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The clinical utility of patients’ self-rated postoperative pain after major surgery – the perspective of healthcare professionals'
Jönköping University, School of Health and Welfare, HHJ. ADULT.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The Numeric Rating Scale (NRS) is suitable in postoperative settings, yet, the implementation has shown varying results. This has raised issues about the pain scales contribution to the identifying and understanding of pain. The aim of this thesis was to describe the clinical utility of patients’ self-rated postoperative pain after major surgery from a healthcare professional perspective.

The aim of study I and II was to describe healthcare professionals’ perceptions of the use of pain scales, and to through considering critical incidents describe care experiences and actions taken by healthcare professionals’ when assessing pain. Participants in study I (N=25) and II (N=24) were enrolled- registered nurses and physicians with clinical experiences of pain scales. The aims of study III and IV were to determine the clinical applicability of NRS mode- and maximum- measures, and the NRS mode- and median measures at rest and during activity based on patients self-rated pain. The aim in study IV was additionally to determine the number of NRS ratings needed for the calculation of these measures. The number of surgical and orthopedic patients who completed study III were: n=157 and study IV: n=479.

Study I and II confirmed earlier findings of patients’ self-reported pain scores as a facilitator in the understanding of their postoperative pain. Organizational routines, documentation devices, clinical competence, continuity in care, collaborative actions, time, and individual routines were healthcare related factors affecting the use of pain scales (I, II). Patient-related facilitating factors were patients’ ability and willingness to communicate pain, while disability and unwillingness to communicate or inconsistency in verbal communication with observed behaviors were barriers (II). Time and multidimensional communication approaches could bridge these barriers (I, II).

Study III and IV showed acceptable reliability for the mode, median and maximum measures. Rank correlations for individual median scores, based on four ratings, versus patients’ retrospective self-rated average pain, were moderate and strengthened with increased numbers of ratings. The Svensson method showed an individual variation within the expected outcome and a significant systematic group change towards a higher level of reported retrospective pain. The calculated pain measures, particularly concerning pain at rest, generally were lower than patients’ recall of pain.

The findings described beneficial effects of patient self-reported pain, however present healthcare did not fully support the utilization of pain scales. Because of the simple measurement characteristics, the use of daily NRS average pain measures, patients’ pain can be followed until resolved. The measures could additionally become important patient reported outcome measures and thus constitute new motivators to increase the utilization of pain scales.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2017. , 84 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 081
Keyword [en]
healthcare professionals, pain scales, postoperative pain assessment, collaboration, communication, routines, habits
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-35361ISBN: 978-91-85835-80-5 OAI: oai:DiVA.org:hj-35361DiVA: diva2:1088348
Public defence
2017-05-11, Forum Humanum, School of Health and Welfare, Jönköping, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-20 Created: 2017-04-12 Last updated: 2017-04-24Bibliographically approved
List of papers
1. Healthcare professionals' perceptions of the use of pain scales in postoperative pain assessments
Open this publication in new window or tab >>Healthcare professionals' perceptions of the use of pain scales in postoperative pain assessments
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2014 (English)In: Applied Nursing Research, ISSN 0897-1897, E-ISSN 1532-8201, Vol. 27, no 1, 53-58 p.Article in journal (Refereed) Published
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-25837 (URN)10.1016/j.apnr.2013.11.001 (DOI)000331019400007 ()24387871 (PubMedID)2-s2.0-84892976157 (ScopusID)
Available from: 2015-02-04 Created: 2015-02-04 Last updated: 2017-04-12Bibliographically approved
2. Healthcare professionals’ descriptions of care experiences and actions when assessing postoperative pain – a critical incident technique analysis
Open this publication in new window or tab >>Healthcare professionals’ descriptions of care experiences and actions when assessing postoperative pain – a critical incident technique analysis
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2016 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 30, no 4, 802-812 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-28942 (URN)10.1111/scs.12308 (DOI)26709955 (PubMedID)2-s2.0-84952837637 (ScopusID)
Funder
Medical Research Council of Southeast Sweden (FORSS)
Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2017-04-12Bibliographically approved
3. 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
4. The clinical applicability of a daily summary of patients’ self-reported postoperative pain - a repeated measure analysis
Open this publication in new window or tab >>The clinical applicability of a daily summary of patients’ self-reported postoperative pain - a repeated measure analysis
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2017 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702Article in journal (Refereed) Epub ahead of print
Abstract [en]

AIM AND OBJECTIVES:

(I) to determine if a central tendency, median, based on patients' self-rated pain is a clinically applicable daily measure to show patients' postoperative pain on the first day after major surgery (II) and to determine the number of self-ratings required for the calculation of this measure.

BACKGROUND:

Perioperative pain traits in medical records are difficult to overview. The clinical applicability of a daily documented summarising measure of patients' self-rated pain scores is little explored.

DESIGN:

A repeated measure design was carried out at three Swedish country hospitals.

METHODS:

Associations between the measures were analysed with non-parametric statistical methods; systematic and individual group changes were analysed separately. Measure I: pain scores at rest and activity postoperative day 1; measure II: retrospective average pain from postoperative day 1.

RESULTS:

The sample, 190 general- and 289 orthopaedic surgery patients with a mean age of 65; 56% were men. 44% had a pre-operative daily intake of analgesia, and 77% used postoperative opioids. A range of 4-9 pain scores seem to be eligible for the calculation of the daily measures of pain. Rank correlations for individual median scores, based on four ratings, versus retrospective self-rated average pain, were moderate and strengthened with increased numbers of ratings. A systematic group change towards a higher level of reported retrospective pain was significant.

CONCLUSIONS:

The median values were clinically applicable daily measures. The risk of obtaining a higher value than was recalled by patients seemed to be low. Applicability increased with increased frequency of self-rated pain scores and with high-quality pain assessments.

RELEVANCE TO CLINICAL PRACTICE:

The documenting of daily median pain scores at rest and during activity could constitute the basis for obtaining patients' experiences by showing their pain severity trajectories. The measures could also be an important key to predicting postoperative health-related consequences.

Place, publisher, year, edition, pages
John Wiley & Sons, 2017
Keyword
documentation; numerical rating scale; pain; repeated measures; self-rated
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-35350 (URN)10.1111/jocn.13818 (DOI)28334471 (PubMedID)
Available from: 2017-04-11 Created: 2017-04-11 Last updated: 2017-04-12

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