Nurses’ Strategies for Managing Pain in the Postoperative Setting

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.

Remote transmission monitoring for postoperative perineural analgesia after major orthopedic surgery: A multicenter, randomized, parallel-group, controlled trial

STUDY OBJECTIVE

After surgery, patients reported the delay in receiving help as the primary factor for poorly controlled pain. This study aimed to compare the effectiveness of patient management through two communication modalities: remote transmission (RT) versus bedside control (BC). We hypothesized that using remote technology for pump programming may provide the best postoperative infusion regimen for the patient's self-assessment of pain and adverse events.

DESIGN

A multicenter, randomized, parallel-group, controlled trial.

SETTING

Anesthesiology department and orthopedic surgery ward at three university hospitals.

PATIENTS

Eighty patients undergoing orthopedic surgery with postoperative perineural patient-controlled analgesia were included.

INTERVENTIONS

Two groups (n = 40 for each group) were formed by randomization. In the postoperative period, perineural analgesia was followed up via an RT system or BC for 72 h.

MEASUREMENTS

A nurse assessed daily pain, sensory and motor blocks and adverse events. Patients completed a questionnaire three times a day and alerted for any problem according to the group (RT system or nurses' follow-up). On the third postoperative day, the nurse removed the catheter, completed the final assessment, and collected the historical data from the pump. A physician's shorter response time to change the patient control analgesia (PCA) program was the primary endpoint.

RESULTS

Of the 80 patients, 71 were analyzed (34 were randomized to the RT group and 37 to the BC group). Fifty-eight pump setting changes were noted. Analysis of repeated evaluations shows that mean time (SD) to change the PCA pump settings was significantly lower in the RT group (20 min (22.3 min)) than in the BC group (55.9 min (71.1 min)); mean difference [95% CI], -35.9 min [-74.3 to 2.4]); β estimation [95% CI], -34 [-63 to -6], p = 0.011). Pain relief, sensory and motor blocks did not differ between the groups: β estimation [95% CI], 0.1 [-0.4 to 0.6], p = 0.753; 0.5 [-0.4 to 1.4], p = 0.255; 0.9 [-0.04 to 1.8], p = 0.687, respectively. β = -34 [-63 to -6], p = 0.011). The consumption of ropivacaine, nurse workload and the cost of the analgesia regimen decreased in the RT group. No differences were noted in satisfaction scores or complication rates.

CONCLUSIONS

The response time for the physician to change the PCA program when necessary was shorter for patients using RT and alerts to the physician were more frequent compared with spot checks by nurses. RT helps to decrease nurses' workload, ropivacaine consumption, and costs but did not affect postoperative pain relief, complication rate, or patient-reported satisfaction score.

IRB CONTACT INFORMATION

Comité de Protection des Personnes, Sud Méditerranée III, Montpellier-Nîmes, France, registration number EudraCT A01698-35.

CLINICAL TRIAL NUMBER

ClinicalTrials.gov ID:NCT02018068 PROTOCOL: The full trial protocol can be accessed at Department of Anesthesiology and Critical Care Medicine, Medical Research and Statistics Unit, Lapeyronie University Hospital, Avenue Doten G Giraud, Montpellier, France. s-bringuierbranchereau@chu-montpellier.fr.

Survey of physician comfort and attitudes on perioperative opioid prescription in patients with chronic pain

Objective:

This study examines current practices, experiences, beliefs, concerns regarding negative outcomes and confidence of non-pain specialty anaesthetists regarding prescribing opioids to chronic pain patients.

Design:

An electronic cross-sectional survey was conducted by physicians from the Division of Anaesthesiology, excluding pain specialists, at the Singapore General Hospital.

Methods:

An online survey was conducted, investigating: (a) sociodemographic and practice characteristics; (b) current opioid prescribing practices; (c) experiences and beliefs towards prescribing opioid analgesics for chronic non-malignant pain; (d) confidence and comfort when prescribing opioids; and (e) educational and training needs in chronic pain management.

Results:

A total of 123 anaesthetists (80.9%) responded to the survey. It was noted that only 38.2% of respondents were comfortable managing patients with chronic pain. The majority (86.2%) felt that anaesthetists should be the primary doctors in the management of postoperative pain in chronic pain patients, and 61% believed that chronic pain trained specialist anaesthetists should be responsible; 92.7% of respondents agreed that patients who are educated about their pain tend to do better. Most importantly, 96.7% of respondents feel that they will benefit from more education regarding pain management in chronic pain patients.

Conclusions:

The majority of non-pain specialist anaesthetists recognise the importance of education regarding pain management for non-malignant chronic pain patients. Many feel that they are not confident in managing these patients and will benefit from continuing medical education and self-assessment courses to improve their confidence. These results could be used to enrich current pain management courses.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

The impact of a standard pain assessment protocol on pain levels and consumption of analgesia among postoperative orthopaedic patients

BACKGROUND

Pain is a leading concern in post-surgical orthopaedic settings; andeffective pain assessment tools are important aspects of pain management.

OBJECTIVE

This study assessed the effect of using standard pain assessment protocols (SPAP) on pain levels, pain management, and analgesia consumption among patients in the first 24 h following orthopaedic surgery.

