Preoperative Pain Management Education: A Quality Improvement Project Katherine F. O’Donnell, DNP, APRN, FNP-BC The management of pain is one of the greatest clinical challenges for nurses who care for patients during the postoperative period. It can be even more challenging for patients who must manage their own pain after discharge from the health care facility. Research shows that postoperative pain continues to be undermanaged despite decades of education and evidence-based guidelines. Ineffective management of postoperative pain can negatively impact multiple patient outcomes. The purpose of this quality improvement project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients’ postoperative pain management outcomes. The project was conducted with patients undergoing same-day laparoscopic cholecystectomy in an outpatient general surgery service at a teaching institution. Patients in the intervention and comparison groups completed the American Pain Society Patient Outcome QuestionnaireRevised during their first postoperative clinic visit 2 weeks after surgery. Results showed that patients who received the preoperative education intervention reported less severe pain during the first 24 hours postoperatively, experienced fewer and less severe pain medication side effects, returned to normal activities sooner, and used more nonpharmacologic pain management methods postoperatively compared with those who did not receive the education. Keywords: patient education, postoperative pain, pain management outcomes. Ó 2015 by American Society of PeriAnesthesia Nurses
THE MANAGEMENT OF postoperative pain is challenging for health care professionals. Although research shows improvements in some aspects, studies also show that postoperative pain continues to be poorly managed.1,2 Patients may find the management of their own pain after discharge
Katherine F. O’Donnell, DNP, APRN, FNP-BC, is a Family Nurse Practitioner, Department of General Surgery, University of Texas Health Science Center, San Antonio, Texas. Conflict of interest: None to report. Address correspondence to Katherine F. O’Donnell, Department of General Surgery, University of Texas Health Science Center, 8300 Floyd Curl Drive, San Antonio, TX 78229; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2015.01.013
Journal of PeriAnesthesia Nursing, Vol 30, No 3 (June), 2015: pp 221-227
equally challenging and daunting. It is imperative that pain is optimally controlled at all points postoperatively to prevent negative outcomes such as deep vein thrombosis, atelectasis, pulmonary embolism, chronic pain, increased length of hospital stay, and readmission because of unrelieved pain.3 Pain can decrease the ability to return to work quickly, contributing to financial and emotional burdens for patients and families.2,3
Overview of the Literature The Centers for Disease Control and Prevention reported that nearly one billion surgical procedures were performed in the United States in 2006, with the number increasing annually,4 making postoperative pain the most common cause of pain. Postoperative pain is considered acute pain, resulting from
221
222
tissue damage, inflammation, and the healing process in general.5 Most patients report pain after surgery, but pain levels vary depending on the type of surgery, comorbidities, previous experiences with pain, age, gender, and patient expectations.6 This combination of factors makes it difficult to predict the level of pain the patient will experience and how well pain will be tolerated, underscoring the wide variability among patients in terms of the pain experience. Inadequate assessment and management of postoperative pain can result in patients experiencing anxiety, insomnia, increased stress, and limited mobility, in addition to or as a result of unrelieved pain.3,6,7 Other factors contributing to the problem of insufficient pain management include poor communication between patient and providers, unrealistic patient expectations, and lack of proper patient education.8 The consequences of poorly managed pain can lead to negative outcomes such as the development of chronic pain, deep vein thrombosis, atelectasis, and delayed resumption of normal daily and work activities.3,6
KATHERINE F. O’DONNELL
pain control, goals of treatment, the degree of pain the patient may experience, and the importance of reporting pain, especially if the patient is unable to participate in recovery activities because of poorly controlled pain.2 Pain management options, including both pharmacologic and nonpharmacologic methods, should be explained and made available.13–15
Project Design: The Iowa Model The framework for this project was based on Marita Tilter’s Model of Evidence-Based Practice to Promote Quality Care.16 Dr Titler’s framework evolved from a quality assurance model and is applied in the investigation of quality improvement issues. The model is based on problemfocused or knowledge-focused triggers to initiate the process of examining current practice and to find the best evidence to improve outcomes. Based on the evidence gathered, changes in practice are instituted, and the effects of these changes on patient outcomes are monitored over time.16,17
Obstacles to pain management include deficiencies in patient knowledge about pain management,9,10 lack of systematic and comprehensive assessment, improper use of pain assessment tools,11 inadequate or incomplete documentation, and barriers related to clinicians’ knowledge and attitudes about pain.12 Tools exist for the assessment of pain in patients who can report pain and those who cannot, such as neonates, infants, toddlers, and critically ill or cognitively impaired patients.11 The process of assessing pain includes the use of age and condition-appropriate assessment tools, ongoing documentation of the patient’s pain experience, treatment measures, reassessment of the patient’s response to treatment, and adjustments in the treatment plan if indicated.
