Applied Nursing Research 27 (2014) 53–58
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Healthcare Professionals' Perceptions of the Use of Pain Scales in Postoperative Pain Assessments Lotta Wikström, RN, PhD student a, b,⁎, Kerstin Eriksson, RN, PhD student a, b, 1, Kristofer Årestedt, RN, PhD c, d, e, 2, Bengt Fridlund, RNT, Professor a, 3, Anders Broström, RN, Professor a, f, 4 a
School of Health Sciences, Jönköping University, Jönköping, Sweden Department of Anaesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden d Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden e Palliative Research Centre, Ersta Sköndal University College and Ersta Hospital, Stockholm, Sweden f Department of Clinical Neurophysiology, University Hospital, Linköping, Sweden b c
a r t i c l e
i n f o
Article history: Received 13 June 2013 Revised 24 October 2013 Accepted 2 November 2013 Keywords: Postoperative pain Pain scales Pain assessments
a b s t r a c t Aim: To describe how healthcare professionals perceive the use of pain scales in postoperative care. Background: Pain scales are important but not an obvious choice to use in postoperative care. No study has explored how healthcare professionals experience the use of pain scales. Methods: An explorative design with a phenomenographic approach was used. The sample consisted of 25 healthcare professionals. Semistructured interviews were performed. Results: Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations. Conclusions: Healthcare professionals described that pain scales contribute to the understanding of patient's postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings. Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales depends on patient's needs and organization. © 2014 Elsevier Inc. All rights reserved.
1. Introduction An investigation of postoperative pain normally begins with a screening followed by a more thorough assessment if patients are in pain (e.g., including questions on location and duration of the pain). Pain is however a subjective experience that can be hard to communicate, both between patient and staff, as well as between staff with different professions. It is therefore recommended in guidelines that patient's self-report of pain should be screened by using a valid pain scale (Gordon et al., 2005). The extent to which pain scales are used (Abdalrahim, Majali, & Bergbom, 2008, Ene, Nordberg, Bergh, Gaston-Johansson, & Sjöström, 2008) and how assessments of postoperative pain are performed are explored only in a few studies (Klopper, Andersson, Minkkinen, Ohlsson, & Sjöström, 2006, Manias, Bucknall, & Botti, 2004). The results indicate that the use of pain scales Conflict of Interest. None. ⁎ Corresponding author. Tel.: +46 36321000; fax: +46 36325055. E-mail addresses: [email protected] (L. Wikström), [email protected] (K. Eriksson), [email protected] (K. Årestedt), [email protected] (B. Fridlund), [email protected] (A. Broström). 1 Tel.: +46 363 21000; fax: +46 363 25055. 2 Tel.: +46 480 446974; +46 709 206462 (mobile). 3 Tel.: +46 361 01233; +46 767 611233 (mobile). 4 Tel.: +46 10103 25 34. 0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.11.001
such as numeric rating scale (NRS), visual analogue scale (VAS) or verbal scale (VS) is not an obvious choice. The implementation of validated pain scales has been difficult in clinical settings despite educational programs (Ene et al., 2008). Screening for the presence of pain, without using pain scales still occurs and is instead based on the patient's appearance and behavior, what they express and how much pain “it usually is” after a certain type of surgery. Age, sex or ethnicity is taken into consideration (Klopper et al., 2006), and changes in vital signs such as pulse rate, blood pressure and respiratory rate are also used (Richards & Hubbert, 2007; Clabo, 2007). Quality of care is related to a well -functioning communication between healthcare professionals (Havens, Vasey, Gittell, & Lin, 2010), and pain scales are described as improving the screening of patient's pain and communication between healthcare professionals and patients (Gordon et al., 2005). The nurse's performance in screening for postoperative pain is mainly focused in research because they are described as playing an important role in postoperative pain management (Dihle, Bjölseth, & Helseth, 2006, Schafheutle, Cantrill, & Noyce, 2004). No studies describing the enrolled nurse's or physician's use of pain scales have been found. However, in Sweden enrolled nurses perform much of patient's daily care including screening for pain, but they are not trained to distributing drugs to patients. Further, according to Hartog, Rothaug, Goettermann,
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Zimmer, and Meissner (2010) the physician's competence in this area is necessary to obtain a well-functioning pain management. To contribute to a better understanding on how pain scales can provide an improved communication around pain, the aim of this study was to describe how healthcare professionals perceive the use of pain scales in postoperative care. 2. Methods
Table 2 Interview guide used in the data collection with healthcare professionals (n = 25). What does the patient's pain mean to you as a health professional? How do you perceive the importance of assessment with a pain scale the first postoperative days? How do you perceive your responsibility/role in pain assessment? How do you perceive the patients responsibility/role in pain assessment? How do you perceive pain assessment in relation to action/pain treatment? How do you perceive assessing pain several times a day?
2.1. Design, method description and setting With permission from the Regional Ethics Committee for Human Research in Linköping, Sweden, an explorative design with a phenomenographic approach was chosen. The goal with phenomenography is to explore variations in people's perceptions of the surrounding world (e.g., how they perceive, understand and remember various aspects of a phenomenon). It is substance-oriented (searching for the underlying structure of variance) and differentiates between two types of description: the first order perspective (i.e., the real facts that can be observed), and the second order perspective (i.e., how the person perceives something). Phenomenography uses the second order perspective (Marton & Both, 1997). Phenomenology on the other hand aims to find the essence of a phenomenon (Holloway & Wheeler, 2006). The study was performed in one university and three county hospitals in the south of Sweden. Healthcare professionals of different professions working with postoperative care in orthopedic and general surgery wards were asked to participate. In Sweden physicians, nurses and enrolled nurses have knowledge about pain screening, but it is mainly performed by nurses. National guidelines recommend pain screening using NRS, VAS or a verbal scale; frequency of assessments is, however, not specified. Three of the included hospitals had routines according to the national guidelines (i.e., performing screenings at least every fourth hour using pain scales). The fourth hospital used assessments based on expressions, appearances and behaviors of the actual patient. All hospitals used electronic patient records.
2.4. Data analysis Data analysis was conducted according to the phenomenographic tradition described by Sjöström and Dahlgren (2002) (Table 3). The main researcher carried out the data analysis with continuous reflections on each step from the other members in the research team until consensus was established (downgrading of Table 3). 3. Findings An overview of the findings and quotations in relation to all perceptions is presented in Table 4. 3.1. The use of pain scales facilitated the understanding of postoperative pain
2.2. Participants A purposeful sample of healthcare professionals with clinical experience of pain scales in postoperative care was selected. The physicians were all performing both surgery and ward rounds, while the selected nurses end enrolled nurses' performed daily care duties. The selection was based on variation in age, sex, profession and employment on a surgical or orthopedic ward. One physician and one enrolled nurse declined participation, without giving reasons. Characteristics of the participants (n = 25) are shown in Table 1 (downgrading of Table 1).
3.1.1. Pain scales facilitated the discovery of pain Pain scales were perceived being useful in detecting pain in patients who for various reasons, i.e., tiredness after anesthesia and fear of unnecessary interruptions, did not tell healthcare professionals about their pain. Frequent screenings for pain were described as necessary to detecting pain early. An interval of 3 to 4 hours was expressed too long the first day after surgery, especially for those patients who did not report pain. Table 3 Phenomenographic data analysis according to Sjöström and Dahlgren (2002) as used in the present study.
