Journal of Psychosomorrc Research, Vol. 34, No. 5, pp. 543-552. 1990. Printed in Great Britain.
POSTOPERATIVE RELEVANT PATIENT
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0022-3999/90 $3.00 + .I0 1990 Pergamon Press plc
PAIN EXPERIENCES: AND STAFF ATTITUDES
HELEN R. WINEFIELD,* MARY KATSIKITIS,* LEANNE M. HART,? and BRUCE F. ROUNSEFELL~ (Received
11 October 1989; accepted in revised form 22 March 1990)
Abstract-Postoperative pain continuesto occur, despiteboth advancesin analgesic techniques and recognition of the damaging effect of pain upon recovery. This study set out to describe the pain experiences of successive cholecystectomy patients in a large teaching hospital, using three different pain measures and self-reports of anxiety and pain-related attitudes and experiences. Nurses and doctors in surgical wards provided parallel information about their pain-related attitudes and practices. A substantial proportion of patients suffered significant postoperative pain, apparently related to their fear of addiction and reluctance to ask for extra analgesic help. Nurses were more convinced than patients that patients should have more control of their own pain relief. Barriers to effective pain relief are seen to include cognitive, attitudinal and systemic factors; some suggestions are offered for reform of relevant hospital practices. INTRODUCTION
POSTOPERATIVEpain originates with surgical trauma and its neurophysiology and pharmacology are reasonably well-understood. Because it causes a pattern of autonomic ‘stress’ arousal, postoperative pain can interfere with sleep, impede recovery and cause complications such as respiratory depression [l-4]. Effective analgesic techniques are available but are frequently not used [ 1, 51. Responsibility for this outcome has been attributed to hospital staff failures to administer prescribed analgesia, their adherence to dosage schedules known to be ineffective, and associated delays, anxieties and ignorance [557]. Numerous technical innovations are being introduced in the field of anaesthesia, so questions arise about whether pain-control outcomes have been or will be improved. The present study was undertaken in order to explore several related issues. Firstly, we wished to describe the extent and course of pain experienced by patients undergoing a common surgical procedure in a modern teaching hospital, and, using a variety of standardized measuring instruments, to investigate relationships between pain, anxiety, intake of opioid analgesics, and patient age and sex. Our purpose here was not only to explore the psychological aspects of the experience of surgery, but also to gather information which could be used as baseline data for staff education and in subsequent evaluation of new analgesic practices and procedures which the hospital was about to introduce. As it was expected on the basis of the literature [8,9] and our own clinical observations that unrelieved pain would be discovered, out study also sought to investigate reasons for this unnecessary suffering. To do this we studied the attitudes and beliefs about pain and pain management which were held by patients, nurses and medical staff at the hospital during the same period. These cognitions and their associated *Department of Psychiatry, University of Adelaide, South Australia. tDepartment of Anaesthesia and Intensive Care. Address for correspondence: Dr H. R. Winefield, Dept Psychiatry, University 498, Adelaide, South Australia 5001, Australia. 543
of Adelaide,
GPO Box
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HELEN
R. WINEFIELD et al
analgesic practices seemed to offer a key to understanding possible barriers to pain relief. We focus in this paper on these barriers and their implications for practices, and thus will not review the extensive literatures on preoperative psychological preparation for surgery, or psychosocial approaches to pain
effective hospital anxiety, control.
METHOD
(a) Subjects were successive elective cholecystectomy patients at a major metropolitan teaching hospital. who were aged 21-80 yr and gathered into the study over a period of seven months. They all underwent the same surgical procedures (a right upper-quadrant transverse incision), under the care of IO different consultants and in four different wards. Patients were excluded from the study if they suffered from additional painful conditions, underwent other concurrent surgical procedures, or were non English-speaking. One patient declined to participate, four had prohibitive language difficulties, and five others were missing from the study due to the timing of their hospital stays (e.g. coinciding with leave by the Research Officer). Altogether 61 patients provided at least partial data: their mean age was 56.3 yr and 77.0% were female. Six (10.2%) were employed and the remainder were pensioners (n = 34; 57.6%) or engaged in home duties (n = 19; 32.2%). Fewer patients were available for study on day 6 due to 21. (34.4%) having been discharged. (b) All of the hospital interns (n = 59) and all the registrars in surgical areas (n = 15) were asked to complete questionnaires, and 38 did so. giving a return rate of 51.4%. Mean age was 26.5 yr and 69.4% were male. (c) All registered nurses rostered to work in the surgical wards of the hospital, including all shifts and part-time as well as full-time employees, but excluding relieving and agency staff, were asked to complete questionnaires (n = 308). Cooperation was shown by 207 nurses (return rate = 67.2”/0): their mean age was 27.6 yr and 86.2% were female. Measures
and procedures
Patients’ age, sex, occupation and details about their surgery and analgesic medication were gathered from hospital records. Self-report ratings of pain were collected from patients by a nurse Research Officer, on the first, second, third and sixth postoperative days. These included a Visual Analog Scale rating (VAS: from 0 = no pain to 10 = worst pain imaginable) [8], the McGill Pain Questionnaire Pain Rating Index (PRI) [IO], and a self-report Comfort Score based on a 5-point rating scale developed by P. Bruggemann. a nurse at the hospital who had extensive experience of recovery after abdominal surgery: 0 = in constant pain. I = sedated but complaining of pain when roused , 2 = pain on deep inspiration but otherwise comfortable. 3 = comfortable with deep inspiration, 4 = comfortable with a cough. This measure will be referred to as the Bruggemann Comfort Scale (BCS). The Spielberger State Anxiety Scale [I I] vvas also completed by patients on each occasion. In addition, on the third postoperative day patients were interviewed between IO a.m. and I pm., using a 14.item questionnaire concerned with their pain experiences and beliefs. Belief in the possibility of addiction to hospital pain-killers is ofparticular concern in this report. Medical and nursing staff of the hospital supplied information about their practices and beliefs concerning postoperative pain management. by returning questionnaires which had been distributed to them in the wards. Questions referred to responses to a hypothetical patient complaining of pain before being due for more Pethidine, pain relief goals (complete relief. as much pain relief as possible. or just enough relief to make the patient comfortable), who should control the patient’s pain. the possibility of addiction to opioid analgesics. satisfdaction with own education in pain control. and a 5-point rating of pain relief adequacy at the hospital. Statistical analysis of the data aimed (1) to decribe the course of patient pain over the frst six postoperative days. and see whether it was influenced by amount of injected opioid analgesia, or patient sex. age or anxiety level. and (3) to explore connections between patient experiences. patient and staff beliefs, and stall’ analgesic practices.
