Perioperative psychological support in the operating room improves anxiety, depression, and recovery in orthopedic patients

Abstract

BACKGROUND

Orthopedic surgery often induces perioperative anxiety and depression owing to pain, functional limitations, and uncertainty regarding outcomes, which may exacerbate physiological stress responses, impair hemodynamic stability, and hinder postoperative recovery. While psychological support is typically provided preoperatively in wards, psychological distress often peaks in the operating room immediately before anesthesia induction, a critical period frequently overlooked in structured interventions. We hypothesize that implementing a standardized, multidimensional psychological support protocol within the operating room during this critical window can effectively reduce perioperative anxiety and depression and accelerate recovery in orthopedic patients.

AIM

To evaluate the impact of an operating room-based psychological intervention on perioperative anxiety, depression, and recovery in orthopedic patients.

METHODS

This retrospective study included 150 orthopedic surgery patients at the Henan Provincial People’s Hospital. Patients were divided into control (routine care, n = 75) and intervention (operating room psychological intervention, n = 75) groups. Anxiety Self-rating Anxiety Scale (SAS), depression Self-rating Depression Scale (SDS), pain (Visual Analog Scale), recovery time, and patient satisfaction were measured and compared. Logistic regression analysis was performed to identify factors affecting postoperative anxiety and depression.

RESULTS

The intervention group demonstrated lower postoperative anxiety and depression than the control group, with SAS scores of 49.00 (46.00-49.00) vs 49.00 (49.00-54.00) (P = 0.001), SDS scores of 50.00 (47.00-51.00) vs 52.00 (50.00-54.00) (P < 0.001). Postoperative pain was lower in the intervention group [5.00 (5.00-6.00) vs 6.00 (5.00-7.00) (P = 0.001)]. Recovery improved with shorter incision healing time [12.00 (11.00-13.00) days vs 13.00 (12.00-14.00) days, P < 0.001] and reduced hospital stay [7.00 (6.00-8.00) days vs 8.00 (7.00-9.00) days, P = 0.005]. Patient satisfaction was higher (Z = -2.585, P = 0.010). Multivariate analysis confirmed the intervention as protective against postoperative anxiety and depression (odds ratio = 0.252, 95% confidence interval: 0.099-0.639).

CONCLUSION

Operating room-based psychological intervention effectively reduces perioperative anxiety and depression, alleviates postoperative pain, accelerates recovery, and enhances satisfaction in orthopedic patients, representing a valuable non-pharmacological adjunct to perioperative care.

Key Words: Operating room nursing; Psychological intervention; Orthopedic surgery; Anxiety and depression; Postoperative pain; Perioperative nursing

Core Tip: This study highlights the clinical value of implementing a structured, multidimensional psychological intervention in the operating room during the critical pre-anesthesia period for orthopedic patients. This targeted protocol effectively reduced perioperative anxiety and depression, mitigated postoperative pain, shortened recovery time, and improved patient satisfaction. It serves as an independent protective factor against postoperative psychological distress, offering a practical, nonpharmacological strategy to optimize perioperative outcomes, especially in high-risk patients with multiple psychological vulnerability factors.

INTRODUCTION

With the growing adoption of enhanced recovery after surgery, orthopedic perioperative management has progressively shifted from a focus on surgical technical success to a more comprehensive emphasis on patients’ functional recovery and overall care experience[1,2]. During this transition, the patient’s psychological state, a key and controllable factor affecting the postoperative rehabilitation process, has become increasingly important[2]. Clinical practice indicates that orthopedic patients experience higher rates of perioperative anxiety than patients undergoing other types of surgery, largely because of acute trauma, chronic pain, functional disorders, and uncertainty about surgical prognosis[3,4]. Existing research data show that the prevalence of perioperative anxiety among non-tumor surgery patients is approximately 23%, whereas rates among orthopedic patients-especially spinal surgery patients-are significantly higher, exceeding 46% in some studies[4]. Perioperative negative emotions can activate excessive physiological stress responses and adversely affect intraoperative hemodynamic stability, postoperative pain perception, early functional exercise compliance, and long-term quality of life through neuroendocrine and immunomodulatory pathways[5-7].

