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Postoperative pain assessment and impact of pain on early physical recovery, from the patients' perspective
Jönköping University, School of Health and Welfare. Länssjukhuset Ryhov i Jönköping.ORCID iD: 0000-0003-3270-6318
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Pain is a common postoperative experience. Guidelines recommend performing regular pain assessments, which include self-rated pain and additional communication to capture patients' experiences. During hospitalisation, pain intensity is found to be a vital factor influencing other aspects of an early physical recovery, and is consequently an important item in questionnaires for recovery. These tools consist of extensive questionnaires which are difficult to use in everyday clinical work. A simplified method of monitoring postoperative recovery would benefit both patients and healthcare professionals.

Aim: The overall aim of this thesis was twofold: (A) to determine the ability of extending the use of pain ratings to reflect and predict early physical postoperative recovery and (B) to describe patients’ perspectives on pain assessments.

Methods: The studies were carried out at one (I), three (IV) and four hospitals (II, III) involving general surgical and orthopaedic inpatients. Two quantitative methods were used based on data from questionnaires and medical records. They consisted of one cross-sectional study (I) and one study with repeated measures (IV). An association was sought between pain intensity and postoperative recovery on days 1 and 2 (I, IV), and prehospital data (IV). Two qualitative methods were used involving a phenomenographic (III) approach and Critical Incident Technique (IV), where semi-structured interviews were performed postoperatively and analysed inductively in accordance with the approach.

Results: An association was found between moderate/severe average pain intensity compiled from monitoring records and impact on early physical postoperative recovery on day 1 (I). Retrospective average pain intensity at rest and during activity reflected impact on recovery on postoperative day 1 (IV). Severe pain intensity at rest and during activity on postoperative day 1 predicted impact on physical recovery items on day 2 (IV). The use of the Numeric Rating Scale (NRS 0-10) was considered to facilitate communication about pain, but to involve difficulties of interpretation and place demand on healthcare professionals and care routines (II). Patients’ descriptions of their experiences when in need of describing pain indicated two main areas: patients’ resources when needing to describe pain and ward resources for performing pain assessments (III). Descriptions of their actions when they were in pain indicated two main areas: patients used active strategies when needing to describe pain or patients used passive strategies when needing to describe pain (III).

Conclusions: This thesis contributes to knowledge about the possibility of using patients' self-rated average pain intensity to reflect early physical postoperative recovery on day 1 and to predict recovery on the following day. The pain scale gave patients and healthcare professionals a shared vocabulary, which facilitated communication. Furthermore, dialogue during pain assessments was described as critical in ascertaining whether pain intensity had an impact on different aspects of physical recovery. Environmental factors such as the attitude of healthcare professionals, workload and staffing influenced how pain assessments were performed.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2017. , 77 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 080
Keyword [en]
pain assessment, pain intensity, pain scale, physichal recovery, postoperative care
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-35346ISBN: 978-91-85835-79-9 (print)OAI: oai:DiVA.org:hj-35346DiVA: diva2:1087979
Public defence
2017-05-10, Forum Humanum, School of Health and Welfare, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-20 Created: 2017-04-10 Last updated: 2017-04-12Bibliographically approved
List of papers
1. Using mode and maximum values from the Numeric Rating Scale when evaluating postoperative pain management and recovery
Open this publication in new window or tab >>Using mode and maximum values from the Numeric Rating Scale when evaluating postoperative pain management and recovery
2013 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 5-6, 638-647 p.Article in journal (Refereed) Published
Abstract [en]

Aims and objectives: To (1) examine the clinical applicability of compiled mode and maximum values from the Numeric Rating Scale (NRS) by comparing the correspondence between patient perceptions of pain and pain values from monitoring records, as well as (2) to study the relationship between mode and maximum values and self-assessed ability for early postoperative recovery.

Background: Documentation of pain remains a problem despite recommendations of quality improvements. To examine the correlation between patient perceptions and documented pain therefore becomes important. Few have studied how pain affects recovery.

Design: A quantitative cross-sectional design was used in which 157 postoperative patients answered a questionnaire on pain intensity and recovery. A parallel examination of pain in monitoring records was conducted.

Results: A total of 57% had a mode value calculated from records between 0 and 3 on postoperative day 1 and 69% on day 2. A maximum value between 4 and 10 was found in monitoring records for 73% on day 1 and for 67% on day 2. The correspondence between mode value from monitoring records and the patients’ retrospective perceptions was 88% for NRS 0–3 and 92% between maximum value and NRS 4–10. The correlation between documented pain and retrospectively identified pain for mode value of the NRS in all (0–10) was rather weak (r = 0·37), while maximum value had a stronger correlation (r = 0·53).