2.3. Data collection According to the phenomenographic tradition semi-structured interviews (Marton & Both, 1997) were conducted. An interview guide (Table 2) was designed by the research team which had long experience of postoperative pain and phenomenography. The guide was based on recommendations from the American Pain Society (Gordon et al., 2005). Before the interviews the importance of Table 1 Socio-demographic characteristics of healthcare professionals (n = 25). Sex; male, female Age; years, range Profession, enrolled nurses, nurses, physicians Years of experience in postoperative care; 1–5, 6–10, N10 Employment: orthopedic, general surgery
telling self-perceived experiences and concrete examples to avoid superficial descriptions from what is heard from other healthcare professionals was stressed. Probing questions such as “could you explain more” were used. Two pilot interviews were performed. Since the guide worked well the pilot interviews were included in the data analysis. The interviews took place in a quiet room on the ward where the participant was employed and lasted up to 40 minutes; they were audiotaped and transcribed verbatim. The number of interviews from the three professions reflects the proportion of users of pain scales at the included units. The main researcher who has long experience of postoperative pain management performed all interviews between June and November 2012 (downgrading Of Table 2).
6/19 23–63 6/15/4 8/6/11 17/8
1. Familiarization. The 25 interviews containing 242 pages (A4) were read several times to become familiar with the data and obtain a sense of the whole. 2. Compilation. Answers from all responders on a certain topic were compiled into statements. A total of (420) significant statements corresponding to the aim of this study were identified. 3. Condensation. The individual statements were reduced. 4. Grouping. Groupings were made on similar statements. Totally there were 17 pre-perceptions found that distinctly differed from one another. 5. Comparison. Including statements in the perceptions were thoughtfully read to ensure similarities within the perception and differences between the perceptions. 6. Naming. Perceptions and the emerged descriptive categories were discussed and named with an adequate level of abstraction to emphasize their essence. 7. Contrastive comparison. The obtained descriptive categories were compared in terms of similarities and differences. Finally 4 descriptive categories and 13 perceptions were found, Table 4.
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Table 4 Quotations/Perceptions from the performed interviews with health care professionals. Statements
Perceptions
Descriptive categories
“The scale is a good complement to the conversation about the pain, it may well be that you miss any patient with pain … someone who does not dare....and can say a number, instead.” (N, a: 57, 11 y.o.e) “I see this as important (pain screening several times a day).. I get to know when the patient is in pain.. in order to ease the pain when it hurts the most.” (N, a: 23, ½ y.o.e) “When you have a number.. instead of “don't have much pain” “have much pain”…it's easier when you take over to understand.” (N, a: 51, 7 y.o.e.) “If you often ask the patient using a scale, maybe they do not come up in pain peaks.. but remain on an even level. That's how I see the scale.” (E.N. A: 61, 43 y.o.e.) “And it's also different.. Some can say a high number but say no, not so much pain that I need an injection. But my first thought would be: the higher number the more pain killer. Then you probably go with injections instead of tablets.” (N, a: 47, 22 y.o.e.) “..NRS is a good tool, above all to communicate pain and to convey how good the analgesic effect was.” (Ph, a: 31, 3 y.o.e) “… it's not always that patients understand even if they received information, but it is an important role you have to inform the patients because assessments of pain intensity begins with information.” (N, a: 23, ½ y.o.e.) “..and then I ask if they think it is acceptable to have that level of pain and if they answer no I begin to discuss whether they want pain relief and what level they want to come down to.” (N, a: 24, ½ y.o.e.) “All figures and measurements you use could make you blind, one has to see what the patients looks like and say.” (N, a: 39, 12 y.o.e.) “..I think it is about giving the right information.. to receive an adequate rating..” (N, a: 30, 10 y.o.e.) “..It is all about your own routines and how long you've been working too, often it's the young ones who perform pain assessments.” (N, a: 24 ½ y.o.e.) “You can't write (in electronic records) that when the patient moves it is 7 and when the patient is resting it is 1-2..this may lead to improper training, rehabilitation.. because they don't dare move because of pain.” (E.N. a 43, 6 y.o.e.) “Directly postoperatively.. you need doing it often.. if you have a short acting treatment it has to be done several times an hour.” (Ph, a: 37, 12 y.o.e.)
Pain scales facilitated discovery of pain
The use of pain scales facilitated the understanding of postoperative pain
Pain scales visualized pain progress Pain scales facilitated handover between healthcare professionals Pain scales facilitated prevention of pain Pain scales facilitated choice of pain treatment
The use of pain scales facilitated treatment of pain
Pain scales facilitated evaluation of pain treatment Pain scales demanded additional The use of pain scales demanded a assurance of patients' understanding multi-dimensional approach Pain scale interpretation demanded additional dialogue Pain scale interpretation demanded additional observations Pain scales usage was affected by The use of pain scales was affected by health care professional's knowledge work situations Pain scales usage was affected by habits of healthcare professionals Pain scales usage was affected by management Pain scales usage was affected by prioritization of tasks
N: nurse, E.N.: enrolled nurse, Ph: physician, a:age, y.o.e: years of experience.
3.1.2. Pain scales visualized the pain progress Performing pain screening with a scale several times per day was perceived to increase the understanding of the patient's experience of pain. Fluctuations in pain intensity over 1 day or several days were described as more easy to follow. Healthcare professionals described being able to detect when and in which situations the patients experienced pain. This was expressed helpful in giving a picture of the effects of pain relieving actions and supported decisions of adjustments to medication. 3.1.3. Pain scales facilitated handover between healthcare professionals Together with information on what medication was given, the documentation from pain scales was perceived supportive in handovers and during ward rounds. The ratings were described as explaining choice of treatment, which gave the healthcare professionals a sense of security. The ratings were also expressed to enable prioritizing patients; when patients gave a high rating the healthcare professionals acted faster. Further, pain scales were perceived to avoid the risk for misunderstandings and enable descriptions of pain with a common language if used by all healthcare professionals. 3.2. The use of pain scales facilitated treatment of pain 3.2.1. Pain scales facilitated prevention of pain The length of stay after surgery was in general described as short which gave healthcare professionals little time to evaluate pain treatment. Frequent screenings for pain after surgery were expressed to enable being “one step ahead” in controlling pain. This approach was perceived to result in prevention of break through pain and enhanced the opportunities of individualized treatment with respect to pain intensity, side effects, ability to mobilize and carry out necessary exercises. Low ratings were expressed to prevent long
lasting pain conditions, ensure comfort and help the patient to go back to normal life as soon as possible. 3.2.2. Pain scales facilitated choice of pain treatment Pain scales were described as useful in the choice of drugs or pain relieving care actions such as cold packs at breakthrough pain. It was perceived useful in the choice of giving the patient long lasting or short acting drugs and in the decision on what doses would be given to the patient. Other care actions described were to give comfort by changing patient positions, and time to talk. 3.2.3. Pain scales facilitated evaluation of pain treatment The healthcare professionals described that pain scales were useful tools in the evaluation of pain relieving actions when the patients expressed their pain intensity before and after treatment. It was perceived to be an approach that gave a clear answer about if pain relieving care actions were needed and if chosen actions had to be supplemented or not by comparing the ratings before and after given treatment or other pain relieving care actions. 3.3. The use of pain scales demanded a multidimensional approach 3.3.1. Pain scales demanded additional assurance of patients' understanding Assuring a patient's understanding of pain was described important as there were patients who experienced difficulties in explaining pain intensity with a rating. Pain scales were perceived not to be appropriate for all patients. Before using a scale it was described essential to assess the patient's cognitive abilities. It was expressed necessary to explain the scales several times because it could be hard to discover cognitive impairments as patient's condition could fluctuate during the postoperative phase. The patients' willingness to express their pain with a scale was perceived unrelated to the