Traditional perioperative psychological support is mostly limited to preoperative visits and ward-based education, while patients’ psychological stress often peaks during transfer to the operating room before anesthesia induction[8]. Patients at this stage are prone to being in a highly vulnerable state due to the unfamiliar environment and perceived loss of control, yet systematic psychological intervention is rarely provided[8]. In June 2024, the Orthopedic Center of our hospital implemented an innovative, structured, and standardized psychological intervention program, led by a trained team of operating room nurses, into the routine operating room nursing care. During the critical window, from patient admission to the initiation of anesthesia, multi-dimensional psychological nursing was systematically implemented, including information support, emotional reassurance, cognitive reconstruction, and relaxation guidance.

However, the precise effect of this innovative clinical practice on patient outcomes needs to be verified and quantified through rigorous scientific studies. Accordingly, this retrospective cohort study was designed to systematically collect and compare clinical data from patients undergoing orthopedic surgery before and after the implementation of the operating room psychological intervention. This study analyzed the differences between the two groups in terms of key indicators, including perioperative anxiety and depression, postoperative pain as assessed using the Visual Analog Scale (VAS), analgesic consumption, early ambulation time, length of hospital stay, and patient satisfaction. By objectively evaluating the clinical effect of immediate, operating room-based psychological intervention on patients’ psychological stress and postoperative rehabilitation, this study aims to provide clinical evidence supporting the integration of mind-body-focused perioperative care models, with the operating room as the key node.

MATERIALS AND METHODS

Patient characteristics

A total of 150 patients who underwent orthopedic surgery at Henan Provincial People’s Hospital between June 2024 and June 2025 were retrospectively selected as participants. The inclusion criteria were: (1) Patients undergoing elective orthopedic surgery at our hospital; (2) Age ≥ 18 years old; (3) Complete clinical data required for this study; and (4) Patients were conscious 1 day postoperatively. The exclusion criteria were: (1) Emergency surgery; (2) Multiple fractures; (3) Congenital malformations, developmental diseases, or bone tumors; (4) A history of severe psychiatric and neurological disorders (e.g., major depressive disorder, schizophrenia, dementia, or intellectual disability) that may significantly affect the validity of psychological scale scores; and (5) Concurrent major non-orthopedic surgery, which could confound postoperative rehabilitation indicators. This study was reviewed and approved by the Ethics Committee of the Henan Provincial People’s Hospital.

Method of grouping

Participants were assigned to control and intervention groups according to the implementation of the operating room psychological intervention program. Patients who underwent surgery before (June-December 2024) and after (January-June 2025) implementation were included in the control and intervention groups, respectively. As this was a retrospective study, the sample size included all patients meeting the inclusion and exclusion criteria during the study period. A total of 186 patients were initially identified from the hospital’s electronic medical records. After excluding 36 patients during screening and balancing baseline data between groups, 75 patients were included in each (control and intervention) group.

Methods of intervention

Control group: Patients received routine operating room nursing care, including routine preoperative checks, vital sign monitoring, intraoperative sterile operation cooperation, and safe postoperative transfer.

Intervention group: In addition to routine care, patients received psychological intervention in the operating room. The intervention included the following components: (1) Orientation and cognitive preparation: Upon entering the operating room, nurses used standardized language to introduce the environment and outline the process. Patients were informed of the current stage of care and procedures (e.g., establishing intravenous access and connecting monitoring devices) to be performed in the next 10-15 minutes and an approximate timeline, thereby reducing unfamiliarity and uncertainty and establishing controlled expectations; (2) Empathic emotional assessment and reassurance: Nurses actively observed patients’ emotional states and asked brief, supportive questions (e.g., “How are you feeling now? Are you nervous?”). Emotional responses were normalized (e.g., “Feeling nervous before surgery is a common reaction”), and empathic listening and reassurance were provided to enhance emotional support and doctor-patient trust; (3) Sensory guidance and distraction technique: Prior to potentially uncomfortable operations (such as skin disinfection and puncture), nurses gave a brief sensory warning (e.g., “The skin will feel somewhat cool after disinfection”). Patients were then instructed to perform slow abdominal breathing (“inhale deeply through the nose, feel the bulge of the abdomen, and exhale slowly through the mouth”) or silently count breaths to redirect attention away from the medical procedure and toward the rhythm of breathing; (4) Simplified mindfulness-based relaxation training: When feasible, patients were guided to perform simple progressive muscle relaxation for approximately 2-3 minutes. Patients were guided to tighten and relax the hand, shoulder, and neck muscles and pay attention to the contrasting experience of tension and relaxation to reduce the overall muscle tension and anxiety level; and (5) Immediate positive feedback and postoperative psychological preparation: Before anesthesia induction or before the patient leaves the room, nurses provided specific and positive feedback (e.g., “You did a very good job in the cooperation just now”). Patients were also informed about the common early postoperative period (e.g., “It’s normal to wake up and feel somewhat dry in the throat”) and coping strategies to establish a positive psychological preset for postoperative recovery.

