Patients' decision-making strategies for managing postoperative pain

Testing a model for person-centred pain management: A systematic review and synthesis guided by the Fundamentals of Care framework

AIMS

To test a model for person-centred pain management using qualitative evidence in the literature and refine it based on the results.

DESIGN

A qualitative systematic review with thematic synthesis using the Fundamentals of Care framework.

METHODS AND DATA SOURCES

A literature search in February 2021 in six scientific databases: CINAHL, PsycInfo, Pubmed, Scopus, Social Science Premium Collection and Web of Science, reported using ENTREQ and PRISMA. Quality assessment was performed for the individual studies. Thematic analysis and the GRADE-CERQual approach were used in the synthesis including the assessment of confidence in the evidence.

RESULTS

The model was tested against the evidence in 15 studies appraised with moderate or high quality and found represented in the literature but needed to be expanded. A refined model with a moderate/high confidence level of evidence presents elements to be used in a holistic care process; The nurse is guided to establish a trusting relationship with the patient and enable communication to identify and meet pain management needs using pharmacological and non-pharmacological management. Nurse leaders are guided to support this process by providing the right contextual conditions.

CONCLUSIONS

The strengths of the confidence level in the refined model, and that it is represented from the nurse and patient perspectives in nursing research across countries and cultures, support our recommendation for empirical evaluation.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The model links the knowledge of pain management elements from individual studies together into actions to be performed in clinical practice. It also outlines the organizational support needed to make this happen. Nurses and nursing leaders are suggested to test the model to implement person-centred pain management in clinical practice.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPACT

What Problem Did the Study Address? There is a need to transfer available evidence of person-centred pain management into practice to relieve the patient from pain. What Were the Main Findings? Person-centred pain management is of high priority for patients and nurses around the world and can be performed in a holistic care process including patient-nurse trust and communication, supported by contextual conditions to deliver timely pharmacological and non-pharmacological pain management addressing the patient's physical, psychosocial and relational care needs. Where and on Whom will the Research Have an Impact? The model is to be tested and evaluated in clinical practice to guide the providers to relieve the patient from pain.

REPORTING METHOD

Relevant EQUATOR guidelines were used to report the study: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Patients' Active Participation in Postoperative Pain Management in an Urban Hospital of Vietnam: Implications for Patient Empowerment

Active participation in pain management is vital to improve postoperative pain outcomes. However, this issue has not been fully examined in Vietnam. This study aimed to examine the active participation of patients in pain management after surgery, as well as explore its effect on acute postoperative pain.

A hospital-based survey on 245 patients after surgery was conducted. Information about demographic and clinical characteristics, pain intensity and active participation in pain management was collected. Multivariate regression models were utilized to determine the associations.

53.9% of patients reported that they were informed about the postoperative pain relief method before surgery. One-third (33.5%) of patients selected preferred pain relief methods; 46.1% reported that they asked physicians when feeling pain immediately after surgery; 49.8% asked physicians when pain was not relieved after taking medications, and 52.2% asked physicians for their current pain in the time of interview. Age and occupation were found to be positively associated with active participation score. Patients being informed about the postoperative pain relief method before surgery had 0.87 points higher than those not receiving explanation (Coef. = 0.87; 95%CI = 0.49-1.26). Patients with high active participation scores were more likely to have pain improvement (OR = 3.41, 95%CI = 2.37-4.92).

This study highlights a low level of active participation in postoperative pain management among Vietnamese patients. Routinely providing information about pain control before surgery, and encouraging patients to actively participate in pain management are essential to improve postoperative pain outcomes.

Utilization of non-pharmacological methods and the perceived barriers for adult postoperative pain management by the nurses at selected National Hospitals in Asmara, Eritrea

Background

Pharmacological methods are widely used for postoperative pain management however, poorly controlled pain continues to pose a significant challenge. Non pharmacological methods could contribute to the unresolved postoperative pain management in assisting nurses’ routine care and reducing the need for medication. This study aimed to assess nurses’ utilization of non-pharmacological methods in postoperative pain and the perceived barriers for their implementation at the National Hospitals.

Methods

This was a descriptive cross sectional study conducted among 154 nurses working at the National Referral Hospitals and Sembel Private Hospital. A standardized five-point Likert-scale questionnaire which assesses nurses’ utilization of selected non-pharmacological methods and the perceived barriers for the implementation was used to collect data. Descriptive statistics for the demographic data, independent samples t-test, one way ANOVA and factorial ANOVA were used to analyze the data. Statistical significance level was set at P < 0.05.