RESULTS Patient
experienws
of postoperuti?e
paiu
Unwanted side-effects were experienced by 14 patients after their cholecystectomy: 13 suffered vomiting or nausea, three suffered urinary problems, and nursing notes showed one case each of failure of wound healing, ‘flu’, and pneumonia. . * t
Postoperative
pain
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As pethidine is known to have a relatively short duration of action [12], patients receiving pethidine (n = 36) were compared with those receiving omnopon or morphine (n = 25). They did not differ by t tests in age, anxiety or any measure of pain on any occasion, and it therefore seems reasonable to combine the drugs in an equivalence formula (see below). Table I shows the means and standard deviations of patient responses to the three pain measures over the four assessment occasions (postoperative days I, 2, 3 and 6). This table also shows patient State anxiety, and the amount of opioid analgesia received, on each day. Drugs administered are expressed as Standard Units of Opioid (SUO), where 1 SUO = 130 mg pethidine = 20 mg omnopon = 13 mg morphine [ 121. Drugs had been ordered for 3-4 hourly pm (60.7% of cases) or 4 hourly pm (39.3%) administration (where pm denotes a regime where drugs are provided upon patient request after the specified time interval). Total opioids administered by injection over the first three days averaged 4.89 SUOs (SD 2.90). A variety of oral analgesics, principally paracetamol and dextropropoxyphene, were also administered but will not be further reported here as our main interest lies in the more powerful opioids. A steady decline in all three measures of experienced pain is evident from days l--6. By the third day, 81.5% of patients marked the visual analog pain scale (VAS) below the mid-point of the range, and 38.2% felt comfortable except for deep inspiration, and 18.5% even with a cough (points 3 and 4 on the BCS). Analgesia administered also decreased with time, while anxiety showed a tendency in the same direction. Anxiety levels are somewhat lower than those quoted in the test manual [It] for surgical patients (mean = 42.7) but similar to those found in a study of Australian coronary artery graft patients [13] (means 32.3-35.2). Language or communication difficulties prevented 13 patients for whom other data were available, from completing the McGill Pain Questionnaire, and others refused due to feeling too tired, drowsy or sick. Words chosen by at least 30% of patients to describe their pain from the McGill Pain Questionnaire list were: for day 1 sharp, cramping, pulling, sore, tender, annoying and nauseating; for day 2 sharp, tender, tiring, annoying; for day 3 sharp, tugging, pulling, sore, tender, tiring, annoying, tight nagging; for day 6 itchy, sore, tender, annoying, tight, nagging. Correlations between the pain and anxiety measures, over days l-6, are shown in Table II. The relationship between the simple ratings of pain (VAS and BCS) and the more complicated PRI, increases in strength with time up until day 3. Anxiety
TABLE I.-PAIN,
ANXIETY
AND
Day VAS BCS PRI Anxiety suo SUO = nil for
AMOUNTOF ANALGESIA RECEIVED OVER THE FIRST SIX DAYS AFTER CHOLECYSTECTOMY
I
4.20 (2.40) 1.87 (0.77) 16.16 (7.91) 35.97 (8.29) 2.57 (1.38) 1.6%
Day 2
Day 3
Day 6
3.41 (2.40) 2.27 (0.76) 13.58 (7.80) 35.23 (9.59) 1.65 (1.33) 16.7%
2.42 (2.3 1) 2.67 (0.86) 12.13 (8.70) 33.58 (10.15) 0.64 (1.02) 59.6%
0.88 (1.11) 3.55 (0.63) 6.63 (5.84) 30.30 (8.47) 0.02 (0.10) 97.1%
Figures are means with standard deviations in parentheses, for Visual Analog Scale for pain (VAS), Bruggemann Comfort Score (BCS), McGill Pain Rating Index (PRI), Spielberger State Anxiety scale (anxiety), and Standard Units of Opioid (SUO).
HELEN R. WINEFIELD et al.
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TABLE U--PEARSON r CORRELATIONS BETWEEN PAIN (VISUAL ANALOG SCALE, BRUGGEMANNCOMFORT SCALE, AND MCGILL PAIN RATING INDEX) AND ANXIETY (SPIELBERGERSTATE ANXIETY) MEASURES,AND ANALGESIARECEIVED(IN STANDARD UNITS OF OPIOID). AFTERCHOLECYSTECTOMY
Day 1 VAS BCS PRI Anxiety Day 2 VAS BCS PRI Anxiety Day 3 VAS BCS PRI Anxiety Day 6 VAS BCS PRI
Anxiety
suo
0.26 -0.21
0.18’ 0.06 0.24
-0.02 -0.10 0.19 0.06
-0.60**
0.45* ~-0.37;
0.36* 0.30 0.14
0.19 ~ 0.39** 0.25 0.28
-0.54**
0.63** -0.42*
0.37* -0.28 0.52**
-0.67**
0.60’* -0.27
0.70** -0.68** 0.53’
BCS
PRI
-0.58**
(n = 60)
(n = 58)
(n = 54) 0.27 -0.32’ 0.07 O.OI
(n = 28)
#
*p < 0.01;
**p < 0.001. #Correlations have not received any opioid.
been
calculated
because
only
one
patient
and VAS are significantly correlated from day 2, anxiety and PRT are correlated from day 3, and anxiety and BCS are correlated by day 6. The amount of opioid administered shows little relationship with experienced pain, except that on days 2 and 3 patients with a lower BCS score got more analgesia. Correlations between analgesia received on the first two days and pain reports of the following day were also calculated. The only relationship reaching statistical significance was that amount of opioid received on day 2 was related to BCS score of day 3, r = - 0.36. p < 0.01, probably because analgesia received on days 2 and 3 was correlated, I’ = 0.41, p < 0.001. In response to the questionnaire, 98.0% of the patients reported having experienced postoperative pain. which was worse than expected for 30.0%. The 98.0% of patients who had received analgesic injections reported that these had given them ‘complete’ or ‘a lot‘ of relief (71.4%), ‘some’ relief (24.5%), or ‘little’ or ‘no’ relief (4.1%). Pain relief lasted less than 2 h for 34.7%, 334 h for 42.9%. and more than 4 h for 22.4%. When pain returned, 37.5% asked for another injection rather than waiting for one to be offered. For those who asked, 26.3% found that the injection was usually delayed rather than prompt and if anything, delays tended to be longer during the day than at night. The 45% of patients who had had morning operations were significantly more comfortable at the first postoperative assessment than those who had had afternoon operations, BCS means 2.15 and 1.67 respectively. f(df = 57) = 2.57. p < 0.02, and rated their pain as less severe on the second day, VAS means 2.65 and 4.01 respectively, r(df = 56) = 2.22. p < 0.05. These differences can be attributed to the longer period between the operation and the pain assessment. and demonstrate the
Postoperative
pain
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sensitivity of the pain measures. There were no sex differences in patients’ pain experiences. Patients aged below 65 yr had significantly lower BCS scores on day 2 than did those over 65: means 2.19 and 2.96 respectively, t(df = 59) = 2.12, p < 0.05, but the two age groups did not differ in other pain measures or anxiety. The younger group received more opioids on the first day, means 2.89 and 2.07 repectively, t (df = 59) = 2.35, p < 0.05, and on the second day, mean 1.98 and 1.10, t (58) = 2.62, p = 0.01. In order to explore the overlapping influences upon postoperative pain of patient medical and psychological characteristics, multiple regressions were carried out with day 3 pain measures as dependent variables. Predictors were patient age, sex, day 3 opioid intake and, anxiety and belief in the possibility of addiction, entered in that order to check the independent contribution of the psychological variables. Only with BCS as the dependent variable did the overall regression equation approach significance (F(df = 5,33) = 2.39, p < 0.06), with 26.6% of the variance accounted for. Adding anxiety and fear of addiction had increased the explained variance by 12.5%. Patient attitudes
to pain control
