Original Article Postoperative Pain: Nurses’ Knowledge and Patients’ Experiences Lavonia Francis, DNP, RN, NEA-BC,* and Joyce J. Fitzpatrick, PhD, RN, FAAN†

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From the *Mount Sinai Medical Center, New York, New York; †Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Address correspondence to Lavonia Francis, DNP, RN, NEA-BC, Senior Director of Nursing, Mount Sinai Medical Center, One Gustave Levy Place, New York, NY 10029. E-mail: [email protected] Received June 25, 2011; Revised May 2, 2012; Accepted May 24, 2012. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.05.002

ABSTRACT:

The aim of this study was to determine nurses’ knowledge and attitudes regarding postoperative pain and identify postoperative patients’ pain intensity experiences. The assessment and management of acute postoperative pain is important in the care of postoperative surgical patients. Inadequate relief of postoperative pain can contribute to postoperative complications such as atelectasis, deep vein thrombosis, and delayed wound healing. A pilot study with an exploratory design was conducted at a large teaching hospital in the eastern United States. The convenience samples included 31 nurses from the gastrointestinal and urologic surgical units and 14 first- and second-day adult postoperative open and laparoscopic gastrointestinal and urologic patients who received patient-controlled analgesia (PCA). The Knowledge and Attitudes Survey Regarding Pain was used to measure nurses’ knowledge about pain management. The Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure patients’ pain intensity. The nurses’ mean score on the Knowledge and Attitudes Survey Regarding Pain was 69.3%. Patients experienced moderate pain, as indicated by the score on the SF-MPQ. There is a need to increase nurses’ knowledge of pain management. Ó 2013 by the American Society for Pain Management Nursing The assessment and management of acute postoperative pain is an important aspect in the care of surgical patients. Pain management is a vital component in the recovery of postoperative patients. Pain can diminish a patient’s ability to participate in postoperative interventions such as coughing, deep breathing, and ambulating. These interventions are key elements in preventing postoperative complications. Challenges such as lack of patient assessment in managing pain and lack of appropriate use of analgesics have been reported (Gunningberg & Idvall, 2007; Idvall & Berg, 2008; White & Kehlet, 2010). Pain management is multifaceted and requires a multidisciplinary approach in improving patient outcomes.

BACKGROUND Owing to the subjective nature of pain, assessment and management of pain can be a complex process. Timing, route, and appropriate use of analgesics need to Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 351-357

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be considered in the management of pain. Despite advances in pain management, such as patient-controlled analgesia (PCA) and multimodal analgesia, patients continue to experience moderate to severe pain (Bedard, Purden, Sauve-Larose, Certosini, & Schein, 2006; Brown, Constance, Bedard, & Pruden, 2011; Niemi-Murola, Poybia, Onkinen, Rhen, Makela, & Niemi, 2007). The role of the nurse is pivotal in the assessment and management of postoperative pain. Nurses need to understand the pathophysiology of pain and recognize that pain management is vital in the recovery of postoperative patients. Pain assessment and reassessment are components of the nurse’s role that are key in pain management. Therefore, the purpose of this pilot study was to determine nurses’ knowledge and attitudes regarding postoperative pain and identify patients’ level of pain intensity.

PAIN MANAGEMENT AND ASSESSMENT The most reliable indicator of pain is the patient’s selfreport (Institute for Clinical Systems Improvement, 2008). Patients communicate pain verbally and through body and facial expressions. Therefore, patient observation and the use of pain assessment tools, such as the visual analog scale (VAS) need to be used in the assessment of postoperative pain. Nurses’ and patients’ assessment of pain has been documented (Gunningberg & Idvall, 2007; Sloman, Rosen, Rom, & Shin, 2005). Sloman et al. (2005) studied nurses’ ratings of pain intensity and suffering compared with patients’ own ratings of these variables in adult surgical patients. Patients completed the Short-Form McGill Pain Questionnaire (SF-MPQ), VAS, and demographic questionnaire. Nurses assessed their assigned patients and then completed the same questionnaires. The findings indicated that nurses significantly underrated pain compared with patients on pain sensation (t ¼ 3.131; p ¼ .002), pain affect (t ¼ 4.410; p ¼ .0001), present pain intensity at rest (t ¼ 3.498; p # .001), present pain intensity on movement (t ¼ 6.278; p # .0001), overall pain intensity (t ¼ 2.235; p ¼ .028), and patient suffering due to pain (t ¼ 3.774; p # .0001). There were no statistically significant effects found for demographic or cultural data. Gunningberg and Idvall (2007) used a descriptive and comparative design to study the quality of postoperative pain management. Paired patient and nurse assessments of patients’ pain management were conducted in general and thoracic surgery services. The Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire was completed by patients and nurses. Audit of patient records was also completed.