Quality control

To ensure the consistency and effectiveness of the intervention measures, the following quality control measures were adopted in this study: (1) A standardized “Psychological Intervention Operating Manual for the Operating Room” was developed, detailing the specific language, operation steps, and time points for the five intervention dimensions; (2) All the operating room nurses involved in the intervention received unified training, which included theoretical lectures, scenario simulation exercises, and clinical practice assessments. Only those who passed the training could participate in the study; (3) During the study period, nursing managers randomly selected intervention cases on a regular basis and conducted process verification through operating room monitoring videos to ensure the consistency and standardization of the intervention implementation; and (4) Regular quality control meetings were held to provide feedback and address the issues identified during the implementation process.

Indicators of observation

Anxiety and depression: Anxiety and depression were assessed using the Self-rating Anxiety Scale (SAS)[9] and Self-rating Depression Scale (SDS)[10], at 1 day preoperatively and 3 days postoperatively. The SAS contains 20 items assessing emotional, physical, and psychological symptoms of anxiety (such as nervousness, fear, palpitations, and sleep disorders, etc.), rated on a 4-point Likert scale ranging from 1 (“no or little time”) to 4 (“most or all of the time”), according to the frequency of symptoms. SAS scores of ≥ 50 points indicate anxiety symptoms (50-59 points: Mild, 60-69: Moderate anxiety, ≥ 70 points: Severe anxiety). The SDS also contains 20 items evaluating psycho-affective symptoms, somatic symptoms, and psychomotor disorders (such as low mood, hopelessness, loss of appetite, and slow thinking) and is scored similarly. SDS scores of ≥ 53 points indicate depressive symptoms (53-62: Mild depression, 63-72: Moderate depression, and ≥ 73: Severe depression).

Pain: The VAS was used to assess pain at rest 24 hours before and after surgery using a straight line 10 cm long, with two ends marked as “no pain” (score 0) and “the most unbearable pain” (score 10). The patients marked the corresponding position according to their pain perception, and the distance from the marking point to the starting point was measured as the VAS score. Higher scores indicate greater pain intensity.

Postoperative rehabilitation: The time to first ambulation, wound healing time, and length of hospital stay were recorded.

Occurrence of adverse events: The incidence of adverse events within 3 months postoperatively, including infection, bleeding, and lower-extremity venous thrombosis, was recorded.

Nursing satisfaction: Patient satisfaction with operating room nursing was assessed on four levels; very satisfied, relatively satisfied, generally satisfied, and not very satisfied.

Analysis of the factors affecting postoperative anxiety and depression: Based on the occurrence of postoperative anxiety and depression, the participants were classified into anxiety and depression groups and non-anxiety and depression groups. Patients with an SAS score of ≥ 50 and an SDS score of ≥ 53 were classified into the anxiety and depression group, respectively, and patients with scores below the threshold were included in the non-anxiety/depression group. Univariate analysis was conducted to preliminarily screen for potential influencing factors of anxiety and depression, followed by multivariate logistic regression to determine independent influencing factors of perioperative anxiety and depression in patients undergoing orthopedic surgery.

Statistical analysis

Statistical software (SPSS 26.0) was used to analyze the data. Measurement data were expressed as mean ± SD, and comparisons between groups were analyzed using the group t-test. The count data were expressed as n (%), and the χ² test was used for comparison between groups. The rank-sum test was used when the data were in a ranked distribution. Univariate and multivariate logistic regression analyses were conducted to explore the independent factors influencing anxiety and depression in patients who underwent orthopedic surgery within 3 days postoperatively. Statistical significance was set at P < 0.05.

RESULTS

Clinical characteristics

Table 1 shows that there were no significant differences in baseline data, such as gender, age, body mass index, education level, accompanying individuals, average monthly income, smoking history, drinking history, diabetes, hypertension, cause of injury, or fracture site between the control and intervention groups (P > 0.05).