METHODS

In total, 101 patients were recruited and assigned to the comparison group (n = 50) and experimental group (n = 51). SPAP was used in the experimental group while the comparison group received routine care. Pain levels at rest and during movement and analgesic consumption were compared between the two groups.

FINDINGS

There were significant differences in pain levels between the comparison and experimental groups. The experimental group consumed significantly less pain medication at 8-11 h of opioid medications and 12-15 h of non-opioid medications (P < .001). The use of non-pharmacological modalities was significantly higher in the experimental group compared to the comparison group (P < .001).

CONCLUSIONS

Regular pain assessment and management using SPAP can promote pain management and reduce pain levels as well as reduce analgesia administration and promote the use of non-pharmacologic approaches. These outcomes can result in fewer side effects for patients.

IMPLICATIONS

The findings suggest that using SPAP can result in improved outcomes as well as the use of non-pharmacologic approaches to pain management. This approach can result in better outcomes and increased communication between the nurse and the patient.

Clinical cues used by nurses to recognize changes in patients' clinical states: A systematic review

The aim of this systematic review was to examine the clinical cues used by acute care nurses to recognize changes in clinical states of adult medical and surgical patients that occurred as usual consequence of acute illness and treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist were followed. Four databases and reference lists of included studies were searched: from 1,049 studies, 38 were included. There were 26 subjective and 147 objective cues identified; only 6% of all cues described improvements in patients' clinical states. The most common clinical cues used were heart rate, blood pressure and temperature. Many studies (n = 31) focused on only one element of assessment, such as physiological stability, pain, or cognition. There was a paucity of studies detailing the complexity of acute care nurses' assessment practices as they would occur in clinical practice and a disproportionate focus on the objective assessment of deterioration. Studies are needed to understand the full breadth of cues acute care nurses use to recognize clinical change that includes both improvement and deterioration.

Undesirable Postoperative Anesthesia Outcomes at Two National Referral Hospitals: A Cross-Sectional Study in Eritrea

Background

Postoperative undesirable anesthesia outcomes are common among patients undergoing surgery. They may affect body systems and lead into more serious postoperative problems. This research is conducted in the Eritrean National Referral Hospitals with the aim of assessing the prevalence of undesirable anesthesia outcomes during the postoperative period.

Method

A cross-sectional study design was applied on 470 patients who underwent different types of surgeries within a three-month period. Patients were interviewed 24 hours after operation (POD 1) using the Leiden Perioperative care Patient Satisfaction questionnaire (LPPSq). This study reports one component of a large study conducted. The dimension "Discomfort and needs" of the LPPSq was considered, and the measurements of that dimension are presented in this report. Items of the dimension were standardized and measured using a five-point Likert scale from "Not at all" to "Extremely." Multivariable logistic regression was used to look for the association of the outcomes with the types of surgery and types of anesthesia using SPSS (Version 22).

Results

The prevalence were computed in two manners, prevalence of those with 'at least a little bit' outcomes, which was computed to see the total occurrence of these outcomes, and prevalence of those having 'more than moderate' outcomes to see the severe experience of these outcomes. Prevalence of the predominant undesirable outcome, postoperative pain, for 'at least a little bit' and 'more than moderate' were 82.6% and 43.6%, respectively. The rest of the postoperative undesirable outcomes were less frequently reported.

Conclusion

Postoperative pain was found to be the most prevalent undesirable outcome. Enhancement of proper assessment and management of postoperative pain through the development and implementation of specific pain management modalities is needed.

Postoperative Pain Management among Registered Nurses in a Vietnamese Hospital

This study examined the postoperative pain management practices among registered nurses in an urban hospital in Vietnam. Data of 90 nurses about postoperative pain management practices and pain management at the department were collected. Results indicated that 83.3% of nurses reported that they regularly assessed the degree of pain for postoperative patients. Only 32.2% used assessment tools such as the numeric rating scale to measure pain. Experience in pain management and having guidelines in the department were associated with a higher score in pain management practice. Findings suggested that facilitating the use of pain instruments and developing pain management guidelines should be prioritized.

Nursing Workload, Knowledge about Pain, and Their Relation to Pain Records

PURPOSE

To study the relationship between frequency of pain assessment and nursing workload, and also to analyze the frequency of pain assessment and its relation to knowledge and attitudes toward pain on nursing professionals in intensive care unit.

METHODS

An ambispective study was conducted in a Spanish tertiary-level intensive care unit between October 2017 and April 2018. For measurement of workload, the Nursing Activities Score scale was used, and for measurement of pain knowledge, the Knowledge and Attitudes Survey Regarding Pain was used.

RESULTS

There were 1,207 measurements among 41 nurses and 1,838 among 317 patients. The average nursing workload was high (70.97 points). We found statistically significant positive association between nursing workload and the frequency of assessment (p < .001), as well as frequency of assessment and patients with communicative capacity (p = .008).

CONCLUSIONS

Nursing workload affects the registration and assessment of patients' pain, resulting in a greater number of records as the workload performed by nurses increases. It is necessary to study in greater depth how the severity of pain, gender of the patients, and workload of nurses influence pain registration and assessment.

Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review

Objective

Productive patient-clinician communication is an important component of effective pain management, but we know little about how patients and clinicians actually talk about pain in clinical settings and how it might be improved to produce better patient outcomes. The objective of this review was to create a conceptual model of patient-clinician communication about noncancer pain, review and synthesize empirical research in this area, and identify priorities for future research.

Methods

A conceptual model was developed that drew on existing pain and health communication research. CINAHL, EMBASE, and PubMed were searched to find studies reporting empirical data on patient-clinician communication about noncancer pain; results were supplemented with manual searches. Studies were categorized and analyzed to identify crosscutting themes and inform model development.

Results

The conceptual model comprised the following components: contextual factors, clinical interaction, attitudes and beliefs, and outcomes. Thirty-nine studies met inclusion criteria and were analyzed based on model components. Studies varied widely in quality, methodology, and sample size. Two provisional conclusions were identified: contrary to what is often reported in the literature, discussions about analgesics are most frequently characterized by patient-clinician agreement, and self-presentation during patient-clinician interactions plays an important role in communication about pain and opioids.

Conclusions

Published studies on patient-clinician communication about noncancer pain are few and diverse. The conceptual model presented here can help to identify knowledge gaps and guide future research on communication about pain. Investigating the links between communication and pain-related outcomes is an important priority for future research.

Spanish Version of the Knowledge and Attitudes Survey Regarding Pain

A variety of valid tools are available to assess staff knowledge and attitudes regarding pain, among which is the Knowledge and Attitudes Survey Regarding Pain. Although this instrument has been widely and successfully used, a valid and adapted Spanish version is yet to be developed. The purpose of this study was to validate the Spanish version of the Knowledge and Attitudes Survey Regarding Pain. After translating and back-translating this tool, we conducted a cross-cultural adaptation and construct validation with 102 participants, including nursing professionals (in palliative care, oncology, and intensive care) from five health centers and final-year nursing students. All participants were recruited in the Principality of Asturias, Spain. We also evaluated the internal consistency and test-retest correlations. Cronbach's α was .781, and Pearson's r and the intraclass correlation coefficient between the test and retest scores were .881 and .883, respectively. The mean questionnaire scores in the test and retest phases were 65.8% and 67.6%, respectively. Palliative care nurses had the highest score, 70.8%, which differed significantly from the rest of the groups. The Spanish version of the Knowledge and Attitudes Survey Regarding Pain can effectively differentiate nursing staff in terms of their pain expertise. The results indicate that Spanish nurses have a gap in pharmacologic knowledge that is comparable to that found in other countries, but their foundation in general pain concepts was solid.

Postoperative Pain Management: A Bedside Perspective

PURPOSE

Postoperative pain management is an ongoing challenge in surgical care, during which inadequate relief can contribute to postoperative complications, and nurses are key figures in this process. The aim of the present study was to gain knowledge of how nurses provide postoperative pain management for women undergoing major surgery for endometriosis.

DESIGN

An ethnographic field study, consisting of semi-structured interviews and participant observations, was conducted in a setting of 2 gynecological units within a large Scandinavian university hospital.

METHOD

The participants were mainly nurses and patients. The overall focus for the field observations and interviews was on how the participants interacted and made care decisions concerning pain. The analysis focused on nurse-patient interaction in postoperative bedside care. A principal theme, pain-related nursing practice emerged, together with the sub-themes nurse-patient interaction, interpretation and assessment of pain and pain management, which represented a circular process, identified in bedside practice.

CONCLUSIONS

To some extend the postoperative pain management was influenced by unexpressed health beliefs and routine actions, and patient involvement was not prominent. Furthermore, the existing guidelines for pain management did not seem useful to the nurses.

CLINICAL IMPLICATIONS

There is a need to develop a new and more practice-oriented postoperative pain management, in ways that also integrate the patient experience.

Anesthetists and Surgeons Predict Postoperative Pain

PURPOSE

Nurses, surgeons and anesthetists are responsible for the management of postoperative pain. This study aimed to investigate surgeons', surgical residents', anesthesiologists', and anesthetic residents' predictions of patients' postoperative pain and satisfaction with pain management, compared to patients' postoperative ratings.

DESIGN

The bias and limits of agreement between physician and patient ratings of postoperative pain were compared.

METHODS

Doctors and patients completed a pain questionnaire (Numeric Rating Scale 11-point) regarding patients' overall pain, worst pain, and dissatisfaction with pain management during the first three days postoperatively.

FINDINGS

All doctors overestimated the degree of pain. Possible reasons include the efforts of the postoperative multidisciplinary team. Surgeons were the most accurate regarding patients' worst pain. The limits of agreement for doctor and patient ratings were very wide.

CONCLUSIONS

Postoperative pain management is better than predicted.

Effectiveness of pain management educational interventions on nurses' knowledge and attitudes regarding postoperative pain management: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify the effectiveness of pain management education programs (PMEPs) in improving the level of knowledge and the attitudes of nurses working in adult surgical departments and intensive care units on postoperative pain management.

