The Effect of Virtual Forest Bathing on Bariatric Surgery Patients

The Effect of Virtual Forest Bathing on Pain, Anxiety, Fear, Sleep Quality, Vital Signs, and Cortisol Levels in Patients Undergoing Bariatric Surgery: A Randomized Controlled Trial

This study will be conducted at the General Surgery Clinic of City Hospital in Erzurum between August 2025 and April 2026 using a randomized controlled experimental design. In the power analysis, it was determined that the sample of the study should be 70 patients in total, 35 patients in each group, with a medium effect size of 0.5% according to Cohen (42), a margin of error of 0.05%, a confidence interval of 0.95%, and a 95% universe representation power. Patients will be assigned to either the experimental or control groups using a random number generator using a two-block randomization method (random.org). Given that exposure to nature through virtual reality increases physiological arousal and promotes positive mood, the study aimed to evaluate the effects of virtual forest bathing on pre- and postoperative pain, anxiety, fear, sleep, vital signs, and cortisol levels in patients undergoing bariatric surgery.

Bariatric surgery is considered an effective method for the treatment of obesity and is increasingly being performed worldwide. While bariatric surgery is an effective method for weight loss and control, the physiological changes caused by excess weight caused by surgical and anesthesia procedures can lead to postoperative complications. Before and after bariatric surgery, uncertainty about the surgical process, concerns about the surgical procedure and anesthesia procedures, and postoperative lifestyle changes and concerns about potential complications all contribute to an increased surgical stress response in obese individuals. Integrating non-pharmacological interventions into the treatment process, rather than focusing solely on pharmacological methods, is crucial. These approaches can be effective in alleviating the physical and psychological symptoms associated with surgery; they can support the recovery process by reducing anxiety and improving sleep quality. Techniques based on distraction, such as virtual reality, music therapy, and breathing exercises, do not produce any side effects, unlike pharmacological agents. These methods also help patients maintain basic physiological parameters such as blood pressure, respiration, and pulse rate, while also contributing to increased comfort and satisfaction. One of these innovative approaches is forest bathing, also known as "Shinrin-yoku," meaning "immersing in the forest atmosphere." Forest bathing utilizes the healing effects of forests to improve health and prevent disease through forest walks. Forest atmospheres are known to contain numerous healing factors that play an important role in the prevention and treatment of health problems through sensory input. There is evidence that forest bathing can help individuals regain attention and foster more positive emotions. Forest environments have positive effects on the cardiovascular system, nervous system, endocrine system, immune system, and mental health. This study was designed considering the need for evidence regarding the pre- and postoperative use of virtual forest bathing in the context of nursing care. It is believed that virtual forest bathing may have positive effects on pain, anxiety, fear, sleep patterns, cortisol, and vital signs in patients undergoing bariatric surgery during the pre- and postoperative periods. Virtual forest bathing has demonstrated successful results in various areas and with different patient groups for reducing stress and anxiety. However, there are limited studies specifically related to bariatric surgery, both in our country and elsewhere. Some studies abroad have shown that such psychological support methods have positive effects on surgical stress, but the number of studies conducted in this area in our country is quite limited. Therefore, this study is valuable in providing scientific data to healthcare professionals in our country. As experimental research on forest bathing intensifies, medical and healthcare professionals have focused on the forest's ability to boost immunity and reduce stress. They have concluded that even short-term forest bathing can help strengthen the body's immune system and improve mood. Implementing holistic, non-pharmacological interventions for patients experiencing both physical and psychological challenges before and after bariatric surgery is crucial. Virtual reality-based nature interventions are considered among the innovative and effective approaches that can be integrated into nursing care during this process. In this context, the study aimed to evaluate the effects of virtual forest bathing on pain, anxiety, fear, sleep patterns, vital signs, and cortisol in patients undergoing bariatric surgery before and after surgery.

Inclusion Criteria:

• Willingness to participate in the study
• Ability to communicate verbally
• Absence of any psychiatric disorder
• Undergoing bariatric surgery
• No prior experience with virtual forest bathing

Exclusion Criteria:

• Inability to establish communication
• Presence of major hearing or visual impairment
• Presence of any condition that may affect decision-making ability (e.g., psychological disorders, dementia)
• Use of medications that may affect cognitive status (e.g., sedatives, antipsychotics)
• Patients who report having previously experienced virtual forest bathing will be excluded from the sample