Table 1 Clinical characteristics, n (%).

Clinical data	Control group (n = 75)	Intervention group (n = 75)	χ2/t	P value
Gender			0.684	0.408
Male	41 (54.67)	46 (61.33)
Female	34 (45.33)	29 (38.67)
Age (years)	61.17 ± 5.96	59.95 ± 5.94	1.263	0.209
Education level			0.329	0.848
Primary school and below	28 (37.33)	31 (41.33)
Junior high school	27 (36.00)	24 (32.00)
High school and above	20 (26.67)	20 (26.67)
Attendant			0.794	0.373
Relatives	61 (81.33)	65 (86.67)
Non-relatives1	14 (18.67)	10 (13.33)
Average monthly income (Yuan)			0.707	0.4
≤ 5000	49 (65.33)	44 (58.67)
> 5000	26 (34.67)	31 (41.33)
Smoking			0.515	0.473
Have	24 (32.00)	20 (26.67)
No	51 (68.00)	55 (73.33)
Drinking			1.31	0.252
Have	39 (52.00)	32 (42.67)
No	36 (48.00)	43 (57.33)
T2DM			0.743	0.389
Have	28 (37.33)	23 (30.67)
No	47 (62.67)	52 (69.33)
Hypertension			0.35	0.554
Have	15 (20.00)	18 (24.00)
No	60 (80.00)	57 (76.00)
Cause of injury			0.249	0.618
Acute traumatic injury	43 (57.33)	46 (61.33)
Chronic strain and degenerative diseases	32 (42.67)	29 (38.67)
Location of fracture			0.926	0.629
Spinal column	26 (34.67)	31 (41.33)
Limbs	30 (40.00)	29 (38.67)
Others	19 (25.33)	15 (20.00)

¹Includes situations such as being accompanied by a caregiver or not.

T2DM: Type 2 diabetes mellitus.

Anxiety and depression

Table 2 indicates that the SAS and SDS scores of the two groups were similar before surgery (all P > 0.05). After surgery, the SAS and SDS scores for both groups were comparatively lower than preoperative scores. The decrease in the intervention group was greater than that in the control group (all P < 0.05).

Table 2 Anxiety and depression in the two groups.

Grouping	SAS		SDS
	Preoperative	Postoperative	Preoperative	Postoperative
Control group	53.00 (51.00, 58.00)	49.00 (49.00, 54.00)a	55.00 (53.00, 58.00)	52.00 (50.00, 54.00)a
Intervention group	54.00 (52.00, 58.00)	49.00 (46.00, 49.00)a	56.00 (53.00, 58.00)	50.00 (47.00, 51.00)a
Z	-1.086	-3.386	-0.928	-4.567
P value	0.278	0.001	0.354	< 0.001

^aP < 0.05.

SAS: Self-rating Anxiety Scale; SDS: Self-rating Depression Scale.

Condition of pain

Table 3 shows that the VAS scores assessed 24 hours before surgery were similar between the two groups (Z = -0.537, P = 0.591). At 24 hours after surgery, VAS scores increased in both groups relative to preoperative values. However, the perceived degree of pain was higher in the intervention group (Z = -3.198, P = 0.001). There was no significant difference in the number of rescue analgesics used within 48 hours after surgery between the two groups (Z = -1.382, P = 0.167).

Table 3 Condition of pain.

Grouping	VAS		The number of rescue analgesics used during the 48 hours after surgery
	Preoperative (24 hours)	Postoperative (24 hours)
Control group	5.00 (4.00, 5.00)	6.00 (5.00, 7.00)	2.00 (2.00, 3.00)
Intervention group	5.00 (4.00, 5.00)	5.00 (5.00, 6.00)	2.00 (2.00, 3.00)
Z	-0.537	-3.198	-1.382
P value	0.591	0.001	0.167

VAS: Visual Analogue Scale.

Postoperative rehabilitation

Table 4 indicates that the intervention group, compared to control group demonstrated a shorter time of first ambulation [40.00 (31.00, 48.00) vs 39.00 (31.00, 43.00)], wound healing [13.00 (12.00, 14.00) vs 12.00 (11.00, 13.00)] and length of hospital stay [8.00 (7.00, 9.00) vs 7.00 (6.00, 8.00)] in the control group were shorter than those in the control group, whereas the wound healing time and length of hospital stay were statistically significant (both P < 0.05).