Translation and Validation of the Toronto Pain Management Index, French-Canadian Version

Background To provide effective pain management, nurses must have sufficient knowledge and adequate beliefs about pain management. In Quebec, however, nurses seem to be generally uninvolved in pain management, and there is little significant evidence shedding light on nurses' pain management knowledge and beliefs in postoperative settings. To perform such studies, a valid questionnaire in French to assess nurses' knowledge and beliefs is required. Some valid questionnaires are available in English, but none are available in French. Purpose This article describes the process of translation, adaptation, and preliminary validation of the Toronto Pain Management Index into French. Results For temporal stability of the Toronto Pain Management Index, French-Canadian version, the result of intraclass correlation coefficient for the total score of this questionnaire is 0.59 (CI: 0.44-0.72). Conclusion Following this process, the French version of this questionnaire has suitable face and content validity and can be used to evaluate nurses' knowledge and beliefs about pain management in postoperative settings.

An Integrative Review of the Literature on Pain Management Barriers: Implications for the Canadian Clinical Context

Despite decades of pain research, substandard pain management continues to be distressingly prevalent across health-care settings. This integrative literature review analyzes and synthesizes barriers to effective pain management and identifies areas for future investigation in a Canadian context. Three sets of key barriers were identified through thematic analysis of 24 original research studies published in the period 2003-13: patient, professional, and organizational. These barriers rarely occurred in isolation, with many studies reporting examples in all three categories. This suggests that interventions need to reflect the multifactorial nature of pain management. Reframing pain education as a public health initiative could lead to sustainable improvement, as could the strengthening of partnerships between patients and health-care providers. There are tremendous opportunities for the advanced practice nurse to take a lead in pain management. The delivery of high-quality care that encompasses effective pain management strategies must be a priority for nursing. Research approaches, such as pragmatic mixed methods, that offer contextual understanding of how pain is managed are suggested.

The ethics of postoperative pain management: Mapping nurses' views

AIM

We explored the positions of nurses working in hospitals regarding the acceptability of refusing to give a repeat dose of painkiller to a postoperative patient who requested it. These positions were compared with that of lay people, physicians, and other health professionals.

DESIGN AND METHODS

Factorial design was used to assess the impact of 6 situational factors: the patient's age, the current level of pain as assessed by the nurse, the number of requests, the level of risk associated with the administration of a repeat dose, the outcome of surgery, and the giving of alternative mild analgesics. We implemented a combination of scenario technique and of cluster analysis. Data were collected from April 2013 to December 2015.

PARTICIPANTS

138 registered nurses, 32 nurse's aides, 33 physicians, 23 psychologists, and 169 lay people participated in the study.

RESULTS

We found 4 qualitatively different meaningful positions. A plurality of participants (57% of nurses) considered that refusing was not acceptable, irrespective of circumstances. A substantial minority of participants (but 52% of physicians) considered that refusing was acceptable only if the level of pain was low and the risk was high. Other participants (mostly lay people) considered that refusing was always acceptable each time a risk of side effects, either serious or simply mild, was present.

Factors influencing orthopedic nurses’ pain management: A focused ethnography

Aim: The aim of this study was to explore the factors influencing orthopedic surgery nurses’ decisions to administer pro re nata (PRN) opioid analgesia for postoperative pain.

Background: Fast-track surgery programs reduce length of stay by identifying and addressing factors causing patients to remain in hospital, including pain (H. Kehlet, Lancet. 2013;381:9878(9878)). The management of acute pain is an important component of quality care for patients after total knee arthroplasty.

Methods: The study used a qualitative design of focused ethnography. Ten nurses working on an orthopedic surgery unit at a large urban hospital in western Canada participated in semistructured interviews that used a patient vignette to examine factors that influenced participants’ pain management in the context of fast-track surgery. Interviews were transcribed and analyzed using thematic analysis and constant comparison.

Findings: Nurses described a complex clinical environment where the interplay of several factors informed decisions to administer PRN opioid analgesia. The unit’s culture and physical space influenced nurses’ assessments of pain and their decisions whether to treat pain with PRN opioids. Each nurse’s self-concept affected pain management decisions because of perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient’s expression of pain from within the milieu of the unit culture and their unique self-concept.

Conclusion: Understanding the complexity of factors that influence nurses’ postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the challenging setting of fast-track surgeries.

Pain: A content review of undergraduate pre-registration nurse education in the United Kingdom

BACKGROUND

Pain is a global health issue with poor assessment and management of pain associated with serious disability and detrimental socio economic consequences. Pain is also a closely associated symptom of the three major causes of death in the developed world; Coronary Heart Disease, Stroke and Cancer. There is a significant body of work which indicates that current nursing practice has failed to address pain as a priority, resulting in poor practice and unnecessary patient suffering. Additionally nurse education appears to lack focus or emphasis on the importance of pain assessment and its management.

DESIGN

A three step online search process was carried out across 71 Higher Education Institutes (HEIs) in the United Kingdom (UK) which deliver approved undergraduate nurse education programmes. Step one to find detailed programme documentation, step 2 to find reference to pain in the detailed documents and step 3 to find reference to pain in nursing curricula across all UK HEI websites, using Google and each HEIs site specific search tool.

