Stress symptoms among adolescents before and after scoliosis surgery

ORIGINAL ARTICLE

Stress symptoms among adolescents before and after scoliosis surgery: correlations with postoperative pain Anna-Clara Rullander, Mats Lundstr€ om, Marie Lindkvist, Bruno H€ aggl€ of and Viveca Lindh

Aims and objectives. The aim of this study was to describe stress symptoms among adolescents before and after scoliosis surgery and to explore correlations with postoperative pain. Background. Scoliosis surgery is a major surgical procedure. Adolescent patients suffer from preoperative stress and severe postoperative pain. Previous studies indicate that there is a risk of traumatisation and psychological complications during the recovery period. Design. A prospective quantitative cohort study with consecutive inclusion of participants. Methods. A cohort of 37 adolescent patients aged 13–18. To assess the adolescents’ experiences before surgery and at six to eight months after surgery, the Trauma Symptom Checklist for Children – Alternative version, Youth Self-Report and Kiddie Schedule for Affective Disorder and Schizophrenia for children 12–18 were used. The Visual Analogue Scale was used for self-report of postoperative pain on day three. Results. Rates of anxiety/depression and internalising behaviour were significantly higher before surgery than six months after. Preoperative anger, social problems and attention problems correlated significantly with postoperative pain on day three. At follow-up, postoperative pain correlated significantly with anxiety, social problems and attention problems. Conclusions. The results of this study indicate a need for interventions to reduce perioperative stress and postoperative pain to improve the quality of nursing care. Relevance to clinical practice. Attention to preoperative stress and implementation of interventions to decrease stress symptoms could ameliorate the perioperative process by reducing levels of postoperative pain, anxiety, social and attention problems in the recovery period.

What does this paper contribute to the wider global clinical community?

• Nurses need to detect and assess •

•

preoperative stress in adolescent patients. Postoperative pain is often undertreated, therefore nurses need to assess postoperative pain and offer adequate pain management. Nursing need to learn and implement stress-reduction techniques to help the adolescent patient cope with preoperative stress and anxiety.

Key words: adolescent, anxiety, idiopathic scoliosis, pain, perioperative, stress symptoms Accepted for publication: 29 October 2015

Authors: Anna-Clara Rullander, RN, MScN, PhD Student, Department of Nursing, Ume a University, Ume a; Mats Lundstr€ om, PhD, RNT, Senior Lecturer, Department of Nursing, Ume a University, Ume a; Marie Lindkvist, Stat PhD, Senior Lecturer, Department of Statistics, Ume a University and Departments of Public Health and Clinical Medicine, Epidemiology and Global Health, Ume a University, Ume a; Bruno H€aggl€ of, MD, PhD, Professor, Department of

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Clinical Sciences, Child and Adolescent Psychiatry, Ume a University, Ume a; Viveca Lindh, PhD, RN, Senior Lecturer, Department of Nursing, Ume a University, Ume a, Sweden Correspondence: Anna-Clara Rullander, PhD Student, Department of Nursing, Ume a University, 90187 Ume a, Sweden. Telephone: +46 90 7869861. E-mail: [email protected]

© 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094, doi: 10.1111/jocn.13137

Original article

Introduction Scoliosis surgery is a major surgical procedure, and one of the most extensive elective surgeries performed on adolescents today. The ethology of adolescent idiopathic scoliosis (AIS) is multifactorial. About 1–3% of all adolescents have AIS, and of them approximately 80% are girls. Most commonly they are diagnosed in early adolescence and admitted to surgery at an age of 12–16 years of age (Weinstein et al. 2008). Adolescents going through this type of surgery have to be carefully informed about the procedure, including about potential risks, postoperative pain and a difficult recovery. Although the young patient has to know about the perioperative procedure, this information may cause concerns when the patient is confronted with the risks of surgery and the prospect of severe postoperative pain (Rullander et al. 2013a). In our previous studies, patients describe traumatising and distressing experiences during surgery and also severe postoperative pain and nausea (Rullander et al. 2013b). Other studies have shown that significant stress factors affecting postoperative pain include self-perceived level of deformity, preoperative information, preoperative catastrophising and preoperative heart rate (Ip et al. 2009). These pre- and postoperative stress and trauma symptoms, and their correlation with postoperative levels of pain, have been inadequately studied among AIS patients.