Table 4 Postoperative rehabilitation.

Grouping	Time of first ambulation (hours)	Time of wound healing (days)	Length of hospital stay (days)
Control group	40.00 (31.00, 48.00)	13.00 (12.00, 14.00)	8.00 (7.00, 9.00)
Intervention group	39.00 (31.00, 43.00)	12.00 (11.00, 13.00)	7.00 (6.00, 8.00)
Z	-1.602	-4.426	-2.797
P value	0.109	< 0.001	0.005

Adverse events

Table 5 indicates that although the between-group difference was not statistically significant (χ² = 1.336, P = 0.248), the overall incidence of postoperative adverse events, including infection, bleeding, and lower-extremity venous thrombosis, was lower in the intervention group than in the control group (5.33% vs 8.00%).

Table 5 Adverse events, n (%).

Grouping	Infection	Bleeding	Venous thrombosis of the lower extremities	Other	Overall incidence
Control group	2 (2.67)	1 (1.33)	2 (2.67)	2 (2.67)	6 (8.00)
Intervention group	1 (1.33)	1 (1.33)	1 (1.33)	2 (2.67)	4 (5.33)
χ2					1.336
P value					0.248

Satisfaction

Table 6 indicates that the rate of very high satisfaction among patients in the intervention group was higher than that in the control group, while the rate of low satisfaction was lower. There was a significant difference in the overall satisfaction between the two groups (Z = -2.585, P = 0.010).

Table 6 Patients’ satisfaction with nursing work, n (%).

Grouping	Group	Very satisfied	Relatively satisfied	Generally satisfied
Control group	13 (17.33)	31 (41.33)	27 (36.00)	4 (5.33)
Intervention group	28 (37.33)	26 (34.67)	19 (25.33)	2 (2.67)
Z	-2.585
P value	0.010

Univariate analysis of influencing factors of anxiety and depression in patients

Among the 150 participants, 38 cases of postoperative anxiety and/or depression were identified (incidence rate: 25.33%). Table 7 shows significant differences between the anxiety/depression group and the non-anxiety/depression group in terms of age, education level, accompanying personnel, type of surgery, and nursing methods (all P < 0.05). The overall situation for other indicators was similar (all P > 0.05).

Table 7 Univariate analysis of influencing patients’ postoperative anxiety and depression, n (%).

Clinical data	Total	Anxiety and depression group (n = 38)	Non-anxiety and depression group (n = 112)	χ2/t	P value
Gender				0.556	0.456
Male	87 (58.00)	24 (27.59)	63 (72.41)
Female	63 (42.00)	14 (22.22)	49 (77.78)
Age (years)	60.56 ± 5.96	62.84 ± 5.85	59.79 ± 5.82	2.793	0.006
Education level				8.256	0.016
Primary school and below	59 (39.33)	21 (35.59)	38 (64.41)
Junior high school	51 (34.00)	13 (25.49)	38 (74.51)
High school and above	40 (26.67)	4 (10.00)	36 (90.00)
Attendant				9.19	0.002
Relatives	126 (84.00)	26 (20.63)	100 (79.37)
Non-relatives1	24 (16.00)	12 (50.00)	12 (50.00)
Average monthly income (Yuan)				0.364	0.546
≤ 5000	93 (62.00)	22 (23.66)	71 (76.34)
> 5000	57 (38.00)	16 (28.07)	41 (71.93)
Smoking				0.224	0.636
Have	44 (29.33)	10 (22.73)	34 (77.27)
No	106 (70.67)	28 (26.42)	78 (73.58)
Drinking				0.000	0.996
Have	71 (47.33)	18 (25.35)	53 (74.65)
No	79 (52.67)	20 (25.32)	59 (74.68)
T2DM				3.802	0.051
Have	51 (34.00)	8 (15.69)	43 (84.31)
No	99 (66.00)	30 (30.30)	69 (69.70)
Hypertension				0.552	0.457
Have	33 (22.00)	10 (30.30)	23 (69.70)
No	117 (78.00)	28 (23.93)	89 (76.07)
Cause of injury				2.897	0.089
Acute traumatic injury	89 (59.33)	27 (30.34)	62 (69.66)
Chronic strain and degenerative diseases	61 (40.67)	11 (18.03)	50 (81.97)
Location of fracture				4.37	0.112
Spinal column	57 (38.00)	16 (28.07)	41 (71.93)
Limbs	59 (39.33)	18 (30.51)	41 (69.49)
Others	34 (22.67)	4 (11.76)	30 (88.24)
Type of surgery				11.308	0.004
Major/open surgery	50 (33.33)	20 (40.00)	30 (60.00)
Medium-sized surgery	64 (42.67)	15 (23.44)	49 (76.56)
Small/minimally invasive surgery	36 (24.00)	3 (8.33)	33 (91.67)
Nursing intervention				6.908	0.009
Control group	75 (50.00)	26 (34.67)	49 (65.33)
Intervention group	75 (50.00)	12 (16.00)	63 (84.00)

