The pain experience of post surgical patients following the implementation of an evidence-based approach.

Abstract

Effective pain management has been shown to promote earlier mobilization, adequate rest, reduced hospital stays, postoperative complications, and costs. A multidisciplinary quality improvement team worked together to develop and implement a comprehensive evidence-based program for postoperative pain management. The purpose of this study was to assess surgical patients' pain status, satisfaction, and beliefs with regard to pain management prior to (Phase 1) and following the implementation of the program (Phase II). On postoperative day two, patients rated their pain, its impact on their activity, and answered questions about pain management and their satisfaction with pain treatment. Significant differences were found between Phase I and Phase II patients. More patients in Phase II (83%) received evidence-based orders compared with patients in Phase I (35%). Patients in Phase II had lower pain scores and experienced fewer disturbances in sleep, walking, and general activities. Patients in Phase II were less likely to believe that good patients avoid talking about pain. The results suggest that addressing pain management through a variety of strategies targeted at the level of the institution, the clinician, and the patient may lead to desired changes in practice and better outcomes for patients.

Full text

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The Pain Experience of
Post Surgical Patients
Following the
Implementation of an
Evidence-Based
Approach
yyy Denise Bédard, MSc(N), PhD,*
Margaret Ann Purden, PhD†Nicole Sauvé-Larose, MSc,‡
Cynthia Certosini, MSc,* and Constance Schein, MSc§
yABSTRACT:
Effective pain management has been shown to promote earlier mobi-
lization, adequate rest, reduced hospital stays, postoperative complica-
tions, and costs. A multidisciplinary quality improvement team
worked together to develop and implement a comprehensive evi-
dence-based program for postoperative pain management. The pur-
pose of this study was to assess surgical patients’ pain status, satisfac-
tion, and beliefs with regard to pain management prior to (Phase 1)
and following the implementation of the program (Phase II). On post-
operative day two, patients rated their pain, its impact on their activ-
ity, and answered questions about pain management and their satis-
faction with pain treatment. Significant differences were found
between Phase I and Phase II patients. More patients in Phase II
(83%) received evidence-based orders compared with patients in
Phase I (35%). Patients in Phase II had lower pain scores and experi-
enced fewer disturbances in sleep, walking, and general activities. Pa-
tients in Phase II were less likely to believe that good patients avoid
talking about pain. The results suggest that addressing pain manage-
ment through a variety of strategies targeted at the level of the institu-
tion, the clinician, and the patient may lead to desired changes in
practice and better outcomes for patients.
© 2006 by the American Society for Pain Management Nursing
Despite years of work by clinicians, educators, and professional agencies, pain
management practices remain inadequate and many patients still experience
insufficient relief from pain (Devine et al., 1999; McCaffery, Ferrell, & Pasero,
2000; Neitzel, Miller, Shepherd, & Belgrade, 1999; Watt-Watson, Stevens, Garf-
inkel, Streiner, & Gallop, 2001). This is an important issue in health care because
From *Sir Mortimer B. Davis-
Jewish General Hospital,†McGill
University School of Nursing, and
‡McGill University Health Center,
Montreal, Canada,§Saint Anne of
Winona, Benedictine Health
System, Minnesota.
Address correspondence and reprint
requests to Denise Bédard, MSc(N),
PhD, Clinical Nurse Specialist, Surgery,
Sir Mortimer B. Davis-Jewish General
Hospital, 3755 Cote des Neiges,
Montreal, Quebec, Canada H3T 1E2.
E-mail: dbedard@nurs.jgh.mcgill.ca
1524-9042/$32.00
© 2006 by the American Society
for Pain Management Nursing
doi:10.1016/j.pmn.2006.06.001
Original Articles
Pain Management Nursing, Vol 7, No 3 (September), 2006: pp 80-92

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effective pain management has been shown to pro-
mote earlier mobilization, increase patient comfort
and satisfaction, and reduce hospital stays and cost of
care (Agency for Health Care Policy and Research
[AHCPR], 1992).
