chapter ii literature review concepts and theories of...
TRANSCRIPT
CHAPTER II
LITERATURE REVIEW
The literature review presents concepts and theories of pain, types of pain,
postoperative pain, pathophysiology of postoperative pain, impact of postoperative
pain, postoperative pain management, factors related to postoperative pain
management, and nurses’ role in pain management in Bhutan.
Concepts and Theories of pain
Pain is often described in the literature as a subjective complaint that acts as
a warning sign (Hartrick, 2004). Pain is “whatever the experiencing person says it is,
existing whenever he/ she says it does” (McCaffery & Pasero, 2002). This definition
emphasizes that pain is a subjective experience. It also stresses that the patient, not the
health care provider, has the authority on the pain, and that his or her self-report is the
most reliable indicator of pain. According Gate control theory, pain is not just a
physiological response to tissue damage but also includes behavioral and emotional
responses expected and accepted by one cultural group which may influence the
perception of pain (Melzack & Wall, 1965; Miaskowski, 2004). Some Psychologists
linked pain with suffering and suggested that certain psychological modulators of pain
sensitivity were dependent on the patient’s characteristics (Jones & Zachariae, 2004).
As a result of the changes in the conceptualization of pain, multidisciplinary
approaches to its treatment have been developed.
Many theories have been proposed to explain the mechanisms of pain
caused by the body tissue trauma or damage of peripheral nerves. In 1943 Livingston
cited in (Bonica, 2000) proposed the theory of central summation. He suggested that
stimulation resulting from nerve and tissue damage activates fibers that project to
neuron pools in the spinal cord, in consequence, creating activity that spreads to
lateral horn cells and ventral horn cells in the spinal cord, activating the sympathetic
nervous system, and somatic motor system. As a result, this activation produces
vasoconstriction of the blood vessels, increases work load of heart, and induces
muscular spasm, and fear and anxiety (Bonica, 2000).
14
Hardy, Wolff, and Goodell (1952) introduced biopsychosocial theory of pain
that explained the influence of the psychological factors on pain. The theory
suggested the two components of pain: the perception of pain, and the reaction to
pain. The perception of pain is a process that has special structural, functional, and
perceptual properties, and is accomplished by means of simple and primitive neural
receptive and conductive mechanisms. The reaction to pain, conversely, is a complex
process relating the cognitive functions of past experience, culture, and a range of
psychological factors that influence the reaction to pain stimuli. In other words, this
theory is linking the stimulus intensity and the perception of pain.
In 1959, Noordenbos cited in Bonica (2000) proposed the sensory
interaction theory. This theory proposed that there are two systems involved in
transmission of pain: a slow system that involved the unmyelinated and thinly
myelinated fibers, and a fast system that involved the large myelinated fibers.
Noordenbos suggested that the slowly conducting somatic afferent fibers and small
visceral afferents project into the dorsal horn of the spinal cord and inputs from the
small fibers are transmitted to the brain to produce pain. The fast-acting fibers inhibit
transmission of impulses from the small fibers, and prevent summation from
occurring (Bonica, 2000).
The classic gate control theory of pain, described by Melzack and Wall
(1965) proposed to explain the relationship between pain and emotions. According to
this theory, a gating mechanism occurs when a pain impulse travels to the dorsal horn
of the spinal cord where trigger cells (T-cells) influence the transmission of pain
impulses. The pain stimulation of the large-diameter fibers inhibits the transmission of
pain, the gate closes, and impulses are less likely to be transmitted to the brain. On the
other hand, when smaller fibers are stimulated, the gate is opened. This mechanism is
influenced by descending nerve fibers from areas in the brain that regulate thought,
beliefs, and emotions. The gate-control theory helps to understand the role of
psychological factors in the perception of pain. The theory explains the effects of
some interventions such as distraction and imagery in relieving pain. All of the
proceeding theories have explained pain related to tissue damage that is mostly related
to acute pain such as the postoperative pain.
15
Types of pain
Pain has been classified into two types, acute pain and chronic pain. Acute
pain is a complex, unpleasant experience with emotional, and cognitive, as well as
sensory, features that occur in response to tissue trauma. Acute pain resolves with
healing of the underlying injury (Americian Pain Society [APS], 2001). Acute pain is
usually nociceptive, but may be neuropathic. Common sources of acute pain include
trauma, surgery, labor, medical procedures, and acute disease states, and are usually
accompanied by physiological and behavioral responses of the patient (APS, 2001;
Vadivelu, Christian, Whitney, & Sinatra, 2009). Acute pain serves as an important
biological function, as it warns of the potential for or extent of injury. A host of
protective reflexes (e.g. withdrawal of a damaged limb, muscle spasm, autonomic
responses) often accompany it. Postoperative pain is an acute pain that lasts less than
three months (Mackintosh, 2005).
Chronic pain is recognized as pain that extends beyond the period of
healing, with levels of identified pathology that often is low and insufficient to
explain the presence or extent of the pain. Chronic pain is also defined as a persistent
pain that “disrupts sleep and normal living, ceases to serve a protective function, and
instead degrades health and functional capability. Chronic pain may be nociceptive,
neuropathic, or both and caused by injury (e.g. trauma, surgery), malignant
conditions, or a variety of chronic non-life threatening conditions (e.g. arthritis,
fibromyalgia, neuropathy). Chronic pain represent disease itself and last more than
three to six months (APS, 2001; Simpson, 2008; Vadivelu et al., 2009).
Postoperative pain
Definition and incidence of postoperative Pain
Postoperative pain is the normal, predicted physiological response to an
adverse chemical, thermal, or mechanical stimulus associated with surgery. It is
generally time-limited and is responsive to therapy (International Association for
Study of Pain [IASP], 1994; Mackintosh, 2007). Acute postoperative pain is defined
as a complex unpleasant experience with emotional and sensory features that occur in
response to trauma (IASP, 1994). Postoperative pain is a chemical, thermal or
16
mechanical stimulus resulting from tissue injury due to surgery (Coll, Ameen, &
Mead, 2003). Postoperative pain is an unpleasant symptom experienced by patient
due to trauma.
Unrelieved pain is a central health care problem (Dahl et al., 2003;
Dunwoody, Krenzischek, Pasero, Rathmell, & Polomano, 2008; Layzell, 2008;
Manias, 2003). Costantini, Viterbori, and Flego (2002) undertook a large-scale study
in Italy to determine the prevalence of pain among 4121 patients in 30 hospitals.
Findings concluded that over 56% of patients experienced pain in the 24 hours
postoperatively, with almost 30% being of severe intensity. It was verified that over
43% of participants experienced pain during the interview. Similarly, Salomon et al.
(2002) established that 55% of 998 patients in a large hospital in France had
experienced pain in the previous 24 hours.