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understanding of the scale. It was perceived to be wrong to persuade patients who preferred using their own language describing their postoperative pain. 3.3.2. Pain scale interpretation demanded additional dialogue Healthcare professionals perceived difficulties in interpretation of the patient's ratings. Difficulties in converting experienced pain into a rating were perceived as a reason. There were patients who reported low ratings but asked for treatment and vice versa. Additional dialogue was described important to find out what the ratings mean to the patient. To question the patients about the need for pain treatment, side effects, pain at rest, movement in bed or out of bed and in different positions was perceived to be one approach to find out the need for pain relieving actions regardless the answer from the pain scales. 3.3.3. Pain scale interpretation demanded additional observations As healthcare professionals perceived difficulties in interpretation of the answers from the patients they also expressed the need for additional observations. A fear of depending on readings from the scale and forgetting “the clinical eye” was described. When observations conflicted with what the patient expressed, a desire to believe the patient and fears of missing a patient in pain were described. A holistic perspective i.e., to observe the patient's facial expressions, eyes and movements or breathing, heart rate and blood pressure was perceived essential. 3.4. The use of pain scales was affected by work situations 3.4.1. Pain scales usage was affected by healthcare professional's knowledge Insecurity about how to use a scale was expressed by healthcare professionals. One risk described was that they added their own values to the patient's ratings, while another was that patients compared their ratings with other patients. The healthcare professionals expressed it being essential to convey the nature of subjectivity of the pain experience to the patients. Knowledge about the pain scales was described explaining that healthcare professionals would spend time on explaining and motivating the patients to use pain scales. The lack of education was perceived as one reason why healthcare professionals choose not to use pain scales. 3.4.2. Pain scales usage was affected by habits of healthcare professionals Personal habits were perceived as related to length of experience and age, older healthcare professionals with long experience were described more likely to use other approaches than pain scales when screening for pain. Pain screenings were described by healthcare professionals as “this is how I usually do it”. For example, two different scales were described as being mixed on the same occasion to facilitate the understanding of the patient's pain and descriptions of worst possible pain varied. 3.4.3. Pain scales usage was affected by management It was perceived that management and local guidelines affected performance of pain screenings. Directions and encouragement from the management were expressed as stimulating factors. The importance of creating simple routines for screening was emphasized as implementation of new routines was expressed as resource demanding. Monitoring records on paper was perceived to enhance the adherence to routines while insufficient documentation possibilities in electronic records were described as a potential risk factor when prescribing pain treatment. 3.4.4. Pain scales usage was affected by prioritizing of tasks To obtain time, a need for combining screening for pain with other care routines was expressed. Frequent screenings were described as
needed the first day/days after surgery and should be stopped when the patient “found pain manageable”. Pain screenings with defined intervals were perceived inadequate because the patients' different needs of attention are related to patient's personality, experienced pain, duration of drugs given and possible side effects (downgrading of Table 4). 4. Discussion of methodological issues In qualitative research credibility, dependability, confirmability and transferability build trustworthiness. Credibility refers to the truth of interpretation of data (Holloway & Wheeler, 2006). This was strengthened by the knowledge in the research team which consisted of researchers with experience from postoperative pain and phenomenography. Dependability refers to the stability i.e., a high inter subjective agreement in repeated research (Holloway & Wheeler, 2006, Sjöström & Dahlgren, 2002). The interview guide and all steps in the study are described in Tables 3 and 4 to enable replicating the study. Confirmability refers to the objectivity of data (Holloway & Wheeler, 2006). The interviews were conducted by the main researcher who had limited experience interviewing which can affect the first interviews. Further, pre-understanding can affect the interviewing and analyzing process, but the research team contributed with an objective methodological approach rather than a clinical approach during the analysis. It is also possible to value the relevance of the perceptions by reading quotes in Table 4. Transferability refers to the results that can be applicable in other settings (Holloway & Wheeler, 2006). The participants in this study represented three professions from both surgical and orthopedic settings from four different hospitals and had varied experience of using pain scales. A purposeful sample was carried out when including participants, although a strategically choice is the preferred method for data collection (Marton & Both, 1997). This was caused by the fact that only some units included enrolled nurses in routines on pain screenings and few physicians had experience of using pain scales. Results from phenomenographic research are possible to transfer to similar settings bearing in mind that further perceptions are possible to find. Humans vary in their way of experiencing phenomena, and the phenomenographic approach can illuminate differences important to refer to in meetings with healthcare professionals and patients in both education and clinical practice. 5. Discussion The main findings of this study were that healthcare professionals perceived that pain scales facilitated the understanding of postoperative pain and the choice of treatment and pain relieving care actions. The use of pain scales was described as demanding a multidimensional approach i.e., additional assurance of patient understanding, additional dialogue and observations, but was also expressed to be affected by knowledge, support from ward management, guidelines and tools for documentation. Pain scales in this study were perceived to facilitate the understanding of postoperative pain in several aspects i.e., to detect pain, follow pain over time and represent a common language. The need for screening pain was expressed as being more important when patients' did not tell pain, which coincide with recommendations of the performing of reassessments according to the patient's needs (Gordon et al., 2005). Dihle et al. (2006) found that nurses who took an active role in detecting pain seemed to achieve better pain relieved patients. This has been explained by Idvall, Bergqvist, Silverhjelm, and Unosson (2008) who found that patients who expressed great trust in healthcare professionals expected to be asked about pain. Further, pain scales were described in this study to avoid the risk for misunderstandings by enabling descriptions of pain in a common language. This result is in line with Young, Horton, and Davidhizar
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(2006) who stated that pain scales contributed to better understanding of patient's pain. Few, if any, studies have described how pain scales could contribute to choice of treatment and pain relieving care actions in clinical practice. Pain scales were in this study to describe how to facilitate pain treatment by supporting and explaining the choice of treatment. High ratings were helping healthcare professionals to take quicker actions by choosing short acting drugs or changing patient's position. To achieve low ratings were expressed as necessary to prevent pain which often requires treatment with opioids. However, pain management algorithms focusing on adequate titrating of opioids in relation to patient's ratings have resulted in increased patient satisfaction. They have also increased incidences of serious adverse drug reactions (Vila et al., 2005). Screening for pain with pain scales are therefore recommended in guidelines to be complemented by assessments of side effects from drugs, effects on physical function and patient satisfaction (Gordon et al., 2005). This was also expressed as being essential by the healthcare professionals in this study. However, several ratings over time were expressed as visualizing pain progress that they were not always used to in clinical decisions. This can be explained by the difficulties in interpreting pain ratings. Screening for pain with pain scales were described as being complex and demanding a multidimensional approach. Ensuring patients' understanding of pain scales was described as essential, but achieving appropriate ratings was sometimes perceived as a challenge when patients lacked preoperative information and when patient's cognitive condition postoperatively could fluctuate. Coker, Papaioannou, Kaasalainen, and Dolovich (2012) also described patients' difficulties in converting experienced pain into a number. These findings correspond with Young et al. (2006) who described nurses' difficulties in interpreting patient's ratings when they did not correspond with what nurses could observe clinically. A desire to