Essay title - Nurses’ Ability to Assess Pain After Major Surgery
Several studies have shown that many patients receive inadequate treatment for their pain after major surgery (Brown & Mackey 1993, Closs et al. 1993, Elander et al. 1993, Bamberger et al. 1994). In spite of experiencing post-operative pain many patients felt satisfied with their pain relief (Donovan 1993). Meehan et al. (1995) investigated patients' (n = 51) perception and satisfaction with pain management for 5 days immediately after thorax surgery. Despite the fact that several patients in the group experienced severe pain, 96% of the patients experienced effective pain management. Pain treatment after thoracic surgery is particularly important in view of the damaging effects of chest wall pain with the increased risk of pulmonary complications (Sebanathan et al. 1993). In a study by Puntillo & Weiss (1994) the authors examined pain intensity in 98 patients after coronary artery bypass graft surgery or after abdominal vascular surgery. The authors showed that patients with higher pain intensity scores had significantly more atelectasis. Moore(1994) interviewed 20 patients after coronary artery bypass surgery, 1 day prior to discharge. The patients described the pain from their chest incision as 'grabbing', 'tight pressure' and 'tingling', especially when turning in bed and moving in and out of bed or chair. When coughing, a sharp, short stabbing, knife-likepain was perceived which made them feel as if they were going to explode. In an extensive Swedish investigation studying patients (n = 1161) after coronary bypass grafting it was shown that 42% of the patients had chest pain on various occasions up to 2 years after surgery. Their chest pain was well correlated with chest pain during the exercise test but not with signs of myocardial ischaemia (Brandrup-Wongsen et al. 1997).
Nurses have a very important function in the treatment of patients' pain. Often they have to administer prescribed drugs and to choose the right dose for individual patients. Cohen (1998) investigated patients (n = 109) with a structured interview to ascertain the adequacy of pain relief. Nurses (n = 121) were given a questionnaire derived from Marks & Sachar (1993). This was a written self-administered questionnaire consisting of a series of clinical situations in the form of vignettes and multiple choice questions which, among other things, assessed how the nurses decided on the doses of analgesics to administer. Cohen showed that nurses selected dosages far below the real needs of the patients.
McCaffery & Ferrell (1991) held pain control workshops for 456 nurses in six cities in the United States of America. The authors experienced that nurses' decisions on pain control were influenced by the patients' behaviour. Calvillo & Flaskerud (1993) showed that in spite of the lack of significant differences in postoperative pain by Mexican American women and Anglo-American women there was a significant difference in pain scores between the two ethnic groups when evaluated by the nurses. The authors concluded that the nurses underestimate pain when they do not recognize the way patients express their pain.
In a study by Zalon (1993) the author compared nurses' assessment of postoperative pain with the patients' own assessment. This study showed that the majority of the nurses underestimated their patients' pain. Similar results were found by Sjostrom et al. (1997) which showed that both nurses and physicians underestimated the patients' pain, but nurses did so to a greater degree.
The importance of nurses being educated in pain and pain control is described in a study by Foglesong et al. (1997). The authors described that the nurses at two hospitals participated in a 6-hour workshop concerning assessment of pain and management of analgesics. One month after the workshop it was shown that more patients than previously received analgesics 4 hours after recovery room discharge. It was also shown that more patients received dosages of analgesics equal to the maximum prescribed in a 24-hour period (Foglesong et al. 1997).
The idea for this current investigation arose when the thorax department in a university hospital, in southern Sweden, decided to arrangea study day about pain and pain treatment for all registered nurses working at the department.
Study Aim and Questions
The aims of this investigation were: to describe patients' evaluation of pain and the treatment of pain after thorax surgery via sternotomy; to repeat the evaluation with another group of patients following a study day for nurses, featuring pain and pain treatment; and to examine whether the study day influenced the nurses in their treatment of pain.
- How do patients evaluate their pain after thorax surgery via sternotomy, during the second to the sixth postoperative day, and also retrospectively before discharge?
- In what way does a study day on the theme of pain affect the patients' experience of pain and pain treatment?
- Which dosages do the nurses wish to give and what dosages do nurses actually choose to give from the standing order, both before and after a study day?
- Does a study day influence the nurses' attitudes to pain and knowledge of pain treatment?