More recently Strohbuecker, Mayer, Sabatowski, and Evers (2005)
interviewed 561 patients. It was reported that in the 24-hours postoperatively 63% of
these patients experienced pain with 58% indicating that their pain was moderate to
severe and 36% identifying the pain as severe in nature. Sawyer, Haslam, Robinson,
Daines, & Stilos (2008) established the prevalence of postoperative pain in 114
patients in a large Canadian teaching hospital. The incidence of pain in these patients
was 71% at the time in which the interview was carried out. In addition, almost 32%
of patients experienced moderate to severe pain at the time of interview. It was found
that in the 24 hours postoperative period, over 76% reported moderate to severe pain,
and 47.3% reported severe pain.
Pathophysiology of postoperative pain
Although a comprehensive overview of the nociceptive processing of acute
postoperative pain is beyond the scope, there have been several recent developments
in the study of the nociception of acute postoperative pain. Neurophysiologic and
pharmacological studies suggest that incisional pain differs in its mechanism from
other inflammatory or neuropathic pain. Hyperalgesia in the region of the incision is
thought to be mediated by sensitization of Aδ-fibre and C-fibre nociceptors and the
conversion of mechanically insensitive or silent Aδ nociceptors to mechanically
sensitive fibers after incision. Studies showed an important role of α-amino-3-
17
hydroxy-5-methyl-4-isoxazole-propionate (AMPA)/ kainate ionotropic excitatory
amino acid receptors for incision-induced pain, hyperalgesia, and spinal sensitization.
Increased lactate concentrations and low pH occur in skin and muscle wounds after
incision and suggest that an ischemic pain mechanism might contribute to
postsurgical pain. Central neuronal sensitization probably contributes to postoperative
pain and hyperalgesia. Neurophysiological studies in animal models have shown an
increase in the prevalence and rate of spontaneous activity of spinal dorsal horn
neurons after skin and deep muscle incision. However, the precise role of central
sensitization in the development of persistent postoperative pain is uncertain (ASA,
2012; Wu & Raja, 2011).
Impact of postoperative pain
Unalleviated postoperative pain can result in both short and long term
negative consequences. These undesirable effects can cause detrimental outcomes for
patients in terms of mortality and morbidity. Unrelieved postoperative pain may result
in a variety of physiological reactions including: an increase in cardiac output, heart
rate, blood pressure, and oxygen consumption (Hutchison, 2007; Smeltzer & Bare,
2004; Spacek, 2006; Twycross, 2002). These physiological responses may predispose
the patient to the development of various disorders, including myocardial infarction,
myocardial ischemia, and left ventricular dysfunction (Smeltzer & Bare, 2004). In the
postoperative period unrelieved pain can cause a decrease in mobility. Immobilization
can subsequently result in complications such as the formation of thrombosis, the
development of respiratory problems including pneumonia, as well as the breakdown
of skin, particularly pressure areas, and constipation. Unrelieved pain can have
negative impact in terms or quality of life both physically, and psychologically
(Spacek, 2006; Twycross, 2007).
Furthermore it has been suggested that even momentary intervals of acute
pain in the postoperative period can induce lasting chronic pain. It has been noted in
the literature that unrelieved postoperative pain can predispose patients to delayed
recovery, and a prolonged hospital stay (Hunter, 2000; Roykulcharoen & Good 2004).
Additionally, unalleviated postoperative pain generates problems for society in terms
of increased costs and healthcare expenditure. Inadequate pain control has been
18
described as being unethical, uneconomical, and clinically unsound (Hunter, 2000).
The consequences of inadequately treated postoperative pain responses can be broadly
classified as inflammation, hyperalgesia, hyperglycaemia, protein catabolism,
increased free fatty acid levels (lipolysis), and changes in water and electrolyte flux.
1. Acute postoperative hypertension
Acute postoperative hypertension (APH) is a common occurrence after
surgery that has important implications. APH has an early onset, being observed
within 2 hours after surgery, and is typically of short duration, with most patients
requiring treatment for 6 hours or less. Occasionally, APH may persist for 24 48
hours. Postoperative complications of APH may include hemorrhagic stroke, cerebral
ischemia, encephalopathy, myocardial ischemia, myocardial infarction, cardiac
arrhythmia, congestive heart failure with pulmonary edema, failure of vascular
anastomosis, and bleeding at the surgical site. For some complications, it is not clear
whether the blood pressure elevation precedes the development of the complication or
is a sequele of the complication (ASA, 2012; Mackintosh, 2007).
2. Hyperglycemia
Hyperglycemia is broadly proportional to the extent of the injury response.
Injury response mediators stimulate insulin-independent membrane glucose
transporters glut-1, 2 and 3, which are located diversely in brain, vascular
endothelium, liver and some blood cells. Circulating glucose enters the cells that do
not require insulin for uptake, resulting in cellular glucose overload and diverse toxic
effects. Excess intracellular glucose non-enzymatically glycosylates proteins such as
immunoglobulin, rendering them dysfunctional (Vanden-Berghe, 2004).
Alternatively, excess glucose enters glycolysis and oxidative phosphorylation
pathways, leading to excess superoxide molecules that bind to nitric oxide (NO), with
formation of peroxynitrate, ultimately resulting in mitochondrial dysfunction and
death of cells served by glut-1, 2 and 3 (Carli & Schricker, 2009). Even modest
increases in blood glucose can be associated with poor outcome particularly in
metabolically challenged patients such as people with diabetes. Fasting glucose levels
over 7mmol/L or random greater than 111mmol/L were associated with increased in
hospital mortality, a longer length of stay, and higher risk of infection in intensive
care patients (Vanden-Berghe, 2004).
19
3. Lipotoxicity
Free fatty acid (FFA) levels are increased due to several factors associated
with the injury response, and its treatment and can have detrimental effects on cardiac
function. High levels of FFA can depress myocardial contractility (Korvald, Elvenes,
& Myrmel, 2000). Increase myocardial oxygen consumption (without increased work)
and impair calcium homeostasis and increase free radical production leading to
electrical instability and ventricular arrhythmias (Oliver & Opie, 1994).
4. Protein catabolism
The injury response is associated with an accelerated protein breakdown and
amino acid oxidation, in the face of insufficient increase in protein synthesis.
Following abdominal surgery, amino acid oxidation and release from muscle is
increased by 30% and 90% respectively, while whole body protein synthesis
increased only 10% (Harrison, Lewin, Halliday, & Clark, 1989). Fifty grams of
nitrogen may be lost (1 g nitrogen = 30 g lean tissue) which is equivalent to 1500 g of
lean tissue after cholecystectomy. Importantly, the length of time for return of normal
physical function after hospital discharge had been related to the total loss of lean
tissue during hospital stay (Chandra, 1983). Protein represents both structural and
functional body components, thus loss of lean tissue may lead to delayed wound
healing, reduced immune function and diminished muscle strength all of which may
contribute to prolonged recovery, and increased morbidity (Watters, Clancey,
Moulton, Briere, & Zhu, 1993). An overall reduced ability to carry out activities of
daily living (ADLs) results from muscle fatigue and muscle weakness. Impaired
nutritional intake, inflammatory metabolic responses, immobilization, and a
subjective feeling of fatigue may all contribute to muscle weakness. Such effects are
broadly proportional to the extent of injury but there are major variations across
populations, with durations also varying up to 3 to 4 weeks (Christensen, Nygaard,
Stage, & Kehletlet, 1990).