Background Nurses have an important role in adolescent perioperative care, which includes interpreting symptoms, measuring and alleviating pain, and comforting patients. It also includes preparing for surgery by informing the patient and parents about what to expect, providing a calm and secure environment and being responsive to the patient’s needs. Nursing skills are needed for pharmacological treatment, medical technical equipment and psychological preparation (Lucas 2008). However, despite widely available pain management guidelines, there are discrepancies between nursing practice and guidelines in perioperative nursing (Dihle et al. 2006). Scoliosis surgery is generally known to cause severe postoperative pain (Rullander et al. 2013b). Pain is a highly subjective and individual experience. Undertreated pain can lead to traumatic experiences and affect the patient for a long time postoperatively (Rullander et al. 2013a). Connelly and colleagues (Connelly et al. 2014) studied 50 AIS patients to explore predictors and trajectories of postoperative pain. Pain outcomes were measured up to six months after surgery, and anxiety was measured preoperatively. © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Stress among adolescents, scoliosis surgery

They found that preoperative anxiety was a predictor of postoperative pain. Medical traumatic stress can be a consequence of postoperative pain in adolescent patients (Kassam-Adams 2006). It can be perceived as realistic or as a sense of threat. Furthermore, severe pain that is extremely terrifying and a feeling of helplessness can lead to traumatic stress. Posttraumatic stress can occur after medical events that have been traumatic, and preoperative traumatic stress can affect the level of postoperative pain (Marsac et al. 2014). The term stress can refer to adolescents feeling tense, restless, nervous, worried and having difficulties concentrating. Stress symptoms can be described in terms of stress, anger, depression and anxiety (Stromback et al. 2013). Stress and stress symptoms can be difficult to detect in adolescent patients as adolescents appear less likely to report anxiety spontaneously, and are less likely to behave anxiously (Fortier et al. 2011). There can be a number of reasons for preoperative stress. One dimension of stress symptoms can be an experience of reduced well-being during the perioperative period. Factors that influence the feeling of well-being in early adolescence comprise feelings of being in control, fitting in, having friends, esthetical parameters, family, school and activities outside school (Leversen et al. 2012). All these aspects of well-being are challenged and affected during the perioperative procedure. For example, feelings of being in control may be under threat during hospitalisation, when the adolescent becomes dependent on health care professionals and family members. This applies not only during actual surgery but also in terms of having confidence, receiving pain treatment, managing personal hygiene and getting help with mobilisation. For an adolescent person in the process of teenage emancipation, this can prove difficult (Hutton 2002). The influence of stressors before scoliosis surgery has been poorly studied. Coping strategies differ from person to person as well as between different periods in a person’s life. LaMontagne and colleagues found that a person’s coping strategies are influenced by their personality type (LaMontagne et al. 2004), with consequences for their well-being in the recovery process following major surgery. Esthetical aspects and body image are important as well; women are more likely to explore their identities than men, and tend to be less satisfied with their body appearance (Wangqvist & Frisen 2013). Patients are informed ahead of surgery about the postoperative scar and visible changes to their body, and this might be a stressor for the adolescent patient. Carr et al. (2005) found an association between pre- and postoperative anxiety and depression, and that postoperative pain had a negative impact on both postoperative

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anxiety and depression. Regarding AIS patients, there is a lack of knowledge about recovery and postoperative stress symptoms and the connection to preoperative stress and postoperative pain. In a previous study, there were indications that preoperative stress and postoperative pain had traumatising consequences for the adolescent patient (Rullander et al. 2013a). Therefore, the aim of this study was to describe stress symptoms among adolescents before and after scoliosis surgery and to explore correlations with postoperative pain. There were three hypotheses. 1 Preoperative stress symptoms correlate with higher levels of stress symptoms at the six-month follow-up. 2 Preoperative stress symptoms correlate with postoperative pain on day three. 3 Postoperative pain on day three correlates with the level of stress symptoms at the six-month follow-up.