RESULTS

The word pain featured minimally in programme documents with 9 (13%) documents making reference to it, this includes 3 occurrences which were not relevant to the programme content. The word pain also featured minimally in the content of programmes/modules on the website search, with no references at all to pain in undergraduate pre-registration nursing programmes. Those references found during the website search were for continuing professional development (CPD) or Masters level programmes.

CONCLUSION

In spite of the global importance of pain as a major health issue both in its own right, and as a significant symptom of leading causes of death and illness, pain appears to be a neglected area within the undergraduate nursing curriculum. Evidence suggests that improving nurse education in this area can have positive impacts on clinical practice, however without educational input the current levels of poor practice are unlikely to improve and unnecessary patient suffering will continue. Undergraduate nurse education in the UK needs to review its current approach to content and ensure that pain is appropriately and prominently featured within pre-registration nurse education.

Standardising analgesic administration for nurses: a prospective intervention study

Background Uncontrolled pain reduces quality of life, delays recovery from surgery and can potentially contribute to the development of chronic pain. Strategies to improve pain management are desirable in view of these detrimental outcomes, yet frequently they are predominately medically based despite nurses playing key roles in pain assessment and analgesic administration. Objective To develop an algorithm-based guidance addressing nurses' pain assessment and analgesic administration and investigating its impact on quality of pain management. Setting Two orthopaedic units in a university hospital. Method An interdisciplinary expert panel consisting of physicians, nurses and clinical pharmacists developed an algorithm-based guidance in analgesic administration for nurses. The guidance was based on current guidelines addressing the appropriate use of analgesics. In a prospective intervention study, clinical pharmacists acted as independent monitors who assessed nurses' pain assessment and analgesic administration before (control period: usual care without any further support) and after implementation of the algorithm-based guidance (intervention period). We evaluated patient-nurse contacts for guideline adherence. We predefined guideline adherence (main outcome) as fulfilling all three of the following criteria: (A) nurses' pain intensity assessment, (B) their assessment of the patients' need for analgesics, and (C) analgesic administration depending on patients' individual pain intensity (including choice of prescribed analgesics). Main outcome measure Adherence to pain management guidelines. Results We analysed 706 patient-nurse contacts with 162 patients in the control and 748 contacts with 168 patients in the intervention period. Without support, guidelines were followed in 6 % of the patient contacts. We achieved an increase to 54 % (p < 0.001) after guidance implementation (main outcome). Guideline adherence decreased with rising pain intensity (slope coefficient -0.763, p < 0.001). Conclusion Especially in patients suffering from severe pain, current guidelines were not strictly followed by nurses when administering analgesics. Guideline adherence improved eightfold by implementing an algorithm-based guidance.

Postoperative pain documentation in a hospital setting: A topical review

Background and aims

Nursing documentation supports continuity of care and provides important means of communication among clinicians. The aim of this topical review was to evaluate the published empirical studies on postoperative pain documentation in a hospital setting.

Methods

The review was conducted through a systematic search of electronic databases: Web of Science, PubMed/Medline, CINAHL, Embase, Ovid/Medline, Scopus and Cochrane Library. Ten studies were included. Study designs, documented postoperative pain information, quality of pain documentation, reported quality of postoperative pain management and documentation, and suggestions for future research and practice improvements were extracted from the studies.

Results

The most commonly used study design was a descriptive retrospective patient record review. The most commonly reported types of information were pain assessment, use of pain assessment tools, useof pain management interventions, reassessment, types of analgesics used, demographic information and pain intensity. All ten studies reported that the quality of postoperative pain documentation does not meet acceptable standards and that there is a need for improvement. The studies found that organization of regular pain management education for nurses is important for the future.

Conclusions

Postoperative pain documentation needs to beimproved. Regular educational programmes and development of monitoring systems for systematic evaluation of pain documentation are needed. Guidelines and recommendations should be based on the latest research evidence, and systematically implemented into practice.

Implications

Comprehensive auditing tools for evaluation of pain documentation can make quality assessment easier and coherent. Specific and clear documentation guidelines are needed and existing guidelines should be better implemented into practice. There is a need to increase nurses’ knowledge of postoperative pain management, assessment and documentation. Studies evaluating effectiveness of high quality pain documentation are required.

Healthcare professionals' descriptions of care experiences and actions when assessing postoperative pain - a critical incident technique analysis

BACKGROUND

Pain is a common postoperative symptom, and length of hospital stay after surgery is short which highlights the importance of pain assessments. Experiences of assessing pain are mainly described from the perspective of nurses. In postoperative care, enrolled nurses and physicians also assess pain. It is therefore important to take note of their experiences to improve postoperative pain assessments.

OBJECTIVES

The aim of this study was, through considering critical incidents, to describe care experiences and actions taken by healthcare professionals when assessing postoperative pain.

METHODS

An explorative design employing critical incidents technique analysis was used. A total of 24 strategically selected enrolled nurses, nurses and physicians employed at orthopaedic or general surgery wards in four Swedish hospitals were interviewed. The intention was to reach variation in age, sex, profession and professional experience.

