Eloise C.J. Carr, BSc (Hons), MSc, PhD, RN, PGCEA, RNT.
Senior Lecturer, Institute of Health and Community Studies, Bournemouth UniversityResearch carried out over several decades to explore the experience of postoperative pain in hospital suggests that many patients experience moderate to severe pain (Marks and Sachar, 1973; Cohen, 1980; Abbot et al, 1992). The Royal College of Surgeons and College of Anaesthetists strongly advocated that all major hospitals in the UK should have an acute pain service (RCS/CA, 1990). By 1995 approximately 44% of hospitals reported having some form of acute pain service, with virtually every hospital responding (79%) using some form of modern analgesic technique such as patient-controlled analgesia (PCA) or epidural infusion (Harmer et al, 1995).
Research carried out over several decades to explore the experience of postoperative pain in hospital suggests that many patients experience moderate to severe pain (Marks and Sachar, 1973; Cohen, 1980; Abbot et al, 1992). The Royal College of Surgeons and College of Anaesthetists strongly advocated that all major hospitals in the UK should have an acute pain service (RCS/CA, 1990). By 1995 approximately 44% of hospitals reported having some form of acute pain service, with virtually every hospital responding (79%) using some form of modern analgesic technique such as patient-controlled analgesia (PCA) or epidural infusion (Harmer et al, 1995).
The majority of acute pain research continues to use single evaluation measures, such as pain intensity or analgesic consumption, which do not reflect the patient's wider experience (Bendelow and Williams, 1995). There is a lack of consideration of other outcomes that measure how pain affects patients' recovery from surgery and, indeed, what these outcomes might be.
Eighty-five women were recruited to take part in a study to explore the effect of postoperative pain on patient recovery following major gynaecological surgery (Carr, 2000). Findings from telephone interviews with 37 of these women, which took place between four and six weeks after their surgery are also reported. Several important factors emerged from the analysis of these conversations, which give a greater understanding of the experience of pain following surgery and the implications for nursing care.
This longitudinal study employed several data collection methods to explore the experience of pain and how this affected a variety of outcomes, such as mood, general activity and sleep during the postoperative period. A total of 85 women undergoing major gynaecological surgery consented to participate in the study.
To measure the effect of pain on patient outcomes, two instruments were used: the Hospital Anxiety and Depression Scales (HADS) (Zigmond and Snaith, 1983) and the Brief Pain Inventory (BPI) (Cleeland and Ryan, 1994).
Participants were asked to complete the HADS pre-operatively and then again on Days 2, 4 and 10. At these times, the BPI, information relating to analgesic consumption and the reason for discontinuation of the PCA was collected. Information relating to pain from nursing notes was also transcribed. To gain a greater understanding of the patients' responses on the completed questionnaires and to increase validity, a semi-structured taped telephone interview was conducted at between four and six weeks postoperatively. Women who had made a good recovery (low pain) and those who experienced high levels of pain were interviewed. A total of 37 interviews took place.
The majority of patients (58; 68.2%), experienced a worst-pain score of 5 or more (on a scale of 0-10) on Day 2, suggesting the modalities of analgesia were ineffective at providing optimal pain relief when patients most needed it. On Day 4 nearly half the sample (n=41) indicated that their worst pain was still at level 5 or above. By Day 10 pain had lessened, but the intensity of pain for some patients continued to be a problem; 21 patients (24.7%) scored 5 or more and one patient scored 10.
On the day of surgery all patients received a strong opioid (morphine) either via an epidural or a PCA device. Surprisingly, as many as 42.4% (n=36) of patients were no longer receiving opioids by the end of the first postoperative day, increasing to 96.4% (n=82) by 6pm on Day 2. Many patients did not know why their PCA had been discontinued (Figure 1). The discontinuation of PCA should be discussed with the patient and instigated when pain levels have subsided to ensure the philosophy of patient control is continued. Introducing a non-steroidal anti-inflammatory drug (NSAID) before discontinuation eases the transition from parenteral opioids.
By Day 3 approximately half the patients had received a compound analgesic with an NSAID and the remaining patients just one type of analgesic (NSAID, compound or paracetamol), with only three patients not taking any analgesic. By Day 10, over a quarter of participants (n=23) continued to take two types of analgesia, with 35.3% (n=30) preferring to take only one type and 37.6% (n=32) taking no analgesia at all.