Postoperative pain management was identified as a problem for clinicians at the University of Texas Health Science Center, San Antonio (UTHSCSA) Outpatient Surgery Clinic. Thus, using Tilter’s model, postoperative pain management served as the project’s problem-focused trigger. Patients returning to the clinic after surgery often reported having poorly controlled pain, inadequate understanding of pain and analgesics, and insufficient knowledge about medication side effects. Some returned to the emergency department because of unrelieved postoperative pain. Other problems identified were frequent patient requests for pain medication refills, whereas other patients were unable to return to work because of excessive pain.
Efforts to increase patients’ knowledge about pain and analgesic choices may increase their likelihood of achieving optimal pain control postoperatively. With shorter hospital stays and an increase in same-day surgical procedures, it is imperative that patients be comfortable enough to participate in the recovery process and resume self-care activities quickly in the postoperative period. Preoperative education is a vehicle for preparing patients about their role in the pain management plan and postoperative recovery. Education should include information about the importance of
In an effort to improve postoperative pain management after discharge with the goal of reducing the identified negative outcomes at UTHSCSA, the author (hereafter referred to as the project director) developed an evidence-based pilot project to educate patients preoperatively about postoperative pain management. The project targeted patients undergoing elective outpatient laparoscopic cholecystectomy. The educational program provided patients with information about taking medications correctly, managing side effects, using nonpharmacologic pain management techniques,
PREOPERATIVE PAIN MANAGEMENT EDUCATION
and identifying warning signs such as severe pain, uncontrolled nausea and vomiting, and severe constipation after surgery.
Project Implementation The project director held four meetings with faculty providers and support staff before implementing the project. The purpose of these meetings was to introduce the project goals and objectives to staff and solicit their input and feedback. A copy of the project abstract, the patient education content and written materials, and the questionnaire that was to be administered to patients postoperatively were provided to those who attended the meetings. They were told about the target population (patients undergoing same-day laparoscopic cholecystectomy) and that the project director developed the written materials and would provide the preoperative education and administer the postoperative questionnaire. The UTHSCSA Institutional Review Board approved the study as exempt, which means the research did not require monitoring by UTHSCSA. The project started in January 2013.
The Patient Education Tool and Postoperative Questionnaire During the first preoperative clinic visit, patients selected for the intervention group provided consent to receive one-on-one education about postoperative pain, which included content on taking medications correctly, medication side effects, managing side effects, using nonpharmacologic methods to reduce pain, and the importance of reporting poorly controlled pain as soon as possible. The project director developed a written education information form in both English and Spanish that highlighted the key pain management points (Table 1). Each patient in the intervention group was given the information form and instructed to make a postoperative visit with the project director 2 weeks after surgery. The project director was the only person responsible for providing the educational material, collecting and storing questionnaires, and ensuring patients returned for their postoperative visit 2 weeks later. At the 2-week postoperative visit, patients in the intervention group and patients in the compari-
223
son group who underwent same-day laparoscopic cholecystectomy but did not receive verbal or written preoperative education were asked to complete the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R).18 The APS-POQ-R was first developed in 1991 and revised in 2010.18 The tool asks patients to answer 12 questions and measures six postoperative quality aspects: pain severity/relief; impact of pain on activity, sleep and mood; side effects of treatment; helpfulness of information; ability to participate in decision making about pain treatment; and use of nonpharmacologic methods. The project director also collected the age and sex of each patient.