FINDINGS

In pain assessments, patient-related facilitators were patients' verbal and emotional expressions including pain ratings, while lack of consistency with observed behaviours was a barrier. Clinical competence, continuity in care and time were healthcare-related facilitators. The actions healthcare professionals took were gathering facts about patients' pain manifestations and adapting to patients' communication abilities. Patient observations, either passive or active were used to confirm or detect pain. Collaboration between healthcare professionals, including consultations with pain experts, social workers and relatives, strengthened understanding of pain.

CONCLUSIONS

Communication skills and working conditions have an impact on performance of pain assessment. Patient comfort without compromising safety is reached by including healthcare professionals' dissimilar responsibilities when collecting patients' and relatives' perspectives on current pain.

Measures of clinical accuracy and indicators of the nursing diagnosis of delayed surgical recovery

Delayed surgical recovery is a phenomenon of global concern that affects the results and costs of postoperative care. The aim of this study was to verify the accuracy of the defining characteristics of the diagnosis of delayed surgical recovery in patients after the fifth day in postoperative care. A cross-sectional observational study was conducted with 72 surgical patients to measure sensitivity, specificity, positive and negative predictive values, positive likelihood ratios and negative odds ratios. Diagnoses and the area under the ROC curve were analysed to investigate the diagnostic accuracy of each defining characteristic. Most patients were male (65.3%) with an average length of education of 17.4 years (SD = 1.88) and a mean age of 57.39 years (SD = 16.04), and 55 (76.4%) had the diagnosis of delayed surgical recovery. The variable time after surgery showed a statistical relationship with the diagnosis of delayed surgical recovery (p = .012). Seven characteristics showed high positive predictive values: postpones resumption of work/employment activities, fatigue, perception of needing more time to recover, requiring help to complete self-care, report of discomfort, evidence of interrupted healing of the surgical area, and difficulty in moving about. The only factor in the study that was associated with the diagnosis was postoperative surgical site infection (p = .028).

Improving the management of post-operative acute pain: priorities for change

Poor management of post-operative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. It is therefore important that all patients undergoing surgery should receive adequate pain management. However, evidence suggests this is not currently the case; between 10% and 50% of patients develop chronic pain after various common operations, and one recent US study recorded >80% of patients experiencing post-operative pain. At the first meeting of the acute chapter of the Change Pain Advisory Board, key priorities for improving post-operative pain management were identified in four different areas. Firstly, patients should be more involved in decisions regarding their own treatment, particularly when fateful alternatives are being considered. For this to be meaningful, relevant information should be provided so they are well informed about the various options available. Good physician/patient communication is also essential. Secondly, better professional education and training of the various members of the multidisciplinary pain management team would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain at different points along pain pathways, more widespread adoption of patient-controlled analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational change could provide similar benefits; introducing acute pain services and increasing their availability towards the 24 hours/day ideal, greater adherence to protocols, increased use of patient-reported outcomes, and greater receptivity to technological advances would all help to enhance performance and increase patient satisfaction. It must be acknowledged that implementing these recommendations would incur a considerable cost that purchasers of healthcare may be unwilling or unable to finance. Nevertheless, change is under way and the political will exists for it to continue.

Complexity of Pain, Nurses' Knowledge, and Treatment Options

The complexity of pain requires nurses to conduct in-depth assessments, be knowledgeable about influential factors (ie, age, culture, health status), and treat pain with the least harmful and most beneficial interventions. The monotherapy use of analgesics, the fifth vital sign, and a 1-dimensional scale have fallen short of satisfactory results. Pain is the most frequent reason individuals seek health care and cost billions of dollars. Nurses are pivotal in the management of pain. Nurses who are knowledgeable about pain and pain management improve patient outcomes and patient satisfaction scores. Research results indicate the need to advance nurses' knowledge in pain management through various educational offerings.

Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical practice

AIMS AND OBJECTIVES

To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar.

BACKGROUND

Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context.

DESIGN

A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline.

METHODS

A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland.

CONCLUSIONS

Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery.

RELEVANCE TO CLINICAL PRACTICE

A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes.

Postoperative pain management among surgically treated patients in an Ethiopian hospital

Background

Incidence of postoperative pain has been reported to be between 47–100%. Ineffective postoperative pain management results in tangible and intangible costs. The purpose of this study was to assess the processes and outcomes of pain management in the surgical wards of Jimma University Specialized Hospital, Ethiopia.

Methods and Findings

A prospective cross sectional study was conducted among 252 postoperative patients during February 13 to April 30, 2012. A contextually modified and validated (Cronbach’s α coefficient of 0.78) American Pain Society Patient Outcome Questionnaire was used to assess pain experience of patients. Patients’ charts were reviewed to assess the pattern of analgesic use. Incidence of postoperative pain was 91.4%, and remained high over 3 measurements (McNemar’s; p<0.05), and 80.1% of the patients were undertreated. The mean pain intensity, and pain interference on functional status were 6.72±1.44 and 5.61±1.13 on a 10 point Numerical rating scale respectively; both being strongly correlated(r = 0.86: p<0.001). Pain intensity was varied by ethnicity, education and preoperative information (ANOVA; P<0.05). Only 50% of the patients were adequately satisfied with their pain management. As needed (prn), solo analgesic, null analgesic, and intramuscular orders were noted for 31.3%, 89.29%, 9.7% and 20.1% of the prescription orders respectively. Though under dose, diclofenac and tramadol were the top prescribed medications, and only 57% of their dose was administered. Linear regression model showed that the predictors of satisfaction were sex of an individual and pain interference with functional status.