¹Includes situations such as being accompanied by a caregiver or not.

T2DM: Type 2 diabetes mellitus.

Multivariate analysis of the influencing factors of anxiety and depression in patients

Table 7 shows indicators with significant differences between the groups in the univariate analysis were used as independent variables, with postoperative anxiety and depression as the dependent variables in the multivariate logistic regression analysis (Table 8 includes the assignment of each variable). The results of the multivariate analysis in Table 9 show that old age [odds ratio (OR) = 1.089], education level of primary school or below (OR = 4.410), accompaniment by non-family members (OR = 3.260), and surgery type (major/open surgery, OR = 9.475) were risk factors for postoperative anxiety and depression in orthopedic surgery patients. In contrast, psychological intervention in the operating room was a protective factor (OR = 0.252).

Table 8 Variable assignment.

Variables	Assignment of value
Dependent variable
Postoperative anxiety and depression	1 = anxiety and depression, 0 = non-anxiety, and depression
Independent variables
Age	Enter actual values
Education level	2 = primary school and below, 1 = junior high school, and 0 = high school and above
Attendant	1 = relatives and 0 = non-relatives
Type of surgery	2 = major/open surgery, 1 = medium sized surgery, and 0 = small/minimally invasive surgery
Nursing intervention	1 = control group and 0 = intervention group

Table 9 Multivariate analysis of influencing factors of anxiety and depression in patients.

Variables	β	SE	χ2	P value	OR	95%CI
Age	0.085	0.041	4.395	0.036	1.089	1.006-1.179
Education level (high school and above)				-	1	-
Junior high school	1.189	0.711	2.798	0.094	3.285	0.815-13.240
Primary school and below	1.484	0.694	4.572	0.032	4.410	1.132-17.185
Attendant	1.182	0.520	5.155	0.023	3.260	1.175-9.042
Type of surgery (small/minimally invasive surgery)				-	1	-
Medium-sized surgery	1.246	0.743	2.814	0.093	3.478	0.811-14.919
Major/open surgery	2.249	0.755	8.872	0.003	9.475	2.158-41.611
Nursing intervention	-1.379	0.476	8.410	0.004	0.252	0.099-0.639
Constant	-8.516	2.761	9.511	-	-	-

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

With an aging global population and the high incidence of sports-related injuries, the burden of orthopedic diseases is increasing, accompanied by a steady rise in the number of patients receiving surgical treatment[11,12]. Such an increase requires the clinical management model to evolve from simply pursuing the success of surgical techniques toward a systematic plan to comprehensively improve the perioperative experience and long-term functional outcomes of patients[13]. In this process, identification and intervention of nontechnical, modifiable factors influencing rehabilitation are of critical importance. As the core physical space for surgical intervention and a period of peak acute psychological stress, the operating room provides a unique opportunity for immediate and efficient delivery of integrated care[14]. However, high-quality evidence is required to confirm the clinical benefits of embedding structured psychological support programs in this high-load clinical environment. In this study, a retrospective cohort analysis was conducted to systematically evaluate the impact of an integrated operating room-based care model on perioperative outcomes in patients undergoing elective orthopedic surgery. The findings showed that the patients receiving psychological intervention exhibited significantly lower anxiety and depression scores at 3 days postoperatively as well as reduced pain intensity 24 hours after surgery compared to those receiving routine nursing care. The wound healing time and total length of hospital stay were also shorter, and nursing satisfaction was greater in the intervention group. The above findings confirm that the implementation of a standardized psychological intervention in the operating room may serve as an effective non-drug intervention strategy to optimize perioperative outcomes in orthopedic patients across multiple dimensions, including emotional well-being, pain control, physiological rehabilitation, and medical care experience.