5. Injury-induced organ dysfunction
Pain from injury sites can activate sympathetic efferent nerves, and increase
heart rate, inotropy, and blood pressure. Sympathetic activation increases myocardial
oxygen demand, and reduces myocardial oxygen supply, the risk of cardiac ischemia,
particularly in patients with pre-existing cardiac disease is increased. Enhanced
20
sympathetic activity can also reduce gastrointestinal (GI) motility. Severe pain after
upper abdominal, and thoracic surgery contributes to an inability to cough and a
reduction in functional residual capacity, resulting in atelectasis, and ventilation-
perfusion abnormalities, hypoxemia, and an increased incidence of pulmonary
complications. The injury response also contributes to a suppression of cellular, and
humoral immune function, and a hypercoagulable state following surgery, both of
which can contribute to postoperative complications. Patients at greatest risk of
adverse outcomes from unrelieved acute pain include very young or elderly patients,
those with concurrent medical illnesses, and those undergoing major surgery (Liu &
Wu, 2008).
In summary, acute postoperative pain leads to physical and psychological
consequences. It leads to complications, delay recovery from surgery, adding in the
increasing rate of morbidity, poor patient outcome, and frequent readmission to the
hospitals, and over all unwanted sufferings for the patients, and the family members.
Management of postoperative pain
Postoperative pain management is a comprehensive action of nurses in
relieving postoperative pain including assessment, intervention, evaluation, and
documentation. The goal of postoperative pain management is to reduce or eradicate
discomfort, prevent complications, facilitate the recovery process, and to attain a pain
free status whenever possible (APS, 2003; IASP, 1994).
1. Assessment
In order to accomplish adequate pain control, it is necessary to assess pain
on a regular schedule as well as following any new pain control intervention. In
general, pain should be assessed approximately 15-30 minutes after administering
parenteral medication, and 60 minutes after administering oral medication. During the
initial 24-hour postoperative period, pain should be assessed at least every 2 to 4
hours. If pain is well controlled, the pain intensity should be assessed routinely with
vital signs (IASP, 1994; Mackintosh, 2007; Vickers, 2007). Assessment of pain
involves asking the patient to describe the pain (quality, duration, onset), determine
pain location from the patient’s report, document intensity, quality and location,
21
depending upon the condition of the patient, a comprehensive pain assessment
including description of behavior, and impact, assessing adverse effects associated
with inadequate or intolerable interventions (sedation, inadequate respiration, nausea,
vomiting, pruritis, numbness and weakness) is done.
Quantifying the intensity of pain is an essential part of initial, and ongoing
pain assessment; it is quantified by number of scales. Commonly used unidimensional
scales in assessment of pain include the Verbal Rating Scale (VRS), the Numeric
Rating Scale (NRS), a Visual Analog Scale (VAS), and a Pictorial Facial Scale. The
choice of pain scale may depend on the patient’s age, ability to communicate, and
other specific circumstances (ASA, 2012; Mackintosh, 2007).Without assessment it is
impossible to identify the nature of pain, the individual characteristics of pain or to
gauge the effectiveness of pain management interventions (Pain is subjective in
nature, the multidimensions of pain includes physiological, sensory, cognitive,
affective and socio-cultural dimensions (Hinshaw, Feethaw, & Shaver, 1999;
Giordano, Abramson, & Boswell, 2010).
1.1 Intensity evaluation of pain intensity or severity is always an important
aspect of any complete pain assessment and should be conducted in a manner
appropriate to the population. In other words, approaches for assessing pain intensity
should be valid, and reliable for the patient’s age, and other potential factors that may
impact successful, and accurate reporting of pain (e.g. sex, race, education, sensory
capability). Pain intensity is the least stimuli at which the person perceives a sensation
(Mackintosh, 2007; McCaffery & Pasero 1999).
1.2 Quality in the assessment of pain, information on pain quality is critical.
The quality of pain is determined by sensory, affective, and evaluative properties of
pain including constant, burning, pulsing, intermittent, shooting, and electric shock
like pain. It has been demonstrated clinically that patients with neuropathic pain are
significantly more likely to use six particular sensory adjectives (“electric-shock,”
“burning,” “tingling,” “cold,” “pricking,” and “itching”) to describe their pain
(Bressler, Hange, & Mcguire, 1986; Coll et al., 2003).
1.3 Location the location, and distribution of the pain is important clinical
information because most patients have two or more sites of pain. Neuropathic pain
often correlates with the degree of neural lesion. Most often pain is projected and,
22
with few exceptions, the pain distribution matches the level of the lesion. The pain
that the patient may be referring to may be different than the one the nurse or
physician is talking about. Having the patient point to the painful area can be more
specific, and help to determine interventions (Mackintosh, 2007; McCaffery &
Pasero, 1999).
1.4 Duration The duration of the pain include whether its onset was sudden
or gradual, and whether the pain is intermittent, continuous, or paroxysmal.
Breakthrough pain refers to a transitory exacerbation or flare of pain occurring in an
individual who is on a regimen of analgesics for continuous pain. Patients need to be
asked, “Is your pain always there, or does it come and go?” or “Do you have both
chronic, and breakthrough pain?” (Mackintosh, 2007; McCaffery & Ferrell, 1997).
1.5 Aggravating/ alleviating factors asking the patient to describe the
factors that aggravate or alleviate the pain will help to plan interventions. A typical
question might be, “What makes the pain better or worse?”Analgesics, non-
pharmacologic approaches (massage, relaxation, music or visualization therapy,
biofeedback, heat or cold), and nerve blocks are some interventions that may relieve
the pain. Other factors (movement, physical therapy, activity, intravenous blood
draws, mental anguish, depression, sadness, bad news) may intensify the pain (ASA,
2012; Mackintosh, 2007; McCaffery & Pasero 1999).
There are many assessment tools found in the literature, and many scales
have been developed to assist nurses in determining the severity of pain. The use of
standardized scales has several advantages. Firstly, they are reliable and objective,
and thus the accurate way to rate pain severity (Ware, Epps, Herr, & Pachard, 2006).
Secondly, they take short time to implement. Thirdly, the same scales can be used to
assess the effectiveness of interventions (Coll et al., 2003). The commonly suggested
standardized tools are the Numeric Rating Scale (NRS), and the Visual Analogue
Scale [VAS] (Coll et al., 2003; Mackintosh, 2007). When using the NRS, the patient
is asked to rate his pain intensity on a scale of 0 (no pain) to 10 (the worst possible
pain). The VAS is a horizontal line, 100 mm in length, anchored by word descriptors
at each end. The patient marks on the line the point that represents his current state.
The VAS score is determined by measuring in millimeters from the left hand end to
the patient’s marks (Coll et al., 2003; Mackintosh, 2007).
