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Journal of Neuroscience Nursing:
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Patient Expectations of Quality of Life Following Lumbar Spinal Surgery

Saban, Karen L.; Penckofer, Sue M.

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Author Information

Questions or comments about this article may be directed to Karen L. Saban, PhD RN APN CNRN, at KSaban@luc.edu. She is an assistant professor at the Marcella Niehoff School of Nursing at Loyola University, Chicago, IL.

Sue M. Penckofer, PhD RN, is a professor at the Marcella Niehoff School of Nursing at Loyola University, Chicago, IL.

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Abstract

Spinal surgery is one of the most frequently performed surgeries in the United States. In 2003, almost 450,000 cases were performed for problems related to lumbar herniated disks, stenosis, and degenerative changes. It has been reported that patient expectations play a role in perceived quality of life (QOL). Because surgery is frequently a last resort for patients with spinal disease, patients often have high expectations of their outcomes of surgery. Patient expectations of surgical outcome may play an important role in recovery and perceived QOL. The research on patient expectations of surgery in the spinal surgery literature is limited. This study examined the relationships between perceived QOL, expectations, and level of optimism. A sample of 57 patients completed questionnaires designed to measure perceived QOL, expectations, and optimism before lumbar spinal surgery and 3 months after surgery. The major findings of the study are as follows: (a) patients with higher degrees of optimism reported better perceived QOL; (b) increased fulfillment of expectations was associated with better postoperative QOL; and (c) both expectations and level of optimism were significant predictors of postoperative QOL. These findings will help nurses better understand how patients' expectations can affect their perceived QOL while recovering from lumbar spinal surgery.

Low back pain is the second most common neurological problem in the United States. Almost 450,000 lumbar spinal surgeries for herniated disks, stenosis, and degenerative changes were performed in the United States in 2003 (Agency for Healthcare Research and Quality, 2006). The term lumbar spinal surgery, for the purposes of this article, includes procedures such as microdiskectomy, laminotomy, and laminectomy, which are used for a variety of nonmalignant‐related diseases of the lumbar spine. The most common diagnoses are herniated disk and spinal stenosis. Patient perceived quality of life (QOL) has become an increasingly common health outcome indicator in the spinal surgical population. However, study data disagrees about how QOL is defined and measured.

Calman (1984) hypothesized that perceived QOL is the gap between one's expectations and actual experience (Fig 1). He believed that patients would have a high QOL if their expectations were matched and fulfilled by their experiences. The opposite is also true: patients have a low QOL if their experiences do not meet their expectations. Patient expectations of surgical outcome may be an important consideration in spinal surgery patients because patients often view surgery as a cure for their symptoms (DeBerard, 1998). More often than not, however, surgery only reduces the severity of symptoms, but does not eliminate them (DeBerard). Knowledge of what patients expect their postoperative QOL to be may help clinicians identify potential areas of patient dissatisfaction with their recovery process, which would allow clinicians to intervene appropriately.

Fig 1
Fig 1
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The aims of this study were (a) to describe preoperative and postoperative perceived QOL, patient expectations, and level of optimism; (b) to examine the relationships between perceived QOL, patient expectations, and level of optimism; and (c) to determine the extent to which patient expectations of postoperative QOL and level of optimism predict postoperative QOL 3 months after lumbar spinal surgery.

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Review of Relevant Literature

Patient Expectations and Postoperative Lumbar Spine Outcomes

Three studies were found that evaluated the relationship between patient expectations and QOL in the spinal surgical population. In these studies, QOL was operationalized as either perceived health or functional status.

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Patient Expectations and Perceived Health Status

In a retrospective study, DeBerard (1998) studied worker's compensation patients from Utah who had undergone lumbar spinal fusions at least 2 years before the study. Of the 203 patients eligible, 144 (71%) participated in the study. DeBerard found that 46% of patients felt that their back or leg pain was worse than what they had expected following surgery, and 42% felt that their QOL had not changed as a result of lumbar fusion surgery. DeBerard suggested that patients' expectations for a positive outcome may be unrealistic, and “that can result in patients being disappointed and unsatisfied following surgery” (p.104): he found that many patients felt that lumbar surgery “would completely resolve their pain and allow them to be 'good as new' in terms of functional abilities” (p.104). The limitations of this study were the retrospective nature of the research and possible respondent burden resulting from the detailed interviews being done by telephone. In addition, optimism, which has been suggested to influence expectations and perceived QOL (Scheier & Carver, 1987), was not measured.