The patient investigation included two groups of patients: group 1 consisted of 39 patients prior to the study day for the nurses and group 2 consisted of 41 patients after this had taken place. The patients were included consecutively, from a surgical department at a university hospital in southern Sweden. They were recruited during two 3-week periods and with selection criteria: mentally healthy adults who had had thorax surgery via sternotomy. Transplant patients were excluded since they generally had a more severe form of treatment both before and after the surgery and also needed further time in ICU.
In group 1 (prior to the study day), one patient decided not to participate in the investigation with daily pain evaluation and with the interview before discharge. In group 2 (after the study day), four patients chose not to participate.
All nurses in the thorax department (n = 75) received a questionnaire prior to the study day, 74 questionnaires were returned, of which five were removed as they were incomplete. The questionnaire was answered by 38 nurses from ICU (intensive care unit) and 31 nurses from the thorax surgical ward. Three months after the study day the same questionnaire was given to the same nurses by the ward sisters. On this occasion 26 ICU nurses and 23 ward nurses answered the questionnaire. No reminder was given. Finally, a retrospective study of the case notes of the patients included in the study was carried out.
A visual analogue scale (VAS) (Huskisson 1974) was used for daily pain evaluation. VAS is a scale stretching from no pain to pain as bad as it could be and described as mild, moderate and severe. The visual analogue scale is graduated from 0 to 100 mm.
During the interview with the patients before discharge, a questionnaire previously used in a study by Donovan (1993) was utilized. The questionnaire had not been validated by Donovan. To check validity of the Swedish version it was given to three patients.
The nurses answered a questionnaire formulated by Marks & Sachar (1993), adapted by Cohen (1998) and Lavies et al. (1992). Cohen (1998) validated the questionnaire with the help of a panel of nurses. The questionnaire was translated into Swedish and adjusted to Swedish conditions. Validity of the translated version was checked with a small group of nurses familiar with the area but not working on the wards taking part. The questionnaire consisted of 13 questions and was designed to give information about nurses' attitudes and their knowledge about pain and treatment. It also included questions concerning their interpretation of the standing orders.
The patients in this study received information from the investigator about the aim and procedure of the study. This was given to them on the same day they returned to the ward from the ICU after surgery. Informed consent was obtained and the patients were informed that the participation was optional and if they choseto participate they could discontinueat any time. The patients were also informed that their answers were confidential and that all identification was removed from data collection tools and that only code numbers were used. When the patients, during the daily evaluation of pain, stated that they were in pain, they always were asked by the investigator: Would you like me to contact the nurse so you can get some treatment for your pain?
The study was approved by the Medical Research Ethics Committee of the University Hospital, Lund, Sweden.
Procedures and data collection
Daily evaluation of pain by the patients themselves was conducted by the investigator and took place once a day during their stay on the thorax ward. This was always performed directly after lunch. This time was chosen as it suited both the ward routine and the investigator. One group of patients (group 1) were questioned prior to the study day and another group (group 2) were asked the same questions 3 months after the study day. The time period of 3 months was chosen to allow for the possible effects of the study day to reach a steady state for the nurses and therefore reflect the present reality.
The investigator conducted a short interview with the patients before discharge. They were asked to review their pain and the pain treatment. Pain assessment retrospectively was carried out to gain knowledge about patients' experience of pain as a whole. In connection with the daily visits, memoranda were written about special occurrences and observations by the investigator. The nurses from the thorax surgery department answered a questionnaire at the start of the study day and again 3 months later. The study day dealt with: physiology and pharmacology associated with pain, assessment of pain, strategies for the treatment of pain, presentation of a study about ICU nurses' attitudes towards pain treatment, and a study of patients' experience of the pain treatment at the clinic.
For statistical analysis of the doses, the Mann-Whitney test was used. Comparison between retrospective pain evaluation and pain evaluation during daily visits was performed by means of a stratified Mann-Whitney test with patient as stratum. Pain was analysed by first computing a Mann-Whitney rank sum for each day separately, and then adding the five rank sums quantities obtained (one for each day). The significance of that sum was assessed by the Monte Carlo technique (Good 1994), i.e. the 75 patients were randomly divided into two groups of 38 and 37 patients, respectively, and the corresponding sum of five test quantities was computed; this procedure was repeated 1000 times, and the P value is the relative frequency of the test quantities exceeding that from the actual data set.