believe that patients pain ratings and fears of missing a patient in pain was expressed. To overcome described difficulties our findings suggest that patient's knowledge about how to use pain scales is essential and that additional dialogue and observations supplement patient's pain ratings. Our findings clearly reflected the fact that pain is a subjective and individual experience. Healthcare professionals described that patients varied in how they converted pain into a rating. This might cause problems to differentiate a cut-off point between mild and moderate pain as mentioned in other studies (Dijk et al., 2012). Gerbshagen, Rothaug, Kalkman, and Meissner (2011) found NRS 4 as the threshold for tolerable postoperative pain, and most patients from another recent study considered NRS 5–6 as bearable postoperative pain (Dijk et al., 2012). The nature of pain can explain why our and other studies (Klopper et al., 2006, Schafheutle et al., 2004) have found that the performance of pain screening include interpretation of what the patient says and looks like. These findings strengthen that additional dialogue and observations are important in clinical situations to reassure what the ratings mean to the patients. Fears for under- and overtreatment seems relevant if relying on pain scales only (Dijk et al., 2012, Hanks, 2008). Work situations such as healthcare professionals' habits in this study were found to affect the use of pain scales. How changes of behavior (i.e., using pain scales) in clinical practice occur is not well studied but is raised as being one barrier in implementation of evidence based care (Nilsen, Roback, Broström, & Ellström, 2012). We found that healthcare professionals with good knowledge of pain scales used them more and expressed the need for spending more time achieving patient understanding of the pain scales. This is in line with research where information is found to increase patient's satisfaction of pain management (Warren Stomberg, Wickström, Joelsson, Sjöström, & Haljamäe, 2003). On the contrary, lack of knowledge could lead to personal habits that could cause misunderstandings. One example in this study was the described benefits
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of mixing pain scales (NRS, VS) on the same occasion. This approach demands awareness of the limited possibilities in achieving an appropriate rating when the ratings from the two scales were compared. However, healthcare professionals should bear in mind that the NRS have recently been shown to have weak correlation (0.38) with the VS. This indicates that words on the VS can be valued differently by patients (Dijkers, 2010). Our findings indicate that the use of pain scales also is depending on organizational factors such as encouraging leadership and possibilities to perform reliable documentation. Care managers play an important role to enhance quality in care (Warren Stomberg et al., 2003). The healthcare professionals in this study described simple routines on documentation to be one factor for success in using pain scales. Monitoring records on paper were reported to enhance the adherence to routines which coincide with findings from Gordon et al. (2008) who implemented a monitoring record including important parameters reflecting patient's pain. Despite that electronic records have been used for several years in clinical practice there are remaining difficulties to achieve resembling documentation. Electronic records were, in this study, described as reducing adherence to routines on screening for pain and were perceived as a potential risk for under treatment. Our findings describe a need for further development on easily accessible documentation of postoperative pain for all healthcare professionals. This is also identified by Samuels (2012) who has demonstrated the need for standardized documentation in electronic medical records. The expressed difficulties in interpretation of pain ratings could be explained by the need for a deeper knowledge about what conclusions from patient's ratings it is possible to make when having to take into consideration the variations of experiencing and expressing pain. However, Rognstad et al. (2012) found that healthcare professionals described themselves as competent in postoperative pain management. Despite this, many patients still suffer from postoperative pain (Fletcher, Fermian, Mardaye, & Aegerter, 2008). Interdisciplinary, collaborative care planning is highlighted by Carr, Reines, Schaffer, Polomano, and Lande (2005) and Gordon et al. (2008) to avoid this. Good relations and communications between nurses and physicians are showed to enhance the quality of patient care (Havens et al., 2010). Further, documentation of patient's pain, side effects, function and satisfaction were keys to better understanding (Gordon et al., 2008) and could contribute to continuous measurements of quality of care with rapid feedback, available to all healthcare professionals (Meissner et al., 2008, Samuels, 2012). 5.1. Implications for practice and future research In clinical situations the pain scales are in several aspects useful in screening patient's pain. Frequent pain screening the first day/days after surgery may enhance the possibilities of avoiding break through pain and can be especially helpful in communication with patients who are reluctant in telling pain. Pain scales are good tools in following patients' pain over time which is helpful in decisions on when pain relieving actions are most needed. Further, the ratings can guide decisions on choices of doses of drugs and other pain relieving strategies and is a good tool in reassessments. Difficulties in the interpretation of pain ratings could be overcome by a deeper knowledge about how to use pain scales. However, achieving appropriate ratings from pain scales demand awareness of the subjectivity of pain experiences, as well as to allow for variations of experiencing and expressing pain. Further, efforts to ensure a patient understanding include assessing patient's cognitive condition and to give uniform information about the end points of the scales. Pain ratings should be supplemented with a dialogue and observations including effects, side effects and function and patient satisfaction to reassure what the ratings mean to the patient. Furthermore, it is essential to ask questions about the pain intensity
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at rest and at activity to achieve a true rating that can support relevant choices of pain relieving actions. However, healthcare professionals should respect patients' choice to express their pain with their own words referring to difficulties in interpreting pain into a rating. These findings need to be emphasized in local guidelines as patient's safety is in danger when healthcare professionals solely rely on a rating when treating pain. Pain scales can contribute to a common language between healthcare professionals in handovers, ward rounds, consultations and documentation. Developing electronic monitoring sheets for postoperative pain, made accessible for all healthcare professionals, would encourage interdisciplinary discussions on improvements for postoperative pain both in the daily work and in the work on improvements of routines. Whether efforts on enhancing quality of pain screening and documentation would lead to enhancing a patient's quality of life, the first postoperative day's remains to be examined in future research. 6. Conclusion Healthcare professionals describe that frequent screening for pain with pain scales contribute to the understanding of patient's postoperative pain and facilitate the choice of treatment and other pain relieving care actions if ratings are considered by all healthcare professionals. It is important to ensure patient understanding and be aware about patient's variations in interpretation of pain ratings. Additional dialogue and observations are necessary to reassure what the ratings mean to the patient. The use of pain scales depends on patient's needs and how the management of ward work is organized. Acknowledgments The authors express special thanks to the Academy for Health Care, County Council of Jönköping, Sweden and (FORSS) The Research Council of Southeast Sweden. The authors express special thanks to Sweden and the Department of Anaesthesia and Intensive Care at Ryhov County Hospital who have given financial support. References Abdalrahim, M. S., Majali, S. A., & Bergbom, I. (2008). Documentation of postoperative pain by nurses in surgical wards. Acute Pain, 10, 73–81, http: //dx.doi.org/10.1016/j.acpain.2008.04.001. Carr, D. B., Reines, H. D., Schaffer, J., Polomano, R. C., & Lande, S. (2005). The impact of technology on the analgesic gap and quality of acute pain management. Reg Anesth Pain Med, 30(3), 289–291, http://dx.doi.org/10.1016/j.rapm.2004.10.009. Clabo, L. M. L. (2007). An ethnography of pain assessments and the role of social context on two postoperative units. J Adv Nurs, 61(5), 531–539, http: //dx.doi.org/10.1111/j.1365-2648.2007.04550.x. Coker, E., Papaioannou, A., Kaasalainen, S., & Dolovich, L. (2012). Nurses perceived barriers to optimal pain management in older adults on acute medical units. Appl Nurs Res, 23, 139–146, http://dx.doi.org/10.1016/j.apnr.2008.07.003. Dihle, A., Bjölseth, G., & Helseth, S. (2006). The gap between saying and doing in postoperative pain management. J Clin Nurs, 15, 469–479. Dijk, J. F. M., Wijck, A. J. M., Kappen, T. H., Peelen, L. M., Kalkman, C. J., & Schuurmans, M. J. (2012). Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross sectional study. Int J Nurs Stud, 49, 65–71, http://dx.doi.org/10.1016/j.ijnurstu.2011.07.009.