Results The pilot project focused on patient responses to four of the 12 questions about postoperative pain on the APSPOQ-R. The four questions were selected because they corresponded with the pain education information form that was distributed to the participants. They asked about the presence of severe pain in the first 24 hours postoperatively, side effects, return to normal activity, and use of nonpharmacologic methods to relieve pain. Twenty-four patients completed the questionnaire, 13 in the intervention group and 11 in the comparison group (Table 2). Five patients in the intervention group and four patients in the comparison group received education and completed questionnaires in Spanish. Twenty-two of the 24 patients who participated in the study reported severe pain during the first 24 hours postoperatively. Patients in the intervention group experienced severe pain 54.6% of the time during the first 24 hours postoperatively, whereas those in the comparison group reported experiencing severe pain 65.5% of that time. Participants were asked about how much pain prevented or interfered with return to normal activities, such as getting out of bed, walking, sitting in a chair, falling asleep, and staying asleep. Both groups reported interference with these activities, but the comparison group reported significantly greater frequency with difficulty getting out of bed, positioning, falling asleep, and staying asleep than the intervention group (Figure 1). The groups were similar in reports of interference with activities performed when out of bed.
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Table 1. Patient Education Information Form What You Need to Know About Postoperative Pain Pain control after surgery is very important. When your pain is controlled, you sleep better, eat better, and return to normal activities sooner. You may recover more quickly from your surgery and get back to work sooner. The following information will help you understand how to manage your pain after surgery. 1. Take pain medication as directed. The best time to take medication is when the pain first begins. If pain is worse with activity, such as walking or going to the bathroom, take the medication on a regular schedule. 2. Manage side effects early. Some medications cause constipation or nausea. Take medications with food to avoid nausea and also take a stool softener daily to prevent constipation. 3. Report side effects, such as severe nausea, vomiting, or constipation. 4. Comfort measures, such as heat, ice, massage, relaxation, walking, or listening to music, may help. 5. Communicate with your provider if your pain is not controlled. You may need different medication or a stronger dose to relieve your pain. 6. Be sure to make a postoperative visit and discuss any problems with your pain management.
Patients rated the severity of analgesic side effects, such as nausea, drowsiness, itching, and dizziness. Most patients reported at least one side effect in the first 24 hours postoperatively; however, the severity of side effects was significantly higher in the comparison group than in the intervention group (Figure 2). Patients in both groups used a variety of nonpharmacologic methods to manage their pain, but those in the intervention group used multiple methods and used them more frequently (61.5%) than those in the comparison group (54.4%) (Figure 3). The use of cold packs was the most common nonpharmacologic method used, and listening to music was the least common.
roscopic cholecystectomy (N 5 24); 13 received preoperative education and 11 did not. Patients who received the preoperative education intervention experienced severe pain in the first 24 hours postoperatively less often than those who did not receive the education intervention. This result was clinically significant. It is possible that because they did not receive preoperative education, those in the comparison group did not know how to correctly take pain medication or did not understand the importance of taking scheduled analgesic doses to prevent pain from becoming severe. The higher incidence of side effects in the comparison group may have caused some patients to stop or
Discussion The purpose of this pilot project was to evaluate the effectiveness of a preoperative pain management patient education program in improving patients’ postoperative outcomes. Patients who participated in the study underwent same-day lapa-
Table 2. Participant Demographics Characteristic Male Female Age (y) 18-30 31-50 51-65 Older than 65
Intervention Group
Comparison Group
1 12
2 9
4 6 3 0
5 5 1 0
Figure 1. Interference with activities. Values in xaxis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
PREOPERATIVE PAIN MANAGEMENT EDUCATION
Figure 2. Side effects. Values in x-axis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
reduce their analgesic intake as well. Some patients also reported experiencing problems filling their prescriptions on the day of surgery, so taking pain medication was delayed.
225
Although the education intervention appeared to have a positive impact on reducing the severity of pain, it is very concerning that 22 (92%) of the 24 patients who participated in the project reported severe pain after surgery. Both groups reported that pain limited return to normal activities, which is common when pain is poorly controlled. It is also possible that patients did not fully understand the rationale for moving, coughing, and deep breathing to prevent complications. Most patients also reported side effects, and some experienced multiple side effects. These findings were likely from a combination of the surgical procedure itself, anesthetic medication, and pain medications. However, the high incidence of side effects underscores the importance of teaching patients how to prevent and manage them after surgery. Avoiding or controlling side effects can prevent unnecessary complications, including intractable nausea and vomiting, severe constipation, and uncontrolled pain. Clearly, institutions should consider strategies in addition to patient education that will improve these types of findings.