Patients answered that decisions about when they should receive more pain-killer should be made by themselves (55.6%), their doctor (20.0%), or a nurse (24.4%). However, only 37.3% affirmed that they would have liked more control over their own pain relief, and 33.3% believed that ‘it’s possible to become addicted to strong pain-killers while in hospital’. There were no significant relationships between patients’ attitudes and their pain experiences on the day of the questionnaire. There were no sex differences in patient attitudes. However, younger patients (under 65) were more likely than older to have asked rather than waited for pain relief, X’(df = 1) = 3.79, p = 0.05, and would have liked more control of their own pain relief, X*(df = 2) = 8.29, p < 0.05. Patients of any age who had asked rather than waited for pain relief would have liked more control of their own pain relief, X2(df = 1) = 6.85, p < 0.01, and also disbelieved in the possibility of addiction to hospital pain-killers, X*(df = 1) = 5.10, p < 0.05. Only four of 50 respondents (8%) answered no to the direct question ‘Have you been generally satisfied with your own pain relief?’ Although this number is too small for statistical analyses, it is of interest that all four reported pain no more nor less than they expected, three had experienced less than complete relief from injections, three had had less than 3 hours’ relief from injections, and all four were under 60. Doctors’
and nurses’ practices
in pain control
When prescribing opioid analgesia for postoperative pain, most doctors (67.6%) reported ordering variable doses pm. In the hypothetical situation of a patient complaining of severe pain before being due for another dose, 8 1.2% of nurses would contact medical staff for advice, and 86.8% of doctors would reduce the dose interval. Complete relief of pain was the goal for 18.4% of doctors and 32.2% of nurses: doctors were significantly more likely than nurses to aim at just enough pain relief for the patient to be comfortable, X’(df = 2) = 23.57, p < 0.001. When the interns and Resident Medical Officers (n = 28) were compared with the more senior
HELEN R. WINEFIELII er al
548
Registrars (n = 6), the former were less frequently satisfied with their education in pain control, 10% and 67% respectively, X’(df = 1) = 9.15, p < 0.01, and more likely to rate the probability of addiction as 10% or more, X’(df = 1) = 8.67, p < 0.01. Doctors’
and nurses’
beliefs regarding
pain control
A lower proportion of doctors than nurses felt that they had been adequately educated in pain control, 18.4% and 53.9% respectively, X?(df = 2) = 18.36, p < 0.001. Only 34.2% and 33.3% respectively felt that overall pain relief at the hospital was excellent or good. Nurses were more likely than doctors to feel that nurses should be given more control over the patients’ pain relief, x’(df = 2) = 7.93, p < 0.02. However, when asked if patients should be given more control, similar proportions of doctors (68.4%) and nurses (63.1%) said yes, while a significantly lower proportion of patients agreed (37.3%), X’(df = 3) = 12.79, p < 0.01. When asked how often opioid analgesics cause respiratory depression on surgical wards, doctors were significantly more likely than nurses (26.3% and 9.7% respectively) to reply often or very often, X’(df = 2) = 12.60, p < 0.01. A similar cautiousness is indicated by doctors being more likely than nurses to estimate the probability of addiction as 50% or 100% (27.0% and 9.5% respectively), X’(df = 2) = 10.15, p < 0.01. There were no significant relationships between doctors’ and nurses’ estimates of the probability of addiction and their self-reported goals in pain management. DISCUSSION
This study offers detailed information about the pain experienced during recovery in hospital from a common surgical procedure (cholecystectomy). The fact that all patients underwent the same operation reduces the ambiguities of studies which treat together patients undergoing heterogeneous surgical procedures. Furthermore the present research used multiple methods and occasions of pain measurement, has a relatively large patient sample with a good participation rate, and provides separate analyses of doctor and nurse attitudes which are seen to differ substantially. The questionnaire return rates for nurses was adequate, but diappointing for doctors; it may be assumed that doctors who declined to take part were less well informed than those who did. Only relatively junior doctors participated. Results are, however. easier to interpret than where all grades of medical staff from consultants to interns have been aggregated; also it is the junior doctors who in practice make many analgesic decisions. Puin experiences
and nzeusures
The actual amount of pain suffered seems comparable to that previously reported for cholecystectomy patients by Taenzer and colleagues [8]. Somewhat less pain in the first two days in this study could perhaps be due to different analgesic practices or to a different patient population, the others being younger (mean age 47 yr), and our results have suggested worse pain in younger patients. Taenzer’s results agreed with ours in the high correlation between VAS and McGill PRI pain scores, and in the relatively low correlations between pain and opioid medication received. The weakness of the relationship between pain and drug-intake is not surprising given
Postoperative
pain
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that sometimes pain led to drug intake then relief, and sometimes drugs presumably prevented pain. Closer attention would need to be paid to the timing and sequences of drug administration and the pain experience to properly understand the role of drugs, along with anxiety reduction, in analgesia. Our results differ from the earlier report in that correlations between State anxiety and opioid use were not apparent in the present study. The several methods of pain measurement used in this study are highly correlated with each other, particularly from the second postoperative day onwards. By the third day and thereafter, pain is related more closely to anxiety than to analgesia received, as has been found previously [I, 21. The 5-point BCS is quick and easy to administer, refers specifically to behaviours important in recovery after abdominal surgery, and correlates well with previously-published measures. It can therefore be advocated for wider use with this population. A modified form of the VAS (with numbers O-10 specified) has also been advocated [13] as a pain measure which patients have little difficulty in completing. The McGill Pain Questionnaire on the other hand, places demands on patient language skills and concentration which restrict its suitability for routine use, while it offers correspondingly rich information about experiences. Perhaps these demands explain the relatively lower correlation between PRI scores and other pain measures on the first postoperative day. Although there was steady reduction in patients’ experienced pain over time, considerable unnecessary and possibly deleterious distress was experienced. By the third postoperative day one patient in five (18.5%) still had moderate to severe pain as indicated on the visual analogue scale, and 36.4% had pain on deep inspiration or even more constantly. Six of the 36 day three respondents to the McGill Pain Questionnaire described their pain as stabbing, seven as aching, four as piercing, three each as tearing and miserable, and one each for terrifying and dreadful. The sources of patient pain and their implications for procedural reforms will be discussed below. They appear to include patient anxiety about surgery and about analgesic drugs, corresponding staff anxieties which inhibited the delivery of effective analgesia, and features of the system of analgesic decision-making by staff. Sources
of‘postoperatiz~e
pain