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Br J Anaesth, 107(4), 619–626, http: //dx.doi.org/10.1093/bja/aer195. Gordon, D. B., Dahl, J. L., Miaskowski, C., Mc Carberg, B., Todd, K. H., Paice, J. A., et al. (2005). American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med, 165, 1574–1580. Gordon, D. B., Rees, S. M., Mc Causland, M. P., Pellino, T. A., Sanford-Ring, S., SmithHelmenstine, J., et al. (2008). Improving reassessment and documentation of pain management. Jt Comm J Qual Patient Saf, 34(9), 509–517. Hanks, S. (2008). The law of unintended consequences when pain management leads to medication errors. Pharm Ther, 33(7), 420–425. Hartog, C. S., Rothaug, A., Goettermann, A., Zimmer, A., & Meissner, W. (2010). Room for improvement: Nurses' and physicians' views of a post-operative pain management program. Acta Anaesthesiologica, 54, 277–283, http://dx.doi.org/10.1111/j.13996576.2009.02161.x. Havens, D. S., Vasey, J., Gittell, J. H., & Lin, W. L. (2010). Relational coordination among nurses and other providers: Impact on the quality of patient care. J Nurs Manag, 18, 926–937, http://dx.doi.org/10.1111/j.1365-2834.2010.01138.x. Holloway, I., & Wheeler, S. (2006). Qualitative research in nursing health care. Oxford: Wiley and Blackwell. Idvall, E., Bergqvist, A., Silverhjelm, J., & Unosson, M. (2008). Perspectives of Swedish patients on postoperative pain management. Nurs Health Sci, 10, 131–136, http: //dx.doi.org/10.1011/j.1442-2018.2008.00380.x. Klopper, H., Andersson, H., Minkkinen, M., Ohlsson, C., & Sjöström, B. (2006). Strategies in assessing postoperative pain - A South African study. Intensive Crit Care Nurs, 22(1), 12–21, http://dx.doi.org/10.1016/j.iccn.2005.05.001. Manias, E., Bucknall, T., & Botti, M. (2004). Assessment of pain in the postoperative context. West J Nurs Res, 26(7), 751–769, http://dx.doi.org/10.1177/013945904267699. Marton, F., & Both, S. (1997). Learning and awareness. Mahwah: N.J. Erlbaum Associates. 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Healthcare Professionals' Perceptions of the Use of Pain Scales in Postoperative Pain Assessments Lotta Wikström, RN, PhD student a, b,⁎, Kerstin Eriksson, RN, PhD student a, b, 1, Kristofer Årestedt, RN, PhD c, d, e, 2, Bengt Fridlund, RNT, Professor a, 3, Anders Broström, RN, Professor a, f, 4 a
School of Health Sciences, Jönköping University, Jönköping, Sweden Department of Anaesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden d Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden e Palliative Research Centre, Ersta Sköndal University College and Ersta Hospital, Stockholm, Sweden f Department of Clinical Neurophysiology, University Hospital, Linköping, Sweden b c
a r t i c l e
i n f o
Article history: Received 13 June 2013 Revised 24 October 2013 Accepted 2 November 2013 Keywords: Postoperative pain Pain scales Pain assessments
a b s t r a c t Aim: To describe how healthcare professionals perceive the use of pain scales in postoperative care. Background: Pain scales are important but not an obvious choice to use in postoperative care. No study has explored how healthcare professionals experience the use of pain scales. Methods: An explorative design with a phenomenographic approach was used. The sample consisted of 25 healthcare professionals. Semistructured interviews were performed. Results: Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations. Conclusions: Healthcare professionals described that pain scales contribute to the understanding of patient's postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings. Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales depends on patient's needs and organization. © 2014 Elsevier Inc. All rights reserved.
1. Introduction An investigation of postoperative pain normally begins with a screening followed by a more thorough assessment if patients are in pain (e.g., including questions on location and duration of the pain). Pain is however a subjective experience that can be hard to communicate, both between patient and staff, as well as between staff with different professions. It is therefore recommended in guidelines that patient's self-report of pain should be screened by using a valid pain scale (Gordon et al., 2005). The extent to which pain scales are used (Abdalrahim, Majali, & Bergbom, 2008, Ene, Nordberg, Bergh, Gaston-Johansson, & Sjöström, 2008) and how assessments of postoperative pain are performed are explored only in a few studies (Klopper, Andersson, Minkkinen, Ohlsson, & Sjöström, 2006, Manias, Bucknall, & Botti, 2004). The results indicate that the use of pain scales Conflict of Interest. None. ⁎ Corresponding author. Tel.: +46 36321000; fax: +46 36325055. E-mail addresses: [email protected] (L. Wikström), [email protected] (K. Eriksson), [email protected] (K. Årestedt), [email protected] (B. Fridlund), [email protected] (A. Broström). 1 Tel.: +46 363 21000; fax: +46 363 25055. 2 Tel.: +46 480 446974; +46 709 206462 (mobile). 3 Tel.: +46 361 01233; +46 767 611233 (mobile). 4 Tel.: +46 10103 25 34. 0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.11.001
such as numeric rating scale (NRS), visual analogue scale (VAS) or verbal scale (VS) is not an obvious choice. The implementation of validated pain scales has been difficult in clinical settings despite educational programs (Ene et al., 2008). Screening for the presence of pain, without using pain scales still occurs and is instead based on the patient's appearance and behavior, what they express and how much pain “it usually is” after a certain type of surgery. Age, sex or ethnicity is taken into consideration (Klopper et al., 2006), and changes in vital signs such as pulse rate, blood pressure and respiratory rate are also used (Richards & Hubbert, 2007; Clabo, 2007). Quality of care is related to a well -functioning communication between healthcare professionals (Havens, Vasey, Gittell, & Lin, 2010), and pain scales are described as improving the screening of patient's pain and communication between healthcare professionals and patients (Gordon et al., 2005). The nurse's performance in screening for postoperative pain is mainly focused in research because they are described as playing an important role in postoperative pain management (Dihle, Bjölseth, & Helseth, 2006, Schafheutle, Cantrill, & Noyce, 2004). No studies describing the enrolled nurse's or physician's use of pain scales have been found. However, in Sweden enrolled nurses perform much of patient's daily care including screening for pain, but they are not trained to distributing drugs to patients. Further, according to Hartog, Rothaug, Goettermann,
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Zimmer, and Meissner (2010) the physician's competence in this area is necessary to obtain a well-functioning pain management. To contribute to a better understanding on how pain scales can provide an improved communication around pain, the aim of this study was to describe how healthcare professionals perceive the use of pain scales in postoperative care. 2. Methods
Table 2 Interview guide used in the data collection with healthcare professionals (n = 25). What does the patient's pain mean to you as a health professional? How do you perceive the importance of assessment with a pain scale the first postoperative days? How do you perceive your responsibility/role in pain assessment? How do you perceive the patients responsibility/role in pain assessment? How do you perceive pain assessment in relation to action/pain treatment? How do you perceive assessing pain several times a day?
2.1. Design, method description and setting With permission from the Regional Ethics Committee for Human Research in Linköping, Sweden, an explorative design with a phenomenographic approach was chosen. The goal with phenomenography is to explore variations in people's perceptions of the surrounding world (e.g., how they perceive, understand and remember various aspects of a phenomenon). It is substance-oriented (searching for the underlying structure of variance) and differentiates between two types of description: the first order perspective (i.e., the real facts that can be observed), and the second order perspective (i.e., how the person perceives something). Phenomenography uses the second order perspective (Marton & Both, 1997). Phenomenology on the other hand aims to find the essence of a phenomenon (Holloway & Wheeler, 2006). The study was performed in one university and three county hospitals in the south of Sweden. Healthcare professionals of different professions working with postoperative care in orthopedic and general surgery wards were asked to participate. In Sweden physicians, nurses and enrolled nurses have knowledge about pain screening, but it is mainly performed by nurses. National guidelines recommend pain screening using NRS, VAS or a verbal scale; frequency of assessments is, however, not specified. Three of the included hospitals had routines according to the national guidelines (i.e., performing screenings at least every fourth hour using pain scales). The fourth hospital used assessments based on expressions, appearances and behaviors of the actual patient. All hospitals used electronic patient records.
2.4. Data analysis Data analysis was conducted according to the phenomenographic tradition described by Sjöström and Dahlgren (2002) (Table 3). The main researcher carried out the data analysis with continuous reflections on each step from the other members in the research team until consensus was established (downgrading of Table 3). 3. Findings An overview of the findings and quotations in relation to all perceptions is presented in Table 4. 3.1. The use of pain scales facilitated the understanding of postoperative pain
2.2. Participants A purposeful sample of healthcare professionals with clinical experience of pain scales in postoperative care was selected. The physicians were all performing both surgery and ward rounds, while the selected nurses end enrolled nurses' performed daily care duties. The selection was based on variation in age, sex, profession and employment on a surgical or orthopedic ward. One physician and one enrolled nurse declined participation, without giving reasons. Characteristics of the participants (n = 25) are shown in Table 1 (downgrading of Table 1).