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Patient Expectations and Functional Outcomes

Lutz et al. (1999) measured patient expectations and general and specific functional outcomes preoperatively in 273 patients who were undergoing lumbar diskectomy. Their study compared the expectations of patients with those of their physicians. They reported that patients who expected shorter recovery times postoperatively were more pleased with their outcomes 12 months postoperatively than patients who expected longer recovery times. Patients who expected a shorter recovery time did not have significantly different scores on the functional measurements compared to patients who had longer recovery expectations; however, actual recovery times were not reported. Overall, physicians expected patients to do better after surgery than they actually did. These results suggest that patients who expected shorter recovery times, although having similar functional measurements than patients who expected longer recovery times, may have been generally more optimistic and therefore more satisfied with their results.

Iversen, Daltroy, Fossel, and Katz (1998) evaluated the relationship between expectations of pain and function and postoperative outcomes in patients undergoing surgery for lumbar stenosis. Iversen and colleagues used a convenience sample (n = 305) and followed patients preoperatively and 6 months postoperatively. They found that patients who had a high number of expectations had somewhat better outcomes than patients who had a low‐to‐moderate number of expectations. Unfortunately, the expectations were measured as “yes” or “no,” and the degree to which expectations were fulfilled was not assessed. The number of expectations a patient has may not be as important as the degree to which they are fulfilled.

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Patient Expectations in Other Populations

Although only three studies were found that measured expectation in relation to QOL in the spinal surgery population, overall, the literature suggests that expectations do play a significant role in influencing a number of outcome variables. Many studies were found in the medical literature that evaluated how patient expectations are related to other patient outcomes, such as pain (Bayer, Coverdale, Chiang, & Bangs, 1998; Cole, Mondloch, Hogg‐Johnson, & Early Claimant Cohort Prognostic Modelling Group, 2002; Dawson et al., 2002; Galer, Schwartz, & Turner, 1997), return to work (Cole et al.), and anticipatory nausea from chemotherapy (Hickok, Roscoe, & Morrow, 2001).

In a systematic review of the data examining the relationship between patients' recovery expectations and their health outcomes, only 16 out of 1,243 references (6.58%) provided at least moderate quality evidence of a relationship between recovery expectations and health outcomes (Mondloch, Cole, & Frank, 2001). Of these 16 studies, 15 were observational; a single study was experimental. The most commonly studied disease was myocardial infarction, followed by cardiac surgery, chronic pain, and psychiatric conditions. Mondloch et al. reported that only two studies shared a common question about the measurement of patient expectation, which was anticipation of postoperative pain on a scale of not at all to extremely; however, both studies had been completed by the same researchers. Mondloch et al. concluded that patient expectations are an important consideration in measuring health outcomes. However, reliable and valid tools should be developed to measure patients' expectations of treatment outcome.

Even though several approaches have been used to study expectations and QOL, the studies were limited because of a lack of valid and reliable tools for measuring expectations. Although these studies used well‐accepted measurement tools to gauge QOL, few studies evaluated the influence of patient expectations on perceived QOL. Researchers should clarify and specify the types of expectations measured. For instance, are they measuring patient expectations of QOL, functional status, or satisfaction with clinical outcome?