23
Several studies had been undertaken with a view to ascertain how nurses
assess postoperative pain. Manias, Bucknall, and Botti (2004) conducted an
observational study with 52 nurses caring for patients in the postoperative period.
A total of 316 cases were observed which involved nurses in the process of
assessment, and management of postoperative pain. It was established that 43.7% of
the times no pain assessment was carried out by nurses. The incorporation of a pain
assessment tool occurred in less than 9% of the cases. Furthermore, when patients
expressed difficulty in comprehending the tool, there was little attempt made by
nurses to clarify the meaning. In order for patients to effectively rate their pain, it is
essential that they fully comprehend the pain assessment tool.
Similarly, the study of Idvall and Berg (2008) described how 221 orthopedic
patients assessed their quality of care by utilizing the questionnaire ‘Strategic and
Clinical Quality Indicators in Postoperative Pain Management’. It was illustrated that
the regular use of pain assessment tools received a low score where only 21% of the
sample of patients totally agreed that a pain assessment tool was used on several
occasions each day.
Sloman, Rosen, Rom, & Shir (2005) used descriptive comparative design to
compare patients’ self-ratings of pain with nurses’ ratings of the patients’ pain in
Israel. Questionnaire for pain sensation, pain affect, and present pain intensity (PPI) at
rest and on movement; (b) visual analogue scales for overall pain intensity, suffering,
and satisfaction with treatment were used. The result of the study showed that nurses
significantly underestimated all dimensions of pain on the above scales, (t =3.131, p =
.002), pain affect (t = 4.410, p < .001), PPI at rest (t = 3. 498, p < .001), PPI on
movement (t = 6.278, p < .001), overall pain intensity (t = 2.235, p = .002), and
patient suffering due to pain (t =3.774, p < .001).
Furthermore, pain necessarily may not be associated with a change in
physical signs. In the study of Gillies, Smith, and Parry (1999) out of 351 patients
surveyed, almost half of these participants believed that the nurses did not know when
they were in pain. Despite this revelation from the patients, the healthcare
professionals in this study believed that their pain assessments were always (100%),
usually (70%), or sometimes (27%) accurate.
24
2. Pain interventions
The principal goal of postoperative pain management is to reduce or
eradicate discomfort, prevent complications, facilitate the recovery process and to
attain a pain free status whenever possible (IASP, 1997). Traditionally, pain
management interventions were focused predominantly on the use of pharmacological
therapies alone. However, more recently it has been acknowledged that the inclusion
of non-pharmacological therapies integrated into the provision of postoperative care
plays an important role in enhancing, and augmenting the relief of postoperative pain.
Subsequently, a multidimensional approach in the alleviation of postoperative pain is
a prerequisite to achieving optimum pain relief. The choice of pain therapy is
determined by the location, severity and character of pain (Spacek, 2006; Smeltzer &
Bare 2004).
2.1 Pharmacological interventions
Pharmacological interventions are primary in the management of acute
postoperative pain. Opioid analgesics are the cornerstone of pharmacological
interventions for postoperative pain management (World Health Organization
[WHO], 1998). Usually three types medications are used to alleviate patient’s
postoperative pain including opioids analgesics, non-opioids analgesics, and adjuvants
(Mackintosh, 2007; WHO, 1998).
2.1.1 Opioid analgesics
Opioids are fundamentally the most potent, and effective analgesics
prescribed in postoperative pain thus they are the foundation of pharmacological
management of acute postoperative pain (WHO, 1998). Opioids are the derivatives of
opium that can modulate the perception of pain by binding to mu, kappa, or delta
receptors in the periphery, dorsal horn, and central nervous system (Kanner, 2003;
Barber, 1997). Opioid analgesics consist of natural agents including morphine,
codeine, and synthetic agents such as fentanyl. Currently there are two types of
opiods analgesics, the opiods agonists include codeine, methadone, hydromorphine,
meperidine, morphine, and fentanyl, the opioids agonist-antagonist includes
burenorphine, nalbuphine, butorphanol, and pentazocine. The common route of
opioids administration includes oral, parenteral, and intrathecal.
25
However, analgesics have many side effects including respiratory
depression, addiction, sedation, constipation, puritus, nausea and vomiting (Barber,
1997; Mackintosh, 2007). Tolerance, physical dependence, and psychological
dependence are not considered to be the adverse effects of opioids, however these are
the key concepts nurses should understand. Misconceptions of these terms lead to
inadequate pain treatment. Tolerance is a phenomenon in which a patient is less
susceptible to the effect of drug as a consequence of its prior administration. There
are three types of tolerance, acute, chronic, and cross tolerance. Acute tolerance is a
term used to describe tolerance that develops very rapidly following either a single
dose or a few doses given over a period of time. Chronic tolerance is described for the
observation that a drug administration over a longer period of time produces reduced
drug effects. Cross tolerance is used when tolerance to one drug confers tolerance to
another (Dafters & Odber, 1989).
Physical dependence is the term used to describe the phenomenon of
withdrawal when opioid is abruptly discontinued or an opioid antagonist is
administered. Both tolerance, and physical dependence are predictable
pharmacological effects seen in response to repeated administration of opioids.
Psychological dependence or addiction is described as a pattern of drug use
characterized by a continued carving for an opiod, manifested as compulsive, drug
seeking behavior, and overwhelming involvement in drug use (WHO, 1998).
Misconception about incidence of opioid addiction is high, is well documented in
pain literature (McCaffery & Ferrel, 1996).
2.1.2 Non-opioid analgesics
Other analgesic preparations are also considered and utilized in the
management of postoperative pain. Alternative non-opioid analgesics such as non-
steriodal anti-inflammatory drugs (NSAIDs), and acetaminophen (paracetamol) are
being regularly utilized. NSAIDs play a pivotal role in postoperative pain
management when used in combination with opioids. NSAIDs are a group of
chemical agents with a spectrum of analgesic, antiinflammatory and antipyretic
effects (Krenzischek, Dunwoody, Polomano, & Rathmell, 2008). It has been
demonstrated that NSAIDs improve analgesia by producing a synergistic analgesic
effect, and decrease opioid dosage (Spacek, 2006). Consequently, this opioid sparing
26
effect can essentially decrease opioid-related adverse effects such as respiratory
depression. Acetaminophen (paracetamol) is an effective analgesic available in both
oral and intravenous preparations. The exact mechanism of action remains unclear but
it is advantageous for the reason it is well tolerated with minimal contra-indications
(Macintyre & Schug, 2007; Vickers, 2007).
2.1.3 Adjuvant analgesics
These medications are used in combination with opioids and non-
opioids to manage pain. These agents include anticonvulsants, antidepressants,
corticosteroids, adrenergics agonist, and local anesthetics (Mackintosh, 2007).