3.1.1. Pain scales facilitated the discovery of pain Pain scales were perceived being useful in detecting pain in patients who for various reasons, i.e., tiredness after anesthesia and fear of unnecessary interruptions, did not tell healthcare professionals about their pain. Frequent screenings for pain were described as necessary to detecting pain early. An interval of 3 to 4 hours was expressed too long the first day after surgery, especially for those patients who did not report pain. Table 3 Phenomenographic data analysis according to Sjöström and Dahlgren (2002) as used in the present study.
2.3. Data collection According to the phenomenographic tradition semi-structured interviews (Marton & Both, 1997) were conducted. An interview guide (Table 2) was designed by the research team which had long experience of postoperative pain and phenomenography. The guide was based on recommendations from the American Pain Society (Gordon et al., 2005). Before the interviews the importance of Table 1 Socio-demographic characteristics of healthcare professionals (n = 25). Sex; male, female Age; years, range Profession, enrolled nurses, nurses, physicians Years of experience in postoperative care; 1–5, 6–10, N10 Employment: orthopedic, general surgery
telling self-perceived experiences and concrete examples to avoid superficial descriptions from what is heard from other healthcare professionals was stressed. Probing questions such as “could you explain more” were used. Two pilot interviews were performed. Since the guide worked well the pilot interviews were included in the data analysis. The interviews took place in a quiet room on the ward where the participant was employed and lasted up to 40 minutes; they were audiotaped and transcribed verbatim. The number of interviews from the three professions reflects the proportion of users of pain scales at the included units. The main researcher who has long experience of postoperative pain management performed all interviews between June and November 2012 (downgrading Of Table 2).
6/19 23–63 6/15/4 8/6/11 17/8
1. Familiarization. The 25 interviews containing 242 pages (A4) were read several times to become familiar with the data and obtain a sense of the whole. 2. Compilation. Answers from all responders on a certain topic were compiled into statements. A total of (420) significant statements corresponding to the aim of this study were identified. 3. Condensation. The individual statements were reduced. 4. Grouping. Groupings were made on similar statements. Totally there were 17 pre-perceptions found that distinctly differed from one another. 5. Comparison. Including statements in the perceptions were thoughtfully read to ensure similarities within the perception and differences between the perceptions. 6. Naming. Perceptions and the emerged descriptive categories were discussed and named with an adequate level of abstraction to emphasize their essence. 7. Contrastive comparison. The obtained descriptive categories were compared in terms of similarities and differences. Finally 4 descriptive categories and 13 perceptions were found, Table 4.
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Table 4 Quotations/Perceptions from the performed interviews with health care professionals. Statements
Perceptions
Descriptive categories
“The scale is a good complement to the conversation about the pain, it may well be that you miss any patient with pain … someone who does not dare....and can say a number, instead.” (N, a: 57, 11 y.o.e) “I see this as important (pain screening several times a day).. I get to know when the patient is in pain.. in order to ease the pain when it hurts the most.” (N, a: 23, ½ y.o.e) “When you have a number.. instead of “don't have much pain” “have much pain”…it's easier when you take over to understand.” (N, a: 51, 7 y.o.e.) “If you often ask the patient using a scale, maybe they do not come up in pain peaks.. but remain on an even level. That's how I see the scale.” (E.N. A: 61, 43 y.o.e.) “And it's also different.. Some can say a high number but say no, not so much pain that I need an injection. But my first thought would be: the higher number the more pain killer. Then you probably go with injections instead of tablets.” (N, a: 47, 22 y.o.e.) “..NRS is a good tool, above all to communicate pain and to convey how good the analgesic effect was.” (Ph, a: 31, 3 y.o.e) “… it's not always that patients understand even if they received information, but it is an important role you have to inform the patients because assessments of pain intensity begins with information.” (N, a: 23, ½ y.o.e.) “..and then I ask if they think it is acceptable to have that level of pain and if they answer no I begin to discuss whether they want pain relief and what level they want to come down to.” (N, a: 24, ½ y.o.e.) “All figures and measurements you use could make you blind, one has to see what the patients looks like and say.” (N, a: 39, 12 y.o.e.) “..I think it is about giving the right information.. to receive an adequate rating..” (N, a: 30, 10 y.o.e.) “..It is all about your own routines and how long you've been working too, often it's the young ones who perform pain assessments.” (N, a: 24 ½ y.o.e.) “You can't write (in electronic records) that when the patient moves it is 7 and when the patient is resting it is 1-2..this may lead to improper training, rehabilitation.. because they don't dare move because of pain.” (E.N. a 43, 6 y.o.e.) “Directly postoperatively.. you need doing it often.. if you have a short acting treatment it has to be done several times an hour.” (Ph, a: 37, 12 y.o.e.)
Pain scales facilitated discovery of pain
The use of pain scales facilitated the understanding of postoperative pain
Pain scales visualized pain progress Pain scales facilitated handover between healthcare professionals Pain scales facilitated prevention of pain Pain scales facilitated choice of pain treatment
The use of pain scales facilitated treatment of pain
Pain scales facilitated evaluation of pain treatment Pain scales demanded additional The use of pain scales demanded a assurance of patients' understanding multi-dimensional approach Pain scale interpretation demanded additional dialogue Pain scale interpretation demanded additional observations Pain scales usage was affected by The use of pain scales was affected by health care professional's knowledge work situations Pain scales usage was affected by habits of healthcare professionals Pain scales usage was affected by management Pain scales usage was affected by prioritization of tasks
N: nurse, E.N.: enrolled nurse, Ph: physician, a:age, y.o.e: years of experience.