The findings revealed that the mean score for four question items in general surgery and five items in thoracic surgery was >4.5, which indicated high quality of patient care. Patients in general surgery experienced more pain than patients in thoracic surgery. Patients in general surgery assessed their worst pain to be significantly higher than the nurses did. The mean score for the patients’ worst pain during the past 24 hours was 5.7 and the nurses’ score was 4.5 on a scale range of 0-10. A significant difference was found in both services in the assessments of worst pain during the past 24 hours between patients, nurses, and documentation in the patient record. Pain intensity assessment was documented significantly more often in general surgery (41%) than in thoracic surgery (6.7%). Idvall, Berg, Unosson and Brudin (2005) investigated the differences between nurse and patient assessments of postoperative pain management in two hospitals with the use of the Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire. The findings revealed that the correlation between patient and nurse ratings for both hospitals regarding worst pain during the past 24 hours was statistically significant (r ¼ 0.57-0.59). Patients rated their worst pain during the past 24 hours higher than the nurses’ rating (p < .05). Idvall and Berg (2008) also used the Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire in their study of how orthopedic patients assessed the quality of care they received. One of the question items rated highest was that pain relief was addressed promptly when requested. The item rated lowest was the regular use of a pain assessment instrument. Eid and Bucknall’s (2008) retrospective audit of patients’ medical records demonstrated that nurses’ documentation of pain assessment and management was insufficient in their study of postoperative pain management in older patients (n ¼ 43) with hip fractures. The study findings indicated that there was no documentation of pain intensity rating using the VAS in 77% of the reviewed medical records and no documentation of pain assessment in 65% of the records. Neither nonpharmacologic intervention nor pain management education was documented. Lin and Wang (2005) examined the effects of postoperative nursing intervention for pain related to abdominal surgical patients’ preoperative anxiety, pain attitude, and postoperative pain. A questionnaire and the Brief Pain Inventory were used. The findings revealed that there was a statistically significant difference (F ¼ 174.03; p < .001) in the mean anxiety scores after the preoperative nursing intervention for pain between the experimental group and the control group. Additionally, there was a statistically significant

Postoperative Pain and Patients’ Experiences

difference (F ¼ 260.58; p < .001) in pain attitude and pain scores between the two groups. The researchers suggested that preoperative nursing intervention for pain has positive effects on preoperative pain anxiety and attitude and pain perception.