Results

The study found out that emotional support (45.5%), helping with daily activities (67.5%) and creating a comfortable environment (61%) were mostly used while, cognitive-behavioral (5.9%) and physical methods (5.8%) were hardly used. The results also showed that, characteristics such as, age (p = 0.013), level of education (p = 0.012), work experience (p = 0.001) and place of work (p = 0.001), were significantly related to the use of non-pharmacological methods at bivariate level. However, hospitals were the only determinants of the non-pharmacological methods at multivariable level with a statistical significance of (p < 0.001). On the perceived barriers; heavy work load (87.7%), shortage of time (84.4%), limited resources (82.5%), deficit in the guidelines for pain management (77.3%), patient’s uncooperative behavior (57.1%), language difference (64.4%), nurse’s lack of knowledge (50%) and experience (40.3%) were identified.

Conclusion

The use of non-pharmacological methods in the studied hospitals varied greatly due to knowledge and experience of the nurses. Therefore, it is recommended that exposure and training for all health care providers at all level is a paramount importance in order to appreciate the benefits of non-pharmacological methods applicable to postoperative pain management. This could be achieved through on job training, seminars, scientific conferences and other brainstorming forums.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12912-020-00492-0.

[Pain assessment in routine care : A prospective observational study in an orthopedic unit]

INTRODUCTION

Although well-established guidelines give advice on how to use analgesics, measure pain, and organize pain treatment, many patients still suffer from avoidable severe pain. We assume one reason for this is that pain is inadequately addressed in routine patient contacts. Thus, we aimed to evaluate the extent to which pain was addressed during patient contacts in routine orthopedic care.

MATERIALS AND METHODS

In a prospective observational study in an orthopedic unit of a university hospital, we invited physicians and nurses during their routine patient contacts to be observed by independent, trained monitors. The monitors systematically assessed all pain-related aspects, which were analyzed descriptively afterwards.

RESULTS

The monitors documented 572 physician-patient contacts with 7 physicians and 108 patients and 578 nurse-patient contacts with 12 nurses and 102 patients. Physicians and nurses asked their patients about pain in 20 and 16 % of the patient contacts, respectively. While in physician-patient contacts, patients most frequently addressed their current pain situation (in 35 % of contacts), in nurse-patient contacts, patients most frequently addressed their need for analgesics (52 %). Patients rated their pain intensity in 16 % of physician-patient contacts vs. 17 % of nurse-patient contacts.

CONCLUSIONS

Using a comprehensive external monitoring procedure, we found that systematic pain assessment was not optimally standardized and implemented for systematic, individualized pain therapy by physicians or nurses in our routine care setting.

Patients' decision-making experiences in the acute healthcare setting--a case study

BACKGROUND

The transition from being an ordinary citizen to a hospitalised patient can be a daunting experience particularly for the uninitiated and inexperienced. Patients are likely to have questions such as 'where do I go?', 'what should I do?', 'when?' and 'who should I ask?' The process for making practical moment-to-moment decisions is often complex and fraught with difficulties. Identifying critical points in the hospitalisation experience may provide insights into the quality of hospital management systems and professional practices from a patient perspective.

OBJECTIVE

This study aimed to identify institutional practices and structures in the context of acute healthcare settings which impact on patient moment-to-moment decision-making experiences.

METHOD

A case study approach was used as the exploratory methodology, and interviews were conducted with three former adult inpatients. In order to gain an understanding of each participant's experiences, data collecting strategies used in this research were a semistructured interview and document analysis of information documents, such as hospital supplied pamphlets, provided to the researcher by the participants.

RESULTS

The study identified five major themes. Identified as being critical to the participants were information sharing by healthcare professionals, professional advice and professional role identification. Less so were environment and everyday life. Associated with these themes were the participant's common experience of being confined in unfamiliar surroundings, adjusting to institutional routines and of being heavily dependent on others.

CONCLUSION

Findings indicate that patient moment-to-moment decision-making may be informed and enhanced in several areas: relevant and timely information sharing, varying the dress code between the different professions, reducing conflicting professional advice, clear signage around the hospital, and flexible visiting hours, telephones and clocks in patient rooms.