Patient anxiety. A complete understanding of patient anxiety while in hospital would need to take account of variables not considered in this study such as trait anxiety, informational preparation for surgery [13, 15, 161, and satisfaction with the emotional support from staff and others [17]. Expressions of support from staff in the form of attentive listening would be expected to reduce patient anxiety-at the same time of course, they would facilitate accurate pain assessment. Even otherwiseassertive individuals experience depersonalization and a sense of helplessness while in hospital [18], thus most patients hesitate to trouble staff (who always seem so ‘busy’) for fear of being regarded as a nuisance. Anxieties over drug addiction. Patients, like doctors and to a lesser extent nurses, greatly overestimated the true risk of developing a drug addiction while in hospital, which is less than 1% [19]. It was the patients who believed in the possibility of addiction to pain-killers who were more reluctant to ask for pain relief. Recent media campaigns in Australia against drug-taking have tended to be sensational in tone and focused on ‘hard’ drugs rather than on abuse of alcohol and tobacco. It is worth
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HELENR. WINEFIELDet al
noting by the way, that the pm regime being used in this hospital has been identified as the one most likely to reinforce pain expression and thus promote dependence [20]. Other sources of patient reluctance to ask for analgesia may be the aversiveness for some of the side-effects such as drowsiness and perceived loss of control, or cultural acceptance of stoicism regarding pain expression. Only a third of patients reported asking for relief when, as frequently happened, pain returned before the next dose of analgesia was due. If patients do not for whatever reason express their need, the pm regime has no chance to operate effectively. It therefore should be emphasized to patients, even those who do not wish or do not feel competent to make decisions about their own pain control, that they must let staff know if pain has not been controlled. The next step of course is to ensure that patient requests are attended to promptly, rather than after the delays which are frequent especially during the day, and without any signs, however, subtle of staff disapproval and discouragement. Patient views about being in charge of their own pain control seemed to be inconsistent. The majority (56%) thought they should have decision-making power, but only a minority (37%) of the present subjects explicitly agreed that they would have liked more control. It seems likely that making available more information on drug side-effects and how to self-regulate analgesia intake, would allow patients to catch up with hospital staff in their acceptance of the idea. Certainly the younger patients seemed ready and even eager to assume greater control of their analgesia. Age differences were most noticeable in patient attitudes, apparent in amount of opioid received, and least evident in actual pain reported. Stqflnerd,for education. Doctors are more conservative than nurses in relinquishing analgesic decision-making power to patients, probably because they estimate the risks of respiratory depression and of addiction as being higher. The most junior doctors (the interns) are the least well-informed and the most conservative group; these are, however, the people who are usually given responsibility for writing out the drug orders. Perhaps therefore, any changes to practice should best be achieved by re-education of the doctors, to whom nurses feel obliged to refer decision-making, and who in any case feel more dissatisfied with their current education in pain control. Improved undergraduate education in pain control could often be achieved just by including the topic in the curriculum. This is one avenue for reform, but the influence of the surgical consultants who are ultimately responsible for the patient is probably greater. Our findings do not adequately explore the relationships between staff attitudes and practices, and further investigation of this topic is clearly needed. S~:rtm~ churucteristics. Oden [5] has identified the problem that no one member of the medical team is held to be responsible for pain control and the assessment of analgesic interventions. The routine collection of pain measures, and the designation of someone as responsible for pain control, would act to overcome this barrier. Four-fifths of both doctors and nurses in this study favoured the introduction of a simple pain measuring system. Nurses are on the spot 24 hr per day. Changes in nursing education and administration may mean upgraded, academc qualifications for nurses and correspondingly greater assertiveness and confidence in taking responsibility for patient care. The anaesthetist has been the person most frequently suggested by nurses as appropriate to manage pain relief [7]. As anaesthetists do not routinely visit all patients postoperatively, there is little opportunity or incentive for them to influence
Postoperative
pain
551
pain control policies at ward level. Thus one conclusion from our study is the need to consider a possible expansion of the anaesthetist’s responsibility in postoperative pain control. Most teaching hospitals now accommodate behavioural scientists with the necessary skills for the collaborative research needed as a basis for policy changes. Conclusions The introduction of patient-controlled analgesia using self-dosage intravenous machines rather than intermittent injections, and of epidural and subcutaneous opioids, potentially heralds a period of change in hospital pain-control policies and practices. As the new techniques are tried and evaluated, patient pain will need to be monitored routinely and analgesia effectiveness assessed, often for the first time. Our results confirm the usefulness for regular ward use of Visual Analog Scales and the Bruggemann Comfort Scale; the more time-consuming McGill Pain Questionnaire provides a wealth of experiential information but may better suit the later stages of recovery. Unnecessary and potentially harmful postoperative pain continues to occur. Analysis of the barriers to more effective pain control [5] takes into consideration knowledge, attitudes and systemic reasons for the currently inadequate anaesthesia confirmed by our results. The present study gives considerable insight into the knowledge gaps and dysfunctional attitudes on the part of both patients and staff, which hinder maximum reduction of experienced pain; at the same time further research is obviously required. Better educational preparation for interns and nurses, re-education for consultant surgeons, an expanded role for anaesthetists in monitoring and directing postoperative pain control, and more informational support for patients, are suggestions arising from this research which might remove some of the barriers to reduction of patients’ distress. Ackr2o~~/~,~lgement,r--We are grateful for the cooperation of the participating staff and patients, and to Anna Chur-Hansen for help with data analysis. This research was supported by an Early Career Development Grant from the Royal Adelaide Hospital to Graeme Newcombe and Nick Lavies.
REFERENCES I. WILSON PR. Postoperative analgesia. Med J Ausr 1989; 150: 393-396. 2. CHAPMAN CR. New directions in the understanding and management of pain. SOC Sci Med 1984; 19: 1261-1278. 3. KNIGHT L, MEHTA M. Post-operative pain relief. Br J Hasp Med 1978; 19: 462469. 4. WATTS CT. Inadequate analgesia. Lancet 1975; 1: 678. 5. OVEN RV. Acute postoperative pain: Incidence, severity, and the etiology of inadequate treatment. Arm&h C/in N Am 1989; 7: l-15. 6. DONOVAN BD. Patient attitudes to postoperative pain relief. Anaesfh Infens Care 1983; 11: 125-129. 7. CHAPMAN PJ, GANENDRAN A, SCOTT RJ, BASFORD KE. Attitudes and knowledge of nursing staff in relation to management of postoperative pain. Aus! N Z J Surg 1987; 57: 447450. 8. TAENZER P. Postoperative pain: Relationships among measures of pain, mood, and narcotic requirements. In: Pain Measurement und Assessment (Edited by MELZACK R), pp. 111~118. New York: Raven Press, 1983. 9. TAENZER P, MELZACK R, JEANS ME. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986; 24: 331-342. 10. MELZACK R. The McGill Pain Questionnaire. In: Pain Measurement und Assessement (Edited by MELZACK R), pp. 4147. New York: Raven Press, 1983.