Figure 3. Use of nonmedicine methods. Values in x-axis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
KATHERINE F. O’DONNELL
226
Patients in the intervention group were instructed to use nonpharmacologic methods in conjunction with pain medications to control their pain during the first 24 hours after surgery and beyond. It is encouraging that patients in both groups used a variety of nonpharmacologic methods and that those who received the education intervention were more likely to use them. The difference between the groups suggests that providing information regarding the use of nonpharmacologic pain methods is valuable.
Limitations This project was limited by its small sample size and restricted time for providing the patient education during the preoperative visit. Exclusion of individuals having emergency laparoscopic cholecystectomy limited the sample size. The small sample size also prevented statistical analysis (ie, results were interpreted as percentages). Larger randomized controlled studies would avoid these problems and are needed to extrapolate findings. Of note, 9 of the 11 patients in the comparison group reported that they received some verbal education about postoperative pain management during their preoperative visit, making comparison with the intervention group difficult. It is not clear who provided the information, what content was included, and when the education was provided.
Update and Future Recommendations Data collection continued for a year after the pilot study ended. A total of 98 patients were studied. Results are currently being analyzed and will be reported in a subsequent article. As a result of this project, the preoperative education content has been incorporated into the hospital’s electronic medical record, and work is underway to insure that all patients receive the postoperative pain management education sheet as part of their preoperative education. In the future, it would be beneficial to more aggressively educate both inpatients and outpatients preoperatively about how to manage their pain after discharge. Using technology such as cell phone applications and digital versatile discs is a way to reinforce information that is provided during
face-to-face education sessions. Providing prescriptions before surgery for analgesics that are to be taken postoperatively may help patients avoid problems obtaining these medications on the day of surgery. Combining both prescription medications with practical nonpharmacologic methods may lead to lower opioid doses, fewer opioid-related side effects, and better pain control overall.19 Research that explores the inclusion of other nonpharmacologic methods such as prayer, meditation, and low-impact exercise is also needed. Future research should include a larger sample size and randomization of patients to control for differences between groups.
Summary Self-management of pain after discharge is an essential part of recovery after surgery, but is a challenge for many patients. When pain is poorly controlled, patients can experience delayed recovery, prolonged hospitalization, inability to return to work, and possible adverse sequelae including deep vein thrombosis, pneumonia, and chronic pain. This pilot project provided preoperative patient education in an effort to improve postoperative outcomes in patients undergoing elective outpatient surgery. Information on taking medications correctly, managing side effects, identifying warning signs, and using nonpharmacologic methods for pain control were included in the education session. Results suggest that preoperative education may decrease the severity of postoperative pain, the frequency and severity of side effects, increase patients’ use of nonpharmacologic methods to control pain, and reduce the negative impact pain can have on important patient activities during the postoperative period.
Acknowledgments The author thanks Cecily L. Betz, PhD, RN, FAAN, Editor-inChief of the Journal of Pediatric Nursing: Nursing Care of Children and Families for her assistance in writing the original article; Michelle A. Price, PhD, Director, Finance and Administration, Department of General Surgery, University of Texas Health Science Center, San Antonio, Texas, for her mentoring and guidance in this research and statistical analysis; and Nancy Kofoed, RN, PhD, at Loma Linda University for her assistance with the development of the original Capstone project.
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References 1. Apfelbaum JL, Connie C, Shilpa SM, Tong JG. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534-540. 2. Wood S. Postoperative pain 2: Patient education, assessment and management, part 1 of 2-part series. Nurs Times. 2010;106:14-16. 3. Agency for Healthcare Research and Quality. National Guidelines Clearinghouse, Guideline Summary NGC-7980. Postoperative pain management. In: Guidelines on Pain Management, 2010. Available at: http://www.guideline.gov/content.aspx? id523897&search5postoperative1pain. Accessed December 20, 2014. 4. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;11:1-10. 5. Pasero C, McCaffery M. Orthopaedic postoperative pain management. J Perianesth Nurs. 2007;22:160-171. 6. Mackintosh C. Assessment and management of patients with post-operative pain. Nurs Stand. 2007;22:49. 7. Glindvad J, Jorgensen M. Postoperative education and pain in patients with inguinal hernia. J Adv Nurs. 2007;57:649-657. 8. McCaffery M, Herr K, Pasero C. Assessment. In: Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management. St. Louis, MO: Elsevier/Mosby; 2011. 9. Oshodi TO. The impact of preoperative education on postoperative pain. Part 2. Br J Nurs. 2007;16:790-797. 10. Oshodi TO. The impact of preoperative education on postoperative pain. Part 1. Br J Nurs. 2007;16:706-710.