Patient participation in quality pain management during an acute care admission

OBJECTIVES

The objective of the study was to explore patient participation in the context of pain management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease.

METHODS

This is a single-institution study, with a case-study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including preadmission and predischarge patient interviews (n=98), naturalistic observations (n=48), and focus group interviews (n=2).

RESULTS

Patients' preference for participation in pain management was not always commensurate with their involvement in pain management. Patients displayed a greater understanding of their role in pain management in terms of reporting pain and the use of multimodal analgesics after surgery. The majority of patients, however, did not understand the importance of reporting pain to avoid complications. Patients had limited opportunity to participate in their pain management. On occasions in which clinicians did involve patients, the involvement appeared to be focused on reporting pain rather than treatment of pain.

DISCUSSION

Patient participation in pain management during hospitalization is not optimal. This has implications for the quality of pain management patients receive. Higher engagement of patients in their pain management during hospitalization is required to ensure comfort, reduce potential for complications, and adequately prepare the patients to manage their pain following discharge from hospital.

Numeric rating scale: patients' perceptions of its use in postoperative pain assessments

AIM

The purpose of this study was to describe how patients perceive the use of the numeric rating scale in postoperative pain assessments.

BACKGROUND

There are recommendations to use a pain scale to follow patients' postoperative pain. Most patients prefer the NRS but there is a discrepancy between patients and healthcare professionals how to interpret the ratings from the pain assessments.

METHODS

A descriptive design with a phenomenographic approach was used. Semi structured interviews were held with 25 patients.

RESULTS

Three description categories emerged that illustrate patients' perceptions; use of the NRS facilitated communication of pain, it put demands on healthcare professionals and care routines and it contained interpretation difficulties.

CONCLUSION

The NRS has a place in pain management according to the patients but there is a need for a dialogue to give the patients the opportunity to describe their pain and set a common goal.

SOULAGE-TAVIE: development and validation of a virtual nursing intervention to promote self-management of postoperative pain after cardiac surgery

This article is the report of the development and validation of a tailored Web-based intervention for postoperative pain self-management in adults who underwent cardiac surgery. The development of SOULAGE-TAVIE included four main phases: (1) identification of a clinical problem, (2) outline design, (3) clinical operationalization, and (4) production. The validation of the intervention's feasibility and acceptability was made through pilot testing with 30 patients expecting cardiac surgery over 4 months in 2010. SOULAGE-TAVIE consists of a 30-minute computer-tailored preoperative educational session about postoperative pain management. Activities and information were tailored according to a predetermined profile. Two short reinforcements were provided in person postoperatively. Ninety-six percent of participants agreed that the strategies proposed responded to their needs. An iterative process among various sources of knowledge gave place to an innovative approach to preoperative education. Pilot testing provided preliminary support for the acceptability and feasibility of a tailored Web-based intervention. Patient empowerment is complementary yet crucial in the current context of care and may contribute to improved pain relief. The use of information technologies can increase personalization and accessibility to health education in a complex environment of care.

The Ghanaian surgical nurse and postoperative pain management: a clinical ethnographic insight

Nurses form an indispensable part of the clinical team that manages postoperative pain (POP). Within a particular clinical context, nurses perceive and respond to pain based on specific factors. This study aimed at illuminating the perceptions and responses of Ghanaian surgical nurses regarding their patients' POP. It also identified the factors that influenced nurses' pain responses. A focused ethnography was used, and data were collected through individual interviews. Sampling was performed purposively to include junior, senior, day, and night nurses who cared for surgical patients. Concurrent data analysis was performed and data were saturated with 12 individual interviews. The findings indicated that nurses perceived POP as an individual phenomenon, and nurses responded to patients' pain by administering analgesics and by using nonpharmacologic measures. Factors that influenced the nurses' response were individual factors, such as commitment, discretion, fear of addiction, and organizational factors, such as organizational laxity and challenges of teamwork. The study recommended that nurses should be educated, supported, and encouraged to ensure pain relief after surgery and that they should see pain relief as a priority postoperative care to avert the negative repercussions of poorly managed POP.