Methods Participants For this study 37 adolescents were consecutively recruited from four Swedish spine centres. There were 32 girls and five boys in the recruited group.

Inclusion criteria Inclusion criteria were idiopathic scoliosis, age 12–18, and knowledge of spoken and written Swedish. Participants were informed orally and in writing, and gave their consent in writing. Parents’ consent was also obtained.

Study design and procedure This was a prospective quantitative study with consecutive inclusion of study patients. Three psychometric instruments: Trauma Symptom Checklist for Children – Alternative (TSCC-A), Youth Self-Report (YSR) and Kiddie Schedule for Affective Disorder and Schizophrenia for children 12– 18 (K-SADS) were used to screen for anxiety, stress or any presence of post-traumatic stress symptoms (PTSS) related to experiences from the hospital visit. K-SADS was also used to detect potential confounders, i.e. traumatic events during the recovery period, not associated with surgery. No such confounders were found in this sample. The instrument includes questions about traumatic events and other experiences that can affect the outcome scores at follow-up. Pain was self-measured using Visual Analogue Scale (VAS). Via telephone the first author (A-C. R) made appointments with the adolescents at the spine centre on admission day –

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the day prior to surgery. The participants answered the questionnaires with the first author present in the room to be able to answer and clarify questions if necessary, and in some cases read the questions aloud to the participant. All participants answered the three questionnaires before and then six to eight months after surgery. For the follow-up, the first author made appointments with the adolescents via telephone, and meetings took place either at the spine centre on the same day as the surgery follow-up, or in the nurses’ room at the adolescent’s school.

The instruments Trauma Symptom Checklist for Children – Alternative (Briere 1996) is a 44-item self-report questionnaire designed by John Briere to measure trauma-associated psychological sequelae in children and adolescents who have experienced trauma (e.g. physical violence, major losses, witnessing violence to others or natural disasters). It has been translated into Swedish and validated in a Swedish context (Nilsson et al. 2008). Reliability (internal consistency) in the Swedish context was 0
94 (Cronbach’s alpha), and test–retest correlations between 0
56–0
81 (Pearson correlation). Validity is tested with factor analysis, correlations, and criterion validity. The TSCC-A consists of two validity scales: under-response and hyper-response, and five clinical scales: anxiety, depression, post-traumatic stress, dissociation and anger. Each symptom item is rated according to its frequency of occurrence using a 4-point scale ranging from 0 (‘never’) to 3 (‘almost all of the time’). The Swedish manual for TSCC contains reference scores from a normative test group of 728 children and adolescents aged from 10–17. Youth Self-Report is completed by subjects to describe their own functioning. The instrument has been validated and translated into Swedish (Broberg et al. 2001) for young people 6–18 years of age. Reliability (internal consistency) was 0
66. Validity for YSR has been tested by content, criterion and construct validity and all showed good validity when tested in a clinical and a referred group (Achenbach & Rescorla 2001). YSR has been tested in a Swedish context (Broberg et al. 2001) on a normative sample consisting of 2522 adolescents aged from 13–18. For this study, the Problem checklist part of the instrument was used. The problem checklist consists of a 112-item questionnaire where the respondent scores symptoms/behaviours on a three point scale (0 = absence, 1 = presence and 2 = almost all the time). They score their experience at the present time and what they have experienced during the past six months. The Problem Checklist comprises eight core Syndrome Scales: Anxious/Depressed, Withdrawn/Depressed, Somatic © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Original article