2.2 Non-pharmacological interventions
It is considered that these therapies help the standard pharmacological
treatment in pain management. While medical drugs are being used for treating the
somatic (physiological) dimension of the pain non-pharmacological therapies aim to
treat the affective, cognitive, behavioral, and socio-cultural dimensions of the pain. In
general they are stated as physical, cognitive, behavioral, and other complementary
methods or as invasive or non-invasive methods. Meditation, progressive relaxation,
dreaming, rhythmic respiration, therapeutic touch, transcutaneous electrical nerve
stimulation (TENS), hypnosis, musical therapy, acupuncture, and cold and hot
treatments are non-invasive methods (Taylor & Stanbury, 2009; Mackintosh, 2005).
2.2.1 Massage
Massage is defined as the systematic manipulation of soft tissues by
manual or mechanical means. Nurses have used massage such as a back rub to
improve circulation, promote comfort, and enhance sleep. More recently investigators
had examined hand, and foot massage as an alternative to back or body massage. The
duration of massage varies from 5 to 20 minutes (Wells et al., 2005).
Mitchinson et al. (2007) conducted a randomized controlled trial with 605
patients undergoing major surgery to test whether massage therapy relieves
postoperative pain, and anxiety among patients who experience unrelieved
postoperative pain. Patients were assigned to the following 3 groups: (1) control
(routine care), (2) individualized attention from a massage therapist (20 minutes), and
(3) back massage by a massage therapist each evening for up to 5 postoperative days.
The findings revealed that compared to the control group, patients in the massage
27
group experienced short-term (preintervention vs postintervention) decreases in pain
intensity (p = .001), pain unpleasantness (p = .001), and anxiety (p = .007). In
addition, patients in the massage group experienced a faster rate of decrease in pain
intensity (p = .002) and unpleasantness (p = .001) during the first 4 postoperative days
compared with the control group. There were no differences in the rates of decrease in
long-term anxiety, length of stay, opiate use, or complications across the 3 groups.
2.2.2 Cognitive strategies
Distraction technique changes patient’s sense of control as well as
increases pain tolerance, and decreases pain intensity. This technique helps to reduce
mild to moderate pain during certain procedures including change of dressing,
intramuscular injection, and vein puncture. Distractions techniques include rhythmic
breathing, listening to music, laughing, counting, watching television, reading,
exercising, resting, talking on phone, and visiting places and people (Mackintosh,
2007, Wells et al., 2005).
Music as a non-pharmacological treatment for pain was tested by Roy,
Peretz, & Rainville, (2008) and Zhao and Chen (2009). Both studies evaluated effects
of musical interventions upon pain perception and both studies reported that pleasant
or cheerful music decreased perceptions of pain induced by heat while unpleasant or
sad music increased perceptions of pain under the same conditions. Zalewsky, Vinker,
Fiada, Livon, & Kitai, (1998) surveyed 118 patients whose surgery was performed
while music played in the surgical suite, 95% of participants did not feel disturbed by
the background music, 89% reported feeling more positive about their surgery, and
80% thought that the music supported the doctor’s performance and, therefore, led to
a better patient-doctor interaction.
2.2.3 Relaxation
There are many methods available to achieve a relaxation. Some
require initial training, and practice to be used effectively; progressive muscle
relaxation, systematic relaxation, and autogenic training skills that require some
practice. Each session using progressive, systematic, or autogenic training may take
15–30 minutes. Typically in research, the instructions are delivered via audiotape, a
method that may be used for hospitalized patients as well. Simpler forms of
relaxation, which may be more suitable to institute during an acute pain episode,
28
include rhythmic breathing (Good, Anderson, Ahn, Cong, & Stanton-Hicks, 2005;
Roykulcharoen, & Good, 2005; Wells et al., 2005).
He at al. (2010) conducted a quasi-experimental pre and post-test design
with a convenience sample of 108 registered nurses in two public hospitals in
Singapore. The results revealed that there was a statistically significant increase in
nurses’ use of five non-pharmacological methods for children’s postoperative pain
relief between pre- and post-test. These were: imagery (p = .001), positive
reinforcement (p = .004), thermal regulation (p = .003), massage (p < .001) and
positioning (p = .046).
Furthermore, He et al. (2011) conducted a survey with a convenience sample
of 151 registered nurses (RNs) in Singapore, to examine nurses’ use of non-
pharmacological methods for school-age children’s postoperative pain relief. The
result revealed that nurses who were younger, had less education, lower designation,
less working experience, and no children of their own used non-pharmacological
methods less frequently. Non-pharmacological methods used were relaxation,
breathing technique, distraction, positive reinforcement, preparatory information,
imagery, positioning, thermal regulation, massage, emotional support, comforting/
reassurance, touch, presence, helping with activities of daily living, and creating a
comfortable environment.
Similarly Kwekkeboom, Bumpus, Wanta, and Serlin (2008) conducted a
study with sample of 724 oncology staff nurses to examine the nurses’ use of four
nondrug interventions (music, guided imagery, relaxation, distraction) and to identify
factors that influence their use in practice. The results indicated that the percentages
of nurses who reported administering the strategies in practice at least sometimes
were 54% for music, 40% for guided imagery, 82% for relaxation, and 80% for
distraction. Use of each non-drug intervention was predicted by a composite score on
beliefs about effectiveness of the intervention (e.g. perceived benefit; p = .025) and a
composite score on beliefs about support for carrying out the intervention (e.g. time; p
= .025). In addition, use of guided imagery was predicted by a composite score on
beliefs about characteristics of patients who may benefit from the intervention (e.g.
cognitive ability; p = .005).
29
3. Evaluation
Ongoing assessment is necessary to evaluate changes in pain and the
effectiveness of management. The American Pain Society stresses that heath care
professionals should consider pain as the fifth vital sign (Campbell, 1995; Merboth &
Barnason, 2000). Therefore, the patient’s pain should be assessed at least as often as
vital signs are taken or whenever necessary to monitor effectiveness, and side effects
of the intervention. Accuracy in pain assessment is a major factor in measuring the
adequacy of pain management. This implies that health care professionals should
identify the presence of postoperative pain for each patient, and score its intensity
using standardized scales (APS, 2003; JCAHO, 2002). Pain scores are documented in
writing, making them readily available to all the health care professionals.
4. Documentation
Documentation of patient care is an integral, and necessary duty required of
nurses which underscores professional autonomy. Additionally, the documentation of
care structures the domain of nursing in a way that is identifiable (Heartfield, 1996).
Nursing records are purposeful in ensuring, and sustaining consistency and continuity
of care (Griffith, 2004). Although documentation is not direct patient care it is
extremely beneficial as it enables to monitor the progress of the patients. Evaluation
of care is a particularly important nursing duty as it determines the patient’s ongoing
needs, any progress made, the effectiveness of interventions, and it provides a means
for nurses to make decisions about care. Documentation is the central way in which
care is evaluated, and this underpins the significance of comprehensive nursing notes
to ensure appropriate evaluation of care. Subsequently, regardless of how good the
care provided to patients, if there is no documentation, substantiation and evaluation
of high quality clinical practice cannot be verified (Chanvej et al., 2004).
