Few experimental studies have evaluated the efficacy of continuing educational programs aimed at the improvement of nurses’ pain-management skills. This study assessed whether a standardized educational program aimed at nurses could increase the use of the Numeric Rating Scale-11 in both documenting and reducing postoperative pain-intensity levels in hospitalized surgical patients. The study had a quasi-experimental pre- and post-intervention design. Data were collected from records of surgical patients prior to and after the standardized educational program was completed. There were no significant differences between pre- and post-intervention groups in terms of either pain-documentation frequency or pain-intensity level. The study showed no increase in the frequency of postoperative pain documentation and no reduction of surgical patients’ postoperative pain-intensity level. This finding indicates that the standardized educational program on postoperative pain management was insufficient to bring about changes in clinical practice.
Important goals of managing postoperative pain (POP) are to minimize pain and discomfort, facilitate the recovery process, and avoid complications [
Several studies [
Gunnarsdóttir et al. [
Several comprehensive quality-improvement studies conducted between 2000 and 2005 have displayed positive results [
To our knowledge, only three studies with less comprehensive and expensive interventions have been conducted [
This study assessed whether a standardized educational program aimed at nurses could increase the use of the NRS-11 in documenting and reducing POP intensity level in hospitalized surgical patients.
The study had a quasi-experimental pre- and post-intervention design [
The inclusion criteria were records of hospitalized surgical patients aged 18 years and above who had undergone abdominal or orthopedic surgery with pain documented using theNRS-11 three times or more, from the day of surgery to the fifth postoperative day or discharge. Exclusion criteria were records of surgical patients with pain documented using theNRS-11fewerthan three times, from the day of surgery to the fifth postoperative day or discharge. Data were collected between September and December 2009 prior to the educational intervention and from May to October 2010 after the intervention.
A registration instrument was developed based on the hospital’s pain paper schema, which included the following variables: NRS-11 pain-intensity ratings on arrival at the PACU and on discharge from the PACU, NRS-11 pain-intensity ratings, on arrival to the surgical unit, NRS-11pain-intensityratings at rest and in movement in the surgical ward, whether or not analgesics were given when the pain-intensity level was above 3 on the NRS-11, and variables for nausea and other pains. The pain paper schema follows patients through the entire surgical trajectory, from arrival at the PACU to discharge from the hospital, and is part of the surgical patient’s record. Additional demographic and clinical information was obtained on age, sex, preoperative risk in accordance with the American Society of Anesthesiologists (ASA), which is a 5-point scale, type of surgery, and type of anesthesia (main or supplementary anesthesia).
Data were collected from the hospital’s pain paper schema in the patient’s record and transferred into the registration instrument developed for this study.
Data were collected from the day of surgery until the fifth postoperative day or discharge. The data collection was performed by one nurse, and every 20th transferred registration was controlled. The educational program was pilot tested with eight nurses, who found it easy to understand. No corrections were made.
The educational program included a 20-minute standardized PowerPoint presentation with 24 slides based on guidelines from the IASP [
The PowerPoint presentation included the following:
1) Background: included a definition of pain [
2) Description of the NRS-11: the reliability and validity of the scale;
3) Proper use of the NRS-11: the importance of communicating pain, the aim of NRS ≤ 3 in the postoperative phase, and how to ensure that the patient understands the scale and the method of documentation.
The discussion following the PowerPoint presentation was primarily concerned with the practical application of the NRS-11, how to inquire about pain, why to trust patients’ self-reporting on pain, and the importance of documenting pain.
The educational program was carried out by 17 nursing students in either the second and third year of their bachelor’s program as part of mandatory pedagogical training in clinical practice. The authors introduced the students to the educational program and provided them with a manuscript to support the Power Point presentation. During the presentation and the following discussion, the students were always accompanied by one of the authors. The standardized educational program was offered at various times during the day and evening shifts in order to facilitate participation.
All nurses in the four surgical units and the PACU were encouraged by the management to attend the educational program. However, participation was voluntary. On average, 80% of the nurses from the surgical units and 90% of those from the PACU attended the lectures, and a total of 123 nurses participated in 18 lectures with 2 - 15 nurses per lecture.
In accordance with the Norwegian Regional Ethical Committee, it was unnecessary to obtain informed consent from the patients, nurses, and students. The nurses who participated in the educational program were informed about the project by their managers. The study was approved by the Norwegian Social Science Data Services and the hospital’s Ethics Committee.
