The Effect of Education on Intrusive Thoughts and Postoperative Recovery in Patients Undergoing Rhinoplasty: A Randomized Controlled Trial

1. Introduction

The nose is a crucial esthetic and functional organ. However, they can become deformed for various reasons (e.g., disease, injury, and congenital). Rhinoplasty is performed to correct these deformities and to improve the appearance of the nose and face [1,2,3]. Rhinoplasty is the most frequently performed surgical procedure in plastic and nasal surgeries. The demand for rhinoplasty has increased significantly over the last 20 years. The main reasons for this increasing demand are personal interest, media awareness, and advances in surgical practice. The growing trend towards rhinoplasty comprises young men and women [3,4]. With the increasing demand for rhinoplasty, it should be kept in mind that this surgical intervention can have various effects not only on the aesthetic and functional results but also on the psychological state of patients.

Regardless of whether the surgery is minor or significant, patients may experience physical and psychological problems. These problems include the emergence of a stress response, weakening of the immune system, adverse effects on organ function, and effects on lifestyle [5,6]. Next to these, anxiety is one of the most common psychological problems encountered in surgical practice. Anxiety can be described as an emotional reaction characterized by inner distress and a sense of impending danger, usually arising in response to an unknown or uncertain threat and accompanied by fear whose source cannot be clearly identified, manifesting with both psychological and physical symptoms [7,8]. Studies have shown that 60-80% of patients experience preoperative anxiety [9]. Preoperative anxiety is often intertwined with intrusive thoughts. Increased anxiety levels, especially before surgical intervention, can cause individuals to produce negative scenarios and mentally fixate on these thoughts [10,11,12]. Reasons for preoperative anxiety include as patient age, hospital experience, type of surgery, uncertainty, surgical environment, and privacy [13]. This anxiety has been reported for patients undergoing rhinoplasty as well. Previous studies have also indicated that patients who undergo rhinoplasty experience more psychopathological problems [14,15]. The reasons for this include general anesthesia, the need for hospitalization, staying away from work and social life, and concerns about aesthetic results [5,16].

On a similar line, quality of recovery is a significant health indicator determined by an individual's regaining control in these areas. This results in patients returning to their daily lives and achieving preoperative independence or dependency levels [17,18]. Studies have shown that psychological problems, such as anxiety, fear, and stress, seen before surgery negatively affect the quality of postoperative recovery and quality of life to varying degrees [18,19]. Indeed, negative psychological consequences may occur after rhinoplasty, and a decrease in quality of life may occur. One of the main reasons for this situation is the low quality of recovery, which can lead to prolonged recovery times, delayed discharge, increased costs, complications, and psychological problems [20,21]. For all these reasons, reducing the level of anxiety before surgery is very important and facilitates compliance with the surgical process [21,22,23].

Many pharmacological and non-pharmacological methods have been used to reduce anxiety in patients during the preoperative period. Pharmacological methods such as benzodiazepines or antihistamines are primarily used to relieve anxiety. However, pharmacological agents have many side effects such as anaphylaxis, addiction, polypharmacy, organ damage, and tolerance development. It is essential to use nonpharmacological methods to reduce the side effects of pharmacological methods. These interventions will alleviate the effects of surgery, reduce anxiety, and accelerate postoperative recovery [24,25,26]. Accordingly, some non-pharmacological interventions are used to alleviate preoperative anxiety in patients scheduled for rhinoplasty [27,28,29,30]. Patient education, one of these interventions, is important for preventing diseases and regaining health, and studies have demonstrated its effectiveness in reducing preoperative anxiety in rhinoplasty patients [5,16,31]. It has also been shown to reduce postoperative complications, hospital stay, and patient satisfaction [5,32,33]. In addition, some studies have shown that patient education during the perioperative process has positive effects on postoperative recovery [26,32,34,35,36,37,38].

When the literature was reviewed, no studies were found examining the effect of education given to patients undergoing rhinoplasty surgery on patients' intrusive thoughts and postoperative recovery level. In this context, this study aimed to investigate the effect of education given to patients who undergo rhinoplasty surgery, type of aesthetic surgery, on preoperative intrusive thoughts and postoperative recovery level.

Hypotheses

H1: There is a statistically significant difference between the preoperative intrusive thoughts of patients in the intervention and control groups.

H2:  There is a statistically significant difference between the postoperative recovery levels of the patients in the intervention and control groups.

2. Materials and Methods

2.1. Study Design

This was a single-center randomized controlled trial. However, the data collectors were not blinded. Clinical trial number (NCT No: NCT06771297) was obtained.