The present study found that the adoption of a
new comprehensive approach to pain management in
the surgical division of an acute care hospital was
effective in decreasing patients’ self-reported pain and
its effect on their daily activities. This work suggests
that in order to be successful, an evidence-based pain
management program should be multifaceted, target-
ing values, knowledge, and skills about managing pain
at the level of the patient, the clinician, and the insti-
tution.
LITERATURE REVIEW
Over the past decade, numerous studies have at-
tempted to evaluate interventions aimed at improving
the management of postoperative pain and patient
outcomes, but with varying degrees of success (Bach,
1995; Closs, Briggs, & Everitt, 1999; MacDonald &
Hilton, 2001; Neitzel et al., 1999; Reimer-Kent, 2003;
Salomäki,Hokajärvi,Ranta,
Stomberg, Wickstrom, Joelsson, Sjöström, & Haljamäe,
2003). Studies that have evaluated interventions to
improve postoperative pain management have shown
inconsistent results. The interventions mainly targeted
health care professionals, very few included patients
and no study included the institution. The majority of
the studies were pre-post designs, control groups
were not a common feature, and none of the studies
evaluated the sustainability of the changes over time
(Bach, 1995; MacDonald & Hilton, 2001; Merbooth &
Barnason, 2000; Neitzel et al., 1999; Richardson, 2001;
Salomaki et al., 2000). Many of these studies focused
on orthopedic patients which limited the generaliz-
ability of the findings (Closs et al., 1999; MacDonald &
Hilton, 2001; Neitzel et al., 1999; Richardson, 2001;
Ripouteau et al., 2000). In addition, several method-
ological issues made comparison of the results across
the studies difficult. These included the use of a variety
of pain measures with varying degrees of psychomet-
ric rigor, differences in the acceptable cut off point for
pain, and variation in the timing of pain measurement.
The majority of studies used a multiple-intervention,
approach (Bach, 1995; Closs et al., 1999; MacDonald &
Hilton, 2001; Merbooth & Barnason, 2000; Neitzel et
al., 1999; Reimer-Kent, 2003; Richardson, 2001; Ripou-
teau et al., 2000; Salomäki et al., 2000; Stomberg et al.,
2003) to improve postoperative pain management,
and two studies used a single-intervention approach
(Dalton et al., 1999; Devine et al., 1999).
&Alahuhta,2000;
Single-intervention Studies
Dalton et al. (1999) and Devine et al. (1999) studied
the impact of introducing a pain management guide-
line with clinicians. Although Dalton et al. reported
use of the guideline by nurses in their study they
provided no results regarding changes in practice or
patients’ pain. Devine et al.’s intervention showed that
the number of patients who were taught how to re-
port pain and to set a pain goal increased over time.
The chart reviews showed a significant increase in
pain assessment. There were, however, no significant
improvements in patients’ pain or satisfaction with
pain management. They concluded that the availability
of an evidence-based guideline alone is insufficient to
improve patient outcomes and proposed that the in-
stitution needs to play a role in making pain manage-
ment a valued part of the culture.
Multiple-intervention Studies
Three studies were found that used multiple strategies
to change pain management practices, mainly with
orthopedic patients (Closs et al., 1999; MacDonald &
Hilton, 2001; Neitzel et al., 1999; Richardson, 2001;
Ripouteau et al., 2000). The studies used a combina-
tion of strategies that included: formal staff education
programs to introduce the AHCPR guidelines or local
guidelines, information posters displayed in nursing
stations, pain assessment tool, patient education ma-
terial, and coaching sessions. Two of these studies,
however, did not evaluate patient outcomes (Richard-
son, 2001; Ripouteau et al., 2000), and one study
showed no improvement in pain scores (Neitzel et al.,
1999). Merbooth and Barnason’s (2000) study with
thoracotomy patients who had undergone a thoracot-
omy used multiple strategies that included an educa-
tional program, policies and procedures, posters, a
newsletter providing tips on pain management, a pain
reference manual, a pain assessment flow sheet, and
pocket reference cards. They focused exclusively on
patient outcomes and did not evaluate changes in
practice. At three days after surgery, the average pain
ratings were found to be below the acceptable level of
pain (4.82/10). Patients rated their satisfaction with
physical comfort at 94/100 compared with previous
ratings of 78.3. Nevertheless, it is not clear whether
these improvements were related to changes in prac-
tice.