NURSES’ KNOWLEDGE OF PAIN MANAGEMENT Matthews and Malcolm (2007) surveyed two groups of nurses with the Nurses’ Knowledge and Attitudes Survey Regarding Pain. The nurses in group 1 worked at an orthopedic center and completed a knowledge and competency program in pain management. Group 2 nurses attended a pain conference but did not complete the knowledge and competency program. The nurses in group 2 worked in a variety of clinical areas. The overall mean score on the survey for both groups was 73.8%. The findings showed that there was no significant difference in the total of correct responses between the two groups. However, there was a severe deficit in knowledge related to questions regarding nonpharmacologic interventions and opioid use in chronic pain conditions. Another finding was that group 1 had a higher correct response rate (p ¼ .001) than group 2 for the scenario questions. Wilson (2007) studied nurses’ knowledge of pain management among 35 oncology nurse specialists and 37 general nurses with the use of a revised version of the Knowledge and Attitudes Survey Regarding Pain. Wilson reported that the oncology nurse specialists’ mean score (79.42%) was higher than the mean score (64.86%) of the general nurses; however, the nurse specialists’ knowledge scores were not consistent with their years of experience. Abdalrahim, Majala, Stomberg and Bergdam (2010) explored nurses’ knowledge and attitudes toward pain on surgical units before and after implementation of a postoperative management program. A 21-item questionnaire was used and patient records audited. The overall score for correct answers on the questionnaire during the preintervention phase was 45.7%. The score increased to 75% after implementation of the program. Improvement was also noted in documentation of pain management in the patients’ records after implementation of the postoperative pain management program. Wang and Tsai (2010) studied nurses’ knowledge and barriers regarding pain management among 370 intensive care unit nurses in 16 hospitals. The findings indicated that the overall average of correct response rate for the Nurses’ Knowledge and Attitudes Survey was 53.4%. The researchers also reported that nurses’ knowledge of pain management was significantly and

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negatively related to perceived barriers to pain management (r ¼ 0.12; p < .01).

METHODS Design and Setting A descriptive exploratory design was used. The pilot study was conducted at a large full-service teaching hospital in the eastern United States. Samples Thirty-one registered nurses from the gastrointestinal and urologic surgical units participated. Newly hired nurses with 0.80). Internal consistency reliability was established with items reflecting both knowledge and attitude (r > 0.70) (Ferrell & McCaffery). Postoperative Pain Intensity. Patients’ pain intensity was measured by three scores on the SF-MPQ. The SF-MPQ provides quantitative measures of clinical pain (Melzack, 1975). The SF-MPQ was developed from the long-form McGill Pain Questionnaire (Melzack, 1987). The SF-MPQ consists of three sections. The first section of the questionnaire consists of 15 adjectives that describe sensory and affective dimensions of pain. Eleven items represent sensory descriptors of pain and four items represent affective descriptors of pain. Each descriptor has four responses as follows: 0 ¼ none; 1 ¼ mild; 2 ¼ moderate; and 3 ¼ severe. Subjects respond by rating each descriptor of their pain ‘‘now.’’ Three pain scores are derived from the sum of the intensity values of the descriptors chosen for sensory, affective, and combined scores of the patient’s chosen descriptors. The range of possible scores for each descriptor is 0-3 and range of possible combined scores is from 0 to 45. The higher the score, the greater the intensity of pain. The second section of the SF-MPQ consists of a VAS. The VAS scale ranges from no pain to worst possible pain. Subjects are shown the scale and are instructed to place a mark on the scale indicating their pain level. The third section of the SF-MPQ consists of the present pain intensity (PPI) index. The ratings for the PPI are 0 ¼ no pain; 1 ¼ mild pain; 2 ¼ discomforting pain; 3 ¼ distressing pain; 4 ¼ horrible pain; and 5 ¼ excruciating pain. A separate score is reported for each section. The higher the score, the greater the intensity of pain. The SF-MPQ has been tested for evidence of reliability and validity. A study was conducted to compare the long form and short form of the McGill Pain Questionnaire (Melzack, 1987). The first section of the SF-MPQ was compared to the long form with 90 patients. The study groups included patients in postsurgical and obstetrical units and patients with musculoskeletal pain in a physiotherapy department. The findings of the study revealed that the sensory, affective, and total scores from the short and long forms of the McGill Pain Questionnaire were significantly correlated. Correlation coefficients were r ¼ 0.88 (p ¼ .001) (Melzack, 1987). Procedure Institutional Review Board approval was obtained before data collection. Patients were approached on the first and second postoperative days. The researcher interviewed the patients using the SF-MPQ and demographic questionnaire after obtaining signed consent. Face-to-face recruitment of nurses was done by

attending unit staff meetings. The investigator described the study and explained the purpose of the study. Research packets containing a cover letter, demographic questionnaire, the Knowledge and Attitudes Survey Regarding Pain, and return envelope were distributed to the nurse participants.