Conclusion

Despite patients’ paradoxical high satisfaction with pain management, the majority of patients were inadequately and inappropriately treated. Thus, further research is needed to determine how best to break down current barriers to effective pain management.

Seeking empowerment to comfort patients in severe pain: a grounded theory study of the nurse's perspective

BACKGROUND

Hospital patients experience significant pain, which can delay healing and increase the risk of developing chronic pain. Nurses are affected by patients' ongoing pain and may cope with consequent anxiety and helplessness by distancing themselves from such patients. Understanding nurses' responses to patients in severe pain will inform strategies to support their coping, their patients and, ultimately, their retention in the nursing workforce.

OBJECTIVES

The aim of the study was to develop a substantive theory explaining the hospital nurse's perspective of caring for patients in severe pain.

DESIGN

The study used grounded theory method.

SETTINGS

Data were collected on four acute care wards in a 610 bed Australian hospital.

PARTICIPANTS

The sample included 33 nurse participants and 11 patient participants. Selection criteria for nurse participants were those who worked in the four study wards, cared for patients who experienced severe pain, and consented to be included. Selection criteria for patient participants were those who self-reported pain at intensity of seven or more on a scale of 0-10, were aged 18 years or older, could speak and read English, and consented to be included.

METHODS

Theoretical sampling directed the collection of data using semi-structured interviews with nurses and participant observation, including structured observations of nurses who cared for patients in pain. Data were analysed using constant comparison method.

RESULTS

Nurse participants encountered a basic psychosocial problem of feelings of disempowerment when their patients experienced persisting severe pain. In response, they used a basic psychosocial process of seeking empowerment to provide comfort in order to resolve distress and exhaustion associated with disempowerment. This coping process comprised three stages: building connections; finding alternative ways to comfort; and quelling emotional turmoil.

CONCLUSIONS

The substantive theory proposed a link between the stress of nurses' disempowerment and a coping response that provides direction to support nurses' practice. Strategies indicated include enhanced communication protocols, access to advanced practice nurses, use of nonpharmacological comfort measures, utilization of ward-based pain resource nurses, and unit-specific pain management education. Further research to verify and extend the substantive theory to other settings and nursing populations is warranted.

Predictors of nurses' knowledge and attitudes toward postoperative pain in Greece

Undertreatment of postoperative pain can aggravate patient outcomes and is associated with attending nurses' knowledge deficits or negative attitudes toward pain. The aim of this study was to investigate knowledge and attitudes toward postoperative pain of surgical department nurses and to identify predictors of their knowledge and attitudes. This was a descriptive, cross-sectional survey that took place in the departments of general surgery, orthopedics, neurosurgery, ear-nose-throat surgery, and obstetrics/gynecology at five Greek hospitals. Participants were a convenience sample of registered and assistant nurses. Nurses were asked to complete a three-section questionnaire, which included demographics, a Knowledge and Attitudes Survey Regarding Pain (KASRP) tool modified for postoperative pain, and seven questions capturing personal characteristics, working conditions, and feelings about work. One hundred eighty-two questionnaires were completed. Average scores were 45.35% for modified KASRP tool; 28.57% for pain assessment; 55.44% for general pain management; and 47.13% for use of analgesics. Four of the five most commonly missed items referred to use of analgesics. More previous personal experience of postoperative pain (p = .002) and being a registered nurse (p = .015) predicted higher modified KASRP tool score. Participation in continuing education programs and department of employment were also associated with differences in the modified tool score. The knowledge deficits and negative attitudes of the nurses toward postoperative pain highlight the role of pregraduate and continuing education, appropriately specialized for each surgical department, in the development of empathy toward patients in pain and of clinical competency regarding pain assessment and administration of analgesics.

Development and validation of an observation tool for the assessment of nursing pain management practices in intensive care unit in a standardized clinical simulation setting

Pain management in the intensive care unit is often inadequate. There is no tool available to assess nursing pain management practices. The aim of this study was to develop and validate a measuring tool to assess nursing pain management in the intensive care unit during standardized clinical simulation. A literature review was performed to identify relevant components demonstrating optimal pain management in adult intensive care units and to integrate them in an observation tool. This tool was submitted to an expert panel and pretested. It was then used to assess pain management practice during 26 discrete standardized clinical simulation sessions with intensive care nurses. The Nursing Observation Tool for Pain Management (NOTPaM) contains 28 statements grouped into 8 categories, which are grouped into 4 dimensions: subjective assessment, objective assessment, interventions, and reassessment. The tool's internal consistency was calculated at a Cronbach's alpha of 0.436 for the whole tool; the alpha varies from 0.328 to 0.518 for each dimension. To evaluate the inter-rater reliability, intra-class correlation coefficient was used, which was calculated at 0.751 (p < .001) for the whole tool, with variations from 0.619 to 0.920 (p < .01) between dimensions. The expert panel was satisfied with the content and face validity of the tool. The psychometric qualities of the NOTPaM developed in this study are satisfactory. However, the tool could be improved with slight modifications. Nevertheless, it was useful in assessing intensive care nurses' pain management in a standardized clinical simulation. The NOTPaM is the first tool created for this purpose.