The effect of pain on the six outcome variables (activity, mood, walking, relationships, sleep and quality of life) on the BPI questionnaire on Days 2, 4 and 10 indicated that pain interfered with activity the most and relationships with other people the least. The experience of pain was influenced by time. For example, activity often increased when patients went home and this increased their pain, as one patient said: 'It felt more painful walking around and I was probably doing more ... not resting. It was silly things, like getting out of your own bed or up from the sofa.'
To determine if there was a difference in mean pain scores between patients scoring as 'cases' (score of 7 or more out of 21) and 'non-cases' for anxiety and depression on Days 2, 4 and 10, a test of between-subjects ANOVA (analysis of variance) was performed (Figures 2 and 3). For anxiety, there was a significant difference in mean worst pain scores for patients scoring as cases compared to those scoring as non-cases, on Days 2, 4 and 10.
Patients who were anxious were more likely to have higher pain scores than those who were less anxious. Recognising those patients who are anxious and introducing strategies to address their anxiety could reduce their experience of pain. There was no significant difference between mean worst pain scores for those patients scoring more than seven for depression, except for Day 4 when it was highly significant (<0.0001). this="" might="" have="" related="" to="" the="" anticipatory="" fear="" of="" discharge="" from="" hospital="" and="" losing="" the="" relative="" security="" of="" the="">0.0001).>
Patients' descriptions of pain - While the questionnaire results suggest that pain was not optimally managed and patients experienced pain which interfered with a range of outcomes, there was little understanding of what might have contributed to this. The findings from the telephone interviews, conducted at between four and six weeks after surgery with 37 women, add an important dimension to the study, as they illuminate the processes that contributed to the findings and give a more complete picture of the experience of pain.
Each telephone interview was transcribed and then coded. From the coded information, six major themes emerged: expectations of pain; describing the pain; analgesia; helping pain; increasing pain; and discussing pain with a professional. Five of the categories relate specifically to information and are now explored further and discussed in relation to other research findings and the implications for practice.
Expectations of pain - It appears that patients expect pain after surgery and that their anxieties may be exacerbated either by previous experiences or what they have heard from others. Nearly two-fifths of the patients interviewed (n=14) talked about their expectations of pain, often using the word 'dread' and expressing fear about the pain they expected after surgery. One patient said: 'So when I had this operation I was sort of petrified and dreading the worst.'
For some, the pain they experienced was unexpected in terms of the amount or location. It was also evident that medical staff expected the patients to experience pain. One patient said: 'I mentioned that there was a lot of pain there and they explained that I would have to expect that because they had had to make so many cuts. But I had thought the worst of it would be over by that stage.'
Research exploring expectations of postoperative pain and its relief indicate that the public have little or no understanding of the nature of postoperative pain or of the methods available to treat it (Scott and Hodson, 1997; Owen and Gould, 1997). Patients have also been found to underestimate the pain they will experience after surgery (Carr, 1990). In a study of 186 patients waiting for major surgery, less than 5% learned about pain control from nursing and medical staff, with 85% indicating that family and friends were their sources of information (Jairath and Kowal, 1999). It is important to assess previous pain experiences and expectations. This information can then be used as a baseline for patient education and provides an opportunity to explore any misconceptions. It is likely that, when patients are more informed about pain and its management, they will be less accepting of inadequate pain relief.
Describing the pain - Pain is a multidimensional experience and has been reported to have three major components: sensory, emotional and cognitive (Melzack and Wall, 1973; Karoly, 1985). It was evident from the interviews that the experience of pain reflected these dimensions and patients used a variety of words to describe their pain. One patient described her pain thus: 'It was absolutely agonising. There was a small pain across the wound like a burning. The pain in my side was terrible. It just didn't seem to go.'
The cognitive component of pain relates to the meaning of the pain. Understanding that the pain they were experiencing was due to bruising, wind or constipation was important as it gave meaning and often reduced anxiety and uncertainty about the cause. One patient said: 'The worst part was the wind. I mean that was appalling, that had me in tears, that was so bad.'
When pain is assessed it is important that more than just the intensity of the pain is measured. Patients should be asked to choose words that describe the pain and how it is affecting them. Those words may help diagnose the cause of the pain and enable nursing interventions to be tailored accordingly.
Analgesia - Two main themes relating to this category were unwanted side-effects and barriers. These contributed to an unwillingness to take analgesia even when pain was significant. One patient said: 'You can still have the drug but you're still worried ... they say to you 'It's your choice' but you don't know how much you can really take.'
