Nursing management of postoperative pain: perceived care and actual practice
Postoperative pain management is a major responsibility of nurses who provide care for patients recovering from surgery. In the postsurgical environment, the nurse has a pivotal role in assessing the patient with pain, implementing both doctor and nurseinitiated pain interventions and evaluating the patient's response to pain control treatments. Apart from its humanitarian utility, effective relief of postoperative pain is a critical element of a patient's postoperative recovery. Failure to manage pain effectively in the immediate postoperative period can produce undesirable immediate and longterm physical and psychological consequences that can severely disrupt an individual's quality of life. Despite the availability of multidimensional assessment measures, sophisticated pharmacological therapies and a greater range of complementary pain therapies, postoperative pain remains treated ineffectively by those professionally responsible for its management. In particular, evidence indicates that nurses are poor managers of their patients' postoperative pain. This thesis reports research that was conducted in two stages to explore, describe and analyse how nurses managed their patients' postoperative pain and their perceptions of factors that influenced this practice. A predominantly descriptive design was utilised in Stage 1 of the study to collect data from patients' hospital records and with a demographic questionnaire administered to nurses. This was complemented with interview data from nurses in Stage 2. Previous studies offer limited views of the clinical realities of nursing practice in postoperative pain management. From this perspective, there is a need for research that incorporates these realities to permit analysis of clinical practice and greater understanding therefore of the problem of poor postoperative pain management. The purpose of this study was to provide an illuminative and authentic account of nursing practice in postoperative pain management. For the first part of Stage 1, data were collected retrospectively from nurses' documented accounts of pain assessment and intervention over the first three postoperative days for 100 patients in a major adult acute care teaching hospital. Analysis of nurses' documented responses to patients' reports of postoperative pain revealed that less than one-third of all responses could be considered appropriate for pain management. In particular, nurses failed to provide any pharmacological relief for 53% of patients' reports or severe and excruciating pain. Exploration of the influence of nurses' professional characteristics of education and experience on pain management practice was then undertaken in part 2 of Stage 1 with the use of a demographic questionnaire distributed to 106 nurses who were identified as signatories to the documented responses identified in part 1. Results indicated that length of professional experience accounted for most variations in practice, with older, more experienced nurses managing pain more appropriately than their younger and less experienced colleagues. Irrespective of education or experience, however, nurses failed to respond appropriately to patients reporting excruciating pain. In Stage 2, in-depth interviews were conducted with 8 nurses caring for postoperative patients at the research site. Thematic content analysis revealed four major themes from nurses' perceptions of their practice of postoperative pain management that served to elucidate and enrich the findings of Stage 1 of the research. These were finding out about the patient's pain, making decisions about pain and pain management, individual factors affecting pain management, and interpersonal and organisational factors affecting pain management. This thesis provides an authentic account of nursing practice in postoperative pain management, and contributes understanding and insight into factors that provoke ineffective management of pain after surgery. It has implications for the development of intervention strategies aimed at improving nursing practice, at both individual and organisational levels, and suggests new directions for nursing education and research toward achieving optimum care and eliminating unnecessary pain for patients recovering from surgery.
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ABSTRACT: Background: Unrelieved post-operative pain continues to be a major clinical challenge, despite advances in management. Although nurses have embraced a crucial role in pain management, its extent is often limited in Iranian nursing practice. Aim: To determine Iranian nurses' perceptions of the barriers and facilitators influencing their management of post-operative pain. Methods: This study was qualitative with 26 participant nurses. Data were obtained through semi-structured serial interviews and analysed using the content analysis method. Findings: Several themes emerged to describe the factors that hindered or facilitated post-operative pain management. These were grouped into two main themes: (1) barriers to pain management after surgery with subgroups such as powerlessness, policies and rules of organization, physicians leading practice, time constraints, limited communication, interruption of activities relating to pain, and (2) factors that facilitated post-operative pain management that included the nurse–patient relationship, nurses' responsibility, the physician as a colleague, and nurses' knowledge and skills. Conclusion: Postoperative pain management in Iran is contextually complex, and may be controversial. Participants believed that in this context accurate pain management is difficult for nurses due to the barriers mentioned. Therefore, nurses make decisions and act as a patient comforter for pain after surgery because of the barriers to effective pain management.International Nursing Review 11/2008; 55(4):468 - 475. DOI:10.1111/j.1466-7657.2008.00659.x · 0.95 Impact Factor
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