RESULTS Sample There were two samples for this pilot study, a convenience sample of 31 nurse participants and a convenience sample of 14 patient participants from three surgical units at a large teaching hospital in the eastern United States. Sixty nurse questionnaires were distributed; 31 (51.6%) nurse participants returned completed questionnaires. Seventy-two patients were approached; 14 patients agreed to participate in the study, for a response rate of 19%. Patients who were not willing to participate were either not interested or requested that the investigator come back on another day. For logistical reasons it was not possible to contact them on another day. The nurses were not paired with the patient participants. Characteristics of Nurse Participants The nurses’ ages ranged from 22 to 62 years. The mean age for the nurse participants was 36 years (SD 12.1). Twenty five (80.6%) were female and 6 (19.4%) male. The educational characteristics of the nurse participants included education level and pain management education. Twenty-eight nurse participants (90.3%) received a Bachelor of Science in Nursing (BSN) as their basic nursing preparation and one (3.2%) received an Associate degree. Two participants (6.5%) received a Master of Science in Nursing. Eleven of the nurse participants (44%) had not attended a pain management education session outside the study facility. Seven (28%) had attended a half-day pain management educational session and seven (28%) had attended a full-day pain educational session. The work-related characteristics examined were years of nursing experience, years working on current unit, and years of other surgical experience. Years of nursing experience ranged from 1 to 40 years with a mean of 7.9 years (SD 9.1). Fourteen nurse participants (48.3%) had 20 years of experience. Years of other surgical experience ranged from 1 to 28 years with a mean of 8.1 years (SD 8.2). Six nurse participants (20.7%) had surgical experience of 1-5 years; 2 (6.9%) had 6 to 10 years; 1 (3.4%) had

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Postoperative Pain and Patients’ Experiences

11 to 15 years, 1 (3.4%) had 16-20 years, and 1 (3.4%) had >20 years of other surgical experience. Sample characteristics of the nurses are included in Table 1. The mean score on the Knowledge and Attitudes Survey Regarding Pain was 69.3%. These results are included in Table 2. There were no significant differences found between the mean scores and the demographic variables of the nurse participants. Characteristics of Patient Participants The patients’ ages ranged from 28 to 71 years. The mean age was 51 years (SD 12.9). Six (42.9%) were female and 8 (57.1%) male. Eleven (78.6%) patients were white, 2 (14.3%) were black, and 1 (7.1%) was of another racial background. Twelve patients’ birth place was the United States (85.7%), and 2 (14.3%) were born outside of the United States. Four of the patient participants (28.6%) completed high school, 3 (21.4%) received a bachelor degree, 3 (21.4%) received a master degree, and 4 (28.6%) had other educational background. Sample characteristics of the patients are included in Table 3. Fourteen postoperative day 1 and day 2 gastrointestinal and urologic patients participated in the study. The operative procedures were as follows: one (7.1%) open urologic procedure; one (7.1%) laparoscopic urologic procedure, ten (71.4%) open gastrointestinal procedures; and two (14.3%) laparoscopic gastrointestinal procedures. Eleven of the patient participants (78.6%)

TABLE 1. Characteristics of Nurse Participants (n ¼ 31)

Age (y) 22-35 36-55 56-62 Sex Female Male Education MSN BSN Associate Pain management education None Half day Full day Nursing experience (y) 20

n

%

15 10 3

53.5 35.7 10.7

25 6

80.6 19.4

2 28 1

6.5 90.3 3.2

11 7 7

44 28 28

14 8 3 2 2

48.3 27.6 10.3 6.9 6.9

TABLE 2. Nurse Participants (n ¼ 31): Knowledge and Attitudes Survey Regarding Pain

Overall Score Score by age (y)

Postoperative pain: nurses' knowledge and patients' experiences.

The aim of this study was to determine nurses' knowledge and attitudes regarding postoperative pain and identify postoperative patients' pain intensit...
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