11. Coll AM, Ameen JRM, Mead D. Postoperative pain assessment tools in day surgery: Literature review. J Adv Nurs. 2004; 46:124-133. 12. Abdalrahim MS, Majali SA, Stomberg MW, et al. The effect of postoperative pain management program on improving nurses’ knowledge and attitudes toward pain. Nurse Educ Pract. 2011;11:250-255. 13. Topcu SY, Findik UY. Effect of relaxation exercises on controlling postoperative pain. Pain Manag Nurs. 2012;13: 11-17. 14. Tracy S, Dufault M, Kogut S, et al. Translating best practices in nondrug postoperative pain management. Nurs Res. 2006;55:S57-S67. 15. Pasero C. One size does not fit all: Opioid dose range orders. J Perianesth Nurs. 2014;29:246-252. 16. Taylor-Piliae RE. Utilization of the Iowa Model in establishing evidence-based nursing practice. Intensive Crit Care Nurs. 1999;15:357-362. 17. Doody CM, Doody O. Introducing evidence into nursing practice: Using the IOWA model. Br J Nurs. 2011;20:661-664. 18. Gordon DB, Polomano RC, Pellino TA, et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: Preliminary psychometric evaluation. J Pain. 2010;11:1172-1186. 19. Watkins AA, Johnson TV, Shrewsberry AB, et al. Ice packs reduce postoperative midline incision pain and narcotic use: A randomized controlled trial. J Am Coll Surg. 2014;219: 511-517.
THE MANAGEMENT OF postoperative pain is challenging for health care professionals. Although research shows improvements in some aspects, studies also show that postoperative pain continues to be poorly managed.1,2 Patients may find the management of their own pain after discharge
Katherine F. O’Donnell, DNP, APRN, FNP-BC, is a Family Nurse Practitioner, Department of General Surgery, University of Texas Health Science Center, San Antonio, Texas. Conflict of interest: None to report. Address correspondence to Katherine F. O’Donnell, Department of General Surgery, University of Texas Health Science Center, 8300 Floyd Curl Drive, San Antonio, TX 78229; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2015.01.013
Journal of PeriAnesthesia Nursing, Vol 30, No 3 (June), 2015: pp 221-227
equally challenging and daunting. It is imperative that pain is optimally controlled at all points postoperatively to prevent negative outcomes such as deep vein thrombosis, atelectasis, pulmonary embolism, chronic pain, increased length of hospital stay, and readmission because of unrelieved pain.3 Pain can decrease the ability to return to work quickly, contributing to financial and emotional burdens for patients and families.2,3
Overview of the Literature The Centers for Disease Control and Prevention reported that nearly one billion surgical procedures were performed in the United States in 2006, with the number increasing annually,4 making postoperative pain the most common cause of pain. Postoperative pain is considered acute pain, resulting from
221
222
tissue damage, inflammation, and the healing process in general.5 Most patients report pain after surgery, but pain levels vary depending on the type of surgery, comorbidities, previous experiences with pain, age, gender, and patient expectations.6 This combination of factors makes it difficult to predict the level of pain the patient will experience and how well pain will be tolerated, underscoring the wide variability among patients in terms of the pain experience. Inadequate assessment and management of postoperative pain can result in patients experiencing anxiety, insomnia, increased stress, and limited mobility, in addition to or as a result of unrelieved pain.3,6,7 Other factors contributing to the problem of insufficient pain management include poor communication between patient and providers, unrealistic patient expectations, and lack of proper patient education.8 The consequences of poorly managed pain can lead to negative outcomes such as the development of chronic pain, deep vein thrombosis, atelectasis, and delayed resumption of normal daily and work activities.3,6
KATHERINE F. O’DONNELL
pain control, goals of treatment, the degree of pain the patient may experience, and the importance of reporting pain, especially if the patient is unable to participate in recovery activities because of poorly controlled pain.2 Pain management options, including both pharmacologic and nonpharmacologic methods, should be explained and made available.13–15
Project Design: The Iowa Model The framework for this project was based on Marita Tilter’s Model of Evidence-Based Practice to Promote Quality Care.16 Dr Titler’s framework evolved from a quality assurance model and is applied in the investigation of quality improvement issues. The model is based on problemfocused or knowledge-focused triggers to initiate the process of examining current practice and to find the best evidence to improve outcomes. Based on the evidence gathered, changes in practice are instituted, and the effects of these changes on patient outcomes are monitored over time.16,17