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Patient Expectations and Optimism

The personality trait of optimism was widely addressed in the healthcare literature as a factor that affected perceived health outcomes. However, no studies that considered optimism in patients undergoing lumbar spinal surgery were found. A number of the references in the psychology literature considered expectancy outcomes to be closely related to optimism (Harkapaa, Jarvikoski, & Estlander, 1996; Scheier & Carver, 1987; Scheier, Matthews, Owens, & Magovern, 1989). In this literature, optimism was considered a generalized outcome expectancy and different from expectation in that optimism was considered a trait (rather than a characteristic) and was more stable than expectations. In addition, optimism referred to general rather than specific expectations. A number of studies demonstrated that optimism predicted better outcomes in coronary bypass patients (Corace, 2000; Morris, 1998; Scheier et al.), cardiac rehabilitation patients (Glazer, Emery, Frid, & Banyasz, 2002), and heart transplant patients (Leedham, Meyerowitz, Muirhead, & Frist, 1995).

In summary, the literature suggests that both expectations and level of optimism influence patient treatment outcomes. However, few studies considered how patient expectations of spinal surgery may be related to postoperative perceived QOL. Our study considered patient expectations of their postoperative perceived QOL and their level of optimism. Predicted expectations and fulfillment of expectations were measured.

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Methods

Design

Our longitudinal one‐group pretest‐posttest study was part of a larger study that examined the relationships between changes in pain, mood, optimism, social support, functional status, perceived health status, patient expectations, and perceived QOL of patients undergoing lumbar spinal surgery (Saban, 2006). This article focuses on the relationships between perceived QOL, patient expectations, and optimism.

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Sample

The inclusion criteria were patients who were undergoing elective lumbar surgery for the first time for degenerative changes, herniated disks, or both, and who were 18 years of age or older with the ability to read and write English. Patients undergoing lumbar surgery for these conditions were chosen because they were expected to make at least some symptom and functional improvements within 3 months postoperatively. Patients with cancer, spinal cord injury, cauda equina, and more than two levels of fusion were excluded from the study in order to control for significantly different recovery trajectories. Both genders and different ethnic groups were included in the study based upon meeting the inclusion criteria.

Of the 94 patients who were approached for participation in the study, 73 completed the preoperative questionnaire. Of those, 57 (78%) completed the postoperative follow‐up questionnaire. Patients (n = 57) averaged 53.4 years of age with age ranging from 21 to 84 years (Table 1). Slightly more women (52.6%) than men (47.4%) participated in the study. Most participants were married (70.2%). The majority of patients were white (89.5%) and had at least some college education. Only 19.3% of patients were working full‐time without any restrictions. A total of 36.8% of patients indicated preoperatively that they had decreased their work hours or were not able to work because of their back problem. Of these patients, 14% were receiving disability because of their back problem. Most participants were professionals (33.3%), secretaries or clerks (12.3%), or retired (12.3%). The most common surgical procedures were lumbar microdiskectomy (59.7%) and lumbar fusion (22.8%). Most patients (71.9%) had only one spinal segment operated on and the majority (80.7%) did not require instrumentation.

Table 1
Table 1
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Procedure

The study was approved by the university and hospital institutional review boards. Using a consecutive convenience sample, the researchers conducted the study at five Midwestern hospitals. Four sites were community‐based hospitals, and one site was a university teaching hospital. Surgical technique and procedures were considered similar among these sites. A 1‐page information sheet inviting patients who met the inclusion criteria to participate in the study was made available in waiting rooms and exam rooms. In addition, potential participants were identified by the surgeons and clinic nurses.

Potential participants were informed of the purpose, risk, and benefits of the study. All participants were informed of their right to withdraw from the study at anytime and given a copy of their signed consent form. After researchers obtained informed consent, participants completed a preoperative questionnaire booklet 2‐14 days before surgery and then a postoperative questionnaire booklet approximately 3 months after surgery. A phone call was made 1‐2 weeks after the postoperative questionnaires were mailed to patients to remind them to complete the questionnaires.

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Instruments

Questionnaires included written tools to measure patient demographics, perceived QOL, expectations, and level of optimism. Demographic data included information such as patient age, gender, marital status, race, and work status.