The significant reduction in postoperative anxiety and depression scores in the intervention group may be due to the direct action of structured interventions (such as directional notification, empathic comfort, and breathing guidance) during the peak period of preoperative stress. These interventions effectively break the vicious cycle of fear and anxiety by enhancing patients’ sense of control, reducing uncertainty, and providing immediate emotional support[15-17]. This investigation demonstrates that psychological nursing can advance from scattered, ward-based education to a continuous, dedicated intervention delivered in the operating room, thereby achieving better clinical effectiveness. It should be noted that in this study, the SAS and SDS scales were used to assess the anxiety and depression status of patients 3 days after surgery. Although these scales are widely used in domestic perioperative studies, they were not specifically designed for surgical scenarios. The reason why we chose SAS and SDS for this study is that these two scales have been well-established in domestic perioperative research, with good reliability and validity. Moreover, the scale items are clear and the clinical operation is convenient, making them suitable for implementation in orthopedic perioperative patients. Three days after the surgery, patients may still be affected by factors such as pain, residual sedative effects, insufficient sleep, and discomfort from the drainage tube, which may cause interference with the completion and accuracy of the questionnaires. Moreover, the 20-item questionnaire may increase the burden on patients. Future research could consider using simplified scales specifically designed for surgical scenarios, such as the Hospital Anxiety and Depression Scale or the Amsterdam Preoperative Anxiety Scale. These scales have more concise items and have been validated in the orthopedic population, and may be more suitable for psychological assessment of perioperative patients.

Beyond psychological benefits, this study also demonstrated positive extension to physiological rehabilitation. In this study, although the median SAS scores of both groups after surgery were 49.00, the interquartile range of the intervention group (46.00-49.00) was more concentrated compared to the control group (49.00-54.00). Furthermore, the upper quartile of the control group (54.00) was higher compared with the intervention group (49.00), indicating that the control group contained more patients with higher postoperative anxiety levels. This statistically significant difference suggests that the psychological intervention in the operating room may mainly exert its effect by reducing the anxiety levels of high-risk patients. It is worth noting that in this study, the VAS score of the intervention group at 24 hours after surgery was lower than that of the control group, while there was no difference in the number of rescue analgesic drug administrations between the two groups at 48 hours after surgery. This phenomenon suggests that the psychological intervention in the operating room does not simply achieve pain relief by replacing or reducing analgesic drugs but is more likely to exert its effect by changing the patient’s perception and emotional response to pain. Psychological intervention may reduce patients’ catastrophizing thinking about pain-that is, their excessive negative interpretation and helplessness regarding pain, while enhancing their pain self-efficacy-that is, an individual's confidence in coping with and managing pain[18]. Effective pain control is the cornerstone of early functional rehabilitation and was evident through quicker wound healing and shorter hospital stays in the intervention group[19,20].

To further clarify the mechanisms of operating room-based psychological nursing in alleviating postoperative anxiety and depression, this study included “whether to accept operating room psychological intervention” as the core independent variable in a multivariate logistic regression model. The results identified old age, low education level, lack of family care, and major or open surgery as independent risk factors for postoperative anxiety and depression. Together, these factors define a group of perioperative “psychological high-risk” patients. Importantly, operating room psychological intervention emerged as an independent protective factor (OR = 0.252, 95% confidence interval: 0.099-0.639), and this effect remained statistically significant after adjusting for the above demographic and clinical risk factors. This result highlights the universal value of psychological nursing in the operating room and suggests that it may provide key clinical benefits for patients with multiple psychological risk factors. Therefore, the systematic integration of this method is an embodiment of humanistic care for all patients and a pragmatic approach to implementing precise psychological protection for high-risk patients and promoting perioperative psychological management through individualization and stratification.

