Surgery is one of the situations that can cause stress and anxiety in patients (1). Surgery is a deliberate change in the anatomical structures of the body for the purpose of creating comfort, alleviating or eliminating pathological processes, and repairing traumatic injuries (2). Surgery is a stressful experience for patients and their families due to the physical and psychological stress it causes. The fear of the unknown, loss of control, and potential risk of harm all contribute to this anxiety-inducing situation (3, 4). Several studies demonstrated that physical stress, psychological stress, stress due to hospitalization, self-care stress, and spiritual stress are the main sources of stress experienced by patients who are candidates for various surgery that result in enhancing the risk of complications, morbidity, and mortality (5–11). A situation is stressful when it is perceived by a person as threatening and uncontrollable and that person does not have the necessary resources to face the situation (12). Previous studies indicate that the statistics for anxiety and stress in patients undergoing surgery are significant (13–16); therefore, assessment and appropriate interventions are needed (17–20). The skills that an individual develops throughout their life, particularly cognitive and emotional skills that are acquired when individuals are facing stressful situations, play a crucial role in their ability to manage stress (21).

There are a variety of tools available for assessing stress levels. One commonly used scale is the Perceived Stress Scale (PSS), which measures an individual’s perceived level of stress. The original version of the PSS was developed by Cohen et al. in 1983 and consisted of 14 items (22). PSS10- item and PSS 4- item are shorter forms of the PSS scale. Psychometric properties of the above scale have been done in different countries among the numerous participants including Italian precarious workers (23), Czech general adult population (24), Chinese cardiac patients who smoke (25), patients with Multiple Sclerosis in the USA (26), German adults (27), Arabic Version among women Emeriti students (28), Brazilian pregnant women (29), Chinese adults during the COVID-19 Pandemic (30), Ecuadorian university students (31), Korean patients with chronic diseases (32), and in different languages such as the Swedish (33) and France versions (34).

The 10-item version has been used in most of the studies, and on the other hand, the results of numerous studies also showed that the psychometric properties of PSS-10 are higher than they are in the PSS-14 and PSS-4 (23–26, 35); for this reason, we chose to assess the validity and reliability of the 10-item version in our study. Only one study in Iran assessed the factorial validity of the 14-item version of this scale in cancer patients (36), but psychometric properties have not been thoroughly investigated and the reliability was not reported. Also, two studies conducted in Iran were among different samples (chronic headache and asthmatic patients) (37, 38). Therefore, the purpose of this study was to examine the psychometric properties of Persian versions of the PSS-10 (PSS-10-P) in postoperative patients.

This methodological cross-sectional study was carried out between October to December 2023. Patients from 17 Shahrivar Hospital, Amol, Iran, were recruited for this study.

Perceived stress is commonly defined as the perception of stressful events encountered within a defined timeframe. Given the significant impact of stress on health (49), the primary objective of the current investigation was to assess the psychometric properties of the PSS-10 in Iranian surgical patients. The results of this research revealed that the PSS-10 exhibited acceptable factor structure, validity, and reliability.

The study found that the Persian version of the 10-item Perceived Stress Scale (PSS-10-P) had 10 items divided into two categories: lack of stress management and coping with stress. These two factors explained 83.82% of the variance in stress levels among Iranian surgical patients. In line with the objective of maximizing variance in factor analysis, reported variances of 56.23% (50) and in two other studies reported variances of 56.8% (49) and 61.9% (51).