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Perceived Quality of Life

Perceived QOL was measured using an overall QOL index score similar to that of the Schedule of the Evaluation of the Individual Quality of Life‐Direct Weights (SEIQoL‐DW; Browne, O'Boyle, McGee, McDonald, & Joyce, 1997; Hickey et al., 1996). This measurement supported Ferrans's (1990) definition of QOL as “a person's sense of well‐being that stems from satisfaction or dissatisfaction with areas of life that are important to him/her” (p.15). Unlike many standardized QOL instruments, the SEIQoL‐DW allows the responders to choose the most important areas in life critical to his or her individual QOL (Browne et al.).

The SEIQoL‐DW is derived from the full Schedule for the Evaluation of the Individual Quality of Life (SEIQoL), which uses judgment analysis to quantify various factors that contribute to the overall QOL score. In our study, QOL was measured in a manner similar to the SEIQoL‐DW. The original SEIQoL‐DW has three steps. Subjects are asked to (1) identify the five most important domains (cues) that constitute their QOL; (2) weight the importance of each domain relative to the others by assigning a percentage to each domain so that the sum of all five domains equals 100%; and (3) rate their level of satisfaction with each of the five domains on a 0‐100 mm visual analog scale (VAS). The original SEIQoL‐DW requires the presence of an investigator to assist the patient in completing the tool. For patient ease and to allow patients to complete the tool in their homes postoperatively, participants (1) identified the five most important domains that constituted their QOL; (2) rated each domain's level of importance on a 0‐10 Likert scale (0 = not important to 10 = most important) rather than assigning a percentage to each domain; and (3) rated satisfaction for each domain on a 0‐10 Likert scale (0 = not satisfied to 10 = very satisfied). To generate a score for each of the five domains identified by the patient, the satisfaction value and importance value for each respective domain were multiplied together. These identified domain scores were then averaged to provide one score indicative of perceived QOL. The mean QOL score ranged from 0 to 100 with a higher score indicating better QOL.

Expectation was defined as a belief about the probability of the occurrence of something in the future that incorporates one's values and that may change over time.

The original SEIQoL, which estimates reliability and validity through judgment analysis, has been found to have satisfactory psychometric properties (O'Boyle, 1992, 1994; Waldron, O'Boyle, Kearney, Moriarty, & Carney, 1999). The SEIQoL‐DW has yielded validity and reliability results similar to the SEIQoL, even though the tools are not considered to be interchangeable (Browne et al., 1997). Because the domains are not interrelated, test‐retest was performed between the preoperative scores and postoperative scores. In our study, intraclass correlations ranged from 0.43 to 0.71. These reliabilities were low most likely because of the 3‐month period between tests and the change in health because of the surgery.

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Patient Expectations of Quality of Life

Iversen et al. (1998) define expectations as values patients assign to particular outcomes, but Jones (1977) describes expectations as the perceived probability of an outcome. For this study, both the concepts of value and probability were used. Expectation was defined as a belief about the probability of the occurrence of something in the future that incorporates one's values and that may change over time.

No standardized tools were available to measure patient expectations of QOL. In our study, patient expectations were measured in a related manner to the SEIQoL‐DW in which both predicted and fulfilled expectations were compared. A similar modification of the SEIQoL‐DW was used in a study that considered the relationship between QOL and depression (Moore, Hofer, McGee, & Ring, 2005). To measure predicted expectations, patients were asked to preoperatively rate what they expected their level of satisfaction to be with each of the five QOL domains 3 months after surgery. Expectation scores were obtained by multiplying the level of importance (0 to 10) by the level of expected satisfaction (0 to 10) for each domain and then calculating the mean of the five domain scores, which resulted in a mean total weighted score ranging from 0 to 100. This method of measuring expectation is consistent with the definition of expectation that it is based on the probability of something in the future that incorporates one's values (Kravitz et al., 1996).

Fulfillment of expectations of QOL was measured by asking patients to postoperatively rate their level of satisfaction with each of the five domains that they had identified preoperatively. Predicted minus fulfilled expectations was calculated by comparing the degree of fulfillment of each expectation to predicted levels of expectations. For example, a patient may have preoperatively predicted that his mean postoperative weighted QOL would be an 80 (on a scale of 0 to 100 with 0 being the lowest QOL and 100 being the highest QOL). Postoperatively, if the patient rated his QOL as a 60, predicted minus fulfilled expectations for the domain of health would be a 20, indicating that expectations of postoperative QOL were not met. In other words, in this example, the patient had a lower postoperative QOL than he had expected.