Obstacles to pain management include deficiencies in patient knowledge about pain management,9,10 lack of systematic and comprehensive assessment, improper use of pain assessment tools,11 inadequate or incomplete documentation, and barriers related to clinicians’ knowledge and attitudes about pain.12 Tools exist for the assessment of pain in patients who can report pain and those who cannot, such as neonates, infants, toddlers, and critically ill or cognitively impaired patients.11 The process of assessing pain includes the use of age and condition-appropriate assessment tools, ongoing documentation of the patient’s pain experience, treatment measures, reassessment of the patient’s response to treatment, and adjustments in the treatment plan if indicated.
Postoperative pain management was identified as a problem for clinicians at the University of Texas Health Science Center, San Antonio (UTHSCSA) Outpatient Surgery Clinic. Thus, using Tilter’s model, postoperative pain management served as the project’s problem-focused trigger. Patients returning to the clinic after surgery often reported having poorly controlled pain, inadequate understanding of pain and analgesics, and insufficient knowledge about medication side effects. Some returned to the emergency department because of unrelieved postoperative pain. Other problems identified were frequent patient requests for pain medication refills, whereas other patients were unable to return to work because of excessive pain.
Efforts to increase patients’ knowledge about pain and analgesic choices may increase their likelihood of achieving optimal pain control postoperatively. With shorter hospital stays and an increase in same-day surgical procedures, it is imperative that patients be comfortable enough to participate in the recovery process and resume self-care activities quickly in the postoperative period. Preoperative education is a vehicle for preparing patients about their role in the pain management plan and postoperative recovery. Education should include information about the importance of
In an effort to improve postoperative pain management after discharge with the goal of reducing the identified negative outcomes at UTHSCSA, the author (hereafter referred to as the project director) developed an evidence-based pilot project to educate patients preoperatively about postoperative pain management. The project targeted patients undergoing elective outpatient laparoscopic cholecystectomy. The educational program provided patients with information about taking medications correctly, managing side effects, using nonpharmacologic pain management techniques,
PREOPERATIVE PAIN MANAGEMENT EDUCATION
and identifying warning signs such as severe pain, uncontrolled nausea and vomiting, and severe constipation after surgery.
Project Implementation The project director held four meetings with faculty providers and support staff before implementing the project. The purpose of these meetings was to introduce the project goals and objectives to staff and solicit their input and feedback. A copy of the project abstract, the patient education content and written materials, and the questionnaire that was to be administered to patients postoperatively were provided to those who attended the meetings. They were told about the target population (patients undergoing same-day laparoscopic cholecystectomy) and that the project director developed the written materials and would provide the preoperative education and administer the postoperative questionnaire. The UTHSCSA Institutional Review Board approved the study as exempt, which means the research did not require monitoring by UTHSCSA. The project started in January 2013.
The Patient Education Tool and Postoperative Questionnaire During the first preoperative clinic visit, patients selected for the intervention group provided consent to receive one-on-one education about postoperative pain, which included content on taking medications correctly, medication side effects, managing side effects, using nonpharmacologic methods to reduce pain, and the importance of reporting poorly controlled pain as soon as possible. The project director developed a written education information form in both English and Spanish that highlighted the key pain management points (Table 1). Each patient in the intervention group was given the information form and instructed to make a postoperative visit with the project director 2 weeks after surgery. The project director was the only person responsible for providing the educational material, collecting and storing questionnaires, and ensuring patients returned for their postoperative visit 2 weeks later. At the 2-week postoperative visit, patients in the intervention group and patients in the compari-
223
son group who underwent same-day laparoscopic cholecystectomy but did not receive verbal or written preoperative education were asked to complete the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R).18 The APS-POQ-R was first developed in 1991 and revised in 2010.18 The tool asks patients to answer 12 questions and measures six postoperative quality aspects: pain severity/relief; impact of pain on activity, sleep and mood; side effects of treatment; helpfulness of information; ability to participate in decision making about pain treatment; and use of nonpharmacologic methods. The project director also collected the age and sex of each patient.