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12. GRAY TC. NUNN JF. UTTINC;JE. G~vzcv-crlAncrr\thesicr r’ol. 1. Fourth Edn. London: Butterworth. 1980. 13. POSTLETHWAI~FR. STIKLIY-X; G, PIXX C. Stress inoculation for acute pain: A clinical trial. J B&x Mctl 1986: 9: 219~237. 14. JEYSFN MP. KAROLY P. ~‘RIDKI)AN EF. BLAUII F. BUKNS RS. The subjectlye experience of acute pain An assessment of the utility of IO indices. C/in J Puirl 1989: 5: I53 159. IS. WHSLNBEKC; M. Pain and pain control. P.c)~hr~/ Bzrll 1977; 84: IOOX~-1044. Hnd surgery. In: T/x, Ev-p~~icv~cc, of ///rx~.c.~. (Edited h> 16. NFWMAN S. Anxiety, hospitalization. FITI.I,ATRI(.K R. HINTON J, NI:WMAN S, SCAMBLCKG. THOMPSON J). London: Tavistock. 1984. 17. WIN~FI~LU HR. KATSIKI~IS M. Medical professional support and cardiac rehabilitation of males and females. J f.~who.wn~ Ret 1987: 31: 567 573 18. TAYLOR SE. Hospitel patient behavior: Reactance. helplessness. or control? .I .Soc, IVY 1979: 35: I56 184.
POSTOPERATIVE RELEVANT PATIENT
0
0022-3999/90 $3.00 + .I0 1990 Pergamon Press plc
PAIN EXPERIENCES: AND STAFF ATTITUDES
HELEN R. WINEFIELD,* MARY KATSIKITIS,* LEANNE M. HART,? and BRUCE F. ROUNSEFELL~ (Received
11 October 1989; accepted in revised form 22 March 1990)
Abstract-Postoperative pain continuesto occur, despiteboth advancesin analgesic techniques and recognition of the damaging effect of pain upon recovery. This study set out to describe the pain experiences of successive cholecystectomy patients in a large teaching hospital, using three different pain measures and self-reports of anxiety and pain-related attitudes and experiences. Nurses and doctors in surgical wards provided parallel information about their pain-related attitudes and practices. A substantial proportion of patients suffered significant postoperative pain, apparently related to their fear of addiction and reluctance to ask for extra analgesic help. Nurses were more convinced than patients that patients should have more control of their own pain relief. Barriers to effective pain relief are seen to include cognitive, attitudinal and systemic factors; some suggestions are offered for reform of relevant hospital practices. INTRODUCTION
POSTOPERATIVEpain originates with surgical trauma and its neurophysiology and pharmacology are reasonably well-understood. Because it causes a pattern of autonomic ‘stress’ arousal, postoperative pain can interfere with sleep, impede recovery and cause complications such as respiratory depression [l-4]. Effective analgesic techniques are available but are frequently not used [ 1, 51. Responsibility for this outcome has been attributed to hospital staff failures to administer prescribed analgesia, their adherence to dosage schedules known to be ineffective, and associated delays, anxieties and ignorance [557]. Numerous technical innovations are being introduced in the field of anaesthesia, so questions arise about whether pain-control outcomes have been or will be improved. The present study was undertaken in order to explore several related issues. Firstly, we wished to describe the extent and course of pain experienced by patients undergoing a common surgical procedure in a modern teaching hospital, and, using a variety of standardized measuring instruments, to investigate relationships between pain, anxiety, intake of opioid analgesics, and patient age and sex. Our purpose here was not only to explore the psychological aspects of the experience of surgery, but also to gather information which could be used as baseline data for staff education and in subsequent evaluation of new analgesic practices and procedures which the hospital was about to introduce. As it was expected on the basis of the literature [8,9] and our own clinical observations that unrelieved pain would be discovered, out study also sought to investigate reasons for this unnecessary suffering. To do this we studied the attitudes and beliefs about pain and pain management which were held by patients, nurses and medical staff at the hospital during the same period. These cognitions and their associated *Department of Psychiatry, University of Adelaide, South Australia. tDepartment of Anaesthesia and Intensive Care. Address for correspondence: Dr H. R. Winefield, Dept Psychiatry, University 498, Adelaide, South Australia 5001, Australia. 543
of Adelaide,
GPO Box
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R. WINEFIELD et al
analgesic practices seemed to offer a key to understanding possible barriers to pain relief. We focus in this paper on these barriers and their implications for practices, and thus will not review the extensive literatures on preoperative psychological preparation for surgery, or psychosocial approaches to pain
effective hospital anxiety, control.
METHOD
(a) Subjects were successive elective cholecystectomy patients at a major metropolitan teaching hospital. who were aged 21-80 yr and gathered into the study over a period of seven months. They all underwent the same surgical procedures (a right upper-quadrant transverse incision), under the care of IO different consultants and in four different wards. Patients were excluded from the study if they suffered from additional painful conditions, underwent other concurrent surgical procedures, or were non English-speaking. One patient declined to participate, four had prohibitive language difficulties, and five others were missing from the study due to the timing of their hospital stays (e.g. coinciding with leave by the Research Officer). Altogether 61 patients provided at least partial data: their mean age was 56.3 yr and 77.0% were female. Six (10.2%) were employed and the remainder were pensioners (n = 34; 57.6%) or engaged in home duties (n = 19; 32.2%). Fewer patients were available for study on day 6 due to 21. (34.4%) having been discharged. (b) All of the hospital interns (n = 59) and all the registrars in surgical areas (n = 15) were asked to complete questionnaires, and 38 did so. giving a return rate of 51.4%. Mean age was 26.5 yr and 69.4% were male. (c) All registered nurses rostered to work in the surgical wards of the hospital, including all shifts and part-time as well as full-time employees, but excluding relieving and agency staff, were asked to complete questionnaires (n = 308). Cooperation was shown by 207 nurses (return rate = 67.2”/0): their mean age was 27.6 yr and 86.2% were female. Measures
and procedures
Patients’ age, sex, occupation and details about their surgery and analgesic medication were gathered from hospital records. Self-report ratings of pain were collected from patients by a nurse Research Officer, on the first, second, third and sixth postoperative days. These included a Visual Analog Scale rating (VAS: from 0 = no pain to 10 = worst pain imaginable) [8], the McGill Pain Questionnaire Pain Rating Index (PRI) [IO], and a self-report Comfort Score based on a 5-point rating scale developed by P. Bruggemann. a nurse at the hospital who had extensive experience of recovery after abdominal surgery: 0 = in constant pain. I = sedated but complaining of pain when roused , 2 = pain on deep inspiration but otherwise comfortable. 3 = comfortable with deep inspiration, 4 = comfortable with a cough. This measure will be referred to as the Bruggemann Comfort Scale (BCS). The Spielberger State Anxiety Scale [I I] vvas also completed by patients on each occasion. In addition, on the third postoperative day patients were interviewed between IO a.m. and I pm., using a 14.item questionnaire concerned with their pain experiences and beliefs. Belief in the possibility of addiction to hospital pain-killers is ofparticular concern in this report. Medical and nursing staff of the hospital supplied information about their practices and beliefs concerning postoperative pain management. by returning questionnaires which had been distributed to them in the wards. Questions referred to responses to a hypothetical patient complaining of pain before being due for more Pethidine, pain relief goals (complete relief. as much pain relief as possible. or just enough relief to make the patient comfortable), who should control the patient’s pain. the possibility of addiction to opioid analgesics. satisfdaction with own education in pain control. and a 5-point rating of pain relief adequacy at the hospital. Statistical analysis of the data aimed (1) to decribe the course of patient pain over the frst six postoperative days. and see whether it was influenced by amount of injected opioid analgesia, or patient sex. age or anxiety level. and (3) to explore connections between patient experiences. patient and staff beliefs, and stall’ analgesic practices.