Another patient mentioned side-effects: 'One in particular I stopped taking because they were causing constipation. I took the other ones, which were stronger and longer acting.'
In the ward where the study took place, the self-administration of medicines was permitted for patients who had been assessed as suitable. Despite continued recommendations for round-the-clock prescribing, all analgesia was written up on a pro rata basis (RCS/CA, 1990; Audit Commission, 1997). It was evident that many patients chose not to take regular analgesia but endured pain due to unpleasant side-effects or misconceptions about analgesia.
Nursing staff are in a position to be able to educate patients about the benefits of regular analgesia in preventing complications and aiding recovery and to explore any concerns they may have. Patient education must be an integral part of providing effective pain management.
Relief from pain - Two strategies for helping pain were mentioned by a significant number of respondents: analgesia and rest/staying still. A study of the experience of postoperative pain among 16 elderly women in hospital found that they endured their pain and the most common strategy for reducing it was lying still (Zalon, 1999). It is well documented that reduced mobility after surgery is associated with a greater risk of postoperative complications. The assessment should ascertain patients' level of pain on movement as well as while resting. This may ensure patients are comfortable enough to walk around the ward or to the bathroom regularly. In our study, patients continued to mention analgesia as a strategy that helped their pain even when they continued to experience significant levels of pain.
Two non-pharmacological strategies were mentioned as helpful by women in the present study who experienced low levels of pain after surgery. The first was a positive mental attitude or determination to get better quickly and the other was the use of a homeopathic remedy called Arnica montana, a remedy used to reduce bruising. One patient said: 'Well, I think a lot of it is mental. I was determined before I had the operation that I was going to get on well.' Another commented: 'Yes, I took Arnica four days before and about five or six days after as soon as I was able to ... That was for the bruising. It helped the bruising and swelling.'
The psychological benefit to patients of feeling they had some control over their pain and were actively helping themselves was likely to be very positive and contribute to pain relief. Studies have shown that positive coping has been significantly correlated with less pain in the surgical patient (Buckelew et al, 1992; Thomas et al, 1995). While evidence for the use of non-pharmacological interventions in postoperative pain remains weak (Sindhu, 1996) individuals obviously felt differently. Many patients attend pre-admission clinics, where nurses can encourage patients to use self-help strategies they might already know about or introduce them to information about strategies other patients have found beneficial.
The role of reassurance - Concerns about pain at home accounted for 30% (n=10) of patients visiting their GP. Reassurance that the pain did not indicate anything abnormal was often sufficient to alleviate their worries and reduce the pain. One patient commented: 'I had this terrible pain and I went to see the GP with it. It was absolutely agonising. It did get a bit easier the next day and the GP ... he checked everything. He said 'I think it's just par for the course. I can't see anything wrong'. Since then I've just had niggling pain but if I overdo it I get the pain.'
Studies that have explored the needs of patients on discharge from hospital have identified that information about pain is frequently inadequate (Moore, 1994; Goodman, 1997; Shultz et al, 1997), despite being a common problem (Bruster et al, 1994). Interviews with 20 patients recovering from coronary artery bypass surgery identified a number of unmet needs regarding information about their recovery after they had received a standard education programme (Moore, 1994). Patients wanted to hear words that described the sensations they would experience and detailed information about the duration of experiences associated with recovery. There appears to have been little research in this area, with most focusing on pre-operative information. Information leaflets for those being discharged from hospital could be developed with patients contributing their own experiences. A follow-up telephone service is another way in which patients could obtain reassurance with regard to pain or discomfort without visiting their GP.
Summary and conclusion
The experiences of many patients suggest that pain is still inadequately managed after surgery and lack of information continues to be a major problem following discharge from hospital (Mooney and Symonds, 2001). Patients have low expectations and inadequate coping strategies and knowledge of pain, and many health-care professionals continue to provide inadequate analgesia and information. The findings from this study suggest a number of areas where nurses could make a significant impact to improve the situation (Box 1).
For over 20 years the importance of giving information and its relationship to pain have been reported (Boore, 1978; Johnson et al, 1978; Johnston and Vogele, 1993) and patients have identified nurses teaching them about their condition as one of the most important nursing activities (Webb and Hope, 1995). Patients need to be informed about the sensations they are likely to experience during their recovery, both in hospital and at home. They also need information, not on analgesics alone, but on why it is important to take them. Nurses have the opportunity to provide patients with information that can significantly affect their experience of pain after surgery and really make a difference.
