training on the
anxiety and information levels of patients, and concluded
that the average anxiety score was 41.6 (37.1 - 46.1) in
patients who received video-modeled training and 60.8
(56.6 - 65.0) in patients who did not receive this training.
[26] Educational programs designed according to the
needs of patients also are found to help satisfy the pa-
tient’s need for knowledge, to decrease anxiety, to
shorten the discharge time, and to allow discharge with
less cost [22,26,27].
2. Materials and Methods
The study was conducted between November 2007 and
May 2009. It was carried out quasi-experimentally on
patients between 18 - 60 years, who were hospitalized
for inguinal hernia operation in the General Surgery
Clinic of Research Hospital of Atatürk University and
Süleyman Demirel Medical Centre in Erzurum. Consi-
dering the age group to which the inventory could be
applied, and their ability to understand, the study in-
cluded only those patients between 18 - 60 years of age.
Sample selection was not performed in this study due
to the limited time and small number of cases. Patients
were selected from the population using a nonprobability
sampling method, and they were categorized into ex-
perimental and control groups by a nonprobability/ran-
dom sampling method. It is generally accepted that the
number of samples should be at least 30 in experimental
and control groups [28,29]. Therefore, the data were col-
lected until the number of patients had reached 90. This
allowed sorting of 30 patients into the control group, 30
into the VCD training group, and 30 into the booklet
training group. The groups were examined in the order of
the control group, VCD group, and booklet group. The
study included adult patients (and their mothers) who
were to undergo inguinal hernia operations, were to be
hospitalized in the clinic for at least 2 days, were be-
tween 18 - 60 years of age, did not have any apparent
primary chronic disease, were not on antidepressants,
could read, write, and communicate in Turkish, and
whose hospital attendants were their mothers. Question-
naires were prepared by the researcher, in line with the
information in the literature [24,26]. In the first section,
there were 11 questions related to the identifying charac-
teristics of the patients. These questions sought answers
regarding the patient’s “age; gender; hospital experience;
operative experience; if yes, the number of previous op-
erations; place of residence; education status, career
status, hospital experience, operative experience, and
health insurance”. The second section included the anxi-
ety levels of the patients, which were evaluated by means
of the revised State Anxiety Inventory (STAI) developed
by Spielberger. The adaptation of STAI to Turkish, as
well as the reliability and validity studies, were done by
Öner and Le Compte. The reliability coefficients, as de-
termined by alpha correlations in the adaptation of STAI
to Turkish, were 0.83 and 0.92, while that for the present
study was 0.72. The reliability coefficients determined in
the STAI for children were 0.82 for the state anxiety in-

N. KARABULUT ET AL.305
ventory and 0.72 in the present study [9]. The third sec-
tion included the Pain Follow-up Form, the Visual Ana-
logue Scale, and the Verbal Rating Scale values. The
Visual Analogue Scale (VAS) is a scale developed by
Price et al. (1983) and measures patient’s pain severity.
VAS is a scale in which two ends are named differently
on a vertical and horizontal line measuring 10 cm (0 = no
pain, 10 = severest pain). The patient is asked to mark on
this line the point corresponding to the pain severity
he/she feels. The distance between the marked point and
the lowest end on the line (0 = no pain) is measured and
the numerical value found designates the patient’s pain
severity [30]. Before the study, a pilot study was carried
out in order to determine whether the questions and in-
formation booklet were understandable. For this purpose,
15 patients (5 from the control group, 5 from the VCD
training group, and 5 from the booklet training group)
were included. State anxiety inventory and question-
naires were given to the patients in all three groups 48
hours prior to the operation. The VCD and booklet
groups were given training 24 hours before the operation.
Inventories (state anxiety inventory for adults) were
given to all three groups 24 hours before the operation
and 24 hours after the operation. In all three groups, in
the control and experiment groups, post-operative Visual
Analogue Scale and Verbal Rating Scale tests were ap-
plied at 1/2, 1, 2, 3, 4, 5, 6, 7, 12, 24 hours. The study
was initiated after making the necessary corrections in
the questionnaire and training materials, in line with the
data obtained from a pilot study. These pilot data were
not included in the current study results. Questionnaire
and inventories (identifying characteristics of the patients,
and State Anxiety Inventory for adults) were given 48
and 24 hours pre-operatively and 24 hours postopera-
tively in the control group.