3.1.2. Pain scales visualized the pain progress Performing pain screening with a scale several times per day was perceived to increase the understanding of the patient's experience of pain. Fluctuations in pain intensity over 1 day or several days were described as more easy to follow. Healthcare professionals described being able to detect when and in which situations the patients experienced pain. This was expressed helpful in giving a picture of the effects of pain relieving actions and supported decisions of adjustments to medication. 3.1.3. Pain scales facilitated handover between healthcare professionals Together with information on what medication was given, the documentation from pain scales was perceived supportive in handovers and during ward rounds. The ratings were described as explaining choice of treatment, which gave the healthcare professionals a sense of security. The ratings were also expressed to enable prioritizing patients; when patients gave a high rating the healthcare professionals acted faster. Further, pain scales were perceived to avoid the risk for misunderstandings and enable descriptions of pain with a common language if used by all healthcare professionals. 3.2. The use of pain scales facilitated treatment of pain 3.2.1. Pain scales facilitated prevention of pain The length of stay after surgery was in general described as short which gave healthcare professionals little time to evaluate pain treatment. Frequent screenings for pain after surgery were expressed to enable being “one step ahead” in controlling pain. This approach was perceived to result in prevention of break through pain and enhanced the opportunities of individualized treatment with respect to pain intensity, side effects, ability to mobilize and carry out necessary exercises. Low ratings were expressed to prevent long
lasting pain conditions, ensure comfort and help the patient to go back to normal life as soon as possible. 3.2.2. Pain scales facilitated choice of pain treatment Pain scales were described as useful in the choice of drugs or pain relieving care actions such as cold packs at breakthrough pain. It was perceived useful in the choice of giving the patient long lasting or short acting drugs and in the decision on what doses would be given to the patient. Other care actions described were to give comfort by changing patient positions, and time to talk. 3.2.3. Pain scales facilitated evaluation of pain treatment The healthcare professionals described that pain scales were useful tools in the evaluation of pain relieving actions when the patients expressed their pain intensity before and after treatment. It was perceived to be an approach that gave a clear answer about if pain relieving care actions were needed and if chosen actions had to be supplemented or not by comparing the ratings before and after given treatment or other pain relieving care actions. 3.3. The use of pain scales demanded a multidimensional approach 3.3.1. Pain scales demanded additional assurance of patients' understanding Assuring a patient's understanding of pain was described important as there were patients who experienced difficulties in explaining pain intensity with a rating. Pain scales were perceived not to be appropriate for all patients. Before using a scale it was described essential to assess the patient's cognitive abilities. It was expressed necessary to explain the scales several times because it could be hard to discover cognitive impairments as patient's condition could fluctuate during the postoperative phase. The patients' willingness to express their pain with a scale was perceived unrelated to the
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understanding of the scale. It was perceived to be wrong to persuade patients who preferred using their own language describing their postoperative pain. 3.3.2. Pain scale interpretation demanded additional dialogue Healthcare professionals perceived difficulties in interpretation of the patient's ratings. Difficulties in converting experienced pain into a rating were perceived as a reason. There were patients who reported low ratings but asked for treatment and vice versa. Additional dialogue was described important to find out what the ratings mean to the patient. To question the patients about the need for pain treatment, side effects, pain at rest, movement in bed or out of bed and in different positions was perceived to be one approach to find out the need for pain relieving actions regardless the answer from the pain scales. 3.3.3. Pain scale interpretation demanded additional observations As healthcare professionals perceived difficulties in interpretation of the answers from the patients they also expressed the need for additional observations. A fear of depending on readings from the scale and forgetting “the clinical eye” was described. When observations conflicted with what the patient expressed, a desire to believe the patient and fears of missing a patient in pain were described. A holistic perspective i.e., to observe the patient's facial expressions, eyes and movements or breathing, heart rate and blood pressure was perceived essential. 3.4. The use of pain scales was affected by work situations 3.4.1. Pain scales usage was affected by healthcare professional's knowledge Insecurity about how to use a scale was expressed by healthcare professionals. One risk described was that they added their own values to the patient's ratings, while another was that patients compared their ratings with other patients. The healthcare professionals expressed it being essential to convey the nature of subjectivity of the pain experience to the patients. Knowledge about the pain scales was described explaining that healthcare professionals would spend time on explaining and motivating the patients to use pain scales. The lack of education was perceived as one reason why healthcare professionals choose not to use pain scales. 3.4.2. Pain scales usage was affected by habits of healthcare professionals Personal habits were perceived as related to length of experience and age, older healthcare professionals with long experience were described more likely to use other approaches than pain scales when screening for pain. Pain screenings were described by healthcare professionals as “this is how I usually do it”. For example, two different scales were described as being mixed on the same occasion to facilitate the understanding of the patient's pain and descriptions of worst possible pain varied. 3.4.3. Pain scales usage was affected by management It was perceived that management and local guidelines affected performance of pain screenings. Directions and encouragement from the management were expressed as stimulating factors. The importance of creating simple routines for screening was emphasized as implementation of new routines was expressed as resource demanding. Monitoring records on paper was perceived to enhance the adherence to routines while insufficient documentation possibilities in electronic records were described as a potential risk factor when prescribing pain treatment. 3.4.4. Pain scales usage was affected by prioritizing of tasks To obtain time, a need for combining screening for pain with other care routines was expressed. Frequent screenings were described as
needed the first day/days after surgery and should be stopped when the patient “found pain manageable”. Pain screenings with defined intervals were perceived inadequate because the patients' different needs of attention are related to patient's personality, experienced pain, duration of drugs given and possible side effects (downgrading of Table 4). 4. Discussion of methodological issues In qualitative research credibility, dependability, confirmability and transferability build trustworthiness. Credibility refers to the truth of interpretation of data (Holloway & Wheeler, 2006). This was strengthened by the knowledge in the research team which consisted of researchers with experience from postoperative pain and phenomenography. Dependability refers to the stability i.e., a high inter subjective agreement in repeated research (Holloway & Wheeler, 2006, Sjöström & Dahlgren, 2002). The interview guide and all steps in the study are described in Tables 3 and 4 to enable replicating the study. Confirmability refers to the objectivity of data (Holloway & Wheeler, 2006). The interviews were conducted by the main researcher who had limited experience interviewing which can affect the first interviews. Further, pre-understanding can affect the interviewing and analyzing process, but the research team contributed with an objective methodological approach rather than a clinical approach during the analysis. It is also possible to value the relevance of the perceptions by reading quotes in Table 4. Transferability refers to the results that can be applicable in other settings (Holloway & Wheeler, 2006). The participants in this study represented three professions from both surgical and orthopedic settings from four different hospitals and had varied experience of using pain scales. A purposeful sample was carried out when including participants, although a strategically choice is the preferred method for data collection (Marton & Both, 1997). This was caused by the fact that only some units included enrolled nurses in routines on pain screenings and few physicians had experience of using pain scales. Results from phenomenographic research are possible to transfer to similar settings bearing in mind that further perceptions are possible to find. Humans vary in their way of experiencing phenomena, and the phenomenographic approach can illuminate differences important to refer to in meetings with healthcare professionals and patients in both education and clinical practice. 5. Discussion The main findings of this study were that healthcare professionals perceived that pain scales facilitated the understanding of postoperative pain and the choice of treatment and pain relieving care actions. The use of pain scales was described as demanding a multidimensional approach i.e., additional assurance of patient understanding, additional dialogue and observations, but was also expressed to be affected by knowledge, support from ward management, guidelines and tools for documentation. Pain scales in this study were perceived to facilitate the understanding of postoperative pain in several aspects i.e., to detect pain, follow pain over time and represent a common language. The need for screening pain was expressed as being more important when patients' did not tell pain, which coincide with recommendations of the performing of reassessments according to the patient's needs (Gordon et al., 2005). Dihle et al. (2006) found that nurses who took an active role in detecting pain seemed to achieve better pain relieved patients. This has been explained by Idvall, Bergqvist, Silverhjelm, and Unosson (2008) who found that patients who expressed great trust in healthcare professionals expected to be asked about pain. Further, pain scales were described in this study to avoid the risk for misunderstandings by enabling descriptions of pain in a common language. This result is in line with Young, Horton, and Davidhizar