Conclusion: Mode and maximum values could be used as outcome measures when evaluating postoperative pain. Pain affects recovery negatively, but more research is needed to strengthen the evidence for the use and clarify the link between pain and recovery.

Relevance to clinical practice: International organisations emphasise the importance of improving pain assessment. Mode and maximum values are easy to compile for nurses and can, together with assessments of how experienced pain levels affect postoperative recovery, improve treatment of postoperative pain.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-20357 (URN)10.1111/j.1365-2702.2012.04225.x (DOI)22946909 (PubMedID)
Available from: 2013-01-22 Created: 2013-01-22 Last updated: 2017-04-12Bibliographically approved
2. Numeric rating scale: patients' perceptions of its use in postoperative pain assessments
Open this publication in new window or tab >>Numeric rating scale: patients' perceptions of its use in postoperative pain assessments
Show others...
2014 (English)In: Applied Nursing Research, ISSN 0897-1897, E-ISSN 1532-8201, Vol. 27, no 1, 41-46 p.Article in journal (Refereed) Published
Abstract [en]

Aim

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

Background

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

Methods

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

Results

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

Conclusion

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

Keyword
Pain scale; Pain assessment; Postoperative pain; Patients' perceptions
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-25838 (URN)10.1016/j.apnr.2013.10.006 (DOI)000331019400005 ()24332467 (PubMedID)2-s2.0-84892984387 (Scopus ID)
Available from: 2015-02-04 Created: 2015-02-04 Last updated: 2017-04-10Bibliographically approved
3. Patients’ experiences and actions when describing pain after surgery – A critical incident technique analysis
Open this publication in new window or tab >>Patients’ experiences and actions when describing pain after surgery – A critical incident technique analysis
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2016 (English)In: International Journal of Nursing Studies, ISSN 0020-7489, E-ISSN 1873-491X, Vol. 56, 27-36 p.Article in journal (Refereed) Published
Abstract [en]

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.

Keyword
collaboration; critical incident technique; healthcare professionals; postoperative pain assessment
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-28940 (URN)10.1016/j.ijnurstu.2015.12.008 (DOI)000371844700004 ()26709955 (PubMedID)2-s2.0-84953216205 (Scopus ID)
Funder
Futurum - Academy for Health and Care, Jönköping County Council, SwedenMedical Research Council of Southeast Sweden (FORSS)
Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2017-04-10Bibliographically approved
4. Association of pain ratings with the prediction of early physical recovery after general and orthopaedic surgery - A quantitative study with repeated measures
Open this publication in new window or tab >>Association of pain ratings with the prediction of early physical recovery after general and orthopaedic surgery - A quantitative study with repeated measures
Show others...
2017 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648Article in journal (Refereed) Epub ahead of print
Abstract [en]

Aim: To compare different levels of self-rated pain and determine if they predict anticipated early physical recovery in patients undergoing general and orthopaedic surgery.

Background: Previous research has indicated that average self-rated pain reflects patients' ability to recover the same day. However, there is a knowledge gap about the feasibility of using average pain ratings to predict patients' physical recovery for the next day.

Design: Descriptive, quantitative repeated measures. Methods: General and orthopaedic inpatients (n = 479) completed a questionnaire (October 2012-January 2015) about pain and recovery. Average pain intensity at rest and during activity was based on the Numeric Rating Scale and divided into three levels (0-3, 4-6, 7-10). Three out of five dimensions from the tool "Postoperative Recovery Profile" were used. Because few suffered severe pain, general and orthopaedic patients were analysed together.

Results: Binary logistic regression analysis showed that average pain intensity postoperative day 1 significantly predicted the impact on recovery day 2, except nausea, gastrointestinal function and bladder function when pain at rest and also nausea, appetite changes, and bladder function when pain during activity. High pain ratings (NRS 7-10) demonstrated to be a better predictor for recovery compared with moderate ratings (NRS 4-6), day 2, as it significantly predicted more items in recovery.

Conclusion: Pain intensity reflected general and orthopaedic patients' physical recovery postoperative day 1 and predicted recovery for day 2. By monitoring patients' pain and impact on recovery, patients' need for support becomes visible which is valuable during hospital stays.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keyword
Assessment, Nurse-patient interaction, Nurse-patient relationships, Pain, Postoperative care, Quantitative approaches
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-35340 (URN)10.1111/jan.13331 (DOI)28475240 (PubMedID)2-s2.0-85020059107 (Scopus ID)
Note

Part of doctoral thesis in its submitted form.

Available from: 2017-04-10 Created: 2017-04-10 Last updated: 2017-07-06

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