Complaints, Social Problems, Thought Problems, Attention Problems, Rule-breaking Behaviour, Aggressive Behaviour and two broad band domains of internalising and externalising problems. YSR also has a domain for post-traumatic stress problems. Kiddie Schedule for Affective Disorder and Schizophrenia is an instrument for structured interviews (Kaufman et al. 1997) with questions to investigate earlier and/or present episodes of psychopathology among children and adolescents. The instrument was translated into Swedish and approved by the author in 2001. Test–retest reliability was shown to be in the excellent to good range (j coefficient 0
77–1
0) and interrater agreement 93 – 100% (Kaufman et al. 1997). The instrument includes questions about experienced traumas and has a supplement with questions about symptoms which could be associated with the traumas. Each item in the structured interview is scored from 0–3 where 0 = no information, 1 = no symptom present, 2 = symptom present but not pathological, and 3 = symptom present requiring further investigation and treatment. Visual Analogue Scale: In this study, the scale for selfmeasurement of pain was used (Bijur et al. 2001). Previous studies have shown that pain is severe on the third postoperative day (Kotzer 2000), so this study uses pain measurements from the third postoperative day and the participants rated their pain every fourth hour, and the ratings was documented in the study protocol.

Statistics Descriptives for the psychometric scales are presented with mean and standard deviations. For investigation of the normality, assumption of the scales, skewness was used. Differences between preoperative measures and follow-up measures were compared using paired samples t-tests. Simple linear regression was used to investigate the associations between the outcome postoperative pain and explanatory variables (preoperative measures for the different scales). Further, linear regression was used for several analyses using postoperative measurements of the scales as dependent variables and postoperative pain as an independent variable. p ≤ 0
05 was considered significant. SPSS (IBM SPSS Statistics Data Editor Version 22, IBM Corp, Armonk, NY) software was used for calculations. All three questionnaires were correctly completed; there is no data missing. In some cases, VAS ratings during the third postoperative day were not documented in the study protocol. The Last Observation Carried Forward (LOCF) method (Howell 2008) was used to adjust for missing VAS ratings.

© 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Stress among adolescents, scoliosis surgery

Ethical approval Ethics approval was obtained from the Regional Ethical Review Board in Ume a Dnr 08-056M, 2011-99-31M, 2013-37-32M.

Results Demographics Of the 37 adolescents in the sample, 32 were girls, with a mean age of 15
8, and 5 were boys, with a mean age of 16
1. The intention for this study was to include the total population of scoliosis patients from the four spine centres, but some of the eligible patients declined (n:7, all girls), some surgeries were cancelled due to infections (n:7, one boy and six girls), and others were dropouts for logistic reasons (n:5, one boy and four girls). Reasons for not wanting to participate have not been fully clarified, but included patients not being interested in participating, being unwilling to spend time answering questions, and having parents who were unwilling to let their child participate. One of the studied patients did not want to continue with the study after being discharged from hospital and eight participants could not be reached by the researcher after they had been discharged from hospital and that left 28 remaining participants for the follow-up. Overall, mean values for the TSCC-A and YSR scales were higher before surgery than after, except for the domain attention problems in YSR. The higher preoperative scores showed significant p-values for anxiety/depression (p:0
05) and internalising (p:0
05) on the YSR scale (Table 1). The mean values from the scores of the psychometric instruments did not show any pathological tendencies (Achenbach & Rescorla 2001, Broberg et al. 2001), but some individuals in the study sample had high scores. Two of the adolescent patients had high scores throughout, or slightly above mean values for a normative sample (Broberg et al. 2001). Linear regression (Table 2) was used for analysing correlations between postoperative pain (dependent variable) and preoperative instrument measurements one by one. The level of pain correlated significantly with preoperative anger (p:0
02), social problems (p:0
01) and attention problems (p:0
05) (Table 2). Linear regression was also used to test scores from follow-up measurements made with the instruments against the level of postoperative pain. Each domain from the

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A-C Rullander et al. Table 1 Descriptive measures (mean and standard deviation) for the different scales, preoperatively and at follow-up

Trauma Symptom Checklist for Children – Alternative

Youth Self-Report

n:28

Preoperative values Mean (St Dev)

Follow-up values Mean (St Dev)

p-Value*

Anxiety Dissociation Anger Depression PTS-symptoms Anxiety/depression Withdrawn/depression Somatic complaints Social problems Thought problems Attention problems Rule-breaking behaviour Aggressive behaviour Internalising Externalising PTS-symptoms