Results The pilot project focused on patient responses to four of the 12 questions about postoperative pain on the APSPOQ-R. The four questions were selected because they corresponded with the pain education information form that was distributed to the participants. They asked about the presence of severe pain in the first 24 hours postoperatively, side effects, return to normal activity, and use of nonpharmacologic methods to relieve pain. Twenty-four patients completed the questionnaire, 13 in the intervention group and 11 in the comparison group (Table 2). Five patients in the intervention group and four patients in the comparison group received education and completed questionnaires in Spanish. Twenty-two of the 24 patients who participated in the study reported severe pain during the first 24 hours postoperatively. Patients in the intervention group experienced severe pain 54.6% of the time during the first 24 hours postoperatively, whereas those in the comparison group reported experiencing severe pain 65.5% of that time. Participants were asked about how much pain prevented or interfered with return to normal activities, such as getting out of bed, walking, sitting in a chair, falling asleep, and staying asleep. Both groups reported interference with these activities, but the comparison group reported significantly greater frequency with difficulty getting out of bed, positioning, falling asleep, and staying asleep than the intervention group (Figure 1). The groups were similar in reports of interference with activities performed when out of bed.
KATHERINE F. O’DONNELL
224
Table 1. Patient Education Information Form What You Need to Know About Postoperative Pain Pain control after surgery is very important. When your pain is controlled, you sleep better, eat better, and return to normal activities sooner. You may recover more quickly from your surgery and get back to work sooner. The following information will help you understand how to manage your pain after surgery. 1. Take pain medication as directed. The best time to take medication is when the pain first begins. If pain is worse with activity, such as walking or going to the bathroom, take the medication on a regular schedule. 2. Manage side effects early. Some medications cause constipation or nausea. Take medications with food to avoid nausea and also take a stool softener daily to prevent constipation. 3. Report side effects, such as severe nausea, vomiting, or constipation. 4. Comfort measures, such as heat, ice, massage, relaxation, walking, or listening to music, may help. 5. Communicate with your provider if your pain is not controlled. You may need different medication or a stronger dose to relieve your pain. 6. Be sure to make a postoperative visit and discuss any problems with your pain management.
Patients rated the severity of analgesic side effects, such as nausea, drowsiness, itching, and dizziness. Most patients reported at least one side effect in the first 24 hours postoperatively; however, the severity of side effects was significantly higher in the comparison group than in the intervention group (Figure 2). Patients in both groups used a variety of nonpharmacologic methods to manage their pain, but those in the intervention group used multiple methods and used them more frequently (61.5%) than those in the comparison group (54.4%) (Figure 3). The use of cold packs was the most common nonpharmacologic method used, and listening to music was the least common.
roscopic cholecystectomy (N 5 24); 13 received preoperative education and 11 did not. Patients who received the preoperative education intervention experienced severe pain in the first 24 hours postoperatively less often than those who did not receive the education intervention. This result was clinically significant. It is possible that because they did not receive preoperative education, those in the comparison group did not know how to correctly take pain medication or did not understand the importance of taking scheduled analgesic doses to prevent pain from becoming severe. The higher incidence of side effects in the comparison group may have caused some patients to stop or
Discussion The purpose of this pilot project was to evaluate the effectiveness of a preoperative pain management patient education program in improving patients’ postoperative outcomes. Patients who participated in the study underwent same-day lapa-
Table 2. Participant Demographics Characteristic Male Female Age (y) 18-30 31-50 51-65 Older than 65
Intervention Group
Comparison Group
1 12
2 9
4 6 3 0
5 5 1 0
Figure 1. Interference with activities. Values in xaxis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
PREOPERATIVE PAIN MANAGEMENT EDUCATION
Figure 2. Side effects. Values in x-axis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
reduce their analgesic intake as well. Some patients also reported experiencing problems filling their prescriptions on the day of surgery, so taking pain medication was delayed.