The remaining studies have targeted clinicians
and have demonstrated improved practice as well as
better pain levels and/or satisfaction in patients. Three
of these studies, however, have methodologic limita-
tions. Reimer-Kent’s (2003) interventions included
multiple strategies such as a pain management guide-
line as well as medical orders, medication records, and
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Pain Experience of Postsurgical Patients

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a clinical pathway that were preprinted to respect the
guideline. The study showed that pain relief was re-
corded on every shift for the first six days in 95% of
undergoing cardiac surgery patients. Pain relief was
recorded by nurses as a summary note for the shift
(effective or ineffective). No details were provided
about the actual pain scores of patients or how nurses
averaged such scores over the course of a shift to
determine the efficacy of pain relief. MacDonald and
Hilton’s (2001) study evaluated the Frail Elder Pain
Management Program (FEPMP) for patients with hip
fracture repairs. The FEPMP included educational ses-
sions, preprinted analgesic orders, pain flow sheets,
written information, and clinical support. They re-
ported that surgeons’ prescriptions and nurses’ pain
practices improved significantly. Pain assessment mod-
estly improved. There were significantly more patients
with good to adequate pain control. Unfortunately, the
results were based on a random sample of 50 charts in
where only 17 (?50%) contained sufficient documen-
tation to be evaluated. Stomberg and colleagues’
(2003) comparison of two hospitals’ approaches to
pain management (anesthesia-based service Hospital I
versus no overall service Hospital II) showed signifi-
cantly better outcomes in Hospital I than Hospital II in
assessment and documentation of pain, patients’ pain
levels, patient satisfaction, and nurses’ confidence
with pain management. There was no discussion how-
ever, as to whether the two hospitals were compara-
ble in terms of experience, education, and skill mix of
the staff.
The final three studies developed pain manage-
ment strategies for both patients and professionals.
The researcher reported changes in pain and practice.
Closs, Briggs, and Everitt (1999) used a pre-post con-
trol group design to test several interventions to im-
prove nurses’ pain assessment skills and reduce post-
operative night time pain and improve sleep in 417
orthopedic patients. A patient booklet was developed,
nurses were mentored to use an assessment tool, and
a hospital pain guideline was distributed. The experi-
mental group experienced a higher frequency of pain
assessments and significantly lower average and worst
pain scores than the control group. Nevertheless,
there was no increase in patient initiated pain report-
ing.
Salomäki, Hokajärvi, Ranta, and Alahuhta’s (2000)
study of 200 gynecology patients used a prepost de-
sign with a control group to evaluate the effectiveness
of an education and mentoring program for nurses and
written material for patients to improve pain after
surgery. The intervention group was more likely to
receive analgesics on a regular basis and experienced
greater pain relief and lower worst pain scores than
the preintervention group.
Bach (1995) used planned organizational change
to improve postoperative pain management. A multi-
disciplinary group developed strategies to implement
the AHCPR acute pain guideline with clinicians and
updated patient education materials. A pre-post evalu-
ation of nurses’ knowledge showed improvement in
all areas, but 20% of the nurses continued to show
concern about opioid addiction. Chart reviews con-
ducted after the implementation of the guideline
showed improvement in assessment of pain and use of
the pain intensity scale. An additional 20% of patient
respondents rated their pain relief as good. Similarly,
there was a 10% increase in patients’ satisfaction with
staff’s responsiveness to their pain.
Previous work suggests that multi-intervention ap-
proaches are useful for the management of postoper-
ative pain. Further research is required to test these
approaches in different surgical populations. This
study developed a comprehensive evidence-based pro-
gram for the surgical division of a large university
teaching hospital and evaluated changes both in prac-
tice and patient outcomes.