Registered nurses' personal responses to postoperative pain: a descriptive qualitative study

This paper explores if nurses' personal responses to postoperative pain contribute to its continuing poor management. A descriptive qualitative design used a purposive sample of 16 registered nurses (RNs), from inpatient surgical areas in the United Kingdom, to participate in one semistructured interview. These were recorded and transcribed verbatim. Analysis used Morse and Field's four stages. A complex picture of collective and individual responses emerged; uncritical adoption of the medical model, with pain as normal and focus on technical aspects of management conforming to a "reference typology." However, individual RNs were also influenced by other personal factors, and findings indicate that scrutinizing individual competency is essential to improve individual and collective practice.

Treinamento e avaliação sistematizada da dor: impacto no controle da dor do pós-operatório de cirurgia cardíaca

Neste estudo analisou-se o efeito do Treinamento e uso de Ficha de Avaliação Sistematizada para controle da dor após cirurgia cardíaca, sobre a intensidade da dor e o consumo de morfina suplementar. Três grupos de pacientes foram submetidos a um ensaio clínico não randomizado com prescrição analgésica padronizada. No Grupo I, a equipe de enfermagem não recebeu treinamento sobre avaliação e manejo da dor e cuidou dos doentes conforme a rotina da instituição. Nos grupos II e III, toda a equipe foi treinada. A equipe de enfermagem do grupo II utilizou a Ficha Sistematizada sobre Dor, e a do grupo III não a utilizou. O grupo II apresentou dor menos intensa e maior uso de morfina suplementar. O treinamento associado à Ficha de Avaliação aumentou a chance de identificar a dor e influenciou o processo de decisão do enfermeiro na administração de morfina, favorecendo o alívio da dor dos pacientes.

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).

The impact of experience on undergraduate preregistration student nurses' responses to patients in pain: a 2-year qualitative longitudinal study

The management of pain is consistently reported as a problematic area of practice, with limited evidence of improvements in the past 30 years. This study explores the impact of experience on student nurses' responses to patients in pain. Sixteen volunteers from a cohort of undergraduate student nurses in the U.K. participated in a qualitative longitudinal study that used two semistructured interviews 18 months apart. Interview transcripts were analyzed with the use of thematic content analysis for each individual interview stage and then additionally to identify relationships between each stage. Participants revealed an initial lack of interest in nearly all aspects of pain. At the second stage of interviews, some participants expressed increasing discernment and empathy toward patients in pain, although some continued to have minimal interest. Findings suggest that an active interest in pain is essential so that individuals can react critically to assumptions of the clinical culture they are exposed to. Further research is needed to identify how an active interest can by developed among those students for whom experience has little positive impact. Without active interest, apathy, aversion to change, and continued poor pain management practices are likely to continue.

Empirical review supporting the application of the "pain assessment as a social transaction" model in pediatrics

Despite decades of research, national mandates, and widespread implementation of guidelines, recent reports suggest that the quality of pain assessment and management in hospitalized children remains suboptimal. The mismatch between what is advocated and what is done in practice has led experts to argue for a conceptual shift in thinking, where the pain assessment process is viewed from a complex social communication or transaction framework. This article examines the empirical evidence from the recent pediatric pain assessment and decision-making literature that supports adaptation of Schiavenato and Craig's "Pain Assessment as a Social Transaction" model in explaining pediatric acute pain management decisions. Multiple factors contributing to children's pain experiences and expressions are explored, and some of the difficulties interpreting their pain scores are exposed. Gaps in knowledge related to nurses' clinical pain management decisions are identified, and the importance of children's and parents' preferences and roles and the influence of risks and adverse events on decision making are identified. This review highlights the complexity of pediatric nurses' pain management decisions toward the clinical goal of improving comfort while minimizing risk. Further study evaluating the propositions related to nurses' decisions to intervene is needed in pediatric clinical settings to better synthesize this model for children.

[Descriptive study of the postoperative pain assessment and documentation process in a university hospital]

Several studies have shown that patients often receive inadequate treatment of postoperative pain. The aim of the present descriptive study was to examine and analyze various data related to the postoperative pain assessment of 40 patients who underwent elective surgery. Pain journals were to be completed by patients during every waking hour for the first three postoperative days to assess both pain intensity and pain unpleasantness. A post hoc analysis of patient records permitted verification of pain assessment by nurses for each patient. The results showed that not only was postoperative pain rarely assessed using a valid scale, it was also poorly documented. In addition, when nurses assessed and documented postoperative pain using a numerical scale, their results were very different from patients' assessments. For the first postoperative day, the mean (± SD) pain intensity documented by nurses on a 0 to 10 numerical scale was 1.57±0.23, while the mean pain intensity noted by patients using the same scale was 3.82±0.41. Statistical analysis showed that there was no significant correlation between mean pain intensity documented by nurses and the mean pain intensity noted by patients.