Data were analyzed using SPSS version 17.0 for Windows (SPSS, Inc., Chicago, IL). Descriptive statistics were used to assess demographic and clinical characteristics, as well as pain-intensity scores. Owing to low data frequencies of the variables for other pains, nausea, vomiting, and whether or not analgesics were administered, these variables were omitted from the statistical analysis. Analyses on surgical-unit levels were not possible owing to the low frequency of data; hence, the four surgical units were collapsed into one unit. Results were recorded as mean, standard deviation (SD), median, range, and number (percentage). Differences between pre- and post intervention patient groups were analyzed using Student’s independent-samples t-test and a chi-square test. Student’s independent-samples t-test and/or the Mann-Whitney U test were used to compare the mean scores of pain before and after the educational program. A p-value less than 0.05 indicated that the variable estimated was statistically significant.
The sample included 355 (40.8%) of a total of 870 records from patients who had undergone abdominal or orthopedic surgery in the preintervention period and 363 (42.6%) of a total of 852 records in the post intervention period. For conformity with the inclusion criteria, every record included in the sample had a pain paper schema in which POP was documented at least three times.
Approximately two-thirds of the patients were female, their mean age was in the low 60 s, and both groups had a median ASA score of 2 (range 1 - 4).
Pre-intervention | Post-intervention | |||
---|---|---|---|---|
N# | (%) | N# | (%) | |
Age (years mean ± SD*) | 63 (mean) | 16 (±SD*) | 62 (mean) | 16 (±SD*) |
ASA (mean ± SD*) | 2.2 (mean) | 0.6 (±SD*) | 2.1 (mean) | 0.7 (±SD*) |
Gender | ||||
Female | 232 | (66) | 227 | (63) |
Male | 117 | (34) | 132 | (37) |
Surgery | ||||
Orthopedics | 295 | (84) | 266 | (73) |
Abdominal | 56 | (16) | 97 | (27) |
Main anesthesia | ||||
General anesthesia | 175 | (50) | 206 | (57) |
Blocks(spinal, epidural, regional) | 178 | (50) | 155 | (43) |
Supplementary anesthetics | ||||
Epidural and regional nerve blocks | 84 | (24) | 82 | (23) |
Local infiltration analgesia | 75 | (47) | 77 | (48) |
Local infiltration | ||||
Yes | 171 | (50) | 191 | (53) |
No | 170 | (50) | 167 | (47) |
*SD: Standard deviation; #Sample size may vary due to missing data.
On arrival at the PACU the median POP intensity level was 0.0 (Range 10) in the pre-test vs. 0.0 (Range 10) in the post-test, on discharge from the PACU median was 2.0 (Range 6) vs. 2.0 (Range 5), and on arrival at the surgical unit it was 2.5 (Range 8) vs. 2.8 (Range 7).
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The frequency of POP documentation using the NRS-11from the second to the fifth postoperative day was so low that these data were omitted from the analyses.
This study assessed whether a standardized educational program could increase the documentation of pain and reduce the POP intensity level of hospitalized surgical patients. The results showed no significant difference in the frequency of POP documentation, which agrees with the findings of Michaels et al. [
In contrast to our study, Ravaud et al. [
The discussion that followed the educational program in our study often concerned whether nurses could trust patients’ self-report of pain. In the educational program, we gave an example of how a patient can self-report a pain level of 7 on the NRS-11 and still retain the ability to read a newspaper. Some nurses questioned this example and stated they would not trust such a patient’s subjective report of pain. However, not trusting patients’ self-report of pain is seen as a barrier to effective POP pain relief [
Previous studies have shown that nurses in general maintain low levels of documentation of their nursing
activities [
In this study, no significant reductions in the patients’ POP intensity levels were found three months after the education program. This result contrasts with the studies of Ravaud et al. [
The results of our study showed that the mean pain-intensity level conformed to the guidelines of the IASP [
Our study had several limitations. The inclusion of only one hospital reduces the generalizability of the results. Moreover, the study design would have been stronger if a control group had been included, and the exclusion of records from surgical patients with fewer than three NRS-11 documentations may have influenced the results. Finally, we collected data only from the pain paper schema and not from the patients’ records, which may represent a weakness of this study. We suggest three areas for future research, 1) nurses’ beliefs and attitudes as this remain a major barrier for optimal POP management and calls for nurses to audit their own practice [
The standardized educational program conducted as a single session in this study resulted in no increase in the frequency of POP documentation using the pain-rating scale (NRS-11) and no decrease of the POP intensity level in hospitalized surgical patients assessed after three months.
The hospital and the nursing college gave time and financial support to this quality improvement study.
We do not have any conflict of interest with any issue discussed in this article