For our study, test‐retest reliability based on intraclass correlations between preoperative (predicted expectations) and postoperative (fulfilled expectations) measurements ranged from 0.37 to 0.76. These reliabilities were low most likely because of a change in patients' health after surgery, as well as a 3‐month period between test administrations.

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Optimism

Optimism was measured using the Life Orientation Test‐Revised (LOT‐R; Scheier, Carver, & Bridges, 1994). The LOT‐R is a minor modification of the LOT (Scheier & Carver, 1985). The LOT‐R consists of 10 questions, each with 5‐point Likert scales that count toward the overall dispositional score. Possible total score ranges from 0 to 24 with 0 being a very low level of optimism to 24 being a high level of optimism. Scheier et al. (1994) report a norm score of 15.16 from a sample of healthy men and women. Cronbach's alpha of 0.78 and a test‐retest correlation of 0.68 were described, which indicates a reliable tool. For our study, preoperatively the Cronbach's alpha was 0.81 and postoperatively 0.85, which demonstrates excellent reliability.

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Data Analysis

Data were analyzed with SPSS 14.0 (SPSS Inc., Chicago, IL) software package. Descriptive statistics and dependent t tests were used to describe and compare differences between preoperative and postoperative variables. Pearson r correlations were used to examine relationships between variables. Linear regression analysis was used to determine predictors of postoperative QOL.

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Findings

Quality of Life

To measure QOL, 57 patients each nominated five domains important to their QOL at both the preoperative and postoperative data collection time points, which resulted in a total of 285 possible cues for each time period. Individual domains, in their original form, were sorted and categorized by content. Data from each domain were placed into 12 overall categories (Fig. 2).

Fig 2
Fig 2
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The overall frequency of domain nominations was similar at each time point. Family (preoperative, 22.8%; postoperative, 21.4%) and health (18.2%; 16.8%) were the two most frequently nominated domains at both the preoperative and postoperative time points. Social life, finances, work, leisure, and religion and spirituality were the next most commonly nominated domains.

Patients were also asked to rate the importance of each of their domains on a scale of 0 to 10 (0 = not important to 10 = most important). Preoperative importance ratings were negatively skewed (coefficient = ‐.816). The mean importance rating for all domains preoperatively was 8.43 with a range of 0 to 10 and a standard deviation of 1.14 and for all domains postoperatively was 8.48 with a range of 0 to 10 and a standard deviation of 0.929. The overall difference between the overall preoperative and postoperative importance scores was not significant (t [54] = ‐.294, p = .770). However, an analysis of importance ratings for preoperative and postoperative domain categories revealed that importance ratings for social life and leisure were significantly different between the preoperative and postoperative periods (p < .05; Table 2); social life became significantly less important after surgery, and leisure activities became more important after surgery. These changes may have been related to the recovery process.

Table 2
Table 2
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Patients were asked to rate their level of preoperative and postoperative satisfaction with each domain on a scale of 0 to 10 (0 = not satisfied at all and 10 = very satisfied; Table 3). The overall preoperative satisfaction level mean for all domains was 6.31 (range = 0‐10, SD = 2.80) and the overall postoperative satisfaction mean was slightly higher at 6.74 (range = 0‐10, SD = 2.49). However, the difference between the overall preoperative and postoperative satisfaction scores was not significant (t [52] = ‐1.812, p = .076). The differences between the preoperative and postoperative level of satisfaction with the domains of health (t [44] = ‐3.92, p < .01) and social life (t [30] = 2.07, p < .05) were significant (Table 3). As expected, level of satisfaction with health significantly improved after surgery. However, satisfaction with social life significantly decreased after surgery. Reasons for this decrease may have included patients having had decreased social activities during their recovery from surgery.