Patients' experience of pain after thorax surgery via sternotomy
Patients' experience of pain was registered once a day, from the second to the sixth postoperative day. This was done with group 1 before and with group 2 after the study day on the theme of pain, which was held for all the nurses at the clinic (Figure1).
The diagram shows a low evaluation of pain by most patients during the daily visits and an even lower evaluation after the study day. This difference is significant (P = 0.006 according to one sample Mann-Whitney test for repeated observations).
Pharmacological treatment of pain
The pharmacological treatment of pain, as used in the thorax department during the time of the study, consisted mainly of three drugs, ketobemidone, an opioid for parenteral administration, dextropropoxyphene (so-called 'weak' opioid) and paracetamol for oral treatment. The nurses were delegated to administer analgesics according to standing order which prescribed ketobemidone 2.5-5 mg, intravenously administered while on the ICU and the same dose subcutaneously administered while on the ward, sometimes together with paracetamol 0.5-1 g orally. When given an opioid per oral administration, the choice would bedextropropoxyphene 50-100 mg. All drugs were prescribed to be given as required.
The patients' daily amounts of respective drugs, obtained from their case notes, are presented below (Figures 2-4). The increased amount of ketobemidone administered during days one and two was reflected in the reduced amount of dextropropoxyphene given.
Retrospective evaluation of pain and viewpoints about pain relief
When the patients were asked during the interview to recall their pain experience, 76% of the patients had had pain post-operatively (six patients were not available for interview before the study day and three were not available after the study day). According to VAS, retrospective pain evaluation by these patients, 46 mm (mean) was estimated before (group 1) and 43 mm after the study day (group 2). Patients' retrospective evaluation of pain was significantly higher than during the daily visits both before (P = 0.0017) and after (P = 0.0003) the study day.
Thirty-eight per cent of the patients evaluated their pain retrospectively to 50 mm or more, according to VAS. This result was the same both before and after the nurses' study day. In the interview immediately prior to discharge 95% of the patients said they were satisfied with their pain relief. The patients who had said that they were in pain postoperatively where also asked 'Why were you satisfied if you still had pain?' To this question most of the patients answered that it was because they had expected pain after surgery, six of the patients said their reason was that they did not want to bother the nursing staff by asking for analgesics.
Patients with evidence of severe pain
A small group (8%) of the patients experienced more pain daily than the others. They evaluated their pain during the second to the sixth postoperative day as being, on average, more than 40 mm (range 48-73 mm), according to VAS. The retrospective pain evaluation by these patients was 51 mm (mean) measured by VAS. According to daily memoranda the common observation concerning these patients was that they behaved or expressed themselves in a way such that the nurses had difficulty in recognizing and interpreting their pain behaviour.
Nurses' choice of dosage related to their opinion of intravenous opioid
On ICU the standing order recommended ketobemidone, as first choice, intravenously with dose-interval 2.5-5 mg. When the ICU-nurses were asked in the questionnaire 'Which dose of ketobemidone do you choose for a 60-year-old man weighing 70 kg?', they chose a dose of just above 3 mg. This they chose both before and after the study day. When studying the case notes it was obvious that the ICU nurses often chose to deviate from the standing order and gave a lower dose of ketobemidone than prescribed. The doses of ketobemidone, titrated intravenously and given within half an hour, or doses given as one dose subcutaneously in combination with an intravenous dose, has been regarded as one dose. Before the study day, the patients received a mean dose of 2.0 mg ketobemidone intravenously. After the study day they received 2.4 mg which is a significant increase (P = 0.0047). The difference between the nurse's choice of dose, according to the questionnaire, and the given dose, according to case notes, is significant both before (P < 0.00005) and after (P < 0.00005) the study day. The ward nurses administered doses which were in accordance with standing orders.
The nurses were asked the following:
After thorax surgery a patient received, as required, 5 mg ketobemidone intravenously (at the ICU)/5 mg ketobemidone subcutaneously (at the ward) every fourth hour. If he complains of pain already 3 hours after his last doseand asks for a new dose would you: request the patient to wait another hour; give a reduced dose; givea dose of pethidine (at the ICU); give oral analgesics (at the ward); give another 5 mg ketobemidone; ask the physician for advice?