Abdalrahim, Majali, and Bergbom (2008) conducted a retrospective
approach to collect data on nurses’ documentation of pain assessment and
management in the first 72 hours postoperatively in surgical wards. A total of 322
records at six hospitals in Jordan were audited using three audit instruments; Pain and
Anxiety Audit Tool, the North American Nursing Diagnosis Association (NANDA)
form for characteristics of acute pain, and comprehensiveness assessment tool. The
results showed that there was no evidence of pain assessment documentation on the
30
first day of surgery in 113 (35%) of patient’s records. Pain location was the most
recorded information for pain assessment in 197 (61%) notes, and only14 (4.3%)
nurses used a pain scale. More than 53% of the records lacked information about
medication for pain management. There was a significant difference (p < .05) in all
the categories of pain documentation between the first day, and the subsequent days.
Nurses documented patients’ self-report of pain [297 (92.3%)], and patients’ crying
[200 (62.1%)]. More than 80% (273) of the records were ranked below the minimum
score for a satisfactory documentation. Chanvej et al. (2004) audited 425 patients’
records to evaluate the quality of postoperative pain documentation in the first 72
hours postoperatively. The study revealed that documentation of pain both before and
after giving analgesics were scarce, pain assessment items were documented
inconsistently, and below accepted standards. Similarly Stomberg, Lorentzen,
Joelsson, Lindquist, and Haljamae (2003) studied 2890 registered cases in the
database, a homogeneous 2-years sample of documentation charts. They found that
only 58% of the data charts were properly completed and entered into the database.
The database documentation routines were not found to function optimally.
Manias (2003) conducted a study in which nurses’ notes in 100 patients’
records of the postoperative period were audited. The study showed that nurses
documented inadequately in four major areas: pain assessment, use of
pharmacological intervention, use of non-pharmacological interventions, and outcome
of interventions.
Theory of Reasoned Action
The Theory of reasoned action of Ajzen and Fishbein (1980), assumes that
most actions of social relevance are under volitional control. Thus an individual’s
intention to perform or not perform an action is the immediate determinant of that
behavior. Usually there is a strong correlation between the intention to act and the
action. Barring unforeseen circumstances, where an action is under volitional control,
a person will act in accordance with the intention. Behavioral intentions are function
of personal, and interpersonal factors: a personal belief and the perceived beliefs of
significant others. When individuals believe that a behavior will result in valued
31
consequences, and they believe that important referents consider the behavior to be
worthwhile, they are likely to execute that behavior. Ajzen recognized that difficulties
are encountered when behavior is not favored by not having the necessary
opportunities or resources to act, i.e. the behavior is not volitional.
According to Ajzen and Fishbein (1980) Knowledge is the information and
skills acquired through education or experience regarding any behavior. Knowledge is
the base for development of nursing actions, such as those required for postoperative
pain management. For example, for patients experiencing pain, nurses should have
knowledge about patients’ expression of pain, pain physiology, drug actions, as well
as sources, and effects of pain. Nurses need this knowledge to perform nursing actions
to relieve patients’ pain (Ajzen & Fishbein, 1980).
According to Ajzen and Fishbein (1980) attitude is an individual’s positive
or negative feeling towards an object or feelings associated with performing a specific
action. A person’s attitude towards an object is based on his salient beliefs about that
object. An individual’s attitude towards pain management, for example, is a function
of his belief about pain management. If those beliefs associate the object or issue with
favorable attributes his attitude would tend to be positive. Conversely, a negative
attitude would result if the person associates pain management with unfavorable
attributes. It could be said that a person’s attitude toward some object or issue is
determined by his or her beliefs and that attitudes are measured by assessing the
beliefs of the person. The nurse would hold a favorable attitude towards a given
action (administering pain medication) if he or she believed that the performance of
the action would lead to mostly positive outcomes; on the other hand, if the nurse
believed that negative outcomes would result from the action, then he or she would
hold a negative attitude towards it (Ajzen &Fishbein, 1980).
Ajzen and Fishbein (1980) describes self-efficacy as a control factor,
reflecting the individual’s perceived control over the behavior, and beliefs about
the ease or difficulty of performing the behavior. This incorporates the individual’s
perception of the presence or absence of the necessary resources and opportunities to
perform the behavior.
32
Factors Related to Postoperative Pain Management
According to the Agency for Healthcare Research and Quality (2002), there
are three factors related pain management including healthcare system related factors,
patients related factors, and healthcare professionals related factors. However, in this
study healthcare professional (nurses) related factors including knowledge, attitude,
and self-efficacy regarding postoperative pain management were examined. It is
evident from the literature that nurses scoring high in knowledge of pain management
have positive attitude and high self efficacy in pain management (Ampomah, 2009;
Chiang et al., 2006; Glajchen & Bookbinder, 2001). Therefore, this review focused in
knowledge, attitude, and self efficacy of nurses regarding postoperative pain
management since nurses are the health professional who care the postoperative
patient all round the clock.
1. Knowledge of postoperative pain management
Knowledge of postoperative pain management is nurses’ theoretical and
practical understanding of postoperative pain, and its management including
knowledge of assessment, intervention, evaluation, and documentation. The Theory of
Reasoned Action (Ajzen & Fishbein, 1980) states that knowledge is the information
and skills acquired through education or experience regarding any behavior. It
assumes that individuals having good knowledge of given behavior are more likely to
perform the behavior. Therefore, in order to be competent in the provision of high-
quality pain management, nurses must be knowledgeable in all facets of pain
management and the evidence-based strategies underpinning these practices.
Adequate pain management is reliant on the knowledge, attitudes, and subsequent
skills of healthcare professionals (Lewthwaite et al., 2011).
Numerous studies had been conducted to evaluate nurses’ knowledge of pain
management. A descriptive correlation study was used by Basak (2010) in
Bangladesh to examine the level of knowledge and attitudes, and nurses’ practices
regarding post-operative pain management with a sample of 100 nurses. He found
nurses had low level of knowledge and negative attitude, presented by the total mean
score of 59.05% (S.D = 5.62) with a minimum and maximum scores of 40% and 70%.
Nurses’ practice regarding postoperative pain management was in moderate level
presented by mean score of 77.81%, (S.D = 10.94) (Basak, 2010).
33
A descriptive study was used by Al-Shaer et al. (2011) with a sample of 129
registered nurses (RN). They found the average knowledge score was 25.9 (S.D =
2.5). Scores ranged from a minimum of 20 to a maximum of 31. The majority of
respondents (n = 79, 61.2%) received a letter grade of B (80%-89%) or higher. No
statistical differences existed in knowledge scores with respect to shift worked, work
status, age category, and total years of nursing practice. Nurse having worked 16 or
more years on their particular nursing unit scored significantly higher than nurses who
having worked 1-5 years on their unit (Mean = 27.2; S.D = 2.3 vs. Mean = 25.0; S.D
= 2.5; p < .001).Total knowledge scores did not differ significantly by degree
preparation of the nurse. Baccalaureate prepared nurses (Mean = 26.4; S.D = 2.6),
and diploma prepared nurses (Mean = 26.0; S.D = 1.7) scored higher than nurses who
held an associate’s degree (Mean =25.7; S.D = 2.5). Baccalaureate prepared nurses
scored significantly higher on the 16 assessment items compared to nurses with other
preparation (p = .003).The authors concluded that although the results of this study
indicated relatively high knowledge scores, some nurses were not prepared adequately
to care for patients who experience pain. Knowledge of pain management principles,
and interventions was insufficient. Nurses continue to demonstrate inadequate
knowledge of pain assessment, and pain management interventions (Al-Shaer et al.,
2011).