2.2. Setting and Participants

This study included patients scheduled for rhinoplasty surgery in a state hospital's otolaryngology and plastic surgery clinic between January and December 2024.

2.3. Sample Size

The sample size was calculated using the G*Power 3.1. According to a similar study by Topan et al. (2022), the effect size was 0.632 [5]. The study's sample size was 82 (41 intervention group, 41 control group) with 80% power, a 5% margin of error, and an effect size of 0.632. In addition, a sensitivity power analysis was conducted to assess whether the study’s sample size provided enough power to detect the average effect sizes reported in this study. With α = .05, 1– β = 80 and 41 participants in the control and intervention groups, respectively, an effect size (i.e., Cohen’s d) of ±0.55 could be obtained. This theoretical effect size is smaller than the average effect size we found for the PITI scores of the surgery morning, which was -1.94. This provides additional support that the study had enough power.

2.4. Eligibility Criteria

The study included patients aged 18 years or older who were scheduled for aesthetic nose surgery for the first time; were mentally healthy; had no vision, hearing, or speech problems; and volunteered to participate.

Patients who had previously undergone nasal surgery for any reason and did not volunteer were excluded from the study.

2.5. Randomization

In this study, the patients were assigned to the intervention (n = 41) and control (n = 41) groups using the random method provided by the randomizer.org platform. The algorithm provided by randomizer.org was used to create the groups, and each patient's assignment to the group was performed objectively and unbiasedly by the researcher (Figure 1).

2.6. Data Collection Instruments

We collected the study data using the Personal Information Form, Preoperative Intrusive Thoughts Scale, and Postoperative Recovery Index.

2.6.1. Personal Information Form

The personal information form, prepared by researchers according to the literature to collect research data, consisted of 12 questions about the patient's demographic characteristics and health status.

2.6.2. Preoperative Intrusive Thoughts Inventory (PITI)

It was developed by Crockett et al. (2007) to investigate the anxiety experienced by patients before surgery andprovide a rapid assessment of preoperative anxiety [12]. The Turkish validity and reliability of the scale were conducted by Çakır and Karabulut (2019) [39]. It has two sub-dimensions: loss of control anxiety and post-procedural anxiety. This scale, consisting of 20 items, is evaluated for each question as (0) never, (1) sometimes, (2) often, or (3) often, and has a 4-point Likert type. Scores can be obtained on a scale between 0-60. A score of 15 or higher reliably identifies patients who have experienced clinically significant anxiety [39]. In the study by Çakır and Karabulut, the Cronbach’s alpha value of the PITI was 0.94 and the PITI score for the Turkish sample was 28.92 [39]. In this study, Cronbach’s alpha was 0.929 one day before surgery and 0.848 on the morning of surgery.

2.6.3. Postoperative Recovery Index (PoRI)

The Postoperative Recovery Index was developed by Butler et al. (2022) and a Turkish validity and reliability study was conducted by Cengiz and Aygin (2019) [40,41]. The index consists of five subdimensions and 25 items. The sub-dimensions are psychological, physical activity, general, bowel, and desire symptoms. When determining the sub-dimension score, the scores of the relevant items were added, and their arithmetic means were calculated. All items were added to the total score, and their arithmetic means were calculated. According to the scoring system of the PoRI, scores range from 1 to 5; a mean score of 1 indicates no difficulty, scores greater than 1 and less than 1.5 indicate little difficulty, scores between 1.5 and less than 2.5 indicate moderate difficulty, scores between 2.5 and less than 3.5 indicate severe difficulty, and scores between 3.5 and 5 indicate extreme difficulty in postoperative recovery [41]. In Cengiz and Aygin's study, the Cronbach's alpha value of the PoRI was0.96 and the PoRI score for the Turkish sample was reported to be 3.39 [41]. In this study, the Cronbach's alpha value was 0.900 two days after surgery and 0.876 one week after surgery.

2.7. Intervention

The intervention group received preoperative and discharge education in the study, which included a PowerPoint presentation and brochure. Initially, a PowerPoint presentation with numerous visuals and videos was prepared for patient education based on existing literature [42,43,44]. Then, the prepared patient education was then presented to expert opinions (clinic doctors and academicians working in surgical nursing). After expert opinion, the necessary corrections were made in line with the suggestions, and the final version of the education was prepared. Subsequently, a brochure containing the main points of the presentation was prepared. Education sessions were provided in the patient's room using a laptop. During the education, the patient's relatives were asked to leave the room, which was kept quiet. Each educational session lasted approximately 30-45 minutes.