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(2006) who stated that pain scales contributed to better understanding of patient's pain. Few, if any, studies have described how pain scales could contribute to choice of treatment and pain relieving care actions in clinical practice. Pain scales were in this study to describe how to facilitate pain treatment by supporting and explaining the choice of treatment. High ratings were helping healthcare professionals to take quicker actions by choosing short acting drugs or changing patient's position. To achieve low ratings were expressed as necessary to prevent pain which often requires treatment with opioids. However, pain management algorithms focusing on adequate titrating of opioids in relation to patient's ratings have resulted in increased patient satisfaction. They have also increased incidences of serious adverse drug reactions (Vila et al., 2005). Screening for pain with pain scales are therefore recommended in guidelines to be complemented by assessments of side effects from drugs, effects on physical function and patient satisfaction (Gordon et al., 2005). This was also expressed as being essential by the healthcare professionals in this study. However, several ratings over time were expressed as visualizing pain progress that they were not always used to in clinical decisions. This can be explained by the difficulties in interpreting pain ratings. Screening for pain with pain scales were described as being complex and demanding a multidimensional approach. Ensuring patients' understanding of pain scales was described as essential, but achieving appropriate ratings was sometimes perceived as a challenge when patients lacked preoperative information and when patient's cognitive condition postoperatively could fluctuate. Coker, Papaioannou, Kaasalainen, and Dolovich (2012) also described patients' difficulties in converting experienced pain into a number. These findings correspond with Young et al. (2006) who described nurses' difficulties in interpreting patient's ratings when they did not correspond with what nurses could observe clinically. A desire to believe that patients pain ratings and fears of missing a patient in pain was expressed. To overcome described difficulties our findings suggest that patient's knowledge about how to use pain scales is essential and that additional dialogue and observations supplement patient's pain ratings. Our findings clearly reflected the fact that pain is a subjective and individual experience. Healthcare professionals described that patients varied in how they converted pain into a rating. This might cause problems to differentiate a cut-off point between mild and moderate pain as mentioned in other studies (Dijk et al., 2012). Gerbshagen, Rothaug, Kalkman, and Meissner (2011) found NRS 4 as the threshold for tolerable postoperative pain, and most patients from another recent study considered NRS 5–6 as bearable postoperative pain (Dijk et al., 2012). The nature of pain can explain why our and other studies (Klopper et al., 2006, Schafheutle et al., 2004) have found that the performance of pain screening include interpretation of what the patient says and looks like. These findings strengthen that additional dialogue and observations are important in clinical situations to reassure what the ratings mean to the patients. Fears for under- and overtreatment seems relevant if relying on pain scales only (Dijk et al., 2012, Hanks, 2008). Work situations such as healthcare professionals' habits in this study were found to affect the use of pain scales. How changes of behavior (i.e., using pain scales) in clinical practice occur is not well studied but is raised as being one barrier in implementation of evidence based care (Nilsen, Roback, Broström, & Ellström, 2012). We found that healthcare professionals with good knowledge of pain scales used them more and expressed the need for spending more time achieving patient understanding of the pain scales. This is in line with research where information is found to increase patient's satisfaction of pain management (Warren Stomberg, Wickström, Joelsson, Sjöström, & Haljamäe, 2003). On the contrary, lack of knowledge could lead to personal habits that could cause misunderstandings. One example in this study was the described benefits
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of mixing pain scales (NRS, VS) on the same occasion. This approach demands awareness of the limited possibilities in achieving an appropriate rating when the ratings from the two scales were compared. However, healthcare professionals should bear in mind that the NRS have recently been shown to have weak correlation (0.38) with the VS. This indicates that words on the VS can be valued differently by patients (Dijkers, 2010). Our findings indicate that the use of pain scales also is depending on organizational factors such as encouraging leadership and possibilities to perform reliable documentation. Care managers play an important role to enhance quality in care (Warren Stomberg et al., 2003). The healthcare professionals in this study described simple routines on documentation to be one factor for success in using pain scales. Monitoring records on paper were reported to enhance the adherence to routines which coincide with findings from Gordon et al. (2008) who implemented a monitoring record including important parameters reflecting patient's pain. Despite that electronic records have been used for several years in clinical practice there are remaining difficulties to achieve resembling documentation. Electronic records were, in this study, described as reducing adherence to routines on screening for pain and were perceived as a potential risk for under treatment. Our findings describe a need for further development on easily accessible documentation of postoperative pain for all healthcare professionals. This is also identified by Samuels (2012) who has demonstrated the need for standardized documentation in electronic medical records. The expressed difficulties in interpretation of pain ratings could be explained by the need for a deeper knowledge about what conclusions from patient's ratings it is possible to make when having to take into consideration the variations of experiencing and expressing pain. However, Rognstad et al. (2012) found that healthcare professionals described themselves as competent in postoperative pain management. Despite this, many patients still suffer from postoperative pain (Fletcher, Fermian, Mardaye, & Aegerter, 2008). Interdisciplinary, collaborative care planning is highlighted by Carr, Reines, Schaffer, Polomano, and Lande (2005) and Gordon et al. (2008) to avoid this. Good relations and communications between nurses and physicians are showed to enhance the quality of patient care (Havens et al., 2010). Further, documentation of patient's pain, side effects, function and satisfaction were keys to better understanding (Gordon et al., 2008) and could contribute to continuous measurements of quality of care with rapid feedback, available to all healthcare professionals (Meissner et al., 2008, Samuels, 2012). 5.1. Implications for practice and future research In clinical situations the pain scales are in several aspects useful in screening patient's pain. Frequent pain screening the first day/days after surgery may enhance the possibilities of avoiding break through pain and can be especially helpful in communication with patients who are reluctant in telling pain. Pain scales are good tools in following patients' pain over time which is helpful in decisions on when pain relieving actions are most needed. Further, the ratings can guide decisions on choices of doses of drugs and other pain relieving strategies and is a good tool in reassessments. Difficulties in the interpretation of pain ratings could be overcome by a deeper knowledge about how to use pain scales. However, achieving appropriate ratings from pain scales demand awareness of the subjectivity of pain experiences, as well as to allow for variations of experiencing and expressing pain. Further, efforts to ensure a patient understanding include assessing patient's cognitive condition and to give uniform information about the end points of the scales. Pain ratings should be supplemented with a dialogue and observations including effects, side effects and function and patient satisfaction to reassure what the ratings mean to the patient. Furthermore, it is essential to ask questions about the pain intensity
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at rest and at activity to achieve a true rating that can support relevant choices of pain relieving actions. However, healthcare professionals should respect patients' choice to express their pain with their own words referring to difficulties in interpreting pain into a rating. These findings need to be emphasized in local guidelines as patient's safety is in danger when healthcare professionals solely rely on a rating when treating pain. Pain scales can contribute to a common language between healthcare professionals in handovers, ward rounds, consultations and documentation. Developing electronic monitoring sheets for postoperative pain, made accessible for all healthcare professionals, would encourage interdisciplinary discussions on improvements for postoperative pain both in the daily work and in the work on improvements of routines. Whether efforts on enhancing quality of pain screening and documentation would lead to enhancing a patient's quality of life, the first postoperative day's remains to be examined in future research. 6. Conclusion Healthcare professionals describe that frequent screening for pain with pain scales contribute to the understanding of patient's postoperative pain and facilitate the choice of treatment and other pain relieving care actions if ratings are considered by all healthcare professionals. It is important to ensure patient understanding and be aware about patient's variations in interpretation of pain ratings. Additional dialogue and observations are necessary to reassure what the ratings mean to the patient. The use of pain scales depends on patient's needs and how the management of ward work is organized. Acknowledgments The authors express special thanks to the Academy for Health Care, County Council of Jönköping, Sweden and (FORSS) The Research Council of Southeast Sweden. The authors express special thanks to Sweden and the Department of Anaesthesia and Intensive Care at Ryhov County Hospital who have given financial support. References Abdalrahim, M. S., Majali, S. A., & Bergbom, I. (2008). Documentation of postoperative pain by nurses in surgical wards. Acute Pain, 10, 73–81, http: //dx.doi.org/10.1016/j.acpain.2008.04.001. Carr, D. B., Reines, H. D., Schaffer, J., Polomano, R. C., & Lande, S. (2005). The impact of technology on the analgesic gap and quality of acute pain management. Reg Anesth Pain Med, 30(3), 289–291, http://dx.doi.org/10.1016/j.rapm.2004.10.009. Clabo, L. M. L. (2007). An ethnography of pain assessments and the role of social context on two postoperative units. J Adv Nurs, 61(5), 531–539, http: //dx.doi.org/10.1111/j.1365-2648.2007.04550.x. Coker, E., Papaioannou, A., Kaasalainen, S., & Dolovich, L. (2012). Nurses perceived barriers to optimal pain management in older adults on acute medical units. Appl Nurs Res, 23, 139–146, http://dx.doi.org/10.1016/j.apnr.2008.07.003. Dihle, A., Bjölseth, G., & Helseth, S. (2006). The gap between saying and doing in postoperative pain management. J Clin Nurs, 15, 469–479. Dijk, J. F. M., Wijck, A. J. M., Kappen, T. H., Peelen, L. M., Kalkman, C. J., & Schuurmans, M. J. (2012). Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross sectional study. Int J Nurs Stud, 49, 65–71, http://dx.doi.org/10.1016/j.ijnurstu.2011.07.009.
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