4
71 4
57 3
00 3
00 5
96 5
39 3
00 3
79 2
79 3
86 5
04 3
96 6
61 12
18 10
57 7
71

3
75 4
50 2
25 2
93 5
53 4
11 2
67 3
04 2
43 3
29 5
21 3
82 6
43 9
82 10
25 6
64

0
07 0
88 0
07 0
86 0
48 0
05 0
42 0
10 0
28 0
22 0
70 0
79 0
75 0
05 0
71 0
06

(2
93) (3
10) (2
33) (2
42) (3
43) (3
49) (2
16) (3
17) (1
89) (2
88) (3
10) (1
93) (5
52) (6
74) (4
97 (3
53)

(2
24) (2
63) (2
40) (1
99) (3
79) (2
91) (1
54) (2
87) (1
83) (2
91) (3
09) (2
82) (2
99) (5
60) (4
64) (2
74)

*Paired samples t-test. p-Value ≤ 0
05 was considered significant.

Table 2 Simple linear regression analyses investigating correlations between the dependent variable Pain day three and preoperative measurement of the scales as independent variables Pain day 3 (mean = 4
03) St dev 1
62 Independent variable ↓

Preoperative measurement

Trauma Symptom Checklist for Children – Alternative

Anxiety Dissociation Anger Depression PTS-symptoms Anxiety/depression Withdrawn/depression Somatic complaints Social problems Thought problems Attention problems Rule-breaking behaviour Aggressive behaviour Internalising Externalising PTS-symptoms

Youth Self-Report

Table 3 Simple linear regression analyses investigating correlations between postoperative measurements of the scales used as different dependent variables and Pain day three used as an independent variable

p-Value

St B-coeff

Dependent variables ↓

Six-month follow-up measurement

0
40 0
39 0
02 0
07 0
20 0
10 0
49 0
25 0
01 0
08 0
05 0
15 0
33 0
11 0
21 0
06

0
16 0
16 0
42 0
34 0
25 0
32 0
13 0
23 0
48 0
34 0
37 0
28 0
19 0
31 0
24 0
36

Trauma Symptom Checklist for Children – Alternative

Anxiety Dissociation Anger Depression PTS-symptoms Anxiety/depression Withdrawn/depression Somatic complaints Social problems Thought problems Attention problems Rule-breaking behaviour Aggressive behaviour Internalising Externalising PTS-symptoms

Youth Self-Report

p-Value ≤ 0
05 was considered significant.

instruments was defined as a dependent variable and tested against the level of postoperative pain. The level of pain correlated significantly with anxiety (p:0
03) in TSCC-A, and with social problems (p:0
01) and attention problems (p:0
04) in YSR (Table 3).

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Postop pain day 3 p-Value

St B-coeff

0
03 0
13 0
19 0
47 0
35 0
18 0
82 0
53 0
01 0
14 0
04 0
29

0
42 0
31 0
27 0
15 0
19 0
27 0
05 0
13 0
54 0
30 0
41 0
22

0
89 0
29 0
45 0
52

0
03 0
22 0
16 0
13

Discussion The aim of this study was to describe stress symptoms among adolescents before and after scoliosis surgery, and to explore correlations with postoperative pain. Main findings were that the studied adolescents scored higher © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Original article