The content of the education given before surgery included nasal anatomy and functions, information about rhinoplasty surgery, preparation for the night before surgery, preoperative education topics (breathing exercises, extremity exercises, and the process of standing up after surgery), and what to do on the day of surgery.

The content of the education given before discharge included information on situations that may be encountered after surgery, side effects that may occur after rhinoplasty, points to which patients should pay attention to, information on the use of nasal tampons and splints, symptoms, and conditions to be careful about at home after discharge, when to apply to the hospital, and what to do to protect nasal health.

2.8. Data Collection

Patients in the intervention group were administered the Personal Information Form and PITI one day before surgery. The questionnaires were administered, and the patients were given preoperative patient education through a PowerPoint presentation. After the education, the patients' questions were answered and a copy of the education presentation was given as a brochure. PITI was administered again on the morning of surgery. The patient was discharged on the second postoperative day. On the day of discharge, the first PoRI was administered, and the patients received discharge education. After the education, the patients' questions were answered and a copy of the education presentation was given as a brochure. One week later, PoRI was applied again.

Patients in the control group received routine nursing care and the scales were administered simultaneously with those in the intervention group.

2.9. Ethical Statement

Before starting the study, written permission was obtained from the Ethics Committee of X University Faculty of Medicine (Number: B.30.2. ATA.0.01.00/818), and the hospital where it was conducted. The patients were first informed of the study, and their written consent was obtained.

2.10. Data Analysis

The data obtained from the study were analyzed using SPSS for Windows 22.00 statistical package program. The numbers, percentages, arithmetic means, and standard deviations were used in the distribution of the descriptive characteristics of the groups. The chi-squared test was used to compare the control variables of the groups. Independent t-tests and Mann-Whitney U tests were used to compare the mean scores of preoperative intrusive thoughts and postoperative recovery levels between the groups. The normality of the data distribution was assessed using Skewness and Kurtosis coefficients, and values between -2 and +2 were considered to be normally distributed [45]. A significance was set at p < .05 was considered for statistical significance.

3. Results

Eighty-two patients participated in the study. Between January and December 2024, patients in the control group received standard nursing care, while those in the intervention group received preoperative and postoperative patient education. The participant recruitment and allocation processes are illustrated in a flow diagram. Ninety-six patients underwent rhinoplasty during the study period. Six patients were excluded from the study because they did not meet the study criteria. Eight of the remaining 90 patients declined to participate and 82 patients were included in the study. No patients withdrew from the study during the study period, and the study findings from these 82 patients (41 in the control group and 41 in the intervention group) were analyzed at the end of the study.

Table 1 shows the distribution of patient characteristics between the intervention and control groups. The differences between the groups in terms of age, sex, education status, marital status, employment status, income status, surgical experience, and comorbid diseases were not statistically significant (p > .05). The groups were similar and showed homogeneous distribution (Table 1).

Table 2 presents the PITI total and sub-dimension mean scores of the patients in the intervention and control groups before and after training. Before the training, no statistically significant difference was found between the PITI total and sub-dimension mean scores of the patients in the intervention and control groups (p > .05), and the effect sizes were small (Cohen’s d = 0.19–0.20). On the morning of surgery, the PITI total and sub-dimension mean scores of the patients in the intervention group were found to be significantly lower than those of the patients in the control group (p = .000) (Table 2). The effect sizes were large (Anxiety about loss of control: d = -1.98; Post-procedure anxiety: d = -1.84; Total PITI: d = -2.01), indicating a strong intervention effect (Table 2).

Table 3 presents the PoRI sub-dimensions and total mean scores of the patients in the intervention and control groups. On the second postoperative day, the mean scores for the physical activities and psychological symptoms sub-dimensions of the patients in the intervention group were significantly lower than those of the control group (p < .05), with small-to-moderate effect sizes (physical activities: d = -0.46; psychological symptoms: d = -0.55). For the other sub-dimensions and total PoRI score, no statistically significant difference was found (p > .05), and effect sizes ranged from trivial to small (d = -0.12 to -0.32). On the seventh postoperative day, the mean PoRI total score of the patients in the intervention group was significantly lower than that of the control group (p < .05), with a small-to-moderate effect size (d = -0.45). Although the PoRI sub-dimension mean scores of the intervention group were also lower than those of the control group on the seventh day, these differences were not statistically significant (p > .05), and effect sizes were small (d = -0.05 to -0.43) (Table 3).