Similarly, Abdalrahim, Majali, Stomberg, and Bergbomet (2011) explored
nurses’ knowledge, and attitudes towards pain in surgical wards in Jordan. The
sample consisted of sixty five registered nurses, and questionnaire (NKAS) comprised
of 21items were designed to test nurses’ knowledge of pain and their attitudes toward
its management. The finding revealed the overall percentage of correct answers of the
65 nurses was 45.7%, corresponding to an average number of correct answers of 9.2
of the 21 questions. The author concluded that participants had inadequate knowledge
of postoperative pain management (Abdalrahim et al., 2011).
A descriptive correlational study was used by Ampomah (2009) to compare
the knowledge, attitudes, and beliefs about pain management of West African-born
nurses working in the United States with their United States-born counterparts
including 187 nurses. Thirty seven item Nurses Knowledge and Attitude Survey
Regarding Pain (NKASRP) originally designed by Betty Ferrell and McCaffery in
34
1987, and revised in 2005 was modified into a 30 items questionnaire to assess the
knowledge of nurses regarding pain management. The study found insufficient
knowledge of pain management between West African born and United Sates born
nurses [50.7% West African vs. 60.1% United States] (Ampomah, 2009).
A descriptive cross-sectional study design was used by Lui, So, and Fong
(2008) to explore the knowledge, and attitudes regarding pain management among
nursing staff working in medical units in Hong Kong with a convenience sample of
143 nurses. Among the 25 items about pain management being assessed, the
percentage of correct scores on NKASRP was 47.72%, with a range of 20-76. The 10
items most frequently answered incorrectly indicated that the participants were weak
in pharmacological and non-pharmacological interventions for patients experiencing
pain. 71.3% of the participants believed that the most accurate judge of the intensity
of pain was the patient, only 1.4% believed that no patients over reported the amount
of pain. Discrepancy between participants’ attitudes, and practice was further
supported by the two scenarios used in NKASRP; even when two patients reported
the same level of pain, the participants believed that the one expressing discomfort to
be suffering a higher level of pain than the one with a relaxed manner. In addition,
71.1% of the participants believed that the patient should have to endure as little pain
as possible and should have prompt treatment. However, 64.3% would advise patients
to use non-drug techniques alone rather than concurrently with pain-relieving
medications. Findings of the study revealed that the participants had inadequate
knowledge of, and misconceptions about pain relief interventions (Lui et al., 2008).
2. Attitude towards postoperative pain management
An adequate postoperative pain management is reliant on the knowledge of
nurses. In addition to the knowledge of postoperative pain management, nurses
attitude of postoperative pain management significantly contributed to effective
postoperative pain management. Attitude towards postoperative pain management is
nurses’ positive or negative feeling towards postoperative management including pain
assessment, intervention, evaluation, and documentation. The TRA states an
individual will have positive attitude if he/she believes that the performance of the
behavior will lead to mostly positive outcomes, on the other hand, if the individual
believes that negative outcomes will result from the behavior, then he or she will hold
35
a negative attitude towards it. Therefore, if a nurse believes that her action leads to
positive outcomes such as comfort, and satisfaction to the patient, then she would
have a positive attitude towards postoperative pain management.
The literature recognized that, due to the subjective nature of pain, nurses’
attitude contribute to under treatment of pain. This can happen when clinicians make
pain management decisions for patients based on their own beliefs, and do not accept
patients’ self reporting as the ‘gold standard’ (Nash et al., 1993, Pasero & McCaffery,
2001). Nash et al. (1993) used focus based interviews with 19 participants to ascertain
that nurses’ attitudes affected pain management, and their administration of analgesia
particularly opiates. Their study revealed a range of erroneous beliefs, for example
that smaller patients need less analgesia, and terminally ill patients should have more
analgesia. Similarly, Richards and Hubert (2007) sought to understand the experience
of nurses with regard to pain relief, and concluded that expert nurses preferred to view
the patient holistically, listening to what the patient had to say and looking for other
pain cues before deciding what pain relief was suitable. The participants in this
qualitative pilot study stated that they found it difficult to put their own judgments
aside and accept what the patient said. These nurses further admitted to struggling
with their individual biases relating to pain and pain management.
Likewise a recent study of Phuong (2012), with a sample of 124 surgical
nurses found that the mean score of nurses’ attitudes toward postoperative pain
management was 69.35 (S.D = 5.26), the independent subscale such as scheduling
analgesic mean score was 12.09 (S.D = 1.39), the mean score of pain assessment was
21.49 (S.D = 1.91), the mean score for misconception for pain management, the use of
opioids was 27.65 (S.D = 2.99), and the mean score of non-pharmacological
management subscale was 8.12 (S.D = 1.13). McMillan, Tittle, Hagan, Laughlin, &
Tabler (2000) cited in Phuong (2012) found a variety of nursing attitudes that
interfere with the appropriate management of postoperative pain, nurses feel that
patients should experience pain as it a normal physiological functioning, they had a
fear that patient will be addicted to pain medication, and land up in respiratory
depression.
On the other hand Layman, Horton, and Davidhizar (2006) used a
convenience sample of 52 nurses in Midwest community hospital in the USA using
36
open ended questionnaires, with an aim to determine nurses’ attitude towards pain
management and found that attitude scores ranged from 6 to 28 with an overall mean
score of 8.3 indicating a positive attitude towards pain management. Positive beliefs
about pain assessment tools included the fact that ‘They help patients to be as
comfortable as possible’ and were ‘very beneficial to the patient’s well-being’. Others
stated, ‘Tools were an important part of assessing the pain properly and addressing the
problem effectively’. Some believed that ‘they are the best in resolving the problems
of pain’. These comments seemed to indicate that the use of the pain tool assisted
them in determining patients’ overall welfare, comfort, and assessing pain efficiently.
Other positive beliefs related to the value of pain assessment tools included providing
objective and measurable data. In fact, 22 responses supported this view and the belief
that the tools provided ‘accountability’ and helped to collect data. The use of the pain
tools gave nurses positive attitudes and beliefs that they could perform pain
assessment in a reliable, and dependable way through accurate documentation of pain
(Layman et al., 2006).
In addition, Boegeskov, Svantesson, and Bergbom (1994) used a qualitative
study with a sample of eight nurses from a Danish post anesthetic care unit. Most
nurses believed that patients should expect some level of postoperative pain, and that
short-lived pain is acceptable. Most expressed fear over the use of opioids,
particularly related to side-effects and the possibility of addiction (Boegeskov et al.,
1994).