225
Although the education intervention appeared to have a positive impact on reducing the severity of pain, it is very concerning that 22 (92%) of the 24 patients who participated in the project reported severe pain after surgery. Both groups reported that pain limited return to normal activities, which is common when pain is poorly controlled. It is also possible that patients did not fully understand the rationale for moving, coughing, and deep breathing to prevent complications. Most patients also reported side effects, and some experienced multiple side effects. These findings were likely from a combination of the surgical procedure itself, anesthetic medication, and pain medications. However, the high incidence of side effects underscores the importance of teaching patients how to prevent and manage them after surgery. Avoiding or controlling side effects can prevent unnecessary complications, including intractable nausea and vomiting, severe constipation, and uncontrolled pain. Clearly, institutions should consider strategies in addition to patient education that will improve these types of findings.
Figure 3. Use of nonmedicine methods. Values in x-axis assigned to data for the purpose of statistical analysis. This figure is available in color online at www.jopan.org.
KATHERINE F. O’DONNELL
226
Patients in the intervention group were instructed to use nonpharmacologic methods in conjunction with pain medications to control their pain during the first 24 hours after surgery and beyond. It is encouraging that patients in both groups used a variety of nonpharmacologic methods and that those who received the education intervention were more likely to use them. The difference between the groups suggests that providing information regarding the use of nonpharmacologic pain methods is valuable.
Limitations This project was limited by its small sample size and restricted time for providing the patient education during the preoperative visit. Exclusion of individuals having emergency laparoscopic cholecystectomy limited the sample size. The small sample size also prevented statistical analysis (ie, results were interpreted as percentages). Larger randomized controlled studies would avoid these problems and are needed to extrapolate findings. Of note, 9 of the 11 patients in the comparison group reported that they received some verbal education about postoperative pain management during their preoperative visit, making comparison with the intervention group difficult. It is not clear who provided the information, what content was included, and when the education was provided.
Update and Future Recommendations Data collection continued for a year after the pilot study ended. A total of 98 patients were studied. Results are currently being analyzed and will be reported in a subsequent article. As a result of this project, the preoperative education content has been incorporated into the hospital’s electronic medical record, and work is underway to insure that all patients receive the postoperative pain management education sheet as part of their preoperative education. In the future, it would be beneficial to more aggressively educate both inpatients and outpatients preoperatively about how to manage their pain after discharge. Using technology such as cell phone applications and digital versatile discs is a way to reinforce information that is provided during
face-to-face education sessions. Providing prescriptions before surgery for analgesics that are to be taken postoperatively may help patients avoid problems obtaining these medications on the day of surgery. Combining both prescription medications with practical nonpharmacologic methods may lead to lower opioid doses, fewer opioid-related side effects, and better pain control overall.19 Research that explores the inclusion of other nonpharmacologic methods such as prayer, meditation, and low-impact exercise is also needed. Future research should include a larger sample size and randomization of patients to control for differences between groups.
Summary Self-management of pain after discharge is an essential part of recovery after surgery, but is a challenge for many patients. When pain is poorly controlled, patients can experience delayed recovery, prolonged hospitalization, inability to return to work, and possible adverse sequelae including deep vein thrombosis, pneumonia, and chronic pain. This pilot project provided preoperative patient education in an effort to improve postoperative outcomes in patients undergoing elective outpatient surgery. Information on taking medications correctly, managing side effects, identifying warning signs, and using nonpharmacologic methods for pain control were included in the education session. Results suggest that preoperative education may decrease the severity of postoperative pain, the frequency and severity of side effects, increase patients’ use of nonpharmacologic methods to control pain, and reduce the negative impact pain can have on important patient activities during the postoperative period.
Acknowledgments The author thanks Cecily L. Betz, PhD, RN, FAAN, Editor-inChief of the Journal of Pediatric Nursing: Nursing Care of Children and Families for her assistance in writing the original article; Michelle A. Price, PhD, Director, Finance and Administration, Department of General Surgery, University of Texas Health Science Center, San Antonio, Texas, for her mentoring and guidance in this research and statistical analysis; and Nancy Kofoed, RN, PhD, at Loma Linda University for her assistance with the development of the original Capstone project.
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