Abbot, F.V., Gray-Donald, K., Sewitch, M.J. et al. (1992)The prevalence of pain in hospitalized patients and resolution over six months. Pain 50: 15-28.
Audit Commission. (1997)Anaesthesia Under Examination. London: Audit Commission.
Bendelow, G.A., Williams, S.J. (1995)Transcending the dualism: towards a sociology of pain. Sociology of Health and Illness 17: 2, 139-165.
Boore, J. (1978)Prescription for Recovery (RCN Research Series Publication). London: Royal College of Nursing.
Bruster, S., Jarman, B., Bosanquet, N. et al. (1994)National survey of hospital patients. British Medical Journal 309: 1542-1546.
Buckelew, S.P., Conway, R.C., Shutty, M.S. et al. (1992)Spontaneous coping strategies to manage acute pain and anxiety during electrodiagnostic studies. Archives of Physical Rehabilitation 73: 594-598.
Carr, E.C.J. (1990)Postoperative pain: patients' expectations and experiences. Journal of Advanced Nursing 15: 89-100.
Carr, E.C.J. (2000)Exploring the effect of postoperative pain on patient outcomes following surgery. Acute Pain 3: 4, 183-193.
Cleeland, C., Ryan, K.M. (1994)Pain assessment: global use of the Brief Pain Inventory. Annals of the Academy of Medicine 23: 2, 129-138.
Cohen, F. (1980)Post-surgical pain relief: patient's status and nurses' medication choice. Pain 9: 265-274.
Goodman, H. (1997)Patients' perceptions of their education needs in the first six weeks following discharge after cardiac surgery. Journal of Advanced Nursing 25: 1241-1251.
Harmer, M., Davies, K.A., Lunn, J.N. (1995)A survey of acute pain services in the United Kingdom. British Medical Journal 311: 360-361.
Jairath, N., Kowal, N. (1999)Patient expectations and anticipated responses to postsurgical pain. Journal of Holistic Nursing 17: 1184-196.
Johnson, J.E., Rice, V.H., Fuller, S.S. Endress, M.P. (1978)Sensory information, instruction in coping strategy and recovery from surgery. Research in Nursing and Health 1: 1, 4-17.
Johnston, M., Vogele, C. (1993)Benefits of psychological preparation for surgery: a meta-analysis. Annals of Behavioural Medicine 15: 245-256.
Karoly, P. (1985)The assessment of pain: concepts and procedures. In: Karoly, P. (ed.). Measurement Strategies in Health Psychology. Chichester: John Wiley and Sons.
Marks, R., Sachar, E. (1973)The undertreatment of medical inpatients with narcotic analgesics. Annals of Internal Medicine 78: 173-181.
Melzack, R., Wall, P.D. (1973)Psychophysiology of pain. International Anaesthesiology Clinics 8: 3-33.
Mooney, G.P., Symonds, A. (2001)They just said come in for a day: patients' experiences of day case surgery. Primary Health Care Research and Development 2: 55-61.
Moore, S. (1994)Development of discharge information for recovery after coronary artery bypass surgery. Applied Nursing Research 7: 170-177.
Owen, S., Gould, D. (1997)Underwater seal chest drains: the patient's experience. Journal of Clinical Nursing 6: 3, 215-225.
Royal College of Surgeons of England and College of Anaesthetists. (1990)Commission on the Provision of Surgical Services. Report of the Working Party on Pain after Surgery. London: Royal College of Surgeons of England and College of Anaesthetists.
Scott, N.B., Hodson, M. (1997)Public perceptions of postoperative pain and its relief. Anaesthesia 52: 438-442.
Shultz, A., Geary, P., Casey, F. (1997)Joining education and service in exploring discharge needs. Journal of Community Health Nursing 14: 3, 141-153.
Sindhu, F. (1996)Are non-pharmacological nursing interventions for the management of pain effective? A meta-analysis. Journal of Advanced Nursing 24: 1152-1159.
Thomas,V.J., Heath, M., Rose, D. et al. (1995)Psychological characteristics and the effectiveness of patient-controlled analgesia. British Journal of Anaesthesia 74: 271-276.
Webb, C., Hope, K. (1995)What kind of nurses do patients want? Journal of Clinical Nursing 4: 101-108.
Zalon, M.L. (1999)Pain's interference with sleep in surgical patients. In: Abstracts: 9th World Congress on Pain. Vienna, Austria: IASP Press.
Zigmond, A.S., Snaith, R.P. (1983)The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 67: 361-370.