The first factor of the PSS-10-P was designated as “Lack of stress management”. The term “stress management” is commonly utilized and appears to possess a well-defined definition (52). Inadequate stress management is when someone doesn’t have good strategies to deal with stress, which can harm their physical, mental, and emotional health. Symptoms can include headaches, fatigue, and more. If not managed, it can lead to distress and feeling overwhelmed. Effective stress management involves skills like problem-solving, time management, and relaxation techniques to navigate stress and maintain well-being (53). Interventions aimed at stress management encompass a range of techniques that offer opportunities for personal development (54). The focus on stress management is crucial to safeguard individuals’ physical and emotional well-being, as well as their capacity to function effectively in their daily lives. It is imperative to recognize stress and implement strategies to manage it effectively to mitigate the adverse repercussions it may engender (55). Lack of stress management means not having the right tools to deal with stress, which can have negative impacts on mental and physical health. It can lead to anxiety, depression, physical pain, and overall reduced quality of life. Without proper stress management, individuals may struggle with stressful situations and face long-term consequences on their health and functioning (56). Clinical studies have demonstrated that patients who exhibit a predefined adaptive stress response during surgery tend to experience superior recovery outcomes compared to those who do not (57). The items associated with the first factor underscore the importance for healthcare professionals to identify instances of inadequate stress management in patients. By imparting stress management techniques to patients, healthcare providers can help prevent the detrimental impacts of stress on surgical patients and can facilitate their swift recovery.

The second factor of (PSS-10-P) was denoted as “Coping with stress”. Coping, as defined, refers to the mental strategies and behavioral responses employed to manage stressful situations, whether they originate internally or externally. This term specifically pertains to purposeful, conscious decisions made with the aim of alleviating or enduring stress (58). Also Managing stress involves actively and intentionally addressing challenges that can trigger negative emotions. This includes utilizing strategies such as meditation, counseling, and engaging in hobbies to effectively manage and decrease stress levels. Coping with stress does not entail completely avoiding stress, but rather learning to handle it healthily to enhance overall well-being and resilience (56). The experience of preoperative stress induced by anesthesia and surgery prompts patients to employ coping mechanisms in an endeavor to regain a sense of emotional control. When coping is supported by specific techniques or external assistance, its efficacy may be enhanced (59). Consequently, nurses can play a pivotal role in alleviating the stress experienced by surgical patients by identifying their existing strengths in stress management and augmenting these capabilities through the application of stress coping strategies.

The CFA revealed that the data did not align well with the model, a finding consistent with previous studies (49, 60). Based on the analysis of construct validity and reliability, there is insufficient evidence to justify the utilization of two distinct sub-scales within the current population. The study’s outcomes also indicate that the items on this scale exhibit robust divergent and convergent validity. Divergent validity signifies complete segregation between constructs, while convergent validity is evident when elements of a construct are closely semantically related and account for variance (61).

Furthermore, the internal consistency coefficients of the scale dimensions demonstrate that the items within each factor exhibit substantial internal correlations, aiding in the clarification and measurement of a broader concept. Essentially, the components of each dimension effectively represent and assess a specific concept. Given the existing cross-cultural gap in health outcomes research (50), utilizing the PSS-10-P in the Persian culture with appropriate cultural variables can facilitate the identification of perceived stress among surgical patients and inform necessary interventions to mitigate it.

The EFA results revealed the extraction of two factors, with ten items., which collectively account for 83.82% of the total variance in perceived stress among Iranian surgical patients. The findings affirm the appropriateness of employing the Persian iteration of the PSS-10-P as a dependable and valid instrument for assessing perceived stress in postoperative patients Healthcare professionals can effectively employ the PSS-10-P to educate patients on stress reduction strategies, thereby facilitating quicker post-surgical recovery and minimizing the likelihood of complications.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The Ethics Committee of Mazandaran University of Medical Sciences (Sari, Iran) gave its approval to this study (Ethics code: IR.MAZUMS.REC.1402.599). The participants were given a thorough explanation of the study’s goals and methods, as well as assurances that their participation was entirely voluntary. The researcher gave the scale to the patient to complete by themselves. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

HS: Formal analysis, Supervision, Writing – original draft, Writing – review & editing. ES: Writing – review & editing. EH: Writing – original draft, Writing – review & editing. OK: Writing – original draft, Writing – review & editing. RF: Writing – original draft, Writing – review & editing. PN: Data curation, Writing – original draft.