The identification of advanced age, low educational level, unrelated caregivers, and major/open surgery as independent risk factors for postoperative anxiety and depression can be analyzed from both social-psychological and clinical pathology perspectives. Age-related declines in physiological reserve, increased comorbidity burden, and reduced neurocognitive function may render elderly patients more vulnerable to surgical stress and less resilient psychologically[21]. Moreover, elderly patients’ concerns regarding postoperative independence and long-term functional prognosis may further exacerbate perioperative psychological stress[22]. Chen et al[23] reported that cognitive behavioral therapy can effectively alleviate psychological anxiety and pain in patients undergoing joint replacement surgery in both short-term (1 week) and long-term (3 months) follow-up, although it has no significant effect in patients aged ≥ 70 years. Lower educational levels may restrict patients’ ability to understand, process, and integrate medical information, leading to fuzzy cognition of surgical risk, the rehabilitation process, and the prognosis, thereby fostering uncertainty, catastrophizing thinking, and sustained anxiety-depression cycles[24]. Yang et al[25] demonstrated that negative emotion is an independent factor affecting the prognosis of patients with pituitary tumors and that education level is an independent factor affecting the negative emotions of patients. Also, the lack of caregivers may indicate relatively weak family support during the highly stressful perioperative period, significantly aggravating feelings of loneliness and helplessness while diminishing psychological coping resources[26,27]. Furthermore, major or open surgery typically involves extensive tissue trauma, a complex physiological stress response, prolonged recovery, and increased complication risk. Together, these factors increase both physical burden and psychological threat, predisposing patients to emotional disorders with anxiety and depression as the core[28].

This study confirmed that operating room psychological intervention is an independent protective factor against postoperative anxiety and depression through multilevel mechanisms. At the cognitive and emotional levels, empathy assessment and normalization feedback enhance patients’ sense of security and control while correcting their negative cognitive assessment of the surgical experience. At the physiological level, guided abdominal breathing and progressive muscle relaxation activate the parasympathetic nervous system, antagonize stress-mediated neuroendocrine and immune activation, and alleviate anxiety-related somatic symptoms. Slow-paced breathing exercises such as abdominal breathing can affect heart rate variability, by enhancing parasympathetic nerve activity and counteracting the excessive excitation of the sympathetic nerve during stress, thereby lowering heart rate and blood pressure and alleviating anxiety-related physical symptoms[29]. At the same time, progressive muscle relaxation training is proved to reduce the levels of stress hormones in the body. Ozhanli et al[30] also confirmed that progressive relaxation exercises can reduce postoperative pain and anxiety levels, although its effect on cortisol did not reach statistical significance, but the overall trend supports its positive role in perioperative stress management. Moreover, Shukla et al[31] found that music therapy for orthopedic surgery patients can significantly reduce serum cortisol levels and reduce the demand for sedative drugs during surgery, which further supports the feasibility of non-pharmacological psychological intervention in regulating the stress response through neuroendocrine pathways. These findings suggest that immediate positive feedback in perioperative psychological intervention and postoperative psychological expectations can help form positive behavioral reinforcement and rehabilitation expectations, promoting patients' early recovery and treatment compliance from the behavioral motivation level. Therefore, as a non-drug, low-cost, and integrated nursing strategy, psychological intervention in operating room provides effective psychological resilience support for perioperative patients, especially high-risk groups with multiple risk factors, by regulating the continuous process of cognition, emotion, physiology, and behavior.

This study has some limitations. As a single-center, retrospective cohort study, the results may be subject to selection bias, information bias, and confounding factors. Although these were adjusted for in the multivariate analysis, the interference of unmeasured confounding factors could not be excluded. Additionally, this study mainly evaluated the psychological and rehabilitation indicators in the short term (3 days after surgery and during hospitalization) but lacked follow-up data on the patients’ long-term quality of life, functional recovery, and psychological state. However, rehabilitation after orthopedic surgery is a continuous and multi-stage process. During the patients’ return to their families and society after discharge, their psychological state, pain perception, functional recovery, and quality of life may experience new fluctuations. Therefore, future research should conduct prospective randomized controlled trials with multicenter design, large sample sizes, and long-term follow-ups (such as 1 month and 3 months postoperatively) to further verify the universality and long-term benefits of this intervention plan.

CONCLUSION

In conclusion, the integration of standardized psychological intervention in operating room through routine nursing practice is an effective and feasible non-pharmaceutical strategy for optimizing perioperative outcomes in orthopedic patients across multiple dimensions, including emotional well-being, pain management, rehabilitation process, and patient experience, providing key protective support for high-risk patients with multiple psychological risk factors. This study provides important clinical evidence for promoting an integrated body-mind perioperative care model.