Table 3
Table 3
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In addition, overall mean QOL scores were calculated. The overall QOL mean scores on a scale of 0 to 100 (0 = the worst QOL and 100 = the best QOL) preoperatively was 53.98 and postoperatively 58.84. Although the postoperative QOL mean was improved from the preoperative measurement, the difference was not significant (t [56] = ‐1.955, p = .056). However, given that it approached the .05 level of significance, this result suggests a trend toward improvement.

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Patient Expectations of QOL

The mean for preoperative expectations of QOL was 67.05 on a scale of 0 to 100 (0 = lowest expectations and 100 = highest expectations) indicating that patients had fairly high expectations of their postoperative QOL. At the postoperative time point, patients were asked to rate their fulfillment (level of satisfaction) with each of the QOL domains that they had nominated at the preoperative point (the investigator provided them with a list of their preoperative QOL domains). The postoperative fulfillment of expectations mean score (60.17) was lower than the preoperative expectations mean score (67.05). This difference was significant (t [56] = 3.067, p < .01) and indicated that patients' expectations before surgery were significantly higher than their fulfilled expectations after surgery.

The changes between predicted expectations and fulfilled expectations for the satisfaction ratings for each QOL domain category were also analyzed (Table 4). Results revealed that fulfillment of expectations were significantly lower than expected for the domains of health (t [45] = 2.62, p < .05) and social life (t [29] = 2.58, p < .05). The only domain that exceeded predicted expectations was finances, but that was not statistically significant.

Table 4
Table 4
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Optimism

Overall, participants reported a moderate level of optimism both preoperatively (M = 14.9) and postoperatively (M = 14.6). Levels of optimism were slightly lower than the reported norm of 15.16 which had been taken from a sample of healthy men and women (Scheier et al., 1994). Lower optimism levels in our study may have been because back pain was chronic for many of the study participants. Levels of optimism did not change significantly from the preoperative to the postoperative points (t [56] = .716, p = .477). These findings are consistent with the view that optimism is a stable personality trait (Scheier et al., 1994).

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Relationships between QOL, Expectations, and Optimism

The relationships between the variables of QOL, patient expectations, and optimism were explored using Pearson product‐moment correlation coefficients. Change in QOL scores between the preoperative and postoperative time points was negatively associated with the difference between predicted expectations and fulfilled expectations (r = ‐.327, p < .01). In other words, participants whose expectations were fulfilled had the most improvement in their postoperative QOL. Interestingly, level of optimism and expectations were not correlated. Patients with high levels of optimism did not necessarily have higher expectations of their postoperative QOL.

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Predictors of Postoperative QOL

Optimism and the difference between fulfilled and predicted expectations both significantly predicted postoperative QOL when entered into a linear regression model. This set of independent variables explained a significant proportion of variance in the postoperative QOL scores (F [2, 53] = 8.31, p = .001). The model accounted for an R‐square of .239 explaining 24% of the variance in postoperative QOL. Examination of individual beta‐coefficients indicated that the variables of optimism (â = .394, p < .01) and difference between predicted and fulfilled expectations (â = .296, p < .05) accounted for statistically significant amounts of variation in postoperative QOL.

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Discussion

Although there was improvement in QOL postoperatively, it was not significant. These findings support Calman's (1984) hypothesis that QOL is the gap between one's expectations and experience. Participants in this study may not have demonstrated improvement in their QOL because their expectations were not met. In addition, a significant difference may not have been found between the two time points because at the time the preoperative questionnaire was administered (about 1‐2 weeks prior to surgery) patients may have already been anticipating an improved QOL. Therefore, they may not have considered their significant pain and functional disabilities in the same light as they would have had they not been anticipating an improvement in their health in the near future. Thus, the preoperative QOL scores may have been higher resulting in a smaller difference between preoperative and postoperative QOL scores.

In general, patients predicted their overall QOL to be significantly higher than it actually was 3 months after surgery (preoperative expectation M = 67.05, postoperative fulfillment M = 60.17, F = 3.067, p < .003). In other words, their expectations of how their lives would be 3 months after surgery were not met. Overall, participants reported a moderate level of optimism both preoperatively (M = 14.9) and postoperatively (M = ‐14.6). The total score also did not change significantly between the preoperative and postoperative time points (t [54] = .716, p = .447). These findings are consistent with the view that optimism and pessimism are stable personality traits (Scheier et al., 1994).