4. Discussion

Rhinoplasty is an elective surgical procedure in which patients’ psychological readiness and expectations play a crucial role in both perioperative experience and postoperative recovery. Despite its high prevalence worldwide, limited evidence exists regarding structured perioperative education targeting intrusive thoughts and recovery outcomes in this population. This study examined the effects of preoperative and postoperative education on preoperative intrusive thoughts and postoperative recovery in patients undergoing rhinoplasty.

The findings showed a significant decrease in the preoperative intrusive thoughts levels of patients in the intervention group. The mean PITI score of patients in the experimental group on the morning of surgery was significantly lower than that of patients in the control group. In addition to statistical significance, the effect sizes for PITI scores on the morning of surgery also indicate a strong clinical effect. Cohen's d values obtained for the total PITI and its subscales indicate a significant decrease in intrusive thoughts in the intervention group. This result supports the finding that preoperative education is effective in reducing patients' intrusive thoughts and anxiety. Accordingly, when studies on patient education are examined in the literature, it has been stated that education provided before surgery reduces anxiety and allows patients to be better prepared for the surgical process [13,32,46,47,48]. Doğan et al. (2024) provided brochure-supported education to patients undergoing septorhinoplasty before surgery and determined that this education had a significant effect on preoperative anxiety [16]. Topan et al. (2022) examined the effect of education given to patients before rhinoplasty on anxiety and concluded that the education provided made a significant difference to anxiety [5]. Parveen et al. (2016) provided preoperative education to patients who had undergone cataract surgery and found that the preoperative anxiety levels of patients in the experimental group were lower than those in the control group [49]. Jlala et al. (2010) conducted a randomized controlled trial to evaluate the effect of preoperative multimedia information on anxiety in patients undergoing surgery under regional anesthesia. They reported that patients who watched the informative video had significantly lower preoperative and postoperative anxiety levels compared to those who received standard information [9]. Patient education positively changes individuals’ behavior by ensuring that they acquire the necessary knowledge, attitudes, and skills to protect, improve, and maintain their health. This process helps patients understand the stages of medical interventions, feel more confident, and reduce their anxiety regarding the unknown [50,51,52]. In this regard, the findings of our study are consistent with the existing literature and support the positive effect of preoperative education on anxiety.

When the postoperative recovery level was evaluated, no statistical difference was found between the total mean PoRI scores on the second day after surgery. However, the mean scores of the physical activities and psychological symptoms sub-dimensions of the PoRI on the second day after surgery were lower in the intervention group than in the control group, and this difference was statistically significant. When examining the effect sizes, a small to moderate effect was observed on the second postoperative day, particularly in psychological symptoms and physical activities. A small effect was observed in the total recovery score. This difference may be related to the effect of the education given to the intervention group in the preoperative period about the problems they may encounter in the early postoperative period and coping methods, and the fact that the education reduced the anxiety level of the patients before surgery; therefore, the observed difference can be considered not only statistically significant but also clinically meaningful. In the early postoperative period, both groups had high PoRI scores. However, on the seventh day after surgery, the PoRI scores decreased in both the groups. The total PoRI scores were significantly lower in the experimental group than in the control group. The increase in the effect size of the total PoRI score on seventh postoperative day suggests that the training also provides a clinically meaningful contribution in the later stages of the recovery process. Overall, the findings indicate that structured training produces a small to moderate but clinically valuable effect. These findings are consistent with other studies and show that patient education can positively affect the recovery process. İlgin et al. (2024) determined that preoperative education given to patients undergoing mastectomy positively affected the quality of postoperative recovery [53]. Brodersen et al. (2023) conducted a systematic review examining the effect of preoperative education on postoperative recovery. This systematic review revealed that preoperative education has many positive effects on the postoperative recovery process [38]. Another study stated that the application of an eHealth strategy consisting of educational videos and video consultations with patients undergoing coronary artery bypass surgery positively affects recovery [54]. Other studies have similarly reported that patient education positively affects the recovery process [5,32,55]. In this context, the findings of our study are consistent with the existing literature and support the positive effect of preoperative education on the recovery process.

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5. Limitations

This study has some limitations. First, it was conducted at a single center, and the sample size was relatively small. Second, the fact that the patients who participated in the study were volunteers may have caused the results to reflect only a specific patient group. Another limitation of this study is that the long-term effects of the provided education were not evaluated. Finally patients’ level of understanding of the delivered educational content was not assessed using an objective measurement tool.

6. Conclusions

This study shows that education provided to patients undergoing rhinoplasty via PowerPoint presentations and brochures is effective in reducing preoperative and postoperative anxiety and contributes positively to the postoperative recovery process. Emphasizing the importance of patient education during the surgical process and disseminating such programs will significantly improve the quality of patient care.