RESULTS Patient
experienws
of postoperuti?e
paiu
Unwanted side-effects were experienced by 14 patients after their cholecystectomy: 13 suffered vomiting or nausea, three suffered urinary problems, and nursing notes showed one case each of failure of wound healing, ‘flu’, and pneumonia. . * t
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As pethidine is known to have a relatively short duration of action [12], patients receiving pethidine (n = 36) were compared with those receiving omnopon or morphine (n = 25). They did not differ by t tests in age, anxiety or any measure of pain on any occasion, and it therefore seems reasonable to combine the drugs in an equivalence formula (see below). Table I shows the means and standard deviations of patient responses to the three pain measures over the four assessment occasions (postoperative days I, 2, 3 and 6). This table also shows patient State anxiety, and the amount of opioid analgesia received, on each day. Drugs administered are expressed as Standard Units of Opioid (SUO), where 1 SUO = 130 mg pethidine = 20 mg omnopon = 13 mg morphine [ 121. Drugs had been ordered for 3-4 hourly pm (60.7% of cases) or 4 hourly pm (39.3%) administration (where pm denotes a regime where drugs are provided upon patient request after the specified time interval). Total opioids administered by injection over the first three days averaged 4.89 SUOs (SD 2.90). A variety of oral analgesics, principally paracetamol and dextropropoxyphene, were also administered but will not be further reported here as our main interest lies in the more powerful opioids. A steady decline in all three measures of experienced pain is evident from days l--6. By the third day, 81.5% of patients marked the visual analog pain scale (VAS) below the mid-point of the range, and 38.2% felt comfortable except for deep inspiration, and 18.5% even with a cough (points 3 and 4 on the BCS). Analgesia administered also decreased with time, while anxiety showed a tendency in the same direction. Anxiety levels are somewhat lower than those quoted in the test manual [It] for surgical patients (mean = 42.7) but similar to those found in a study of Australian coronary artery graft patients [13] (means 32.3-35.2). Language or communication difficulties prevented 13 patients for whom other data were available, from completing the McGill Pain Questionnaire, and others refused due to feeling too tired, drowsy or sick. Words chosen by at least 30% of patients to describe their pain from the McGill Pain Questionnaire list were: for day 1 sharp, cramping, pulling, sore, tender, annoying and nauseating; for day 2 sharp, tender, tiring, annoying; for day 3 sharp, tugging, pulling, sore, tender, tiring, annoying, tight nagging; for day 6 itchy, sore, tender, annoying, tight, nagging. Correlations between the pain and anxiety measures, over days l-6, are shown in Table II. The relationship between the simple ratings of pain (VAS and BCS) and the more complicated PRI, increases in strength with time up until day 3. Anxiety
TABLE I.-PAIN,
ANXIETY
AND
Day VAS BCS PRI Anxiety suo SUO = nil for
AMOUNTOF ANALGESIA RECEIVED OVER THE FIRST SIX DAYS AFTER CHOLECYSTECTOMY
I
4.20 (2.40) 1.87 (0.77) 16.16 (7.91) 35.97 (8.29) 2.57 (1.38) 1.6%
Day 2
Day 3
Day 6
3.41 (2.40) 2.27 (0.76) 13.58 (7.80) 35.23 (9.59) 1.65 (1.33) 16.7%
2.42 (2.3 1) 2.67 (0.86) 12.13 (8.70) 33.58 (10.15) 0.64 (1.02) 59.6%
0.88 (1.11) 3.55 (0.63) 6.63 (5.84) 30.30 (8.47) 0.02 (0.10) 97.1%
Figures are means with standard deviations in parentheses, for Visual Analog Scale for pain (VAS), Bruggemann Comfort Score (BCS), McGill Pain Rating Index (PRI), Spielberger State Anxiety scale (anxiety), and Standard Units of Opioid (SUO).
HELEN R. WINEFIELD et al.
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TABLE U--PEARSON r CORRELATIONS BETWEEN PAIN (VISUAL ANALOG SCALE, BRUGGEMANNCOMFORT SCALE, AND MCGILL PAIN RATING INDEX) AND ANXIETY (SPIELBERGERSTATE ANXIETY) MEASURES,AND ANALGESIARECEIVED(IN STANDARD UNITS OF OPIOID). AFTERCHOLECYSTECTOMY
Day 1 VAS BCS PRI Anxiety Day 2 VAS BCS PRI Anxiety Day 3 VAS BCS PRI Anxiety Day 6 VAS BCS PRI
Anxiety
suo
0.26 -0.21
0.18’ 0.06 0.24
-0.02 -0.10 0.19 0.06
-0.60**
0.45* ~-0.37;
0.36* 0.30 0.14
0.19 ~ 0.39** 0.25 0.28
-0.54**
0.63** -0.42*
0.37* -0.28 0.52**
-0.67**
0.60’* -0.27
0.70** -0.68** 0.53’
BCS
PRI
-0.58**
(n = 60)
(n = 58)
(n = 54) 0.27 -0.32’ 0.07 O.OI
(n = 28)
#
*p < 0.01;