stress symptoms before than after surgery, that levels of stress symptoms before surgery correlate positively with postoperative pain on day three, and that postoperative pain on day three correlates positively with stress symptoms six to eight months after surgery. The first hypothesis was that preoperative stress symptoms correlate with higher levels of stress symptoms at the six-month follow-up. This hypothesis was not supported by the findings in the study. In a study on knee surgery patients premedication addressed to decrease preoperative anxiety had positive effects on both postoperative pain levels and functional recovery for two days after surgery, although the pharmacological half-life of the premedication drug was exceeded by far (Menigaux et al. 2005). However, in the present study there was no evidence that there is a linear correlation between preoperative stress, postoperative pain and stress symptoms at the six-month follow-up. In a review, Tones and colleagues (Tones et al. 2006) found that AIS patients may exhibit poorer psychosocial functioning, body image and health-related quality of life than their healthy peers. Our findings that the adolescent patients scored higher in the anxiety/depression and internalising domain preoperatively than postoperatively may be in line with Tones’ study. AIS patients tend to internalise problems which could have a negative impact on stress symptoms before surgery. The second hypothesis was that preoperative stress symptoms correlate with postoperative pain on day three, and this hypothesis was supported by the findings in the study. Kleiman et al. (2011) found that ‘fear of pain or somatic sensations’ was a fundamental factor in the experience of pain, and included aspects such as catastrophising, anxiety and anxiety sensitivity (Kleiman et al. 2011). There are studies that support the finding that preoperative stress symptoms correlate with the postoperative outcome, particularly the level of postoperative pain (Vaughn et al. 2007). In accordance with Kleiman et al. (2011), the sample in the present study scored higher before surgery in the anxiety domain. It is reasonable to assume that Kleiman’s theory that ‘fears of pain or somatic sensations’ play an important role in the experience of pain which applies to our assumption that preoperative stress correlate with postoperative pain. Adolescent patients tend not to report anxiety spontaneously (Fortier et al. 2011). If nurses, as a matter of routine, asked the patients to self-measure anxiety and/or fear with VAS they would have an opportunity to take action and intervene to reduce stress and fear preoperatively (Abend et al. 2014). In the present study, there was no significant association between scores on the TSCC-A and YSR instruments of preoperative anxiety and postoperative pain although anger, social problems and attention problems © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Stress among adolescents, scoliosis surgery

showed significant associations with postoperative pain. This can be compared with Stoddard and colleagues (Stoddard et al. 2014) who found associations between anxiety, irritability and mood disorders (Stoddard et al. 2014). One might assume that feeling stress in general before major surgery causes specific stress symptoms such as anger, social problems and attention problems, and further that adolescents with high levels of anger, social problems and attention problems might be at risk of increased feelings of stress before major surgery. The symptoms caused by stress before surgery could also be explained by adolescents having symptoms of adjustment disorder (American Psychiatric Association, 2013). Adjustment disorder is a condition caused by one or several stressors, and can lead to emotional and/or behavioural disturbances lasting for up to six months (American Psychiatric Association, 2013). Preoperatively, the YSR domain of social problems was positively correlated with postoperative pain. Items in the domain include dependency, loneliness, not getting along with family/peers, jealousy, being teased, not being liked, being clumsy, being argumentative, difficulties concentrating, feeling nervous, feeling fearful, feeling sad and withdrawn, etc. These are items which are probably influenced by preoperative stress in general. This may also be the case with items in the Internalising behaviour domain, which would be in line with other studies showing that preoperative worries are expressed in various ways (Fortier et al. 2011), and can be a risk factor for developing adjustment disorder (American Psychiatric Association 2013). A fearful temperament is related to the outcome and the level of experienced postoperative pain. Most adolescents going through scoliosis surgery are girls, and often between 12–16 years old. According to a study by Broberg et al. (2001) in a Swedish context, girls tend to score higher than boys in many problem-oriented domains in the YSR. In their study, adolescent girls scored significantly higher than boys in a normative data sample, especially concerning anxiety, depression and internalising problems (Broberg et al. 2001). This is something to take into account when preparing for major surgery. The third hypothesis, about postoperative pain on day three correlates with the level of stress symptoms at the sixmonth follow-up, was supported. Postoperative pain significantly correlates with anxiety, social problems and attention problems in the follow-up measurement. Page and colleagues (Page et al. 2013) showed in a study that anxiety sensitivity is a significant predictor for paediatric postsurgical pain between six months to one year after surgery. Another study, by Dimova and colleagues, showed an immediate alteration of short-lasting pain-related vigilance,