METHODS
Background
Clinical observations on the surgical units and readings
on postoperative pain indicated a need to improve the
approach to pain management. The practices found to
be in use such as dosage range, choice of opioid
(meperidine), and “as-needed” (PRN) administration
were not consistent with current evidence for contin-
uous pain. The clinical nurse specialist and the nursing
director decided to make pain management a clinical
objective for the hospital’s surgical division. In May
1998, the Continuous Quality Improvement (CQI)
Committee of the Surgical Division was created. An
interdisciplinary team including a head nurse, a clini-
cal nurse specialist, a consultant in pain management,
the director of coordinated care, the surgical nursing
director, nine surgical nurses, the chief of surgical
services, three pharmacists, and an anesthetist con-
ducted a literature review. The goal was to identify the
standard of care in postoperative pain management
and evidence-based strategies to change practice.
Based on these findings, a comprehensive multifaceted
approach to postoperative pain management was de-
signed. Patients, clinicians, and the institution were
targeted to bring about a cultural shift in pain manage-
ment practice that would lead to better patient out-
comes. The intervention was designed to address val-
ues, knowledge, and skill in pain management in all
three groups.
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A summary of the comprehensive evidence-based
pain management program and a timeframe were pre-
sented to the CQI Steering Committee and approved.
The evidence on cost savings, improved patient out-
comes as well as an explanation why the existing pain
management approach in the institution was not opti-
mal and the reasons for making it a priority were
presented. The program was guided by the following
question: “Would implementation of a comprehensive
evidence-based program for pain management result
in a significant difference in evidence-based orders,
level of pain, impact of pain, satisfaction, and beliefs
between patients in Phase I and Phase II?”
Design and Sampling
A quasi-experimental design guided the evaluation of
the postoperative pain management program. In Phase
I of the study (baseline), a patient survey was con-
ducted before the implementation of the interven-
tions. The Phase I sample (n ? 76) served as a histor-
ical comparison group to evaluate changes in practice
and patient outcomes (pain level, impact of pain, sat-
isfaction, and beliefs) following implementation of the
program. In Phase II of the study, two years after the
implementation of the program, a second patient sur-
vey was done (n ? 71). Patient selection in both
phases of the study used convenience sampling to
recruit English and French adult in-patients who were
undergoing surgery. Patients who were cognitively
impaired and unable to respond to the interview were
excluded. Patients undergoing neurosurgery or colo-
rectal surgery were not included because some of the
guideline could not be applied to these two groups.
The sample size for Phase I was based on the estimated
average worst pain score (M ? 5.88), and projected
variation (standard deviation 2.52) around the average
score was based on data collected from the first 17
patients recruited for Phase I. The power calculation
for Phase II (n ? 71) was based on data from Phase I
and assumed an ability to detect a two-point difference
in worst pain scores with alpha set at 0.05 and a power
of 0.85.
Instrumentation
Measurement of patient outcomes. The American
Pain Society Patient Outcome Questionnaire (APS-
POQ, 1995) includes: four questions about the level of
pain experienced in the past 24 hours: overall pain,
current pain, worst pain, and average pain. Patients
are asked to score their pain on an 11-point scale with
0 representing “no pain” to 10 representing “worst
pain possible.” Six questions ask how pain interferes
with daily living. Patients rate the impact as 0 or “no
interference” to a possible 10 or “complete interfer-
ence.” One question addresses the level of satisfaction
with pain treatment with 0 indicating “very dissatis-
fied” to six indicating “very satisfied.” Seven questions
pertain to beliefs about pain and its management.
Several items on the APS-POQ were adapted from
previously validated tools. The items assessing pain
intensity were drawn from the Brief Pain Inventory
Questionnaire (Daut, Cleeland, & Flanery, 1983). This
instrument is widely used for assessing pain, its effect
on mood, and patient function. It has been shown to
be reliable and valid (Daut et al., 1983; Daut & Clee-
land, 1982) and has been used with surgical patients
(Ward & Gordon, 1994). The items addressing satisfac-
tion are constructed according to Ware, Snyder,
Wright, and Davies (1983), who provided extensive
evidence for the validity of such items (Ware & Hays,
1988). The questions about beliefs are derived from
the Barriers Questionnaire (Ward et al., 1993). The
instrument has reported internal consistency, excel-
lent test–retest reliability, and demonstrated content
and construct validity (Ward et al., 1993). The APS-
POQ takes approximately 15 minutes to complete. A
French version of the questionnaire was also used
(Beauregard, Pomp, & Choiniere, 1998).