**p < 0.001. #Correlations have not received any opioid.
been
calculated
because
only
one
patient
and VAS are significantly correlated from day 2, anxiety and PRT are correlated from day 3, and anxiety and BCS are correlated by day 6. The amount of opioid administered shows little relationship with experienced pain, except that on days 2 and 3 patients with a lower BCS score got more analgesia. Correlations between analgesia received on the first two days and pain reports of the following day were also calculated. The only relationship reaching statistical significance was that amount of opioid received on day 2 was related to BCS score of day 3, r = - 0.36. p < 0.01, probably because analgesia received on days 2 and 3 was correlated, I’ = 0.41, p < 0.001. In response to the questionnaire, 98.0% of the patients reported having experienced postoperative pain. which was worse than expected for 30.0%. The 98.0% of patients who had received analgesic injections reported that these had given them ‘complete’ or ‘a lot‘ of relief (71.4%), ‘some’ relief (24.5%), or ‘little’ or ‘no’ relief (4.1%). Pain relief lasted less than 2 h for 34.7%, 334 h for 42.9%. and more than 4 h for 22.4%. When pain returned, 37.5% asked for another injection rather than waiting for one to be offered. For those who asked, 26.3% found that the injection was usually delayed rather than prompt and if anything, delays tended to be longer during the day than at night. The 45% of patients who had had morning operations were significantly more comfortable at the first postoperative assessment than those who had had afternoon operations, BCS means 2.15 and 1.67 respectively. f(df = 57) = 2.57. p < 0.02, and rated their pain as less severe on the second day, VAS means 2.65 and 4.01 respectively, r(df = 56) = 2.22. p < 0.05. These differences can be attributed to the longer period between the operation and the pain assessment. and demonstrate the
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sensitivity of the pain measures. There were no sex differences in patients’ pain experiences. Patients aged below 65 yr had significantly lower BCS scores on day 2 than did those over 65: means 2.19 and 2.96 respectively, t(df = 59) = 2.12, p < 0.05, but the two age groups did not differ in other pain measures or anxiety. The younger group received more opioids on the first day, means 2.89 and 2.07 repectively, t (df = 59) = 2.35, p < 0.05, and on the second day, mean 1.98 and 1.10, t (58) = 2.62, p = 0.01. In order to explore the overlapping influences upon postoperative pain of patient medical and psychological characteristics, multiple regressions were carried out with day 3 pain measures as dependent variables. Predictors were patient age, sex, day 3 opioid intake and, anxiety and belief in the possibility of addiction, entered in that order to check the independent contribution of the psychological variables. Only with BCS as the dependent variable did the overall regression equation approach significance (F(df = 5,33) = 2.39, p < 0.06), with 26.6% of the variance accounted for. Adding anxiety and fear of addiction had increased the explained variance by 12.5%. Patient attitudes
to pain control
Patients answered that decisions about when they should receive more pain-killer should be made by themselves (55.6%), their doctor (20.0%), or a nurse (24.4%). However, only 37.3% affirmed that they would have liked more control over their own pain relief, and 33.3% believed that ‘it’s possible to become addicted to strong pain-killers while in hospital’. There were no significant relationships between patients’ attitudes and their pain experiences on the day of the questionnaire. There were no sex differences in patient attitudes. However, younger patients (under 65) were more likely than older to have asked rather than waited for pain relief, X’(df = 1) = 3.79, p = 0.05, and would have liked more control of their own pain relief, X*(df = 2) = 8.29, p < 0.05. Patients of any age who had asked rather than waited for pain relief would have liked more control of their own pain relief, X2(df = 1) = 6.85, p < 0.01, and also disbelieved in the possibility of addiction to hospital pain-killers, X*(df = 1) = 5.10, p < 0.05. Only four of 50 respondents (8%) answered no to the direct question ‘Have you been generally satisfied with your own pain relief?’ Although this number is too small for statistical analyses, it is of interest that all four reported pain no more nor less than they expected, three had experienced less than complete relief from injections, three had had less than 3 hours’ relief from injections, and all four were under 60. Doctors’
and nurses’ practices
in pain control
When prescribing opioid analgesia for postoperative pain, most doctors (67.6%) reported ordering variable doses pm. In the hypothetical situation of a patient complaining of severe pain before being due for another dose, 8 1.2% of nurses would contact medical staff for advice, and 86.8% of doctors would reduce the dose interval. Complete relief of pain was the goal for 18.4% of doctors and 32.2% of nurses: doctors were significantly more likely than nurses to aim at just enough pain relief for the patient to be comfortable, X’(df = 2) = 23.57, p < 0.001. When the interns and Resident Medical Officers (n = 28) were compared with the more senior
HELEN R. WINEFIELII er al
548
Registrars (n = 6), the former were less frequently satisfied with their education in pain control, 10% and 67% respectively, X’(df = 1) = 9.15, p < 0.01, and more likely to rate the probability of addiction as 10% or more, X’(df = 1) = 8.67, p < 0.01. Doctors’
and nurses’
beliefs regarding
pain control
A lower proportion of doctors than nurses felt that they had been adequately educated in pain control, 18.4% and 53.9% respectively, X?(df = 2) = 18.36, p < 0.001. Only 34.2% and 33.3% respectively felt that overall pain relief at the hospital was excellent or good. Nurses were more likely than doctors to feel that nurses should be given more control over the patients’ pain relief, x’(df = 2) = 7.93, p < 0.02. However, when asked if patients should be given more control, similar proportions of doctors (68.4%) and nurses (63.1%) said yes, while a significantly lower proportion of patients agreed (37.3%), X’(df = 3) = 12.79, p < 0.01. When asked how often opioid analgesics cause respiratory depression on surgical wards, doctors were significantly more likely than nurses (26.3% and 9.7% respectively) to reply often or very often, X’(df = 2) = 12.60, p < 0.01. A similar cautiousness is indicated by doctors being more likely than nurses to estimate the probability of addiction as 50% or 100% (27.0% and 9.5% respectively), X’(df = 2) = 10.15, p < 0.01. There were no significant relationships between doctors’ and nurses’ estimates of the probability of addiction and their self-reported goals in pain management. DISCUSSION
This study offers detailed information about the pain experienced during recovery in hospital from a common surgical procedure (cholecystectomy). The fact that all patients underwent the same operation reduces the ambiguities of studies which treat together patients undergoing heterogeneous surgical procedures. Furthermore the present research used multiple methods and occasions of pain measurement, has a relatively large patient sample with a good participation rate, and provides separate analyses of doctor and nurse attitudes which are seen to differ substantially. The questionnaire return rates for nurses was adequate, but diappointing for doctors; it may be assumed that doctors who declined to take part were less well informed than those who did. Only relatively junior doctors participated. Results are, however. easier to interpret than where all grades of medical staff from consultants to interns have been aggregated; also it is the junior doctors who in practice make many analgesic decisions. Puin experiences
and nzeusures
The actual amount of pain suffered seems comparable to that previously reported for cholecystectomy patients by Taenzer and colleagues [8]. Somewhat less pain in the first two days in this study could perhaps be due to different analgesic practices or to a different patient population, the others being younger (mean age 47 yr), and our results have suggested worse pain in younger patients. Taenzer’s results agreed with ours in the high correlation between VAS and McGill PRI pain scores, and in the relatively low correlations between pain and opioid medication received. The weakness of the relationship between pain and drug-intake is not surprising given