Upon admission to the clinic, the VCD training group
was given the questionnaire and inventories and, on the
same day, the group watched the VCD that had been
prepared by the researcher, in line with the literature and
with consultation and support from the staff of the Fa-
culty of Communication at Atatürk University. The VCD
group was shown the VCD by the researcher. Later, a
place was provided for the patients (and their mothers)
who wanted to watch the VCD again. Accordingly, the
patients watched the VCD in the computer room of the
general surgery clinic. The total duration of the VCD is
12 minutes. The State Anxiety Inventory for adults was
given 24 hours before and 24 hours after the operation.
In order to increase the effectiveness of the VCD training
and to make it more realistic, the nurse responsible for
the clinic was educated beforehand and she participated
in the recording of the VCD.
The booklet training group was also given the ques-
tionnaire form (identifying characteristics of the patient
and the mother) as well as the State Anxiety Inventory
for adults, 48 hours before the operation. On the same
day, booklets were distributed and the questions were
answered. The training was given individually in an
empty room and lasted for 20 - 30 minutes. The booklet
group was given training once by the researcher. The
State Anxiety Inventory for adults was given 24 hours
before and 24 hours after the operation, and postopera-
tive Visual Analogue Scale and Verbal Rating Scale was
applied post-operatively at 1/2, 1, 2, 3, 4, 5, 6, 7, 12, 24
hours. In the study, anxiety levels were evaluated at three
time periods (48 hour before the operation, 24 hours be-
fore the operation, and 24 hours after the operation). Pa-
tients who undergo unguinal hernia operation are gene-
rally discharged after 48 hours, as these are not compli-
cated operations. In previous studies, anxiety measure-
ments were done before and after the training.31 The
present study aims to perform a deeper analysis.
The patients in the control group were given a small
amount of information regarding the operation in the
pre-operative clinical routine (pre- and post-operative
nutrition, hour of admission to the operating room, dura-
tion of hospitalization).
2.1. The VCD and Booklet Included the
Following Topics
2.1.1. Physical Structure of the Hospital
The outer appearance, entrance, and general clinic of the
hospital were introduced.
2.1.2. Hospital Life
Information was provided about meal hours and proce-
dures, visiting, attendance, and communication.
2.1.3. Information about the Operation
The nurse and other health personnel in the clinic were
introduced. The devices used in the hospital and operat-
ing room, including masks, gloves, and caps, were in-
troduced and their functions were explained. How the
patient would be brought to the operating room, and by
which health personnel, were shown. Information was
given about the environment of the operating room, the
devices and procedures used there, as well as the pa-
tient’s transport to the recovery room after the comple-
tion of the operation. The procedures to be performed
after the patient regained consciousness were also de-
tailed. During the training, information was provided
regarding the operation; the probe, IV catheter, etc. that
might be involved, the probable complications that could
develop, and the procedures that would be followed in
case of pain. The booklet contains drawings and photo-

N. KARABULUT ET AL. 306
graphs that reflect the hospital environment.
The contents of the video and booklet are identical.
The researcher conducted the study by visiting the
clinic every day to find out if any new patients who meet
the eligibility criteria of the study had been hospitalized.
2.2. Statistical Analysis
The data in the study were used to form a database and
were tabulated using SPSS Windows 10.0 software.
Mauchly’s variance analysis, Bonferroni correction ana-
lysis, and Pearson correlation test were used in the
evaluation of the data [9,28].
2.3. Ethical Consideration
Consent was obtained from the hospital and department
before initiating the study. In addition, the patients were
told about the aims of the study and the procedures to
follow. In addition, any questions they had were an-
swered. Afterwards, the patients were asked for verbal
permission. Upon their consent, the study was initiated.
3. Results
The age average of patients included in the research was
45.60 ± 11.08 in the control group, 43.80 ± 14.30 in the
booklet group, and 44.96 ± 12.80 in the VCD group. In
the control group, 56.7% were male patients, while
53.3% and 56.7% in the booklet and VCS groups respec-
tively were females. Gender distribution differences were
not statistically significant among the three groups (p >
0.05) (Table 1). In terms of education status, 50%,
73.3% and 76.7% of the control group, booklet group,
and VCD group, respectively, were primary school
graduates. The difference between the education status of
patients in the control, booklet and VCD group was
found to be statistically significant (p < 0.05) (Table 1).
In terms of the marital status of patients, 90%, 83.3%,
and 90% of the control group, booklet group, and VCD
group, respectively, were married. The difference be-
tween the marital status of patients in all three groups
was found to be statistically significant (p < 0.05). Dis-
tribution among the patients in terms of operation ex-
perience revealed that 50%, 56.7%, and 53% of the pa-
tients in the control group, booklet group, and VCD
group, respectively, had a previous operation experience.