Level of optimism significantly predicted postoperative QOL. In addition, patients whose fulfilled expectations were closest to or higher than their predicted expectations were more satisfied with their postoperative QOL.

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Limitations

The study had several limitations. The most significant limitation was the small sample size (N = 57). A larger sample size may have demonstrated significant improvement in QOL. The second limitation was that the investigator had to develop a measurement based on the SEIQoL‐DW to include patient ratings of expectations of their postoperative satisfaction with their five domains of QOL identified preoperatively because no standardized tool existed. This study was the first time expectations of QOL were measured in this manner. Although the method of asking patients to predict their level of satisfaction with the QOL domains that they nominated as being important to them was theoretically sound (based upon an individualistic view of QOL), these results should be interpreted as only preliminary. In addition, the modifications of the SEIQoL‐DW for this study did not allow for patients to assign a percentage value to indicate the importance of each of the five domains. Using the 0‐10 Likert scale to rate the importance of the five domains (Table 2) may have generated somewhat different results than the original SEIQoL‐DW. However, the findings from the current study suggest that the revised methodology generated domains (family, health, and relationships) that have been reported as important by other investigators (Ring, Höfer, Heuston, Harris, & O'Boyle, 2005; Willener & Hantikainen, 2005). Also, because patients assigned values of importance for the domains that were fairly high (Table 2), it suggests that they may have had difficulty identifying one domain as more important than another. Previous research does suggest that patients have difficulty discriminating the importance of domains in QOL (Russell & Hubley, 2005; Trauer & Mackinnon, 2001; Wettergren, Björkholm, & Languis‐Eklöf, 2005).

Another limitation was that the study had no control group. Individuals may predict their future QOL to be higher regardless of whether they expect upcoming medical treatment or positive change in their lives. The use of a control group would enhance the interpretation of findings related to expectations. In addition, future studies measuring expectations should consider using a more specific measure of expectations, such as expectations of future functional and pain status.

Lastly, the inclusion of various types of lumbar surgical procedures for herniated disks, degenerative changes, and spinal stenosis was a limitation. Age differences as well as other variables among these groups may have influenced findings. A more homogeneous group would have allowed for better interpretation of findings.

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Implications

Despite its limitations, the findings of this study contribute to the body of neuroscience nursing knowledge in several ways. It is the first known study that considered individualized QOL, expectations, and optimism in the spinal surgery population. In addition, even though nurses and physicians educate their patients about what to expect in terms of postoperative outcomes, these explanations may not be detailed enough or account for the patients' unique circumstances. Patients in this study predicted that their postoperative QOL would be much better than it actually was 3 months after surgery. Patients whose fulfilled expectations were closest to or higher than their predicted expectations were more satisfied with their postoperative QOL. Discussing patient expectations of surgery both before surgery, and perhaps even more importantly, during the recovery period may allow patients to develop and maintain realistic goals for their postoperative course. Furthermore, discussing the degree of fulfillment of patient expectations postoperatively could help nurses identify potential areas of patient dissatisfaction. This would allow them to better work with patients to realign their expectations.

Lastly, optimism played a role in how patients evaluated their postoperative QOL. Identification of levels of optimism, perhaps by administering the LOT‐R before surgery may help clinicians identify patients at risk for poor outcomes. More research about optimism in this patient population is needed.

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Summary

Perceived quality of life is an important outcome measure in spinal surgery patients. This study identified two predictors of postoperative quality of life: optimism and patient expectations. A better understanding of how optimism and expectations influence perceived QOL will help neuroscience nurses better prepare patients for back surgery as well as assist nurses in managing patient postoperative expectations.

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Acknowledgment

The authors would like to kindly acknowledge the Neuroscience Nursing Foundation and the Chicago Institute of Neurosurgery and Neuroresearch for their financial support of this study.

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