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that sometimes pain led to drug intake then relief, and sometimes drugs presumably prevented pain. Closer attention would need to be paid to the timing and sequences of drug administration and the pain experience to properly understand the role of drugs, along with anxiety reduction, in analgesia. Our results differ from the earlier report in that correlations between State anxiety and opioid use were not apparent in the present study. The several methods of pain measurement used in this study are highly correlated with each other, particularly from the second postoperative day onwards. By the third day and thereafter, pain is related more closely to anxiety than to analgesia received, as has been found previously [I, 21. The 5-point BCS is quick and easy to administer, refers specifically to behaviours important in recovery after abdominal surgery, and correlates well with previously-published measures. It can therefore be advocated for wider use with this population. A modified form of the VAS (with numbers O-10 specified) has also been advocated [13] as a pain measure which patients have little difficulty in completing. The McGill Pain Questionnaire on the other hand, places demands on patient language skills and concentration which restrict its suitability for routine use, while it offers correspondingly rich information about experiences. Perhaps these demands explain the relatively lower correlation between PRI scores and other pain measures on the first postoperative day. Although there was steady reduction in patients’ experienced pain over time, considerable unnecessary and possibly deleterious distress was experienced. By the third postoperative day one patient in five (18.5%) still had moderate to severe pain as indicated on the visual analogue scale, and 36.4% had pain on deep inspiration or even more constantly. Six of the 36 day three respondents to the McGill Pain Questionnaire described their pain as stabbing, seven as aching, four as piercing, three each as tearing and miserable, and one each for terrifying and dreadful. The sources of patient pain and their implications for procedural reforms will be discussed below. They appear to include patient anxiety about surgery and about analgesic drugs, corresponding staff anxieties which inhibited the delivery of effective analgesia, and features of the system of analgesic decision-making by staff. Sources
of‘postoperatiz~e
pain
Patient anxiety. A complete understanding of patient anxiety while in hospital would need to take account of variables not considered in this study such as trait anxiety, informational preparation for surgery [13, 15, 161, and satisfaction with the emotional support from staff and others [17]. Expressions of support from staff in the form of attentive listening would be expected to reduce patient anxiety-at the same time of course, they would facilitate accurate pain assessment. Even otherwiseassertive individuals experience depersonalization and a sense of helplessness while in hospital [18], thus most patients hesitate to trouble staff (who always seem so ‘busy’) for fear of being regarded as a nuisance. Anxieties over drug addiction. Patients, like doctors and to a lesser extent nurses, greatly overestimated the true risk of developing a drug addiction while in hospital, which is less than 1% [19]. It was the patients who believed in the possibility of addiction to pain-killers who were more reluctant to ask for pain relief. Recent media campaigns in Australia against drug-taking have tended to be sensational in tone and focused on ‘hard’ drugs rather than on abuse of alcohol and tobacco. It is worth
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HELENR. WINEFIELDet al
noting by the way, that the pm regime being used in this hospital has been identified as the one most likely to reinforce pain expression and thus promote dependence [20]. Other sources of patient reluctance to ask for analgesia may be the aversiveness for some of the side-effects such as drowsiness and perceived loss of control, or cultural acceptance of stoicism regarding pain expression. Only a third of patients reported asking for relief when, as frequently happened, pain returned before the next dose of analgesia was due. If patients do not for whatever reason express their need, the pm regime has no chance to operate effectively. It therefore should be emphasized to patients, even those who do not wish or do not feel competent to make decisions about their own pain control, that they must let staff know if pain has not been controlled. The next step of course is to ensure that patient requests are attended to promptly, rather than after the delays which are frequent especially during the day, and without any signs, however, subtle of staff disapproval and discouragement. Patient views about being in charge of their own pain control seemed to be inconsistent. The majority (56%) thought they should have decision-making power, but only a minority (37%) of the present subjects explicitly agreed that they would have liked more control. It seems likely that making available more information on drug side-effects and how to self-regulate analgesia intake, would allow patients to catch up with hospital staff in their acceptance of the idea. Certainly the younger patients seemed ready and even eager to assume greater control of their analgesia. Age differences were most noticeable in patient attitudes, apparent in amount of opioid received, and least evident in actual pain reported. Stqflnerd,for education. Doctors are more conservative than nurses in relinquishing analgesic decision-making power to patients, probably because they estimate the risks of respiratory depression and of addiction as being higher. The most junior doctors (the interns) are the least well-informed and the most conservative group; these are, however, the people who are usually given responsibility for writing out the drug orders. Perhaps therefore, any changes to practice should best be achieved by re-education of the doctors, to whom nurses feel obliged to refer decision-making, and who in any case feel more dissatisfied with their current education in pain control. Improved undergraduate education in pain control could often be achieved just by including the topic in the curriculum. This is one avenue for reform, but the influence of the surgical consultants who are ultimately responsible for the patient is probably greater. Our findings do not adequately explore the relationships between staff attitudes and practices, and further investigation of this topic is clearly needed. S~:rtm~ churucteristics. Oden [5] has identified the problem that no one member of the medical team is held to be responsible for pain control and the assessment of analgesic interventions. The routine collection of pain measures, and the designation of someone as responsible for pain control, would act to overcome this barrier. Four-fifths of both doctors and nurses in this study favoured the introduction of a simple pain measuring system. Nurses are on the spot 24 hr per day. Changes in nursing education and administration may mean upgraded, academc qualifications for nurses and correspondingly greater assertiveness and confidence in taking responsibility for patient care. The anaesthetist has been the person most frequently suggested by nurses as appropriate to manage pain relief [7]. As anaesthetists do not routinely visit all patients postoperatively, there is little opportunity or incentive for them to influence
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pain
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pain control policies at ward level. Thus one conclusion from our study is the need to consider a possible expansion of the anaesthetist’s responsibility in postoperative pain control. Most teaching hospitals now accommodate behavioural scientists with the necessary skills for the collaborative research needed as a basis for policy changes. Conclusions The introduction of patient-controlled analgesia using self-dosage intravenous machines rather than intermittent injections, and of epidural and subcutaneous opioids, potentially heralds a period of change in hospital pain-control policies and practices. As the new techniques are tried and evaluated, patient pain will need to be monitored routinely and analgesia effectiveness assessed, often for the first time. Our results confirm the usefulness for regular ward use of Visual Analog Scales and the Bruggemann Comfort Scale; the more time-consuming McGill Pain Questionnaire provides a wealth of experiential information but may better suit the later stages of recovery. Unnecessary and potentially harmful postoperative pain continues to occur. Analysis of the barriers to more effective pain control [5] takes into consideration knowledge, attitudes and systemic reasons for the currently inadequate anaesthesia confirmed by our results. The present study gives considerable insight into the knowledge gaps and dysfunctional attitudes on the part of both patients and staff, which hinder maximum reduction of experienced pain; at the same time further research is obviously required. Better educational preparation for interns and nurses, re-education for consultant surgeons, an expanded role for anaesthetists in monitoring and directing postoperative pain control, and more informational support for patients, are suggestions arising from this research which might remove some of the barriers to reduction of patients’ distress. Ackr2o~~/~,~lgement,r--We are grateful for the cooperation of the participating staff and patients, and to Anna Chur-Hansen for help with data analysis. This research was supported by an Early Career Development Grant from the Royal Adelaide Hospital to Graeme Newcombe and Nick Lavies.
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