The difference between the three groups was not statisti-
cally significant (p > 0.05) (Table 1). The mean state
anxiety scores of the patients in the control group were
38.13 (SD = 8.00) at 48 hours before the operation, 47.13
(SD = 10.07) at 24 hours before the operation, and 32.96
(SD = 5.92) at 24 hours after the operation. However, the
mean state anxiety scores of the patients in the VCD
training group were 47.00 (SD = 6.00) at 48 hours before
the operation, 26.56 (SD = 2.89) at 24 hours before the
Table 1. Comparison of the identifying characteristics of patients in Control, Booklet, and VCD groups.
Identifying Characteristi cs Control Group Booklet Group VCD Group
Age Average 45.60 ± 11.08
F = 0.181
43.80 ± 14.30
SD = 2
44.96 ± 12.80
p > 0.05
Control Group Booklet Group VCD Group
Gender Number % Number % Number %
Female 13 43.3 16 53.3 17 56.7
Male 17 56.7 14 46.7 13 43.3
x
2 = 0.044 SD = 2 p > 0.05
Education Status
Primary School 15 50.0 22 73.3 23 76.7
High School 15 50.0 8 26.7 7 23.3
x
2 = 10.0 SD = 2 p < 0.05
Marital Status
Married 27 90.0 25 83.3 27 90.0
Single 3 10.0 5 16.7 3 10.0
x
2 = 5.37 SD = 2 p < 0.05

N. KARABULUT ET AL.307
operation, and 24.46 (SD = 2.84) at 24 hours after the op-
eration. The mean state anxiety scores of the patients in
the booklet group were 42.30 (SD = 7.73) at 48 hours be-
fore the operation, 26.80 (SD = 3.36) at 24 hours be- fore
the operation, and 24.66 (SD = 2.26) at 24 hours after the
operation. The difference in the state anxiety scores of the
patient in the groups according to time was statistically
significant in the control group (p < 0.001) and in the
VCD training group (p < 0.001), and was significant in the
booklet training group (p < 0.001) (Table 2).
State anxiety levels of the patients in the control group
24 hours before the operation was found to be higher
than were those observed at other time measurement
points. State anxiety levels of the children in the VCD
training group 48 hours before the operation were found
to be higher than were those observed at the other time
measurement points. The differences presented in Table
2 results from the measurement performed 48 hours be-
fore the operation (according to Bonferroni correction
analysis). State anxiety levels of mothers 48 hours before
the operation were high in the video and booklet training
groups. In the evaluation of the patient’s mean intergroup
state anxiety scores 48 hours before the operation, the
average score was 37.06 (SS = 8.00) in the control group,
47.00 (SS = 6.00) in the VCD group, and 42.30 (SS =
7.73) in the booklet group. The mean state anxiety scores
at 24 hours before the operation were 47.13 (SS = 10.07)
in the control group, 26.56 (SS = 2.89) in the VCD group,
and 26.80 (SS = 3.36) in the booklet group. The scores at
24 hours after the operation were 32.96 (SS = 5.92) in
the control group, 24.46 (SS = 2.84) in the VCD group,
and 24.66 (SS = 2.26) in the booklet group. The differ-
ences between the groups in favor of the VCD group 24
hours before and after the operation were statistically
significant at all three time points (p < 0.001, 48 hours
before the operation; p < 0.001, 24 hours before and after
the operation). As a result of these findings, it was de-
termined that the training given primarily with VCD (24
hours before and after the operation) was more effective
in reducing the anxiety levels of patients (Table 3).
In Tabl e 4, a significant difference was found between
VRS and VAS levels of the control, booklet, and VCD
groups at all measurement times (p < 0.001).
4. Discussion
In the maintenance and improvement of a person’s health
status, the educational role of the nurse has a consider-
able significance in activating the control mechanisms in
states of illness. The nurse assumes the role of an expert
Table 2. Comparison of the scale application times and state anxiety scores of patients in the control, booklet and VCD
groups.
State Anxiety Score Average
Scale Application Time Control Group n = 30Booklet Group n = 30VCD Group n = 30
X SS X SS X SS F p
48 Hours Before the Operation 37.06 8.00 42.30 7.73 47.00 6.00 13.88 p < 0.001
24 Hours Before the Operation 47.13 10.07 26.80 3.36 26.56 2.89 103.442 p < 0.001
24 Hours After the Operation 32.96 5.92 24.66 2.26 24.46 2.84 43.832 p < 0.001
Table 3. Comparison of the average state anxiety scores according to scale application times in the control, booklet, and VCD
groups.