Measurement of practice outcomes. A data-collec-
tion log was developed to extract data from the pa-
tient’s medical chart about the medications used to
manage the patient’s pain (type of analgesia, fre-
quency, route, and dosage ordered). When the order
did not meet the evidence-based standard, the reasons
were indicated on the form (e.g., PRN order, dosage
range, etc.).
Background variables. During the interview, pa-
tients were asked about use of analgesics at home,
years of residency in Canada, and country of origin of
their parents. Information about the patient’s age, lan-
guage, gender, surgical procedure, length of surgery,
and history of previous surgeries was gathered from
the chart.
PROCEDURES
The Phase 1 (baseline) patient survey was conducted
after approval from the CQI Steering Committee and
consultation with the Research Ethics Board of the
institution (Table 1). The results of this survey were
presented at the CQI rounds and Nursing Grand
Rounds in order to sensitize a critical mass of profes-
sionals to the issue of pain management. Based on the
survey results and the information obtained from the
literature, the new evidence-based guideline (includ-
ing preprinted orders) was developed and approved
by various executive and leadership groups within the
institution (Appendix 1). The implementation of the
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TABLE 1.
Summary of the Comprehensive Evidence-Based Postoperative Pain Management Program
Pre-Implementation Phase Interventions
Sensitize to the issue of pain
management and set
objectives
Institution
—The Continuous Quality Improvement Committee of the Surgical Division was
created.
Clinicians
—Review best practice literature on postoperative pain management.
Institution
—A summary of the pain management program (interventions, patient and
practice outcomes) and a time frame were presented to the CQI Steering
Committee and approved.
—Phase 1: pre-intervention survey on postoperative pain management.
Institution
—Presentation of the pre-intervention survey results at the Continuous Quality
Improvement Rounds.
Clinicians
—Nursing Grand Rounds on postoperative pain management.
—Development of the evidence-based guideline for postoperative pain
management including preprinted orders.
Institution
—Presentation of the evidence-based guideline for postoperative pain
management to executive and leadership groups including:
a) Nursing Executive Committee
b) Surgical Committee
c) Board of Directors
d) Nursing Focused Documentation Committee
e) Pharmacy and Therapeutics Committee
f) Medical Executive Committee
g) Medical Records Committee
Survey
Sensitize to survey results
and develop the evidence-
based guideline
Implementation PhaseInterventions
Educate cliniciansClinicians
—Outreach visits to chief surgeons, intensivists, and surgical head nurses:
Informal meetings to discuss the evidence-based guideline for postoperative
pain management, changes in postoperative pain management, and concerns
regarding changes in practice including beliefs and attitudes.
—Educational sessions (rounds, inservice, two-day course on pain
management) that address rationale for changes in pain management practice
and include the exploration of clinical knowledge, beliefs, and attitudes related
to pain and its management.
—Posters on postoperative pain management acted as reminders on the units,
and evidence-based guideline is available on the units.
Patients and families
—Educational materials for pain management developed and distributed at
preadmission clinic and on the surgical units.
—Teaching patients and families and addressing their beliefs related to pain
management (listening, acknowledging and discussing their beliefs).
—Engaging patients in their pain management and clarifying patient’s role, i.e.,
coaching patients on how to participate, to assess, and manage their pain.
Clinicians
—Monthly audit and feedback on the use of evidence-based orders.
Clinicians
—Head nurses, clinical nurse specialists and nurse educators on surgical units
worked together to promote best practice in postoperative pain management.
—Integration of the evidence-based guideline into the orientation sessions of
new nurses and medical staff.
—Staff meetings and nursing rounds that focused on pain management.
Educate patients and their
families
Evaluate sustainability of the
improvements
Mentor
Evaluation Phase
Survey —Phase II: Post-intervention survey to evaluate progress.
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Bédard et al.