Web-based nursing intervention for self-management of pain after cardiac surgery: pilot randomized controlled trial

BACKGROUND

Most adults undergoing cardiac surgery suffer from moderate to severe pain for up to 6 days after surgery. Individual barriers and attitudes regarding pain and its relief make patients reluctant to report their pain and ask for analgesic medication, which results in inadequate pain management. More innovative educational interventions for postoperative pain relief are needed. We developed a Web-based nursing intervention to influence patient's involvement in postoperative pain management. The intervention (SOULAGE-TAVIE) includes a preoperative 30-minute Web-based session and 2 brief face-to-face postoperative booster sessions. The Web application generates reflective activities and tailored educational messages according to patients' beliefs and attitudes. The messages are transmitted through videos of a virtual nurse, animations, stories, and texts.

OBJECTIVE

The aim of this single-blinded pilot randomized trial was to investigate the preliminary effects of a virtual nursing intervention (SOULAGE-TAVIE) to improve pain relief in patients undergoing cardiac surgery.

METHODS

Participants (N = 60) were adults scheduled for their first cardiac surgery. They were randomly assigned to the experimental group using SOULAGE-TAVIE (n = 30) or the control group using usual care, including an educational pamphlet and postoperative follow-up (n = 30). Data were collected through questionnaires at the time of admission and from day 1 to day 7 after surgery with the help of a blinded research assistant. Outcomes were pain intensity, pain interference with daily activities, patients' pain barriers, tendency to catastrophize in face of pain, and analgesic consumption.

RESULTS

The two groups were comparable at baseline across all demographic measures. Results revealed that patients in the experimental group did not experience less intense pain, but they reported significantly less pain interference when breathing/coughing (P = .04). A severe pain interference with breathing/coughing (pain ranked ≥ 7/10) was reported on day 3 after surgery by 15% of the patients in the experimental group (4/27), as compared to 44% (7/16) in the control group. On day 7 after surgery, participants in the experimental group also exhibited fewer pain-related barriers as measured by the Barriers Questionnaire-II (mean 10.6, SD 8.3) than patients in the control group (mean 15.8, SD 7.3, P = .02). No difference was found for pain catastrophizing. However, in both groups, means revealed a lower tendency to catastrophize pain before surgery as measured by the Pain Catastrophizing Scale (control group mean 1.04, SD 0.74; experimental group mean 1.10, SD 0.95) and after surgery (control group mean score 1.19, SD 0.94; experimental group mean score 1.08, SD 0.99). Finally, the experimental group consumed more opioid medication (mean 31.2 mg, SD 23.2) than the control group (mean 18.8 mg, SD 15.3, P = .001).

CONCLUSIONS

This pilot study provides promising results to support the benefits of this new Web-tailored approach that can increase accessibility to health education and promote pain relief without generating more costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01084018; http://www.clinicaltrials.gov/ct2/show/NCT01084018 (Archived by WebCite® at http://www.webcitation.org/6CoTBkIoT).

Improvements and difficulties in postoperative pain management

BACKGROUND

This review examines postoperative pain (POP) management from the perspectives of healthcare providers, patients, and institutions. It summarizes current thought about POP, including difficulties and recent improvements in the field.

METHODS

Studies were identified from PubMed, MEDLINE, and the search engine Google Scholar and by hand-searching reference lists from review articles and research papers (1998-2009). The search was limited to articles published in the English language. Given the broad review of POP, a complete review of all the potential articles was not possible. Thus, an inclusion criterion was defined, and we retrieved only those studies that included the term postoperative pain treatment, together with 1 or more of the following terms: adult patients, education, interdisciplinary teams, attitudes, physicians, and nurses. Two hundred twenty studies were retrieved, and 93 studies were sufficiently close to the topic of this review. They were organized according to the following themes: POP management as it relates to healthcare providers, patients, and institutions; changing trends in healthcare education in relation to various POP interventions; and the role of policy makers concerning improvements and challenges in the management of POP.

RESULTS

Interdisciplinary teams are needed to implement multimodal methods to treat POP in ways that will provide patients with interventions that will improve their ability to cope with the physical and psychosocial aspects of POP. This is hindered by a lack of hospital financial resources, a lack of educational programs, a lack of knowledge regarding diverse pharmacological options, and lingering negative attitudes toward certain treatments, especially opioids.

CONCLUSIONS

Successful POP management depends on providers' receiving education and information. Policy makers and organizations are called upon to actively intervene by formulating programs and promoting a feedback system, or else POP will remain a neglected issue.