State Anxiety Score Average
Groups 48 hours before 24 hours before 24 hours after
N
X SS X SS X SS
Control Groups 30 37.06 8.00 47.13 10.07 32.96 5.92
Mauchly’s W = 0.704 SD = 2 p < 0.001
Booklet Groups 30 42.30 7.73 26.80 3.36 24.66 2.26
Mauchly’s W = 0.287 SD = 2 p < 0.001
VCD Group 30 47.00 6.00 26.56 2.89 24.46 2.84
Mauchly’s W = 0.210 SD = 2 p < 0.001

N. KARABULUT ET AL. 308
Table 4. Comparison of VRS and VAS Values of Patients in the control, booklet, and VCD groups according to Measurement
Times.
Time GROUP X ± SS VRS X ± SS VAS
Control 4.773 ± 0.44 86.066 ± 8.50
Booklet 4.266 ± 0.44 79.100 ± 10.24 1/2 hour
VCD 4.166 ± 0.59 76.200 ± 7.48
Control 4.100 ± 0.30 75.833 ± 8.80
Booklet 3.466 ± 0.50 62.600 ± 12.86 1st hour
VCD 3.533 ± 0.50 62.900 ± 11.66
Control 3.400 ± 0.49 61.866 ± 9.50
Booklet 2.733 ± 0.63 44.833 ±1 2.55 2nd hour
VCD 2.766 ± 0.62 45.166 ± 13.33
Control 3.133 ± 0.62 55.666 ± 12.86
Booklet 2.466 ± 0.50 38.266 ± 11.16
3rd hour
VCD 2.866 ± 0.62 37.366 ± 11.33
Control 2.900 ± 0.75 45.900 ± 13.67
Booklet 2.066 ± 0.44 31.466 ± 9.75 4th hour
VCD 2.266 ± 0.44 29.766 ± 9.56
Control 2.500 ± 0.68 39.533 ± 13.32
Booklet 2.100 ± 0.30 28.533 ± 7.78
5th hour
VCD 1.900 ± 0.60 25.733 ± 6.96
Control 2.633 ± 0.76 39.966 ± 12.12
Booklet 2.033 ± 0.31 25.866 ± 6.50 6th hour
VCD 1.566 ± 0.50 22.500 ± 5.85
Control 2.366 ± 0.66 33.066 ± 11.34
Booklet 1.833 ± 0.46 23.233 ± 7.01 7th hour
VCD 1.433 ± 0.50 19.233 ± 5.46
Control 2.200 ± 0.40 30.100 ± 8.90
Booklet 1.200 ± 0.40 14.733 ± 5.53
12th hour
VCD 1.366 ± 0.49 11.133 ± 3.13
Control 1.866 ± 0.62 24.400 ± 9.18
Booklet 1.133 ± 0.34 11.333 ± 5.39
24th hour
VCD 1.300 ± 0.53 7.733 ± 2.19
F = 79.200 p = 0.000 F = 68.447 p = 0.000
by determining the educational needs of both the patient
and his/her family and by providing these individuals
with extensive information and education [32].
At the end of the study, education and marital status of
patients in the control, booklet, and VCD groups were
found to be significant, and these were observed to be
similar in terms of gender and age. Comparable charac-
teristics among patients are a desirable condition in terms
of providing homogeneity. According to the identifying
characteristics of patients, the difference between state

N. KARABULUT ET AL.309
anxiety score averages was statistically significant (p <
0.05). Inter-group state anxiety score averages of patients
revealed that the difference between groups 48 hours
after the operation was statistically significant (Table 2).
Both at 24 hours before and 24 hours after the opera-
tion, the difference between the groups was statistically
significant (p < 0.001) (Table 2). This significance was
associated with the increase in the low state anxiety score
average in the control group 24 hours before the opera-
tion. After the operation, there was a reduction in the
state anxiety levels, due to the decrease in stress resulting
from anticipation of the operation. As state anxiety is
related to momentary events, the state anxiety score av-
erage was initially high in the booklet and VCD group,
but decreased 24 hours before the operation as a cones-
quence of the education given to the patients. Because
the patient knew that he/she would be discharged after
the operation, state anxiety averages decreased even
more and were statistically different in all three groups.
When the intra-group state anxiety score average of pa-
tients was examined over time, the score average in the
control group 48 hours before the operation was 37.06,
and it increased to 47.13 in this group 24 hours before
the operation. In the booklet group, while the state anxi-
ety score average 48 hours before the operation was
42.00, it decreased to 26.80 in the this group 24 hours
before the operation. Similarly, this score decreased from
47.00 to 26.56 in the VCD group 24 hours before the
operation. After the operation, state anxiety score aver-
age decreased in all three groups. In line with these re-
sults, the comparison of state anxiety score averages of
in-group patients according to time was found to be sta-
tistically significant (p < 0.001) (Table 3). This finding
reveals that education given by different education
methods was able to reduce the state anxiety score aver-
age levels of patients and that it had proven to be effect-
tive. According to the obtained results, state anxiety
score averages of patients in the booklet and VCD
groups, who had received a planned education, were
lower than were those of patients who had not received
any education.