The majority of ICU nurses (39%) chose to give a reduced dose, 24% would give another 5 mg and 21% would ask the physicians for advice. Sixteen per cent of the ICU nurses did not answer the question or chose more than one alternative. Of the ward-nurses 7% chose to give a reduced dose, 42% would give another 5 mg, 19% chose to give analgesics 'per os' and 13% would contact the physician for advice. Of the ward nurses 19% did not answer the question or chose more than one alternative. After the study day 63% of the ICU nurses and 30% of the ward nurses did not answer this question or chose more than one alternative.
Before the study day the nurses were asked in the questionnaire to evaluate doses of the analgesics, whether they felt these to be over-prescribed, under-prescribed or about the right amount. About 55% of the clinics' nurses answered that the prescriptions were right and the remaining nurses thought the doses were underprescribed. On the question 'what is the probability of a postoperative patient, given 5 mg ketobemidone every fourth hour for a week, becoming addicted', the alternatives for this answer were 100%, 50%, 10% or < 1%. Most of the nurses (66%) thought that the risk of addiction was under 1%. It was also noted that 12% of the nurses answered that 50% of the patients were at risk of addiction. Nineteen per cent of the nurses thought that addiction occurs in 10% of the patients and 3% did not answer the question.
Almost all of the nurses (93%) thought that a simple pain-scoring system would be helpful in assessing patient's pain. On the above questions there was no obvious difference between the answers given by the nurses from the ICU and those on the ward. Further more there is no difference between the answers given before and after the study day.
The current study shows that the patients (group 1) before the study day had evaluated their pain to a higher score at VAS compared with the patients (group 2) who evaluated their pain after the study day. No definite conclusions can be drawn from these results as the patients in the two groups were not the same individuals. The study day contributed to an increased supply of parenteral administered opioids during the first two postoperative days and to a reduced supply of oral opioids. It is possible that the increased supply of parenteral administered opioids might have had an effect on the patients' experience of pain.
Most physicians believed that nurses should have more control over patients' pain relief (Lavies et al. 1992). This is due to the fact that the nurses work closer to the patients at the bedside. McCaffery et al. (1990) pointed out that one problem is that nurses have not been sufficiently prepared to take on an increased responsibility for pain control. The authors were of the opinion that it would be beneficial to invest in higher quality pain education for nurses.
The objective of postoperative pain management is to provide adequate analgesia. This perhaps needs to be more strongly defined in nursing education (Chapman et al. 1987). The present investigation focused on nurses' management of pain control but there are also studies, both earlier and current, which show that physicians also have inadequate knowledge and under-treat patients' pain (Marks & Sachar 1993, Lavies et al. 1992).
Patients in group 1 (before the study day) evaluated their pain higher than patients in group 2 (after the study day) did. This can be due to the fact that the study day contributed to the increased intravenous administration of opioids during the first and the second postoperative days. The results, on the other hand, can also be due to a difference between the two groups of patients.
The nurses in ICU gave larger dosages of opioids after the study day, a significant difference when compared to before. According to the results of the questionnaire, the study day had had no influence on nurses' knowledge and attitudes to pain treatment. This may indicate that one single study day is not sufficient to contribute to changes in the attitude of nurses working with pain and pain control. Foglesong et al. (1997) indicated that the continuous education of nursing staff had an impact on nurses' attitudes.
Another way is to teach patients preoperatively about pain and pain relief and to illuminate the importance of pain relief so that they will feel free to request analgesics when they feel they need them, and not try to 'bebrave' (Cohen 1998).
This investigation shows that after a study day on the theme of pain arranged for all registered nurses in the thorax surgery department of one hospital, a group of patients evaluated their pain after the study day to be lower than another group of patients who completed evaluations prior to the study day. Results showed that the ICU nurses consistently gave lower doses than the lowest recommended dose according to standing orders both before and after the study day. However, the results also illustrated that after the study day the patients received an increased amount of intravenous administered analgesics on the first and second postoperative days.
Retrospective pain evaluation after cardiac surgery by patients just before discharge was significantly higher than the daily measurements. In this study a small group (8%) of patients suffered more evident pain daily. There was no difference between the answers to the questionnaire, regarding attitudes and knowledge, from nurses in ICU or from the ward. According to answers given in the questionnaire the study day did not influence the nurses' appraisal of dosage, or their attitudes and knowledge regarding opioids and assessment pain.
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