Similarly, a qualitative study was undertaken in Australia by Helmrich et al.
(2001) to investigate nurses’ attitudes, and use of non-pharmacological therapies for
pain relief. It was establish that the majority of nurses (89.2%) stated they integrate
non-pharmacological therapies to assist in the management of patients’ pain.
Conversely, inspection of patient records in various studies identified that the
documentation of non-pharmacological approaches to pain management was minimal
to non-existent. However, it was unknown whether nurses utilized any non-
pharmacological approaches in these studies or simply excluded to document those
(Helmrich et al., 2001).
According to Power (2005) non-pharmacological therapies were seldom
utilized for acute postoperative pain relief. Several barriers hindering the
37
implementation of non-pharmacological interventions by nurses for the relief of pain
had been cited in the literature which includes: a lack of resources, time constraints,
lack of knowledge regarding non-pharmacological approaches to pain relief and lack
of professional support.
3. Self-efficacy in postoperative pain management
With increase in knowledge of postoperative pain management, attitude of
nurses change from negative to positive, subsequently, it affect the self-efficacy of
nurses in postoperative pain management. The TRA states that individual with high
internal control factor (self-efficacy) tend to perform behavior with ease and
confident. Therefore, in this study it was assumed that nurses with high self-efficacy
would manage postoperative confidently. A study of Chiang et al. (2006) examined
self-efficacy of 181 nurses in Taiwan after an educational program. Data were
collected by an extensive questionnaire that assessed nurses’ knowledge, attitudes,
and self-efficacy pain assessment and pharmacological and non-pharmacological pain
management. Before the pain education, the standard score for self-efficacy was
73.37, indicating that nurses were fairly confident at assessing and managing
children’s pain. The total standard score of self-efficacy at post-test was 87.7,
indicating that nurses’ self-efficacy in managing pain significantly (p < .001)
increased after the pain education program (Chiang et al., 2006).
Similarly, in a statewide cross-sectional survey conducted in Australia by
Edwards et al. (2001) to determine registered nurses' attitudes, subjective norms, and
perceived control, and self-efficacy to administer opioids to patients with pain. Four
hundred and forty six nurses participated in the study including the primary area of
clinical experience was surgical/ perioperative (29.4%), medical (19.5%), critical
care/ accident and emergency (13%), midwifery (11.9%), mental health (6.7%),
oncology (5.6%), gerontology (4.9%), pediatrics (3.6%), and general nursing (5.4%).
A self-report instrument, the Pain Management Survey was used. Results indicated
that respondents' attitudes towards opioids, and their administration to patients with
pain were generally positive. However, responses to particular items highlighted the
presence of negative attitudes that could have a major influence on nurses' pain
management. Nearly 40% of respondents did not agree that, in general, children and
patients with a history of opioid addiction should be given opioids for pain relief.
38
Over 20% agreed or were unsure whether patients who ordered analgesics every 4
hours and reported pain within those 4 hours should have to wait until their pain
relieving medication was due. One-third (32.8%) of respondents considered opioids
should not be required for longer than 3 days post-operatively and nearly 20% were
unsure about this. Nearly half (47.8%) felt that, in general, patients should be
encouraged to have non-opioids rather than opioids for pain relief. Just over one-third
(36%) agreed it was best to administer the least possible amount of opioids (Edwards
et al., 2001).
Nurses’ role in postoperative pain management in JDWNRH
Thimphu, Bhutan
Postoperative pain management is an important nursing responsibility.
Nurses in Bhutan play vital role in management of postoperative pain. There are three
categories of nurses in Bhutan including general nurse midwife (GNM) with diploma
in nursing education, bachelor degree nurses, and master degree nurses in JDWNRH.
However, the roles and responsibilities of all three categories of nurses are same
pertaining to postoperative pain management.
Although nurses receive very little knowledge of pain management during
the initial nursing training, they gain substantial knowledge from inservice taining,
short course training, from role model, feed back from evaluation, and on job training.
To ensure that nurses are capable of doing postoperative pain management activities,
they are kept on rotation for period of three to four months in different wards involved
in the care of postoperative patients. The senior nurses supervise the junior nurses in
daily nursing activities for a period of one year. During this period the senior nurses
teaches, guide, support, encourage, and help the novice nurses to gain knowledge, and
learn good nursing practices.
The head nurses of all the wards go for evening nursing rounds, and guide
the novice nurses in the performance of the postoperative pain management. Every
month, the head nurse meets with the medical director, and the nursing superintendent
to present the progress of the respective wards. Further the head nurses organizes
39
meeting with other nurses to share the views and plans to improve the management of
postoperative pain management.
Knowledge gained through practice, from role models, inservice trainings,
short course, and the physicians help nurses in the management postoperative pain.
The following pain management standard is followed in JDWNRH Thimphu, Bhutan.
The nurses assess the postoperative pain by physiological monitoring including
measurement blood pressure, and pulse. Administer the prescribed pain medications,
along with the non-pharmacological interventions depending upon the individual
judgment of the nurses. The evaluation of pain, the effects, and side effects of the
medications are done routinely. Further the physicians should be notified if the pain is
not relieved. The non-pharmacological methods includes, provision of a suitable
calm environment for the patient, eliminating sources of discomfort, such as full
bladder, infiltration of IV etc. Reposition the patient regularly to eliminate pressure
sores. Encouraging patient to move extremities while in the bed because activity
decreases muscle spasm and booster circulation. Teach the patients comfort measures
including relaxation, deep breathing exercises, listening to music, reading, watching
television, moving or coughing to prevent complications. However, opioid
administration had been identified as the area for greatest decision making and
potential conflict in nurses’ pain management this may be the lead nurses to develop
negative attitude towards managing pain adequately. Systemic opioid analgesics,and
NSAIDs are mostly prescribed as a variable dose and given by nurses on a PRN basis.
Thus, the nurses make the decisions concerning medication for pain relief.
Summary
Several studies were conducted around the world to evaluate nurse’s
knowledge of pain management, attitudes towards pain management, where there are
different cultures, different level of education, advanced technology, and well
developed nursing services. It was evident from literature, despite of advanced
technology in pain management nurses have inadequate knowledge of pain
management, negative attitude, and low self-efficacy in pain management. However,
the context of Bhutan is different, nursing service is developing, very little technology
40
and little research, and different culture, therefore this study is deemed necessary to
be conducted. In conclusion, pain is a subjective, and very personal experience
associated with actual or potential tissue damage. It is unpleasant emotional and
sensory experience. Despite of well developed technology, and advancement in pain
management, studies showed that postoperative pain is inadequately assessed and
managed by nurses. Unrelieved postoperative pain has many deleterious effects to the
body, and patients have to suffer unnecessarily. Therefore it is crucial responsibility
of the nurses to assess, and manage postoperative pain adequately, for this action
nurses need to have a good knowledge of pain management, positive attitude, and
confidence in the planning, and intervening the modalities of pain management.