In the literature, it is stated that people remember 10%
of what they read, 20% of what they hear, 30% of what
they see, and 50% of what they both see and hear, pro-
vided that time is held constant [33]. In research carried
out by Akkaş [34], education given to patients in preo-
perative period was found to reduce their anxiety level.
In the study of Asilioglu and Celik [35], The effect of
preoperative education on anxiety of open cardiac sur-
gery patients,it is shown that the anxiety level of the
educated group is lower than the control group. In the
research carried out by Yorulmaz and Özbayır [36], who
investigated “the pre-operative and post-operative anxi-
ety level of patients who would undergo laparoscopic
cholecystectomy”, state-trait anxiety score averages be-
fore the operation were found to be higher than were
those measured after the operation. There was no statis-
tically significant difference found between pre-operative
and post-operative state-trait anxiety scores (p < 0.05). In
the study of Roth-Isıgkeit and his friends, named Deve-
lopment and evaluation of a video program for presenta-
tion prior to elective cardiac surgery, it is concluded that
The findings obtained in this study are consistent with
the results of the studies indicating that training with
visual tools is more effective than with other types of
material [37].
Doering S. Behensky and his friends stated that “Pre-
operative presentation of videotapes is used as an adjunct
method for the preparation of patients prior to surgery”
in their study named. Videotape preparation of patients
before hip replacement surgery improves mobility after
three months.
A marked decrease was observed in the state anxiety
score averages of patients who had been recipients of an
informative nursing approach. In the current study, the
results demonstrated that an informative nursing ap-
proach was effective in reducing state and trait anxiety (p
< 0.05). An examination of the post-operative pain levels
of patients seen in the present work revealed a significant
difference in the VRS levels between control and ex-
perimental groups at all measurement points (p < 0.001).
Similarly, at all measurement points, a significant dif-
ference was found in the VAS levels between the two
groups (p < 0.001). VAS pain scores in the control group
of the present study were high at the first measurement
point and showed higher scores continuously through to
the last time point. The VAS pain scores of patients in
the booklet and VCD groups were lower at the beginning
and decreased even further by the end of the experiment-
tal period, compared to the control group. As the educa-
tion given to the patients had a similar positive effect on
pain, pain scores in the first and last measurement were
lower in both the booklet and VCD group. This finding
was in agreement with a previous study by Özberksoy
and Özbayır [39] on the “effect of preoperation informa-
tive and educational nursing approaches on the post-
operation pain and anxiety level in patients with breast
cancer”. In this earlier study, VAS values with lower
scores were also recorded in the education group com-
pared to the control group.
Sjöling et al. [40] have investigated the “effect of pre-
operation information on anxiety level, post-operative
pain and pain control satisfaction in patients with total
knee arthroplasty”. Lower scores of VAS values were
recorded in all of the education groups compared to the
control group. This difference was observed more ex-

N. KARABULUT ET AL. 310
plicitly on the third day, and VAS values showed inter-
ruption at an earlier period in the experiment group,
which also reported less pain compared to the control
group. Pre-operation anxiety values of informed patients
were also found to be lower. The results were defined as
statistically significant (p < 0.05). In a study by Karay-
urt [27], which investigated the “effect of different pre-
operative education programs on the anxiety and pain
levels of patients”, the patients in the group that had re-
ceived routine care reported the highest level of pain.
Pain levels were lowest in the group that had received
education.
5. Conclusions and Suggestions
Lack of information related to possible pre-operation and
post-operation conditions increases the anxiety level of
patients. This causes post-operative emotional problems
and a more intense sense of pain. Therefore, the follow-
ing suggestions may be introduced for nurses and re-
searchers:
 Including pre-operation education, which is not prac-
ticed at all in most hospitals or is practiced only in an
unplanned way in some, into nursing applications;
 Allocating time to the patient during the pre-opera-
tion period, establishing a one-to one communication
with the patient and allowing him/her to express his/
her feelings and thoughts;
 Providing patients pre-operatively with written in-
formation and instructions that will be followed dur-
ing their stay in the hospital.
6. Contributions
Study design: NK, FC data analysis: NK manuscript
preparation: NK,
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