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catastrophising and anxiety due to major acute pain (Dimova et al. 2013). Risk factors for unfavourable surgical outcome were duration of surgery and high levels of acute postoperative pain. Peters and colleagues (Peters et al. 2007) studied 625 patients and found that surgery lasting longer than three hours was a risk factor for increased pain, increased risk of functional limitations, negative effects on recovery and negative effects on quality of life at the sixmonth follow-up after surgery. They also found that preoperative fear of surgery affected the outcome and that fear of long-time consequences of surgery was associated with more pain. With these results in mind, one can understand that AIS patients may be at risk of negative psychological outcomes during the recovery period, as many of them feel stress before surgery, as the duration of scoliosis surgery exceeds six hours and as they often experience high levels of postoperative pain. The findings from the present study make it reasonable to assume that levels of postoperative pain would be lower with a preoperative intervention to reduce stress-related symptoms. Nurses in perioperative care need to be trained in stress-reducing techniques such as cognitive-behavioural interventions, coping techniques, adolescent psychology and interview techniques (LaMontagne et al. 2003). Interviewing the patient preoperatively increases the possibility of getting a deeper understanding of the individual personality, and thus to individualise information and preoperative preparation. Preoperative interventions intended to reinforce the adolescents’ own coping strategies (LaMontagne et al. 2003) would help them reduce stress and cope with postoperative pain. Nursing assessments of preoperative stress symptoms should be a part of perioperative care. VAS self-measurement can be used to estimate any presence of preoperative stress as well as its level. VAS is commonly used for pain self-measurement and is easy to understand and interpret.

Methods discussion Limitations The small sample in this study is a limitation as a large sample might have enriched the results, furthermore covariates such as gender and socio-demographic parameters were not possible to calculate in this small sample. With specially trained nurses carrying out the pain measurements, there might have been less missing data. However, this study gives the reader a picture of the studied adolescents’ experience of undergoing scoliosis surgery today, at a spine centre in Sweden. The preoperative ratings took place on admission day as the patients in the study had preoperative information about what to expect during and after the hospital visit.

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The preoperative measurement may therefore have been influenced by that information and by preoperative stress which can occur prior to surgery, possibly starting already the day surgery date is set. There are several reasons for the missing data in the postoperative VAS ratings. These include the nurse in charge having too many things to do, nurses forgetting the study protocol and misunderstandings. Ethical considerations The adolescents in the study were asked to complete the YSR and TSCC-A questionnaires and to answer questions in the K-SADS structured interview, which are all wellestablished instruments. All the studied adolescents, as well as their guardians, gave their written consent. In some cases, recalling stressful events and earlier experiences may have been distressing, but verbalising earlier experiences and stressful memories can also have a therapeutic effect. In the process of data collection, it was the same person (A-C.R) who met the studied adolescents both pre -and postoperatively. The fact that they met the same person on both occasions may have had a calming effect on the adolescents in their postoperative ratings. All the studied adolescents were offered psychological assistance from a psychologist at the spine centre if needed.

Conclusion The results from this sample suggest that the levels of stress symptoms before major surgery correlate with levels of postoperative pain, further that the level of postoperative pain, in its turn, correlates with the level of anxiety during the recovery period. Preoperative anger, social problems and attention problems correlate with the level of postoperative pain in AIS patients. Preoperative interventions for detecting and reducing stress-related symptoms, and interventions to help the adolescent patient cope with postoperative pain, could increase the quality of perioperative care, together with individual care plans and improved pain management.

Relevance to clinical practice Educational interventions concerning pain measurement and pain assessment might improve attitudes to pain and postoperative pain management and can also improve attitudes to pain and pain management. These are interventions that could help optimise perioperative care in adolescents undergoing major surgery, and levels of stress and stress symptoms from postoperative pain could be reduced during the patient’s recovery period. © 2016 John Wiley & Sons Ltd Journal of Clinical Nursing, 25, 1086–1094

Original article

Stress among adolescents, scoliosis surgery

Contributions

Funding

Study design: ACR, BH, VL; Data collection: ACR; Data analysis: ACR, MLi, MLu, VL; Manuscript preparation: ACR, VL, MLu.

Jerring Foundation, the Oskar Foundation, the Mayflower Charity Foundation for Children, the Solstickan Foundation and the Kempe Foundation.

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